My Home is My Marae: Kaupapa M�aorievaluation of an approach to injuryprevention

Brooke Hayward,1 Mataroria Lyndon,1 Luis Villa,1 Dominic Madell,1

Andrea Elliot-Hohepa,2 Lyndsay Le Comte1

To cite: Hayward B,Lyndon M, Villa L, et al. MyHome is My Marae: KaupapaM�aori evaluation of anapproach to injuryprevention. BMJ Open2017;7:e013811.doi:10.1136/bmjopen-2016-013811

▸ Prepublication history andadditional material isavailable. To view please visitthe journal (http://dx.doi.org/10.1136/bmjopen-2016-013811).

Received 26 August 2016Revised 9 January 2017Accepted 2 February 2017

1Ko Awatea, CountiesManukau Health, Auckland,New Zealand2OTS Consulting, Rotorua,New Zealand

Correspondence toDr Dominic Madell;dom.madell@middlemore.co.nz

ABSTRACTObjective: The objective of this study was to evaluatethe New Zealand Accident Compensation Corporation’s(ACC) ‘My Home is My Marae’ approach to injuryprevention for wh�anau (families).Setting: Over an 18 month period from November2013 to June 2014, 14 ‘My Home is My Marae’ trialswere conducted across the South Auckland and FarNorth regions of New Zealand. ACC engaged with localM�aori providers of healthcare, education and socialservices to deliver the home safety intervention.Participants: Participants of this evaluation were apurposive sample of 14 staff from six providerorganisations in South Auckland and the Far Northregions of New Zealand.Methods: Kaupapa M�aori theory-based evaluation andappreciative inquiry methodologies underpinned theevaluation. Interview participants led discussions aboutstrengths and weaknesses of the approach, andpartnerships with ACC and other organisations. Theevaluation was also supported by pre-existinginformation available in project documentation, andquantitative data collected by M�aori providers.Results: Five key critical success factors of ‘My Homeis My Marae’ were found from interviews: manatangata (reputation, respect and credibility);man�akitanga (showing care for people); k�anohi-ki-te-k�anohi (face-to-face approach); capacity building forkaimahi, wh�anau and providers and ‘low or no cost’solutions to hazards in the home. Data collected forthe Far North area showed that 76% of the hazardsidentified could be resolved through ‘low or no cost’solutions. Unfortunately, similar data were not availablefor South Auckland.Conclusions: Injury prevention or health promotionapproaches that seek to engage with wh�anau and/orM�aori communities would benefit from applying criticalsuccess factors of ‘My Home is My Marae’.

INTRODUCTIONIn New Zealand, as in other high-incomecountries, unintentional injuries represent asignificant public health problem causingdeath, disability, financial and psychologicalcost.1 The WHO recognises the strong link

between unintentional injuries and socialdeprivation, with more socially deprivedgroups, such as M�aori, having the highestincidence of unintentional injuries.2

Adult M�aori (aged 15–64 years) in NewZealand have higher rates of hospitalisation(1788.0 per 100 000 compared to 1104.5 per100 000; RR 1.62, 95% CI 1.59 to 1.65) andmortality (42.8 per 100 000 compared to 18.7per 100 000; RR 2.29. 95% CI 2.05 to 2.56)than adult non-M�aori due to unintentionalinjury.3 Further, research by Mauri OraAssociates [ref. 4, p. 6] demonstrated thatM�aori are frequently unaware of the “servicesand benefits to which they are entitled”through the Accident CompensationCorporation (ACC) and have lower rates ofaccess to health services, including ACC ser-vices, than non-M�aori. M�aori represent14.6% of the total New Zealand population,and 11.6% of total ACC claims between 2004and 2009 were from this ethnic group.5

Strengths and limitations of this study

▪ Kaimahi (staff ) shared the perspectives orexperiences of wh�anau (family), but the evalu-ation did not involve the direct participation ofwh�anau who had completed home safety auditsalongside kaimahi.

