HEALTH CARE NEEDS FOR OLDER MAORI: A STUDY OF KAUMATUA AND KUIA.

INTRODUCTION

The New Zealand health referral system needs to be adequately assessed in terms of cultural factors related to utilisation. This is partly because of the Maori population's social functioning as a collective culture, but also because Maori social structures of whanau, hapu, and iwi are discernibly different from western populations. The role of older adults within these structures is particularly salient, as elders often assume leadership roles within family and tribal structures, and in conservative Maori social settings such as on marae.

Research with the older adult population has suggested that social networks may contribute significantly to decisions to use health services (Wolinsky and Johnson 1991). Furthermore, Ward (1978) suggests that organisational factors associated with the bureaucratic nature, or the bureaucratic culture, of service delivery settings can serve as a barrier to utilisation among older adults. He further comments that the older adult population tends to be more fatalistic and cautious. It follows that it is harder for older people to penetrate the bureaucracies associated with a fragmented or uncoordinated health care system. Evidence from a range of sources suggests that this is particularly true for Maori.

The Ministry of Health (1997a) reports that there is little information about the health service needs and levels of disability among older Maori. This paper reports on the findings and policy implications of the analysis of sub-sample of kuia and kaumatua in a nationwide study of health care needs. The following section reviews the current state of knowledge of health service utilisation among Maori. Succeeding sections cover the study methods, the results of the study, and a discussion of the findings that is largely devoted to explaining unmet health service needs among kuia and kaumatua. The final section outlines the authors' conclusions.

HEALTH SERVICE UTILISATION AMONG MAORI

The inverse care law (Hart 1971, cited in Gribben 1993) holds that those most in need of health care services have the least available, a proposition supported within the New Zealand context (Barnett 1978, Davis 1984, Salmond 1973, West and Harris 1979, all cited in Gribben 1993). Malcolm (1996) examined utilisation and expenditure rates on primary health care for Maori and low-income New Zealanders in comparison to the national average. Using data for the 1994-95 period collated from a variety of sources, Malcolm concludes that gross under-utilisation of primary health care services is the norm for Maori and economically disadvantaged New Zealanders. He further concludes that poor access and utilisation of primary care is likely to be a significant factor in the high use of hospital inpatient services by these groups. Although health services are widely recognised as only one factor in improving health outcomes, Malcolm highlights the growing international evidence suggesting that inequities in access to and utilisation of health services (especially primary health care services) could be a major factor in inhibiting health gains for the disadvantaged.

In general, research has shown that higher levels of education and income are associated with better personal health (e.g. Smith and Pearce 1984, Victor 1980 cited in Mutchler and Burr 1991). Since health differences between minority and non-minority sub-samples of the population persist even when socio-economic factors are statistically controlled, a number of authors have suggested that comparative inequality, racism, and various forms of discrimination may continue to compromise health for some. In particular, the factors associated with minority group status that include poverty, higher levels of social stresses and consequent psychological distress predispose lower socio-economic groups to poorer health outcomes.

In relation to socio-economic status as an influencing factor for utilisation rates, Nolan (1994) noted the substantial variability across socio-economic status in general medical practitioner utilisation patterns in Ireland (as is the case in other developed countries). Nolan asserts that the observed differentials are a reflection of both the influence of socioeconomic status factors on health and health care use, and the fact that lower socioeconomic status groups are entitled to free or subsidised medical care in many developed countries. The interactions of occupational social class, income, health status and economic incentives for service use are therefore seen as complicating investigations of utilisation patterns.

Yeatts et al. (1992) contend that attitudes of suspicion among ethnic minority groups in the United States toward "helping" services stern from an unfamiliarity with providers of the predominant culture (e.g. white middle class), and from negative past experiences of discrimination. These past experiences have been purported to account for feelings of humiliation, alienation, and fear of ridicule as found among minority populations by a number of studies (e.g. Garcia 1985, Gelfand 1982, Zambrana et al. 1979, McKinlay 1972, Carp 1970, all cited in Yeatts et al. 1992).

New Zealand commentators have discussed communication issues as well as cultural beliefs and practices that may have implications for the medical care of Maori (e.g. Durie 1977, Tipene-Leach 1978). Sachdev (1990) gives a good account of cultural attitudinal and behavioural factors which demand consideration in the medical care of Maori patients. For example, the concepts of tapu and noa may produce potential problems for bedridden Maori inpatients who are expected to engage in mutually incompatible activities of eating and defecating in the same place. Sachdev (1990) contends that some kaumatua and kuia may refuse hospitalisation as a result.

