Rural unpaid caregivers' experiences in northern Aotearoa, New Zealand during the Covid-19 pandemic: A qualitative study.

OBJECTIVE: Rural unpaid caregivers experience different opportunities and challenges than their urban counterparts. Our aim was to understand rural unpaid caregivers' experiences of challenges and opportunities during the Covid-19 pandemic in New Zealand. SETTING: Rural northern New Zealand during the Covid-19 pandemic. PARTICIPANTS: A convenience sample of 10 unpaid rural caregivers, most supporting an older person living with dementia. DESIGN: A qualitative descriptive design. Data included interviews and online workshops, and a thematic analysis. RESULTS: Rural unpaid caregivers observed that some aspects of living in a rural context were helpful during the Covid-19 pandemic. However, tasks such as shopping and long-distance travel and communication (both telephonic and digital) became more complex. Abrupt changes to routine and closure of resources and support groups created challenges. Unpaid caregivers worried about what would happen if they were hospitalised themselves. There was a diversity of experience both across caregivers, of familiar routines and rural context as resources, increased challenges requiring resourcefulness to adapt, and experiences of crisis. Many experienced all three states at different times. CONCLUSION: This research provides valuable insights into challenges and opportunities experienced by rural unpaid caregivers during the Covid-19 pandemic and may help policy-makers and healthcare professionals develop improved emergency preparedness. Multilevel, multisector responses are needed to ensure effective health and social support and access to resources including health care, access to groceries and medication, transport, and communications (telephone and digital). Enhancing rural access to effective and inexpensive online services is particularly important, as is recognition of the value of rural sites or hubs of connection and social interaction.

Older people's Contributions During the COVID-19 Pandemic Response.

During the COVID-19 pandemic, older people were identified as requiring additional support and protection. This multi-method qualitative study shifts this narrative by asking: how did older people contribute to the COVID-19 public health response? We conducted a reflexive thematic analysis of responses from 870 letter-writers and 44 interviewees who were older people living in Aotearoa, New Zealand during the COVID-19 pandemic. Older people made substantial contributions during the COVID-19 pandemic through: 1) volunteering; 2) nurturing; and 3) advocacy/activism. We argue that policy makers should take seriously the ways older people were providers of help and support in this period.

Understanding anger with New Zealand-born Samoan youth: A Samoan qualitative exploration.

OBJECTIVE: Understanding New Zealand-Samoan young people's experiences and definitions of anger. METHODS: Focus group talanoa (discussions) with 12 New Zealand-born Samoan young people guided by 'Teu le Va' methodology. We used a culturally informed thematic analysis approach. RESULTS: Participants defined anger as a 'bottled up' emotion and emphasised understanding cultural contexts that normalised covert and passive ways of expressing anger. Other key themes around anger we identified included experiencing multiple layers of racism and disconnection in westernised social spaces and pressures to juggle traditional Samoan and western identities. Participants also explored gendered expressions of anger. Communicating anger was important, but not in ways that harm communal values. CONCLUSIONS: Culturally appropriate qualitative research helps understand complex cultural determinants of mental health and wellbeing and suicidal behaviour. IMPLICATIONS FOR PUBLIC HEALTH: We must recognise the positive, polycultural capital of a generation that navigates many cultural spaces, including their emotional expressions. Anger should be understood in relation to cultural and societal pressures. Improved understanding of the cultural context of anger can inform systemic responses during crises in mental health and prevention of suicidality.

The timescapes of older adults living alone and receiving home care: An interview study.

In this study, we drew on Barbara Adam's (1998) timescape perspective and applied a timescape lens to our analysis of how nine older adults who live alone, receive home care and are considered by home care professionals to be frail, experience living (in) time. Over a period of eight months, we conducted three interviews with each of the nine participants. We analysed the data using reflexive thematic analysis and drew on timescapes to further interpret our preliminary analysis. Our results show that situated everyday time, place across time, and large-scale time interact in the framing and shaping of older adults' everyday lives. Older adults' embodied experiences of being of advanced age, living alone and receiving home care influenced their timescapes. We propose that paying attention to older adults' timescapes can enable home care professionals and other supporters to consider older adults' health, well-being, vulnerabilities and strengths from a broader perspective than the 'here and now' and thereby enhance the provision of person-centred care.

Older people's views on loneliness during COVID-19 lockdowns.

