Kaupapa Māori approaches to improve Māori eye health: a protocol for a scoping review

Abstract

Introduction and aim

Māori experience higher rates of disease and poorer health outcomes than non-Māori, highlighting inequities in the health system in Aotearoa New Zealand (Aotearoa). Māori eye health has historically been under-researched. Kaupapa Māori (by Māori, with Māori, for Māori) approaches to research have been recognised as critical for developing and informing equitable and inclusive health service solutions for Māori. This scoping review aims to summarise the literature on interventions to improve Māori eye health and investigate the extent to which Kaupapa Māori approaches have been used within these studies.

Methods and analysis

This scoping review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist and informed by Kaupapa Māori research and strengths-based methodologies. Electronic searches of MEDLINE (Ovid), Embase (Ovid) and Google Scholar were performed using keywords focused on Māori eye health, Kaupapa Māori and eye health interventions. The search was performed by an information specialist without language or time restrictions. Peer-reviewed and grey literature reports will be included if they report any intervention that aimed to improve eye health for Māori. Two reviewers will independently screen abstracts and full texts, followed by data charting in Covidence. Data items will include publication, study and intervention characteristics and whether a Kaupapa Māori approach was used, in which case the characteristics of the approach will be charted. The responsiveness to Māori of each included study will be assessed using the MĀORI framework and CONSIDER statement. Data will be summarised in tables, graphs, maps and text.

Ethics and dissemination

To the best of our knowledge, the scoping review is the first to investigate published and publicly accessible literature related to interventions for improving Māori eye health and Kaupapa Māori approaches. Ethical approval is not required for this review as we will include information available in the public domain. We anticipate that the findings will be useful for Hauora Māori providers, organisations, education training and research providers of eyecare services. The scoping review also informs a more extensive project examining Indigenous perspectives in optometry to achieve equitable outcomes. Dissemination will include publication of the scoping review findings in an open-access peer-reviewed journal, as well as presentations at conferences, to Māori community and service organisations, scholars and staff working in the field of Māori eye health.

Registration

Open science framework (https://osf.io/4vqaw/). On 27 February 2025.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This scoping review will use a systematic search by an experienced information specialist and screening and extraction by two independent investigators to identify and summarise the literature on interventions to improve Māori eye health and the extent to which they used Kaupapa Māori approaches.

• A strength of this study is that it uses a strengths-based Kaupapa Māori approach to provide an extensive overview of interventions to improve Māori eye health.

• A limitation of this study is that the findings for Māori may not be generalisable to other populations in Aotearoa or other international Indigenous populations.

Introduction

Rationale

Global Eye Health

The Lancet Global Health Commission on Global Eye Health defined eye health as ‘maximised vision, ocular health and functional ability, thereby contributing to overall health and well-being, social inclusion and quality of life’.¹ The Commission also summarised evidence that good eye health can contribute to mental, social, emotional as well as physical health and well-being.¹ Vision is a highly valued sense, with the loss of eyesight often considered to be worse than losing memory, speech, hearing or a limb.²

In 2020, the Vision Loss Expert Group estimated that 1.1 billion people were living with vision impairment globally.³ Because the leading causes of vision impairment are associated with age and we have a growing and ageing population,³ the global magnitude of vision impairment is projected to increase unless access to high-quality eye care is improved.⁴ An example is presbyopia, which begins in middle age and affects the visual systems’ ability to focus clearly on near objects and thus causes near vision impairment without spectacle correction.⁵ In addition, the last few decades have seen a significant increase in the incidence of myopia among younger people due to reduced outdoor time and increased time spent focusing on near objects and digital devices.⁶ This rapid increase has led to a projection of 50% of the global population being myopic by 2050.⁷ While there are improvements in addressing some treatable eye conditions, as seen in the reduction of endemic trachoma in many parts of the world, coordinated plans to address many common avoidable causes of vision impairment such as cataract, presbyopia, uncorrected refractive error and diabetic retinopathy still require further strategic development of solutions and system approaches.^{1 3}

Indigenous Peoples

Indigenous Peoples form an estimated 476.6 million (6%) of the global population and represent over 5000 distinct ethnicities.^{8 9} Despite the term ‘Indigenous Peoples’ frequently being used in relation to peoples of a specific area with distinct customs, traditions and ethnicities, there are contentions around what this definition means.¹⁰ There is, however, consensus that self-identification, familial and tribal affiliations, and locally preferred nomenclature are critical components of Indigenous identity that assert self-determination.^{8 9} Indigenous Peoples have collective and holistic worldviews that integrate spiritual, mental, family/community, self-determination, societal and community structures and systems.⁸ The definition of eye health outlined in the Lancet Global Health Commission also captures a holistic view of vision and eye health.¹

