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Manase Lua

Marina Elisara

Rachel Kapa-Vivian

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Illness and Statistics Stats for Pacific Pacific people experience mental disorders at a higher levels than the general population. Twenty-five percent of Pacific people had experienced a mental disorder in the past 12 months and 46.5% had experienced a disorder at some stage during their lifetime New Zealand-born Pacific people, 31.4% had a 12-month prevalence of any mental health disorder compared with 15% of Pacific people who migrated after the age of 18. Ministry of Health (2006)

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This presentation is about the demands and requirements of the Western Systems and how we as Occupational Therapists can help people access these systems. As Manase, Rachel and I all work with Pacific people our examples and observations are from this perspective.

This means that some of the concepts that will be highlighted, may be common across areas of health and for many other people.

Remember that culture is a human attempt to meet human need within the environment they exist.

Some of the concepts that are introduced or talked about in this presentation, you may find true for other people who are not of pacific origin.

The part about Western Systems is referring to the governing practices that help meet the needs of the people in countries identified as ‘Western’.

NZ is identified as a Western country. It seemed more appropriate to have Western Systems as not everybody who lives in a Western culture can actually agree or identify with it’s origins.

In the context of this presentation, ‘Western Systems’ refers to the systems that govern our country to help the people meet their needs and access their resources.

We will eventually lead into looking at what skills a person needs to be able to participate in a Western system.

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Western Systems

In order to understand where the term ‘the West’ comes from we need to consider ancient Rome. ‘The West’ was a way of identifying the values and beliefs of the Western Roman Empire as opposed to the Eastern Roman Empire.

The Western world, is a term referring to the countries of Western Europe(plus Greece, Cyprus)and the countries of the Americas, as well all countries of [1], Northern, and Central Europe, Australia and New Zealand.

The concept of the Western part of the earth has its roots in Greco-Roman civilization in the great Europe and the advent of Christianity. In the modern era, Western culture has been heavily influenced by the traditions of The Renaissance, The Protestant Reformation, The Enlightenment, and shaped by expansive colonialism in the 16th-17th Century. In the contemporary religious and respectively cultural meaning, the term Western world refers to the countries of Western Europe as well as countries of European colonial origin in the New World such as the United States of America, Brazil, Mexico, Canada, Australia and Haiti.

From a cultural and sociological approach the Western world is defined as including all cultures that are directly derived from Western European cultures, i.e. Western Europe, the Americas (North and South America), Australia and New Zealand. Together these countries constitute Western society.

Countries of the Western world are generally considered to share certain fundamental political ideologies, including those of liberal democracy, the rule of law, human rights and a high degree of gender equality (although there are notable exceptions, especially in foreign policy). Additionally countries with strong political and/or military ties to Western and Central Europe, NATO and/or the United States, such as Japan, Israel, and South Korea can be said to be Western in a political sense at least.

As such, this definition of the term "Western" is not necessarily tied to the geographic sense of the word.

Systems – noun - a society or the network of institutions that control it, usually regarded as an oppressive force. – Oxford Dictionary

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(Introducing concept of how culture shapes systems, practices, roles and routines using OT framework).

How, why and when people do things is a sensitive thing to talk about.

People can easily misinterpret differences in ways of doing things as being issues of superiority.

This presentation is not about trying to say that one is better than the other, but talking more about what happens when two different worlds come together.

I came across a definition of culture in my Post Grad studies – “Culture is a response to basic human need.”

•Not a problem to solve but a resource to draw on.

•Maslow’s hierarchy of needs like food, safety and security, love and belonging, esteem and identity and self-actualisation are all shaped by culture.

•Culture can inform our understanding of human behaviour; a resources for healing, self-help and positive emotions; a resource for clinical practice and a resource for Mental Health and wellness.

As Occupational Therapists, we are often at looking at how these systems are interacting with each other and whether components of each are functioning or not to achieve the goal.

We usually use this model for the individual – but what if we took a population approach – we would start to see that there are common ways groups of people engage in a task – most likely influenced by meeting the need of a goal and working with the resources within the environment.

