Abstract
In Samoan culture there are three perspectives. The perspective of the person at the top of the mountain, the perspective of the person at the top of the tree, and the perspective of the person in the canoe who is close to the school of fish. In any big problem the three perspectives are equally necessary. The person fishing in the canoe may not have the long view of the person at the top of the tree, but they are closer to the school of fish. This research represents the culmination of all three perspectives, as it sought a range of views both long and short, from women and men and from the Elders and those who work in the health field.
Tuiatua Tupua Tamasese Efi [1]
People of Pacific ethnic origin make up 6% of the population of New Zealand and represent at least 22 different cultures with a greater number of languages. The Pacific population is demographically young with higher fertility rates than the rest of the New Zealand population. Their numbers are expected to double over the next decades. Samoan people make up 51% of this population, living mainly in urban areas of New Zealand's North Island [2].
To date, research focusing on the mental health of this population has been limited. However, hospital admission statistics support the view that Pacific people delay or avoid seeking treatment from mainstream psychiatric services [3]. It has been suggested that one reason for this delay is that the values inherent in the ‘western’ mental health system may be viewed negatively by Pacific people [3].
This project had two aims. The first was to develop a rigorous research method, which would be relevant and acceptable in a Samoan cultural context.
The risks of cross-cultural research which is used to examine the experience of non-western participants from western psychiatric points of view, have been highlighted by a number of authors [4–6]. Kleinman has emphasized the importance of research approaches which examine data using analysis derived from concepts indigenous to the culture in question.
In the Samoan context, the nuances of the Samoan language hold the key to understanding the meaning of important cultural concepts [1]. As well as being the vehicle by which beliefs and values have been transmitted from generation to generation, a person's first language houses their sense of belonging and identity and best explains their world view [1]. The Samoan language, depending on the situation, is spoken either on an informal level or in a mode which is highly formal. The latter is the language with which knowledge is appropriately and most commonly imparted [1]. Protocol and etiquette are critical and allusive linguistic techniques such as ‘riddles and camouflage’ play a key role [1]. Accounting for these factors is necessary in order to develop appropriate and effective research methods for the Samoan context.
The second aim in this study was to identify the views of Samoan people on issues pertaining to mental health and wellbeing. This included inquiry into Samoan explanations of mental health and ill health, identifying Samoan values, concepts and practices relevant to mental health, and seeking participants' views on the extent to which these concepts and practices may have been influenced by western models of health care. It included inviting participant responses to Pacific Island mental health data and seeking their experiences of mental health services in New Zealand, as well as Samoan opinion on effective and culturally appropriate mental health services for Samoan people.
In New Zealand there is a Ministry of Health policy commitment to addressing the specific mental health needs of Samoan and other Pacific Island people [7], [8]. However while it is acknowledged that acceptable mental health services would need to be culturally appropriate, there has been no previous systematic and rigorous research to establish what would constitute acceptable mental health services for Samoan or other Pacific Island people. This research aims to address this gap.
Method
In recent years there has been an increasing recognition of the value of qualitative studies in healthcare research [9]. This is particularly the case in the mental health context when addressing the meaning people from different cultures create to describe their experience and understanding. Cultural meaning that differs from mainstream definitions often becomes marginalized in formal discourse and theory [1].
This research is culturally based as noted in the aims above. The fa'afaletui methodology that was adopted, is set out below. It avoided the danger of Western interpretation and meaning construction and enabled an authentic Samoan based approach. From a Western perspective, postmodern critical theory offers a rationale for this approach to mainstream theorists and practitioners, because it identifies differing constructions of meaning and power differences between them [10]. This study has sought to explore the experience of Samoan people and the meaning they construct around critical mental health issues and definitions. Cultural information of this type seldom features in formal mental health literature.
Data collection
In Samoan culture, issues of importance are always discussed collectively [1]. Therefore a focus group method was chosen for this study. This method provides an opportunity for more in depth discussion than other research techniques, encourages the exploration of meaning and allows systematic comparisons of an individual's experience with those in their group [11]. Of further relevance to the Samoan context, focus groups also allow the development of consensus views around issues of importance [1].
