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Keywords:

  • 80 and over;
  • activity of daily living;
  • aged;
  • leisure activity;
  • social participation

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Aim:  This project explored the usability of the World Health Organisation, International Classification of Functioning, Disability and Health (ICF) for describing older Māori and non-Māori people's self-nominated important activities.

Method:  Within a feasibility-for-cohort study, 112 participants, 33 Māori, aged 75–79 years, and 79 non-Māori, aged 85 years, nominated their three most important activities. Verbatim responses were coded using the ICF classifications and described using non-parametric statistics.

Results:  Men and women mostly named domestic life, interpersonal relationships and recreation and leisure activities. While Māori frequently named extended family relationship activities as being most important, non-Māori named more recreation and leisure activities.

Conclusions:  The ICF is useful for classifying older New Zealanders' important activities, although some activities of older Māori were not specified in the original version used. While important activity patterns were similar for men and women, those related to ancestral connectivity and community collectivity were most important for Māori.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

New Zealand's population is ageing. By the late 2030s one-quarter of the population will be 65 years or older [1]. Accordingly, understanding what helps people age well and live well in advanced age is important. Engaging in activities is related to successful ageing: however, evidence of the types of activity that promote well-being is mixed and, at times, inconclusive.

Participating in leisure time physical activities is positively associated with psychological and physical health and well-being [2,3], improved cognitive performance [4], better self-reported health [5], and enriched Māori cultural health and well-being [6]. New Zealanders aged in their seventies who competed in the South Pacific Masters Games, spoke about improved functional independence and ‘control over their health and well-being’[7]. However, a 13-year cohort study of older Americans showed that engaging in social or productive activities, such as gardening, preparing meals and shopping, offered the same survival benefits as fitness activities [8]. Moreover, in communities with high levels of socioeconomic deprivation, older people are less likely to participate in neighbourhood-based leisure time physical activities [9].

Looking more broadly at older adults' participation: engagement in ‘productive’ activities, especially volunteering, predicts low frailty [10]; doing intellectual activities is associated with better long-term functioning in instrumental activities of daily living [11]; participating socially is positively associated with coping behaviours [12] and survival [13]; and, interestingly, going outdoors daily predicts better functioning in instrumental activities of daily living and self-reported health [14]. Qualitatively, keeping busy is experienced as being well and contributing to the community [15].

Menec [16] found that Canadian older people with greater engagement in social and productive activities were more likely to survive over six years and to retain better function. Of interest, only participation in solitary activities, such as reading and handiwork, predicted greater happiness. Similarly, older Swedes who participated in solitary-active pursuits, such as gardening and other hobbies like woodwork, showed enhanced five-year survival [17] and, in a French study, participating at least twice weekly in stimulating leisure activities, like crosswords or artistic hobbies, was significantly negatively associated with dementia. However, there was ‘no consensus regarding the underlying mechanism involved’[18].

Other studies have described older peoples' activities and time use patterns. Overall, with advancing age, lifestyles tend to become more sedentary [19,20], with more time spent at home alone. Interpreting across time-use studies is problematic owing to the range of standardised instruments used, listing different predefined activities. Despite the variety in how data are collected, watching television, reading books or the newspaper, meeting friends or receiving visitors, and doing housework, gardening or walking are reported in several studies as frequent activities for older people [13,16,20,21]. Men tend to be more physically active [22], while women are more likely to engage in social and home activities, such as arts, crafts, cooking and baking [23]. No similar literature reporting older New Zealanders' everyday or leisure activities was located, although Waldon's [6] study of older Māori peoples' health found most were engaged in marae-based (tribal) activities and whanau (extended family) matters. Nonetheless, time spent doing activities is not necessarily associated with doing things that are important or enjoyable [24,25]. Some evidence suggests that engaging in subjectively important activities is associated with positive health and well-being outcomes, including a sense of purpose and fulfilment in life [26]. Such international findings indicate the importance of exploring the activities that matter most to older New Zealanders.

