Creating an Indigenous Māori‐centred model of relational health: A literature review of Māori models of health

Abstract Aims and objectives Identify the key concepts, principles and values embedded within Indigenous Māori models of health and wellbeing; and determine how these could inform the development of a Māori‐centred relational model of care. Background Improving health equity for Māori, similar to other colonised Indigenous peoples globally, requires urgent attention. Improving the quality of health practitioners’ engagement with Indigenous Māori accessing health services is one area that could support improving Māori health equity. While the Fundamentals of Care framework offers a promising relational approach, it lacks consideration of culture, whānau or family, and spirituality, important for Indigenous health and wellbeing. Design and methods A qualitative literature review on Māori models of health and wellbeing yielded nine models to inform a Māori‐centred relational model of care. We followed the PRISMA guidelines for reporting literature reviews. Results Four overarching themes were identified that included dimensions of health and wellbeing; whanaungatanga (connectedness); whakawhanaungatanga (building relationships); and socio‐political health context (colonisation, urbanisation, racism, and marginalisation). Health and wellbeing for Māori is a holistic and relational concept. Building relationships that include whānau (extended family) is a cultural imperative. Conclusions This study highlights the importance and relevance of relational approaches to engaging Māori and their whānau accessing health services. It signals the necessary foundations for health practitioners to build trust‐based relationships with Māori. Key elements for a Māori‐centred model of relational care include whakawhanaungatanga (the process of building relationships) using tikanga (cultural protocols and processes) informed by cultural values of aroha (compassion and empathy), manaakitanga (kindness and hospitality), mauri (binding energy), wairua (importance of spiritual wellbeing). Relevance to clinical practice Culturally‐based models of health and wellbeing provide indicators of important cultural values, concepts and practices and processes. These can then inform the development of a Māori‐centred relational model of care to address inequity.


| INTRODUC TI ON
An issue plaguing Aotearoa New Zealand's (Aotearoa NZ) health system is the continued inability to achieve health equity for the Indigenous Māori population. Many would argue this constitutes not only a health crisis but also provides an ongoing source of shame for the New Zealand government (Waitangi Tribunal, 2019). This persistent inequity is like the poor health outcomes for Indigenous populations globally, especially in settler-colonial nations such as Australia, Canada, Aotearoa and the United States (Deeble et al., 2008;Gao et al., 2008;Zuckerman et al., 2004).
However, Te Tiriti o Waitangi (a treaty outlining the relationship between Māori and the British Crown that affirmed the rights of Māori -referred to as 'Te Tiriti') sets Aotearoa NZ apart from other colonised nations. Te Tiriti is Aotearoa NZ's founding document, signed by the British Crown representatives and many of the Māori chiefs on 6 February 1840. Te Tiriti paved the way for the establishment of the colonial state of New Zealand. Interpretation of the articles of Te Tiriti is a source of ongoing debate, particularly regarding the inconsistencies between the te reo Māori (Māori language) and English versions (referred to as the Treaty of Waitangi) (Mulholland & Tawhai, 2010;Wilson & Haretuku, 2015). While the intent and interpretation of the two versions of Te Tiriti differ, Article Three affirms Māori rights to equity (Wilson & Haretuku, 2015).

| Enduring inequities
Despite Māori surviving a challenging and adverse history, ongoing colonisation and its effects significantly impact contemporary Māori (Kingi et al., 2017). Health outcomes confirm the inequitable access many Māori have to the social determinants of health, health services, and safe quality health care (Ministry of Health, 2015). Walsh and Grey (2019) found avoidable mortality explained 53% of the seven-year life expectancy gap for Māori and is evidence of the lack of access for Māori to timely, safe, and quality health services. The World Health Organization (WHO) described the social determinants of health, including timely access to healthcare, quality education, optimal working conditions, the ability to engage in leisure activities, quality and safe housing and communities (World Health Organization, 2019). According to the WHO, inequities in access to the social determinants of health are not natural phenomena. Inequities in social determinants stem from ineffectual or inadequate political leadership, social policy, and economic structures that serve those with higher socioeconomic status at the expense of those groups of people with low socioeconomic status.
Māori have inequitable experiences in Aotearoa NZ's publicly funded healthcare system, including amenable health determinants such as racism. Research confirms Māori are more likely than other groups in Aotearoa NZ to encounter structural, cultural, and interpersonal forms of discrimination, marginalisation, and racism when accessing healthcare services (Cormack et al., 2018;Wepa & Wilson, 2019;Wilson & Barton, 2012). These negative experiences, such as being treated differently to others and deficit stereotypes and explanations informing health practitioners' interactions, impact trust and the decisions Māori make about future access to healthcare services (Cormack et al., 2018;Harris et al., 2012aHarris et al., , 2012bWilson & Barton, 2012). Compared to non-Māori, Māori receive poorer quality care when they access healthcare services (Rumball-Smith et al., 2013) and are more likely to encounter adverse events (Davis et al., 2006). Māori are also less likely to be referred to specialist services, less likely to be prescribed effective medication or surgical interventions, more likely to be discharged from hospital earlier, and more likely to die from amenable diseases These can then inform the development of a Māori-centred relational model of care to address inequity.