Participants
All participants were of Samoan descent and living in urban areas in the lower North Island of New Zealand. Tumua ma Pule, the traditional oratorial body that is representative of all villages in Samoa, selected participants from as many villages of origin as possible, aiming for a balance of participants from the two larger islands of Samoa, Sava'i and Upolu. This was intended to increase the breadth of perceptions and experiences of mental health issues.
Fa'afaletui method
Fa'afaletui is a Samoan concept, that was brought to the notice of the researchers by the Elder men and women's focus group participants, to explain the process in which they viewed themselves to be a part. Essentially, fa'afaletui describes a method which facilitates the gathering and validation of important knowledge within the culture.
Gender and relative status within the cultural community were selected as the most appropriate ways to apportion the focus groups. The gender separation allowed relationships and the appropriate cultural protocols to be addressed and permitted issues considered tapu (or sacred and forbidden) which could not be spoken of across gender groups, to be openly discussed. The relative status separation allowed recognition of the roles and responsibilities of elders on the one hand and their particular knowledge of traditional ‘health models’ prior to the Western public health system in Samoa, on the other.
In this study, an Elder men's and an Elder women's group, with a minimum age of 50 years were selected. A women's and a men's provider group were also selected. They represented a range of disciplines within the mental health field. Informed consent was obtained from all participants after personal approaches by Samoan members of the research team, supplemented by written material.
These groups or houses (fale) met separately to address the research questions with a facilitator, who enabled their sharing of knowledge and consensus building. The fa'afaletui process then involved delegations from each of the houses meeting each other and going through the same process together to build a new consensus. The information was threaded and rethreaded among the relational houses until all were agreed that the specific knowledge pieces were valid and authentically reflected the collective experience of the participants. Fa'afaletui is the critical process of weaving (tui) together all the different expressions of knowledge from within various groupings.
Development of focus group questions
In preparing the questions to put to the focus groups, it became apparent to the Samoan researchers that in the Samoan context, issues of health and wellbeing without regard for a Samoan view of the self, have little meaning. In order to discuss what might constitute a mentally well self, participants would need to address the more fundamental issue of a Samoan perspective on the self. This distinction became the basis for the development of the focus group questions. Details of the focus group questions are provided in the Appendix.
Group facilitation
Samoan researchers facilitated all sessions. It was anticipated that the main medium of communication would be the Samoan language and expected that Samoan protocols would be observed. The facilitator's role was to loosely guide discussion, attempting to gather clear and useful responses while encouraging a divergence of opinion and allowing participants to use their own concepts and meanings. In all 14 focus group meetings took place, four for both Elder groups and three for both service provider groups. The Elder groups had an extra meeting that focused on questions about their memory of the treatment of mental health problems prior to the Western public health system in Samoa.
Analysis
Audiotapes of the focus group sessions were transcribed and proofread to ensure accuracy. Specialized terms and vernacular usage were verified.
It was initially planned to translate the transcribed interviews into English prior to the data analysis. However during this process the Samoan researchers became concerned that important concepts discussed in the Samoan language were difficult to translate precisely, resulting in the loss of the essence of some of the information. At this point a decision was made to proceed with the data analysis in the original language of the participants.
The data was coded and categorized into themes manually. The themes consisted of clusters of the subject areas that consistently recurred. These theme areas were then classified and subcategorized in a manner that highlighted the consistently repeating knowledge pieces. A manual approach was employed, because much of the data was given in metaphorical and allusive language, as is common in serious Samoan discourse, and digital theming techniques proved inadequate.
The primary report was completed in Samoan. Copies of this report were given to authoritative participant members from each of the groups to check for coherency, appropriate use of terms and concepts, and an appropriate observance of written protocols and etiquette. The Samoan report was considered to be important both because it represented the initial gathering of primary source data and because it was accessible to Samoan readers. An English report was prepared based on the Samoan report, to be accessible to English speaking health professionals.
Results
There were 12 participants in each of the Elder men and women's groups and ten and eight members for the men and women's service provider groups, respectively.
The results are presented in sections according to the major themes that emerged in the data analysis. Each theme is illustrated with quotations taken from the text.