Kaumatua and Kuia

Generational differences in attitudes may exist among Maori due to different experiences within mainstream health institutions such as hospitals. In discussing policies on the admission of Maori influenza sufferers during the 1918 epidemic, Rice (1988) reports that some hospitals imposed a strict colour bar by refusing to admit Maori. Indeed, some towns illegally prevented Maori from entering. In Whangarei, the mayor declared a health cordon whereby Maori could not enter the built-up area. This ban was later revoked for Maori who were able to produce a certificate signed by a doctor (Keene 1989). Rice (1988) describes tension in the race relations of some North Island regions during World War One, largely due to Maori resistance to conscription in those areas, which "tended to delay the intervention of relief agencies" (Keene 1989:24). The concept of institutional racism in contemporary New Zealand society and social services has been discussed at length elsewhere (Ministerial Advisory Committee 1986, Spoonley 1993, Spoonley 1994).

In a timely study of the health and well-being of kaumatua and kuia (Te Pumanawa Hauora 1997), 397 Maori were interviewed using a networking sampling method. The authors acknowledged the methodological limitations of this sampling method, in that the participants were representative of "a more traditional profile"(1) of kaumatua and kuia (Te Pumanawa Hauora 1997:11). Although others (e.g., Statistics New Zealand 1995, Prime Ministerial Task Force on Positive Aging 1996, both cited in Te Pumanawa Hauora 1997) had previously considered 65 years to be the benchmark for "old age", Te Pumanawa Hauora defined the threshold for the "older adults" among Maori as 60 years based on factors such as relative life expectancy and health experience, or relative proportion of population. With these sampling issues in mind, the major findings of the Te Pumanawa Hauora study relevant to the present study are summarised below.

Medical doctors were the most commonly used health service among participants. Two-thirds of the sample were regularly taking medication, and two-thirds reported having a major or minor disability. Specifically, visual impairment and hearing loss were most frequently reported. However, few of the 397 kaumatua interviewed held private superannuation or medical insurance (87% did not have medical insurance), but tended to rely heavily on State provision for income and health care costs. Most participants (85%) had a Community Services Card with most using their card every few weeks or months. It was found that disability support services were not often utilised by the sample and entitlements to such services and other State support was not well understood.

The authors suggest that low incomes appear to be associated with poorer health among the elders studied, and that kaumatua may have less opportunity to supplement their incomes compared with other New Zealanders of the same age. They further propose that this may be due to increased whanau and marae responsibilities. This idea would seem to hold, at least, for kaumatua and kuia such as those sampled who are actively linked to traditional Maori social institutions such as iwi, hapu, whanau or marae.

The Ministry of Health (1997a) report that there is little information about the health service needs and levels of disability among older Maori. The study reported in this paper examined health status, activity limitations and rates of health service utilisation among kaumatua and kuia, making comparisons with the findings on older adults in general, reported in Flett et al. (1999).

METHOD

The study described in this paper surveyed 1,500 people (all living in the community, i.e. not in institutions) in geographically distinct enumeration districts across both New Zealand main islands, including both rural and urban populations. A Maori sub-sample was drawn from a 1996 cross-sectional survey of older adult service utilisation that used a cluster sample flame (see Flett et al. 1999). Sampling techniques are described in detail elsewhere (Flett et al. 1998).

The sub-sample included 66 kaumatua and kuia aged 60 years or more, and comprised 26 (39%) men and 40 (61%) women. Demographic characteristics of the sub-sample are presented in Table 1. A standardised questionnaire was used to collect information regarding demographic and socio-economic characteristics, physical health, and information regarding health service utilisation. The health and service utilisation measures have been described in Flett et al. (1999).

