It’s about who they are and what they can do: Māori perspectives on frailty in later life | OPEN ACCESS
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There are pervasive health disparities between Māori and non-Māori in Aotearoa New Zealand, and frailty is no exception. Māori experience frailty more often and at a younger age than non-Māori New Zealanders,[[1,2]] with Māori aged 65–70 years being as likely to be frail as non-Māori in their early 80s.[[3]]
There is general agreement that frailty represents an elevated state of risk or vulnerability to a sudden decline in health and other negative outcomes.[[4,5]] There is less agreement about the operationalisation and assessment of frailty. One approach views frailty as a physical syndrome with an underlying biological cause,[[6]] while an alternative approach views frailty as an accumulation of medical deficits.[[7]] Moreover, there have been calls for a more holistic approach to frailty to better inform personalised care and management plans that integrate older individuals’ views and goals.[[8,9]] However, research to understand views on frailty has generally been limited to Western cultures and has not interfaced with the Māori worldview (te ao Māori).
How frailty is conceptualised and understood can shape policies, access to services, care practices and social responses, and in turn the subjective experience of frailty.[[10]] In New Zealand, service delivery for Māori may be compromised if the approach is not comprehensive within a Māori cultural context.[[11]] This qualitative study therefore explored understandings of frailty within te ao Māori to help inform appropriate assessment and support for older Māori with frailty.
Methods
Settings and participants
Three focus groups were held in Canterbury, New Zealand:
- The first group involved six residents in a Māori-model supported living villa, with the discussion taking place in situ. There were five females and one male, all of whom were aged over 65 (66 to 83) and identified as Māori.
- The second group was drawn from an existing network of health professionals working with older Māori and was held at a community venue as part of a regular meeting. Twelve of the 14 professionals identified as Māori and 13 were female.
- The third group was held as part of a hui (meeting) on health services for older Māori in rural communities and was held at the community centre in a small coastal community. The 19 participants ranged in age from 18 to over 70, with the majority aged over 65. Ten participants identified as Māori, two as ‘mixed with Māori heritage’ and seven as Pākehā (New Zealand European). An additional four visitors connected to the participants sat in on some of the discussion.
Most participants were known to one of the facilitators through their personal and professional roles within local Māori communities. Ethics approval was given by the University of Otago Human Ethics Committee (17/151). Here we use the participants’ preferred terms, pōua (older man) and tāua (older woman).
Focus groups
The discussions took place in 1–1.5-hour sessions. Each focus group was co-facilitated by a Māori registered nurse working as clinical assessor with older Māori and a Pākehā gerontology researcher. The discussions were primarily held in English, but as one of the facilitators was bilingual, discussion could be facilitated in te reo Māori (the Māori language) where it arose.
The primary aim of the focus groups was to describe and understand meanings and interpretations of frailty within a Māori worldview. The structure broadly followed a hui process framework:[[12]]
- Mihi and whakawhanaungatanga: welcome and establishing connection.
- Kaupapa: the main purpose of the focus group, with a semi-structured discussion guide focusing on what makes them think of a person as “frail” and exploration focusing on what makes frailty better or worse.
- Poroporoaki: wrapping up. Summary notes were made on a white-board or easel pad throughout the sessions, which enabled initial thematic clustering with the participants present. These were photographed and transcribed for further analysis.
The discussion was also audio-recorded for the supported living and community groups and professionally transcribed.
Analysis
The thematic qualitative analysis was based on the framework approach.[[13,14]] Through the process of in-session summary and repeatedly reading the transcripts, the researchers became aware of key ideas and themes. These were used as the basis for an initial thematic framework to classify the data. The relevant content was charted verbatim into an Excel spreadsheet matrix, with the groups as the rows and the thematic elements as the columns. The matrix was reviewed, discussed and visually mapped in an iterative process. During the mapping and interpretation stage, the resonance with Waikare o te Waka o Meihana model[[15]] was recognised, and this was used to structure the final mapping and presentation of the themes.
Results
Two interlinked, overarching themes in the participants’ understanding of the experience of frailty emerged from across all the groups:
- Frailty is a multidimensional experience, encompassing physical and functional, social and whānau, psychological, environmental and macro-level factors.
- The experience of frailty is a dynamic balance between challenges/deficits and strengths/resources.
In this paper we present the sub-themes within the structure of the Waikare o te Waka o Meihana model (the Meihana model), which was developed to guide health professionals’ interactions, assessments and care within a Māori worldview (Figure 1).[[15]] The Meihana model uses the analogy of a double-hulled canoe, with the two hulls used to represent the interconnection between an individual and their whānau (support network). Five crossbeams strengthen the canoe and represent an individual's physical, psychological and emotional wellbeing, their beliefs and connectedness, their physical environment and the services available to them. The journey of the waka (canoe) is influenced by winds and ocean currents that symbolise historical and social contexts and the influence of Māori worldviews. Navigation brings together the assessment of all these components to enable the health professionals and the individual and/or whānau to plot a course forward.
Figure 1: Summary of themes.
The two hulls: the interconnection between the individual and their whānau
Frailty was seen as a whānau experience. This included the challenges of frailty. For example, whānau wellbeing can be affected by “worrying” and being “tired”, and the older person may worry about this impact. It also included the balancing factors of “good support from whānau”. An example was ensuring access to health services:
“My daughter just barged in and said, ‘you are coming’, and took me over to the doctor. I ended up in hospital having a big operation. If it had been left to me–no, I wouldn’t have gone. So I do have good whānau supports.”
Frailty was seen as challenging social wellbeing and engagement. It was associated with being “withdrawn”, “going out less” and being “lonely”. The death of a life-long partner was highlighted as a powerful factor (“Grief and loss, it’s huge”) that could sometimes lead to the bereaved partner dying “soon after”.
Feeling engaged, useful and connected to other people was intertwined with positive mental wellbeing.[[16]] “Being useful”, “having a purpose” and “manaaki” (giving support) were balancing factors. This could be expressed through their social networks and role as “the centre for our whānau”, and the bonds with “moko” (grandchild/grandchildren).
The five crossbeams
(i) Tinana: physical health and functioning
Participants from across the groups raised physical changes that echo the syndrome of physical frailty,[[ 6]] such as changes in stature or “anua”, weight, muscles and balance. All the groups also raised a vulnerability to and/or presence of health issues and conditions. For example, a greater likelihood of hearing or vision issues, pain, getting sick, healing more slowly, having poor health, hospitalisation and death. The participants suggested nutrition, exercise, traditional remedies and western medications had a role in helping prevent or mitigate frailty.
There was a strong sub-theme around mobility and independence. For one of the participants, the question was simply, “can he push a lawnmower?” Frailty was associated with walking slower, needing help walking and reduced mobility. It was also associated with loss of independence and needing help, relying on others and increased use of services: “like, they need help going to appointments, or going to the grocery shop or just going out generally”.
The participants recognised that pride may stop some older Māori from accepting help or using aids. However, the discussion positioned accepting help as a positive balancing factor of adaptation.[[17]] For example, one person with a tokotoko (walking stick) said, “if I need a stick, I don’t feel old. I just find it’s just a thing there that enables me to get around… I’ve got a walking stick as part of an aid”. Another advised that, if there were younger family members to help, “you make the most of it”. The discussion highlighted that it is important that help is offered proactively as, traditionally, asking for help may be seen as rude or shameful:[[18]] “actually ask… because they’re too whakamā (ashamed) to say or they don’t want to put them out”.
(ii) Hinengaro: psychological and emotional
Cognitive changes were associated with frailty across all the groups. This included “forgetfulness” and “memory”; being slower and needing help with decisions and finances; being “confused” and “not up with the play”; and generally being slower cognitively.
Frailty was also associated with challenges to emotional wellbeing across all the groups. People living with frailty may be “frustrated” and “bored”, “a bit depressed”, “bad-tempered” or “grumpy”. People who were frail were seen as often being “not as confident” as they were in the past and being “nervous” and “worried”. There is likely a two-way relationship between (a) being physically frail as a risk factor for poor emotional wellbeing and (b) poor emotional wellbeing acting as a risk factor for physical frailty (eg, by decreasing motivation for self-care).[[19]]
The participants raised the importance of “mindset”, “personality” and “inner strength” as balancing factors: “It depends what he thinks”. Mauri ora (inner strength, life force) is integral to understanding wellbeing and resilience.[[20]] Having “autonomy”, “mana” (respect) and “confidence” were positive balancing factors. The discussions revealed how supporters can recognise and strengthen these self-concepts or erode them:
“Remember that they’re not deaf, dumb and blind… Sally says, ‘my name’s Sally, not silly’. She’ll say it right in front of them. And they just don’t get the message… and it quietens down and she goes into her little corner and folds and folds and folds… all these ones that think she can’t do anything are around her… I know she’s hōhā or bored.”
The health professionals discussed how safety concerns need to be balanced with maintaining independence, autonomy and “real choices”.
(iii) Taiao: the physical environment
In the context of frailty, transport was a salient aspect of the physical environment, particularly in rural group. There was a recognition that frailty often means giving up driving. For example: “eventually I won’t be able to drive and I will have to rely on my daughter and she works”. The availability and affordability of transport impacted on each participant’s ability to maintain engagement and access services:
“It’s transport, and being able to drive and being able to budget to be able to pay for that transport. So anything within the assistance of transport would be amazing and welcome.”