▪ Provider organisations that participated in thisevaluation were selected by ACC, and it is pos-sible that provider organisations not involved inthe evaluation could have had different experi-ences that were not captured.

▪ While ‘low or no cost’ solutions used in this pro-gramme were identified as potentially highlycost-effective for ACC, a specific cost–benefitanalysis was not carried out.

▪ Incomplete quantitative data meant that it wasnot possible to draw robust conclusions regard-ing the reach of the programme and also pre-sented difficulties in being able to comparedifferent patterns in the hazards identified acrossthe Far North and South Auckland regions.

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The home is the site in which the majority of injuriesleading to ACC claims occur.6 From 2014 to 2015, onein five people in South Auckland made a claim for aninjury in the home.6 South Auckland, includingManukau City, Franklin and Papakura Districts, has apopulation of 524 505, with one in six people beingM�aori. Northland, which includes the Far North,Whangerei and Kaipara Districts, has a population of151 692, with one in three people being M�aori. From2014 to 2015, one in three people in Northland made aclaim for an injury that occurred in their home.6

Further, unintentional injuries are responsible for oneout of three disabilities suffered by adult M�aori.7

Subsequently, prevention of injuries in the home is a keypriority area for ACC and they are working to achieveeffective injury prevention among wh�anau and M�aoricommunities through partnering with hapu/iwi and keyM�aori stakeholders (please see online supplementaryAppendix 1 for a glossary of M�aori words). ‘My Home isMy Marae’ is delivered in partnership with local M�aorihealth, social or community services, in South Aucklandand Far North communities.‘My Home is My Marae’ was informed by M�aori

models of health and what is known to work for M�aorifrom previous injury prevention initiatives and availableliterature. The approach aims to reduce the risk, inci-dence or severity of injury in the home among M�aoricommunities by empowering wh�anau with the knowl-edge and skills they need to identify hazards in theirhome environment, and to take continued action tominimise, isolate or eliminate hazards in their home.‘My Home is My Marae’ aimed to work with the M�aoriworking age population (25–64 years of age), who areknown to be at most risk of a fall at home.6 Theapproach also aimed to be inclusive of all wh�anau, fromtamariki to t�unohunohu, who reside at the same whareof those in the working age population.Over an 18 month period from November 2013 to

June 2014, 14 ‘My Home is My Marae’ trials were con-ducted across the South Auckland and the Far Northregions. ACC engaged with local M�aori providers ofhealthcare, education and social services to deliver thehome safety intervention, as it was considered that therewould be a greater chance of success with messagescoming via established, trusted and local channels. Aftercommitment from the providers was gained, kaimahiwere trained by ACC’s injury prevention consultants toconduct home safety audits. This training involvedequipping kaimahi with the knowledge, skills andresources to capacitate wh�anau to identify and reducehazards that risk injury in the whare, through the imple-mentation of ‘low or no cost’ solutions. ‘Low or no costsolutions’ included, for example, tidying up or reducingclutter such as shoes at the front or back door, tyingelectrical cables together, removing hazards from walk-ways in living spaces, moving poisonous household itemsout of the reach of young children and ensuring spillswere cleaned up before anyone slipped. Using low or no

cost solutions aimed to make addressing hazards in thehome affordable for all wh�anau.Following training, kaimahi worked together with

local wh�anau to conduct the safety audits in theirhomes, to raise awareness of hazards in the home and toassist them in keeping their wh�anau safe. This involvedthe use of standardised ACC collateral including homesafety checklists and teaching aids. The main aspectsthat contributed to the home safety audit are depictedin figure 1. The approach also required that providersmaintained wh�anau engagement and follow-up byreturning 1-year later to review what changes had beenmade.After making small commitments to change in their

whare, wh�anau were provided with a safety product toassist them to further reduce injury risks such as mould/lichen remover, rug grips/non-slip mats/shower mats/bath mats, non-slip paint for outdoor steps, cable gripsor cord winders, step ladders, latches for windows andcupboards, smoke alarms or handrails. In total, kaimahifrom provider organisations visited a total of 646 wharehousing 2897 individuals. In South Auckland, 404 wharehousing a total of 1882 individuals were visited(mean=4.7 people per household), and in the Far North242 whare housing a total of 1015 individuals werevisited (mean=4.7 people per household). The originallogic model for ‘My Home is My Marae’ is presented infigure 2 and depicts ‘My Home is My Marae’ resources(‘inputs’), activities or deliverables and expectedoutcomes.A Kaupapa M�aori evaluation of the ‘My Home is My

