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Journal of Primary Health Care Journal of Primary Health Care Society
Journal of The Royal New Zealand College of General Practitioners
RESEARCH ARTICLE (Open Access)

Ascending the Poutama: culturally responsive diabetes care for Māori communities

Rebekah Crosswell https://orcid.org/0009-0001-0706-7086 1 * , Hinetu Nikora https://orcid.org/0009-0005-1724-1876 1 , Ryan Paul 1 2 , Cathy Buntting 3 , Tom Roa https://orcid.org/0000-0002-3774-7891 4 , Rawiri Keenan https://orcid.org/0000-0001-8312-8525 1 , Apo Aporosa https://orcid.org/0000-0002-4490-9545 1 , Capri Paekau 4 , Glenda Raumati 4 , Suzanne Moorhouse 5 6 , Anna Tiatia Fa’atoese Latu https://orcid.org/0000-0002-3790-8720 1
+ Author Affiliations
- Author Affiliations

1 Division of Health, School of Equity and Innovation, University of Waikato, Hamilton, New Zealand.

2 Te Whatu Ora Waikato, Hamilton, New Zealand.

3 Te Kura Toi Tangata - School of Education & Wilf Malcom Institute of Educational Research (WMIER), University of Waikato, Kirkiriroa, New Zealand.

4 Te Pua Wānanga ki te Aō - School of Māori and Indigenous Studies, University of Waikato, Kirikiriroa, New Zealand.

5 Ngā Miro Community Health Centre, Waikato, New Zealand.

6 Te Puna Hauora Matua o Hauraki (Hauraki Primary Healthcare Organisation), New Zealand.

* Correspondence to: rebekah.crosswell@waikato.ac.nz

Handling Editor: Felicity Goodyear-Smith

Journal of Primary Health Care https://doi.org/10.1071/HC25066
Submitted: 14 April 2025  Accepted: 7 July 2025  Published: 5 August 2025

© 2025 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of The Royal New Zealand College of General Practitioners. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Abstract

Introduction

Type 2 diabetes (T2D) significantly impacts Māori populations in Aotearoa New Zealand (NZ) who experience health disparities including suboptimal disease management.

Aim

To explore culturally responsive approaches to supporting Māori living with T2D from the perspective of healthcare providers.

Methods

Nine semi-structured interviews were conducted with clinicians from various disciplines (general practitioner, podiatrist, exercise physiologist, three kaiāwhina, dietitian, two pharmacists); five clinicians identify as Māori, four as non-Māori. Kaupapa Māori inductive thematic analysis was used.

Results

Four key themes emerged: empowering patient-centred communication, whānau involvement, interprofessional collaboration, and culturally appropriate analogies.

Discussion

The findings underscore the need for holistic, culturally responsive T2D care that prioritises culturally appropriate communication to improve patient engagement, health outcomes and address Māori health disparities.

Keywords: culturally responsive, health communication, health equity, holistic disease management, indigenous health, Kaupapa Māori, patient-centred care, poutama, primary healthcare, type 2 diabetes mellitus.

WHAT GAP THIS FILLS
What is already known: Māori populations experience significant diabetes outcome disparities because of systemic inequities resulting from colonisation, racism and limited access to culturally appropriate care. This necessitates culturally responsive diabetes care tailored to the needs of Māori populations.
What this study adds: This study offers a comprehensive clinician-centred view of culturally responsive care for patients with type 2 diabetes. It focuses on the clinician’s role in seamlessly integrating whānau participation and collaborative practice within Māori communities. The research highlights thoughtful approaches that clinicians utilise to bridge cultural gaps to improve health outcomes. It also introduces and conceptualises the ‘Ascending the Poutama’ framework as a novel, culturally grounded model for understanding and implementing optimal diabetes care.

Introduction

Type 2 diabetes (T2D) disproportionately affects Māori in Aotearoa New Zealand (NZ), with rates three-fold higher than non-Māori, leading to greater complications and mortality.1 The Waikato region of NZ, the setting for this study, exhibits considerable challenges in diabetes management, with a concerning 66.9% of Māori patients failing to meet the clinical target for glycated haemoglobin (HbA1c) of <53 mmol/mol, compared to NZ Europeans who had greater glycaemic management with 56.8% <53 mmol/mol.2 Fundamental causes of these inequities include deeply embedded systemic issues like colonisation and racism, the historical and ongoing neglect of social determinants of health, and significant barriers such as a lack of culturally appropriate care, financial hardship and pervasive stigma.37 Furthermore, optimal diabetes care is significantly impacted by a combination of factors: rural healthcare access limitations8 disproportionately impacting high-priority populations; short 15-min general practitioner (GP) appointments; and insufficient or ineffective communication and education.9

Effective communication is paramount for optimal patient care, directly influencing health outcomes, patient understanding, trust, treatment consensus and medication adherence.10 In T2D, complex pharmacological regimens necessitate strict adherence for glycaemic control.1115 Ineffective communication has been linked to poor self-care behaviours and suboptimal glycaemic management.11,12,14,16,17