The participants, particularly the group of professionals, also expressed their awareness of regional differences and the impact of the Canterbury earthquakes.
(iv) Iwi katoa: support services and systems
The general practitioner was the first point of call for health matters: “that would be your first one, a doctor”. Services that came to them were appreciated, such as a nurse who “came round to make sure you were ok”, or a community pharmacist coming out to explain medications. Listening was the key to appropriate services:
“I think listening is a good key question. Listening to people, which they didn’t have the skills to listen to, they need to go to listening school.”
Pōua and tāua said they would sometimes provide feedback to the health professional when the interaction was unsatisfactory, but they would not return to a health professional who didn’t listen. Developing and maintaining trust was a key to appropriate services.[[15,21]]
(v) Wairua: beliefs regarding connectedness and spirituality
Te oranga wairua (spiritual wellbeing) has been described as “a deeply spiritual and uniquely Māori experience of connectivity”.[[22]] An underlying theme of manaakitanga (generosity and care) as an intrinsic and pervasive positive balancing factor was interwoven through the talk. The older participants had grown up with support for older members of the whānau as a given—“whether we like it or not”, one joked. Being integrated in the whānau involved support being available and needs known: “I think the connectors of the whānau do need to keep poking their noses in and checking up”. A practical expression of manaakitanga was that the rūnanga (tribal authority) could provide practical health support, such as access to free health consultations, which could help provide a sense of security: “if I didn’t have the rūnanga I’d be scared”.
While kaupapa Māori and marae-based care can be highly successful for some, there was recognition that workforce capacity is not robust enough to provide this in all situations, and that it will not necessarily be preferred by all Māori, as there are “some faces you never see” at the marae.
Ngā roma moana: ocean currents
While Māori can have diverse relationships with te ao Māori, Māoritanga (Māori practices and beliefs) can be a source of inner strength and life force (mauri ora).[[20]] Previous research has supported the link between having a connection with traditional cultural practices and places and having greater wellbeing.[[23,24]] This was echoed in the comments of pōua and tāua about how “cultural identity”, “tikanga” and visiting the marae had a positive impact on the experience of frailty (eg, in providing a feeling of being “uplifted” and minimising depression).
Ngā hau e wha: the four winds
Past and current generations are interconnected within a Māori worldview, and there is increasing awareness of how the ongoing impacts of colonisation, racism, migration and marginalisation provide the context for current economic and health disparities.[[25]] The four winds of colonisation, racism, migration and marginalisation provide the context for economic and health disparities.[[15]] The group of health professionals discussed how funding models that provide access at age 65 are inappropriate, as Māori can need earlier access.
Pōua and tāua discussed that “money can be a huge issue” and the impact of the potential cost of doctor fees, prescription fees and transport costs to get to appointments and chemists: “If you don’t have the money, you don’t go”. Budgeting was a potential individual balancing factor, although the relative strength of impact was debated.
An impact of migration could be seen in the perceived barriers to approaching local rūnanga services:
“you’re lucky to belong to the local rūnanga, but there are other Māori there that come from other places, and I made one kuia (older woman) come with me… because she wouldn’t go because it wasn’t for other Māori.”
Whakatere: navigation and strengths
One of the salient messages to emerge across the focus groups is that a culturally appropriate understanding of frailty will not emerge from looking at deficits alone. A focus on deficits not only runs the risk of providing an incomplete understanding of frailty, but also the risk of being perceived as disrespectful: “everyone around here seems to think she’s pakaru (broken)… she ain’t pakaru” and diminishing: “It’s an undermining of them”. This may lead to resistance to the imposition of a label: “whose perception is it?... Yeah well is that my perception?” and following suggestions: “do you know what taringa mārō (stubbornness) means?… I don’t listen”. Among the health professionals, there were misgivings about assessment: “but does it measure wellbeing?”. The discussions provided reminders that at the heart of any approach to frailty must be the core value that “they are still the person” and “it’s about who they are and what they can still do”. Joint navigation for frailty with older Māori and their whānau may be facilitated by a sound foundation of a holistic, strength-based approach and good listening:
“Sometimes, some medical persons, they don’t listen to what you are telling them. They have got their own opinion and you will be going on this pathway not what you think…”
Discussion
The present study was a small exploratory study in a single region and was weighted towards individuals who were well-connected with te ao Māori, and as such it cannot fully explore nuances and diverse experiences of being Māori. However, it was the first study to specifically seek to understand Māori perspectives on frailty.
Participants talked about frailty as being multidimensional and the experience of frailty as being shaped by both deficits and strengths. This understanding of frailty resonates with previous work from other cultures,[[9,26,27]] and yet it was also intrinsically Māori. These themes meshed with and reinforced the value of holistic Māori models of assessment and understanding, such as the Waikare o te Waka o Meihana, te Whare Tapa Whā (the Four Sided House), te Wheke (the Octopus) and te Pae Māhutonga (the Southern Cross Constellation).[[15,29–31]]
In 2000, Markele-Reid and Browne criticised many of the current approaches to frailty for taking an objective approach that focuses on physical deficits and dependency in isolation from strengths, which they argued is not sufficient for understanding the holistic, complex and unique meaning of frailty for an individual.[[28]] According to Markle-Reid and Browne, an understanding of frailty must recognise that the experience of frailty is multidimensional and determined by “the complex interplay of physical, psychological, social, and environment factors” and the perceptions and strengths of the individual. In some ways the decades of thinking around hauora (holistic health) can be seen as providing an example of the kind of approach that Markle-Reid found so lacking in the mainstream biomedical literature on frailty. A strength-based hauora approach that contextualises is more likely to be acceptable, meet needs and align with traditional models for Māori.[[18,20]] Such an approach to culturally appropriate assessment to frailty is relevant to all health professionals, alongside taha Māori (those of Māori descent), as the Māori workforce capacity is not robust enough “to do it all”. As frailty becomes an increasingly dominant theme in services for older people, we hope that further kaupapa Māori work will help to articulate a hauora approach to frailty.
Summary
Abstract
AIM: This study aimed to explore Māori (the indigenous people of Aotearoa New Zealand) understandings of frailty. METHOD: Focus groups were held with older Māori in supported living, health professionals working with older Māori and a rural community. A qualitative thematic analysis was conducted. RESULTS: Two interlinked, overarching themes emerged: (1) Frailty is a multidimensional experience, not simply a physical one. (2) The experience of frailty is a balance between deficits and strengths. The Waikare o te Waka o Meihana model provided a useful framework for structuring the thematic results. CONCLUSIONS: Culturally appropriate and comprehensive support and care for older Māori with frailty will be facilitated by a rounded strength-based approach and listening skills.
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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It’s about who they are and what they can do: Māori perspectives on frailty in later life | OPEN ACCESS
View Article PDF
There are pervasive health disparities between Māori and non-Māori in Aotearoa New Zealand, and frailty is no exception. Māori experience frailty more often and at a younger age than non-Māori New Zealanders,[[1,2]] with Māori aged 65–70 years being as likely to be frail as non-Māori in their early 80s.[[3]]
There is general agreement that frailty represents an elevated state of risk or vulnerability to a sudden decline in health and other negative outcomes.[[4,5]] There is less agreement about the operationalisation and assessment of frailty. One approach views frailty as a physical syndrome with an underlying biological cause,[[6]] while an alternative approach views frailty as an accumulation of medical deficits.[[7]] Moreover, there have been calls for a more holistic approach to frailty to better inform personalised care and management plans that integrate older individuals’ views and goals.[[8,9]] However, research to understand views on frailty has generally been limited to Western cultures and has not interfaced with the Māori worldview (te ao Māori).
How frailty is conceptualised and understood can shape policies, access to services, care practices and social responses, and in turn the subjective experience of frailty.[[10]] In New Zealand, service delivery for Māori may be compromised if the approach is not comprehensive within a Māori cultural context.[[11]] This qualitative study therefore explored understandings of frailty within te ao Māori to help inform appropriate assessment and support for older Māori with frailty.
Methods
Settings and participants
Three focus groups were held in Canterbury, New Zealand:
- The first group involved six residents in a Māori-model supported living villa, with the discussion taking place in situ. There were five females and one male, all of whom were aged over 65 (66 to 83) and identified as Māori.
- The second group was drawn from an existing network of health professionals working with older Māori and was held at a community venue as part of a regular meeting. Twelve of the 14 professionals identified as Māori and 13 were female.
- The third group was held as part of a hui (meeting) on health services for older Māori in rural communities and was held at the community centre in a small coastal community. The 19 participants ranged in age from 18 to over 70, with the majority aged over 65. Ten participants identified as Māori, two as ‘mixed with Māori heritage’ and seven as Pākehā (New Zealand European). An additional four visitors connected to the participants sat in on some of the discussion.
Most participants were known to one of the facilitators through their personal and professional roles within local Māori communities. Ethics approval was given by the University of Otago Human Ethics Committee (17/151). Here we use the participants’ preferred terms, pōua (older man) and tāua (older woman).
