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. 2024 Mar 20;58(7):591–602. doi: 10.1177/00048674241238958

Experiences of physical healthcare services in Māori and non-Māori with mental health and substance use conditions

Ruth Cunningham 1,✉, Fiona Imlach 1, Tracy Haitana 2, Mau Te Rangimarie Clark 2, Susanna Every-Palmer 3, Helen Lockett 1,4, Debbie Peterson 1
PMCID: PMC11193320  PMID: 38506443

Abstract

Objectives:

Inequities in physical health outcomes exist for people with mental health and substance use conditions and for Indigenous populations (Māori in Aotearoa New Zealand). These inequities may be partly explained by poorer quality of physical healthcare services, including discrimination at systemic and individual levels. This study investigated the experiences of people with mental health and substance use conditions accessing physical healthcare and differences in service quality for non-Māori relative to Māori.

Methods:

A cross-sectional online survey of people with mental health and substance use conditions in New Zealand asked about four aspects of service quality in four healthcare settings: general practice, emergency department, hospital and pharmacy. The quality domains were: treated with respect; listened to; treated unfairly due to mental health and substance use conditions; mental health and substance use condition diagnoses distracting clinicians from physical healthcare (diagnostic and treatment overshadowing).

Results:

Across the four health services, pharmacy was rated highest for all quality measures and emergency department lowest. Participants rated general practice services highly for being treated with respect and listened to but reported relatively high levels of overshadowing in general practice, emergency department and hospital services. Experiences of unfair treatment were more common in emergency department and hospital than general practice and pharmacy. Compared to Māori, non-Māori reported higher levels of being treated with respect and listened to in most services and were more likely to report ‘never’ experiencing unfair treatment and overshadowing for all health services.

Conclusion:

Interventions to address discrimination and poor-quality health services to people with mental health and substance use conditions should be tailored to the physical healthcare setting. More needs to be done to address institutional racism in systems that privilege non-Māori.

Keywords: Mental and substance use disorders, physical health, patient experience, health services, discrimination

Introduction

Access to healthcare services and the quality of healthcare are important contributors to unequal physical health outcomes experienced by people with mental health and substance use conditions (MHSUC) (Firth et al., 2019; Institute of Medicine, 2006; World Health Organization, 2018). Interpersonal and systemic discrimination create barriers to accessing quality healthcare (Corrigan et al., 2014; Knaak et al., 2017) which may be compounded in Indigenous and minoritized ethnic groups who are also subjected to racism (Jones et al., 2016).

Healthcare quality and experiences of discrimination can be measured in many ways, but patient feedback is commonly used as part of quality improvement initiatives (Institute of Medicine, 2006). Patients who rate physical healthcare providers highly, on relational as well as technical aspects of care, are more likely to be engaged with their healthcare and have better clinical outcomes (Derksen et al., 2013; Doyle et al., 2013). For people with MHSUC, positive relational aspects of care, such as respect, empathy and being listened to, are particularly important (Cabassa et al., 2014; Sturman et al., 2020).

People with MHSUC often report lower satisfaction with physical healthcare (Kilbourne et al., 2006). While satisfaction has been measured in different healthcare settings including primary care (general practice [GP] and pharmacy; Cabassa et al., 2014; Kilbourne et al., 2006; Pitrou et al., 2020), emergency departments (EDs; Clarke et al., 2014; Corscadden et al., 2021; Navas et al., 2022), hospitals (Chen et al., 2019) and maternity care (Corscadden et al., 2020), studies comparing patient experiences across settings are lacking. These are needed to help target interventions at different settings.

Poorer experiences of physical healthcare can be due to stigma from health professionals towards people with MHSUC (Tyerman et al., 2021; Vistorte et al., 2018) which can lead to discriminatory practices, including diagnostic and treatment overshadowing (Van Nieuwenhuizen et al., 2013). Diagnostic overshadowing occurs when physical symptoms in a person with MHSUC are misattributed to their MHSUC, leading to the diagnosis of a physical condition being overlooked or delayed (Jones et al., 2008). Other factors contributing to diagnostic overshadowing include healthcare system issues such as time pressures, poorly integrated care and insufficient clinician knowledge about MHSUC (Molloy et al., 2023).