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“Culture is a human attempt to meet human need within the environment they exist.”

We are going to have a chance to apply this model through discussing our observations from the video.

When watching this clip, if you could jot down some of your observations according to one of these 3 areas:

1 – Environment – what are the demands of the environment? What are the resources available/needed? How were they accessed?

2 – Occupation- What human need was being met? What were the skills required to be able to execute the task in this environment?

3 – Person – How was a person to acquire the skills and knowledge needed to meet human need within this environment? What kinds of systems or hierarchy enabled a person to do this task?

(Open and stagger different parts of the Chef on a Mission’ video.

Chapter 2 of media resource.

1. Beginning/kitchen/cooking an umu (4minutes)

2.climbing coconut tree

3.Fishing.

Discussion:

Observations according to this model. Discussion based.

Group to provide observations according to the model – Presenters to give feedback, more history, meaning and purpose around what the group identifies.

Presenter to give feedback on how a person would learn that skill or be able to perform that observation.

Point: To show that people are trained to perform in their world from a young age.

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3 main points:

•Culture are the norms of how, why, what and when we do things.

•Culture is largely influenced by humans trying to meet a need with the resources from their environment

•We are trained with the resources from our environment to meet human need

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Continuing with this concept: ‘We are trained with the resources from our environment to meet human need’

3 main points:

1. These two world on their own have found solutions for health, education, justice, order and government.

2. Both world’s carry different value systems – they require a different training, type of thinking for a person to operate in successfully

3. As health professionals, we are able to use our skills to help these two world’s engage successfully

For example, seeing this through the CMOP model

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How values of our world shape the skills we develop and practice

3 main values

The medium in which knowledge is passed down – Western – Literacy. Pacific – observation/auditory

Governance: The process of decision making and meeting ones needs. Western – Autonomous. Pacific – Collective.

Power/influence is gained by: Western – Knowledge. Pacific – people.

Illustrative point:

Health system.

Evidence: Pacific access to health care, suicide rates, mental health rates amongst pacific. How do Pacific people access health care?

Point: skills needed to access the healthcare may not be present

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Some Pacific Models of Health Fonofale–Karl Pulotu Endemann - (Samoan)- House as a symbol of holistic model. Fonua – Sione Tui’tahi (Tongan) – Model for health promotion Fa’afaletui – Carmel Peteru and Kiwi Tamasese (Samoan) - 3 views from mountain, coconut tree, and canoe. Ascertaining facts/knowledge in the houses of elders Tivaevae –Teremoana Maua-Hodges (Cook Islands) - quilting of diverse facts and perspectives Kakala–Konai Helu-Thaman (Tongan) -Cultural process of kumi/search, tui/plaiting, luva/giving ofa Tongan garland or kakala Popao Model & Approach – (Tongan) - Manu Fotu & Taitoko Tafa –­ cultural model using the canoe explaining elements of being and a process of recovery. Notes Models – Give a framework of a persons wellbeing by producing elements Approaches – Gives us a guide on how we will explore and plan to build those elements

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Some Pacific Tools and Assessments Matalafi Matrix – Suaalii-Sauni & Tuia-Thomsen (2009) A cultural formulation tool that was designed to compliment the DSMIV practitioners. Currently used in WDHB and other NGOs. Has been researched. Popao Model The Popao or outrigger canoe has been used as a metaphorical model for mental health service users’ and professionals’ shared understanding of the treatment process as a ‘journey’ towards recovery. Popao Collaborative Assessment Scale - 12 part Questionnaire (knowledge of treatment, sharing in decisions, family dynamics, spirituality, healthy lifestyle) Popao Approach – a detailed process that identifies the elements

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The Fonofale Model The Fonofale Model was developed by Karl Pulotu-Endemann. Named after his maternal grandmother. Pan-Pacific Model of health in the use of New Zealand context. The Fonofale Model was developed soon after the Overstayer/Dawn raids in the 1970s. Contracted by the Ministry of Health in 1994 with a project manager and the Deputy Director of the Ministry of Pacific Island Affairs to consult with Pacific communities throughout NZ Consulted with 19 regions and reported back to the Strategic Direction for Mental Health Services for PI with a collaboration of what PI believed were major determinants of health Notes Karl background in nursing and teaching. Manawatu Polytechnic. The model was refined over time from 1994 It is the primary model that is used for Pacific Service delivery. Has shaped the Utilisation/Policy/Treaty.