Table 1 Demographic Characteristics of Kaumatua and Kuia

                                      n     %
Gender
  Male                                26   39.4
  Female                              40   60.6

Age Groups
  60-69 years                         39   59.1
  70-79 years                         21   31.8
  80-89 years                          5    7.6
  90-99 years                          1    1.5

Young-Old (65-74 years)               39   59.1
Old-Old (75 years and older)          27   40.9

Education
  No School Qualification             49   74.2
  School Certificate                   6    9.1
  Sixth Form/University Entrance       4    6.1
  University Bursary/Scholarship       1    1.5
  Trade/Professional Qualifications    4    6.1

Marital Status
  Married                             23   34.8
  Never married                        6    9.1%
  Separated / divorced                 6    9.1%
  Widowed                             31   47%

Residence
  Urban                               20   30.3
  Rural                               46   69.7

RESULTS

Table 2 shows Maori mean ratings on the measures of physical health. Without exception, the Maori sub-sample reported worse physical illness on all four measures of health than the older adult sample as a whole(2) (see Flett et al. 1999). The pattern of higher physical illness among kaumatua and kuia was obtained for both genders, and at each age grouping. The differences between the Maori and non-Maori sub-samples were substantial, with Maori on average reporting four more physical symptoms, at least one more chronic medical problem, and rated their overall health to be worse than the non-Maori sub-sample (mean rating 0.3 higher on 1-4 scale). The higher rate of physical symptoms reported by kaumatua and kuia (M = 42.04, SD = 12.15) was significantly different from those reported by non-Maori (M = 38.0, SD = 8.51). As shown in Table 2, females reported a higher number and greater severity of physical symptoms than males, a trend consistent with that obtained in the entire sample (see Flett et al. 1999). However, physical symptoms, chronic symptoms, and limitations in functioning, all increased with age in the Maori sub-sample.

Table 2 Mean Self-Rated Health, Physical Symptoms, Chronic Health Symptoms, and Limitations in Bodily Functioning Among Kaumatua and Kuia

             Self-Rated    Physical      Chronic     Limitations in
               Health      Symptoms     Symptoms      Functioning

Gender
 Male        2.0 (1.0)    39.9  (6.7)    3.6 (1.7)    1.5 (2.3)
 Female      2.0 (1.0)    41.5 (13.8)    3.0 (2.0)    2.3 (2.5)

Age Groups
 Young-Old     2 (1.0)    40.8 (12.0)    3.1 (1.9)    2.1 (2.4)
 Old-Old       2 (1.0)    49.2 (10.6)    4.3 (1.3)    4.3 (2.1)

Note. Standard deviations are provided in parentheses.

Other health questions related to specific chronic health conditions diagnosed by a health professional. Figure 1 shows the different types of chronic conditions experienced by this sample of kaumatua and kuia. From the list of 17 conditions, the average number of chronic conditions was 3.3 (standard deviation (SD) = 1.85), but some kaumatua and kuia experienced no chronic conditions, whereas others experienced up to seven different conditions. However, the vast majority (72.2%) of kaumatua and kuia reported between two and four chronic health conditions. Kaumatua and kuia reported a higher incidence of all chronic health conditions than did older pakeha respondents. Specifically, diabetes was 14.5% higher, hypertension was 20.3% higher, heart trouble (e.g., angina or myocardial infarction) was 14.3% higher, respiratory conditions (e.g., bronchitis) was 9.2% higher, asthma was 21.1% higher, stomach ulcers or duodenal ulcers were 4.6% higher, chronic kidney or urinary tract conditions were 6.7% higher, and sight impairment or loss was 12% higher.

[Figure 1 ILLUSTRATION OMITTED]

Similar to the entire sample of older adults, however, kaumatua and kuia reported a lack of difficulty with chronic limitations in daily functioning. Most kaumatua and kuia (65.2%) experienced no restrictions in basic activities, cognitive activities, or household activities. Figure 2 displays the number of difficulties associated with daily living, and shows that the most frequently reported areas of difficulty were walking (17%) and heavy housework (15%).

[Figure 2 ILLUSTRATION OMITTED]

The present study used a variety of approaches to measure the health of participants and, again, bodily limitations were categorised according to the nature of the disability to form two main types: upper body and lower body limitations. As shown in Figure 4, more than one in three kaumatua and kuia reported functional limitation in stooping, crouching or kneeling (39.4%), in walking 500 meters without difficulty (33%), and in walking up 10 steps without rest (34.8%). Almost half (48.5%) of the kaumatua and kuia sub-sample reported difficulty in standing or being on their feet for 2 hours. Substantial variation between Maori and non-Maori elders can be seen in these Figures, with kaumatua and kuia reporting more limitations in lower body functioning apart from stooping. The results were more mixed for upper body functioning.