The Samoan world view and the importance of the relational self
Participants considered that it was not possible to understand Samoan concepts of mental health and ill health without first understanding the Samoan concept of self.
A relational self
Participants explained the nature of the Samoan person as that of a relational being:
It is difficult because there is no such thing as a Samoan person who is independent (of others). You cannot take a Samoan out of the collective context. I cannot say that I am a person, just me; (because) then I will be nothing without my other connections… The idea that a person can be an individual unto him/herself is a new concept which was introduced with Christianity. Christianity introduced the notion that one looked to oneself first. The Samoan belief is that in need, we look to each other. You cannot prosper on your own, by yourself… The self is identity and tofi [responsibilities, heritage and duties].
The Samoan self was described as having meaning only in relationship with other people, not as an individual. This self could not be separated from the ‘va’ or relational space that occurs between an individual and parents, siblings, grandparents, aunts, uncles and other extended family and community members.
In the context of psychiatric services, it was pointed out that individuals who receive treatment without regard for their communities and communal practices were denied a most important source of meaning and life support in their process of healing.
Tapu and sacredness in relationships
Tapu in its fundamental sense means ‘that which is forbidden to the ordinary’, as expressed in cultural protocols and etiquette. Sa has its nearest English equivalent in the word ‘sacred’.
Within va fealoaloa'i (particular relationships of mutual respect) there exist tapu and sa which define by way of… etiquette how one ought to relate to the other. There exist such relationships for example between matai (titled heads of families and villages), between brothers and sisters. These relationships are especially sacred. Within the physical and spiritual domains, there are tapu whose purpose is to ensure that human wellbeing is protected and (given prominence), through its sacred nature. For example, a basic premise of cultural protocol is, it is forbidden (Sa) to stand in the presence of people (while they are seated). There exist protections around Samoan wellbeing because of the relational arrangements with others.
These quotations were typical of the comments of all the groups and emphasize the fundamental importance of language, Samoan etiquette and protocol in protecting the sacred nature of relationships, and maintaining wellbeing in Samoan society.
The Samoan self was described as drawing its sense of worth from its ability to carry out its appropriate roles and responsibilities. Mental ill-health among Samoan people was reported as often understood to be the result of breaches of forbidden or sacred relationships (or breaches of ‘sa’ and ‘tapu’). These cultural notions were clearly viewed as being effectively addressed only within the protocols laid down in the culture.
It was noted that although young people brought up in New Zealand were less influenced by these concepts they were still relevant when the young person faced a crisis in their life.
Spirituality and the self
Prior to the arrival of the ‘good news’, Samoa had her Gods; each island had their Gods; there were Gods of districts, Gods of villages; families also had their own Gods. … our Gods were Gods whom we could see but from 1830 we have been worshipping a God that cannot be seen. … if both (physical and spiritual) natures are not in balance, wellbeing cannot be in balance…
In Samoan culture, Gods were traditionally embodied in the environment in which people lived and genealogical ties could always be traced back to a God. Despite the change in emphasis following the arrival of Christian missionaries to Samoa, a person's relationship to land, sea, ancestors and God remain central to the Samoan sense of self.
Participants described spiritual and mental aspects as being so closely related for Samoan people that psychiatric treatment processes that did not address the spiritual aspect were considered unlikely to be successful.
The whole self cannot be divided
Samoan people believe that the person is ‘itu lua’, that is the person has physical, mental and spiritual aspects.
We view ourselves as whole beings. In other words the spirit, the body, the will. I include the spiritual because there is no Samoan person who… exists outside of a spiritual existence.
In fact the Samoan term for spiritual, ‘fa'aleagaga’ was frequently used by participants to include the mental faculty. It was emphasized that the Samoan self is seen as a total being comprising spiritual, mental and physical elements which cannot be separated.
If I become mentally unwell, everything else is not well. If I become physically unwell, everything else is not well. I cannot say, ‘I will leave my spirituality while I go and get on with my physical function’, or ‘I will put aside my mental function while I undertake my spiritual duty’. The whole person is all parts. The person cannot be divided by anyone.
Participants viewed this being as deriving its sense of wholeness, sacredness and uniqueness from its place of belonging in its family and village, its genealogy, language, land environment and culture.