BACKGROUND AND OBJECTIVES: There have been growing concerns that social distancing and stay-at-home mandates have exacerbated loneliness for older people. Empirical evidence about older people's experiences of loneliness and COVID-19 have quantified this phenomena without considering how older people themselves define and understand loneliness. This paper explores how older New Zealanders conceptualized and experienced loneliness under 'lockdown' stay-at-home measures. METHODS: This multi-methods qualitative study combines data from letters (n = 870) and interviews (n = 44) collected from 914 people aged over 60 and living in Aotearoa, New Zealand during the COVID-19 pandemic. We conducted a reflexive thematic analysis to conceptualise this data. FINDINGS: We identify three interconnected ways in which older people conceptualised and experienced loneliness: (1) feeling disconnected relating to lack of emotional closeness to another often resulting from being physically separated from others and not being able to touch; (2) feeling imprisoned relating to separation from preferred identities and activities and was frequently associated with boredom and frustration; and (3) feeling neglected which often related to feeling let down by generalised and idealised forms of support, such as one's neighbourhood and health care system. DISCUSSION: Older New Zealanders experienced lockdown loneliness in three interconnected ways rather than as a stable and homogenous experience. Maori, Pacific, Asian and New Zealand European older people often discussed loneliness in different ways; attesting to loneliness being a culturally-mediated concept shaped by expectations around desirable social interaction. We conclude the paper with implications for research and policy.

More than prevention: early adoption of HIV pre-exposure prophylaxis (PrEP) by gay and bisexual men in New Zealand.

Pre-exposure prophylaxis (PrEP) minimises HIV risk and New Zealand was one of the first countries to publicly fund PrEP in 2018. However, no studies have explored in-depth the experience and meaning of living 'on PrEP' among individuals at elevated risk of HIV, such as gay and bisexual men. This qualitative study builds on findings from the NZPrEP demonstration project of early PrEP-adopting gay and bisexual men in Auckland, New Zealand. We interviewed 10 of the 150 NZPrEP participants using an ethnicity equity quota (five European ethnicities and five non-European ethnicities). A phenomenologically-inspired thematic analysis was conducted. We identified three themes. The first, Trusting in the Pill, focuses on the relationship between PrEP and its user, while the second theme, A Liberation of Sorts, details the freedom PrEP offered men, sexually, mentally and socially. The final theme, Reframing Risk, explores the risk perceptions and the conflicting discourses surrounding gay and bisexual men using PrEP. This first qualitative study in New Zealand about the experiences of PrEP early-adopters suggests that the role of PrEP extends well beyond HIV prevention and, for many, involves redefining safe sex even in a country with historically high levels of condom promotion and low HIV incidence.

Joy, Jobs, and Sweat: Older Adults' Physical Activity During COVID-19 Lockdowns in New Zealand.

This qualitative narrative correspondence study investigates older adults' experiences of physical activity (PA) during the 2020 COVID-19 pandemic lockdowns in Aotearoa, New Zealand. This paper presents a reflexive thematic analysis of 501 letters received from 568 participants that discussed PA. Participants described PA as bringing joy and rhythm to daily life under stay-at-home measures. The most frequently discussed forms of PA included exercising, gardening, and housework. Four interconnected conceptual themes identified were as follows: (a) renegotiating environmental relationships, (b) social connection, (c) pleasure and PA, and (d) navigating active aging discourses. This paper emphasizes the important environmental and social motivations for becoming and remaining physically active despite restrictions on movement. Older adults' understandings and performance of PA were heavily shaped by active aging discourses. As such, we suggest that initiatives seeking to promote PA should foreground older adults' feelings of connection, productivity, and pleasure and recognize their diversity. This is contrary to current recommendations focused on duration or intensity of older adults' PA.

Creating 'safe spaces': A qualitative study to explore enablers and barriers to culturally safe end-of-life care.

