Whakawhanaungatanga: the importance of culturally meaningful connections to improve uptake of pulmonary rehabilitation by Māori with COPD – a qualitative study

Figures & data

Figure 1 Factors contributing to decisions to attend and decision to stay in pulmonary rehabilitation program within a cultural context.

Table S1 Extracts from transcripts illustrating culturally shared factors influencing decisions to start or continue with pulmonary rehabilitation

Influencing factors	Facilitating uptake of pulmonary rehabilitation	Barriers to uptake of pulmonary rehabilitation
Past experiences
Of exercise	The course it’s really like a circuit training thing, which I could relate to that, because I have been absolutely super fit in my time… I’m actually familiar with circuit training. Lots and lots of circuit training. [M3, male, NZ European, hospital-based program]	Was there anything about the class that made you nervous before you started, or when you first started going? The exercise. I used to think “oh,” you know. And the physio will say “no, keep going, keep going,” you know, you think “I can’t breathe.” I used to be afraid of the breathing. [F5, female, Māori, hospital-based program]
Of health services	Oh, I had um – on one of our courses to do with my diabetes… and I ended up with um, being wheel-chaired, ah, to A&E [Accident & Emergency]. Cause I had a – my muscles pulled and that, I couldn’t – [it] was like – sciatica. So, went to the doctors, the only thing they said is um, tramadol… [So for pulmonary rehabilitation in the hospital] You’re in the right place. If anything goes down. [F5, female, Māori, hospital-based program]	I didn’t like it… They said I had to do this; do that. But they didn’t explain anything about the health, what it does to you… What stopped you coming back? I went to ah, that department, ah, where you blow these things in the tube… I chucked it in too, that one. Pissed me off… Well they told me to blow, blow, blow, blow, keep blowing. And that was – I had a severe – ah, breathing problems! So I chucked it in. [M6, male, Māori, hospital-based program]
Of having COPD	It came to a head 3 years ago when I was on a flight from Auckland to Vancouver. And the last three hours of that flight – it’s a 14-hour flight – I couldn’t breathe. I just spent three hours in the bathroom with my Ventolin inhaler. And that really scared me… And I was in hospital for 4 days when I arrived. [M1, male, NZ European, talking about the event that triggered deciding to eventually attend hospital-based program]	And that exercise in the hospital gym was rubbish. We had to be there at nine o’clock in the morning, I mean anyone with COPD or severe emphysema know, that’s not a really for us. It takes me over an hour just to have a shower. [M16, Māori, marae-based program]
Attitudes and expectations
Attitudes and expectations continued…	Nobody else can help me but myself, so I thought it was time to kick myself in the butt, because okay, I weighed in at a hundred and twenty-six (kilograms). [F4, female, Māori, hospital-based program] I thought, you know, if this is going to be helpful to me, and restore some of my quality of life, then it’s worth doing. [M1, male, NZ European, hospital-based program]	I used to have a bad attitude. I used to think, oh, exercise ain’t going to help me, you know… At first I really had a bit of a negative attitude to it. Cause I have negative attitude to everything. And I’m like “nah, I don’t want to go to that.” You know, I lose interest in things quick. Real quick. [F5, female, Māori, hospital-based program] I mean that’s why I wasn’t there at the end of last year, cause I was still in that dark place, and I was finding excuses every week, why I’m not coming. Even though [the community nurse] and them are trying to push me here, and push me here. Because I wasn’t in the right head space for myself, I didn’t want to bring anyone else down. [M16, male, Māori, marae-based program]
Access issues
Timing of program	There’s plenty of time to catch the buses [to get to pulmonary rehabilitation]. Cause it – it didn’t start till half past ten o’clock. [M6, male, Māori, hospital-based program]	I found that early morning was not good for me. I couldn’t concentrate on what they were doing. And the last thing I wanted to do was walk. [M11, male, Māori, marae-based program, reflecting on time in hospital-based program] They sort of said to me well if I wanted to, I could go for this course, and there was this one and that one, and I sort of thought: well I don’t want to be doing it in the middle of winter. [F2, female, NZ European, hospital-based program]
Duration of program	If it was 12 weeks I’d still come. If it was 6 weeks I’d still come, you know. [M1, male, NZ European, hospital-based program] Attending the class all the time, and it’s only an 8 weeks course, it’s not long enough for me though. I love it. [F4, female, Māori, hospital-based program]	And it was a 9 week course. That was the other thing that put me off a little bit. Nine weeks. I sort of started off by sort of thinking, “oh, it’s only 9 weeks.” And then I sort of started realizing how long 9 weeks was… Well hang on a minute; I could be doing other things. [F2, female, NZ European, hospital-based program]