K E Y W O R D S
cultural competency, cultural safety, fundamental care, Indigenous, literature review, nursepatient relationship What does this paper contribute to the wider global community?
• Culturally relevant and meaningful approaches to health care service delivery are critical for improving equity in Indigenous and other ethnic groups.
• Relational approaches to engaging with Indigenous peoples and their families are cultural imperatives for accessing health services.
• Culturally-based health and wellbeing models provide important cultural values, concepts, practices and processes essential for improving health outcomes.
Māori experience more disease, metabolic disorders, mental illness, maternal health complications and substance abuse issues than other groups (Wilson & Neville, ).
A systematic review of Māori experiences of the public health system in Aotearoa NZ found institutional level barriers, mainly racism and discrimination (Graham & Masters-Awatere, 2020;Wilson & Barton, 2012). Further, the systematic review reported Māori encountered unhelpful healthcare practitioners with negative attitudes. Māori also encountered other barriers related to costs, transport, and organisation of daily lives to access healthcare services (Graham & Masters-Awatere, 2020). However, Graham and Masters-Awatere highlighted the value of whānau support in helping Māori to navigate the healthcare system and provide practical and emotional support. Nonetheless, research with Māori and their whānau found healthcare environments were generally unfriendly and culturally foreign (Wilson & Barton, 2012;Anderson & Spray, 2020). Māori whānau also reported not knowing the rules for engagement with healthcare providers (Wepa & Wilson, 2019). Māori and their whānau often encountered healthcare practitioners who were hostile and disrespectful in their attitudes and behaviours and ineffective in the care they provided. This left Māori whānau feeling marginalised (Wilson & Barton, 2012) and silenced (Wepa & Wilson, 2019) and impacting the quality of services they received.
Such interactions invariably led to Māori and whānau reporting substandard care and not having their healthcare needs met in part or fully. The outcomes of such encounters affected trust, the ability to navigate a complex health system and led to avoidance (Wepa & Wilson, 2019;Wilson & Barton, 2012). As Wepa and Wilson stated, "They survived by having hope, feeling lucky and taking control of their healthcare journey" (p.3).
The Waitangi Tribunal (2019) inquiry into primary healthcare services and outcomes for Māori (the 'WAI2575 report') found detrimental colonial structures functioned in Aotearoa New Zealand's healthcare system. The Waitangi Tribunal highlighted the government's continued inconsistencies in applying the principles of the Treaty, "partnership, active protection and equity" (p. 162), and failed to honour its obligations to provide equitable health outcomes for Māori (Waitangi Tribunal, 2019). The health care system in Aotearoa NZ, is informed primarily by an individualistic, problem-based, and biomedical approach (HQSC, 2019). Such a worldview contradicts a Māori holistic and relational-based worldview of health and wellbeing (Jansen et al., 2008;Willams et al., 2003;Wilson & Barton, 2012). Māori reported hospital-based health care experiences as stressful and alienating that engendered anxiety and discomfort for people and their whānau (extended family network) (Wepa & Wilson, 2019;Wilson & Barton, 2012). For the most part, Māori experience hospital settings not as healing environments but as a place where their cultural and spiritual beliefs and practices were dismissed or not considered. Instead, health services specifically catered to the needs of those belonging to the dominant New Zealand European culture (Wilson & Barton, 2012). The privileging of a western medical worldview and the culturally unsafe environment that creates also impacts the recruitment and retention of Māori health practitioners, evident in the inequity and under-representation of Māori in the health workforce (Sewell, 2017).