The World Health Organisation developed the International Classification of Functioning, Disability and Health (ICF) to provide an interdisciplinary, systematic classification framework [27]. While the tool was designed for cross-cultural use and inter-country comparison, no reports of its usability with Māori are known. The aim of this project, in preparation for a large cohort study, was to explore the feasibility of asking older New Zealanders to name their three most important activities and to test the ICF's utility in coding open responses concerning important activities.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

This project draws on one aspect of a comprehensive feasibility study with at least 100 participants, to inform the development of a New Zealand cohort study aimed at establishing the predictors of ageing well. Findings from other aspects of the study will be reported separately.

A Māori advisory group, Te RōpūKaitaikai o Ngā Tikanga Māori (Protectors of Principles of Conduct in Māori Research) was created to govern all aspects of the study related to Māori, New Zealand's indigenous peoples. A series of hui (community meetings) were conducted to develop relationships with local tribal and regional groups. The interview-based questionnaire was piloted and translated into te reo Māori me ngā tikanga (Māori language and culture) for Māori participants. Subcontracts governing culturally relevant non-probability sampling and interviewing were established with regional health providers and Rūnanga (Māori tribal organisations). Six Māori and two non-Māori interviewers were trained in standardised interviewing techniques and questionnaire implementation with volunteer participants. Inter-rater reliability was established through paired observation.

The study conformed to the provisions of the Declaration of Helsinki and gained ethics approval from the New Zealand, Northern X Regional Ethics Committee.

Recruitment

Included were Māori, aged 75–79 years, and non-Māori aged 85 years, residing at home or in aged care within three urban and rural locations. The age variance reflected the demographic longevity differences. Those with current hospital admission were excluded. Māori were invited to participate by the locally contracted Māori interviewers. Non-Māori were approached by letter from their general practitioner. All potential participants received written information about the study and gave written consent. Fifty-six per cent of the eligible population was enrolled. Reasons for non-participation included (i) unable to be contacted, (ii) participation declined by the person, their family or their general practitioner, or (iii) died before enrolment.

One hundred and twelve older New Zealanders, including nine pilot participants, were enrolled; 64 (57%) women and 48 (43%) men, including 33 Māori (self-identified) and 79 non-Māori (78 New Zealand European and 1 Fijian/European/English). Most lived alone or with a spouse/partner only (77%), and 53% engaged regularly in volunteer or paid work.

Data gathering

Most interviews were conducted at home (80%) and took 3.5 hours on average. This article focuses on the question adapted from the Melbourne Longitudinal Studies on Healthy Ageing Program (MELSHA) [28]; ‘Of all the things you do, which three are the most important to you?’ Verbatim responses were recorded in writing. No probing questions were used if the person nominated fewer than three things. If more than three were stated, the interviewer recorded all responses.

Coding and analysis

A research assistant (SH), trained to use the ICF ‘activities and participation’ (‘d’) component [27], coded all data, working in consultation with a Māori researcher (MK) for all Māori data. Three-level (item) ICF codes were used, allowing data to be collapsed hierarchically into two-level (category) or one-level (domain) codes (see Table 1). For example, ‘extended family relationships’ (d7603) is itemised under the ‘family relationships’ (d760) category, within the ‘interpersonal interactions and relationships’ (d7) domain. ‘Other specified’ or ‘unspecified’ third-level codes were used when ICF items did not adequately match a participant-nominated activity.

Table 1.  ICF activities and participation domains [27]
DomainDomain descriptionDefinition
d1Learning and applying knowledgeLearning, applying the knowledge that is learned, thinking, solving problems and making decisions
d2General tasks and demandsCarrying out single or multiple tasks, organising routines and handling stress
d3CommunicationCommunicating by language, signs and symbols, including receiving and producing messages, carrying on conversations, and using communication devices and techniques
d4MobilityMoving by changing body position or location or by transferring from one place to another, by carrying, moving or manipulating objects, by walking, running or climbing, and by using various forms of transportation
d5Self-careCaring for oneself, washing and drying oneself, caring for one's body and body parts, dressing, eating and drinking, and looking after one's health
d6Domestic lifeDoing domestic and everyday actions and tasks including acquiring a place to live, food, clothing and other necessities, household cleaning and repairing, caring for personal and other household objects, and assisting others
d7Interpersonal interactions and relationshipsActions and tasks required for basic and complex interactions with people (strangers, friends, relatives, family members and lovers) in a contextually and socially appropriate manner
d8Major life areaEngaging in education, work and employment and to conduct economic transactions
d9Community, social and civic lifeEngaging in organised social life outside the family, in community, social and civic areas of life

