He Tohu Ora

As described by Te Whare Tapa Whā model of health, Māori wellbeing encompasses taha wairua (spiritual health), taha tinana (physical health), taha hinengaro (mental/emotional health) and taha whānau (family health) [1]. Further dimensions of Māori health are illustrated by Te Pae Māhutonga model of health promotion, which includes mauriora (cultural identity), te oranga (participation in society), toiora (healthy lifestyles), waiora (physical environment), ngā manukura (community leadership), and te mana whakahaere (autonomy) [2]. Te Pae Māhutonga highlights the importance of other determinants of health, for example mauriora and culture, which is a central determinant of Māori health and wellbeing [3]. Mauriora is reflected in the Index through indicators reflecting cultural identity and participation in Māori society.

Both Te Whare Tapa Whā and Te Pae Māhutonga are holistic models of health that recognise the interrelated nature of aspects of wellbeing. For example, a contaminated water or food source might affect environmental, physical and spiritual wellbeing. To experience good health, all aspects of wellbeing need to be strong and balanced [4].

Whānau is a core aspect of wellbeing for Māori. Whānau can extend beyond immediate family and households to include extended family, neighbours, close friends and even communities [5]. Being in regular contact with whānau may provide an individual with maanaki (support, hospitality and care), access to Māori culture, and sense of identity [5]. The Whānau Ora outcome framework has informed indicator selection for He Tohu Ora. Whānau Ora is a nationwide initiative that provides a whānau-focused and strengths-based approach to support whānau development. It is built on a Māori cultural foundation and utilises the collective strengths and capabilities of whānau to achieve better outcomes in areas such as health, education, housing and employment [6]. Whānau Ora is achieved when whānau are: self-managing and empowered leaders; living healthy lifestyles; participating fully in society; confidently participating in te ao Māori; economically secure and successfully involved in wealth creation; cohesive, resilient and nurturing; and responsible stewards of their natural and living environments.

This indicator measures the extent to which a person feels a sense of community with others in their neighbourhood. It reflects the importance of belonging as a form of social capital, which in turn has a positive effect on health and wellbeing [7, 8]. Within te ao Māori, manaakitanga (support, hospitality and care), tautoko (support), and kotahitanga (unity and solidarity) are important values to have within a community of any form [9]. Within a neighbourhood, this might mean checking on an elderly neighbour, participating in neighbourhood groups (for example neighbourhood watch), or interacting with people from your neighbourhood.

The Canterbury Wellbeing Survey asked respondents the extent to which they agree or disagree that they feel a sense of community with others in their neighbourhood [10]. There were five response options, ranging from strongly agree to strongly disagree.

This indicator presents the proportion of Māori and non-Māori survey respondents who reported agreeing/strongly agreeing that they feel a sense of community within their neighbourhood.

The figure shows that, since 2012, the proportion of respondents reporting feeling a sense of community with others in their neighbourhood has declined for both Māori and non-Māori respondents. The proportion peaked in the two years following the 2011 Christchurch earthquake (non-Māori 54.4% in 2012 and Māori 55.9% in 2013). Prior to 2014, a higher proportion of Māori respondents reported feeling a sense of community with others in their neighbourhood than non-Māori, however in 2014, the Māori proportion (43.4%) dropped below the non-Māori proportion (a decline of 10 percentage points) and has since remained below. Both Māori and non-Māori respondents reported the lowest sense of neighbourhood in September 2015, at 37.2 percent and 46.8 percent, respectively. Throughout this time period, the proportion for Māori has shown greater variation than the proportion for non-Māori, due to smaller absolute numbers. The difference between Māori and non-Māori respondents is not statistically significant, with the exception of April 2015.

Having whānau support in times of need allows people to have material and emotional support, both of which influence health and wellbeing [11]. From a te ao Māori perspective, manaakitanga (showing respect, generosity and care for others) is an important aspect to achieve individual and whānau wellbeing [1]. Not only is it important to receive care from whānau but also to reciprocate that care, particularly towards those who may have greater need, such as younger and older members of whānau [1].

Te Kupenga 2013 asked respondents how easy or hard it would be for them to find someone to help them in times of need (e.g., when they have serious illness) [12]. There were five response options ranging from very easy to very hard.