| Fundamentals of Care
The Fundamentals of Care Framework is being implemented by nurses in Aotearoa to optimise patient-centred care and the quality of nurses' interactions with patients (Aspinall et al., 2020). Several health organisations have implemented a unit-level quality measurement and improvement programme to be assured of the extent of delivery of fundamental care and make the contribution of nursing visible (Parr et al., 2018). The Fundamentals of Care framework was developed by the International Learning Collaborative (ILC) following the Francis Inquiry in England which demonstrated failures of delivery of seemingly basic care by nurses (Kitson et al., 2013).
Its purpose was to ensure the patient's voice was heard within the health system, to provide visibility of the contribution and importance of nursing care and align contextual factors to the nature of nursing care. Nursing care is in fact anything but basic (Kitson et al., 2014), and the framework articulates this complexity when providing patient focussed integrated care, within the context of the care setting. A notable omission in the current Fundamentals of Care framework is culture. Research indicates cultural understandings of people's health and wellbeing can significantly impact equitable access to healthcare for Māori (Wepa & Wilson, 2019;Wilson, 2008). Therefore, the Fundamentals of Care framework requires consideration of the person's cultural beliefs and practices when establishing the nurse-patient relationship and subsequent care provision (Aspinall et al., 2020).
The Fundamentals of Care framework provides a theoretical relational framework to underpin nurses' everyday practice, guiding them in delivering high quality, patient-centred care (Kitson, 2018).
Central to the Fundamentals of Care framework is forming a robust therapeutic relationship between the nurse and patient. The therapeutic relationship enables the nurse and patient to work together to meet the patient's physical, psychosocial, and relational needs while responding appropriately to specific healthcare environments' challenges (Kitson, 2018). According to Kitson (2018), establishing a strong therapeutic relationship with a patient signals a commitment to care and requires five elements: building trust, providing undivided attention to the patient, anticipating the patient's needs, knowing the patient well enough to be able to respond appropriately to their care needs, and being able to evaluate the quality of the relationship (Kitson, 2018). Change is required in the dominant healthcare system to honour Te Tiriti obligations and achieve equity. Such change requires inclusive healthcare services that embrace Māori ways of thinking and being. The key to improving health equity for Māori is addressing the under-representation of the Māori workforce and enabling Māori healthcare practitioners to provide culturally grounded care for Māori (Kingi et al., 2017;Theunissen, 2011). However, achieving the goal of sufficient Māori representation in the workforce will take significant time and commitment. In the meantime, Māori continues to be at risk of accessing sub-optimal and culturally inadequate healthcare, predominantly provided by a non-Indigenous workforce.
Fundamental to improving health equity and the quality of healthcare interactions with Māori is establishing respectful relationships with Māori and their whānau. For this paper, relational care refers to the deliberate nurturing of respectful and meaningful relationships with Māori and their whānau. Relational care is a person-and whānau-centred holistic healthcare practice that evolves through mindful reflection and deliberation (Forsyth, 2017;Pohatu, 2013;Wilson, 2008). A range of Māori models and frameworks exist in the health literature. These have been developed for use in particular contexts that may focus on relational aspects of care embedded within them. Literature reviews enable broader, more exploratory research aims (Grant & Booth, 2009). This allows mapping the key concepts that underpin a field of research, defining the conceptual boundaries of a topic, and clarifying key concepts and definitions thematically within the literature on a specific issue (Arksey & O'Malley, 2005). This literature review goes beyond a scoping review because it will inform clinical practice. The review followed the framework outlined by Arksey and O'Malley (2005) because it provided a systematic framework and process to review the literature. Therefore a literature review methodology was the most appropriate to examine the current literature (that may or may not include research findings) to identity, map, and define critical cultural concepts, values, and principles within Māori models of health. We followed PRISMA guidelines in undertaking this literature review (File S1).