BACKGROUND: Internationally, efforts are being made to promote equity in palliative and end-of-life care for Indigenous peoples. There is a need to better understand the experiences of Indigenous service users and staff. AIM: To explore the views of Maori health practitioners and whanau (family group) caregivers regarding barriers and enablers to culturally safe palliative and end-of-life care. DESIGN: A Kaupapa Maori qualitative study. SETTING/PARTICIPANTS: Interviews were conducted with 103 participants from four areas of the North Island of Aotearoa New Zealand. Participants comprised bereaved whanau (family) of Maori with a life limiting illness and Maori health practitioners. RESULTS: Maori health practitioners undertake cultural and connecting work to promote culturally safe palliative and end-of-life care for Maori patients and their whanau. This work is time-consuming and emotionally and culturally demanding and, for most, unpaid and unrecognised. Non-Maori staff can support this work by familiarising themselves with te reo Maori (the Maori language) and respecting cultural care customs. However, achieving culturally safe end-of-life care necessitates fundamental structural change and shared decision-making. CONCLUSIONS: Our findings indicate that efforts to support equitable palliative care for Indigenous people should recognise, and support, the existing efforts of health practitioners from these communities. Colleagues from non-Indigenous populations can support this work in a range of ways. Cultural safety must be appropriately resourced and embedded within health systems if aspirations of equitable palliative and end-of-life care are to be realised.

Cultural context in New Zealand: incorporating kaupapa Maori values in clinical research and practice.

We examined the importance of understanding and incorporating cultural context within Aotearoa/New Zealand when engaging in clinical research and practice. This paper reports on the qualitative findings of a mixed methods study aimed at determining what effect a cardiac risk reduction exercise and lifestyle management programme, embedded within a kaupapa Maori methodological approach, had on Maori participants. This methodology saw participants able to redevelop a western model cardiac risk reduction programme by introducing a Maori worldview. Our study revealed how the kaupapa Maori approach empowered participants to examine and evaluate not only their own health and lifestyle choices, but those of family and the wider community. Combining biomedical and kaupapa Maori components into the programme was found to benefit participants' mental, physical, spiritual and family well-being.

Health equity and wellbeing among older people's caregivers in New Zealand during COVID-19: Protocol for a qualitative study.

BACKGROUND: Knowledge of the challenges unpaid caregivers faced providing care to older people during the COVID-19 pandemic is limited. Challenges may be especially pronounced for those experiencing inequitable access to health and social care. This participatory action research study, located in New Zealand, has four main objectives, (i) to understand the challenges and rewards associated with caregiving to older care recipients during the COVID-19 pandemic restrictions; (ii) to map and collate resources developed (or mobilised) by organisations during the pandemic; (iii) to co-produce policy recommendations, identify useful caregiver resources and practices, prioritise unmet needs (challenges); and, (iv) to use project results in knowledge translation, in order to improve caregivers access to resources, and raise the profile and recognition of caregivers contribution to society. METHODS AND ANALYSIS: Maori, Pacific and rural-dwelling caregivers to 30 older care-recipients, and 30 representatives from organisations supporting caregivers in New Zealand will be interviewed. Combining data from the interviews and caregivers letters (from an archive of older people's pandemic experiences), framework analysis will be used to examine the interrelated systems of the human ecological model and the impact on caregiving experiences during the pandemic. Resources that service providers had created or used for caregivers and older people will be collated and categorised. Through co-production with caregivers and community partners we will produce three short films describing caregivers' pandemic experiences; identify a suite of resources for caregivers to use in future events requiring self-isolation, and in everyday life; and generate ideas to address unresolved issues.

Social-Level Factors Related to Positive Mental Health Outcomes Following Intimate Partner Violence: Results from a Population-Based Aotearoa New Zealand Sample.

Intimate partner violence (IPV) continues to be an issue for women globally. There remains a gap in research about what contributes to better mental health following IPV. The sociodemographic characteristics and other factors associated with positive mental health were explored among a sample of 454 women aged 16 years and over who reported previous exposure to physical and/or sexual IPV. Sixty-six percent of women reported positive mental health. The cessation of violence, support at disclosure, and ongoing informal support were factors significantly associated with positive mental health. Greater community outreach to improve responses to disclosure and practical support is needed.

Recommendations for Virtual Qualitative Health Research During a Pandemic.

Qualitative health research has been uniquely affected by the COVID-19 pandemic. Various public health directives will likely remain in place until this pandemic is fully controlled, creating long-lasting impacts on the design and conduct of qualitative health research. Virtual qualitative research provides an alternative to traditional interviews or focus groups and can help researchers adhere to public health directives. In this commentary, we respond to methodological needs created by the COVID-19 pandemic. Specifically, we explore unique elements of, and recommendations for, the design and conduct of obtrusive virtual qualitative research (online interviews, online focus groups, and email interviews) and demonstrate crucial ethical, recruitment, analytical, and interpretive considerations. Researchers are currently faced with an ethical imperative to advance virtual qualitative research methods and ensure that rigorous qualitative health research continues during this pandemic and beyond. Our discussions provide a starting point for researchers to explore the potential of virtual qualitative research.