A shared experience of Indigenous Peoples is the loss of cultural customs, land, language and knowledge systems as a consequence of imperialism and colonisation.¹¹ There are international law efforts to protect and uphold Indigenous rights, however Indigenous Peoples continue to be some of the most vulnerable and marginalised populations in the world.^{12 13} This is observed in eye health, with Indigenous Peoples experiencing preventable blindness at higher rates than non-Indigenous peoples,¹² primarily due to inequities in access to and outcomes of healthcare.¹⁴ The need to realise equity in Indigenous eye health has been recognised.¹⁵ When developing systems-level approaches to realise equity in eye health for Indigenous Peoples, it is critical to understand access to interventions and Indigenous Peoples’ knowledge and health practices.

Māori and Kaupapa Māori approaches

Māori are the Indigenous Peoples of Aotearoa New Zealand (Aotearoa), with a population of 904 100 in June 2023 (17.3% of the total population).¹⁶ In line with global trends for Indigenous Peoples, Māori experience reduced access to social determinants of health, have poorer health outcomes and shorter life expectancy than non-Māori.¹⁷

Kaupapa Māori approaches are a methodology that prioritises solutions and research that are by Māori, with Māori and for Māori.¹⁸ Kaupapa Māori approaches to health and well-being are increasing and show evidence of addressing health inequities in Aotearoa.^{19 20} These approaches act to decolonise research and systems by rejecting deficit lens framing and victim blaming, normalising and validating Māori knowledge, and prioritising Māori voices.^{11 21 22}

Two tools that can be used to assess ‘responsiveness to Māori’, a critical component of Kaupapa Māori methodology, are the ‘CONSIDER statement’²³ and ‘The MĀORI framework’.²⁴ The CONSIDER statement includes 17 items across seven domains that aim to strengthen the conduct and reporting of research involving Indigenous Peoples.²³ The Māori framework was developed to improve the safety and responsiveness of surgical care and covers five domains: Māori Leadership and Engagement, Advocacy for Health Equity, Opposes Deficit Analysis, Rejects Racism and Indigenous Data Sovereignty.²⁴

Te kitenga Māori nō Aotearoa—Māori eye health in Aotearoa

At present, no data exists on the number of adults with vision impairment in Aotearoa.²⁵ However, we know that compared with non-Māori, Māori experience higher rates of a range of conditions that can affect the eye and vision, such as diabetes, heart disease and cancer.^{13 25 26} Furthermore, several studies have demonstrated inequities in eye healthcare and outcomes between Māori and non-Māori. Rapata and colleagues summarised Māori eye health literature and highlighted numerous vision impairment inequities for Māori in diabetes-related ocular changes, cataracts, keratoconus and sight-threatening retinopathy.²⁵ Examples include an Auckland study that reported that although Māori experienced an earlier onset of cataract by approximately 10 years, they remained significantly under-represented in the number of scheduled cataract surgeries (4.7%) when compared with general population statistics (17.3%).^{16 27} Additionally, it was shown that Māori had lengthier surgical wait times despite having more significantly advanced cataracts.²⁷ In 2022, Māori were reported to have higher incidence of keratoconus (a degenerative disorder that affects the cornea of otherwise healthy adolescents), with more severe disease.²⁸ Earlier studies show geographically remote Māori populations have intersecting lower socioeconomic status and poorer access to affordable primary or eye care services.^{29 30}

The last few years have seen some positive action to promote Māori eye health. Samuels et al developed a Kaupapa Māori framework with Māori patients and eye health professionals that clinicians can use to enhance engagement with Māori patients in eye health settings.³¹ The framework highlighted that vision is important to the cultural and physical well-being of Māori, and as such, it should be protected.³¹ Their participants’ views were summarised in a Māori whakatauakī (proverb), ‘Ki te kore he whakakitenga, ka mate te iwi’, which translates as ‘If there is no vision, the people will suffer’.³¹ While there is growing awareness of Māori eye health, more research is required to understand Māori eye health, vision loss, the unique eye health challenges faced by Māori communities and whānau, as well as novel Indigenous-informed ways to address inequities.