Focus groups
The discussions took place in 1–1.5-hour sessions. Each focus group was co-facilitated by a Māori registered nurse working as clinical assessor with older Māori and a Pākehā gerontology researcher. The discussions were primarily held in English, but as one of the facilitators was bilingual, discussion could be facilitated in te reo Māori (the Māori language) where it arose.
The primary aim of the focus groups was to describe and understand meanings and interpretations of frailty within a Māori worldview. The structure broadly followed a hui process framework:[[12]]
- Mihi and whakawhanaungatanga: welcome and establishing connection.
- Kaupapa: the main purpose of the focus group, with a semi-structured discussion guide focusing on what makes them think of a person as “frail” and exploration focusing on what makes frailty better or worse.
- Poroporoaki: wrapping up. Summary notes were made on a white-board or easel pad throughout the sessions, which enabled initial thematic clustering with the participants present. These were photographed and transcribed for further analysis.
The discussion was also audio-recorded for the supported living and community groups and professionally transcribed.
Analysis
The thematic qualitative analysis was based on the framework approach.[[13,14]] Through the process of in-session summary and repeatedly reading the transcripts, the researchers became aware of key ideas and themes. These were used as the basis for an initial thematic framework to classify the data. The relevant content was charted verbatim into an Excel spreadsheet matrix, with the groups as the rows and the thematic elements as the columns. The matrix was reviewed, discussed and visually mapped in an iterative process. During the mapping and interpretation stage, the resonance with Waikare o te Waka o Meihana model[[15]] was recognised, and this was used to structure the final mapping and presentation of the themes.
Results
Two interlinked, overarching themes in the participants’ understanding of the experience of frailty emerged from across all the groups:
- Frailty is a multidimensional experience, encompassing physical and functional, social and whānau, psychological, environmental and macro-level factors.
- The experience of frailty is a dynamic balance between challenges/deficits and strengths/resources.
In this paper we present the sub-themes within the structure of the Waikare o te Waka o Meihana model (the Meihana model), which was developed to guide health professionals’ interactions, assessments and care within a Māori worldview (Figure 1).[[15]] The Meihana model uses the analogy of a double-hulled canoe, with the two hulls used to represent the interconnection between an individual and their whānau (support network). Five crossbeams strengthen the canoe and represent an individual's physical, psychological and emotional wellbeing, their beliefs and connectedness, their physical environment and the services available to them. The journey of the waka (canoe) is influenced by winds and ocean currents that symbolise historical and social contexts and the influence of Māori worldviews. Navigation brings together the assessment of all these components to enable the health professionals and the individual and/or whānau to plot a course forward.
Figure 1: Summary of themes.
The two hulls: the interconnection between the individual and their whānau
Frailty was seen as a whānau experience. This included the challenges of frailty. For example, whānau wellbeing can be affected by “worrying” and being “tired”, and the older person may worry about this impact. It also included the balancing factors of “good support from whānau”. An example was ensuring access to health services:
“My daughter just barged in and said, ‘you are coming’, and took me over to the doctor. I ended up in hospital having a big operation. If it had been left to me–no, I wouldn’t have gone. So I do have good whānau supports.”
Frailty was seen as challenging social wellbeing and engagement. It was associated with being “withdrawn”, “going out less” and being “lonely”. The death of a life-long partner was highlighted as a powerful factor (“Grief and loss, it’s huge”) that could sometimes lead to the bereaved partner dying “soon after”.
Feeling engaged, useful and connected to other people was intertwined with positive mental wellbeing.[[16]] “Being useful”, “having a purpose” and “manaaki” (giving support) were balancing factors. This could be expressed through their social networks and role as “the centre for our whānau”, and the bonds with “moko” (grandchild/grandchildren).
The five crossbeams
(i) Tinana: physical health and functioning
Participants from across the groups raised physical changes that echo the syndrome of physical frailty,[[ 6]] such as changes in stature or “anua”, weight, muscles and balance. All the groups also raised a vulnerability to and/or presence of health issues and conditions. For example, a greater likelihood of hearing or vision issues, pain, getting sick, healing more slowly, having poor health, hospitalisation and death. The participants suggested nutrition, exercise, traditional remedies and western medications had a role in helping prevent or mitigate frailty.
There was a strong sub-theme around mobility and independence. For one of the participants, the question was simply, “can he push a lawnmower?” Frailty was associated with walking slower, needing help walking and reduced mobility. It was also associated with loss of independence and needing help, relying on others and increased use of services: “like, they need help going to appointments, or going to the grocery shop or just going out generally”.
The participants recognised that pride may stop some older Māori from accepting help or using aids. However, the discussion positioned accepting help as a positive balancing factor of adaptation.[[17]] For example, one person with a tokotoko (walking stick) said, “if I need a stick, I don’t feel old. I just find it’s just a thing there that enables me to get around… I’ve got a walking stick as part of an aid”. Another advised that, if there were younger family members to help, “you make the most of it”. The discussion highlighted that it is important that help is offered proactively as, traditionally, asking for help may be seen as rude or shameful:[[18]] “actually ask… because they’re too whakamā (ashamed) to say or they don’t want to put them out”.
(ii) Hinengaro: psychological and emotional
Cognitive changes were associated with frailty across all the groups. This included “forgetfulness” and “memory”; being slower and needing help with decisions and finances; being “confused” and “not up with the play”; and generally being slower cognitively.
Frailty was also associated with challenges to emotional wellbeing across all the groups. People living with frailty may be “frustrated” and “bored”, “a bit depressed”, “bad-tempered” or “grumpy”. People who were frail were seen as often being “not as confident” as they were in the past and being “nervous” and “worried”. There is likely a two-way relationship between (a) being physically frail as a risk factor for poor emotional wellbeing and (b) poor emotional wellbeing acting as a risk factor for physical frailty (eg, by decreasing motivation for self-care).[[19]]
The participants raised the importance of “mindset”, “personality” and “inner strength” as balancing factors: “It depends what he thinks”. Mauri ora (inner strength, life force) is integral to understanding wellbeing and resilience.[[20]] Having “autonomy”, “mana” (respect) and “confidence” were positive balancing factors. The discussions revealed how supporters can recognise and strengthen these self-concepts or erode them:
“Remember that they’re not deaf, dumb and blind… Sally says, ‘my name’s Sally, not silly’. She’ll say it right in front of them. And they just don’t get the message… and it quietens down and she goes into her little corner and folds and folds and folds… all these ones that think she can’t do anything are around her… I know she’s hōhā or bored.”
The health professionals discussed how safety concerns need to be balanced with maintaining independence, autonomy and “real choices”.
(iii) Taiao: the physical environment
In the context of frailty, transport was a salient aspect of the physical environment, particularly in rural group. There was a recognition that frailty often means giving up driving. For example: “eventually I won’t be able to drive and I will have to rely on my daughter and she works”. The availability and affordability of transport impacted on each participant’s ability to maintain engagement and access services:
“It’s transport, and being able to drive and being able to budget to be able to pay for that transport. So anything within the assistance of transport would be amazing and welcome.”
The participants, particularly the group of professionals, also expressed their awareness of regional differences and the impact of the Canterbury earthquakes.
(iv) Iwi katoa: support services and systems
The general practitioner was the first point of call for health matters: “that would be your first one, a doctor”. Services that came to them were appreciated, such as a nurse who “came round to make sure you were ok”, or a community pharmacist coming out to explain medications. Listening was the key to appropriate services:
“I think listening is a good key question. Listening to people, which they didn’t have the skills to listen to, they need to go to listening school.”
Pōua and tāua said they would sometimes provide feedback to the health professional when the interaction was unsatisfactory, but they would not return to a health professional who didn’t listen. Developing and maintaining trust was a key to appropriate services.[[15,21]]
(v) Wairua: beliefs regarding connectedness and spirituality
Te oranga wairua (spiritual wellbeing) has been described as “a deeply spiritual and uniquely Māori experience of connectivity”.[[22]] An underlying theme of manaakitanga (generosity and care) as an intrinsic and pervasive positive balancing factor was interwoven through the talk. The older participants had grown up with support for older members of the whānau as a given—“whether we like it or not”, one joked. Being integrated in the whānau involved support being available and needs known: “I think the connectors of the whānau do need to keep poking their noses in and checking up”. A practical expression of manaakitanga was that the rūnanga (tribal authority) could provide practical health support, such as access to free health consultations, which could help provide a sense of security: “if I didn’t have the rūnanga I’d be scared”.
While kaupapa Māori and marae-based care can be highly successful for some, there was recognition that workforce capacity is not robust enough to provide this in all situations, and that it will not necessarily be preferred by all Māori, as there are “some faces you never see” at the marae.
Ngā roma moana: ocean currents
While Māori can have diverse relationships with te ao Māori, Māoritanga (Māori practices and beliefs) can be a source of inner strength and life force (mauri ora).[[20]] Previous research has supported the link between having a connection with traditional cultural practices and places and having greater wellbeing.[[23,24]] This was echoed in the comments of pōua and tāua about how “cultural identity”, “tikanga” and visiting the marae had a positive impact on the experience of frailty (eg, in providing a feeling of being “uplifted” and minimising depression).