Successful diabetes management therefore requires clear, patient-centred communication and robust clinician–patient relationships. To foster patient understanding, clinicians must prioritise simple explanations, avoiding medical jargon.13,16,18 This includes providing accessible information regarding diagnoses, treatment options and medication purposes.13 Crucially, active listening, addressing patient concerns and encouraging shared decision-making significantly enhance understanding and adherence.19 These communication strategies are fundamental to building trust, which is essential for successful T2D management.1114,16,19 Conversely, communication breakdowns, marked by stigma, judgement or a lack of empathy, can erode trust, impede adherence to treatment and negatively impact health outcomes.11,12,14,20

Empathy is an essential component of clinical communication, fostering patient understanding and support.10,11,21 Compassionate clinicians can mitigate patient anxiety20 and strengthen clinician–patient relationships, leading to increased attendance at appointments, as well as improved medication and treatment adherence.10,20,22 Given the significant emotional and cognitive burdens of T2D, clinicians should be particularly sensitive to patient feelings and concerns.23 An empathetic approach can enhance patient satisfaction and overall health outcomes.10,20,22,24

Acknowledging patients’ diverse cultural values, including spirituality, is essential for effective clinical practice.21 Disparities in health perspectives, such as the contrast between Western biomedical and holistic Māori worldviews, which inherently integrate spiritual dimensions,25 necessitate cultural competency to mitigate health inequities.2628 Cultural safety, which emphasises respect for patient values and spiritual beliefs, is crucial for building trust.21,29,30 Indigenous populations, including Māori (tangata whenua of NZ), often report communication barriers with providers, leading to poorer health outcomes.3137

A culturally aligned communication framework, The Hui Process,29,3840 guides effective clinician–patient interactions with Māori through four phases. Mihimihi involves clear introductions, role clarification and confirming the patient’s Māori identity. Whakawhanaungatanga, distinct from mere rapport-building, requires clinicians to connect on a personal level by demonstrating understanding of te ao Māori, including whenua, whānau and te reo Māori, and sharing relevant personal experiences. This establishes a foundation of shared understanding before proceeding with the clinical agenda. Kaupapa transitions to history-taking or the clinical task. Whakamutunga concludes the consultation by ensuring mutual understanding of the discussion and clarifying next steps, including follow-up appointments, referrals and treatment plans.

Although there is research that investigates clinician–patient communication in NZ and Māori healthcare experiences, there is a significant research gap in clinical communication in the management of T2D. This includes a dearth in the literature on pragmatic strategies to incorporate whānau-centred care specifically for clinicians managing patients with T2D. This study bridges the gap by identifying some specific strategies clinicians use to provide culturally safe and effective communication in diabetes care to Māori patients in a semi-rural Waikato setting. It is important to note that this research focuses on the experiences and perspectives of healthcare providers and does not include direct patient outcome data to measure the effectiveness of these strategies. Therefore, the findings represent the clinicians’ views on their self-reported efficacy.

Methods

Study design

This qualitative study, grounded in Kaupapa Māori methodology,41 was part of a larger initiative to improve diabetes education in Māori communities. The core ethical principles guiding the study are shown in Fig. 1. Ethical approval for the study was obtained from the University of Waikato Health and Human Research Ethics Committee (Health) 2024#14.

Fig. 1.

Adherence to Te Ara Tika ethical principles.


HC25066_F1.gif

Participant recruitment

Research participant information forms were distributed to medical centres and healthcare practitioners in a semi-rural small community in the Waikato along with a promotional flyer. Second, the diabetes clinical nurse specialist in the working group recruited clinicians from her organisation through word-of -mouth. Third, a snowballing strategy was utilised,42 whereby participants were invited to inform others who might like to participate. Potential participants received information sheets outlining the study’s purpose, and any queries and concerns were addressed before informed consent was obtained. Individual interviews were conducted face-to-face (kanohi ki te kanohi) or via Zoom (Zoom Video Communications, Inc.), at the participants’ convenience, by a Māori interviewer (RC). A multidisciplinary research team, including Māori (RC, AL, HN, RK, TR, RP) and Pacific (AA) clinicians and researchers, ensured the data collection, analysis and presentation were both medically accurate and culturally safe.

Nine semi-structured interviews were conducted between August and October 2024 with clinicians from various disciplines (general practitioner, podiatrist, exercise physiologist, three kaiāwhina (support workers), dietitian, two pharmacists); five identified as Māori and four identified as non-Māori.

Data collection

Semi-structured interviews, guided by open-ended questions, guided the exploration of clinician experiences in primary health care and community diabetes education, communication and care. Interviews were audio-recorded and lasted 15–60 min. This method proved effective, compared to surveys or questionnaires, as it allowed our team to engage in a flexible, guided dialogue with participants.43 Through a dynamic interview protocol supplemented with probing questions, we could gather rich, open-ended data, delving deep into personal and potentially sensitive topics, uncovering participants’ true thoughts, feelings and beliefs.43 Further, it allowed for relationship development and engagement through a face-to-face (kanohi ki te kanohi) approach, as is commonly utilised in Kaupapa Māori research.41 Participants were offered a $30 petrol voucher as a koha (token of reciprocity and appreciation), although many declined and suggested it be used for patient support.