[Figure 4 ILLUSTRATION OMITTED]

Despite the higher rate of reported health problems among the kaumatua and kuia sub-sample, general practitioner service utilisation was lower in comparison to the entire older adult sample (Figure 5). A total of 51 (77.3%) Maori had sought help from a general medical practitioner during the preceding 12 months, with 79.6% of those visiting their health professional ten times or less. Just over a third (39.4%) of the sub-sample had spent time in bed sick, with most (76.9%) spending a week or less in bed. Almost 20% had visited a ward or clinic as an outpatient, the same number had been admitted as an inpatient for overnight stay at a hospital, and almost 11% had used the accident and emergency department of a public hospital. Of the visits to accident and emergency wards, most participants either visited once or twice, although about 30% visited at least three times.

[Figure 5 ILLUSTRATION OMITTED]

Most kaumatua and kuia (78.8%) had purchased prescription medicine from a chemist in the preceding 12 months, with 27.3% purchasing 1-4 items, 9.1% purchasing 5-9 items, 15.2% purchasing 10-14 items, and 24.2% purchasing 15 or more items. It is notable that, with the exception of accident and emergency use and hospital admissions, rates of health service utilisation for the kaumatua and kuia sub-sample are lower than that of the overall sample of older adults (see Figure 5). Figure 6 shows the type of other health professionals visited by this sample of older adults, and highlights that a low proportion (7.7%) of kaumatua and kuia had visited a medical specialist in the past year. Nonetheless, a higher proportion (4.5%) of kaumatua and kuia have visited an occupational therapist in comparison to their non-Maori counterparts, and there was only a 1.3% difference between Maori and non-Maori elders visits to physiotherapists.

[Figure 6 ILLUSTRATION OMITTED]

Age and gender differences in health and satisfaction were tested.(3) As might be expected given the differences between age groups in Table 2, there was a significant main effect for age. It is noteworthy that this significant effect was not obtained for the entire sample (see Flett et al. 1999). Kaumatua and kuia in the Old-Old age range reported the highest number of physical health symptoms, chronic health symptoms, and limitations in physical functioning. The observed gender differences in Table 2 were not significant.

Comparisons with Te Pumanawa Hauora Findings

In relation to the findings of the Te Pumanawa Hauora study, the present study also found general practitioners to be the most commonly used health services among elders. As in the Te Pumanawa Hauora sample, most participants (73%) had a community services card. Visual impairment and hearing loss were the two most frequently reported chronic health problems in the Te Pumanawa Hauora study. Although sight impairment or loss was 12% higher in the present study for kaumatua and kuia (cf. Flett et al. 1990), they also reported higher incidences of all chronic health conditions, particularly diabetes (14.5% higher), hypertension (20.3% higher), heart trouble (14.3% higher) and asthma (21.1% higher). These comparative chronic illness findings echo those of the latest national health survey (Ministry of Health 1999a).

Explaining Unmet Need

Findings from this study indicate a high level of physical ill health among kaumatua and kuia. The high level of need is clearly visible relative to non-Maori older persons, regardless of age grouping or gender, with Maori reporting more physical symptoms, chronic health problems and poorer self-rated health. In addition, Maori reported higher levels of lower body limitations. Despite higher level of reported health need, Maori use of services was at a lower rate than non-Maori. These findings of poorer health as indicated through varied health status measures, coupled with low levels of health care use, clearly point to unmet need and inequity in access to formal health care among the kaumatua and kuia interviewed.

The results of the study reflect those of earlier New Zealand research and further suggest that the inverse care law also holds for kaumatua and kuia. Explanations for this unmet need are suggested here to include at least several factors:

1. firstly, the observed unmet health care needs of the kaumatua and kuia interviewed may be explained by the potential influence of attitudes and beliefs within a Maori cultural context;

2. secondly Maori social networks may play a significant role in the provision of informal health care and disability support;

3. both of these factors coupled with institutional barriers (e.g. Malcolm 1996, Yeatts et al. 1992, Spoonley 1994) may potentiate the late uptake of services as observed in higher Maori hospital admissions and accident and emergency department use found in the present study.

Cultural Issues

Maori authors have written about Maori perceptions of the medical profession and Maori customary cultural beliefs regarding illness (e.g., Durie 1977, Tipene-Leach 1978). The low level of formal health service use among kaumatua and kuia may reflect attitudinal barriers to such institutions founded on historical distrust and process issues (Durie 1977, Tipene-Leach 1978, Sachdev 1990).