Treatment overshadowing refers to biases in treatment decisions that lead to people with MHSUC receiving suboptimal treatment. This can occur when clinicians do not offer appropriate treatment, delay treatment or offer an inferior treatment because of beliefs that a person with MHSUC will not comply, does not deserve treatment or will not benefit (therapeutic pessimism) or when clinicians do not recognize and address barriers to treatment (Jones et al., 2008; Knaak et al., 2017). We use the term ‘overshadowing’ in this paper to refer to both types of discrimination. Overshadowing may vary across healthcare setting, as different care pathways and clinical configurations affect ongoing patient relationships and siloed care.

The discriminatory factors that lead to worse physical outcomes in people with MHSUC are typically compounded by racism. This raises the expectation that Indigenous and other minoritized peoples with MHSUC would experience poorer quality of care and worse physical health outcomes due to the greatest lifelong exposure to cumulative risk relative to benchmark (Settler) populations (Anderson et al., 2016). However, research investigating the physical health of Indigenous and other minoritized peoples with MHSUC is surprisingly limited (Das-Munshi et al., 2016). There is some evidence that people with MHSUC from benchmark populations have lower rates of physical health problems, reflecting relative privilege compared to minoritized (e.g. African American, Hispanic, Black British) ethnic groups (Carliner et al., 2014; Das-Munshi et al., 2017a; Mangurian et al., 2017), although studies of mortality have found inconsistent results (Chang et al., 2010; Das-Munshi et al., 2017b; Olfson et al., 2015). None of these studies explored whether patterns of inequities were evident for Indigenous peoples relative to benchmark populations, despite this being an established international health research priority (Anderson et al., 2016; Reid et al., 2019).

Despite the diversity of Indigenous peoples globally, health inequities relative to benchmark populations are consistent, and a consequence of the ongoing impacts of colonization (Reid et al., 2019). In Australia, from a hospital-based cohort study, mortality in non-Indigenous people with a mental health condition was found to be much lower than mortality in the sample of Indigenous participants (Karim et al., 2019). In Aotearoa New Zealand (NZ), from a national cohort, mortality from natural causes among non-Indigenous people with a diagnosis of bipolar disorder was lower than the Indigenous Māori cohort (Cunningham et al., 2020). More research on the patterns of relative privilege and disadvantage between Indigenous and non-Indigenous peoples with MHSUC is needed in different contexts and for a range of diagnoses (Reid et al., 2019).

The overall aim of this study was to investigate the quality of physical healthcare for people with MHSUC, in terms of the relational quality of interactions with providers and experiences of discrimination. This paper focuses on experiences across different healthcare service types and for non-Māori and Māori participants. Our research questions were as follows:

  • Did people with MHSUC have different experiences of physical healthcare services across service settings, including primary care, ED, hospital and pharmacy?

  • Did non-Māori with MHSUC have different experiences of physical healthcare settings than Māori with MHSUC?

Methods

We undertook a national online cross-sectional Qualtrics survey of people with MHSUC in NZ who had used physical healthcare services. The questionnaire is available in the Supplemental Material. Ethics approval was granted by the Southern Health and Disability Ethics Committee (reference: 21/STH/216). Consent was assumed by participation in the online survey, as information about the survey, details about privacy and confidentiality and contact details for support or further information were provided in the survey introduction.

Content and development

Participants were asked if they had used healthcare services for physical health in the last 5 years for four service types: GP, ED, hospital and pharmacy. For those who had used each service, participants were asked to think about their interactions in the last 5 years and to assess how often the following happened:

  • I was treated with respect (measure of interpersonal relationship).

  • I was listened to (measure of interpersonal relationship).

  • I was treated unfairly due to my mental health or addiction issues (measure of discrimination).

  • My mental health or addiction issues distracted from my physical healthcare (measure of overshadowing).

Response options for each question were always, most of the time, sometimes, never or unsure.