Marae’ trials was completed by Ko Awatea at CountiesManukau Health (Auckland, New Zealand). The evalu-ation focused on identifying critical success factors ofthe approach, and strengths and weaknesses of thesetrials in the context of what is known to work well forM�aori in injury prevention, and M�aori models of healthand well-being.

Figure 1 Main aspects of ACC home safety audit. ACC,

New Zealand Accident Compensation Corporation.

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METHODThe evaluation involved the participation of a purposivesample of 14 kaimahi from six provider organisationswho shared their whak�aro and experiences delivering‘My Home is My Marae’ with the evaluation team. ACCselected providers that had started the trials earliest andtherefore had the most well-established trials, and wherethere were established working relationships with ACCfrom prior contract work. These were (1) Papat�u�anukuK�okiri Marae, (2) Tamaki Makaurau M�aori Women’sWelfare League, (3) Te Kura Kaupapa M�aori a Rohe oM�angere, (4) Tumaitua Wh�anau Trust, (5) Te Hau Orao Ng�apuhi (previously Kaikohe) and (6) Te Hau Awhio-whio o Ot�angarei Trust.Kaupapa M�aori theory-based evaluation and apprecia-

tive inquiry methodologies underpinned the evaluation.Appreciative inquiry methodology is a ‘glass-half full’approach that looks at the best of what already exists, toprovide a foundation for thinking about how thingscould be in an ideal situation.8 The approach works onthe principle that focussing on what is valued mostallows rapid improvements to a situation to be made.With appreciative inquiry, the best aspects of the pro-gramme and how it functions are held uppermost in theminds of the evaluators. Kaupapa M�aori evaluationapproaches aim to normalise M�aori worldviews, values,ways of doing things, customs and language across evalu-ation processes and outputs.9 Importantly, they also mustaim to make a positive difference among M�aoricommunities.10

Kerr11 summarised principles of kaupapa M�aoriresearch applied throughout this evaluation includingcontrol, challenge, culture, connection, change andcredibility. These principles were demonstrated in

practice by committing to whakawhanaungatangathrough p�owhiri to start the evaluation, and throughoutthe evaluative process involving k�orero, hui and writtencommunication with providers. Throughout the evalu-ation, evaluators maintained an open door policy withall evaluation participants who were encouraged toshare, clarify and raise concerns as they needed.Evaluators travelled around South Auckland and Far

North regions to ensure interviews could be conductedk�anohi-ki-te-k�anohi. Instead of having predeterminedevaluation questioning, kaik�orero led the discussion inthe areas of most importance and relevance to theirexperience. Areas of discussion included, for instance,what was unique about the ‘My Home is My Marae’approach, what worked and did not work well forwh�anau, the success of the partnership approach withACC and other organisations, their experience of pro-gramme resourcing and funding, their experience ofco-constructing and then implementing trials andobserved positive changes in communities broughtabout by the programme. Allowing kaik�orero to leadand direct k�orero was underpinned by our desire tovalue tino rangatiratanga – allowing kaik�orero to exer-cise control over relevant discussion areas and interviewprocedures. Mihimihi, whakawhanaungatanga, and kaiwere also an integral part of the interview process. Timewas dedicated by the interview facilitator and kaik�oreroto accommodate for this before the k�orero started.M�aori interviewers, translators and writers enabled

extensive use of te reo M�aori throughout the interviewand written outputs, while also ensuring M�aori systemsand values were normative in evaluation reporting. AKaupapa M�aori consultant assisted in the design anddelivery of the evaluation throughout its duration, to

Figure 2 Original logic model for ACC’s ‘My Home is My Marae’ approach to injury prevention (provided February 2014). ACC,

New Zealand Accident Compensation Corporation.

