Cultural and social factors and quality of life of Māori in advanced age. Te puawaitanga o ngā tapuwae kia ora tonu – Life and living in advanced age: a cohort study in New Zealand (LiLACS NZ)

Glossary· Māori (normal, usual, natural, common)· Whānau (an extended family)· Hapū (groups of extended families or sub-tribe)· Iwi (tribe)· Te Ao Māori (Māori society)· Pou (the post supporting the ridge pole in the back wall of a Meeting House, expert, teacher, dependable people, reliable people)· Te reo Māori me ngā tikinga (Māori language and culture are inseparable entities, te reo Māori is used to translate the English word, ‘culture in this article')· Tāngata whenua (earliest or indigenous peoples of Aotearoa New Zealand)· Mauri (life principle, special nature, a material symbol of a life principle, source of emotions)· Whakawhānaungatanga (recitation of genealogies or stories about the world, ways by which people come into relationship with the world, with people, and with life)· Marae (sacred gathering place of kin relations)· Te Rōpū Kaitiaki o Ngā Tikanga Māori(the protectors of principles of conduct in Māori research)· Kaupapa Māori (Māori ideology - a philosophical doctrine, incorporating the knowledge, skills, attitudes and values of Māori society, lived experience, a Māori approach to research)· Te Puawaitanga o Ngā Tapuwae Kia Ora Tonu (flourishing life and living)· Whakapapa (to recite in proper order e.g. genealogies, legends, months)· Tikanga (correct procedures, customs, habits, lores, methods, manners, rules, ways, codes, meanings, plans, practices, conventions)· Mātauranga Māori (Māori education, knowledge, wisdom, understanding, skill, knowledge)· Tūrangawaewae (domicile, land, place where people belong through kinship and whakapapa)· Tihei (wā) mauriora! tihei mauriora (the sneeze of life and, the call to claim the right to speak)In theory, Antonio Gramsci makes a distinction between civil and political society. In any civil society,1 certain cultural forms predominate over others, just as certain ideas are more influential than others in the form of cultural leadership which Gramsci has identified as hegemony.1For Māori, tāngata whenua (indigenous peoples of Aotearoa New Zealand), te reo Māori me ngā tikanga (Māori language and culture, hereafter referred to as te reo Māori), Māori ways of knowing, wisdom, and traditions which form our culture have been transferred across generations and, through the process of cultural leadership or hegemony some have changed. Nevertheless, the indigenous people hold on to the values that Māori people are intimately connected and are part of mauri (living force) that exists within the physical, social, and spiritual worlds in which Māori people live and are a part.2How the quality of mauri is lived by Māori from the context of health interviews is an important aspect of this paper to establish 1) the socioeconomic and cultural profile and 2) correlates of quality of life (QOL) of Māori of advanced age.An increasing number of Māori people are living longer. Statistics New Zealand reported that in 2012 approximately 5,000 Māori were aged 80 years and over, considered advanced age, a 50% increase in number from 2002.3 There are few Māori in statutory surveys and even fewer older Māori, justifying a study specifically about this age group.Since Māori people's first contact with non-Māori, the continuing process of colonisation and government policies have adversely influenced Māori people's health, socioeconomic and cultural profile, and