The questions about interpersonal relationships and discrimination were adapted from current national patient experience surveys of primary care and hospital inpatients (Health Quality & Safety Commission New Zealand, 2020a, 2020b, 2021). A refresh and review of these surveys in 2019–2020, which included cognitive pre-testing, did not identify any issues with these questions, although they were not specifically tested on people with MHSUC (Health Quality Safety Commission New Zealand 2021). An existing validated question to assess overshadowing was not found so this question was developed in consultation with the study advisory group, which included clinicians and people with lived experience of MHSUC.

Demographic questions included age, gender, ethnicity, sexual orientation and whether participants lived in rural or urban locations. Participants were asked about MHSUC diagnoses, indicating which diagnoses they had been given from a list including depression, anxiety, schizophrenia, bipolar disorder, personality disorder and addiction, with an ‘other’ option for diagnoses not listed, from which the category of post-traumatic stress disorder (PTSD) was derived. Multiple responses were allowed. Bipolar affective disorder and schizophrenia were combined as a serious mental illness category because of small numbers. Some responses from the ‘other’ option (generalized anxiety, social phobia, agoraphobia, panic disorder) were included within ‘anxiety’. Other diagnoses were not reported separately because of small numbers. This may have led to an undercount of ‘number of MHSUC diagnoses’ for some respondents.

The number of providers seen for MHSUC was counted from a list of providers that included GP, psychiatrist, counsellor, psychologist, nurse, mental health support worker, social worker, peer worker, addiction practitioner, occupational therapist, other allied and complementary health services and ‘other’ services.

The survey questionnaire was reviewed by the advisory group and pre-tested by a person with lived experience of MHSUC (Māori, male).

Recruitment and eligibility

The survey was online from 31 January 2020 to 1 April 2022 and used convenience and purposive sampling methods to identify a range of potential participants. Information and invitations to participate were distributed through Facebook and Twitter by the research team, advisory group members, Equally Well (a group of organizations and individuals working to improve physical health outcomes for people with experience of MHSUC) (Te Pou, 2022), a university student association, in newsletters from large non-governmental organizations (Cancer Society and Heart Foundation) and email distribution lists from non-governmental addiction services, housing services and Māori health providers across NZ.

Participants were eligible if they were aged 18 or over and had used any healthcare service for both MHSUC and a physical health issue in the past 5 years. From 488 visitors to the online survey, 408 agreed to participate. People who only partially completed the survey and did not answer any questions about physical healthcare services were excluded, as was one duplicate response, giving a final dataset of 354 eligible individuals. For this study, participants who did not provide ethnicity data were excluded (n = 51), giving a final analysis sample of 303, of whom 58 identified as Māori. All 303 participants had used at least one of the four health services asked about in the quality questions. For analysis of experience of a particular health service, responses were limited to those who had used that service (GP: n = 295, ED: n = 160, hospital: n = 158, pharmacy: n = 294). The analysis dataset contained anonymous survey responses with no identifying information. The dataset was only accessible to study researchers and stored in secure folders protected by the university digital system.

Data analysis

Since survey responses were from a self-selected sample that was not necessarily representative of all people with MHSUC in NZ, only descriptive and unweighted statistics (sample proportions) were calculated, using Excel version 2205. Participants were not forced to answer any questions so there was variable missing data due to skipped questions or partially completed surveys. Missing responses were excluded from analyses, under the assumption that missing data were missing completely at random (i.e. we assumed that participants who did not provide answers were similar to participants who did). Chi-square tests were performed to test for differences by ethnicity for the sample description but not for comparisons by service type, because of relatively small numbers for some categories.

Responses for ‘always/most of the time’ were combined, to be consistent with similar questions in national patient experience surveys (Health Quality & Safety Commission New Zealand, 2020a, 2020b), which present response options of ‘yes, definitely’, ‘somewhat’ and ‘no’. The other responses presented from this survey were ‘sometimes’ and ‘never’, which were treated separately even though some categories had small numbers, because although neither are indicative of a high-quality healthcare service, the ‘never’ response indicates an extremely poor experience. Unsure responses were included as a separate category as these did not combine naturally into another category and provided distinct information about how the questions were understood.