This indicator presents the proportion of survey respondents who reported it being easy or very easy to get whānau support in times of need, from whānau living in another household.

In 2013, the majority of respondents for Canterbury (80%), the rest of the South Island (76.7%) and New Zealand (81.2%) reported it was easy or very easy to get whānau support in times of need (from whānau living in another household). Canterbury (50.7%) had the highest proportion reporting it was very easy to get whānau support followed by New Zealand overall (46.1%) and the rest of the South Island (43%).

Having strong whanaungatanga (relationship and kinship) is an important dimension of Māori wellbeing. Strong relationships within whānau can provide physical and emotional support, collective action, and a strong sense of identity [3, 5]. Regular contact with whānau who live outside the home is also an important factor for life satisfaction [13]. Contact with whānau may be face-to-face or by utilising technology to communicate. This indicator measures respondents’ level of satisfaction with whānau contact, rather than the amount of contact.

Te Kupenga 2013 asked respondents to consider all types of contact they have with whānau who they do not live with and, overall, if the contact was too much, the right amount, or not enough [12].

This indicator presents the proportion of survey respondents reporting the amount of contact with whānau living in another household was about the right amount, during the past four weeks.

The figure shows that for all three areas in 2013, the majority of respondents reported the contact they had with whānau who they don’t live with was about the right amount. Canterbury respondents had a slightly higher proportion (65.9%) than the rest of the South Island and New Zealand, where the proportion was 64.7 percent and 63.2 percent, respectively.

Unpaid activities may include domestic activity, unpaid child care, aged care and care of people with disabilities. From a Māori worldview, manaakitanga (showing respect, generosity and care for others) and whanaungatanga (relationship and kinship) are important values that contribute to individual and whānau wellbeing [1]. Manaakitanga also extends to participation in the wider society, for example helping out at local marae, schools, churches or sports clubs.

The 2013 Census asked respondents which activities, from a list of options, they had done within the past four weeks, without pay [14].

This indicator presents the proportion of Māori and non-Māori adults who had undertaken unpaid activities in the past four weeks in greater Christchurch.

The figure shows that Māori in greater Christchurch took part in more unpaid activities than non-Māori, at the time of the 2013 Census. The most notable differences between Māori and non-Māori, by type of activity, were for ‘looking after a child who does not live in own household’ (Māori 20.1%; non-Māori 14.4%) and ‘looking after a child who does live in own household’ (Māori 36.2%; non-Māori 27.5%). Additionally, more Māori had helped someone who is ill or has a disability, from both their own household (Māori 9.4%; non-Māori 6.3%) and from another household (Māori 10%; non-Māori 8.3%).  A higher proportion of non-Māori had done household work for their own household, compared with Māori (non-Māori 82.3%; Māori 79.3%).

Whānau wellbeing is a measure of how well an individual thinks their whānau is doing. There is an interdependence between whānau wellbeing and individual wellbeing [15]; for whānau to flourish collectively, each individual member must be well and thriving. Māori who report very high levels of life satisfaction are more likely to report very high whānau wellbeing, than those with overall low life satisfaction [15]. Other contributors to whānau wellbeing include whānau: heritage, wealth, capability, cohesion, connectedness and resilience [3, 16]. The significance of whānau wellbeing has been recognised in evidence, policy and programmes, such as Whānau Ora, a nationwide initiative that provides a whānau-focused and strengths-based approach to supporting families and whānau.

Te Kupenga 2013 asked respondents to think in general how their whānau was doing, rating them on a scale of zero (extremely badly) to ten (extremely well) [12].

This indicator presents the proportion of respondents who rated their whānau as doing well or extremely well.

The figure shows that in 2013 a majority of respondents reported their whānau was doing well, with similar proportions found in Canterbury (74.5%), the rest of the South Island (72.2%) and New Zealand (72.1%). Canterbury had a slightly higher proportion of Māori reporting their whānau was doing extremely well (12.6%), which was 3.8 and 1.3 percentage points higher than the rest of the South Island (8.8%) and New Zealand (11.3%), respectively.