Data analysis

Interviews were transcribed using Kaituhi software (developed by Te Hiku Media), chosen for its non-AI platform to uphold Māori data sovereignty44 and manually checked for accuracy. Two Māori researchers (RC, AL) conducted inductive Kaupapa Māori thematic analysis, involving iterative readings and coding of transcripts to identify significant themes. Collaboration between RC and AL ensured alignment with Māori aspirations and a strength-based (whakamana) approach, avoiding deficit perspectives.45 Thematic findings were presented to the Clinical and Academic Advisory Group (CAAG) for validation of medical and cultural accuracy.

Results

This study’s findings highlight the importance of empowering, patient-centred communication; whānau involvement, interprofessional collaboration; and the use of relevant analogies in diabetes education and management for culturally safe and clinically perceived effective care.

Empowering, patient-centred communication

A key theme that emerged from the study was the importance of using empowering language to foster positive clinician–patient relationships and improve health outcomes. Clinicians particularly emphasised the significance of using language that empowers and motivates patients, rather than language that shames or blames. For example, a kaiāwhina commented: ‘You want people to feel empowered, and so imagine if there was some form of a resource or something of the sort where people would feel like they can, they’ve learnt enough to be able to self-advocate or know where to look’.

Several clinicians highlighted the importance of focusing on positive aspects of patient behaviour and setting achievable goals. A pharmacist seemed to be exemplifying this, stating, ‘I always look for the positive, from my interactions with whānau and sometimes that’s just that they’ve turned up.’ However, although perceived as positive by the clinician, we note that this statement risks perpetuating a deficit-based perspective, as patients often face systemic barriers to appointment attendance, such as childcare, finances, travel, work and whānau commitments, leading to labels such as ‘Did Not Attend’ (‘DNA’) or ‘non-compliant’, which can lead to pervasive labels and biases that remain on a patient's records. This example perhaps demonstrates the divergent potential of some positive responses.

An intentional strategy used by clinicians was the normalisation of diabetes conversations, aimed at reducing stigma and encouraging open communication. As articulated by a dietitian, ‘It’s normalising this conversation rather than hiding it from the other generation’. With the aspiration for these dialogues to be naturally integrated into whānau and community life, clinical normalisation plays a critical role in mitigating stigma and fostering dialogue.

To facilitate effective information exchange, clinicians focused on adapting their language to the patient’s understanding, avoiding complex medical jargon. As one pharmacist noted, ‘I’m trying to get the information over to them without them feeling confronted or scared by it’. Although mitigating anxiety is a key consideration, it is crucial to balance this with avoiding assumptions about patient knowledge and comfort. Strength-based, non-deficit language is essential to whakamana (empower) the patient and create a supportive learning environment.

Whānau involvement

The involvement of whānau was consistently identified by clinicians as crucial to diabetes care, acknowledging the vital role of whānau in providing support and encouragement, and at times with younger whānau, prevention. As one pharmacist stated, ‘You do get the best outcomes when the whole whānau is involved. I wish we could do more with multi-generational whānau.’ This acknowledges the prevalence of multi-generational diabetes and the importance of whānau caregivers. A GP reported, ‘I’ve had situations where the dad needs to come back with his daughter as his daughter’s actually the one that keeps an eye on him or a kuia has to come back with her son cos he’s the one that checks in on her all the time.’

The inherent collectivism of Māori culture, as expressed through iwi, hapū and whānau structures, provides a robust framework for community-based diabetes care. Marae, in particular, offer strategic sites for health promotion and education. As the podiatrist observed, ‘Iwi and community, and like where the people are and they’ve already got the groups gathered. There’s already trust there. And so if the diabetes [knowledge, care, treatment] can go to them, man, you’re gonna reach so many more people and that message is gonna go so much further’. Such community-based support is exemplified by the Kaupapa Māori-based community centre with whom the authors collaborated for this project. The community centre utilises its established community trust to deliver impactful health programs and initiatives, notably for T2D, to many whānau, located next to a prominent local marae.

Interprofessional collaboration

Interprofessional collaboration was identified as essential for optimal diabetes care, with clinicians stressing the importance of communication and co-ordination for addressing complex patient needs and the need for a holistic approach that integrates physical and social determinants of health. A GP highlighted the limitations of a solely clinical biomedical approach: ‘You don’t always know that at the beginning sometimes they don’t really just tell you, ‘Oh, by the way, I’m not looking after myself very well and I live by myself and my cupboards are empty’, but you have to sometimes figure those things out, just I don’t know just by intuition, almost cos if you ask and they’ll say everything’s alright. In that situation I’m lucky enough to have a chronic care nurse that I ask to go visit them’.

