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

• Author: Hirini, Paul R.

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...