Causes of mental illness
All the focus groups expressed the view that mental ill health among Samoan people is often understood as being the result of breaches of forbidden or sacred relationships.
Breaches of tapu and sa
Participants considered that prior to 1920 rare cases of mental illness had usually been attributed to breaches of ‘tapu and sa’. Such breaches were viewed as grave transgressions of family, village or district relational boundaries. They could often result in a curse (malaaumatua) being placed on the offending person or persons.
If a person has been cursed, it is because something has been dealt with irreverently or desecrated. In other words he or she has been assigned the consequences of desecrating sacred protocols.
Curses could be intergenerational. They would frequently condemn the person to a life outside of family and village relationships, and hence a life without purpose.
An example would be the relationship between sisters and brothers. In the Samoan context, this relationship is viewed as especially sacred and it is the role and responsibility of a brother to ensure the safety and welfare of his sister or sisters. As part of this feagaiga (covenant) a sister has the power to curse a brother whose conduct is extremely untoward or neglectful of her.
There are cultural processes that facilitate healing after breaches of ‘tapu and sa’.
The Samoan way of healing is for the family to establish why there has been a curse put on this person and to seek reconciliation through appropriate processes.
Additional pressures in New Zealand
The participants stated that sometimes mental illness results from an inability to fulfil responsibilities and obligations to their families, villages and districts of belonging:
For many Samoans who have migrated here, the reason has been because of family and their responsibilities towards family. There is not enough financially to meet obligations and fulfil responsibilities. (There is) no money, not enough money. The needs from Samoa become a pressure… it becomes difficult for young people to provide (financially) for the family, church obligations, to send remittances (home to Samoa)… these become heavy burdens, the mind tries to cope, then it breaks down.
Pressures of cultural adjustment were also highlighted as possible precipitants of mental ill health:
There are different values and priorities between Samoan culture and the dominant culture, and these values conflict. (Young people)… don't know if they are Palagi (European) or Samoan, they're confused. One of the biggest reasons especially for the younger generations is the different cultures and trying to live in the European way… as well as keeping your identity as a Samoan and playing your role in the family. You've got two (areas) putting a lot of pressure on you to function out in the community and function in here. There are conflicts of cultural identity causing shock and trauma. (Whether the child) was born in New Zealand or brought up in Samoa, there are conflicts with cultures within schools.
These pressures were noted particularly in shifting family relationships. In some families older members become depressed as senior members are accorded lower status, both in earning power and recognition in New Zealand:
… Where we come from, our status is determined by the titles our families hold. In this country the status is determined by our earning power. A senior ranking matai (titled elder) who comes from Samoa finds that he is not employable; he cannot make decisions or undertake his responsibilities. Eventually his mental health will be affected.
For younger people, the push to succeed in a Palagi (European) environment at school, where they are seen as different and often from a low income family, could lead to the development of psychological problems:
… parents have high expectations of their children. There are many things that they are wanting but these are not appropriate to where the mind of the child is at. The child will therefore try their best to realize the parents' expectations.
Racial stereotypes and prejudices held by non-Samoan peers and teachers were also thought to create pressure on young Samoan people in the school setting.
Other factors identified as precipitants for mental ill health included: drug and alcohol abuse, unresolved grief, physical and sexual abuse, and isolation due to the breakdown of traditional collective support systems.
Several major themes emerged from this part of the focus group discussions. Firstly, participants maintained that mental illness was more likely to occur when extended family relationships were disrupted and traditional relational arrangements weakened. Secondly, conflicting values between Samoan culture and the dominant Palagi (European) culture in New Zealand were viewed as a significant ongoing stressor.
A third theme was that mental ill health could be triggered by feelings of failure associated with the inability to meet financial responsibilities within the extended family.
Finally, when traditional Samoan structures of support were fragile or absent, healing and the restoration of emotional and relational harmony were seen as much more difficult to achieve.