Results

Sample description

Nearly, 20% of the survey sample were Māori (Table 1). This compares to an estimated 16.7% of Māori in the national population (Stats, 2020) and 28% of those in contact with secondary mental health and addiction services (Te Whatu Ora, 2023). Nearly, half (48%) of participants were aged 35 and under, and were predominantly female (75%), heterosexual (65%) and living in urban areas (77%). Māori and non-Māori participants were similar in terms of age, sexual orientation and rurality. Māori participants were less likely to be male (p = 0.001; small numbers in the gender diverse group precluded this from testing).

Table 1.

Survey sample characteristics.

Characteristic Māori
n (%)		 Non-Māori
n (%)		 Total
n (%)		 p-value
Age
 18–25 years old 11 (19.0) 45 (18.4) 56 (18.5) 0.898
 26–35 years old 18 (31.0) 72 (29.4) 90 (29.7)
 36–45 years old 14 (24.1) 50 (20.4) 64 (21.2)
 46–54 years old 9 (15.5) 42 (17.1) 51 (16.8)
 55+ years old 6 (10.3) 36 (14.7) 42 (13.9)
Gender
 Female 47 (81.0) 179 (73.1) 226 (74.6) 0.001 (comparing female/male)
 Male 7 (12.1) 51 (20.8) 58 (19.1)
 Gender diverse/prefer not to answer 4 (6.0) 15 (6.1) 19 (6.3)
Sexual orientation
 Heterosexual 33 (57.9) 161 (66.0) 194 (64.5) 0.251
 LGBQA+ 24 (42.1) 83 (34.0) 107 (35.5)
Rurality
 Rural 3 (5.3) 16 (6.7) 19 (6.4) 0.856
 Semi-rural 11 (19.0) 40 (16.7) 51 (17.1)
 Urban 44 (75.9) 184 (76.7) 228 (76.5)
Self-reported MHSUC diagnosis a
 Depression 45 (77.6) 193 (78.8) 238 (78.5) 0.843
 Anxiety 45 (77.6) 178 (72.7) 223 (73.6) 0.443
 Bipolar disorder or schizophrenia 14 (24.1) 44 (21.9) 58 (19.1) 0.282
 Post-traumatic stress disorder 19 (32.8) 35 (14.3) 54 (17.8) 0.001
 Substance use disorder 16 (27.6) 42 (17.4) 58 (19.1) 0.001
 Personality disorder 12 (20.7) 29 (11.8) 41 (13.5) 0.076
Number of MHSUC diagnoses
 One to three 42 (72.4) 198 (80.8) 240 (83.9) 0.090
 Four or more 13 (22.4) 33 (13.5) 46 (16.1)
Number of providers seen for MHSUC in last 12 months
 None to four 38 (65.5) 196 (80.0) 234 (77.2) 0.018
 Five or more 20 (34.5) 49 (20.0) 69 (22.8)
Services used for physical healthcare
 GP 56 (96.6) 239 (97.6) 295 (97.4) 0.670
 ED 33 (56.9) 127 (51.8) 160 (52.8) 0.337
 Hospital 33 (56.9) 125 (51.0) 158 (52.1) 0.435
 Pharmacy 56 (96.9) 238 (97.1) 294 (97.0) 0.380
Total n 58 (19.1) 245 (80.9) 303
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LGBQA+ = lesbian, gay, bisexual, queer, asexual and others; MHSUC = mental health and substance use conditions; GP = general practice; ED = emergency department.

a

Percentage is those who reported the diagnosis compared to the rest of the sample (who did not report this diagnosis; may include those who did not report any diagnosis).

Depression and anxiety were the most common diagnoses for all participants. Non-Māori had a lower proportion of substance use and PTSD diagnoses relative to Māori (p = 0.001). Although Māori and non-Māori participants had a similar pattern of healthcare providers seen for MHSUC in the last 12 months (Table 2), non-Māori were less likely to see five or more providers (p = 0.018; Table 1). Non-Māori participants were also less likely to have four or more diagnoses (14% vs 22%, p = 0.09). For physical healthcare, almost everyone used GP and pharmacy services and around half of the sample had also used hospital or ED service.

Table 2.

Healthcare providers seen for MHSUC in last 12 months by ethnicity.