Coded data were audited by the first author (VW). A computer-generated, random sample of 10% of Māori and non-Māori responses was selected and independently coded by the principal investigator (NK). Discrepancies were adjudicated by all coders (SK, VW, MK and NK). Initially, half of the independently coded Māori responses differed. For example, NK, who was not Māori, interpreted ‘marae (meeting place of people who share ancestors and place) activities’ as acting in a ‘position of responsibility’. During adjudication, discussions clarified that, within te reo Māori me ngā tikanga (Māori language and proper conduct), being with whānau (extended family) and iwi (tribe) underpinned ‘marae activities’ rather than being associated with decision making. Such activities were adjudicated as being ‘family relationships, other specified’ (d7608) inclusive of cultural interpretations related to the extended family context and connectedness to ancestral lands. Family activities named by non-Māori were itemised differently as ‘relationships with extended family’ (d7603).

All ICF-coded data were counted and grouped using descriptive statistics to examine the frequency and patterns of important activities and displayed in a Microsoft Excel spreadsheet. In line with the project's purpose, over-analysis of the data was avoided.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Seventy-three participants (65%) nominated three important activities as requested; 12 declined to respond. The remaining participants nominated between one and five activities. In total, Māori participants reported 99 (a mean of 3.0 per person) and non-Māori reported 216 (a mean of 2.7 per person) important activities.

Patterns of men's and women's important activities were similar across the ICF domains of ‘domestic life’ (d6), ‘interpersonal interactions and relationships’ (d7), and ‘community, social and civic life’ (d9). Three responses only, nominating ‘sleeping’ or ‘resting’ as important activities, were interpreted as getting ‘optimal physical and mental rest and relaxation’[27], and coded under the ‘body functions’ (‘b’) component. The frequency of all ICF first-level activity domains and the three most commonly occurring second-level categories are presented in Table 2.

Table 2.  Frequency table for all important activities by participant ethnicity and sex
ICF DomainMāoriNon-MāoriMaleFemaleTotal
Number of activities (% of all codes for Māori)Number of activities (% of all codes for non-Māori)Number of activities (% of all codes for men)Number of activities (% of all codes for women)Number of activities (% of all codes)
  • Indicates the most frequent categories of activities. d760, family relationships; d920, recreation and leisure; d930, religion and spirituality.

d15 (5)11 (5)9 (7)7 (4)16 (5)
d22 (2)2 (2)1 (1)3 (2)4 (1)
d30 (0)2 (1)2 (1)0 (0)2 (1)
d42 (2)5 (2)2 (1)6 (2)8 (2)
d53 (3)5 (2)2 (1)6 (3)8 (3)
d626 (26)51 (24)28 (21)49 (27)77 (24)
d724 (24)31 (14)28 (21)27 (15)55 (17)
d76022 (22)18 (8)20 (15)20 (11)40 (13)
d85 (5)5 (2)5 (4)5 (3)10 (3)
d932 (32)105 (49)59 (43)78 (44)137 (44)
d92017 (17)86 (40)43 (32)60 (34)103 (33)
d93012 (12)14 (6)11 (8)15 (8)26 (8)
Total number of activities nominated99216136179315

Important activities and ethnicity

Thirty-two per cent of all important activities nominated by Māori, and 49% by non-Māori, related to ‘community, social and civic life’ (d9). Within this domain, 40% of non-Māori and 17% of Māori responses were categorised as ‘recreation and leisure’ (d920), and 6% of non-Māori and 12% of Māori responses as ‘religion and spirituality’ (d930) activities. ‘Interpersonal interactions and relationships’ (d7) accounted for nearly a quarter (24%) of activities nominated by Māori, compared with 14% for non-Māori. Within this, Māori named activities such as ‘supporting family’, ‘attending functions’, ‘family gatherings’, or ‘taking care of mokopuna (grandchildren)’ while non-Māori nominated activities such as visiting with, or talking to, family as being most important.

