Kaumātua Mana Motuhake: peer education intervention to help Māori elders during later-stage life transitions

The population in Aotearoa/New Zealand (hereafter referred to as ‘Aotearoa’), as well as with much of the world, is ageing and with this comes surges in injuries, health problems, and healthcare costs and other burdens on the socio-economic system [1]. In addition, significant inequities exist between Māori (Indigenous people of Aotearoa) and non-Māori in terms of ageing and health outcomes [2‐4], which have cultural, social, individual and economic costs [2‐4].

People encounter significant transition points as they age, such as retirement, loss of spouse, loss of independent living and changing health conditions [1, 5, 6]. Being able to traverse these transitions well involves handling service systems and socio-economic and emotional aspects, whilst having to rely on others more [7‐11]. Kaumātua (elders) who are unable to cope with these transitions may face many deleterious consequences such as social isolation, lower quality of life, and reduced health outcomes [12, 13]. The impact of these transitions for kaumātua are considerable given the context of significant health and social inequities.

This study used a strengths-based approach that highlights the potential of kaumātua (elders) to be solutions to their own challenges building on the strength of their status or mana within Māori culture. Māori culture reveres its elders from the way that Māori whānau (extended family) honour them to the way that tikanga (protocols and customs) on the marae (community meeting space) and in various community settings highlight their importance [14, 15]. This strengths-based approach is what we call kaumātua mana motuhake; mana motuhake is a concept that foregrounds independence and autonomy to achieve actualisation and so that kaumātua can have high quality of life for self and others [16]. Mana motuhake emphasises collective determination and upholding tino rangatiratanga (independence) and mana (status and prestige as viewed by self and others) in defining problems and identifying solutions. In this manner, kaumātua are viewed as key knowledge holders and leaders for the collective benefit of Māori communities. This approach is in contrast to prominent deficit models for health inequities focusing on weakness and dependency [2]. This study is part of the Ageing Well National Science Challenge in Aotearoa (https://​www.​ageingwellchalle​nge.​co.​nz/​), which emphasizes positive ageing as part of the government’s strategic approach to science investment.

Specifically, the intervention for this study was a tuakana-teina (literally, older sibling-younger sibling) peer-educator model where kaumātua work with other kaumātua [16]. The research literature on peer education builds on theories such as the theory of reasoned action [17], diffusion of innovation theory [18], and social learning theory [19] to demonstrate that peer support/education is effective for improving numerous health, social, and economic conditions [20‐23]. Peer education includes a variety of activities delivered by non-professionals to people who are of similar characteristics (e.g., age, health, culture) and experiencing a health or social need [24]. Peer education/support creates new social relationships/networks, often constructed by social and health service providers, and these relationships/networks may include self-help groups [24]. Thus, peer education is distinct from family, organisational, and community support networks where there are pre-existing relationships.

Peer education has been used to assist people in managing various life-transitions, including chronic and acute social and health issues [24]. They are primarily employed within younger populations, but elder peer educators have recently featured in palliative care [25‐27], raising awareness of health [28, 29], successful ageing [30], self-management of chronic conditions [31], and physical activity and fall-prevention in older age [32‐35]. These efforts have demonstrated positive effects of peer education on the recipients.

The current study included two broad outcomes of peer education: hauora (holistic health) and mana motuhake. Māori models of health often include at least four elements of hauora or waiora (health and wellbeing): tinana (physical well-being), hinengaro (mental and emotional well-being), wairua (spiritual well-being), and whanaunga (social well-being). This holistic perspective of health reflects Māori views of the relationship of people to all aspects in the world [36]. Mana motuhake is indicated by such elements as autonomy, economic wellbeing, and life satisfaction [16].

In addition, the peer education model has culturally appropriate features. Tuakana-teina is a Māori customary concept [15] emphasising the relationship between an elder and younger sibling (or cousin) of the same biological sex. However, tuakana-teina has been applied to situations based on training and experiences; this is because the concept is based on reciprocity and responsibility and can be pedagogically applied in peer-education mentor/mentee settings [37]. The tuakana-teina peer-education model in the present research is based on a number of cultural values including pono (truth, integrity, faithfulness), aroha (love, compassion, mercy, empathy) and tika (correctness, justice, fairness) [15, 38]. Further, the peer-education model develops age-friendly social environments that value knowledge and cultural concepts such as whakawhanaungatanga (making social connections), tautoko (advocacy, support) and mātauranga (Indigenous knowledge) [14, 15, 37].

This project sought to answer a single broad research question: What are the outcomes of a ‘tuakana-teina’ peer-educator model, where kaumātua work with other kaumātua in relation to wellness, social integration/connectedness, engagement, life-enhancement, independence, and, in particular, significant life-transitions? This manuscript addresses two specific aims: a) To determine whether the peer education intervention enhanced the social and health outcomes (hauora and mana motuhake) for kaumātua receiving it; and b) to determine the cost-effectiveness of the intervention.

The study protocol for this project was published elsewhere and full details of the project can be found there [39]. Thus, we only present in this paper a brief overview of the methodology, intervention, study design, measures, procedures, and data analysis.