Healthcare provider seen for MHSUC in last 12 months a Māori, n (%) Non-Māori, n (%) Total n (%) who had seen provider
GP 47 (81.0) 207 (84.5) 254 (83.8)
Psychiatrist 26 (44.8) 93 (38.0) 119 (39.3)
Counsellor 31 (53.4) 113 (46.1) 144 (47.5)
Psychologist 26 (44.8) 111 (45.3) 137 (45.2)
Nurse 20 (34.5) 62 (25.3) 82 (27.1)
Mental health support worker 20 (34.5) 60 (24.5) 80 (26.4)
Social worker 11 (19.0) 31 (12.7) 42 (13.9)
Peer worker 10 (17.2) 28 (11.4) 38 (12.5)
Substance use practitioner 6 (10.3) 20 (8.2) 26 (8.6)
Total n 58 245 303
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MHSUC = mental health and substance use conditions; GP = general practice.

a

n (%) of the Māori or non-Māori group who had seen that provider in the last 12 months.

Experiences of physical healthcare services

Tables with numbers of responses for each quality measure by ethnicity are included in the Supplemental Material.

Treated with respect

Overall, participants were more likely to report being treated with respect ‘always or most of the time’ at GP services (91.2%) and pharmacy (91.8%) than at ED (70.6%) or hospital (81.6%; Figure 1). Only a small proportion was ‘unsure’ whether they had been treated with respect. Few reported that any service had ‘never’ treated them with respect.

Figure 1.

Figure 1.

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Treated with respect by physical healthcare services for Māori and non-Māori with mental health and substance use conditions.

There were ethnic differences in reported ratings for being treated with respect by GP, hospital and pharmacy services, with non-Māori reporting higher ratings than Māori. In contrast, ratings for ED were similar (and relatively low) for both Māori and non-Māori.

Listened to

Overall, people more often reported being listened to ‘always or most of the time’ by pharmacy (86.0%) and GP services (77.6%) than hospital (69.0%) or ED (57.5%; Figure 2). No one reported ‘never’ being listened to by GP services but ‘never’ being listened to did occur in other services, particularly ED. Again, there were ethnic differences in the extent to which people reported being listened to by GP and hospital services, with non-Māori being more likely to rate this as occurring ‘always or most of the time’, while this rating was similar between Māori and non-Māori for ED (but relatively low overall) and pharmacy (but relatively high overall).

Figure 2.

Figure 2.

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Listened to by physical healthcare services for Māori and non-Māori with mental health and substance use conditions.

Unfair treatment

Overall, the majority of participants reported ‘never’ being treated unfairly by pharmacy (76%) and GP services (58%) and nearly half reported ‘never’ being treated unfairly by hospital (49%) and ED (44%; Figure 3). There were more ‘unsure’ responses than the previous questions, suggesting that some people were not certain about whether they had been treated unfairly. Overall, around 3–4% of responses were ‘unsure’ for each health service, but fewer non-Māori gave ‘unsure’ responses than Māori.

Figure 3.

Figure 3.

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Unfair treatment by physical healthcare services for Māori and non-Māori with mental health and substance use conditions.

The proportion of non-Māori reporting ‘never’ being treated unfairly was higher than Māori across all services; conversely, the proportion of non-Māori reporting being treated unfairly ‘always or most of the time’ was lower than Māori across all services.

Overshadowing

Overshadowing (where MHSUC diagnosis distracts from physical health issues) was commonly reported overall, occurring ‘always or most of the time’ across GP services (19.1%), ED (26.3%) and hospital (17.7%), but less so in pharmacy (7.2%; Figure 4). ‘Unsure’ responses made up 4–6% of total responses for each health service but were lower in non-Māori. There was a trend across all services for most non-Māori to have ‘never’ experienced overshadowing, with small numbers of participants experiencing overshadowing ‘always or most of the time’. In contrast, fewer Māori participants reported that they had ‘never’ experienced overshadowing generally, and more reported they experienced overshadowing ‘always or most of the time’ particularly in GP services, where this was the experience of nearly two fifths of Māori participants.

Figure 4.