Important activities and sex

Men and women reported remarkably similar patterns of important activities although men more often nominated ‘interpersonal relationships’ (d7) as important, such as ‘keeping my wife happy’ (coded; ‘showing respect, warmth, appreciation, and tolerance in relationships’ (d7100) [27]), and ‘doing things together with my wife’ (‘creating and maintaining close or romantic relationships’ (d7701) [27]). Several women identified ‘talking to family’ as important; interpreted as ‘creating and maintaining a family relationship with members of one's extended family’ (d7603) [27]; whereas ‘seeing my husband comfortable at night’ was coded d6600, meaning ‘taking care of . . . members of the household’[27].

Important activities at home and in leisure

Interestingly, the importance of ‘domestic life’ (d6) activities was similar for Māori (26%), non-Māori (24%), men (21%) and women (27%). Most frequently nominated were gardening (n= 22), constituting 29% of all d6 activities, cooking (n= 16) at 21%, and keeping a tidy house (n= 11) and shopping (n= 11) each making up 13%.

Of activities classified as ‘recreation and leisure’ (d920), 29% of those nominated by Māori, compared with 50% for non-Māori, were ‘arts and culture’ (d9202). The most commonly mentioned were reading newspapers, books or magazines (16 responses), being outdoors (10 responses), walking, socialising (9 responses each), playing cards or doing puzzles (8 responses), and doing handicrafts such as carving, doing woodwork, knitting or drawing (7 responses).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The ICF provides a systematic classification framework for older New Zealanders' self-nominated important activities. The tool's usability is enhanced by clear specification of what is included and excluded under the first-level domains and second-level categories. The online version enabled key word searching, whereas the print version was more useful for inspecting the hierarchical activity–code relationships.

While the ICF was tested with different ethnic groups in a number of countries [27], its utility seemed less relevant within a Kaupapa Māori (Māori philosophy or methodology) context. This might be expected when using the ICF in a new situation. To take account of this, the ‘other specified’ or ‘unspecified’ item codes were at times used to signify Māori culturally bound activities. To illustrate, ‘teaching children about the environment’ was itemised as ‘religion and spirituality, other specified’ (d9308); as passing on deep spiritual understandings about connectivity to the land and natural environment to the younger generations. This same activity, in a different cultural context, might be coded as ‘applying knowledge’ (d179) or ‘non-remunerative employment’ (d855) as voluntary community activity. Using the ICF required some understanding of the purpose of, or benefit derived from, the activity. Therefore its use within any cross-cultural context calls for coders or advisers with culturally specific knowledge.

Some participant-nominated activities seemed to be missing in the ICF; enjoying food or an alcoholic drink, such as having a beer, as a social pastime rather than ‘eating’ or ‘drinking’ as a self-care activity; recording or passing on ancestral or family knowledge; being in the outdoors, at the beach or in the bush as a spiritual engagement; and reminiscing about or remembering the past. Such findings may inform future revisions of the ICF.

The scope of the ICF ‘activity and participation’ component rendered it adequate for coding self-nominated important activities for older Māori and European New Zealanders. Most responses fell within the domestic life, interpersonal interactions and relationships, and community, social and civic life ICF domains. Few were allied to the ICF domains of learning and applying knowledge, general tasks, communication, mobility and self-care. This suggests respondents interpreted the question as including discretionary activities only, or those that held the greatest value or meaning for them. Except for sleeping or resting, activities that could be classified as important, even essential for life, such as eating, washing and dressing, were not named. Such everyday activities may have been regarded by respondents as obligatory and therefore unnecessary to mention.

Patterns of important activities were similar for men and women, with men being more likely to mention interpersonal relationships. This finding runs counter to the literature indicating women are predominantly the ‘kin keepers’ and caregivers. Possibly, the women did not mention relationship-focused activities because relating to, and interacting with, others is a usual thing they do [29]. Most consistently, all participants mentioned one or more domestic life activity as being important with the most frequent being gardening, cooking, keeping a tidy house and shopping. Similarly, international cohort studies report older Americans as often spending time preparing meals (70%), shopping (63%) or gardening (17%) [8]; and older Swedes as gardening often (26%) [17]. While these studies measured activity frequency rather than subjective importance, older adults may spend more time doing important activities. Conversely, little time may be invested in some highly important home and community life activities [25].