Effectiveness of psychiatric services for Samoan people
Strengths of mental health services
There was recognition that there were mental disorders which could only be treated by Western medicine:
… hospitals have their purposes because there are many types of illnesses, and many causes…
Hospital facilities also helped to relieve the burden of care faced by some families, enabling other family members to seek paid employment:
… we have a child who is mentally unwell. The positive aspect is that she is able to be placed in hospital care. The family structure in New Zealand (nuclear families) makes it difficult to work and leave her at home on her own. It is not like Samoa where there is the extended family who are able to care for her.
There was also acknowledgement of the emerging role of Pacific people who were employed as cultural advisors in mainstream mental health services. This was seen as a significant first step in bridging identified cultural gaps.
Weaknesses of mental health services for Pacific Island people
Participants reported that psychiatric treatment of Samoan people in New Zealand was based on Western medical beliefs. This primarily focused on physical modes of treatment:
It is not that the hospital is of no use. The work of the hospital with regards to the treatment of physical illnesses is important. The problem arises where there is a need for holistic treatment, and this is not undertaken… This is true of the treatment for mental unwellness where doctors have separated the whole into three parts, treating only the physical. You cannot divide a Samoan person because if my mind is unwell, everything else becomes unwell…
Language and a lack of familiarity with important cultural issues, were identified as problems with the current mental health services:
Language is one barrier which is creating difficulty for our people. If the Palagi (European) cannot understand a Samoan patient, they treat our people differently (from others). If the patient does not understand (the Palagi), they are treated in a manner which indicates that the Palagi may not be happy with the patient. It is only when they see their own that they sense relief… The Palagi does not understand the Samoan. Our culture and traditions are different… There are no Samoan psychiatrists. Samoans are being diag nosed by people from other cultures who define normality from their own perspective.
Participants emphasized that these issues led to crucial communication problems. For example details regarding symptoms and the frequency and nature of particular psychiatric experiences may be misunderstood by psychiatrists who speak English when interviewing patients whose primary language is Samoan.
References were made to established Maori mental health services in New Zealand which provide culturally appropriate care for Maori patients:
The Maori have made the health system effective for them selves, yet we are lumped with the Palagi (European).
It was stated that where the cause of the unwellness originated from breaches of Tapu and Sa, and where this had a history of being intergenerational, then Western treatment was not effective:
The doctors will try in vain to apply treatment to heal the person, but they will not be successful because the cause of the unwellness is outside of their medical experience. … medication and injections cannot treat this type of illness; it can be healed through appropriate traditional healing.
Culturally appropriate Samoan mental health services
Key cultural factors
Participants considered the Samoan view of self to be a crucial concept in developing culturally appropriate services for Samoan people. This view was of a relational self in which spiritual, mental and physical aspects were considered together as a whole and not treated as separate entities.
They highlighted the important role of Samoan relational arrangements in the healing process and the critical role of the family in nurturing them. The importance of involving the extended family in treatment was emphasized.
Service issues
Participants identified a need for a specific Samoan service for mentally unwell Samoan people combining aspects of both Western and traditional Samoan models of care:
… early recognition of symptoms and causes, changes in behaviour and intervention at an early stage would increase the likelihood of recovery … there should be a hospital service for Samoan people where they can be taken care of … Samoan people are best employed because they understand the needs of Samoan people… … there will be Samoan people who will work there with commitment because they will look after their own people as if they were their mothers or fathers…
Family involvement
Within this service, the participants stated that there should be people trained to provide support and counselling for families of the mentally unwell:
… there need to be family and community education programmes; families need to be supported where needed in therapy and counseling, financial (budgeting)… … it may be that the treatment has not worked and the families are at their wits end. The only thing left is to provide a service within the context of aganu'u (sacred Samoan customs and traditions). In this way, there needs to be an understanding not only of the way of life but also of the culture…
Participants noted different cultural conceptions of confidentiality, and considered that clients of a Samoan service should be able to choose to have their rights to confidential information extended to their families, rather than restricted to individual rights. They pointed out that the family, which provides most of the support and has its own recognized boundaries can be marginalized through current institutional processes and legal requirements for confidentiality and privacy.