Ngā hau e wha: the four winds
Past and current generations are interconnected within a Māori worldview, and there is increasing awareness of how the ongoing impacts of colonisation, racism, migration and marginalisation provide the context for current economic and health disparities.[[25]] The four winds of colonisation, racism, migration and marginalisation provide the context for economic and health disparities.[[15]] The group of health professionals discussed how funding models that provide access at age 65 are inappropriate, as Māori can need earlier access.
Pōua and tāua discussed that “money can be a huge issue” and the impact of the potential cost of doctor fees, prescription fees and transport costs to get to appointments and chemists: “If you don’t have the money, you don’t go”. Budgeting was a potential individual balancing factor, although the relative strength of impact was debated.
An impact of migration could be seen in the perceived barriers to approaching local rūnanga services:
“you’re lucky to belong to the local rūnanga, but there are other Māori there that come from other places, and I made one kuia (older woman) come with me… because she wouldn’t go because it wasn’t for other Māori.”
Whakatere: navigation and strengths
One of the salient messages to emerge across the focus groups is that a culturally appropriate understanding of frailty will not emerge from looking at deficits alone. A focus on deficits not only runs the risk of providing an incomplete understanding of frailty, but also the risk of being perceived as disrespectful: “everyone around here seems to think she’s pakaru (broken)… she ain’t pakaru” and diminishing: “It’s an undermining of them”. This may lead to resistance to the imposition of a label: “whose perception is it?... Yeah well is that my perception?” and following suggestions: “do you know what taringa mārō (stubbornness) means?… I don’t listen”. Among the health professionals, there were misgivings about assessment: “but does it measure wellbeing?”. The discussions provided reminders that at the heart of any approach to frailty must be the core value that “they are still the person” and “it’s about who they are and what they can still do”. Joint navigation for frailty with older Māori and their whānau may be facilitated by a sound foundation of a holistic, strength-based approach and good listening:
“Sometimes, some medical persons, they don’t listen to what you are telling them. They have got their own opinion and you will be going on this pathway not what you think…”
Discussion
The present study was a small exploratory study in a single region and was weighted towards individuals who were well-connected with te ao Māori, and as such it cannot fully explore nuances and diverse experiences of being Māori. However, it was the first study to specifically seek to understand Māori perspectives on frailty.
Participants talked about frailty as being multidimensional and the experience of frailty as being shaped by both deficits and strengths. This understanding of frailty resonates with previous work from other cultures,[[9,26,27]] and yet it was also intrinsically Māori. These themes meshed with and reinforced the value of holistic Māori models of assessment and understanding, such as the Waikare o te Waka o Meihana, te Whare Tapa Whā (the Four Sided House), te Wheke (the Octopus) and te Pae Māhutonga (the Southern Cross Constellation).[[15,29–31]]
In 2000, Markele-Reid and Browne criticised many of the current approaches to frailty for taking an objective approach that focuses on physical deficits and dependency in isolation from strengths, which they argued is not sufficient for understanding the holistic, complex and unique meaning of frailty for an individual.[[28]] According to Markle-Reid and Browne, an understanding of frailty must recognise that the experience of frailty is multidimensional and determined by “the complex interplay of physical, psychological, social, and environment factors” and the perceptions and strengths of the individual. In some ways the decades of thinking around hauora (holistic health) can be seen as providing an example of the kind of approach that Markle-Reid found so lacking in the mainstream biomedical literature on frailty. A strength-based hauora approach that contextualises is more likely to be acceptable, meet needs and align with traditional models for Māori.[[18,20]] Such an approach to culturally appropriate assessment to frailty is relevant to all health professionals, alongside taha Māori (those of Māori descent), as the Māori workforce capacity is not robust enough “to do it all”. As frailty becomes an increasingly dominant theme in services for older people, we hope that further kaupapa Māori work will help to articulate a hauora approach to frailty.
Summary
Abstract
AIM: This study aimed to explore Māori (the indigenous people of Aotearoa New Zealand) understandings of frailty. METHOD: Focus groups were held with older Māori in supported living, health professionals working with older Māori and a rural community. A qualitative thematic analysis was conducted. RESULTS: Two interlinked, overarching themes emerged: (1) Frailty is a multidimensional experience, not simply a physical one. (2) The experience of frailty is a balance between deficits and strengths. The Waikare o te Waka o Meihana model provided a useful framework for structuring the thematic results. CONCLUSIONS: Culturally appropriate and comprehensive support and care for older Māori with frailty will be facilitated by a rounded strength-based approach and listening skills.
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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2. Abey-Nesbit R, Peel NM, Matthews H, et al. Frailty of Māori, Pasifika, and non-Māori/non-Pasifika older people in New Zealand: a national population study of older people referred for home care services. J Gerontol A Biol Sci Med Sci. 2020 Oct 19.
3. Barrett P, Twitchin S, Kletchko S, Ryan F. The living environments of community-dwelling older people who become frail: another look at the living standards of older New Zealanders survey. Soc Policy J N Z. 2006); 28:133–57
4. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013; 381(9868):752-62.
5. Rockwood K, Andrew M, Mitnitski A. A comparison of two approaches to measuring frailty in elderly people. J Gerontol A Biol Sci Med Sci. 2007 Jul 1;62(7):738-43.
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8. British Geriatrics Society. Fit for frailty – consensus practice guidance for the care of older people living in the community and outpatient settings. London, UK: British Geriatrics Society; 2014.
9. Gee SB, Cheung G, Bergler U, Jamieson H. “There’s more to frail than that”: Older New Zealanders and health professionals talk about frailty. J Aging Res. 2019;2019: Article ID 2573239.
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It’s about who they are and what they can do: Māori perspectives on frailty in later life | OPEN ACCESS
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There are pervasive health disparities between Māori and non-Māori in Aotearoa New Zealand, and frailty is no exception. Māori experience frailty more often and at a younger age than non-Māori New Zealanders,[[1,2]] with Māori aged 65–70 years being as likely to be frail as non-Māori in their early 80s.[[3]]
There is general agreement that frailty represents an elevated state of risk or vulnerability to a sudden decline in health and other negative outcomes.[[4,5]] There is less agreement about the operationalisation and assessment of frailty. One approach views frailty as a physical syndrome with an underlying biological cause,[[6]] while an alternative approach views frailty as an accumulation of medical deficits.[[7]] Moreover, there have been calls for a more holistic approach to frailty to better inform personalised care and management plans that integrate older individuals’ views and goals.[[8,9]] However, research to understand views on frailty has generally been limited to Western cultures and has not interfaced with the Māori worldview (te ao Māori).
How frailty is conceptualised and understood can shape policies, access to services, care practices and social responses, and in turn the subjective experience of frailty.[[10]] In New Zealand, service delivery for Māori may be compromised if the approach is not comprehensive within a Māori cultural context.[[11]] This qualitative study therefore explored understandings of frailty within te ao Māori to help inform appropriate assessment and support for older Māori with frailty.
Methods
Settings and participants
Three focus groups were held in Canterbury, New Zealand:
- The first group involved six residents in a Māori-model supported living villa, with the discussion taking place in situ. There were five females and one male, all of whom were aged over 65 (66 to 83) and identified as Māori.
- The second group was drawn from an existing network of health professionals working with older Māori and was held at a community venue as part of a regular meeting. Twelve of the 14 professionals identified as Māori and 13 were female.
- The third group was held as part of a hui (meeting) on health services for older Māori in rural communities and was held at the community centre in a small coastal community. The 19 participants ranged in age from 18 to over 70, with the majority aged over 65. Ten participants identified as Māori, two as ‘mixed with Māori heritage’ and seven as Pākehā (New Zealand European). An additional four visitors connected to the participants sat in on some of the discussion.
Most participants were known to one of the facilitators through their personal and professional roles within local Māori communities. Ethics approval was given by the University of Otago Human Ethics Committee (17/151). Here we use the participants’ preferred terms, pōua (older man) and tāua (older woman).
Focus groups
The discussions took place in 1–1.5-hour sessions. Each focus group was co-facilitated by a Māori registered nurse working as clinical assessor with older Māori and a Pākehā gerontology researcher. The discussions were primarily held in English, but as one of the facilitators was bilingual, discussion could be facilitated in te reo Māori (the Māori language) where it arose.
The primary aim of the focus groups was to describe and understand meanings and interpretations of frailty within a Māori worldview. The structure broadly followed a hui process framework:[[12]]
- Mihi and whakawhanaungatanga: welcome and establishing connection.
- Kaupapa: the main purpose of the focus group, with a semi-structured discussion guide focusing on what makes them think of a person as “frail” and exploration focusing on what makes frailty better or worse.
- Poroporoaki: wrapping up. Summary notes were made on a white-board or easel pad throughout the sessions, which enabled initial thematic clustering with the participants present. These were photographed and transcribed for further analysis.
The discussion was also audio-recorded for the supported living and community groups and professionally transcribed.
Analysis
The thematic qualitative analysis was based on the framework approach.[[13,14]] Through the process of in-session summary and repeatedly reading the transcripts, the researchers became aware of key ideas and themes. These were used as the basis for an initial thematic framework to classify the data. The relevant content was charted verbatim into an Excel spreadsheet matrix, with the groups as the rows and the thematic elements as the columns. The matrix was reviewed, discussed and visually mapped in an iterative process. During the mapping and interpretation stage, the resonance with Waikare o te Waka o Meihana model[[15]] was recognised, and this was used to structure the final mapping and presentation of the themes.