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Brief of elements The Floor or foundation of the Fale: Represents the family. The family can be a nuclear family as well as an extended family or constituted family that are bind by kinship.The history and geneology is in the foundation/floor/family which ties them to titles, lands, motu/island, sea and to the Gods of the Pacific as well as to other cultures. The Roof: (Culture) The roof represents cultural values and beliefs that is the shelter the family for life. Culture is dynamic and therefore constantly evolving and adapting. Important for those who are NZ born. Some Pacific families might lean towards traditional Pacific practices some may orientate themselves to Palagi. These can include beliefs in traditional methods of healing as well as western method. The Four posts Connect culture and family but are also continuous and interactive with each other. Spiritual-this dimension relates to the sense of well being which stems from a belief system that includes either Christianity or traditional spirituality relating to nature, spirits, language, beliefs, ancestors and history, or a combination of both Physical-this dimension relates to biological or physical wellbeing. It is the relationship of the body which comprises anatomy and physiology as well as physical or organic and inorganic substances such as food, water, air and medications that can have either positive or negative impacts on the physical wellbeing Mental-this dimension relates to the wellbeing or the health of the mind which involves thinking and emotions as well as the behaviors expressed. Other-this dimension relates to various variables that can directly or indirectly affect health such as, but not limited to, gender, sexuality/sexual orientation, age, socio-economic status The Fonofale is encapsulated in a cocoon or circle that contains dimensions that have direct or indirect influence on one another. Environment-this dimension addresses the relationships and uniqueness of Pacific people to their physical environment. The environment may be rural or an urban setting. Time-this dimension relates to the actual or specific time in history that impacts on Pacific people. Context-this dimension relates to the where/how/what and the meaning it has for that particular person or people. The context can be in relation to Pacific Island reared people or New Zealand reared people. Other contexts include country of residence, legal, politics and socioeconomics. Elements Brief of elements The Floor: or foundation is Family (nucleus or extended). Represents the connection to other elements. The Roof: (Culture) The roof represents cultural values and beliefs that is the shelter the family for life. The Four posts: Connect culture and family Spiritual-sense of well being which stems from a belief system either Christianity or traditional spirituality. Physical- biological or physical wellbeing. Mental-this dimension relates to the wellbeing or the health of the mind which involves thinking and emotions as well as the behaviours expressed. Other-this dimension relates to various variables that can directly or indirectly affect health such as, but not limited to, gender, sexuality/sexual orientation, age, socio-economic status. Environment: Physical environment. Rural or an urban setting. Time: this dimension relates to the actual or specific time in history that impacts on Pacific people. Context-: where/how/what and the meaning it has for that particular person or people.

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Wellbeing & Relational Self The Relational Self This interconnected relationship between the spiritual element, and the physical and mental dimensions is a reflection of what the Samoan people refer to as ‘Itu Lua’. A person’s self is seen as a total being comprising of spiritual, mental and physical elements which cannot be separated (Bush et al, 2005). Wellbeing This relational self is to communities and communal practices as an important source of meaning and life support. Source and support is denied for Pacific the process of healing is compromised Spirituality, Crisis & Recovery Humanistic perspective LeRoy & Spaniol (2002) Spirituality grounds a persons life and gives them a sense of meaning. Reinforces that spirituality involves relationships “Spirituality holds that all life is interconnected. There is a unity of body, mind and spirit, and, indeed, of everything living on this planet” (Spaniol, 2002). His argument is that mental illness can be traumatic event and that when trauma is present, spiritual disconnection or ‘crisis’ occurs. Notes Relational self This interconnection of wellbeing is a common belief in Maori and across Pacific cultures. E.g. Te Whare Tapa Wha Wellbeing (Pacific) Bush et al, 2005 Spirituality Some youth today have not a strong pacific concept of spirituality as of recent generations