Figure 4.

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Overshadowing by physical healthcare services for Māori and non-Māori with mental health and substance use conditions.

Discussion

This survey of people with MHSUC found differences in experiences of physical healthcare across service types and between Indigenous and non-Indigenous people. Overall, people with MHSUC reported positive experiences with GP and pharmacy services, especially for being treated fairly, with respect and being listened to. Experiences of unfair treatment were more common in ED and hospital services. Overshadowing was relatively common in GP, ED and hospital services, but not in pharmacy.

Non-Māori with MHSUC reported more positive experiences in healthcare services than Māori with MHSUC. Non-Māori were more likely to report being treated with respect and listened to in GP and hospital services compared to Māori but for ED, these measures were low for all participants. A larger proportion of non-Māori participants reported ‘never’ experiencing unfair treatment and overshadowing for all types of health service. This contrasted with the high proportion of Māori who reported experiencing unfair treatment due to MHSUC ‘always, most of the time or sometimes’.

Comparison with other literature

In the 2003 NZ national survey of discrimination experienced by people with MHSUC ‘Respect Costs Nothing’ (Peterson et al., 2004), 23% of participants reported experiencing discrimination when using other (non-mental) health services, a similar proportion to those reporting unfair treatment always or most of the time from ED or hospital services in our survey. However, the ‘Respect Costs Nothing’ survey did not find significantly higher rates of discrimination by health services for Māori compared to NZ European respondents. This may reflect differences in the focus, questions, recruitment and sample between the two surveys, but could also reflect increasing awareness of discrimination and in particular racism in health services over time, which may be contributing to increased reporting among Māori.

In our survey, Māori had higher rates of ‘unsure’ responses for questions about unfair treatment and overshadowing than non-Māori. In the context of pervasive institutional racism (Reid et al., 2019), this uncertainty could be because people were unsure whether unfair treatment or overshadowing had occurred due to MHSUC or due to racism. Other research has also highlighted the impact of institutional and interpersonal racism on Māori with MHSUC and how this leads to poorer quality of care (Cunningham et al., 2020; Manuel et al., 2023).

People with MHSUC in our survey were less likely to report positive experiences than participants in population-based NZ surveys of primary and hospital healthcare consumers (Health Quality & Safety Commission New Zealand, 2022a, 2022b). However, the pattern of more positive experiences in primary care than hospital services was similar. E.g., from the population consumer surveys in 2022, 93% reported always being listened to in primary care, and 83% reported always being listened to in hospital care (Health Quality & Safety Commission New Zealand, 2022a, 2022b). By comparison, in our survey less than 80% reported being listened to always or most of the time in primary care and less than 70% in hospital settings.

These national consumer surveys do not report separate responses for people with MHSUC but do provide responses by ethnicity. Consistently better experiences were found for non-Māori compared to Māori both in the national consumer surveys and in our survey, in line with the extensive evidence that the NZ health system functions better for non-Māori than Maori (Reid et al., 2019; Waitangi Tribunal, 2019).

Most research into healthcare experiences for people with MHSUC has not been disaggregated by ethnicity, but where this has been done Indigenous and minoritized ethnic groups with MHSUC report worse healthcare experiences (Jones et al., 2016). A trend towards lower empathy scores for health professionals from non-white patients was reported in a systematic review of patient experience of clinician empathy, although this was not disaggregated by MHSUC diagnosis (Roberts et al., 2021).

Experiences of discrimination in our survey were more common than in an Australian survey of adults with mental health conditions, where 12% of participants experienced discrimination from (any) health professional in the last 12 months (Morgan et al., 2016). This could be partly due to our survey asking about experiences in the past 5 years, including people with substance use disorder and having a self-selecting not a population-based sample.

Research into experiences with pharmacy services in people with MHSUC has focused on management of MHSUC rather than physical health (El-Den et al., 2021; Murphy et al., 2016). Although pharmacy services are often well regarded, this may be in part due to low expectations or poor understanding of what a high-quality pharmacy service should deliver (Murphy et al., 2016). In ED, people with MHSUC commonly report diagnostic overshadowing, discrimination and not being listened to, with time and throughput pressures, a busy, uncomfortable environment, lack of collaborative care and changing staff all being factors that reduce positive experiences in this setting (Clarke et al., 2014; Corscadden et al., 2021; Navas et al., 2022; Van Nieuwenhuizen et al., 2013).