Results
Two interlinked, overarching themes in the participants’ understanding of the experience of frailty emerged from across all the groups:
- Frailty is a multidimensional experience, encompassing physical and functional, social and whānau, psychological, environmental and macro-level factors.
- The experience of frailty is a dynamic balance between challenges/deficits and strengths/resources.
In this paper we present the sub-themes within the structure of the Waikare o te Waka o Meihana model (the Meihana model), which was developed to guide health professionals’ interactions, assessments and care within a Māori worldview (Figure 1).[[15]] The Meihana model uses the analogy of a double-hulled canoe, with the two hulls used to represent the interconnection between an individual and their whānau (support network). Five crossbeams strengthen the canoe and represent an individual's physical, psychological and emotional wellbeing, their beliefs and connectedness, their physical environment and the services available to them. The journey of the waka (canoe) is influenced by winds and ocean currents that symbolise historical and social contexts and the influence of Māori worldviews. Navigation brings together the assessment of all these components to enable the health professionals and the individual and/or whānau to plot a course forward.
Figure 1: Summary of themes.
The two hulls: the interconnection between the individual and their whānau
Frailty was seen as a whānau experience. This included the challenges of frailty. For example, whānau wellbeing can be affected by “worrying” and being “tired”, and the older person may worry about this impact. It also included the balancing factors of “good support from whānau”. An example was ensuring access to health services:
“My daughter just barged in and said, ‘you are coming’, and took me over to the doctor. I ended up in hospital having a big operation. If it had been left to me–no, I wouldn’t have gone. So I do have good whānau supports.”
Frailty was seen as challenging social wellbeing and engagement. It was associated with being “withdrawn”, “going out less” and being “lonely”. The death of a life-long partner was highlighted as a powerful factor (“Grief and loss, it’s huge”) that could sometimes lead to the bereaved partner dying “soon after”.
Feeling engaged, useful and connected to other people was intertwined with positive mental wellbeing.[[16]] “Being useful”, “having a purpose” and “manaaki” (giving support) were balancing factors. This could be expressed through their social networks and role as “the centre for our whānau”, and the bonds with “moko” (grandchild/grandchildren).
The five crossbeams
(i) Tinana: physical health and functioning
Participants from across the groups raised physical changes that echo the syndrome of physical frailty,[[ 6]] such as changes in stature or “anua”, weight, muscles and balance. All the groups also raised a vulnerability to and/or presence of health issues and conditions. For example, a greater likelihood of hearing or vision issues, pain, getting sick, healing more slowly, having poor health, hospitalisation and death. The participants suggested nutrition, exercise, traditional remedies and western medications had a role in helping prevent or mitigate frailty.
There was a strong sub-theme around mobility and independence. For one of the participants, the question was simply, “can he push a lawnmower?” Frailty was associated with walking slower, needing help walking and reduced mobility. It was also associated with loss of independence and needing help, relying on others and increased use of services: “like, they need help going to appointments, or going to the grocery shop or just going out generally”.
The participants recognised that pride may stop some older Māori from accepting help or using aids. However, the discussion positioned accepting help as a positive balancing factor of adaptation.[[17]] For example, one person with a tokotoko (walking stick) said, “if I need a stick, I don’t feel old. I just find it’s just a thing there that enables me to get around… I’ve got a walking stick as part of an aid”. Another advised that, if there were younger family members to help, “you make the most of it”. The discussion highlighted that it is important that help is offered proactively as, traditionally, asking for help may be seen as rude or shameful:[[18]] “actually ask… because they’re too whakamā (ashamed) to say or they don’t want to put them out”.
(ii) Hinengaro: psychological and emotional
Cognitive changes were associated with frailty across all the groups. This included “forgetfulness” and “memory”; being slower and needing help with decisions and finances; being “confused” and “not up with the play”; and generally being slower cognitively.
Frailty was also associated with challenges to emotional wellbeing across all the groups. People living with frailty may be “frustrated” and “bored”, “a bit depressed”, “bad-tempered” or “grumpy”. People who were frail were seen as often being “not as confident” as they were in the past and being “nervous” and “worried”. There is likely a two-way relationship between (a) being physically frail as a risk factor for poor emotional wellbeing and (b) poor emotional wellbeing acting as a risk factor for physical frailty (eg, by decreasing motivation for self-care).[[19]]
The participants raised the importance of “mindset”, “personality” and “inner strength” as balancing factors: “It depends what he thinks”. Mauri ora (inner strength, life force) is integral to understanding wellbeing and resilience.[[20]] Having “autonomy”, “mana” (respect) and “confidence” were positive balancing factors. The discussions revealed how supporters can recognise and strengthen these self-concepts or erode them:
“Remember that they’re not deaf, dumb and blind… Sally says, ‘my name’s Sally, not silly’. She’ll say it right in front of them. And they just don’t get the message… and it quietens down and she goes into her little corner and folds and folds and folds… all these ones that think she can’t do anything are around her… I know she’s hōhā or bored.”
The health professionals discussed how safety concerns need to be balanced with maintaining independence, autonomy and “real choices”.
(iii) Taiao: the physical environment
In the context of frailty, transport was a salient aspect of the physical environment, particularly in rural group. There was a recognition that frailty often means giving up driving. For example: “eventually I won’t be able to drive and I will have to rely on my daughter and she works”. The availability and affordability of transport impacted on each participant’s ability to maintain engagement and access services:
“It’s transport, and being able to drive and being able to budget to be able to pay for that transport. So anything within the assistance of transport would be amazing and welcome.”
The participants, particularly the group of professionals, also expressed their awareness of regional differences and the impact of the Canterbury earthquakes.
(iv) Iwi katoa: support services and systems
The general practitioner was the first point of call for health matters: “that would be your first one, a doctor”. Services that came to them were appreciated, such as a nurse who “came round to make sure you were ok”, or a community pharmacist coming out to explain medications. Listening was the key to appropriate services:
“I think listening is a good key question. Listening to people, which they didn’t have the skills to listen to, they need to go to listening school.”
Pōua and tāua said they would sometimes provide feedback to the health professional when the interaction was unsatisfactory, but they would not return to a health professional who didn’t listen. Developing and maintaining trust was a key to appropriate services.[[15,21]]
(v) Wairua: beliefs regarding connectedness and spirituality
Te oranga wairua (spiritual wellbeing) has been described as “a deeply spiritual and uniquely Māori experience of connectivity”.[[22]] An underlying theme of manaakitanga (generosity and care) as an intrinsic and pervasive positive balancing factor was interwoven through the talk. The older participants had grown up with support for older members of the whānau as a given—“whether we like it or not”, one joked. Being integrated in the whānau involved support being available and needs known: “I think the connectors of the whānau do need to keep poking their noses in and checking up”. A practical expression of manaakitanga was that the rūnanga (tribal authority) could provide practical health support, such as access to free health consultations, which could help provide a sense of security: “if I didn’t have the rūnanga I’d be scared”.
While kaupapa Māori and marae-based care can be highly successful for some, there was recognition that workforce capacity is not robust enough to provide this in all situations, and that it will not necessarily be preferred by all Māori, as there are “some faces you never see” at the marae.
Ngā roma moana: ocean currents
While Māori can have diverse relationships with te ao Māori, Māoritanga (Māori practices and beliefs) can be a source of inner strength and life force (mauri ora).[[20]] Previous research has supported the link between having a connection with traditional cultural practices and places and having greater wellbeing.[[23,24]] This was echoed in the comments of pōua and tāua about how “cultural identity”, “tikanga” and visiting the marae had a positive impact on the experience of frailty (eg, in providing a feeling of being “uplifted” and minimising depression).
Ngā hau e wha: the four winds
Past and current generations are interconnected within a Māori worldview, and there is increasing awareness of how the ongoing impacts of colonisation, racism, migration and marginalisation provide the context for current economic and health disparities.[[25]] The four winds of colonisation, racism, migration and marginalisation provide the context for economic and health disparities.[[15]] The group of health professionals discussed how funding models that provide access at age 65 are inappropriate, as Māori can need earlier access.
Pōua and tāua discussed that “money can be a huge issue” and the impact of the potential cost of doctor fees, prescription fees and transport costs to get to appointments and chemists: “If you don’t have the money, you don’t go”. Budgeting was a potential individual balancing factor, although the relative strength of impact was debated.
An impact of migration could be seen in the perceived barriers to approaching local rūnanga services:
“you’re lucky to belong to the local rūnanga, but there are other Māori there that come from other places, and I made one kuia (older woman) come with me… because she wouldn’t go because it wasn’t for other Māori.”