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Stigma & Discrimination “There were church members who were seen as helpful, but the stigma of mental illness created a good topic to talk about, for those who were not helpful. Fuelled by misunderstanding, it was a chance for those who did not have family members with mental illness, to talk down about those who suffered from it, and their families. This often led the consumers to being excluded and isolated, not only by the immediate Pacific Island church community, but also by close friends and family” (Mental Health Commission Recovery Series, Malo, 2000). Treatment Process “psychiatric treatment processes that did not address the spiritual aspect were considered unlikely to be successful *for the consumer+” (Bush et al, 2005) Notes Stats for Pacific Te Rau Hinengaro: The New Zealand Mental Health Survey. Key Results. Wellington: Ministry of Health. Treatment Process Study where a study with a Samoan community was approached to talk about mental health services. Bush states that the spiritual and mental dimensions are so closely linked for Pacific people Stigma and Discrimination These Pacific leaders or Matua, are the very support that is put in place to nurture spirituality for their communities but are typically the ones who instigate stigma for people. The lack of support and stigma furthermore, advances feelings of spiritual disconnection and isolation for consumers. This is illustrated in the as the publication reports the exclusion participants felt from their church communities: Crisis & Recovery (Spaniol) -Spirituality/core beliefs or values/morals

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Summary Slide Summary Various models for Pacific. A well known and the longest published is the Fonofale Model Approaches and Tools (Matalafi matrix & Popao model/approach) have been developed from different Pacific groups and are recognized by Pacific services (NGO & DHB) Fonofale gives us elements of a Pacific person, who are all interconnected as a Relational self identity. Spirituality being a core important element. When elements are not nurtured or understood ill heath can develop and/or recovery is compromised

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Manase:

If only dealing and engaging with Pacific people was like this picture! Looks beautiful and tranquil on the surface but this is actually the only island out of the 170+ in the Kingdom of Tonga that the locals avoid and fear the most as it is believed to be cursed and difficult to get on and off it due to submerged reefs. It used to be where the worst criminals were taken to and where execution were done. It has a long and bloody history.

I tis often difficult to engage with Pacific people and particularly recent migrants from the islands. Pacific peoples come from high-power distance and collective cultures where there is high respect for people in positions of authority (real or perceived) such as officials, doctors and nurses. These beliefs and attitudes are often observed by the children.

• This may often influence the way they respond to questions and the way they behave.

• Downplaying their personal circumstances and needs is common.

• Sacrificing personal needs for the wider family/community – collective culture.

• Saying “yes” when they really mean “no” and vice versa.

• Trying not to be a nuisance or a burden to you.

• Outwardly they may seem calm and in no obvious pain or distress but could be a different story in reality. Masking their true feelings and often at their own expense especially to save face.

These are some of the things we cover in our Engaging Pasifika training to assist clinicians and workers engage better. I will now begin to outline some of the core concepts we use.

[TIME: 2 min]

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[OPTIONAL]

Within villages people are divided into different classes-Ali’i –historical geneology-they make the final decision on all matters pertaining to people.

Tulafale: Hold real authority and influence because they control the affairs of the village and provide and advisory role to the Ali’i-appt is for life-succession decided by senior members of village or district.

Faleupolu: provide food, fine mats, tapa and goods to the chief-also considered to be influencial

Tagata nu’u: the rest of the village: role is gasese (carry out chores) and general duties. Villages are further divided by age, gender-traditionally the wives of the Ai’ili and sisters of the Matai are the woman of highest authority. Each family has a Matai or a chief-each family bestows the title to one of its members-most deserving. Not a hierarchy but rather role within the village and the family.

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[OPTIONAL]

[OPTIONAL]

With Christianity, education and business development a middle class has emerged(Mafile’o, 2005). Social rules within the hierachy determines the amount of power and authority one has in government and land ownership-also determines where one places themselves in a meeting or traditional setting such as kava ceremony or funerals, etc. Kinship structure not just based on nuclear family but on extended kainga members. The fahu or oldest sister of the father has high status within a family hierachy.