wellbeing.Health and socioeconomic inequalities throughout the life span are structural and are perpetuated across generations.4,5 Yet, there is evidence that whānau (extended family), hapū (extended families), iwi (tribe) thrive in Te Ao Māori (Māori society)6 With some Māori ageing successfully, then, questions arise around health, socioeconomic and cultural profile; how quality of life will be experienced, and how Māori society will respond within prevailing English-speaking, New Zealand Pākehā (European) society.Māori in advanced age have an important role in Māori whānau, hapū, and iwi and, the wider community. Often with age, their roles and responsibilities increase. In consequence of their whakapapa, role, responsibilities, and knowledge of te reo Māori some Māori in advanced age are the pou, that is the main support of their whānau and hapū.Māori in advanced age are experienced, knowledgeable, and wise; they are influenced by the history, the diverse conditions in which they were raised, tribal aspirations, and enlistment in World War 2 to prove that Māori are citizens of New Zealand at a time of policies that marginalised and discriminated against the indigenous population.Māori aged 80 years and over have lived their lives under policies which have discriminated against them, for example, being punished for speaking te reo Māori in school, and forced to assimilate to the ways of living of the dominant New Zealand Pākehā (European) society.7,8Te reo Māori-determined factors, though, are important to health,9 and socioeconomic and cultural profile, but exactly how and to what extent is not known. What is known, however, is that there are an increasing number of Māori people living longer.Te puawaitanga o ngā tapuwae kia ora tonu – Life and living in advanced age: a cohort study in New Zealand (LiLACS NZ) has engaged Māori and non-Māori in a longitudinal study.10,11This paper focusses on the socioeconomic and cultural profile of Māori participants aged 80 to 90 years in 2010 (baseline), and how these characteristics are related to quality of life (QOL).MethodsLiLACS NZ recruited over 421 Māori (45% of total LiLACS NZ sample) in advanced age (aged 80–90 years in 2010).12,13 and 516 non-Māori participants (data reported elsewhere). Enrolment of the participants used both the New Zealand Māori and General electoral rolls, local health services data bases, whakawhānaungatanga (kin relations) and active promotion of the study in all areas of the community, including marae (sacred gathering place of kin relations), and residential care facilities.Ethical approval for this study was given by the Northern X Regional Ethics Committee NXT09/09/88. A Kaupapa Māori research methodology has been developed for the study with the creation of Te Rōpū Kaitiaki o Ngā Tikanga Māori (the protectors of principles of conduct in Māori research), the group of elders who help to guide the study, recruit Māori organisations and participants, assist in translation of the LiLACS NZ documents from English language to te reo Māori, conduct ceremonial ritual, and oversee the ongoing processes. The methodology for the study was rehearsed in a feasibility study. 