Predictive factors for entry to long-term residential care in octogenarian Maori and non-Maori in New Zealand, LiLACS NZ cohort.

BACKGROUND: Long-term residential care (LTC) supports the most vulnerable and is increasingly relevant with demographic ageing. This study aims to describe entry to LTC and identify predictive factors for older Maori (indigenous people of New Zealand) and non-Maori. METHODS: LiLACS-NZ cohort project recruited Maori and non-Maori octogenarians resident in a defined geographical area in 2010. This study used multivariable log-binomial regressions to assess factors associated with subsequent entry to LTC including: self-identified ethnicity, demographic characteristics, self-rated health, depressive symptoms and activities of daily living [ADL] as recorded at baseline. LTC entry was identified from: place of residence at LiLACS-NZ interviews, LTC subsidy, needs assessment conducted in LTC, hospital discharge to LTC, and place of death. RESULTS: Of 937 surveyed at baseline (421 Maori, 516 non-Maori), 77 already in LTC were excluded, leaving 860 participants (mean age 82.6 +/- 2.71 years Maori, 84.6 +/- 0.52 years non-Maori). Over a mean follow-up of 4.9 years, 278 (41% of non-Maori, 22% of Maori) entered LTC; of the 582 who did not, 323 (55%) were still living and may yet enter LTC. In a model including both Maori and non-Maori, independent risks factors for LTC entry were: living alone (RR = 1.52, 95%CI:1.15-2.02), self-rated health poor/fair compared to very good/excellent (RR = 1.40, 95%CI:1.12-1.77), depressive symptoms (RR = 1.28, 95%CI:1.05-1.56) and more dependent ADLs (RR = 1.09, 95%CI:1.05-1.13). For non-Maori compared to Maori the RR was 1.77 (95%CI:1.39-2.23). In a Maori-only model, predictive factors were older age and living alone. For non-Maori, factors were dependence in more ADLs and poor/fair self-rated health. CONCLUSIONS: Non-Maori participants (predominantly European) entered LTC at almost twice the rate of Maori. Factors differed between Maori and non-Maori. Potentially, the needs, preferences, expectations and/or values may differ correspondingly. Research with different cultural/ethnic groups is required to determine how these differences should inform service development.

Gardens as resources in advanced age in aotearoa NZ: More than therapeutic.

For older people gardens may be paradoxical sites. Whilst gardening is associated in multiple ways with wellbeing and health, gardens may also become a source of frustration and worry as ageing bodies limit gardening activities. Yet determination remains. However, little of the well-established body of work on gardens and old age includes people in advanced age. In this paper, we draw on interviews with Maori and non-Maori 85-90-year olds in Aotearoa, New Zealand, focusing on how they talk about their wellbeing in relation to past, present, and future experiences of home gardening. Our research shows home gardens and gardening figure prominently and positively in the narratives of people in advanced age. Most of our participants described themselves as active gardeners; most also lived with multimorbidity, sometimes severe and complex. Applying positioning theory, we examine how our participants connect gardens and gardening to identity; connectedness; and adaptation and renegotiation of health and wellbeing in ageing bodies. Home gardens are 'more than therapeutic'; while they are protective of health and wellbeing, they are also enabling places for the expression and performance of agency in advanced age. These understandings have practical implications for supporting wellbeing amongst those in advanced age.

Bereaved Families' Perspectives of End-of-Life Care. Towards a Bicultural Whare Tapa Wha Older person's Palliative Care Model.

The views of family carers who provide end of life care to people of advanced age are not commonly known. We conducted a bicultural study with bereaved New Zealand Maori (indigenous) and non-indigenous family carers who, on behalf of their older family member, reflected on the end of life circumstances and formal and informal care experienced by the older person. Semi-structured interviews were undertaken with 58 people (19 Maori and 39 non-Maori), who cared for 52 family members who died aged over 80 years. A Kaupapa Maori thematic analysis of family/whanau perspectives identified examples of good holistic care as well as barriers to good care. These are presented in a proposed Whare Tapa Wha Older Person's Palliative Care model. Good health care was regarded by participants as that which was profoundly relationship-oriented and upheld the older person's mana (authority, status, spiritual power) across four critical health domains: Whanau (social/family), Hinengaro (emotional/mental), Wairua (spiritual) and Tinana (physical) health domains. However, poor health care on one level impacted on all four domains affecting (reducing) mana (status). The "indigenous" model was applicable to both indigenous and non-indigenous experiences of end of life care for those in advanced age. Thus, Indigenous perspectives could potentially guide and inform end of life care for all.

