Background
Kaumātua (older Māori; Indigenous people) in Aotearoa New Zealand experience significant health inequities compared to non-Māori elders [
1‐
3]. Russell et al. [
4] highlighted that “Māori experience systematic disparities in health outcomes, determinants of health, health system responsiveness, and representation in the health sector workforce” (p.10). These inequities result from lack of access to health and/or social services, the unequal distribution of social determinants (e.g., housing, education, income), and structural discrimination resulting from the effects of colonisation [
1,
3,
5].
These inequities and patterns are consistent with other Indigenous peoples, cultures and communities worldwide [
6,
7]. “Globally, health disparities between Indigenous and non-Indigenous populations are ubiquitous and pervasive, and are recognized as being unfair, avoidable, and remediable (p. 512)” [
8]. Thus, the deleterious impacts of colonisation on the Indigenous life-course are endemic internationally. Further, the fact that Indigenous peoples die earlier than their non-Indigenous compatriots creates a great pain and a sense of loss for Indigenous cultures that view their elders as bearers of knowledge critical to survivance [
9]. Māori culture upholds kaumātua as, “carriers of culture, anchors for families, models for lifestyle, bridges to the future, guardians of heritage, and role models for younger generations (p. 14)” [
10].
Māori make up about 17% of the total population in Aotearoa and about 7% of Māori are aged 65 years and older [
11]. Growing up in the 1940-60s, many of today’s kaumātua experienced a more racist society than present, including government policies that fostered monoculturalism and an education system that discouraged and punished children for speaking Te Reo Māori (Māori language) and/or for practicing tikanga Māori (Māori cultural protocols) [
12]. Currently, there are many kaupapa Māori health and social service providers (providers that operate using a Māori worldview) that are funded to address many of the negative health effects arising from this history. However, these providers are typically underfunded, and inequities persist. In the past two years, the New Zealand health system has been reorganised to address these inequities including the development of Te Aka Whai Ora (the Māori Health Authority) and increased funding to support Māori providers.
Because of this historical context and decades of insufficient funding, there are relatively few examples of innovative research programmes to address the health and social needs of kaumātua. However, recent research has developed novel health programmes (i.e., interventions) aimed at addressing such needs [
13,
14]. Even so, the benefits of initiatives from Māori health providers, and other Indigenous evidence, are rarely reported in the literature [
15]. Thus, communities and providers who may benefit from awareness of these programmes and implementing the initiatives, may miss out on key opportunities to address health inequities.
An exception to this pattern in the literature is the tuakana-teina peer education programme. The tuakana-teina (literally, older sibling-younger sibling, but more specifically in this programme—with and without experience) programme is where kaumātua work with other kaumātua to help them work through life transitions and identify health and social services that they might need to help address these transitions [
16‐
18]. The programme uses a strengths-based approach that highlights the potential of kaumātua to be solutions to their own challenges, building on the strength of their mana (status) within Māori culture [
17]. This strengths-based approach was based in kaumātua mana motuhake; mana motuhake emphasises autonomy and independence to achieve actualisation so that kaumātua can enhance wellbeing and quality of life for themselves and others [
19]. This strengths-based approach contrasts with the predominant deficit models for health inequities that focus on dependency and weakness [
20].
The tuakana-teina model has been widely used in areas such as governance, environmental resources, and school mentoring [
21,
22]. This specific tuakana-teina programme was co-developed through a participatory research approach by a Māori community organisation and a group of university researchers and based on an original idea offered by kaumātua [
17,
23]. This programme departs from the traditional tuakana-teina model in that the relationships were not based in genealogy and age although tuakana and teina were matched on sex; the relationships were based on experiences and skills. We have discussed these departures elsewhere; briefly we went through an in-depth co-design process with a kaumātua advisory board and a health and social services expert advisory board in determining the nature of the relationships and name for the programme [
17]. These boards considered other possible labels but decided that tuakana-teina was the most appropriate description despite these departures from the traditional use of the model.
The tuakana-teina programme is also grounded in the extant literature on peer education, including the theoretical (e.g., social learning theory [
24], theory of reasoned action [
25], diffusion of innovation theory [
26]) and empirical literature, which together demonstrates that peer support/education is effective for improving numerous economic, social and health conditions [
27‐
30]. Peer education is offered by non-professionals to people who are of similar characteristics (e.g., culture, health, age) experiencing a social or health issue [
31]. Peer education and support creates new relationships that are distinct from existing family, community and organisational relationships [
31].
Earlier research has found that the tuakana-teina programme enhanced tuakana (experienced peers) communication skills to enact their peer educator role and this impacted positively on their sense of cultural identity, sense of purpose, and wellbeing [
18]. The tuakana-teina programme also increased teina (inexperienced peers) perceived support, knowledge of cultural protocols, social connectedness, and informational support about health and social services [
32]. Additionally, the programme was found to be cost-effective in addressing key social and health outcomes [
32].
The current study builds on the original tuakana-teina programme and addresses several limitations. First, the original study only included a single community provider; we extended the current research to one iwi (tribe) and four community providers. Second, the original tuakana-teina programme only included three conversations, which may not have been enough to establish a strong relationship between the tuakana and teina; the current programme involves six conversations. Finally, the original tuakana-teina programme primarily included kaumātua with strong social and cultural resources. The current study included more participants with key health and social service needs.