Within the ICF ‘recreation and leisure’ (d920) category, over a quarter of activities nominated by Māori and half of those reported by non-Māori (most significantly reading) were itemised as ‘arts and culture’. Other frequently identified recreation activities were being outdoors, walking, socialising, playing cards or doing puzzles, and doing handicrafts such as carving, doing woodwork, knitting or artwork. No participants said watching television was important, yet multiple international studies report it as something older people spend significant time doing [13,16,17,20,21,23,24]. In congruence with this study, the literature also identifies reading, spending time with friends or visitors, and walking as high time-use activities. Similarly, Māori respondents named activities related to the marae, whanau, and passing on knowledge as important, a worldview underpinned by collectivity and intergenerational connectedness. While family and extended family relationships also featured as important for non-Māori, they more frequently named individualistic recreation and leisure activities. These qualitatively different findings endorse the value of including measures of subjective importance in time-use studies with older adults.

Strengths and limitations of the study

Being guided by Kaupapa Māori, with respect, honesty and mutual benefit as foundational ethical values [30], was essential for Māori inclusion in this study. The research approach used aimed to build community-based research capacity and benefit the participant communities through nurturing the relationships between the researchers, community health organisations and local interviewers in preparation for the subsequent cohort study.

Participant numbers for this feasibility study were small and not representative of the population. Hence no inferential data analysis was attempted. The self-nominated important activities were simply recorded without further prompting. This resulted in some one-word or brief responses making coding difficult. For example, the response ‘walking’ could refer to walking for fitness, walking to maintain basic mobility, or walking as a means of travel; each requiring a different ICF item code. In such cases, consistency of coding was sought; however, this may have introduced a systematic bias. Eliciting more detailed responses would improve coding reliability and validity. Participants were not prompted if they nominated fewer than three responses. Inviting participants to say if there was ‘anything else’, until three responses were recorded, may have ensured a fuller dataset.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Overall, the ICF is a useful tool for coding older New Zealanders' self-nominated important activities. However, its application with Māori required careful interpretation of culturally specific activities within the standardised classification terms. In scope, the ICF allowed a diverse range of activities to be grouped and described, and was specific enough to reveal gendered and cultural differences. Consequently, the open ‘important activity’ question was included in the current cohort study and the ICF will be used to analyse the narrative data.

When asked, most New Zealand Māori and non-Māori freely said what things they did were most important to them. For Māori, important activities were more likely to be related to extended family and family relationships, whereas non-Māori placed more importance on recreation and leisure activities. This pattern aligns with general cultural differences related to collectivity and individuality. Participants' responses reveal the inherent worth of seeking to understand what makes an enriched life in advanced age. Participation in important interpersonal relationships, recreation and leisure, and domestic activities all matter in advanced age. Such understandings are important for promoting older people's participation in everyday life, particularly when working across cultures. The nature and range of activities mentioned by these older adults may point to the ‘secret’ of what makes a meaningful life in old age.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The project was supported by a programme grant from the New Zealand Health Research Council and a project grant from Nga Pae o te Maramatunga. We acknowledge the role of the subcontracted organisations: Māori Health Services, Whakatane, Rotorua Area Primary Health Services, Korowai Aroha Health Services, Whakatoea Iwi Social and Health Services in recruiting and interviewing participants. We thank all participants and their families/whanau for supporting the study.

Key Points

  • • 
    The ICF classification tool is useful for analysing and describing what activities matter to older adults.
  • • 
    The ICF is generally applicable across cultures underpinned by philosophically different world views.
  • • 
    Patterns of subjectively important activities were similar for New Zealand men and women, with the greatest percentage of activities being within the domain of community, social and civic life.
  • • 
    Activities related to the extended family and the collective community featured more strongly for older Māori than for older non-Māori, who self-nominated more individualistic recreation and leisure activities.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
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