Community support services
Participants emphasized the need for community based services:
The focus is out in the community. We need to set up a place where we can cater for the needs of our people. Therapy and counseling that connects people to their places and gives a sense of belonging should be made available. … we need a mental health service to cater for the needs of Samoan people run by Samoan people…
Employing Samoan healers
Traditional Samoan medicine and healing knowledge should be valued in the treatment of Samoan people… taulasea (Samoan healers) should be recognized because there are illnesses which can only be treated by fofo Samoa (Samoan healing methods); there are also illnesses which can only be treated by Western medicine… There needs to be education of Samoan psychiatrists and Samoan cultural consultants…
Participants stated that they wanted taulasea and fofo (Samoan healers) to be employed in the mental health services alongside other clinicians. They wished to see the status of traditional healers recognized along with appropriate remuneration.
Enhancing the mental wellbeing of Samoan people
While offering suggestions regarding changes to New Zealand mental health services to improve care provided for Samoan people, participants also identified a need within their own communities to strengthen family relationships and the role of the church.
Participants identified the importance of preventing mental ill health through the strengthening of critical cultural concepts and structures. The emphasis was placed on strengthening of spirituality and relational arrangements within the family, in recognition that the family is the first place of relational harmony, belonging and identity. It is also the primary site of education and nurturance of language and cultural knowledge.
Where families were unable to provide this secure foundation, the churches were identified as being the next most important source of support, providing both a spiritual dimension as well as pastoral care and support for families.
Medical scholarships and research
Participants recommended that medical scholarships be made available for Samoan students to enable a greater proportion to complete medical training and proceed with specialist training in psychiatry. This would enable better recognition of Samoan approaches at a senior level.
They also stated that there was a need for Samoan researchers to undertake qualitative and quantitative research that relates to Samoan people and that this research should be more accessible to Samoan people.
Discussion
Despite recent acknowledgement of the specific mental health issues facing people from cultures indigenous to the South Pacific region, few if any studies have attempted to systematically investigate the views of members of these cultures. Furthermore, research methods traditionally used in the mental health field have not been well accepted by Pacific Island groups [1].
The present study is unique both in terms of the method used as well as the findings. It has developed an innovative research method known as Fa'afaletui which weaves in established qualitative research principles with the values and processes indigenous to Samoan culture. During this research there was an extraordinarily high level of cooperation by the participants, and the breadth and depth of knowledge that was shared, suggested a high degree of acceptance of the research process. Participants raised deeply spiritual material during the course of the research and clearly expected that this would be treated as sacred by the researchers. The trust shown by participants suggests that the research method was found to be culturally relevant and safe. In addition, the Samoan leadership of the project, and focus group facilitation by Samoan researchers in the Samoan language were further factors in the cultural acceptability and validity of the method. The validation of key cultural concepts was strengthened by verification of findings by participants.
Although participants were all Samoan and represented a range of villages in different parts of Samoa, it should be noted that they were all resident in the greater Wellington region of New Zealand, and some findings could be subject to regional differences, for example varying experiences of mental health services. In addition although similarities in cultural values have been described between different Pacific Island cultures, it is not possible to generalize these findings to other Pacific Island communities.
This study found that from a Samoan point of view, understanding the Samoan sense of self is crucial to an understanding of what constitutes mental wellbeing for Samoan people.
The Samoan self described in this study is a relational self. Other collective views of self have been described for a range of diverse non-Western cultures [12–15]. These authors state that it cannot be assumed that developmental theories, therapeutic interventions and mental health service practices that have evolved in cultures with individual concepts of self, will necessarily be relevant for people from collective based cultures. Other authors have highlighted aspects of the phenomenology of major mental disorders such as depression and schizophrenia arguing that differences in presenting symptoms across western and non-western cultures may be accounted for by fundamental differences between individual and collective concepts of self [4–6].
The results of this study challenge a number of prevalent presuppositions about the nature of self in modern psychiatry and raise questions about the assumption that such dominant western views of self are applicable across cultures. In particular the Western notions of the self as being primarily individuated rather than relational, and secular/scientific rather than spiritual, differ substantially from those identified by participants in this study.
In the New Zealand context, specialist Kaupapa Maori mental health services have been established, which have developed whanau (family) centred practices to address collective values in Maori culture [16]. Participants in this study called for similar Samoan or Pacific Island services to specifically address these issues for Samoan patients and their families.