| Identification of relevant studies
A research librarian supported developing the search strategy to identify relevant literature and search the following four databases: CINAHL Plus, PubMed, SCOPUS, and INDEX New Zealand. We also accessed grey literature using the nzreserch.org database. The following keywords and search terms used included: Māori AND ("model* of health" OR "health model*" OR "model* of care" OR "care model*" OR "framework* of health" OR "health framework*" OR "framework* of care" OR "care framework*"). Using the * symbol to identify either singular or plural forms of the search terms was incompatible with the INDEX New Zealand or nzresearch. org databases, therefore singular forms of the search terms were used as follows: Māori AND ("model of health" OR "health model" OR "model of care" OR "care model" OR "framework of health" OR "health framework" OR "framework of care" OR "care framework"), and then repeated using the plural forms of the search terms as follows: Māori AND ("models of health" OR "health models" OR "models of care" OR "care models" OR "frameworks of health" OR "health frameworks" OR "frameworks of care" OR "care frameworks").
The inclusion criteria for selecting studies included: • Literature needed to outline a unique Māori model or framework of health or care. More specifically, each piece of literature was required to refer to a model or framework that focussed on either Māori ways of conceptualising health or the relationship between Māori patients and healthcare practitioners.
• No timeframe was applied because seminal texts included models published in the 1990s. For instance, Mason Durie's Te Whare Tapa Whā model (Durie, 1998) and Rose Pere's Te Wheke model (Pere, 1991) are seminal texts widely utilised and cited in the Aotearoa NZ healthcare sector. Moreover, mātauranga Māori (ancient or traditional knowledge) passed down over generations forms the basis of Māori models of health and care frameworks.
Therefore, from an Indigenous perspective, models or frameworks published further in the past are not necessarily less relevant than those published more recently.
• Only papers written in English were eligible for inclusion.
• Both peer-reviewed and non-peer-reviewed papers were eligible for inclusion in this review to ensure the inclusion of all models and frameworks available.
Exclusion of literature included models or frameworks that focussed on specific areas of Māori health, such as those that looked at health promotion or system-level factors, because this literature review aimed to inform the development of a Māori-centred relational model of care. Arksey and O'Malley (2005) recommended using two reviewers to independently screen all citations against the inclusion and exclusion criteria to select the literature for inclusion in the review.

| Literature selection
First, the reviewer (EM) screened titles and abstracts of retrieved documents against the inclusion criteria. We then retrieved fulltext documents based on the abstracts that met the inclusion criteria. A second reviewer (DW) then reviewed each full-text paper and together both reviewers decided to include or exclude papers from the final review. This process of reviewers independently reviewing the articles and then coming together to reach a consensus occurred throughout the analytic process. The database search identified 412 records. The reference lists of included documents provided a further two records. After screening the title and abstracts and removing duplicates, we retrieved 14 full-text documents. Four of these documents were then excluded based on the inclusion criteria, leaving ten articles about Māori health and wellbeing models (see Figure 1).

| Charting the data
We extracted narrative data from each paper (by reviewer EM). This included: author/s, the date and source of publication; the context for the model (for example, everyday life, hospital or clinical settings); the target population for the use of the model (for example, all people, doctors, nurses, all healthcare practitioners); the discreet dimensions for each model or framework mapped according to the aims of the review.

| Collation, synthesising, and reporting of results
The relationships between the dimensions were collated, sorted and summarised into key themes that captured the underlying cultural and relational concepts and values (Arksey & O'Malley, 2005).
The data synthesis included taking the aggregated data mapped according to the literature review's purposes, which were then thematically sorted and labelled to enable a narrative description. Full-text arƟcles (reporƟng 9 Māori health models) reviewed

F I G U R E 1 Overview of literature selection
Full-text records excluded (n=4)

Reasons:
The themes reflected the relational aspects and dimensions necessary for a Māori model of relational care. During this process, the reviewers (EM and DW) conferred and agreed on the key themes to report narratively.

| RE SULTS
Ten articles describing nine different Māori health models met the criteria for inclusion from 14 articles. Each of these Māori health models provided cultural concepts and principles for use in healthcare practice. Five focussed on optimising the engagement of Māori with health services, while four focussed on Māori perspectives of health and wellbeing (see Table 1). While all models and frameworks varied in their presentation, similarities were also evident. Four overarching themes captured the core cultural concepts and values that would inform the development of a Māori-centred relational model of care (see Table 2). These themes were: (1) Dimensions of health and wellbeing; (2) Whanaungatanga (connectedness); (3) Whakawhanaugatanga (building relationships); and (4) Socio-political health context. Each of these themes is intertwined and underpinned by critical Māori values and concepts. These values and concepts play an integral role in the holistic and relational Māori ontology that influence health and wellbeing, connectedness, and building relationships.
All of these occur within a socio-political context for Māori health and wellbeing that feature colonisation, racism, and marginalisation (see Table 2). Table 3 provides a narrative overview of the findings.