Mutchler and Burr (1991) purport that older adult members of ethnic minority communities have often experienced more profound inequity in access during their lifetimes. Within-group beliefs and personal life experience shape present-day attitudes and behaviours. Negative past experiences (both personal and within-group) of formal health care institutions may partly explain why health service use among kaumatua and kuia is lower than expected, given their reported need. The potential influence of attitudinal barriers needs further consideration in policy and service provision planning for health care delivery and health promotion to modern kaumatua and kuia.

The Health Professional Maori Workforce

A specific health policy goal outlined in the Government's medium-term strategy recommends an accelerated development of the health professional Maori workforce (Ministry of Health 1999b). Maori under-representation in the health workforce results in reduced opportunities for cultural differences to be fully appreciated in the assessment, treatment and rehabilitation of Maori consumers (Douglas 1996). Although no evidence based research exists to estimate what impact more Maori health professionals have or would have on Maori levels of service utilisation, expert opinion suggests that Maori are more likely to seek medical care if their doctor is also Maori (Ashton 1997). A continued focus on accelerating Maori participation in the health care workforce, coupled with changing mainstream attitudes, may assist to improve Maori attitudes toward and access to formal health services.

Social Networks and Cultural Diversity

The influence of social networks within any cultural group, as highlighted by Ward and others, needs to be taken into account in understanding the health care use patterns of a given community. Informal or alternative forms of health care and disability support may be available to kaumatua and kuia that were not acknowledged in the design of the present study. Maori kinship networks such as whanau and hapu, as well as Maori providers such as community-based tribal or Maori services and traditional Maori healers, may have been utilised by kaumatua and kuia in response to their health needs.

Preferences for using kaupapa Maori or alternative forms of assistance also need to be regarded within the context of diversity in Maori lifestyles. The dramatic projected increases in kaumatua and kuia (Statistics New Zealand 1998) will further necessitate careful and considered planning in future health policy, programmes and service delivery systems for older Maori age groups, taking into account increasing diversity within the Maori population. This diversity in cultural backgrounds within Maori society creates a need to consider providing choice to the consumer in the development of public health policy and health service planning.

The Use of Accident and Emergency Services 

Previous research (Lewis 1988) of the Hurt Hospital accident and emergency department found service users (N = 858) to be predominantly males aged between 15-29 years, a finding consistent with previous research. Based on comparisons with local 1986 census data, Maori attended the accident and emergency department twice as frequently as would have been expected. The higher rate of emergency service use by Maori observed in the present study implies that older Maori use of accident and emergency is determined more by health needs that are associated with health crises or emergencies.

Policy implications of the use by Maori elders of accident and emergency services are obvious. Early recognition and prompt health need assessment and treatment is proposed by the Ministry of Health (1997a) to be essential for older people, yet findings such as those reported here suggest ineffectual primary health care delivery to older Maori adults. This is despite the recognition that an increased need for care and support may occur for Maori at an earlier age than non-Maori due to lower life expectancy and earlier onset of preventable chronic health conditions (Ministry of Health 1997a). Apart from policy aimed at improving Maori access to care, and improved integration of services, population-based public health interventions such as health promotion strategies may help address the problems of high rates of preventable health problems and low or late uptake of services among older Maori people.

The Influence of Social Class and Ethnicity

Even after controlling for the influence of social class, unique Maori health disadvantages remain. Davis (1984) examined the influence of social class and ethnicity upon the observed health inequities for Maori. Davis points to the effects of the health delivery system in partly explaining health disparities over and above the effects of similar levels of material resources and lifestyle factors shared by members of a given social class or ethnic group,. He uses research conducted in the United Kingdom to suggest that a health care system may actually reinforce societal inequities, rather than remedying health disparities between social groups. In reference to the New Zealand context of ethnic group and social class differentials in mortality, Davis questions the direction, efficacy and claims to social legitimacy of the entire health care system.

In grouping the different of research that offer explanations for observed ethnic health status differentials, Davis provides two different strands;

1. research in line with the "westernisation" thesis, which emphasises lifestyle, stress and broader socio-cultural factors; and

2. class inequity research, which emphasises the impact of material circumstances and distinguishes between classic "diseases of poverty" and inequity (e.g. accidents and death from respiratory diseases), and the "diseases of affluence" (e.g. diabetes, cancer).

In the case of the New Zealand Maori, Davis suggests that both strands of research are relevant. In looking at the interaction of social class and ethnicity, he concludes that a substantial "ethnic group effect" is clearly apparent for Maori.