One pharmacist described in-home visits: ‘So that’s why I moved to the role where I work alongside a kaimanaaki (support person) in whānau’s homes because often it’s not until you address the social issues that whānau have enough capacity to then address their health issues’. The pharmacist further discussed that complex social factors, including family dynamics, food insecurity and financial and/or transportation challenges, were frequently overlooked within time-limited standard primary care consultations, representing a missed opportunity for further interprofessional collaboration.

Furthermore, interprofessional collaboration provides opportunities for knowledge sharing and skill development among healthcare professionals. As one kaiāwhina noted, ‘We have a mobile pharmacist and it’s absolutely bonus. So when it doesn’t sit in our specialised skills, even though our nurse is feeling confident enough, but she would still bring in the pharmacist.’

Culturally relevant analogies

Clinicians in this study reported utlising analogies to simplify complex medical concepts and improve patient understanding. By drawing comparisons between medical conditions and everyday experiences contained in a patient's cognitive schemata, healthcare providers were able to communicate effectively with patients from diverse backgrounds through cognitive assimilation and accommodation. For example, a GP described: ‘If you imagine a club and there’s a big crowd at the club for an event: if the crowd gets too big, it starts to wreck the building they smash the windows, stain the carpets, block the toilets, you know, and so you’ve got crowd control there, you’ve got bouncers that keep the crowd under control’. The GP considers that this analogy – where blood sugar is the crowd, and crowd control is insulin – helps patients understand the concept of blood sugar regulation and the importance of lifestyle modifications. It can also be adapted to culturally and spiritually relevant places (whilst ensuring sensitivity), such as the local community centre, churches, marae or other places dependent on the person's cultural and social preferences.

Participating pharmacists also utilised analogies to explain complex medication information. One pharmacist explained, ‘I talk about metformin and explain it is kind of like CRC [industries lubricant]. It helps insulin work better and unlock the gates to let the glucose into the cells.’ Another pharmacist uses the analogy of a car, stating, ‘I have a little slide show with pictures and just bringing it right down to analogies between everyday things out there because it’s something that you can actually understand, yeah … we need glucose for energy for our body, just like the car needs petrol to go, and you can see the fact that, yeah, analogy is a really good way’.

Discussion

This study explored strategies and approaches utilised by healthcare professionals to provide culturally safe and effective diabetes education for Māori patients within a semi-rural Waikato town. Although the term ‘clinicians’ is used throughout this paper, we acknowledge the diverse range of experiences and expertise represented within this cohort. The participants, comprising five Māori and four non-Māori clinicians, had varying levels of experience, from those new to their roles to seasoned practitioners, with a median experience of 7 years (range: 1–25 years). Their professional roles also varied, encompassing solely clinical practice, dedicated home or community-based work, and integrated home-based interventions. Further, although clinicians reported positive experiences and perceived success with the strategies reported in this study, we did not collect direct data from patients to substantiate the perspectives of these clinicians. However, the strategies highlighted by the participating clinicians are well-supported by existing literature as effective approaches for improving diabetes management and clinical interactions, particularly in indigenous populations.4657

Clinicians’ experiences in this study align with established best practices and provide a valuable starting point for further investigation. Exploring these findings from a Māori worldview and drawing upon the understanding of Poutama, a traditional Māori representation of incremental growth and ascension, Fig. 2 symbolises the journey of achieving optimal diabetes care for Māori. Specifically, a multi-faceted approach is needed that encompasses four key elements:

  • Empowering language that leads to improved patient understanding

  • Whānau involvement that leads to increased support and adherence

  • Interprofessional collaboration that leads to improved co-ordination of care

  • Culturally appropriate analogies that lead to better patient comprehension and engagement.

Fig. 2.

Ascending the Poutama: steps towards optimal diabetes clinical interactions and care (artwork designed by Associate Professor Anna Tiatia Fa’atoese Latu).


HC25066_F2.gif

Empowering language that leads to improved patient understanding

Clinicians emphasised the significance of utilising empowering language that develops positive therapeutic relationships and enhances patient autonomy. This aligns with previous research demonstrating the effectiveness of patient-centred approaches in improving health outcomes.58 This is further evidenced by a study in NZ involving patient-centred care, using empowering language, which studied patients with T1D and T2D, with significant reductions in HbA1c sustained over a 2-year period after discharge from the service.58 By focusing on patient strengths, setting achievable goals and normalising conversations about diabetes, clinicians can create a supportive and non-judgemental environment that encourages open communication and reduces stigma. This approach is further supported by a 2018 study by Romana, who found that an empowerment-based intervention for patients with suboptimal T2D resulted in improved quality of life and reduced diabetes distress compared to a control group.59

Whānau involvement that leads to increased support and adherence

The study underscored the pivotal role of whānau and community in supporting individuals with diabetes. Clinicians emphasised the importance of involving whānau in the care process, recognising their crucial role in providing emotional, social and practical support. This finding is consistent with prior research demonstrating the effectiveness of community-based approaches and whānau-centred care in improving diabetes outcomes within Māori communities.3,26,5052,60 These approaches recognise the importance of addressing the social determinants of health and leveraging the strengths of community networks, such as marae, community centres and Kaupapa Māori healthcare organisations, to improve health outcomes.