Strengths and limitations

The main limitation of this survey was the relatively small sample size, meaning that the study lacked power to test for differences between Māori and non-Māori within each healthcare service setting. The small sample size also meant we were unable to adjust for confounding factors such as socioeconomic position and access to services, which are known determinants of poorer mental and physical health outcomes, and which disproportionately affect Māori (Baxter, 2008). In our sample, Māori and non-Māori participants had similar demographic characteristics (with the exception of gender), meaning that confounding by these factors is unlikely to explain the patterns of better care experiences among non-Māori. Māori and non-Māori participants also had similar clinical characteristics, although there were some differences in diagnoses and number of providers seen, which could indicate differences in severity. In particular, higher rates of stigmatized conditions such as substance use conditions and personality disorders may have resulted in worse experiences of care among Māori respondents. In our previous analysis of experience of primary care from this survey we found that people with schizophrenia, bipolar disorder and substance use disorder reported worse experiences of care (Cunningham et al., 2023). Although the patterns in the data are suggestive of meaningful ethnic differences, and differences across service settings, more research is needed to confirm these findings.

The self-selecting nature of the sample means the survey is not representative of the whole population, which could introduce bias. For example, due to the online nature of the survey, those without access to Internet services or digital devices would be less likely to participate. If these people had worse healthcare experiences, this could cause a positive bias in the results. Participants were those who had sought help for physical health conditions, which may also have introduced a positive bias, by excluding people with negative healthcare experiences that deterred them from seeking help (Corrigan et al., 2014). However, it is also possible that participants engaged with the survey because of having had negative experiences they wanted to share.

This was the first survey of people with MHSUC in NZ that has attempted to quantify experiences across a range of healthcare quality measures including overshadowing and discrimination due to MHSUC and to examine differences by ethnicity. The survey is also unique in asking about experiences of different types of healthcare services within the same sample, allowing a comparison of services across the same quality measures.

Implications for practice

The worse quality of care reported by people with MHSUC means that this population group should be monitored separately in national patient experience surveys of physical health services, with results being actioned through quality improvement approaches (Coulter et al., 2014). Specific primary care quality indicators for people with MHUSC have been identified (Kronenberg et al., 2017), which are intended to reduce the excess morbidity and mortality from physical health conditions in this population. Existing patient experience surveys could be analysed by recent history of MHSUC in combination with ethnicity. Additional monitoring of patient experience in EDs may also be needed. Without these types of specific and ongoing monitoring, the effect of interventions to improve health services for people with MHSUC will be unknown.

Such interventions need to target multiple factors at societal and community, health system and workforce and individual levels (Liu et al., 2017). Models of care which separate physical and mental health (mind–body dualism) increase the risk of overshadowing and are less likely to be effective than holistic and Indigenous models for providing person- and family-centred care. From our survey, the differences in experiences of healthcare by ethnicity suggest that even among a marginalized group with poor experiences of care, factors related to non-Indigenous privilege are still operating and need to be addressed at all levels. This includes care models tailored to the cultural needs of the patient, ensuring health professionals practice in a culturally safe way, as well as measures to address the inequitable distribution of the determinants of health that unfairly advantage non-Indigenous populations (Cunningham et al., 2018). Further investigation is needed to understand why differences between services exist and how interventions should be targeted by service type.

Reducing stigma and discrimination towards people with MHSUC requires multi-level approaches (Ungar et al., 2016) including a sustained, ongoing commitment to culture change at an organizational level. Supportive training of individual practitioners should counter stereotypes, challenge therapeutic pessimism, highlight stories of positive recovery and emphasize ongoing monitoring and behaviour change (Knaak et al., 2017). Moreover such training should start early (at undergraduate level) and include often overlooked and particularly stigmatized conditions such as substance use (Knaak et al., 2021; Newton-Howes et al., 2021). Trauma-informed care, that acknowledges and responds to the impact of trauma in people with MHSUC, can only be effective when stigma is addressed (Bartholow and Huffman, 2023).