Self-rated health allows respondents to weigh together the different aspects of health that they consider most important [17]. A person’s self-rated health is therefore shaped by their cultural perspective. For example, from a Māori worldview taha wairua (spiritual health) is an essential component of good health. As the aspects of wellbeing are connected, they cannot be compartmentalised, therefore to experience good health all aspects of wellbeing need to flourish [4].

The Canterbury Wellbeing Survey includes the question ‘In general, how would you rate your health?’ [10]. The question has five response options, ranging from poor to excellent.

This indicator presents the proportion of respondents reporting good/very good/excellent self-rated health in the 2017 and 2018 Canterbury Wellbeing Surveys. Note that this question was first included in 2017.

This figure shows that a higher proportion of non-Māori respondents reported their health as good, very good or excellent in 2017 and 2018 than Māori respondents. In 2017, 74.8 percent of Māori respondents and 83.2 percent of non-Māori respondents rated their health as good, very good or excellent, which was a statistically significant difference. In 2018, the proportion for Māori increased to 77.2 percent, while the proportion for non-Māori decreased slightly to 82.6 percent (this difference was not statistically significant).

Overall quality of life is a broad concept that refers to a person’s subjective evaluation of their own circumstances and experience of life, which is embedded in a cultural, social and environmental context. Although this concept is not specific to Māori, it aligns with the te ao Māori perspective of holistic wellbeing, which includes physical, mental/emotional, spiritual, and whānau wellbeing [1]. For Māori, connection to whenua (land) is an important contributor to quality of life [18].

The Canterbury Wellbeing Survey includes the question ‘Would you say that your overall quality of life is…’ with five response options, ranging from extremely poor to extremely good.

This figure shows the proportion of Māori and non-Māori respondents who rated their quality of life as good/extremely good.

The figure shows that since 2012, both Māori and non-Māori respondents’ quality of life has increased overall. The proportion for Māori has remained below the proportion for non-Māori throughout this time period, although the difference was reduced in September 2016 when the proportion for Māori respondents peaked (Māori 79.6%; non-Māori 82.2%). The largest differences between the two groups were noted in September 2012 (Māori 56.4%; non-Māori 74.6%) and September 2015 (Māori 62.1%; non-Māori 78.2%). Throughout this time period, the proportion for Māori has shown more variation than the proportion for non-Māori, due to smaller absolute numbers. The difference between Māori and non-Māori has been statistically significant at several time points (September 2012, September 2013, April 2014, September 2014, and September 2015).

Māori language is a measure of cultural resource and a contributor to cultural identity [1]. For Māori, high levels of cultural efficacy (including speaking te reo Māori, marae protocol and Māori heritage) have been found to be associated with better emotional wellbeing [19]. However, over the last century, the proportion of Māori speakers has declined significantly. In the 2013 Census, 21.3 percent of all Māori reported they could hold a conversation in te reo Māori, a decrease of 3.7 percentage points from 1996 [20]. This declining proportion has sparked efforts to revive te reo Māori among Māori, through community and national initiatives, such as the provision of free te reo Māori language courses and increased funding for Māori television [21].

Te Kupenga 2013 asked respondents how well they were able to speak te reo Māori in day-to-day conversation [12]. The questions had five response options ranging from no more than a few words or phrases to very well.

This indicator presents the proportion of respondents who reported speaking te reo Māori no more than a few words or phrases, not very well, fairly well, well, and very well.

The figure shows that in 2013, there were higher proportions of respondents who reported speaking te reo Māori very well (5%), well (5.6%), or fairly well (12%) at the national level compared with Canterbury and the rest of the South Island. A majority of respondents in Canterbury (58.6%) and the rest of the South Island (51.3%) reported speaking no more than a few words. This compares to 45.3 percent at the national level (a difference of 13.3 and 6 percentage points, respectively).

Māori language is recognised as an important cultural resource which contributes to an individual’s cultural identity and sense of ‘being Māori’ [1]. For Māori, high levels of cultural efficacy (including speaking te reo Māori, Māori heritage, and tikanga me kawa (protocols and processes, including marae protocol) have been found to be associated with better emotional wellbeing [19]. While some Māori may feel whakamā (shy or embarrassed) about speaking te reo Māori – if they are not fluent and are fearful about getting it wrong, particularly those learning later in life – they may still take pride in hearing and understanding the language [22]. This indicator reports on te reo Māori understanding, rather than speaking, noting the distinction between these two aspects of wellbeing. 