Given the increased activity in the recent past in Kaupapa Māori approaches as well as Māori eye health research, it is timely to explore the extent to which these approaches have been used in eye health.

Aim and objectives

The aim of this scoping review is to summarise the literature on how and in what ways Kaupapa Māori approaches have been used in interventions to improve Māori eye health.

We chose to undertake a scoping review as we anticipate a broad range of interventions and outcomes and wish to map the characteristics of the literature reporting these.³²

To achieve our aim, this review will answer the following questions:

1. What types of interventions have been implemented to improve Māori eye health?

2. To what extent have these studies reported using a Kaupapa Māori approach?

3. What is the theory and praxis (Māori principles, Māori worldview, Māori knowledge) of the Kaupapa Māori approaches used?

4. What benefits and challenges do study authors report of the Kaupapa Māori approaches used?

5. What is the responsiveness to Māori of the interventions in Māori eye health and Kaupapa Māori approaches using the MĀORI framework and CONSIDER statement?^{23 24}

Method

This review will be informed by Kaupapa Māori research methodology and will be led and conducted by Māori clinical academics making it ‘by Māori, for Māori’.

Protocol and registration

This protocol is reported according to the relevant items of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines³³ and has drawn on the methods outlined in the Joanna Briggs Institute Manual for Evidence Synthesis.³⁴ The protocol was registered prospectively on Open Science Framework on (05/02/2025 (https://osf.io/4vqaw/).

Eligibility criteria

Concept

We will include studies that report on any intervention (eg, clinical, policy or education) that aims to improve eye health for Māori. Studies will be excluded if they are unrelated to eye health or if they report on interventions to improve the eye health of Indigenous Peoples without reporting results for Māori separately.

Population and context

Studies will be included if they report on our concept of interest in any geographic location and for any age group. Studies can be undertaken in any community, healthcare, whaikaha (disability) or education setting in Aotearoa or any other country (eg, Māori residing in Australia) in the public or private sector. Multi-country studies will be included if they report Māori eye health separately.

Types of studies

We will include sources of evidence in the peer-reviewed published literature and grey literature. We will include any study design for which a full report is available. Conference abstracts and letters to the editor that do not report primary data will be excluded. No language restriction will be applied to the search and Māori researchers will translate Māori documents where required. Every effort will be made to translate studies in languages other than English and Māori.

Search strategy

The search strategy was developed in consultation with an information specialist using a set of terms including Māori Eye Health, Kaupapa Māori, Interventions, Indigenous eye health, Optometry, Eye Care, Vision, Aotearoa, New Zealand, Karu (full search strategy for published literature provided in online supplemental file 1). These terms highlight interventions to improve Māori eye health, including Kaupapa Māori approaches. The search was conducted on the 2nd of January 2025 using MEDLINE (Ovid) and Embase (Ovid) without language or date restrictions. Results from the search will be uploaded into Covidence systematic review software for screening (www.covidence.org). In addition, the reference lists of all included articles will be examined to identify further relevant studies.

We will then search the grey literature using Google to seek additional eligible information in the form of non-peer-reviewed publicly available information that meets our criteria. Grey literature reports will be searched for by one investigator (RW). The process for systematically collecting publicly available information will be based on the grey literature search framework outlined by Godin et al³⁵ First, to identify the relevant publicly available websites, a Google search will be conducted using the search strategy in the online supplemental file 2. The first ten pages (representing 100 searches) will be reviewed using the title and short text underneath.

Through the Google search engine, separate searches will be performed across: New Zealand government websites such as Ministry of Health and Te Whatu Ora (Health New Zealand), professional associations such as New Zealand Association of Optometrists and the Royal Australian and New Zealand College of Ophthalmologists, advocacy groups such as Eye Health Aotearoa, non-profit organisations and charitable trusts such as Kāpō Māori Aotearoa, Blind Low Vision New Zealand as well as eye health service providers including optometrists and ophthalmologists. The search terms will be used to identify eligible information within each website and relevant links within documents to other sources of information when indicated.

The relevant websites’ name/organisation and URL will be entered into an Excel spreadsheet. Then, each of these websites will be searched using the search feature and a combination of keywords included in the online supplemental file 3; when the search feature is not available, the website will be scanned for relevant information. When the search feature is available, results will be reviewed using the title and short text underneath. The search will continue until no more relevant items are identified on a following page. All potentially relevant reports will be exported into Covidence and de-duplicated for title and abstract screening.