Interprofessional collaboration that leads to improved co-ordination of care

The findings highlighted the importance of interprofessional collaboration in providing comprehensive diabetes care. Effective communication and co-ordination between clinicians from various disciplines, such as GPs, nurses, dietitians, pharmacists, kaiāwhina and kaimanaaki were identified as vital for achieving optimal patient outcomes. This aligns with previous research demonstrating the benefits of multidisciplinary care in improving glycaemic control and overall health outcomes in people with diabetes.6167 Furthermore, this study underscored the clinicians’ perspectives of the valuable role of kaiāwhina and other community health workers (kaimanaaki) in addressing the social and psychological needs of patients, accompanying the clinical care provided by healthcare professionals.

Culturally appropriate analogies that lead to better patient comprehension and engagement

Our findings indicate that culturally appropriate communication strategies, including the relatable analogies, are helpful for enhancing patient understanding and engagement. The use of analogies has been shown in a 2022 study by Sekhar to improve patient understanding of complex medical concepts, enhance engagement and improve self-management.68 This included significant improvements in glycaemic control among patients with suboptimal diabetes management, sustained at 6 months post education, highlighting the potential of this approach to improve health outcomes.68

Limitations

This study has several limitations. First, with the study being conducted solely in one specific area (semi-rural Waikato), these findings have the potential to be unique to this community. Because cultural nuances, systemic factors and lifestyles may vary throughout areas in NZ (eg remote rural vs urban), further research with more diverse samples may be useful to investigate the transferability of these findings to other communities. Study findings combined both Māori and non-Māori clinical perspectives and were not reported separately. Given the established impact of cultural concordance on therapeutic relationships and health outcomes,69 separate reporting may have offered greater insights. Although this research has explored clinical viewpoints, there is a definitive need for further investigation into patient-reported effectiveness of these methods. This is because of the potential for patients and clinicians to hold differing perceptions of what constitutes truly culturally responsive care, making the patient perspective an essential component of future inquiry.

Although this study provides valuable insights into the importance of cultural factors in T2D care and clinical interactions, it is crucial to acknowledge the systemic barriers that contribute to health inequities for Māori. These include limited access to quality health care, food insecurity, social and economic disparities, and systemic racism. Addressing these broader systemic issues requires a multi-pronged approach that involves policy changes, system-level interventions and a long-term commitment to equity and justice at all levels of the healthcare system.

Implications for practice and future research

The findings of this study provide insights into culturally responsive care that warrant empirical validation and refinement through future research. We recommend investigating the ‘Ascending the Poutama’ framework’s integration into clinical care settings, particularly through its application in medical education and specialist training and professional development for diabetes clinicians and kaiāwhina. Evaluating the framework’s impact on clinical practice and patient outcomes will be essential for establishing its utility and strengthening its theoretical foundations.

Conclusion

Our findings underscore the essential and strategic implementation of a holistic, whānau-centred approach to diabetes care for Māori. Clinicians report that empowering communication, whānau participation, interprofessional teamwork and the use of appropriate analogies can positively influence patient outcomes. Yet, achieving sustainable improvements in Māori diabetes health requires systemic change that transcends the clinical setting. Just as the Poutama illustrates a journey of incremental learning, clinicians can embark on a series of achievable steps to cultivate cultural competency. Each step, building upon the previous, leads to a higher level of cultural safety and, ultimately, improved diabetes outcomes for Māori.

Data availability

Raw data can be made available upon request from the corresponding author.

Conflicts of interest

The authors declare no conflicts of interest.

Declaration of funding

This research was funded by the Health Research Council of New Zealand, HRC#23/711.

Acknowledgements

The authors would like to acknowledge Dr Felicity Williamson, who was pivotal in providing project management mentorship. She has provided encouragement and expertise for the planning of this project and community engagement. The authors would also like to acknowledge all study participants who shared their experiences, insights and expertise.

References

Diabetes NZ. Type 2 Diabetes - Outcomes Model; 2018. Available at https://www.diabetes.org.nz/news-and-update/2018/9/10/ay3nimo8r9poxb2s03rcxq5vmfz0vv

Chepulis L, Morison B, Keenan R, et al. The epidemiology of diabetes in the Waikato region: an analysis of primary care data. J Prim Health Care 2021; 13(1): 44-54.
| Crossref | Google Scholar | PubMed |

Romana J, Law M, Murphy R, et al. Illness perceptions and diabetes self-care behaviours in Māori and New Zealand Europeans with type 2 diabetes mellitus: a cross-sectional study. N Z Med J 2022; 135(1561): 31-44.
| Crossref | Google Scholar | PubMed |

Jansen P, Bacal K, Buetow S. A comparison of Māori and non-Māori experiences of general practice. N Z Med J 2011; 124(1330): 24-29.
| Google Scholar |