'People haven't got that close connection': meanings of loneliness and social isolation to culturally diverse older people.

Objectives: Social isolation and loneliness among older people are known to have negative effects on health and wellbeing. Few studies, however, have enabled older people to define these concepts in their own terms. This paper based on research in Aotearoa, New Zealand is the first to comparatively outline the meanings of loneliness and social isolation from the perspective of four ethnically diverse groups of older adults (Maori, Pacific, Asian, and NZ European).Method: We interviewed 44 older people and conducted three focus groups with 32 older people. We used thematic and narrative analyses.Results: Loneliness and social isolation were conceptualized as interconnected concepts described as a 'look and feel', a 'state of mind' and as a 'lack of desired companionship'. Participants conveyed sophisticated understandings of the structural underpinnings of both loneliness and social isolation as multi-dimensional, complex, and situated.Conclusions: Older people describe complex and culturally- nuanced understanding and experience of social isolation and loneliness. More culturally appropriate services, greater mental-health support and more service provision on weekends and evenings are needed.

Being With Objects of Meaning: Cherished Possessions and Opportunities to Maintain Aging in Place.

BACKGROUND AND OBJECTIVES: Research regarding the role that cherished possessions play in experiences of aging and daily life has tended to focus on how possessions assist individuals in "looking back" and remembering important experiences, relationships, and identities. Here, we consider how the possessions that older adults keep at home inform their present experiences of aging and also facilitate the ongoing maintenance of aging in place. RESEARCH DESIGN AND METHODS: We employed an interpretive phenomenologically inspired research strategy that enabled an in-depth examination of older adult's experiences of cherished possessions. This approach emphasized participants' own situated meanings. In-depth interviews were followed by participatory photo-elicitation interviews and journaling. RESULTS: The majority of study participants interacted with cherished possessions to connect with their past selves, but also to cope with times of challenge and change in the present, and in some cases, to cultivate a sense of being able to maintain aging in place. For some older adults, however, possessions disrupted sense of self, place attachment, and daily life. Cherished possessions, therefore, play a significant role in opportunities to maintain aging in place. DISCUSSION AND IMPLICATIONS: The material culture of home and its relationship to experiences of aging may provide or disrupt opportunities to maintain aging in place. Interventions based on possessions that are easy to access and employ to provide comfort and affirm peoples' preferred relationships to self, others, and the living environment could make a difference to the quality of life for older adults.

A Study of Asian Children Who are Diagnosed with Autism Spectrum Disorder and Available Support Services in Auckland, New Zealand.

This study reviews the demographic characteristics of Asian children diagnosed with autism spectrum disorder (ASD) in Auckland, New Zealand, the support services they can access, and how more equitable access to health services can be provided. We examined government and non-government support services for Asian children diagnosed with ASD and their families. The findings reflect the complexities of navigating and accessing health, disability, education and social support services. Analysis of Ministry of Health Disability Support Services (DSSs) data suggest that Asians in New Zealand are underrepresented in utilizing DSSs. Drawing on Andersen's health care utilization model, suggestions for more equitable access to health, disability, education and social support include culturally and linguistically appropriate health care and social policies.

What Is Meaningful Participation for Older People? An Analysis of Aging Policies.

BACKGROUND AND OBJECTIVES: The language used to construct policy problems influences the solutions created. Recent aging policies emphasize participation as essential to aging well, encouraging independence and active involvement in all aspects of life. However, it is less clear whether participation in the creation of policies or in policy goals and aspirations is meaningful. This article addresses the question: "How is meaningful participation reflected and enabled in policy?" RESEARCH DESIGN AND METHODS: Eleven global, national, and local policies were purposively selected and analyzed using thematic and discourse analysis. RESULTS: Policies framed population aging as a challenge and active aging as a value as or part of the policy-making process, participation is enabled (or not) through the types of participation encouraged by policy makers and the kinds of participation used to engage with older people. DISCUSSION AND IMPLICATIONS: Our analysis identifies a strong pattern of discourses regarding individual responsibility to age well; underlying tensions between productive and passive participation; and tensions inherent to the concept of consultation. Implications include the need for those in the consultative phase of policy making to engage with diverse older people and to use participatory methods to explore what meaningful participation means for older people themselves.