Additionally, key experts in Māori eye health interventions and Kaupapa Māori approaches in eye health will be contacted to share our list of included studies and a request made to identify further potentially relevant studies or literature that may not have already been identified for consideration to review.

Our intention is to complete the full scoping review by December 2025. If the timeline extends beyond this, we will update the search prior to completing the review.

Study selection

Following the search, all identified citations will be collated and uploaded into Covidence, and duplicates removed. Titles and abstracts will then be screened by two reviewers independently against the inclusion criteria for the review. Potentially relevant sources will be retrieved in full and assessed in detail against the inclusion criteria by two reviewers independently. Reasons for exclusion of sources at the full text stage will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion, or with an additional reviewer. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a PRISMA flow diagram.³³

Data charting

A custom data charting form will be developed in Covidence. The data form will be piloted by two reviewers, and amendments will be made if required. Each included study will be charted independently by two reviewers and discrepancies between the reviewers will be resolved by discussion or in consultation with a third reviewer if required. If a charting item is unclear from an included study, three attempts will be made to contact the corresponding author via email. As the scoping review process is iterative, changes to the protocol may be required as the review progresses. Any adjustments will be outlined in the final review report.

Data items

The following data items will be collected during the data charting process. Members of the research team who are Kaupapa Māori academics (MH, AM, BTA and RW) will apply the Māori framework to our included studies.

1. Publication characteristics:

   1. Author/s.

   2. Title.

   3. Year of publication.

   4. Aim of study.

   5. Type of publication (peer-reviewed, grey literature—report, thesis, technical report).

   6. Source of publication (eg, journal name, website).

   7. Accessibility of publication (whether open source or not).

2. Study characteristics

   1. Study methodology (qualitative, quantitative, mixed-methods).

   2. Location of study (eg, region of Aotearoa).

   3. Study setting (eg, optometry clinic, ophthalmology clinic, education setting, home, marae).

   4. Age and gender of the target population.

3. Intervention Characteristics

   1. Health sector (private, public, non-profit, other).

   2. Level of care (primary, secondary, tertiary).

   3. The ocular problem being addressed.

   4. Description of intervention.

   5. Other ethnicities for which data are reported (comparator group).

4. Does the study state a Kaupapa Māori approach in the methodology? (Yes/No)

   1. For studies using a Kaupapa Māori approach, what were the characteristics of this approach.

      1. Definition and/or description of Kaupapa Māori approach provided.

      2. What Kaupapa Māori principles are articulated by study authors?

      3. Proportion of authors who were Māori.

      4. Did authors include positionality statements? (Yes/No)

      5. Description of benefits and/or challenges of Kaupapa Māori approach as reported by study authors.

5. Responsiveness to Māori—which dimensions of the tool are included in the report:

   1. Using the MĀORI framework:²⁴ (1) Māori leadership and engagement, (2) Advocacy for health equity, (3) Opposes deficit analysis, (4) Rejects racism and (5) Indigenous data sovereignty.

   2. Using the CONSIDER statement:²³ (1) Governance, (2) Relationships, (3) Prioritisation, (4) Methodologies, (5) Participation, (6) Capacity, (7) Analysis and findings and (8) Dissemination.

Synthesis of results

Findings will be summarised in tables, graphs, maps and text to provide insights into the Kaupapa Māori approaches to improve Māori eye health. Where possible, information will be disaggregated by publication and study design characteristics, intervention characteristics, theory and praxis of Kaupapa Māori approaches, assessment of responsiveness using the MĀORI framework²⁴ and CONSIDER Statement and reported benefits of challenges by study authors.

Patient and public involvement

Patients and/or the public will not be involved in the design, conduct or reporting of this research.

Ethics and dissemination

To the best of the authors’ knowledge, no comprehensive review of Kaupapa Māori approaches to Māori eye health interventions has been conducted. Our review will only include published and publicly accessible data and ethical approval is not required. This protocol has been registered in the Open Science Framework (https://osf.io/4vqaw/). We anticipate the findings will be useful to organisations and education providers of eyecare services, training and research. We will publish the review in a peer-reviewed journal and the findings will be presented to stakeholders at relevant conferences. This scoping review is the first phase of a larger project examining Indigenous perspectives in eye health to achieve equitable outcomes.

Please see glossary in online supplemental file 4 for translation of Te Reo Māori words.