Simmons D, Voyle JA. Reaching hard-to-reach, high-risk populations: piloting a health promotion and diabetes disease prevention programme on an urban marae in New Zealand. Health Promot Int 2003; 18(1): 41-50.
| Crossref | Google Scholar | PubMed |

Simmons D, Weblemoe T, Voyle J, et al. Personal barriers to diabetes care: lessons from a multi‐ethnic community in New Zealand. Diabet Med 1998; 15(11): 958-64.
| Crossref | Google Scholar | PubMed |

Chepulis L, Morison B, Cassim S, et al. Barriers to diabetes self-management in a subset of New Zealand adults with type 2 diabetes and poor glycaemic control. J Diabetes Res 2021; 2021: 5531146.
| Crossref | Google Scholar | PubMed |

Ryan T. Comparing health outcomes of rural and urban diabetes patients: an audit of a Maori health provider. Kaitiaki Nurs Res 2021; 12(1): 60-2.
| Google Scholar |

Crosswell R, Norman K, Cassim S, et al. Are patients with type 2 diabetes in the Waikato District provided with adequate education and support in primary care to self-manage their condition? A qualitative study. J Prim Health Care 2024; 16(1): 61-9.
| Crossref | Google Scholar | PubMed |

10  Flickinger TE, Saha S, Roter D, et al. Clinician empathy is associated with differences in patient–clinician communication behaviors and higher medication self-efficacy in HIV care. Patient Educ Couns 2016; 99(2): 220-6.
| Crossref | Google Scholar | PubMed |

11  Norman K, Mustafa ST, Cassim S, et al. General practitioner and nurse experiences of type 2 diabetes management and prescribing in primary care: a qualitative review following the introduction of funded SGLT2i/GLP1RA medications in Aotearoa New Zealand. Prim Health Care Res Dev 2024; 25: e34.
| Crossref | Google Scholar | PubMed |

12  Peimani M, Nasli-Esfahani E, Sadeghi R. Patients’ perceptions of patient–provider communication and diabetes care: a systematic review of quantitative and qualitative studies. Chronic Illn 2020; 16(1): 3-22.
| Crossref | Google Scholar | PubMed |

13  Matthews SM, Peden AR, Rowles GD. Patient–provider communication: understanding diabetes management among adult females. Patient Educ Couns 2009; 76(1): 31-7.
| Crossref | Google Scholar | PubMed |

14  Street RL, Jr. How clinician–patient communication contributes to health improvement: modeling pathways from talk to outcome. Patient Educ Couns 2013; 92(3): 286-91.
| Crossref | Google Scholar | PubMed |

15  Street RL, Jr, Makoul G, Arora NK, et al. How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient Educ Couns 2009; 74(3): 295-301.
| Crossref | Google Scholar | PubMed |

16  Piette JD, Schillinger D, Potter MB, et al. Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population. J Gen Intern Med 2003; 18: 624-33.
| Crossref | Google Scholar | PubMed |

17  White RO, Chakkalakal RJ, Presley CA, et al. Perceptions of provider communication among vulnerable patients with diabetes: influences of medical mistrust and health literacy. J Health Commun 2016; 21(suppl 2): 127-34.
| Crossref | Google Scholar | PubMed |

18  Hong Y-R, Jo A, Cardel M, et al. Patient-provider communication with teach-back, patient-centered diabetes care, and diabetes care education. Patient Educ Couns 2020; 103(12): 2443-50.
| Crossref | Google Scholar | PubMed |

19  Lamiani G, Furey A. Teaching nurses how to teach: an evaluation of a workshop on patient education. Patient Educ Couns 2009; 75(2): 270-3.
| Crossref | Google Scholar | PubMed |

20  Young SA, Azam LS, Meurer JR, et al. The influence of patient and provider communication on diabetes care delivery. J Ambul Care Manag 2016; 39(3): 272-8.
| Crossref | Google Scholar | PubMed |

21  Hojat M, Louis DZ, Markham FW, et al. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med 2011; 86(3): 359-64.
| Crossref | Google Scholar | PubMed |

22  Mazzuca SA, Weinberger M. How clinician communication patterns affect patients’ comprehension and satisfaction. Diabetes Educ 1986; 12(4): 370-3.
| Crossref | Google Scholar | PubMed |

23  Watts E, Patel H, Kostov A, et al. The role of compassionate care in medicine: toward improving patients’ quality of care and satisfaction. J Surg Res 2023; 289: 1-7.
| Crossref | Google Scholar | PubMed |

24  Peel E, Parry O, Douglas M, et al. Diagnosis of type 2 diabetes: a qualitative analysis of patients’ emotional reactions and views about information provision. Patient Educ Couns 2004; 53(3): 269-75.
| Crossref | Google Scholar | PubMed |

25  DeSouza R. Wellness for all: the possibilities of cultural safety and cultural competence in New Zealand. J Res Nurs 2008; 13(2): 125-35.
| Crossref | Google Scholar |