Whakatere: navigation and strengths
One of the salient messages to emerge across the focus groups is that a culturally appropriate understanding of frailty will not emerge from looking at deficits alone. A focus on deficits not only runs the risk of providing an incomplete understanding of frailty, but also the risk of being perceived as disrespectful: “everyone around here seems to think she’s pakaru (broken)… she ain’t pakaru” and diminishing: “It’s an undermining of them”. This may lead to resistance to the imposition of a label: “whose perception is it?... Yeah well is that my perception?” and following suggestions: “do you know what taringa mārō (stubbornness) means?… I don’t listen”. Among the health professionals, there were misgivings about assessment: “but does it measure wellbeing?”. The discussions provided reminders that at the heart of any approach to frailty must be the core value that “they are still the person” and “it’s about who they are and what they can still do”. Joint navigation for frailty with older Māori and their whānau may be facilitated by a sound foundation of a holistic, strength-based approach and good listening:
“Sometimes, some medical persons, they don’t listen to what you are telling them. They have got their own opinion and you will be going on this pathway not what you think…”
Discussion
The present study was a small exploratory study in a single region and was weighted towards individuals who were well-connected with te ao Māori, and as such it cannot fully explore nuances and diverse experiences of being Māori. However, it was the first study to specifically seek to understand Māori perspectives on frailty.
Participants talked about frailty as being multidimensional and the experience of frailty as being shaped by both deficits and strengths. This understanding of frailty resonates with previous work from other cultures,[[9,26,27]] and yet it was also intrinsically Māori. These themes meshed with and reinforced the value of holistic Māori models of assessment and understanding, such as the Waikare o te Waka o Meihana, te Whare Tapa Whā (the Four Sided House), te Wheke (the Octopus) and te Pae Māhutonga (the Southern Cross Constellation).[[15,29–31]]
In 2000, Markele-Reid and Browne criticised many of the current approaches to frailty for taking an objective approach that focuses on physical deficits and dependency in isolation from strengths, which they argued is not sufficient for understanding the holistic, complex and unique meaning of frailty for an individual.[[28]] According to Markle-Reid and Browne, an understanding of frailty must recognise that the experience of frailty is multidimensional and determined by “the complex interplay of physical, psychological, social, and environment factors” and the perceptions and strengths of the individual. In some ways the decades of thinking around hauora (holistic health) can be seen as providing an example of the kind of approach that Markle-Reid found so lacking in the mainstream biomedical literature on frailty. A strength-based hauora approach that contextualises is more likely to be acceptable, meet needs and align with traditional models for Māori.[[18,20]] Such an approach to culturally appropriate assessment to frailty is relevant to all health professionals, alongside taha Māori (those of Māori descent), as the Māori workforce capacity is not robust enough “to do it all”. As frailty becomes an increasingly dominant theme in services for older people, we hope that further kaupapa Māori work will help to articulate a hauora approach to frailty.
Summary
Abstract
AIM: This study aimed to explore Māori (the indigenous people of Aotearoa New Zealand) understandings of frailty. METHOD: Focus groups were held with older Māori in supported living, health professionals working with older Māori and a rural community. A qualitative thematic analysis was conducted. RESULTS: Two interlinked, overarching themes emerged: (1) Frailty is a multidimensional experience, not simply a physical one. (2) The experience of frailty is a balance between deficits and strengths. The Waikare o te Waka o Meihana model provided a useful framework for structuring the thematic results. CONCLUSIONS: Culturally appropriate and comprehensive support and care for older Māori with frailty will be facilitated by a rounded strength-based approach and listening skills.
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1. Richards SJ, D’Souza J, Pascoe R, Falloon M, Frizelle FA. Prevalence of frailty in a tertiary hospital: A point prevalence observational study. Plos one. 2019;14(7): e0219083.
2. Abey-Nesbit R, Peel NM, Matthews H, et al. Frailty of Māori, Pasifika, and non-Māori/non-Pasifika older people in New Zealand: a national population study of older people referred for home care services. J Gerontol A Biol Sci Med Sci. 2020 Oct 19.
3. Barrett P, Twitchin S, Kletchko S, Ryan F. The living environments of community-dwelling older people who become frail: another look at the living standards of older New Zealanders survey. Soc Policy J N Z. 2006); 28:133–57
4. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013; 381(9868):752-62.
5. Rockwood K, Andrew M, Mitnitski A. A comparison of two approaches to measuring frailty in elderly people. J Gerontol A Biol Sci Med Sci. 2007 Jul 1;62(7):738-43.
6. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-57.
7. Hubbard RE, Peel NM, Samanta M, et al. Derivation of a frailty index from the interRAI acute care instrument. BMC Geriatrics. 2015;15(1):1-8.
8. British Geriatrics Society. Fit for frailty – consensus practice guidance for the care of older people living in the community and outpatient settings. London, UK: British Geriatrics Society; 2014.
9. Gee SB, Cheung G, Bergler U, Jamieson H. “There’s more to frail than that”: Older New Zealanders and health professionals talk about frailty. J Aging Res. 2019;2019: Article ID 2573239.
10. Grenier A. The distinction between being and feeling frail: exploring emotional experiences in health and social care. J Soc Work Practice. 2006;20(3):299-313.
11. Pitama, S, Robertson, P, Cram, F. et al. Meihana Model: A clinical assessment framework. N Z J Psychol. 2007; 36(3).
12. Lacey C, Huria T, Beckert L, Gilles M, Pitama S. The Hui Process: a framework to enhance the doctor-patient relationship with Māori. N Z Med J. 2011;124(1347):72-8.
13. Pope C, Ziebland S, Mays N. Qualitative research in health care: Analysing qualitative data. Br Med J. 2000; 320, 114–6.
14. Ritchie, J, Spencer, L. Qualitative data analysis for applied policy research. In Bryman A, Burgess RG editors. Analyzing qualitative data. London: Routledge; 1994, p 173–94.
15. Pitama S, Huria, T, Lacey C. Improving Māori health through clinical assessment: Waikare o te Waka o Meihana. NZ Med J. 2014; 124(1347): 72-8.
16. Cram F. Measuring Māori wellbeing: A commentary. Mai J, 2014; 3(1), 18-32.
17. Fillit H, Butler RN. The frailty identity crisis. J Am Geriatr Soc,2009; 57(2), 348-52.
18. New Zealand Guidelines Group. Best practice evidence-based guideline assessment processes for older people. Wellington NZ: Ministry of Health; 2003.
19. Mezuk, B, Edwards L, Lohman M, Choi M, & Lapane K. (2012). Depression and frailty in later life: a synthetic review. Int J Geriatr Psychiatry, 2012, 27(9), 879-92.
20. Collins A, Hickey H. The role of whanau in the lives of Maori with physical disabilities. Wellington NZ: Families Commission; 2003
21. Walker RC, Walker S, Morton RL et al. Māori patients' experiences and perspectives of chronic kidney disease: a New Zealand qualitative interview study. BMJ open, 2017, 7(1), e013829.
22. Dudley M, Menzies O, Elder H, Nathan L, Garrett N, Wilson D. Mate wareware: Understanding 'dementia' from a Māori perspective. N Z Med J, 2019; 132(1503):66-74.
23. Dyall L, Kepa M, Teh R et al. (2014). Cultural and social factors and quality of life of Māori in advanced age. Te puawaitanga o nga tapuwae kia ora tonu-Life and living in advanced age: a cohort study in New Zealand (LiLACS NZ). NZ Med J, 2014, 127(1393), 62-79
24. Gee S, Stephens M, Liu J, Higgins TR. (2003). Living language: Te reo, ethnic identity, and well-being. He Pukenga Korero: A Journal of Māori Studies, 2003, 7(2), 16-24.
25. Theodore R, Ratima M, Edwards W, Sporle A, Te Morenga L, Kiro C, Ruakere H. How a lifecourse approach can promote long-term health and wellbeing outcomes for Māori. J Indig Wellbeing. 2019;4(1):15-25.
26. Dury S, Dierckx E, Van Der Vorst A et al. Detecting frail, older adults and identifying their strengths: results of a mixed-methods study. BMC Public Health, 2018, 18(1), 191.
27. Puts MT, Shekary N, Widdershoven G, Heldens J, Deeg, DJ. The meaning of frailty according to Dutch older frail and non-frail persons. J Aging Stud, 2009, 23(4), 258-.66.
28. Markle‐Reid, M., Browne, G. Conceptualizations of frailty in relation to older adults. J Adv Nurs, 2003, 44(1), 58-68
29. Durie, MH. A Māori perspective of health. J Soc Sci Med, 1985, 20(5), 483–486.
30. Pere RR. Te Wheke: Whaia te maramatanga me te aroha. In: Middleton S, editor. Women and education in Aotearoa, vol. 1. Wellington: Unwin & Irwin; 1988. p. 6–19.
31. Durie,M. Te Pae Māhutonga: a model for Māori health promotion. Health Promotion Forum of NZ Newsletter 49, 1999.
Contact diana@nzma.org.nz
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It’s about who they are and what they can do: Māori perspectives on frailty in later life | OPEN ACCESS
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There are pervasive health disparities between Māori and non-Māori in Aotearoa New Zealand, and frailty is no exception. Māori experience frailty more often and at a younger age than non-Māori New Zealanders,[[1,2]] with Māori aged 65–70 years being as likely to be frail as non-Māori in their early 80s.[[3]]
There is general agreement that frailty represents an elevated state of risk or vulnerability to a sudden decline in health and other negative outcomes.[[4,5]] There is less agreement about the operationalisation and assessment of frailty. One approach views frailty as a physical syndrome with an underlying biological cause,[[6]] while an alternative approach views frailty as an accumulation of medical deficits.[[7]] Moreover, there have been calls for a more holistic approach to frailty to better inform personalised care and management plans that integrate older individuals’ views and goals.[[8,9]] However, research to understand views on frailty has generally been limited to Western cultures and has not interfaced with the Māori worldview (te ao Māori).