Te Kupenga 2013 asked respondents how well they are able to understand Māori in day-to-day conversation [12]. The questions had five response options ranging from no more than a few words or phrases to very well.

This indicator presents the proportion of respondents that reported understanding te reo Māori very well, well, fairly well, not very well, or no more than a few words or phrases.

In 2013, higher proportions of respondents reported understanding te reo Māori very well (8.1%), well (8%), or fairly well (17%) at the national level compared with Canterbury and the rest of the South Island. Five percent of Canterbury respondents reported understanding te reo Māori very well, compared with 4.2 percent for the rest of the South Island. A majority of respondents (52.6%) from Canterbury reported understanding no more than a few words or phrases, a proportion that was higher than the rest of the South Island and New Zealand (by 9.5 and 14.9 percentage points, respectively).

Tribal identity relates to whether an individual knows and identifies with an iwi (tribe) and hapū/rūnanga (subtribe/marae councils). Knowing one’s iwi and hapū may strengthen cultural identity for whānau and individuals by increasing their access to and participation in te ao Māori [5]. Iwi and hapū identity may be a gateway for cultural engagement opportunities such as kapahaka, access to marae, or knowledge about whakapapa (ancestral heritage) [5]. Additionally, connection to hapū or taura here groups (iwi entities that exist outside their own region) may enable access to social services and health promotion.

Te Kupenga 2013 asked respondents to indicate whether they knew their iwi and hapū [12].

This figure shows the proportion of respondents who knew their iwi and hapū.

The figure shows that in 2013 a majority of respondents for each of the three geographical areas indicated that they knew their iwi (tribe) but a significantly smaller proportion knew their hapū (subtribe). Eighty-five percent of Canterbury respondents reported knowing their iwi, which was a slightly lower proportion than the rest of the South Island (90.1%) and New Zealand (89%). Just over half (54.9%) of all respondents at national level reported knowing their hapū. This proportion was 13.9 and 13.6 percentage points higher than respondents from Canterbury and the rest of the South Island, respectively.

A marae is an essential focal point for whānau, hapū or iwi to privilege te reo Māori and carry out cultural practices, traditions and hui (meetings) [5]. Visiting a marae can provide Māori with a greater cultural identity, cultural confidence and connection to whakapapa (ancestral knowledge) [5]. It also allows access to and participation in te ao Māori practices such as karakia (incantation), rongoā (medicine or remedy) and observance of tikanga me kawa (protocols and procedures) [5]. Additionally, some marae throughout New Zealand offer marae-based health clinics and health promotion programmes with focuses such as smoking cessation, nutrition, fitness, self-defence and first aid [5]. The marae is an important cultural resource which contributes to a secure Māori identity for individuals and whānau [5].

Te Kupenga 2013 asked those respondents who reported ever visiting a marae, if they had been to a marae in the last 12 months [12].

This indicator presents the proportion of respondents, among those who had ever visited a marae, reporting going to a marae in the previous 12 months.

The figure shows that in 2013, a third (33.6%) of Canterbury respondents who had ever visited a marae had visited one in the previous 12 months. This compares to 41.7 percent for the rest of the South Island and 58.2 percent for New Zealand overall.

Tūrangawaewae literally means ‘a place to stand’, but more broadly might relate to where an individual or whānau comes from, either at present or historically [23]. For some Māori, a tūrangawaewae may be an ancestral or local marae, where they connect with the land and feel at home [23]. Having access to a marae as a tūrangawaewae may strengthen cultural identity, which has been demonstrated to benefit wellbeing [1].

Te Kupenga 2013 asked respondents if they have an ancestral marae that they think of as their tūrangawaewae (a place of cultural significance, where they feel they belong because their ancestors are from there) [12]. Those who responded ‘yes’ were asked how connected they felt to their tūrangawaewae. The question had five response options ranging from not at all connected to very strongly connected.

