Holistic health for Pacific seniors from a weekly group gathering run by a Pacific health provider

Aims

The aims of this study were to explore what Pacific seniors are learning about their health and wellbeing and what factors contributed to sustained engagement with this weekly PTO group activity.

Recruitment

We sought participants who attended the PTO senior group gatherings. Although this would predominantly be people of Pacific descent (those who identify with the Pacific Islands beyond Aotearoa NZ), it would likely also include people from other ethnic groups including Māori as tangata whenua (people of the land). PTO offer community support services and do not exclude partners, friends or whānau who wish to attend, but are not of Pacific descent. For those participants for whom the English language was an additional language, a native speaker was provided. People who would find it challenging to participate in a group interview (eg comprehension difficulties) or people who did not regularly attend this group gathering (less than six occasions over 12-month period) were excluded from the study. Advertisements about the study were placed on notice boards at the PTO premises, alongside the senior gathering co-ordinator promoting the study to seniors.

Data collection

Open-ended Group Talanoa were used to collect data at a mutually agreeable location and time, during one of the Friday senior group gatherings. Given the known ethnic diversity within the seniors' group, it was anticipated there would need to be four groups, a Cook Island, Samoan, Tongan, and an other ‘Mixed’ group (representing participants descending from any other Pacific Islands alongside Māori, NZ European and all other participant ethnicity), each with approximately six participants per group.

Group Talanoa were facilitated by Pacific researchers with corresponding Pacific language abilities, who have experience in carrying out these data collection techniques with Pacific participants. An opening lotu (prayer) and welcome was said before each focus group, as well as a lotu to close. The research team asked the Pacific seniors in the focus groups about what they are learning about their health and wellbeing and what factors contributed to sustained engagement with this weekly group activity. Subsequent open-ended questions were explored in alignment with the aforementioned key research question. A specific discussion guide was not used, acknowledging the conversational Talanoa model of enquiry followed within this research.

The Cook Island and ‘Mixed’ focus groups were conducted primarily in English. The Samoan focus group was conducted in a combination of English and Samoan languages. The Tongan focus group was conducted solely in the Tongan language. The focus groups were approximately 60 min in length. All four Group Talanoa were held concurrently followed by sharing food together. Each participant received a grocery voucher following the focus group to acknowledge their valuable knowledge and contribution. Each focus group was digitally voice-recorded. The digital audio was then either transcribed word-for-word (if in the English language) or contextually translated and transcribed and de-identified (by assigning a participant ID#) to protect the participant’s anonymity. Those recordings requiring contextual translation (Samoan and Tongan) were done so by the researcher leading the focus group, as they were closest to the Group Talanoa conversation and best placed for conceptual and contextual interpretation. Each translation was subsequently discussed and verified with a fellow member of the research team fluent in that native language. Given the intention to conduct the data analysis (Tui) process through group discussion within the research team, the interviews were translated into the English language to enable full participation. Field notes were taken by each of the research team following the Group Talanoa to note and record any nuance associated with the responses.

As part of the Luva process of the Kakala Research Framework, there was a planned opportunity to present the initial data analysis and findings back to the seniors and hear their feedback and perspectives.

Culture (Roof/Shelter)

The importance of culture was depicted in a variety of ways.

Special thing about this is the comradeship, everyone getting together, there’s the different island groups, sharing each other’s cultures. (#974 Mixed focus group)

It’s about sharing and supporting one another, so that’s her contribution. (#643 Tongan focus group – researcher interpretation)

She thinks everything that is organised is good. The exercises, the food. Something significant she was saying is having students, the physio students. They learn a lot from them. (#795 Tongan Focus Group – researcher interpretation)

These statements detail how the seniors appreciated their roots as people of the Pacific being acknowledged through the sharing of common values including respect and reciprocity. One senior noted not only enjoying attending and appreciating the cultural connections, but also feeling a responsibility to contribute and support others within the group gathering. Pacific values include an openness, interest and compassion towards others and the opportunity to be with students from a variety of cultures and backgrounds allows for different interpersonal relationships to be formed, which would not otherwise be possible. The sharing and learning are reciprocal with respect to culture, age, and pastime; they are all learning with, from and about one another.

Physical pou (domain)

…exercise is good for your health too as well. That is the only reason I come here is to exercise. Good for your body and make you young. (#280 Cook Island focus group)

Kou tui kapau na’e ‘ikai ke u ha’u au ‘o fakamalohisino, kou ‘osi tokoto au ia. (#643 Tongan focus group, without translation and interpretation)

According to her, she believes that if she wasn’t attending this seniors’ programme, she would have been bedridden by now. (#643 Tongan focus group – researcher interpretation)

She didn’t know before this that you can just be full from eating veggies, just like salads. But this seniors’ programme has allowed her to know what’s good for her and to control what she eats. It’s not stopping her eat meat, but it’s understanding the right amounts and the right types. (#679 Tongan focus group – researcher interpretation)

These passages from the Group Talanoa demonstrate the seniors’ recognition of the value of the exercises built into the group gathering and how they have helped maintain strength and physical function essential to a basic quality of life, but also to a delightful feeling of youthfulness and not being old and frail before your time. This aligns with earlier work completed by Tararo-Ruhe et al.,¹⁹ where strength and balance exercises were added into the exercise options with this same seniors group. The healthy eating and nutrition guidance was also credited, where increased understanding of types, quantities and varieties of food groups were empowering and led to more informed choices.