Similar to the original programme, the current study focused on two broad outcomes of peer education: hauora (holistic health) and mana motuhake. Māori models of health include multiple elements of hauora (health and wellbeing): hinengaro (mental wellbeing), kare ā-roto (emotional wellbeing), whanaungatanga (social wellbeing), wairua (spiritual wellbeing), tinana (physical well-being) and tikanga (cultural wellbeing). This holistic perspective of health reflects Māori views of the relationship of people to all aspects in the world [
33]. Mana motuhake is indicated by such elements as economic wellbeing, life satisfaction and personal autonomy [
19].
This project sought to answer a single broad research question: What are the outcomes of the tuakana-teina programme for kaumātua with the greatest health and social needs? This study serves several specific aims: (a) To determine whether the tuakana-teina programme enhanced the social and health outcomes (hauora and mana motuhake); (b) To identify the types of resources provided; and (c) To determine the cost-effectiveness of the programme.
Discussion
The aims of the study were to identify the impact on outcomes, resources provided and the cost effectiveness of the tuakana-teina programme. The analysis revealed improvements in HRQOL, help with daily tasks, life satisfaction, paying bills and housing problems. Qualitative results supported impacts of the programme on mana motuhake and hauora, through providing intangible and tangible resources. Cost-effectiveness analysis showed that the intervention is cost effective, with a cost per QALY substantially below than the conventional threshold of three times GDP per capita.
The current findings illustrate the positive outcomes of peer support and education with elders. Research demonstrates use of peer support with older populations in terms of issues such as increasing awareness of health issues [
59,
60], palliative care [
40,
61,
62], successful ageing [
63], chronic condition self-management [
64] and physical activity and fall-prevention [
65‐
68]. The current study also further supports the previous research on the tuakana-teina programme to show positive impacts on hauora and mana motuhake outcomes for an elder Indigenous community [
32]. The qualitative responses attribute positive impact of the tuakana-teina programme for participants’ hauora and mana motuhake as well, particularly in terms of mental, emotional, cultural, and spiritual wellbeing. More importantly, the qualitative findings document that the peer education process identified key health issues and provided information and access to resources that had not been identified previously. The tuakana-teina relationship provided a safe space to explore a variety of health issues for kaumātua with key needs.
Overall, the study illustrates that the tuakana-teina programme creates a culturally resonant social environment with important benefits to social connectedness and cultural renewal. The opportunity to connect culturally is significant given the history of devaluing and removing Te Ao Māori and Te Reo Māori for kaumātua when they were younger [
69]. Further, the social connectedness is important as research finds greater social isolation for Māori relative to other New Zealanders [
70], which is significant given its links to poor health [
70,
71].
In addition to being effective, the programme was also cost-effective. The cost per QALY compares favourably with thresholds based on GDP per capita (and three times GDP per capita) and the value of a statistical life year lost. It also compares favourably with the original programme, being more cost-effective in comparison with that programme [
32]. This may reflect a combination of improvements in the efficiency and efficacy of the programme. Identifying cost-effective interventions is a “moral imperative” [
72] for public health care systems like that in New Zealand, particularly in a time of change and reorganisation of the health system, which began in 2022. Indeed, new health delivery options for Māori need a strong evidence base of cost-effective programmes to improve hauora Māori.
The programme demonstrates the importance of implementing the tuakana-teina programme through a participatory and co-design participatory process using an Indigenous-based framework [
35]. The Indigenous participatory process ensures that the programme is grounded in kaupapa Māori and is kaumātua-led and provider-led. The implementation process enabled the new providers to adapt the programme to fit their local culture and take ownership of the implementation process [
18]. Participatory processes are frequently used approached to work with Indigenous communities and to address health inequities [
73]. This study provides further evidence of the benefit of the participatory approaches both for programme effectiveness and implementation effectiveness.
A further implication is the benefit of grounding the tuakana-teina programme in mātauranga Māori (knowledge) or kaumātua mana motuhake. This programme takes a strengths-based rather than the oft-used deficit approach. It aligns with mana motuhake and the programme utilised Māori culture itself for answers to health and social issues through the use of Māori epistemologies surrounding ageing [
19]. The strong mana motuhake impacts in both the survey and qualitative research demonstrated kaumātua feelings of mana motuhake because of the tuakana-teina programme.
The study does have some limitations. First, we had one provider who was not able to use random selection of participants. Second, we used self-report measures without any direct outcome measures. Third, the study took place during the COVID pandemic and thus its implementation had some delays. It is a testament to the excellence and resilience of the providers that they were able to complete the programme despite the challenges created by the pandemic. Finally, the study was non-blinded, clustered, and open to contamination (i.e., participants sharing with others). These are generally unavoidable in a community trial. To mitigate these factors, we applied random selection in most communities and the staggered design was applied at a community level to limit sharing across the providers. However, we did not try to control contamination and blinding as to do so would be counter to the mana motuhake of kaumātua and them wanting to discuss the programme and know what was going on in the programme.
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