This indicator presents the proportion of respondents who reported feeling strongly/very strongly connected to their ancestral marae as tūrangawaewae.

In 2013, most respondents in Canterbury (53.6%), the rest of the South Island (61.4%) and New Zealand (67.1%) reported feeling strongly/very strongly connected to their ancestral marae as tūrangawaewae.

Culture is recognised as a central determinant of health and wellbeing for many ethnic groups [24]. For Māori, having access to culture might refer to knowledge of cultural heritage, speaking te reo Māori or being on a marae. Although iwi, rūnanga and hapū might contribute to the provision of cultural support, whānau are recognised as being a major influencer of cultural identity and capacity [5]. Cultural norms and traditions, such as te reo and tikanga Māori, are inherited through families and passed down generations, just as land or possessions are [5]. Accessing whānau support with Māori cultural practices such as attending a tangihanga (funeral) or saying a karakia (incantation) is an important contributor to an individual’s secure cultural identity, and by extension overall wellbeing.

Te Kupenga 2013 asked respondents how easy or hard it would be to find someone to help with cultural practices (such as going to a tangi, speaking at a hui, or blessing a taonga) [12]. The question had five response options ranging from very hard to very easy.

This indicator presents the proportion of respondents that reported it was very hard/hard, sometimes easy/sometimes hard, easy, or very easy to get whānau support with Māori cultural practices.

The figure shows that in 2013 similar proportions of respondents in Canterbury (31.2%), the rest of the South Island (32.5%) and New Zealand (32.9%) overall reported that it was very easy to get whānau support with Māori cultural practices, while a slightly smaller proportion reported that it was easy in all three geographical areas. Respondents from New Zealand overall had the lowest proportion (14.7%) reporting that it was hard/very hard to get whānau support with cultural practices, followed by Canterbury (20.5%) and the rest of the South Island (21.7%).

Cultural identity is strengthened when there is access to not only cultural heritage but also opportunities for cultural engagement, such as speaking te reo Māori or taking part in kapa haka [5]. Kapa haka, for example, has been identified as having strong links to culture and Māori identity, as well as providing a social, strengths-based environment for rangatahi (youth) [25].

Te Kupenga 2013 asked respondents how important it was to be involved in things to do with Māori culture. There were five response options, ranging from very important to not at all important [12].

This indicator presents the proportion of respondents who reported it was quite/very important to be engaged in Māori culture.

In 2013, just under a third (32.4%) of respondents from Canterbury reported it was quite/very important being engaged in Māori culture. The proportion was lowest for Canterbury, followed by the rest of the South Island (38.1%), and New Zealand overall (46.3%).

A Māori worldview recognises that wellbeing can be connected to unseen and unspoken energies [4]. Wairuatanga (spirituality) is threaded through Māori beliefs, values and practices [26] and is broadly defined as “connection with all aspects of the universe”, such as the connection with whenua (land), the body and mind or a wider connection [3, 4]. From a Māori worldview, spirituality is essential to good health [3, 4]. As Māori spirituality has strong linkages with whenua (land), any harm caused to significant whenua such as maunga (mountain) and awa (river) might disrupt the wairua of Māori and impact their overall wellbeing [4].

Te Kupenga 2013 asked respondents how important spirituality was in their life. There were five response options ranging from not at all important to very important [12].  

This indicator presents the proportion of respondents who reported that spirituality was quite/very important.

The figure shows that in 2013, Canterbury and the rest of the South Island had similar proportions of respondents who reported that spirituality was quite/very important to them, at 42 percent and 40 percent, respectively. The highest proportion, 48.7 percent, was recorded for New Zealand, overall.

Quality housing is an important determinant of health and wellbeing. Good quality housing is warm and dry and provides sufficient space and amenities for the occupants. New Zealand research has demonstrated that retrofitting housing with insulation and ventilation improves health outcomes for residents [27, 28]. Although satisfactory housing could refer to a number of aspects (e.g., space for extended family or close to local amenities), this indicator relates to physical housing quality.