26  Reweti A. Understanding how whānau-centred initiatives can improve Māori health in Aotearoa New Zealand. Health Promot Int 2023; 38(4): daad070.
| Crossref | Google Scholar | PubMed |

27  Polster DS. Confronting barriers to improve healthcare literacy and cultural competency in disparate populations. Nursing 2018; 48(12): 28-33.
| Crossref | Google Scholar | PubMed |

28  Aporosa A. Supernatural curses in Pacific communities. Res Outreach [140] 2024; 36-9.
| Crossref | Google Scholar |

29  Curtis E, Jones R, Tipene-Leach D, et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health 2019; 18(1): 174.
| Crossref | Google Scholar | PubMed |

30  Minton C, Burrow M, Manning C, et al. Cultural safety and patient trust: the Hui Process to initiate the nurse-patient relationship. Contemp Nurse 2022; 58(2–3): 228-36.
| Crossref | Google Scholar | PubMed |

31  O’Hagan L, Eggleton K. How does cultural safety embed into our consultation models? A critical reflection. J Prim Health Care 2023; 15(1): 4-5.
| Crossref | Google Scholar | PubMed |

32  O’Neil JD. The cultural and political context of patient dissatisfaction in cross‐cultural clinical encounters: a Canadian Inuit Study. Med Anthropol Q 1989; 3(4): 325-44.
| Crossref | Google Scholar |

33  Durey A, McEvoy S, Swift-Otero V, et al. Improving healthcare for Aboriginal Australians through effective engagement between community and health services. BMC Health Serv Res 2016; 16: 224.
| Crossref | Google Scholar | PubMed |

34  Elliott CT, de Leeuw SN. Our Aboriginal relations: when family doctors and Aboriginal patients meet. Can Fam Physician 2009; 55(4): 443-4.
| Google Scholar | PubMed |

35  Liaw ST, Lau P, Pyett P, et al. Successful chronic disease care for Aboriginal Australians requires cultural competence. Aust N Z J Public Health 2011; 35(3): 238-48.
| Crossref | Google Scholar | PubMed |

36  Liddell JL. Barriers to healthcare access for a Native American tribe in the Gulf Coast region of the United States. Race, ethnicity, gender and other social characteristics as factors in health and health care disparities. Ed. JJ Kronenfeld. Emerald Publishing Limited; 2020. pp. 73–94.

37  Cumming J, Stillman S, Liang Y, et al. The determinants of GP visits in New Zealand. Aust N Z J Public Health 2010; 34(5): 451-7.
| Crossref | Google Scholar | PubMed |

38  Russell L, Smiler K, Stace H. Improving Māori health and reducing inequalities between Māori and non-Māori: has the primary health care strategy worked for Māori. New Zealand: Health Research Council of New Zealand and The Ministry of Health Wellington; 2013.

39  Lacey C, Huria T, Beckert L, et al. The Hui Process: a framework to enhance the doctor-patient relationship with Maori. N Z Med J 2011; 124(1347): 72-78.
| Google Scholar |

40  Pitama SG, Bennett ST, Waitoki W, et al. A proposed hauora Maori clinical guide for psychologists: using the hui process and Meihana model in clinical assessment and formulation. N Z J Psychol 2017; 46(3): 7-20.
| Google Scholar |

41  Tuhiwai Smith L. Decolonizing methodologies: research and indigenous peoples. Zed Books; 2012.

42  Naderifar M, Goli H, Ghaljaie F. Snowball sampling: a purposeful method of sampling in qualitative research. Strides Dev Med Educ 2017; 14(3): 1-6.
| Google Scholar |

43  DeJonckheere M, Vaughn LM. Semistructured interviewing in primary care research: a balance of relationship and rigour. Fam Med Community Health 2019; 7(2): e000057.
| Crossref | Google Scholar | PubMed |

44  Te Mana Raraunga. Maori Data Sovereignty Network. Our data, our sovereignty, our future; 2023. Available at https://www.temanararaunga.maori.nz/

45  Hyett SL, Gabel C, Marjerrison S, et al. Deficit-based indigenous health research and the stereotyping of Indigenous peoples. Can J Bioeth 2019; 2(2): 102-9.
| Crossref | Google Scholar |

46  Sulfikar ASA, Rachmawaty R, Kadar K. The effectiveness of digital storytelling on self-management of diabetes mellitus patients: a systematic review. Int J Nurs Health Serv 2021; 4(4): 440-6.
| Google Scholar |

47  Gucciardi E, Richardson A, Aresta S, et al. Storytelling to support disease self-management by adults with type 2 diabetes. Can J Diabetes 2019; 43(4): 271-7.e1.
| Crossref | Google Scholar | PubMed |

48  Prasad GV. How the creative use of analogies can shape medical practice. J Eval Clin Pract 2015; 21(3): 455-60.
| Crossref | Google Scholar | PubMed |