| Dimensions of holistic health and wellbeing
The predominant dimensions of Māori holistic health and wellbeing found in the literature are wairua (spiritual), whānau (extended family network), hinengaro (the mind), and tinana (physical) (Barton & Wilson, 2008;Durie, 1998;Love, 2004;Mark & Lyons, 2010;Murray, 2010;Pere, 1991;Pitama et al., 2007;Stevenson, 2018). These dimensions of Māori health and wellbeing are interrelated and connected (see Figure 2). They are fundamental to a person's holistic wellbeing -a stark contrast from most predominant Western approaches to health that tend to view health in terms of physical wellbeing alone (Durie, 1998). Wairua, whānau, hinengaro and tinana are fundamentally interrelated, with the wellbeing of a person and their whānau reliant on all these dimensions being in balance.
Wairua, an often-overlooked dimension, appeared in six of the Māori health and wellbeing models (Barton & Wilson, 2008;Durie, 1998;Love, 2004;Mark & Lyons, 2010;Murray, 2010;Pere, 1991;Pitama et al., 2007). Wairua refers to a person's spirit or soul that exists before the birth of a person and beyond their death. A person's wairua acts as a guide, warning of impending danger through visions and dreams. Importantly, wairua can be either protected or damaged (Mark & Lyons, 2010 (Pitama et al., 2007). In these ways, healthcare practitioners can respectfully acknowledge and support the maintenance of a person's wairua and their whānau by joining them in karakia (Māori prayers) at meaningful times in their treatment journey, for instance.
Within the healthcare context, the Meihana model illustrates the collective roles and responsibilities Māori have in te ao Māori (the Māori world), particularly obligations individuals have to others within their whānau and the whānau as a whole entity (Pitama et al., 2007). This collective orientation highlights the imperative that healthcare practitioners include whānau as a person's support network, especially as whānau can also offer valuable social and medical history for a person. It is also important that healthcare practitioners assess whānau understanding of a patient's condition and provide appropriate education and support to whānau to ensure effective management of a whānau member's health.
Hinengaro featured in three Māori health and wellbeing models (Durie, 1998;Murray, 2010;Pere, 1991). Hinengaro refers to a person's mental dimension, which determines the expression of a person's feelings, sense of self, confidence, and self-esteem. Central to hinengaro is mauri -the spark or essence of life -a state of potential that can be negatively or positively influenced by the environment (Durie, 1998). Hinengaro is the hidden female element within all people (Love, 2004) and involves the source of intuitive intelligence and senses (Pere, 1991). Hinengaro houses our invisible, private thoughts and emotions, indicating the caution required when questioning Māori with an expectation they will reveal their inner personal thoughts and feelings (Durie, 1998). For Māori, the use of indirect questions and metaphors might be more appropriate to avoid breaching a person's sense of privacy (Love, 2004).

TA B L E
Tinana refers to a person's physical dimension (Durie, 1998;Love, 2004;Mark & Lyons, 2010;Pere, 1991;Pitama et al., 2007). Tinana is respected as the body intricately linked to whānau and whakapapa. In particular, the role of women nurturing tamariki (children) from the womb until they reach the age to care for themselves (Pere, 1991). The tinana offers shelter from the external environment providing support for a person's essence (Love, 2004). Thus, the tinana of a person is more than a mere shelter for a person's wairua and hinengaro; it is also the source of sustenance for the person's body and health, regarded as being sacred (tapu). The growth of a fern is used to symbolize interrelated dimensions of health and wellbeing.

Model Culturally-based analogy Relational focus Key core values and concepts
Health and wellbeing: The journey of the growth of a fern is used to symbolize the wellbeing journey of a person. Starting with the seeds that are planted and the consistent nourishment they need to grow, to the progression of the young shoots into a thriving fully grown fern. Each rau or leaf of the fern represents different dimensions of wellbeing that need to be nourished and grown to achieve overall health and wellbeing for Māori. Four-sided whare (house) to represents the four dimensions of health and wellbeing walls that need to be in balance.
Health and wellbeing: Te Whare Tapa reinforces the importance of all aspects of health and wellbeing being in balance. If one or more walls are not the same, it threatens the integrity of the house -that is the holistic health and wellbeing of the person and their whānau.