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contextualise and analyse provider activities and toprovide a framework for the discussion of findings. Huiwith evaluation participants provided an opportunity forthem to challenge preliminary findings and furtherensure that M�aori values and priorities were at the foreof the evaluation.A k�orero record was translated (still using te reo

M�aori to capture cultural terms) and sent to eachkaik�orero to review, clarify, amend or share missed infor-mation, to ensure the record accurately reflected whatthey wished to communicate. This allowed time for parti-cipants to reflect on the k�orero and add any informationthey felt was relevant.K�orero records were thematically analysed with the aid

of NVivo software applying an inductive process.Inductive thematic analysis is a widely applied methodfor the analysis of qualitative data that involves identify-ing underlying data-driven patterns or themes in narra-tive or written materials.12 This process involved theevaluation team first familiarising themselves with therecords through reading, and in discussion with thek�orero facilitator, who offered valuable insights aboutthe interview process, M�aori worldviews and the areas ofdiscussion that kaik�orero were most passionate about.K�orero records were then coded by one evaluator, andthemes developed by three evaluators together withevaluation participants and others as detailed below.We sought to make meaning from the many experi-

ences and perspectives of kaik�orero by forming patternsof ‘truth’.13 As provider experiences were community spe-cific, there was not always consensus regarding whatworked, what did not and what is the best way forward,and therefore finding consensus was not a focus of ana-lyses. Potential themes were presented to representativesfrom all provider organisations, ACC’s Community injuryprevention consultants and ACC’s senior research advisorin hui for review and critique. Feedback from this hui wasthen used to further define and refine key themes.In addition to the knowledge gained through inter-

views, the evaluation was also informed by pre-existinginformation available in project documentation, includ-ing letters of agreement, project plans, an interventionlogic model (previous presented as figure 2) and exist-ing monitoring and evaluation reports. These docu-ments were provided by ACC and consisted largely ofqualitative information. The review of documentationwas used to assist in identifying to what extent delivery ofthe approach aligned with what is already known fromthe literature about what works best for M�aori. Theevaluative processes included reviewing the originallogic model to assist ACC in updating the model. Logicmodel review findings are not included in this article.Project documents provided by ACC to the evaluation

team were also thematically analysed using a deductiveor theory-driven process, whereby existing theoreticalmodels were used to frame and interpret data. Thisenabled the evaluation team to determine how the ‘MyHome is My Marae’ approach aligned with existing

models of M�aori healthcare, and expectations thatM�aori have of ACC.Quantitative data were also provided by ACC in Excel

documents, which detailed the number of whare visited,age of wh�anau present during the home safety audit,total number of wh�anau living in the home, hazards iden-tified and solutions to hazards suggested. This was ana-lysed through basic statistical analyses such as calculatingthe total number of whare visited, total number ofwh�anau included, total number of hazards identified andper cent of hazard types, locations and solutions applied.

RESULTSFive critical success factors underpinning ‘My Home isMy Marae’ were developed from analysis of the k�orero:(1) Mana tangata, (2) man�akitanga, (3) k�anohi-ki-te-k�anohi, (4) capacity building for kaimahi, wh�anau andproviders and (5) ‘low cost/ no cost’ solutions tohazards in the home, which are discussed below.