According to the participants in this study, spirituality must be addressed if the mental health care of Samoan people is to be effective. This is consistent with the findings from other cultures indigenous to the Pacific region. For example, Maori authors have described spirituality as integral to a Maori model of mental wellbeing [17].
In order for a mental health service to adequately address relational, spiritual and holistic aspects of the Samoan self, they would need to transform current approaches to mental healthcare. In this study a range of recommendations of how to do that were put forward by participants. These involved the provision of services that incorporate the beliefs and customs of Samoan people, the use of traditional healers alongside mental health clinicians, and closer links in the healing process with extended families, the churches and the communities in which Samoan people live.
The study also noted the added pressures many Samoan households experience that can lead to mental ill health. Samoan families as a whole tend to occupy a lower socio-economic status than the majority of New Zealanders and the combination of the financial worries low income households experience and the added pressures associated with cultural collective obligations create added stresses for many. Racial stereotypes and prejudices from the mainstream cultural groups contributed further tensions along with the cultural adjustments many immigrant families were undergoing.
Further research is required to establish whether there are themes in common between Samoan perspectives outlined here and the views of other Pacific Island groups. The Fa'afaletui method may well be an appropriate and acceptable research design for investigations with other Pacific Island communities. A current development of this study is involving a similar enquiry into the perspectives of Samoan consumers of mental health services.
Tupuola [18] has emphasized the predicament that young Pacific Island women face growing up in New Zealand, straddling cultures with very different values. Participants in this study also highlighted this point. Similar qualitative research would shed further light on particular psychological stressors faced by New Zealand born people of Pacific Island descent.
A further area for enquiry would be to seek a response from Palagi (European) mental health professionals to the Samoan concept of self and how they would view this as relevant for the mental health care of Samoan people and their families.
There is little epidemiological data available regarding the mental health status of Pacific Island people either in New Zealand or in their countries of origin. Qualitative research using the Fa'afaletui method could be expected to contribute useful information towards finding culturally acceptable methodologies, in order to maximize participation of Pacific Island groups in epidemiological research. Furthermore, future research that adopted this methodology would usefully test the validity of such an approach.
Durie has called for ‘the development of a type of psychiatry which is firmly grounded in a New Zealand identity’ in order to best meet the mental health needs of the Maori community [19]. In a similar way, understanding cultural identity in the Pacific Island context is the key to beginning to address the mental health needs of Pacific Island communities. A collaborative approach to this endeavour can only enrich the development of psychiatry in the South Pacific region.
Footnotes
Acknowledgements
The authors wish to thank Tuiatua Tupua Tamasese Efi for providing profound cultural depth, breadth of social science expertise, and a name for the report.
The researchers also thank the Elders and Mental Health Workers who shared their knowledge and experience, especially: Talolua Toa Afele, Salasala Vaelupe Aluni, the late Leao Walter Brown, Palepa Aleipata Brown, Folole Iaeli Esera, So'onafai Aivaea Malieituia Fata, Fepulea'i Seuao Fa'amanutaeao, Fa'auliuli To Faiumu, Finau Fiaui, Ulatifa Imoana Godinet, Anealeise Emi Patu Laban, Mesepa Tanielu Laban, Thomas Laban, Silipa Mamea, Fuiono Manu'a, Toleafoa Tomanu Masinaanamua, Ale Palelei, Loudeen Parsons, Johnny Pau'u, Lefao Paniani Sa'ena, Mafui'e Sa'ena, Toleafoa Iumai Saivaiese, Ifopo So'o, Papali'i, Fa'asisila, Su'a, Time Utumataiona Tafea, Ta'anoa Taiti, Sina Ta'anoa Taiti, Fa'alelei Te'o, Emi Tuiavi'i, Mele Ahfani Tuilepa, Leapi Tuita'alili, Leaupepe Uili and Iunita Vaofusi.
We thanks George Salmond, Peter Ellis, Sunny Collings, Kath McPerson, Loudeen Parsons, Luamanuvao Winnie Laban, Shane Stuart and members of the Family Centre staff. We also thank the Health Research Council of New Zealand, who funded this research project, and in particular Moera Douthett for her generous support.