TA B L E 1 (Continued)
Each of the models reviewed contained a core set of values, depending on the model's focus, whether it is about health and wellbeing or engagement with health services (see Table 2).

| Whaunaungatanga (connectedness)
Māori health and wellbeing models are grounded in relationships and the notion of whanaungatanga or connectedness (see Figure 2).
The foundation for whanaungatanga is whakapapa, which is the process of tracing genealogical connections through the generations of a whānau to common ancestors. Whakapapa is exemplified by the whakatauakī included in the Te Wheke model, 'Hā ā koro mā, ā kui mā' (the breath of life from ancestors) (Pere, 1991). It affords Māori rights to whanaungatanga and the supports whānau can offer (Love, 2004;Mark & Lyons, 2010;Pere, 1991). Whakapapa provides continuity and unity between individuals, whānau, and hapū in the present, with their ancestors who have gone before them and nurturing future generations (Love, 2004;Pere, 1991). In these ways, the inextricable connection of the past, present, and future occur.
A living generation represents the eternal breath of life passed from one generation to another, traced through whakapapa. In this way, whakapapa is evident in how Māori whānau are dynamically connected and interact to strengthen the whole, receiving 'sustenance' in the process. Being able to contribute to this process is essential for individuals' health and wellbeing and their whānau. It is a source of identity, support, and comfort (Pere, 1991).
The dimension of whānau, as discussed previously in Dimensions of Holistic Health and Wellbeing, is closely entwined with and emerge out of whakapapa. Its inclusion here is because connections and connectedness are fundamental to Māori culture. Whānau is the primary mechanism for connectedness, whereby individuals are integral to the collective whānau. Individuals have an integral obligation and responsibility to the other members and the collective whānau. Therefore, the ability to remain connected to whānau is vital in maintaining Māori health and wellbeing.
Whakapapa also establishes connections not only to people but also to place. Whenua refers to both the placenta and the ancestral lands of a whānau, hapū and iwi. It is whakapapa that connects whānau to their placenta and the land (Mark & Lyons, 2010;Pitama et al., 2007). Te Whetu illustrates how whenua is a fundamental part of Māori identity, existence, and health. Whenua becomes evident when Māori connect who they are to specific maunga (mountain), awa (river), tūrangawaewae (place to stand -such as marae) as part of their whakapapa (Mark & Lyons, 2010;Pitama et al., 2007). The Meihana Model positions whenua as a specific spiritual or genealogical connection between people and land (Pitama et al., 2007).