Mana tangata and man�akitangaAcross kaik�orero, a powerful and consistent messageemerged: the importance of having the right people atACC and in the community to support and deliver ‘MyHome is My Marae’. Having the ‘right’ people facilitated(1) buy-in from provider organisations to deliver theprogramme in local communities, (2) engagement andcredibility with local communities and (3) the integrityof a ‘by and for M�aori’ approach to injury prevention.‘My Home is My Marae’ was led by ACC’s injury preven-tion consultants who are k�anohi kitea and deeplyrespected by staff from provider organisations. Providercommitment to delivering the ‘My Home is My Marae’programme was secured by these consultants as a directresult of the mana tangata, or reputation, respect andcredibility, of these individuals in M�aori communities.The injury prevention consultants acted as key con-

duits between ACC and provider organisations, man-aging k�orero between ACC and providers, deliveringtraining and offering their commitment and support tokaimahi from provider organisations who delivered ‘MyHome is My Marae’. More importantly, however, theinjury prevention consultants were well known and con-nected to local providers and communities in which theprogramme was delivered. As illustrated by the followingquotes, for all providers, the mana tangata of the consul-tants—Hineamaru and Sandra—was pivotal in theirdecision to be a part of the journey in delivering ‘MyHome is My Marae’:

The key is the relationships- and Hineamaru is the keyfor us and if it wasn’t for Hineamaru then we wouldn’thave taken part in this programme… ACC is lucky tohave Hineamaru.

Everything we did we did through Sandra. Sandra was theconduit between ACC and us. We liked that it wasSandra, she was a great go to person, she understood usas M�aori.

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If it was anyone other than Sandra to come and speak tous we would have said ‘no, it’s not worth it’…Sandra istrusted by us and she completed the training which wasabsolutely vital, she came back to the marae and didextra training—so that’s one-to-one going that extra dis-tance. That person is accountable to her marae, herwh�anau and to the [provider organisation].

Kaik�orero advocated that it is also vital to have “theright mix of providers and the right type of peoplechosen to go into the homes” to support wh�anauengagement. As described by one kaik�orero, the ‘MyHome is My Marae’ approach works because “The rela-tionships and partnerships with wh�anau and communityare at our level—they are ours.”Kaimahi observed a deep suspicion of government

agencies among M�aori communities, some of whom are“still fighting for the return of land—their distrust ofgovernment agencies [is high].” As such, ACC was notperceived by providers or wh�anau as a socially or cultur-ally appropriate vehicle for the delivery of messagesabout home safety to wh�anau:

The perception of wh�anau is that the main agenda ofACC is to get wh�anau back into work after suffering injur-ies. Therefore, wh�anau are resistant to a relationship withACC, whereas wh�anau have relationship with us as provi-ders and as members of their community.

This distrust of ACC may also stem from poor previousexperiences with claims processes4 and meant thatkaimahi had to take time for whakawhanaungatanga:meeting, connecting, explaining the kaupapa and assur-ing wh�anau that kaimahi were there for the rightreasons.The providers enabled wh�anau engagement because

kaimahi were local M�aori, carrying local knowledge,speaking the right language, were personally connectedto wh�anau through whakapapa and their residence inlocal communities and had the passion and integrity todeliver messages to wh�anau in a way that is mana enhan-cing; showing wh�anau that they are valued and caredfor.Kaimahi offered the programme unique character-

istics that could not be replicated or reproduced directlyby M�aori who were not k�anohi kitea, or by ACC as anorganisation. These characteristics were man�akitanga,local knowledge, community connection through whaka-papa and local language:

If you don’t know the wh�anau then you will get the doorshut in your face! So having the relationships and trustwith our wh�anau is important. We knew them throughwh�anau and social circles and that’s why the programmewas acceptable.

Kaimahi have to be skilled in engaging with our localpeople. You have to speak their language and be a local.They will ask if you are a local, and if you say no, thenyou will be lucky if they talk to you. They want a

connection and we have had to work at building this con-nection for many years.

As providers we all have the passion so we thrived doingthis programme.