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[OPTIONAL] Faka’apa’apa - respect

to do homage or obeisance

show deference, respect or courtesy

Tauhivaha’angatae - fulfilling the expectations of one’s position

and playing a useful role in the family, society and church one belongs to

Mamahi’ime’a - being passionate about one’s beliefs

to strive or fight for, to stand up for

Lototō – humility

Placing others before self

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Le va is the space where we conduct all of our human relationships, it is the space which provides conventions and norms of human behaviour.

Focus on le va tapuia. All human interactions are in this space, all formal, informal, casual, daily, any and all human relationships and interactions take place.

Va – Space

Tapuia - Sacred

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The development and nurturing of the relationship space, making sure your contribution to the relationship space is positive and accepted, one of building, growing and developing the relationships and entity. Taking responsibility for your roles, doing things better, finding new ways, constantly and consistently improving your contribution in this relationship

e.g. Faiga o feau

Sione:

Sei – worn in the hair or head which is sacred or tapu. Used in the Seitapu model to signify a “competent worker” (both clinically and culturally). Competent is not the right term but widely known and used to denote the skilled worker.

In Tonga, you cannot wear a sei where ever one pleases if you are a Tongan. You may only wear it in your mother’s village where she holds rank i.e. as a sister to her brothers in the village.

In Tonga, sisters always outrank brothers (‘eiki) and their children – Mehekitanga/Fahu…

However, there will be times where you will need support and assistance from others i.e. “5 C’s” model

[TIME: 1 min]

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Manase:

Makafetoli’aki – is a Tongan concept that denotes collaboration and reciprocity. Stones that are smooth were originally rough but over time, their interaction through the natural movement of water and natural process of rubbing and chipping at each other makes them smooth.

Engagement is a two-way and collaborative process. It will take time to establish a rapport and get to know your Pacific service user and their family, but the time invested will reap rewards. This is the essence of true collaboration and partnership where one is willing to be affected or changed by the interaction as much as you are affecting and changing the client and their family, for the better!

It may even involve some tension and pose some challenges along the way, but like all relationships, they need time to shape and smoothe things out.

In this process, change for both parties is inevitable.

[TIME: 1 min]

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Sione:

Tala = means to talk or have a conversation/dialogue

Noa = nothing

Talanoa = talk about nothing!

This is essentially “free” talk ,no agenda and open

Key Pacific concept/s & principle/s for engagement:

• “Fofola e fala kae talanoa e kainga” (Tongan) – this is laying out the metaphoric fala/mat for the service user (and their family) to join you the clinician/worker in a safe, respectful and reciprocal environment or setting. (Source: Talking Therapies Pacific Guide, Te Pou 2010)

Clinical application and resonance:

• Investing the time to establish a genuine and caring relationship with the person. Not being driven by the time constraints or process but willing to “talanoa”. Understanding that going from “A” to “B” is not always the best approach when dealing with Pasifika, sometimes you have to do the “round-about” approach. This is not easy, but can often mean the difference between a poor outcome and a great outcome.

[TIME: 2 mins]

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Sione:

Explain the Kali and the Kaliloa concept.

[TIME: 1 min]

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Manase:

Background:

• Built by the eleventh Tu’i Tonga Tu’itatui (supreme ruler of Tonga) around eleventh or tenth century, during the height of the Tongan empire in the Pacific.

• The Ha’amonga ‘a Maui (burden of Maui) stone Trilithon is located in Heketa near the village of Niutoua in Tongatapu.

• Each block weighs 30-40 tons on average.

• How they were quarried, shipped and erected without pulleys, cranes or modern machinery is still a scientific marvel. It was, and still is, a testament to the traditional cutting edge technology, knowledge and practice of that era.

• Connections to Stonehenge in England / Pyramids in Egypt / Mayan temples

• It was discovered by HM the late King Taufa’ahau IV of Tonga that the top lintel stone has a “V” shape carved into it which aligns with the position and pathway of the sun during the solar solstices and equinoxes. Hence the Sundial analogy used for this model.