Iwi-based health surveys indicate that Maori have difficulty accessing existing services. Some of the perceived barriers include geographical location, lack of financial resources, unavailability of service, fragmentation of service and cultural inappropriateness for Maori consumers (Mana Tangata 1993). One such survey conducted in Whanganui contended that many base-hospital admissions of Maori could be prevented if Maori had access to adequate primary health care.

When considered across different generations of modern Maori, the factors of ethnicity and social class may have important implications for differences between different Maori cohorts in their use of mainstream medical institutions. The study Te Pumanawa Hauora identified poor understanding of entitlements to some health services were identified among participants, suggesting knowledge factors may reduce the utilisation of services by kaumatua. Again, health promotion and service access education have a part to play in improving access to care. In the same study, health service providers raised concerns about kaumatua access to health and disability support services, and about barriers to access such as costs, transport and location (access factors) and cultural relevance (intent factors).

To complement the Te Pumanawa Hauora study, the sample in the present study (although small) was not confined to Maori from a more traditional profile. Furthermore, the comparisons with the findings of Flett et al. enable inequity in access to health care among Maori and non-Maori to be clearly highlighted. The low levels of formal health care use, despite high reported need observed in the present study, clearly indicate that kaumatua and kuia as a group have unmet needs.

CONCLUSIONS

The Crown objective for Maori health is:

   to ensure services are responsive to the cultural values of Maori, continue
   efforts, where appropriate and after consulting Maori, to encourage greater
   participation by Maori at all levels of the health sector, including in
   health service deliver for Maori, strengthen links between Maori health and
   other aspects of Maori development. (Crown's Statement of Objectives for
   1999/00)

The promotion of equity in access and utilisation of health care has become an identified policy goal for New Zealand health services, as it has elsewhere abroad (Malcolm 1995). The focus for targeting health gains for Maori is primarily motivated by need as assessed in view of the significant disparities between Maori and non-Maori, and in "implementing programmes and services that offer the most potential for health gain for Maori and Pacific peoples" (Crown's Statement of Objectives for 1999/00). If this policy objective is to be realised for kaumatua, then health policy development for this group needs to take account of preferences for informal forms of health care and support that may be available through Maori social networks. The potential influence of attitudinal barriers and cultural beliefs also need to be considered.

The dramatic projected increases in kaumatua and kuia (Statistics New Zealand 1998) will further necessitate careful and considered planning in future health policy and health care delivery for the kaumatua and kuia age group. There is a Maori preference for integrated policy and planning to address Maori health needs. It has been suggested that genuine Maori partnership in policy planning and implementation is an imperative for improved health gains for Maori (e.g. Ministry of Health 1997a, Public Health Commission 1994, Te Pumanawa Hauora 1997). Durie suggests that the most central issue to arise from the Hui Whakaoranga (Department of Health 1984) was the notion that significant health gains for Maori could only be achieved if Maori themselves were active participants in shaping policy for health development and in delivery of health care to Maori (Durie 1994).

The value of Maori participation in shaping the delivery of health care to Maori is supported by the Ministry of Health (1999b) which points out that the Government recognises the importance of the:

   ... special relationship between Maori and the Crown under the Treaty of
   Waitangi. It will give recognition to this by working to ensure public
   health and disability support services are responsive to Maori and by
   continuing to enable greater Maori participation in the purchase and
   delivery of health and social services, as signaled in Whaia Te Ora Mo Te
   Iwi. (p.8)

This policy should extend to the recognition of Maori aspirations for autonomy, self-empowerment and a reduced reliance upon the State in health policy planning and the provision of health care. Such recognition will require a vastly improved capacity for Maori participation at all levels of decision making in policy and implementation concerning the health and wellbeing of their living taonga.

[Figure 3 ILLUSTRATION OMITTED]

(1) That is, most study participants had high levels of iwi affiliation, participation in marae affairs and Maori language competency.

(2) Including the Maori sub-sample, the entire older adult sample (N=252) included five participants from Pacific Island communities (i.e., one Cook Island, one Niuean, two Samoan and one Tongan participant). The remainder was Pakeha/New Zealand European.

(3) Significance testing was done using the Multivariate Analysis of Variance (MANOVA) procedure within a 2 x 2 (Gender x Age) between-groups factorial design. The significant main effect for age was F (4, 58) = 3.08, p < .05.

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