12, 13Detailed recruitment and assessment information appears elsewhere10,11 and is briefly summarised here. The Bay of Plenty and Rotorua regions were chosen after careful consideration of availability of older Māori, the need for a balance of rural and urban settings and the presence of strength in te reo Māori. Eligible participants were born between 1 January 1920 and 31 December 1930 and resident in the Bay of Plenty and Lakes District Health Board areas, excluding the Taupo region.Participants were invited by a person or organisation known to them, and informed consent was obtained for each component of the study: interview, physical assessment, blood sample and access to the medical record. A family member or caregiver was invited to be present and act as a proxy if the participant was unable to answer themselves.A comprehensive quantitative questionnaire covered health, social, cultural, environmental and economic status. The interview schedule was translated from English language to te reo Māori by a New Zealand-registered translator and revised by Te Rōpū Kaitiaki to better suit the language and lived experience of the age group.In this paper sociodemographic information, family contact and support, language and cultural practices are reported along with the main outcomes of functional status and QOL. Demographic information: age, gender, marital status, housing, living arrangement, main family occupation, size of family, number of children, was recorded using standardised questions.The deprivation index (NZDep)14 was derived from the address given at the time of the interview. Income was assessed by self-reported receipt of the NZ Superannuation (pension) and any other income. Religious affiliation was assessed by self-report and the importance of faith to wellbeing was asked with a 5 level Likert response. Social support utilised the approach from the MacArthur studies 15 (Appendix 1 – questionnaire items: social):Questions about cultural practices were generated from discussion groups with older Māori 13 and asked about importance of hapu, iwi and tikanga to wellbeing and the effect of colonisation (Appendix cultural questions).Further questions about cultural identity were drawn from the Te Hoa Nuku Roa scale about contact with marae, fluency and use of te reo Māori (Appendix 1).16The experience of discrimination was asked using the New Zealand Health Survey17 questions about discrimination: whether they had been a victim of physical or verbal abuse because of ethnicity less than 12 months ago, greater than 12 months ago: whether they had been treated unfairly by a health professional on the basis of ethnicity within the last 12 months and greater than 12 months ago and whether they had been treated unfairly by a services agency for renting or buying housing.A composite code for ‘ever' been discriminated against was constructed if any of these were ‘yes'. Also asked was, Have you ever been spoken down to as a Māori?Occupation was by self-report of the main lifetime occupation of the participant and their spouse and coded using the “New Zealand Standard Classification of Occupations 1999” from Statistics New Zealand. The highest occupational category of the participant or their spouse was used in analyses.The Nottingham Extended Activities of Daily Living (NEADL) functional assessment tool18 established the functional status of participants and the SF-12 quality of life (QOL).19 The best instrument to assess quality of life for indigenous people is not known as most measures have been developed from a western dominant cultural perspective.The SF-3620 and the SF-1219 are commonly used as health-related QOL measures in many cultures and in New Zealand. However the exact utility of these measures for Māori is not known, despite translation of the SF-12 to te reo Māori. The scale presents two summary