Spiritual pou

And so, it’s good to tell the words out to our friends, not only to our community but other ethnic groups. Yes, so that we can all come and receive all this. It’s a blessing that we can come and do the programme and do the exercise and learn from all these lovely staff of PTO. (#449 Cook Island focus group)

Greetings, thanks to God for bringing us together to enjoy this time. It has been a long time since I came here, because I haven’t been well/have been weak, and now I have come to exercise… (#499 Samoan focus group - translated)

There’s a fear of missing out! They want to continue to attend because too much fellowship and fun would be missed if they weren’t there. (#643 Tongan focus group – researcher interpretation)

There is a clear gratitude to God as the source of this blessing (of this seniors group gathering) and how lucky they feel to have the opportunity to attend such an offering. In this way, the spiritual aspect affirms the benefits of the physical and social aspects – giving them joy, laughter, and a sense of wellbeing. The group gathering is fun, it brings the seniors and staff together in a trusted relationship, like an extended family with love and respect, uplifting their spirits. Consistently, seniors shared their spiritual journey because in the end, their faith in God is a pou (pillar) of support for them.

Mental pou

Now I learn something that I heard from other people, that if you stay at home, you get silly in the mind… (#716 Cook Island focus group)

iloa lou nofo - ua e nofo na o au, you lonely sometimes. E te meet te alu out ma le fale, e te fiafia ai. (#499 – Samoan focus group - Samoan)

I stay home by myself, and you lonely sometimes. To meet and get out of the house, makes you happy. (#499 Samoan focus group - translated)

And it’s a really good experience to me because I got a time off to meet different people from the Pacific, and have fellowship and laugh and talk, and exercise our body because we are getting old. We are retired people, we just stay home and do nothing, we need to go out and meet other people and start moving your body and… it’s quite a good experience to me. Because sometimes you are stressed? And uh, that’s a good time to come and talk to your colleagues over here and release all those pressures to make you feel better. (#736 Samoan focus group – shared in English)

These statements suggest the stress relief that comes from attending this community gathering through exercise and fellowship. There is also a clear understanding of the link and importance of a healthy mind and healthy body and how they go hand-in-hand. Social isolation is prevalent in seniors in Aotearoa NZ, including Pacific seniors,²⁰ and this weekly gathering provides a routine and reason to get out of the house for their own mental wellbeing.

Other pou (age, gender, financial situation, etc)

And I’m really grateful for having them [PTO] … we have our free checkups for our medical checkups, … and that is for us oldies who have lost our husbands. (#344 Mixed focus group)

They appreciate having a van picking them up. Because if it weren’t for the van, then there’ll be a struggle for them to get there. (#643 Tongan focus group – researcher interpretation)

These comments speak to the importance of the programme being free to access, provided in a culturally safe way, addressing barriers to attendance while respecting age and stage of these seniors towards their community.

It should be noted that sometimes researchers had selected similar dialogue but felt that they belonged in different domains. For instance, did this quotation fit in a ‘Culture’ or a ‘Spiritual’ domain or did this quotation fit in a ‘Family’ or a ‘Culture’ domain? Such fruitful and colourful discussions helped refine the Tui process and create the ‘It’s in the weave’ discussion point.

‘It’s in the weave’

The Pacific seniors in this study valued the opportunity to connect weekly through a Pacific health provider and pray, dance, sing, exercise, laugh, and share food together to support their holistic health, and this can be aligned with the pan-Pacific Fonofale Model of Health. Recognising that what one individual gains from attendance is not necessarily the same as the next, but to separate out and discuss each aspect individually diminishes the richness of the narratives shared by the seniors. The values of culture, spirituality and family connections were more intertwined and related to health for them than physical health concerns alone. These connections and supports, between and within culture, spirituality and family and how all are intricately and uniquely woven together with respectful and trusting relationships, are what seem to contribute most to their sense of individual and collective health and wellbeing.

It’s not just a (seniors’) programme. There’s a ‘relationship’ that they have amongst themselves. (Tongan focus group – researcher reflection)

The above comment suggests the new lens through which our researcher now understood and viewed the seniors group gathering to be. Another of our team reflected when considering the research question and the seniors group gathering in relation to the Fonofale Model of Health – ‘It’s in the weave’! What is important to the seniors is the whole (of health) and the whole is so much more than the sum of the parts. Not only must one consider the whole Fonofale Model, but equally appreciate the ‘Va’ (relational space)²¹ and the intricacy, compassion, and spirit of how it is woven together. This aligns with Ioane and Tudor’s²² suggestion that alongside the Fonofale Model, there is a need to take into account the importance of the ‘Va’ within a therapeutic context. When working with Pacific communities, it is important to understand and accept the Pacific world view; that of a collective culture in which Pacific peoples view themselves in relation to others and how they fit in with others.²³