The aim of the study was to examine the impacts of a tuakana/teina peer educator intervention on health and mana motuhake outcomes for kaumātua. A second aim examined the cost effectiveness of the intervention. The analysis revealed improvements over time in the expected direction on most of the variables. However, only three of the variables had statistically significant intervention effects: received support, tribal identity, and trouble paying bills. Qualitative results supported impacts of the intervention on mana motuhake, social connectedness, and tangible/information support related to services. Cost-effectiveness analysis showed that the intervention is cost effective, with a cost per QALY of less than the conventional threshold of three times GDP per capita.

The findings of this study provide further support of the benefit of using peer education with older people. While peer education has been primarily used for younger populations, recent research has found support for its use with older populations in terms of issues such as successful ageing [30], self-management of chronic conditions [31], palliative care [25‐27], raising awareness of health [28, 29], and physical activity and fall-prevention [32‐35]. The current study illustrates that peer education has effects on specific health and social outcomes for an elder Indigenous community, which is a new contribution to the research literature. The qualitative responses appear to attribute significant impact of the intervention, particularly in terms of social connections, self-efficacy, and informational support for health and social services, which likely contributed to the significant improvement on trouble paying bills.

In addition to being effective, the benefits are also cost effective. The cost per QALY compares favourably with thresholds based on three times GDP per capita and value of a statistical life year lost. In a public health care system like New Zealand, where resources are limited, allocation of funding on the basis of cost-effectiveness is a “moral imperative” [72], and our results strongly support the funding of this intervention within this population.

The study demonstrates that a culturally appropriate peer education intervention contributes to age-friendly social environments that can address social connectedness through cultural concepts such as tribal identity, tautoko, and whakawhanaungatanga [15, 37]. The contributions to social connections are significant given research that finds greater social isolation for Māori relative to other New Zealanders [73], which is particularly important given its strong links to poor health [73, 74].

A further key implication of this study is the importance of grounding the intervention in mātauranga Māori, in particular kaumātua mana motuhake. This intervention introduced a Kaupapa Māori approach that is strengths-based rather than deficiency focussed; it addresses a desire to value older people in all settings. In alignment with mana motuhake, the project utilised Māori culture itself for answers to challenges around life transitions by focusing on and valuing Māori epistemologies surrounding ageing [16, 75]. In particular, the qualitative research illustrated kaumātua feelings of mana motuhake as a result of the intervention.

Additionally, the intervention was kaumātua-led and developed and evaluated through a participatory research approach with a kaumātua-focused organisation. CBPR is a frequently used approached to work with Indigenous communities and to address health inequities [42, 76]. This study provides further evidence of the benefit of CBPR approaches and also demonstrates the successful integration of CBPR and Kaupapa Māori research approaches.

The study is not without limitations. First, the measures in the study were all self-report so direct improvement to health cannot be determined. Nonetheless, wellbeing is subjective and thus appropriate for this study. Further, a couple of the measures had lower than desirable measures of internal consistency. Second, while we attempted to use randomization throughout the selection and assignment process, we were not able to complete full random assignment. Despite the fact that there no differences between those randomly assigned and those not randomly assigned, this does provide a limitation to the research. We chose to be inclusive of participants consistent with Kaupapa Māori philosophy rather than force a Western research expectation. Third, the research design was innovative in that it provided a comparison group without withholding the intervention. However, there were limited intervention effects to fully support the efficacy of the intervention. The presence of positive spillover effects from two intervention groups likely results in ATTs that underestimates the true effect of the intervention. The change in measures over time, coupled with the strong qualitative data, leads us to conclude the intervention was effective and cost-effective, but there is need for further testing to confirm the effectiveness and cost-effectiveness of the intervention in other settings. Future research could address this by utilising a research design that allows for clearer separation of intervention groups, or that specifically seeks to estimate the size of positive spillover effects. An additional future direction is to further target the participants in need of the intervention. We did not use inclusion criteria around needs (e.g., loneliness) and it may be that this intervention is more impactful for those with greatest health and social needs.

This study resulted in a culturally-safe and effective tuakana/teina peer education intervention to assist kaumātua work through life transitions, resulting in some positive health and social outcomes, particularly related to social connectedness. The intervention is cost effective and has the potential to help a variety of communities help address equity issues in ageing for Māori and potentially other Indigenous and non-Indigenous communities. The positive outcomes in this project can be attributed to the focus on mana motuhake, being kaumātua-led, and being developed through a participatory approach with a community organisation. Participatory research approaches like those used in this study centre local mātauranga and context.

The findings provide evidence for the importance and relevancy of this study’s approach for creating contextually-based and culturally-safe, age-friendly environments that facilitate engagement and participation by kaumātua. From a policy and practice perspective, this intervention has the potential to effectively address key health and social outcomes in a cost effective manner. The intervention may be a viable alternative in the Aotearoa public health system to current practice whereby kaumātua help other kaumatua to address their needs in later-stage life transitions that may help to address some of the health inequities related to aging for Māori. This is also important given the importance of treaty obligations made by the government with Māori to ensure participation, protection and partnership for Māori. The current intervention supports these obligations by taking a strengths-based approach where kaumātua capacity and cultural knowledge instead of a deficit-based approach.