scores; mental health-related QOL and physical health-related QOL. The maximum score from this instrument is 100 and any score lower that is below 40 indicates poor health and above 60 reasonable and better health.21 Descriptive statistics were used to show the characteristics of men and women. Chi-squared test (χ2) was used to compare men and women.The association between socioeconomic and cultural factors and QOL was assessed by univariate analyses (not shown) using analysis of variance, t-tests and nonparametric statistics depending on the distribution of the data. Factors significant at the 0.2 level (in the univariate models) were entered into a multiple regression model and examined to assess independence and strength of association. The model was adjusted for: gender, age, functional status and meshblock decile using the New Zealand Deprivation index (NZ Dep) related to participant address.14 Models were adjusted for best fit. Final models are presented for outcomes of physical and mental health related to QOL. All analyses were carried out using SAS v9.2 software.22ResultsA total of 421 of 766 Māori eligible for recruitment agreed to be enrolled, 56% recruitment rate. All participants answered a core group of questions (shaded in the tables) and 267 (63%) completed the comprehensive interview.Those who opted for the short interview (150, 36%) were more likely to be in residential care and/or to be incapable of answering the interview questions for themselves (p <0.0001 for both). Four participants did not complete the study on enrolment and so 417 are included in the analysis. 91 (14%) completed the interview in te reo Māori and English and 568 (86%) in English alone. The average number of interviews to complete the comprehensive study was 1.2 (between 1 and 4, SD 0.5) and the median total interview time was 2.5 hours (IQR 2-3hours).The average age of participants was 82.7 years and 42% were men. Table 1 provides an overview of the characteristics of the Māori cohort. More women were widowed than men (42% of men, 74% of women, χ2=41.5 df=2 p<0.001). Just over 40% of the participants were living alone, 27% of men and 51% of women, (χ2=17.6, df=2, p<<0.001), 70 (26%) lived with a spouse and 87 (33%) lived with others. Sixteen (6%) had no children living at the time of the survey, 82 (32%) had 1-3 living children and 160 (62%) had 4–6 surviving children, with on average 16 (SD 23) mokopuna (grandchildren). The majority 212 (81%) reported owning their home outright, 2% had a mortgage and 17% (58) lived in rented accommodation. Almost all 240 (94%) reported the NZ superannuation was their main source of income and for almost half (47%) it was their only source of income. Table 1. Sociodemographic characteristics of Māori participants in LiLACS NZ \r\n \r\n \r\n \r\n Total number recruited\r\n \r\n Men, n (%) 176 (42%)\r\n \r\n Women, n (%) 241 (58%)\r\n \r\n Total 417 (100%)\r\n \r\n \r\n \r\n \r\n \r\n Completed the full questionnaire Completed the partial questionnaire\r\n \r\n 102 75\r\n \r\n 155 89\r\n \r\n 255 164\r\n \r\n \r\n \r\n Age, mean (SD)\r\n \r\n 82.5 (2.8)\r\n \r\n 82.8 (2.7)\r\n \r\n 82.7 (2.8)\r\n \r\n \r\n \r\n Country of birth Born in New Zealand\r\n \r\n 173 (99)\r\n \r\n 239 (99)\r\n \r\n 412 (99)\r\n \r\n \r\n \r\n Born overseas\r\n \r\n 2 (1)\r\n \r\n 2 (1)\r\n \r\n 4 (1)\r\n \r\n \r\n \r\n Childhood family size, mean (SD) total family size\r\n \r\n 7.5 (3.9)\r\n \r\n 7.6 (4.3)\r\n \r\n 7.5 (4.1)\r\n \r\n \r\n \r\n Sisters\r\n \r\n 3 (2.0)\r\n \r\n 3.2 (2.4)\r\n \r\n 3.1 (2.3)\r\n \r\n \r\n \r\n Brothers\r\n \r\n 3.5 (2.7)\r\n \r\n 3.4 (2.4)\r\n \r\n 3.4 (2.5)\r\n \r\n \r\n \r\n Sisters still living\r\n \r\n 1.3 (1.4)\r\n \r\n 1.4 (1.5)\r\n \r\n 1.3 (1.5)\r\n \r\n \r\n \r\n Brothers still living\r\n \r\n 0.9 (1.1)\r\n \r\n 1.1 (1.4)\r\n \r\n 1 (1.3)\r\n \r\n \r\n \r\n Marital status Widowed\r\n \r\n 72 (42)\r\n \r\n 176 (74)\r\n \r\n 257 (50)\r\n \r\n \r\n \r\n Married/ partnered\r\n \r\n 80 (47)\r\n \r\n 50 (21)**\r\n \r\n 120 (32)\r\n \r\n \r\n \r\n Never married/separated/divorced\r\n \r\n 10 (11)\r\n \r\n 13 (5)\r\n \r\n 49 (9.6)\r\n \r\n \r\n \r\n Number of living children None\r\n \r\n 8 (8)\r\n \r\n 8 (5%)\r\n \r\n 16 (6)\r\n \r\n \r\n \r\n 1–3\r\n \r\n 31 (30)\r\n \r\n 51 (33%)\r\n \r\n 82 (32)\r\n \r\n \r\n \r\n 4–6\r\n \r\n 65 (63)\r\n \r\n 95 (62%)\r\n \r\n 160 (62)\r\n \r\n \r\n \r\n Grandchildren, mean (SD)\r\n \r\n 16 (21.8)\r\n \r\n 16 (23.5)\r\n \r\n 16 (22.8)\r\n \r\n \r\n \r\n Living arrangement Alone\r\n \r\n 29 (27)\r\n \r\n 81 (51)**\r\n \r\n 110 (41)\r\n \r\n \r\n \r\n With spouse\r\n \r\n 40 (37)\r\n \r\n 30 (19)\r\n \r\n 70 (26)\r\n \r\n \r\n \r\n With other\r\n \r\n 38 (36)\r\n \r\n 49 (31)\r\n \r\n 87 (33)\r\n \r\n \r\n \r\n If with other person, average number in house\r\n \r\n 3.7 (2.0)\r\n \r\n 3 (1.4)\r\n \r\n 3.3 (1.7)\r\n \r\n \r\n \r\n Type of house Private house\r\n \r\n 87 (84)\r\n \r\n 125 (80)\r\n \r\n 212 (81)\r\n \r\n \r\n \r\n Unit/apartment\r\n \r\n 8 (8)\r\n \r\n 15 (10)\r\n \r\n 23 (9)\r\n \r\n \r\n \r\n Other\r\n \r\n 8 (8)\r\n \r\n 16 (10)\r\n \r\n 24 (9)\r\n \r\n \r\n \r\n Residential care\r\n \r\n 1 (1)\r\n \r\n 1 (1)\r\n \r\n 2 (1)\r\n \r\n \r\n \r\n Home ownership Owns own home outright\r\n \r\n 118 (80)\r\n \r\n 157 (82)\r\n \r\n 275 (81)\r\n \r\n \r\n \r\n Owns own home mortgage\r\n \r\n 3 (2)\r\n \r\n 3 (2)\r\n \r\n 6 (2)\r\n \r\n \r\n \r\n Rent\r\n \r\n 27 (18)\r\n \r\n 31 (16)\r\n \r\n 58 (17)\r\n \r\n \r\n \r\n Deprivation, NZDep score 1–3 Low\r\n \r\n 5 (3)\r\n \r\n 18 (8)\r\n \r\n 23 (6)\r\n \r\n \r\n \r\n 4–7 Medium\r\n \r\n 71 (40)\r\n \r\n 79 (33)\r\n \r\n 150 (36)\r\n \r\n \r\n \r\n 8–10 High\r\n \r\n 100 (57)\r\n \r\n 144 (60)\r\n \r\n 244 (59)\r\n \r\n \r\n \r\n Income Pension only\r\n \r\n 49 (48)\r\n \r\n 71 (46)\r\n \r\n 120 (47)\r\n \r\n \r\n \r\n Other income as well as pension\r\n \r\n 53 (52)\r\n \r\n 82 (54)\r\n \r\n 135 (53)\r\n \r\n \r\n \r\n Main occupation* Professionals\r\n \r\n 48 (27)\r\n \r\n 63 (26)\r\n \r\n 111 (27)\r\n \r\n \r\n \r\n Technical\r\n \r\n 15 (9)\r\n \r\n 30 (12)\r\n \r\n 45 (11)\r\n \r\n \r\n \r\n Non-technical, non-professional\r\n \r\n 113 (64)\r\n \r\n 148 (61)\r\n \r\n 261 (63)\r\n \r\n \r\n \r\n Education Tertiary\r\n \r\n 10 (6)\r\n \r\n 27 (11)\r\n \r\n 37 (9)\r\n \r\n \r\n \r\n Trade\r\n \r\n 5 (3)\r\n \r\n 12 (5)\r\n \r\n 17 (4)\r\n \r\n \r\n \r\n Any secondary\r\n \r\n 99 (59)\r\n \r\n 138 (59)\r\n \r\n 237 (59)\r\n \r\n \r\n \r\n Primary only or none\r\n \r\n 56 (33)\r\n \r\n 59 (25)\r\n \r\n 115 (28)\r\n \r\n \r\n \r\n Religion Anglican\r\n \r\n 52 (53)\r\n \r\n 67 (44)\r\n \r\n 119 (47)\r\n \r\n \r\n \r\n Catholic\r\n \r\n 18 (18)\r\n \r\n 36 (24)\r\n \r\n 54 (22)\r\n \r\n \r\n \r\n Presbyterian\r\n \r\n 6 (6)\r\n \r\n 11 (7)\r\n \r\n 17 (7)\r\n \r\n \r\n \r\n Methodist\r\n \r\n 2 (2)\r\n \r\n 3 (2)\r\n \r\n 5 (2)\r\n \r\n \r\n \r\n Rātana/Paimārie\r\n \r\n 7 (7)\r\n \r\n 10 (7)\r\n \r\n 17 (7)\r\n \r\n \r\n \r\n Ringatū\r\n \r\n 8 (8)\r\n \r\n 5 (3)\r\n \r\n 13 (5)\r\n \r\n \r\n \r\n Destiny/ Church of the Latter Day