Incorporating cultural practices within the group gathering helped address some of the challenges that Pacific seniors face, such as social isolation and loneliness, both aspects of the social determinants of health.²⁴ By participating in cultural activities and practices, seniors can experience a sense of community and belonging, which can have a positive impact on mental health and wellbeing. This has synergies with the Brown Buttabean Motivation (BBM) holistic health programme, where the group exercise context not only helped participants lose weight, but also supported community needs through improved mental health and a sense of connectedness through culture and family.²⁵ Evidence suggests that a closer connection to culture and ethnic identity supports enhanced Pacific health and wellbeing.^17,26 This aligns with some of the findings in Lilomaiava Silulu’s PhD thesis ²⁷ looking specifically at Samoan elders’ perceptions of wellness where Soifua Manuia (good health) was associated with close links to family and faith.

Health system opportunity

To realise the potential of the health system reforms, it is necessary to consider health in different ways ‘looking beyond the person as individual, to the person as part of a collective’.²⁸ As Tamasese et al. explain: ‘The New Zealand mainstream cultural view of the self as individuated stands in contrast to the Pacific views of the self as a total being who exists in relationship to other people’.⁷ Embracing indigenous perspectives about health can challenge and enrich how we think about and practice care in the community.²⁸ The opportunity lies with primary care funders appreciating what it is that is important to Pacific people and partnering with Pacific Health Providers to deliver care in meaningful ways in the right spaces and places. Expressing a deep understanding of indigenous models of care (eg Meihana model²⁹ and Fonofale model¹⁸) and an openness to deliver care in ways that align with these models requires fresh thinking and authentically nurturing the ‘Va’ with trusting relationships with Māori and Pacific health providers.²⁸

The health reforms taking place in Aotearoa NZ are shining a light on health inequities and encouraging new ways of thinking and working with Pacific people. Informed and inclusive approaches to promoting and addressing holistic health must be adopted as part of this.³⁰ This study highlights the value of an allied health-led weekly group gathering for Pacific seniors run by a Pacific health provider in supporting their holistic health and wellbeing needs (and potential chronic health condition outcomes). The more the health system appreciates indigenous models of health and care, giving primacy to culture, spirituality and family, the more tailored services and support can be offered.^31,32 This enhances engagement, learning and consequently improves agency and decision-making in health care. How much might such models of care with allied health working with Pacific providers in the community impact the burden of care within general practice?

This PTO group activity is a great example of what the future of holistic primary care could look like in line with the vision of Te Pae Tata.³ Pacific Trust Otago:

Despite PTO enabling this service for their seniors, they have been unable to secure consistent funding to run the activity on a sustainable basis; yet, such an activity has the potential for more equitable health and social outcomes for Pacific people in Aotearoa NZ.

Strength and limitations of the study

Consistent attempts were made to respectfully honour the process of the Kakala Research Framework.¹² The fact that the researchers involved had established trusting relationships with PTO meant a suitable Teu process was possible and arranging the study logistics occurred collaboratively. The Samoan and Tongan language translation was completed and conceptually validated collaboratively by the research team themselves instead of outsourcing an external service for translation and transcription where the context and concepts might be ‘lost in translation’. The focus groups were aligned with Pacific Nations, as feasible, ensuring voices from seniors who would prefer to share their thoughts in their first language could do so. Neville et al. ³³ recognised that people feel more understood when they can most candidly share how they are feeling in their first language. The fact that the seniors said that Mālie and Māfana were important aspects, and these values were role-modelled throughout the Toli process, suggests that a comfortable environment for Group Talanoa was created. The opportunity to present the findings back to the seniors (Luva) and hear their feedback allowed for further depth analysis and permission to continue to share their perspectives.

Study limitations include the fact that there was only one opportunity for data collection. Therefore, we were unable to canvas the opinions of all the seniors who might typically attend the gathering because if they could not attend on that day, then their responses were not captured. Despite this, the feedback session allowed those unable to be present on the day the opportunity to comment and corroborate what they might have said in line with the findings shared. It is acknowledged that although the focus groups occurred separately within Pacific Island groups, the data analysis did not occur separately. This study was evaluating the health and wellbeing learnings associated with a pan-Pacific seniors group gathering. The data we gathered were commonalities, not differences, and were always intended to be presented from a pan-Pacific perspective as opposed to a specific Tongan or Samoan perspective. Should this line of inquiry grow to explore seniors’ learnings from a variety of wellbeing programmes across the motu (nation), then a specific analysis by Pacific Island group would be possible to explore nuanced similarities and differences, like the work of Lilomaiava Silulu with a specific lens on Samoan senior wellbeing.²⁷

Challenges arose for the corresponding author during the data analysis process in terms of not fully appreciating the complexity and nuance associated with analysing Group Talanoa collected in Tongan/Samoan languages. Convention suggests analysis occurs in the language the data is collected in, but in order for the team to share the tui process (analysis) together, the stories needed to be shared in English also. Working with the Tongan and Samoan researchers and hearing and appreciating their own interpretations and reflections of the data added a uniqueness and richness to understanding the senior perspectives.