[TIME: 2 mins]

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Uasila’a (sundial) model – another way of representing the importance of engagement at the critical first point of contact.

Clinical application:

• Earth/ground – represents your own sense of self or sense of place

• The sun represents the consumer and the sky their family

• The horizon separating earth and sky represented by the point on the lintel is the “Va” = space that relates

• The two grounded post rocks represent Western (clinical) knowledge and practice and cultural (traditional) knowledge and practice. Everything we do for Pacific must be grounded on a solid foundation of self-awareness, self-knowledge and a sense of strong identity.

• Top lintel rock represents the critical point of engagement with the “V” = Va marker. Your burden or Ha’amonga as a clinician is to ensure you can align your clinical and cultural knowledge to meet the needs of the service user and their family.

• If everything (all elements) are in balance and harmony, the V on the lintel should line up with the sun at a certain point of time. You have really only one chance for that initial point of contact to be made well or align. This creates the “Va”.

• This alignment represents “Va” or successful engagement – this takes time but will occur in its own natural time.

This model can also be used to describe the identity issues of Pacific people born and/or raised outside of Tonga. The key concept being a strong sense of self based on a sense of place and clear points of reference.

[TIME: 2 mins]

Monique: (Summarise)

Another way to see Manase’s “Uasila’a” model in action is this image above. This is the Uasila’a concept in practice as portrayed in this image of the competent worker (Pacific or non-Pacific) engaging effectively in the “Va” by contextualising the encounter from within a culturally and clinically safe place we call the “VA”.

• Effective engagement starts with your own self-awareness and sense of “who you are”. This will help you make informed and intuitive decisions based on your clinical and cultural knowledge.

• Human interactions are “felt” so it is often hard to measure or “tick” these indicators as outcomes, but they are powerful none-the-less and must be factored.

• “Fofola e fala kae talanoa e kainga” (Tongan) – this is laying out the metaphoric fala/mat for the service user (and their family) to join you the clinician/worker in a safe, respectful and reciprocal environment or setting. (Source: Talking Therapies Pacific Guide, Te Pou 2010)

• Investing the time to establish a genuine and caring relationship with the person. Not being driven by the time constraints or process but willing to “talanoa”. Understanding that going from “A” to “B” is not always the best approach when dealing with Pasifika, sometimes you have to do the “round-about” approach. This is not easy, but can often mean the difference between a poor outcome and a great outcome.

[TIME: 3 mins]

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Introducing Real Skills Plus Seitapu (RS+S):

•Ensuring an effective and responsive workforce that better serves Pacific service users and their families/aiga is important to Te Pou.

•The purpose for Le Va developing RS+S is to infuse Pasifika into Lets Get Real (LGR).

•Enhances the core benefits of LGR by providing a relational and attitudinal framework to better engage with Pacific service users and their families/aiga.

Some of the challenges considered and factored:

•The largest Pacific ethnic groups are (in order of size): Samoa, Cook Islands, Tonga, Niue, Fiji, Tokelau and Tuvalu. There are many more, each with their own distinct languages, cultures and traditions.

•Some of the values are universal and shared.

•Challenges for the future is the youthful and evolving Pacific population and their evolving needs.

Manase:

The concept of engagement from a Pasifika perspective is not just about getting on and appearing to connect with the service user and their family, but can often require you as a clinician to see things from their perspective and be prepared to challenge your own assumptions (actively use this approach in our training – 5C’s model: corporate, clinical, cultural, consumer and community).

Youth focus – Pacific young people born and/or raised in NZ need the knowledge of their own self / identity (William – role in team to provide this perspective)

Key Pacific concept/s & principle/s for engagement:

• Seeing things from multiple perspectives and having the empathy and good judgment to make the right calls.

Clinical application and resonance:

• Sometimes, it will be best for you to call on the support of others when engaging with Pasifika e.g. matua, elder, other clinician, just to provide other perspectives when engaging, otherwise, be open to other world-views and approaches. You can’t get it wrong if you have the best intentions for the service user and family at heart and genuinely care!

[TIME: 2 mins]

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Manase Lua

Marina Elisara

Rachel Kapa-Vivian

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