The 2018 Canterbury Wellbeing Survey asked survey respondents to rate their satisfaction with the overall quality of the home in which they live (in terms of warmth, insulation, heating, moisture levels, and weather tightness). There were five response options ranging from very dissatisfied to very satisfied. Note that this question was first included in 2017.

This indicator presents the proportion of respondents reporting that they were either satisfied very satisfied with the overall physical quality of their home.

The figure shows that between 2017 and 2018 the proportion of respondents satisfied or very satisfied with the quality of their home has increased slightly for both Māori and non-Māori. In 2017, a higher proportion of non-Māori respondents reported being satisfied or very satisfied (non-Māori 74.8%; Māori 71.8%). The following year, 75.8 percent of Māori respondents and 78.7 percent of non-Māori respondents were satisfied with the quality of their home. There was no statistically significant difference between non-Māori and Māori in 2017 or 2018.

Having sufficient household income contributes substantially to a family’s wellbeing. With an adequate income, a household can access essential goods and services such as quality housing, transport, food, health services, and education. An adequate household income also enables participation in social and recreational activities in the community. Within the Whānau Ora framework, economic security and successful wealth creation is one of the major goals for whānau [6]. Reaching this goal would ensure whānau were able to afford essential everyday items and participate within society.

The 2018 Canterbury Wellbeing Survey asked respondents to rate their satisfaction with how well their total household income met their everyday needs (for things such as accommodation, food and clothing) [10]. Note that this question was first included in 2017.

This indicator presents the proportion of respondents satisfied/very satisfied that household income meets their everyday needs.

This figure shows that in 2017 and 2018 a higher proportion of non-Māori respondents reported being satisfied or very satisfied that their household income met every day needs. The proportion for Māori had increased from 59 percent in 2017 to 61.6 percent in 2018, while the proportion for non-Māori remained the same (67.8%). However, there were no statistically significant differences between the proportions for non-Māori and Māori in 2017 or 2018.

Transport systems and infrastructure (including public transport) influence health and wellbeing by enabling access to other important resources, such as employment, education, social and healthcare services. Transport is also important to cultural identity as it enables access to cultural activities and sites [29]. Owning a car has been identified by some Māori as allowing them to have mana motuhake (independence) to participate in wider society and maintain contact with whānau [29].

The 2018 Canterbury Wellbeing Survey asked respondents to rate their satisfaction with their ease of access to suitable transport to daily activities [10]. There were five response options ranging from very dissatisfied to very satisfied. Note that this question was first included in 2017.

This indicator presents the proportion of respondents that were satisfied/very satisfied with their ease of access to suitable transport to daily activities.

The figure shows that in 2017, a higher proportion of Māori respondents reported being satisfied or very satisfied with their ease of access to transport (Māori 85.9%; non-Māori 79.7%).  In 2018, the proportion in both groups dropped, with the proportion for non-Māori (72.4%) being very similar to the proportion for Māori (71.8%). The difference was not statistically significant in either year.

The natural environment is essential to the wellbeing and identity of Māori as part of their whakapapa (genealogy) and the bond of kinship between all things [30]. Ensuring access to a healthy and clean natural environment (e.g., rivers, lakes, mountains, green spaces) positively affects wellbeing. For example, having access to fish from a clean local body of water provides a healthy and fresh kai option for whānau. In 2014, the government recognised the strong links between Māori wellbeing and a clean environment when Wai Ora (healthy environments) became a leading priority in He Korowai Oranga: Māori Health Strategy [31].

The 2018 Canterbury Wellbeing Survey asked respondents to rate their satisfaction with their ease of access to the natural environment, broadly defined as “access to rivers, lakes, beaches, wildlife, areas, parks, and walking tracks” [10]. Note that this question was first included in 2017.

This indicator presents the proportion of respondents who reported being satisfied/very satisfied with their ease of access to the natural environment. There were five response options ranging from very dissatisfied to very satisfied.

In 2017, 82.3 percent of Māori respondents reported being satisfied or very satisfied with access to the natural environment, which was slightly higher than the proportion for non-Māori (80.7%). In 2018, the proportion for Māori dropped to 74.3 percent, while the proportion for non-Māori remained stable (80.5%). The differences between Māori and non-Māori were not statistically significant at either time point.