| Whakawhanaungatanga (Building relationships)
Whanaungatanga (connections) is an overarching theme within the Māori models of health and wellbeing (see Figure 2). Whakawhanaungatanga, the process of establishing and maintaining relationships, is optimally undertaken as face to face interaction with a genuine, non-judgmental attitude to build trust.
Whakawhanaungatanga is paramount and is a priority as part of collaborative healthcare engagement and activities. Underpinned by whanaungatanga, it is interrelated with whānau and is an integral part of three health and wellbeing models (Barton & Wilson, 2008;Lacey et al., 2011;Pere, 1991). Whanaungatanga is a source of kinship, social roles, and bonds within and outside the whānau -connectedness is vital to building a trusting relationship (Love, 2004). These connections are crucial to the health and wellbeing of the individual and their whānau and engagement with health services and practitioners.
The Hui (to gather or meet) process reinforces the notion that whakawhanaungatanga for Māori is more in-depth than merely building rapport (Lacey et al., 2011). The process of whanaungatanga requires healthcare practitioners to acquire an understanding of te ao Māori from which to access knowledge about relevant cultural values, experiences, and beliefs held by Māori and their whānau.
Critically, whakawhanaungatanga not only requires the person and their whānau to share information about aspects of themselves, but it also requires that the healthcare practitioners disclose and share information.
Tikanga (Māori cultural principles, practices, and customs) govern whakawhanaungatanga, a relational process (Barton & Wilson, 2008;Pitama et al., 2007). More specifically, tikanga guides the process of engagement and a person's actions to ensure they are respectful of everyone's status and that power is shared equitably within that relational space (Barton & Wilson, 2008;Lacey et al., 2011;Pere, 1991;Pitama et al., 2007;Robinson et al., 2020;Stevenson, 2018). For instance, Te Kapunga Putohe provides a framework for healthcare practitioners to ensure cultural customs and practices are supported and encouraged within health services delivery. Offering appropriate cultural support and advocacy for Māori and their whānau is imperative (Barton & Wilson, 2008). Implementing the Meihana Model requires healthcare practitioners to become familiar with cultural practices for Māori and their whānau and to work with Māori about how to enact these alongside clinical investigations and practices (Pitama et al., 2007).
Two cultural values that inform how Māori interact with others are aroha (empathy and compassion) and manaakitanga (kindness, generosity, and support to look after others) (Barton & Wilson, 2008;Robinson et al., 2020). Te Kapunga Putohe explains how a compassionate and empathetic approach from healthcare practitioners nurtures the development of mutual trust and respect with Māori patients and whānau (Barton & Wilson, 2008). The Kapakapa Manawa framework urges 'he ngākau aroha' (a heart of love), which entails healthcare practitioners developing relationships that communicate care, compassion and empathy by being kind-hearted and considering others (Robinson et al., 2020). In addition to engaging with Māori and their whānau in an empathetic and compassionate way, manaakitanga involves demonstrating hospitality, kindness, caring, generosity, and respect. Te Hā o Whānau states that manaakitanga means meeting obligations in ways that uplift others' mana (status and esteem) (Stevenson, 2018). Te Kapunga Putohe stresses manaakitanga encompasses many things in te ao Māori that enhances the mana of everyone. Thus, healthcare practitioners must act in ways that demonstrate manaakitanga when interacting with Māori patients and whānau (Barton & Wilson, 2008).
Mana stems from manaakitanga and refers to the status, prestige, and authority of Māori, their whānau, and others involved (Barton & Wilson, 2008;Love, 2004;Pere, 1991). The power associated with mana should be thought of in terms of 'empowerment' instead of 'power over' (Love, 2004). Everybody is born with mana, and a person's unique mana is linked to their whanau's mana. Mana can be enhanced or diminished by how others act and the actions of individuals themselves or their whānau. Intact mana is crucial for a positive cultural identity (Love, 2004;Pere, 1991). Thus, mana impacts both individual and collective identity. Te Kapunga Putohe refers to 'mana tangata', a person's power from within, and relates to their power and authority around self-determining what is best for oneself (Barton & Wilson, 2008). It is also an acknowledgement that individual Māori do not exist in isolation but are part of a whānau collective. Necessary for mana is a person's mauri or energy that brings to life and binds them to all things in the physical world (Love, 2004;Pere, 1991). When the force or energy of Māori becomes weakened, a disconnection occurs between a person's tinana and wairua (Love, 2004). Thus, how healthcare practitioners undertake manaakitanga enhances the mana and mauri of all of those involved (Barton & Wilson, 2008;Robinson et al., 2020;Stevenson, 2018).
Some of the concepts, such as whanaungatanga, have core cultural values embedded within them. For instance, whanaungatanga encompasses whakapapa, whenua, and whānau, and is inclusive of values like tikanga, aroha, manaakitanga, and mana. Therefore, cultural engagement in a face to face manner aligns with a relational approach. It involves a formal process of mihimihi (greeting), whanaungatanga (everyone establishing their connections), aroha and manaakitanga (compassionately caring for and looking after visitors by ensuring they are fed, for instance), and mana (upholding people's status, authority, and esteem). Manaakitanga or how well people are looked after manifests in the host's mana. Whānau observes and discuss in the community the quality of care applied to the healthcare setting, the quality of engagement and relationships between Māori, their whānau, and healthcare practitioners.

| Socio-political health context
The Meihana model makes explicit that the cultural and sociopolitical health context can influence Māori health (Pitama et al., and their health outcomes: colonisation and migration, racism, and marginalisation (see Figure 2). Te Kapunga Putohe also highlights the need for healthcare practitioners to act as kaitiaki (guardians) as

TA B L E 3 Narrative overview of the results
Māori and their whānau enter the unfamiliar environments of health services and advocate for their needs (Barton & Wilson, 2008).
Consideration of the socio-political health context requires healthcare practitioners to: 1. Undertake an exploration of issues linked to colonisation impacting the health and wellbeing of Māori and their whānau.
These impacts include poverty, socioeconomic status, employment conditions, education opportunities, quality of housing, and the financial ability to engage with the health system.