49  Reading Turchioe M, Grossman LV, Myers AC, et al. Visual analogies, not graphs, increase patients’ comprehension of changes in their health status. J Am Med Inform Assoc 2020; 27(5): 677-89.
| Crossref | Google Scholar | PubMed |

50  Harwood M, Tane T, Broome L, et al. Mana Tū: a whānau ora approach to type 2 diabetes. N Z Med J 2018; 131(1485): 76-83.
| Google Scholar | PubMed |

51  Hale L, Higgs C, Keen D, et al. It is “All About Relationships” in lifestyle programmes for adults living with Type two diabetes underpinned by a person/Whānau-centred care approach. Front Rehabil Sci 2022; 3: 829542.
| Crossref | Google Scholar | PubMed |

52  Tane T, Selak V, Hawkins K, et al. Māori and Pacific peoples’ experiences of a Māori-led diabetes programme. N Z Med J 2021; 134(1543): 79-89.
| Google Scholar | PubMed |

53  Rondhianto R, Siswoyo S, Fathoni A. Effectiveness of empowerment-based diabetes education on diabetes complication prevention: a systematic review. J Aisyah J Ilmu Kesehat 2022; 7(4): 1123-30.
| Crossref | Google Scholar |

54  Funnell MM, Anderson RM, Arnold MS, et al. Empowerment: an idea whose time has come in diabetes education. Diabetes Educ 1991; 17(1): 37-41.
| Crossref | Google Scholar | PubMed |

55  Dickinson JK, Guzman SJ, Maryniuk MD, et al. The use of language in diabetes care and education. Diabetes Educ 2017; 43(6): 551-64.
| Crossref | Google Scholar | PubMed |

56  Dickinson JK. The experience of diabetes-related language in diabetes care. Diabetes Spectr 2018; 31(1): 58-64.
| Crossref | Google Scholar | PubMed |

57  Nurchis MC, Sessa G, Pascucci D, et al. Interprofessional collaboration and diabetes management in primary care: a systematic review and meta-analysis of patient-reported outcomes. J Pers Med 2022; 12(4): 643.
| Crossref | Google Scholar | PubMed |

58  Titchener J. A patient-centred clinical approach to diabetes care assists long-term reduction in HbA1c. J Prim Health Care 2014; 6(3): 195-202.
| Google Scholar | PubMed |

59  Romana JSW. Illness perceptions and diabetes self-care in Māori and New Zealand Europeans. Doctoral Dissertation, University of Auckland, New Zealand; 2018.

60  Tipene-Leach DC, Coppell KJ, Abel S, et al. Ngāti and healthy: translating diabetes prevention evidence into community action. Ethn Health 2013; 18(4): 402-14.
| Crossref | Google Scholar | PubMed |

61  Shortus T, Hermiz O, Burns J, et al. Do multidisciplinary care plans result in better care for patients with type 2 diabetes? Aust Fam Physician 2007; 36: 85-9.
| Google Scholar | PubMed |

62  Ni Y, Liu S, Li J, et al. The effects of nurse‐led multidisciplinary team management on glycosylated hemoglobin, quality of life, hospitalization, and help‐seeking behavior of people with diabetes mellitus. J Diabetes Res 2019; 2019(1): 9325146.
| Crossref | Google Scholar | PubMed |

63  Bain SC, Cummings MH, McKay GA. Multidisciplinary approach to management and care of patients with type 2 diabetes mellitus. Diabetes 2019; 7: 73-81.
| Google Scholar |

64  Taïeb A, Gaëlle L, Roxane D, et al. Efficiency of a multidisciplinary team care approach through a short hospitalization of patients with poorly controlled diabetes mellitus: a 12 months prospective monocentric study. Pan Afr Med J 2022; 41(1): 192.
| Crossref | Google Scholar | PubMed |

65  Saint-Pierre C, Herskovic V, Sepúlveda M. Multidisciplinary collaboration in primary care: a systematic review. Fam Pract 2018; 35(2): 132-41.
| Crossref | Google Scholar | PubMed |

66  Phillips S, Culpepper J, Welch M, et al. A multidisciplinary diabetes clinic improves clinical and behavioral outcomes in a primary care setting. J Am Board Fam Med 2021; 34(3): 579-89.
| Crossref | Google Scholar | PubMed |

67  Leach B, Morgan P, Strand de Oliveira J, et al. Primary care multidisciplinary teams in practice: a qualitative study. BMC Fam Pract 2017; 18: 115.
| Crossref | Google Scholar | PubMed |

68  Sekhar RV. ‘Analogy-Based Comprehensive Diabetes Education’(ABCDE) improves glycemic control of diabetic patients in an underserved population: results of a retrospective chart analysis. Healthcare 2022; 10(3): 409.
| Crossref | Google Scholar | PubMed |

69  Moore C, Coates E, Watson AR, et al. “It’s important to work with people that look like me”: black patients’ preferences for patient-provider race concordance. J Racial Ethn Health Disparities 2023; 10(5): 2552-64.
| Crossref | Google Scholar | PubMed |