How frailty is conceptualised and understood can shape policies, access to services, care practices and social responses, and in turn the subjective experience of frailty.[[10]] In New Zealand, service delivery for Māori may be compromised if the approach is not comprehensive within a Māori cultural context.[[11]] This qualitative study therefore explored understandings of frailty within te ao Māori to help inform appropriate assessment and support for older Māori with frailty.
Methods
Settings and participants
Three focus groups were held in Canterbury, New Zealand:
- The first group involved six residents in a Māori-model supported living villa, with the discussion taking place in situ. There were five females and one male, all of whom were aged over 65 (66 to 83) and identified as Māori.
- The second group was drawn from an existing network of health professionals working with older Māori and was held at a community venue as part of a regular meeting. Twelve of the 14 professionals identified as Māori and 13 were female.
- The third group was held as part of a hui (meeting) on health services for older Māori in rural communities and was held at the community centre in a small coastal community. The 19 participants ranged in age from 18 to over 70, with the majority aged over 65. Ten participants identified as Māori, two as ‘mixed with Māori heritage’ and seven as Pākehā (New Zealand European). An additional four visitors connected to the participants sat in on some of the discussion.
Most participants were known to one of the facilitators through their personal and professional roles within local Māori communities. Ethics approval was given by the University of Otago Human Ethics Committee (17/151). Here we use the participants’ preferred terms, pōua (older man) and tāua (older woman).
Focus groups
The discussions took place in 1–1.5-hour sessions. Each focus group was co-facilitated by a Māori registered nurse working as clinical assessor with older Māori and a Pākehā gerontology researcher. The discussions were primarily held in English, but as one of the facilitators was bilingual, discussion could be facilitated in te reo Māori (the Māori language) where it arose.
The primary aim of the focus groups was to describe and understand meanings and interpretations of frailty within a Māori worldview. The structure broadly followed a hui process framework:[[12]]
- Mihi and whakawhanaungatanga: welcome and establishing connection.
- Kaupapa: the main purpose of the focus group, with a semi-structured discussion guide focusing on what makes them think of a person as “frail” and exploration focusing on what makes frailty better or worse.
- Poroporoaki: wrapping up. Summary notes were made on a white-board or easel pad throughout the sessions, which enabled initial thematic clustering with the participants present. These were photographed and transcribed for further analysis.
The discussion was also audio-recorded for the supported living and community groups and professionally transcribed.
Analysis
The thematic qualitative analysis was based on the framework approach.[[13,14]] Through the process of in-session summary and repeatedly reading the transcripts, the researchers became aware of key ideas and themes. These were used as the basis for an initial thematic framework to classify the data. The relevant content was charted verbatim into an Excel spreadsheet matrix, with the groups as the rows and the thematic elements as the columns. The matrix was reviewed, discussed and visually mapped in an iterative process. During the mapping and interpretation stage, the resonance with Waikare o te Waka o Meihana model[[15]] was recognised, and this was used to structure the final mapping and presentation of the themes.
Results
Two interlinked, overarching themes in the participants’ understanding of the experience of frailty emerged from across all the groups:
- Frailty is a multidimensional experience, encompassing physical and functional, social and whānau, psychological, environmental and macro-level factors.
- The experience of frailty is a dynamic balance between challenges/deficits and strengths/resources.
In this paper we present the sub-themes within the structure of the Waikare o te Waka o Meihana model (the Meihana model), which was developed to guide health professionals’ interactions, assessments and care within a Māori worldview (Figure 1).[[15]] The Meihana model uses the analogy of a double-hulled canoe, with the two hulls used to represent the interconnection between an individual and their whānau (support network). Five crossbeams strengthen the canoe and represent an individual's physical, psychological and emotional wellbeing, their beliefs and connectedness, their physical environment and the services available to them. The journey of the waka (canoe) is influenced by winds and ocean currents that symbolise historical and social contexts and the influence of Māori worldviews. Navigation brings together the assessment of all these components to enable the health professionals and the individual and/or whānau to plot a course forward.
Figure 1: Summary of themes.
The two hulls: the interconnection between the individual and their whānau
Frailty was seen as a whānau experience. This included the challenges of frailty. For example, whānau wellbeing can be affected by “worrying” and being “tired”, and the older person may worry about this impact. It also included the balancing factors of “good support from whānau”. An example was ensuring access to health services:
“My daughter just barged in and said, ‘you are coming’, and took me over to the doctor. I ended up in hospital having a big operation. If it had been left to me–no, I wouldn’t have gone. So I do have good whānau supports.”
Frailty was seen as challenging social wellbeing and engagement. It was associated with being “withdrawn”, “going out less” and being “lonely”. The death of a life-long partner was highlighted as a powerful factor (“Grief and loss, it’s huge”) that could sometimes lead to the bereaved partner dying “soon after”.
Feeling engaged, useful and connected to other people was intertwined with positive mental wellbeing.[[16]] “Being useful”, “having a purpose” and “manaaki” (giving support) were balancing factors. This could be expressed through their social networks and role as “the centre for our whānau”, and the bonds with “moko” (grandchild/grandchildren).
The five crossbeams
(i) Tinana: physical health and functioning
Participants from across the groups raised physical changes that echo the syndrome of physical frailty,[[ 6]] such as changes in stature or “anua”, weight, muscles and balance. All the groups also raised a vulnerability to and/or presence of health issues and conditions. For example, a greater likelihood of hearing or vision issues, pain, getting sick, healing more slowly, having poor health, hospitalisation and death. The participants suggested nutrition, exercise, traditional remedies and western medications had a role in helping prevent or mitigate frailty.
There was a strong sub-theme around mobility and independence. For one of the participants, the question was simply, “can he push a lawnmower?” Frailty was associated with walking slower, needing help walking and reduced mobility. It was also associated with loss of independence and needing help, relying on others and increased use of services: “like, they need help going to appointments, or going to the grocery shop or just going out generally”.
The participants recognised that pride may stop some older Māori from accepting help or using aids. However, the discussion positioned accepting help as a positive balancing factor of adaptation.[[17]] For example, one person with a tokotoko (walking stick) said, “if I need a stick, I don’t feel old. I just find it’s just a thing there that enables me to get around… I’ve got a walking stick as part of an aid”. Another advised that, if there were younger family members to help, “you make the most of it”. The discussion highlighted that it is important that help is offered proactively as, traditionally, asking for help may be seen as rude or shameful:[[18]] “actually ask… because they’re too whakamā (ashamed) to say or they don’t want to put them out”.
(ii) Hinengaro: psychological and emotional
Cognitive changes were associated with frailty across all the groups. This included “forgetfulness” and “memory”; being slower and needing help with decisions and finances; being “confused” and “not up with the play”; and generally being slower cognitively.
Frailty was also associated with challenges to emotional wellbeing across all the groups. People living with frailty may be “frustrated” and “bored”, “a bit depressed”, “bad-tempered” or “grumpy”. People who were frail were seen as often being “not as confident” as they were in the past and being “nervous” and “worried”. There is likely a two-way relationship between (a) being physically frail as a risk factor for poor emotional wellbeing and (b) poor emotional wellbeing acting as a risk factor for physical frailty (eg, by decreasing motivation for self-care).[[19]]
The participants raised the importance of “mindset”, “personality” and “inner strength” as balancing factors: “It depends what he thinks”. Mauri ora (inner strength, life force) is integral to understanding wellbeing and resilience.[[20]] Having “autonomy”, “mana” (respect) and “confidence” were positive balancing factors. The discussions revealed how supporters can recognise and strengthen these self-concepts or erode them:
“Remember that they’re not deaf, dumb and blind… Sally says, ‘my name’s Sally, not silly’. She’ll say it right in front of them. And they just don’t get the message… and it quietens down and she goes into her little corner and folds and folds and folds… all these ones that think she can’t do anything are around her… I know she’s hōhā or bored.”
The health professionals discussed how safety concerns need to be balanced with maintaining independence, autonomy and “real choices”.
(iii) Taiao: the physical environment
In the context of frailty, transport was a salient aspect of the physical environment, particularly in rural group. There was a recognition that frailty often means giving up driving. For example: “eventually I won’t be able to drive and I will have to rely on my daughter and she works”. The availability and affordability of transport impacted on each participant’s ability to maintain engagement and access services:
“It’s transport, and being able to drive and being able to budget to be able to pay for that transport. So anything within the assistance of transport would be amazing and welcome.”
The participants, particularly the group of professionals, also expressed their awareness of regional differences and the impact of the Canterbury earthquakes.
(iv) Iwi katoa: support services and systems
The general practitioner was the first point of call for health matters: “that would be your first one, a doctor”. Services that came to them were appreciated, such as a nurse who “came round to make sure you were ok”, or a community pharmacist coming out to explain medications. Listening was the key to appropriate services:
“I think listening is a good key question. Listening to people, which they didn’t have the skills to listen to, they need to go to listening school.”