Saints of Jesus Christ (Mormon)\r\n \r\n 2 (2)\r\n \r\n 3 (2)\r\n \r\n 5 (2)\r\n \r\n \r\n \r\n Other\r\n \r\n 4 (4)\r\n \r\n 17 (11)\r\n \r\n 21 (8)\r\n \r\n \r\n \r\n How important is faith to your wellbeing? Not at all\r\n \r\n 7 (7)\r\n \r\n 5 (3)\r\n \r\n 12 (5)\r\n \r\n \r\n \r\n A little\r\n \r\n 10 (10)\r\n \r\n 8 (5)\r\n \r\n 18 (7)\r\n \r\n \r\n \r\n Moderately\r\n \r\n 18 (17)\r\n \r\n 17 (11)\r\n \r\n 35 (13)\r\n \r\n \r\n \r\n Very\r\n \r\n 44 (42)\r\n \r\n 71 (45)\r\n \r\n 115 (44)\r\n \r\n \r\n \r\n Extremely\r\n \r\n 26 (25)\r\n \r\n 57 (36)\r\n \r\n 83 (32)\r\n \r\n \r\n \r\n Do you have anyone to help with daily tasks? Yes\r\n \r\n 78 (77)\r\n \r\n 131 (85)\r\n \r\n 209 (82)\r\n \r\n \r\n \r\n No\r\n \r\n 7 (7)\r\n \r\n 10 (6)\r\n \r\n 17 (7)\r\n \r\n \r\n \r\n I don't need help\r\n \r\n 16 (16)\r\n \r\n 14 (9)\r\n \r\n 30 (12)\r\n \r\n \r\n \r\n Unmet need for practical help Yes\r\n \r\n 24 (24)\r\n \r\n 29 (19)\r\n \r\n 53 (21)\r\n \r\n \r\n \r\n Anyone to provide emotional support? Yes\r\n \r\n 82 (81)\r\n \r\n 126 (82)\r\n \r\n 208 (82)\r\n \r\n \r\n \r\n No\r\n \r\n 5 (5)\r\n \r\n 9 (6)\r\n \r\n 14 (5)\r\n \r\n \r\n \r\n I don't need emotional support\r\n \r\n 14 (14)\r\n \r\n 19 (12)\r\n \r\n 33 (13)\r\n \r\n \r\n \r\n Unmet need for emotional support\r\n \r\n 17 (17)\r\n \r\n 23 (15)\r\n \r\n 40 (16)\r\n \r\n \r\n \r\n Shading shows core questions answered by all participants (full and partial). Other questions answered by those that completed full questionnaire only. There were no gender differences in responses unless stated.\r\n** p <0.001; *The highest of spouse and participant, Professional = Legislators, Administrators, Professionals, Agricultural and Fishery Workers (requiring tertiary qualification); technical: Technicians, Associate Professionals and Trades Workers (technical training); Clerks, Service Workers, Sales Workers, Plant/Machine Operators, Assemblers, Elementary Workers (on the job training). NEADL Nottingham Extended Activity of Daily Living Scale, higher score indicates better function. The majority of the sample lived in areas in the highest deprivation tertiles, and half received income in addition to the pension (135 or 53%). Non-technical occupations were the most common and n=54 (13%) had qualifications beyond secondary school. Almost all reported a religion and the importance of faith to wellbeing was reported to be very/extremely important by n=145 (76%).The majority of participants reported someone being available for practical and emotional support however up to 20% could have used more practical or emotional help (Table 1). Those who lived alone were no more or less likely to have practical or emotional support or to report unmet need in these areas than those who lived with spouse or others.Table 2 shows there was a similar level of fluency in te reo Māori among both Māori men and women. The majority of the participants had a moderate to in-depth understanding of te reo Māori. Table 2. Cultural practices of Māori in advanced age (LiLACS NZ) \r\n \r\n \r\n \r\n Total number recruited\r\n \r\n Men, n (%) 176 (42)\r\n \r\n Women, n (%) 241 (58)\r\n \r\n Total 417\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Completed the full questionnaire Completed the partial questionnaire\r\n \r\n 102 75\r\n \r\n 155 89\r\n \r\n 257 164\r\n \r\n \r\n \r\n \r\n \r\n Do you live in the same area as your hapū? No\r\n \r\n 82 (47)\r\n \r\n 131 (55)\r\n \r\n 213 (51)\r\n \r\n \r\n \r\n \r\n \r\n Yes\r\n \r\n 91 (52)\r\n \r\n 108 (45)\r\n