The consistently high ratings for pharmacy across the different quality measures deserve more exploration. Although studies on pharmacy interventions in the community are lacking, the accessibility and frequency of use of pharmacies by people with MHSUC mean that this setting has the potential to improve physical health outcomes through screening for hypertension and diabetes, reviewing and optimizing medication use and supporting health-promoting actions such as smoking cessation (Sud et al., 2021).

Conclusion

Although the majority of people with MHSUC reported positive experiences in most physical healthcare settings, experience of discrimination or overshadowing due to MHSUC was relatively common. Moreover, experiences tended to be worst in ED, best in pharmacy services and better for non-Māori than Māori. Patient-reported experiences on unfair treatment and overshadowing point to entrenched systemic bias. Multi-level monitoring and interventions are needed to address the poorer physical health outcomes in people with MHSUC and tackle systemic racism that underpins inequitable outcomes for Māori.

Supplemental Material

sj-docx-1-anp-10.1177_00048674241238958 – Supplemental material for Experiences of physical healthcare services in Māori and non-Māori with mental health and substance use conditions
sj-docx-1-anp-10.1177_00048674241238958.docx (20.1KB, docx)

Supplemental material, sj-docx-1-anp-10.1177_00048674241238958 for Experiences of physical healthcare services in Māori and non-Māori with mental health and substance use conditions by Ruth Cunningham, Fiona Imlach, Tracy Haitana, Mau Te Rangimarie Clark, Susanna Every-Palmer, Helen Lockett and Debbie Peterson in Australian & New Zealand Journal of Psychiatry

sj-docx-2-anp-10.1177_00048674241238958 – Supplemental material for Experiences of physical healthcare services in Māori and non-Māori with mental health and substance use conditions
sj-docx-2-anp-10.1177_00048674241238958.docx (42.2KB, docx)

Supplemental material, sj-docx-2-anp-10.1177_00048674241238958 for Experiences of physical healthcare services in Māori and non-Māori with mental health and substance use conditions by Ruth Cunningham, Fiona Imlach, Tracy Haitana, Mau Te Rangimarie Clark, Susanna Every-Palmer, Helen Lockett and Debbie Peterson in Australian & New Zealand Journal of Psychiatry

Acknowledgments

The authors thank all the survey participants who contributed to this survey. They also thank all other members of the Tupuānuku study team, in particular Abigail Freeland for putting the survey online, and current and past Advisory Group members who provided advice on the survey content and interpretation of results: Caro Swanson, Catherine Gerard, Ross Phillips, Tony O’Brien, Arran Culver, Sarah Gray, Suzanna Pitama, Suzana Baird, Vanessa Caldwell and John Robinson.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This study was funded by the Health Research Council New Zealand (grant no. 20-216). The funder was not involved in the design of the study; the collection, analysis or interpretation of data; or writing the manuscript and did not impose any restrictions regarding the publication of the manuscript.

Data Availability Statement: The data that support this study cannot be publicly shared due to ethical or privacy reasons.

Supplemental Material: Supplemental material for this article is available online.

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sj-docx-1-anp-10.1177_00048674241238958 – Supplemental material for Experiences of physical healthcare services in Māori and non-Māori with mental health and substance use conditions
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Supplemental material, sj-docx-1-anp-10.1177_00048674241238958 for Experiences of physical healthcare services in Māori and non-Māori with mental health and substance use conditions by Ruth Cunningham, Fiona Imlach, Tracy Haitana, Mau Te Rangimarie Clark, Susanna Every-Palmer, Helen Lockett and Debbie Peterson in Australian & New Zealand Journal of Psychiatry

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Supplemental material, sj-docx-2-anp-10.1177_00048674241238958 for Experiences of physical healthcare services in Māori and non-Māori with mental health and substance use conditions by Ruth Cunningham, Fiona Imlach, Tracy Haitana, Mau Te Rangimarie Clark, Susanna Every-Palmer, Helen Lockett and Debbie Peterson in Australian & New Zealand Journal of Psychiatry

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