Pōua and tāua said they would sometimes provide feedback to the health professional when the interaction was unsatisfactory, but they would not return to a health professional who didn’t listen. Developing and maintaining trust was a key to appropriate services.[[15,21]]
(v) Wairua: beliefs regarding connectedness and spirituality
Te oranga wairua (spiritual wellbeing) has been described as “a deeply spiritual and uniquely Māori experience of connectivity”.[[22]] An underlying theme of manaakitanga (generosity and care) as an intrinsic and pervasive positive balancing factor was interwoven through the talk. The older participants had grown up with support for older members of the whānau as a given—“whether we like it or not”, one joked. Being integrated in the whānau involved support being available and needs known: “I think the connectors of the whānau do need to keep poking their noses in and checking up”. A practical expression of manaakitanga was that the rūnanga (tribal authority) could provide practical health support, such as access to free health consultations, which could help provide a sense of security: “if I didn’t have the rūnanga I’d be scared”.
While kaupapa Māori and marae-based care can be highly successful for some, there was recognition that workforce capacity is not robust enough to provide this in all situations, and that it will not necessarily be preferred by all Māori, as there are “some faces you never see” at the marae.
Ngā roma moana: ocean currents
While Māori can have diverse relationships with te ao Māori, Māoritanga (Māori practices and beliefs) can be a source of inner strength and life force (mauri ora).[[20]] Previous research has supported the link between having a connection with traditional cultural practices and places and having greater wellbeing.[[23,24]] This was echoed in the comments of pōua and tāua about how “cultural identity”, “tikanga” and visiting the marae had a positive impact on the experience of frailty (eg, in providing a feeling of being “uplifted” and minimising depression).
Ngā hau e wha: the four winds
Past and current generations are interconnected within a Māori worldview, and there is increasing awareness of how the ongoing impacts of colonisation, racism, migration and marginalisation provide the context for current economic and health disparities.[[25]] The four winds of colonisation, racism, migration and marginalisation provide the context for economic and health disparities.[[15]] The group of health professionals discussed how funding models that provide access at age 65 are inappropriate, as Māori can need earlier access.
Pōua and tāua discussed that “money can be a huge issue” and the impact of the potential cost of doctor fees, prescription fees and transport costs to get to appointments and chemists: “If you don’t have the money, you don’t go”. Budgeting was a potential individual balancing factor, although the relative strength of impact was debated.
An impact of migration could be seen in the perceived barriers to approaching local rūnanga services:
“you’re lucky to belong to the local rūnanga, but there are other Māori there that come from other places, and I made one kuia (older woman) come with me… because she wouldn’t go because it wasn’t for other Māori.”
Whakatere: navigation and strengths
One of the salient messages to emerge across the focus groups is that a culturally appropriate understanding of frailty will not emerge from looking at deficits alone. A focus on deficits not only runs the risk of providing an incomplete understanding of frailty, but also the risk of being perceived as disrespectful: “everyone around here seems to think she’s pakaru (broken)… she ain’t pakaru” and diminishing: “It’s an undermining of them”. This may lead to resistance to the imposition of a label: “whose perception is it?... Yeah well is that my perception?” and following suggestions: “do you know what taringa mārō (stubbornness) means?… I don’t listen”. Among the health professionals, there were misgivings about assessment: “but does it measure wellbeing?”. The discussions provided reminders that at the heart of any approach to frailty must be the core value that “they are still the person” and “it’s about who they are and what they can still do”. Joint navigation for frailty with older Māori and their whānau may be facilitated by a sound foundation of a holistic, strength-based approach and good listening:
“Sometimes, some medical persons, they don’t listen to what you are telling them. They have got their own opinion and you will be going on this pathway not what you think…”
Discussion
The present study was a small exploratory study in a single region and was weighted towards individuals who were well-connected with te ao Māori, and as such it cannot fully explore nuances and diverse experiences of being Māori. However, it was the first study to specifically seek to understand Māori perspectives on frailty.
Participants talked about frailty as being multidimensional and the experience of frailty as being shaped by both deficits and strengths. This understanding of frailty resonates with previous work from other cultures,[[9,26,27]] and yet it was also intrinsically Māori. These themes meshed with and reinforced the value of holistic Māori models of assessment and understanding, such as the Waikare o te Waka o Meihana, te Whare Tapa Whā (the Four Sided House), te Wheke (the Octopus) and te Pae Māhutonga (the Southern Cross Constellation).[[15,29–31]]
In 2000, Markele-Reid and Browne criticised many of the current approaches to frailty for taking an objective approach that focuses on physical deficits and dependency in isolation from strengths, which they argued is not sufficient for understanding the holistic, complex and unique meaning of frailty for an individual.[[28]] According to Markle-Reid and Browne, an understanding of frailty must recognise that the experience of frailty is multidimensional and determined by “the complex interplay of physical, psychological, social, and environment factors” and the perceptions and strengths of the individual. In some ways the decades of thinking around hauora (holistic health) can be seen as providing an example of the kind of approach that Markle-Reid found so lacking in the mainstream biomedical literature on frailty. A strength-based hauora approach that contextualises is more likely to be acceptable, meet needs and align with traditional models for Māori.[[18,20]] Such an approach to culturally appropriate assessment to frailty is relevant to all health professionals, alongside taha Māori (those of Māori descent), as the Māori workforce capacity is not robust enough “to do it all”. As frailty becomes an increasingly dominant theme in services for older people, we hope that further kaupapa Māori work will help to articulate a hauora approach to frailty.
Summary
Abstract
AIM: This study aimed to explore Māori (the indigenous people of Aotearoa New Zealand) understandings of frailty. METHOD: Focus groups were held with older Māori in supported living, health professionals working with older Māori and a rural community. A qualitative thematic analysis was conducted. RESULTS: Two interlinked, overarching themes emerged: (1) Frailty is a multidimensional experience, not simply a physical one. (2) The experience of frailty is a balance between deficits and strengths. The Waikare o te Waka o Meihana model provided a useful framework for structuring the thematic results. CONCLUSIONS: Culturally appropriate and comprehensive support and care for older Māori with frailty will be facilitated by a rounded strength-based approach and listening skills.
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1. Richards SJ, D’Souza J, Pascoe R, Falloon M, Frizelle FA. Prevalence of frailty in a tertiary hospital: A point prevalence observational study. Plos one. 2019;14(7): e0219083.
2. Abey-Nesbit R, Peel NM, Matthews H, et al. Frailty of Māori, Pasifika, and non-Māori/non-Pasifika older people in New Zealand: a national population study of older people referred for home care services. J Gerontol A Biol Sci Med Sci. 2020 Oct 19.
3. Barrett P, Twitchin S, Kletchko S, Ryan F. The living environments of community-dwelling older people who become frail: another look at the living standards of older New Zealanders survey. Soc Policy J N Z. 2006); 28:133–57
4. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013; 381(9868):752-62.
5. Rockwood K, Andrew M, Mitnitski A. A comparison of two approaches to measuring frailty in elderly people. J Gerontol A Biol Sci Med Sci. 2007 Jul 1;62(7):738-43.
6. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-57.
7. Hubbard RE, Peel NM, Samanta M, et al. Derivation of a frailty index from the interRAI acute care instrument. BMC Geriatrics. 2015;15(1):1-8.
8. British Geriatrics Society. Fit for frailty – consensus practice guidance for the care of older people living in the community and outpatient settings. London, UK: British Geriatrics Society; 2014.
9. Gee SB, Cheung G, Bergler U, Jamieson H. “There’s more to frail than that”: Older New Zealanders and health professionals talk about frailty. J Aging Res. 2019;2019: Article ID 2573239.
10. Grenier A. The distinction between being and feeling frail: exploring emotional experiences in health and social care. J Soc Work Practice. 2006;20(3):299-313.
11. Pitama, S, Robertson, P, Cram, F. et al. Meihana Model: A clinical assessment framework. N Z J Psychol. 2007; 36(3).
12. Lacey C, Huria T, Beckert L, Gilles M, Pitama S. The Hui Process: a framework to enhance the doctor-patient relationship with Māori. N Z Med J. 2011;124(1347):72-8.
13. Pope C, Ziebland S, Mays N. Qualitative research in health care: Analysing qualitative data. Br Med J. 2000; 320, 114–6.
14. Ritchie, J, Spencer, L. Qualitative data analysis for applied policy research. In Bryman A, Burgess RG editors. Analyzing qualitative data. London: Routledge; 1994, p 173–94.
15. Pitama S, Huria, T, Lacey C. Improving Māori health through clinical assessment: Waikare o te Waka o Meihana. NZ Med J. 2014; 124(1347): 72-8.
16. Cram F. Measuring Māori wellbeing: A commentary. Mai J, 2014; 3(1), 18-32.
17. Fillit H, Butler RN. The frailty identity crisis. J Am Geriatr Soc,2009; 57(2), 348-52.
18. New Zealand Guidelines Group. Best practice evidence-based guideline assessment processes for older people. Wellington NZ: Ministry of Health; 2003.
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It’s about who they are and what they can do: Māori perspectives on frailty in later life | OPEN ACCESS
There are pervasive health disparities between Māori and non-Māori in Aotearoa New Zealand, and frailty is no exception.
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