Consider how political environments and events either alienate
or include Māori communities in developing and implementing health services and programmes to improve Māori health outcomes.
3. Become aware of and resist deficit stereotypes of Māori that contribute to bias in clinical decision-making when caring for Māori patients (Pitama et al., 2014).
Recognising people's socio-political health context also encourages healthcare practitioners to understand and explore Māori patients and their whānau experiences living in a racialised society. Understanding Māori and their whānau contexts include being acutely aware of the impacts of institutional, interpersonal, and internalised racism, and becoming knowledgeable about racism and its effects on the health and wellbeing of Māori and their whānau (Pitama et al., 2014). Marginalisation relates to access to determinants of health, access to health services and the quality of healthcare. Therefore, healthcare practitioners should possess current socio-political health context that includes knowledge about Māori health, including incidence and prevalence of illness and disease, morbidity, and mortality rates for Māori about specific illnesses or conditions to inform clinical assessment and practice decisions to reduce the marginalisation of Māori within the health system.

| DISCUSS ION
This review aimed to identify the key concepts, principles and values embedded within Indigenous Māori models of health and wellbeing; and determine how these could inform the development of a Māoricentred relational model of care. We included ten papers that de-   (Reis & Gable, 2003). Thus, healthcare providers need to be mindful not just of the importance of establishing relationships, which is the focus of the Fundamentals of Care framework, but of the tikanga (the process of enacting cultural protocols in the right way) when working with Māori within the health setting.
The Māori models of health and wellbeing demonstrate the importance of understanding the differences in worldview and cultural orientation. Health is a socio-cultural construct that begins its formation within the contexts of a person's whānau, and overtime is shaped and refined (Wilson, 2008 The Pā Harakeke (a grouping of native flax plants) is used as a metaphor to exemplify the multigenerational and functional importance of the connectedness of whānau for the collective wellbeing of the whānau and its members (see Figure 3), highlighted in the following whakataukī (proverb): Hutia te rito o te harakeke, kei hea to komako e ko?
Ki te uia mai koe, he aha te mea nui o te ao?
If you pull out the centre shoot of the flax plant, where will the bellbird sing?
If you ask me, what is the most important thing in the world?
I will tell you, it is people, it is people, it is people.
The rito (centre) shoot represents the tamariki (children) and is surrounded by the awhi rito, representing the parents, and the outer leaves that represent the tupuna (grandparents). The harakeke roots (whānau) provide the foundation and enable it to grow and connect to the surrounding harakeke for support. It is the collective strength of the whānau that ensures its members are cared for and protected. As the whakataukī above indicates, plucking the centre shoot threatens the wellbeing and integrity of the whānau. The Pā Harakeke highlights the importance of connectedness and whānau in the wellbeing of those seeking healthcare.  (Lambert et al., 2014).
For Māori, mātauranga Māori and tikanga provide essential signposts on the cultural imperatives when Māori engage with health services. Linked to adverse outcomes is the poor engagement of Māori and whānau seeking healthcare (Lacey et al., 2011;Wepa & Wilson, 2019). Healthcare practitioners knowledge of key mātauranga and tikanga associated with establishing relationships guides how to build better and meaningful relationships with Māori and their whānau to improve health outcomes and improve equity (Lyford & Cook, 2005;Pitama et al., 2007).
Active engagement with Māori and whānau is essential for establishing successful relationships and, importantly, improving Māori health equity. The processes of mihi (greeting) and whakawhanaungatanga are cultural imperatives for Māori, although the literature on Māori experiences of healthcare signal the need for healthcare practitioners to also be mindful about the manner with which they interact with Māori. Many Māori not trust health practitioners and health services because of their own or other whānau experiences.
Therefore, engaging with Māori and whānau with genuine, caring and non-judgmental attitudes is essential. Evidence supports Māori and whānau experiences of racism, discrimination and differences in the quality of care they receive (Cormack et al., 2018;Pitama et al., 2007;Rumball-Smith et al., 2013;Wepa & Wilson, 2019;Wilson & Barton, 2012). Crucially, consideration of the treatment of Māori within health service contexts must occur given the detrimental impacts on health and wellbeing and the perpetuation of health inequities that adverse treatment and experiences can have for Māori and their whānau.
It is not unusual for Māori and whānau to feel culturally unsafe (Wepa & Wilson, 2019;Wilson & Barton, 2012

| LI M ITATI O N S
This review did not include an appraisal for the quality of the papers included in this review (Grant & Booth, 2009) because instead, they were descriptions of Māori models of health rather than research reports. We only included English language papers, which we recognised may have lost the richness and depth in translating te reo Māori into English. There is the potential for bias even though we had two reviewers who independently undertook the analysis before engaging in consensus discussions to finalise the literature review's findings. To capture the essence of the cultural concepts that underpin a relational approach to care, we carried out an extensive cultural review process in writing this manuscript with Māori cultural advisors, fluent te reo Māori speakers, and experts in Māori health and healthcare service delivery to confirm the literature review findings.