Transport & distance to program	Do you think you would be coming if it wasn’t for the [transport service] support? Nah, I wouldn’t have been coming… Cause I can’t get around – well I can, but I don’t want to. You know, they pick me up and drop me off. [F5, female, Māori, hospital-based program] It’s also very handy for me, I don’t live far away. And I have the car, and I have a disability parking space, that’s handy. And I can park in the disability parking space and walk the rest of the way. So it’s convenient for me to come to the hospital. [F8, female, NZ European, hospital-based program]	I said to her “am I the only Māori coming?” And she said “well there’s meant to be others, but they’re not coming.” And I said “probably because you have to find your own way [F14, female, Māori, from the marae-based program, reflecting on time in the hospital-based program.] I mean I know that going there might help but sometimes when you get out, when you can’t get out of bed or you can’t shower, it’s just I’m stuck to the oxygen. I have to stay home. I can’t do anything, that’s the only reason why I wouldn’t go. [M23, male, Māori, hospital-based program, decline recent opportunity to attend]
Competing responsibilities	I’m a contractor, so I get paid by the hour. So I just had to say to my boss over the next 8 weeks I’ll be away… these Mondays and Thursdays, away from the office [M1, male, NZ European, hospital-based program]	Because I work, I had to actually change days that I worked and everything to be able to attend it… There were a couple of times even then that, because of work, I couldn’t go. [F2, female, NZ European, hospital-based program]
Program experiences
Health effects	[To start with] I just thought “oh, what we’re going – going to get out of it?” But I thought I’ll keep going. But then I said to them, when I’d been to it for a few times, I used to say, “oh, I must admit, it has been doing me good.” I said – before I used to think oh exercise was just a load of – it’s not going to help you, you know, with all the breathlessness and all that. It’s not going to help you. [F5, female, Māori, hospital-based program]	Yeah, and my last class I couldn’t do their stair exercise, and it’s only four steps. Yeah, and that, that, that disheartens me as well. You know, I can’t even do four steps, and then you watch um, the elderly lady going up. It makes me angry that I’ve got myself in that position. Yeah. But yeah, I know that that’s my only way out, is to actually go to those classes. [M23, male, Māori, hospital-based program]
Being part of a group	I like the atmosphere… And although we do exercise, and oh, we all hate doing them. But we do, we put an effort into them… And I love it up here, I love coming here, it’s just – the atmosphere’s totally different [from hospital], and it’s beautiful. [F14, female, Māori, marae-based program] There was a group of us that um, we had so much fun on [the pulmonary rehabilitation program]… we’ve stuck together as a group. And um, and we go out for coffee and we have lunches and, and ah, we go to [the community gym] too once a week. [F22, female, NZ European, hospital-based program]	Basically, the biggest thing I struggled with was that I was. I’m only 42. And how many people 40, 60, 70, 80 year olds [were at pulmonary rehabilitation]? I struggled. [M16, male, Māori, marae-based program] I think there’s always a certain amount of embarrassment to – to show yourself, and what you can’t do, often, in front of other people… So there was a certain sense of reserve about it. [F8, female, NZ European, hospital-based program]
Peer support	Once you’re in this class, and you hear the korero (Māori word for “conversation”) around the table, you do, you get over what you’re feeling, because there’s others behind you that are feeling either worse, or better. And its just – for me, it was sort of like a – a healing part for me. [F14, female, Māori, marae-based program]	I went to like 3 or 4 classes in a row, which is like 3 or 4 weeks. But then I started getting a little bit um, probably a bit too proud, or thinking about nah these, these people are too old for me, or the other way around, I’m too young. [M23, male, Māori, hospital-based program]
Health professional support	They [the health professionals] were the ones to encourage you on, and to – they actually showed you how, and if there was something you couldn’t do… they found something else… And then they’d make sure that: “no, you need to stand with your feet a bit further apart,” or “lean into it more,” or whatever. Whereas when you in a gym you don’t get any of that. [F2, female, NZ European, hospital-based program]