K�anohi-ki-te-k�anohiA unique part of the ‘My Home is My Marae’ approachwas that it took place in the whare of wh�anau. This is asignificant departure from previous approaches under-taken by ACC and providers and is fundamental to theapproach being ‘kaupapa M�aori’ as it allows forface-to-face engagement and whakawhanaungatangawith wh�anau: “This is not just about the project, this isabout creating conversations and talking with ourpeople within the home.”While reflecting on how health or injury prevention

messages were delivered to wh�anau previously, onekaik�orero commented that:

[Before] it was health promotion stuff, standing at asports event, handing out panui, having w�ananga.Wh�anau will be picky and come and not retain anythingat all. It wasn’t very effective. It was a waste of resources.You never really had the opportunity to engage with thewh�anau and see what it actually looked like at theirwhare. Pamphlets were only given—that’s what it used tobe like.

In contrast, ‘My Home is My Marae’ gave kaimahi theopportunity to engage with wh�anau more meaningfullyk�anohi-ki-te-k�anohi in their whare. Kaimahi were grate-ful for and humbled by this opportunity and recognisedthe value in connecting with wh�anau to create oppor-tunities for further work in promoting their health andwell-being:

The project gave us a reason to go into the homes andmeet with wh�anau. We cannot just go into the homesand look around and inspect as this is disrespectful. Thisproject has enabled us to go into the homes and talkwith our [wh�anau] and say we are doing this project, [weneed] your help and this is the understanding of thisproject and why we are here.

However, not all wh�anau were receptive to theface-to-face approach within their whare. Some requiredassurance from kaimahi or preferred to engage withindifferent community settings beyond the home such asthe marae. Reportedly, however, k�anohi-ki-te-k�anohiwas generally of preference to wh�anau and was particu-larly advantageous when engaging with wh�anau whoneeded assistance to complete surveys or checklists. Theapproach was also of particular value to wh�anau whensomeone close to them had experienced an injury inthe past:

The wh�anau enjoyed having us in their whare and wereopen to the project due to someone in their wh�anau(especially their kaumatua) having a fall. The k�orero was

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the wh�anau were extremely grateful to have this oppor-tunity because the dangers or the awareness of dangersin the home have been looked at for their homes.

K�anohi-ki-te-k�anohi repeatedly allowed for (1) kaimahiand provider organisations to better engage and connectwith wh�anau, (2) kaimahi to develop a deeper under-standing of the circumstances, home safety hazards andother health issues occurring in the homes of wh�anauand subsequently to (3) be more responsive to theunique needs and circumstances of wh�anau, and tohazards in the home (increased responsiveness).

Capacity building for kaimahi and wh�anauBuilding capacity among kaimahi and wh�anau was a keystrength of the ‘My Home is My Marae’ approach andhas occurred in two key ways: increasing the capacity ofkaimahi through a train-the-trainer or tuakana-teinaapproach to training; and empowering wh�anau toaddress hazards through changes in their knowledgeabout hazards in the home.Training was delivered to kaimahi to complete home

safety audits collaboratively with wh�anau. Kaik�orero indi-cated that training was highly valuable in providingkaimahi with the knowledge they needed. During thetraining, kaimahi “looked at the principles of the pro-gramme and had to familiarise ourselves with itsresources. We also had to become competent and confi-dent within ourselves and the kaupapa first.” This illus-trates the professional and spiritual journey kaimahitook to learn and apply their new knowledge to makehomes a safer place for wh�anau. The spiritual aspects oftheir work became more pronounced as kaimahientered the homes of wh�anau and became aware of themany hazards and other challenges wh�anau mayencounter in their daily lives. Observing poverty wassomething that kaimahi carried spiritually as they soughtto support and empower wh�anau with needs that oftenfell beyond the scope and resources of ‘My Home is MyMarae’.The tuakana-teina model supports sustainability of the

‘My Home is My Marae’ approach not only by equippingkaimahi with knowledge around reducing hazards in thehome, but also by building leadership and capacityamong wh�anau and rangatahi. As explained by onekaik�orero:

The good thing about it is that we are not only talkingabout the awareness with just the mothers and fathers,it’s with the kids—the mokopuna, koroua, and kuia. Sothis has shown the togetherness and connectedness ofthe wh�anau and it has created a wider awareness and agreater involvement of the dangers within the home.

Observing the impact their work had on wh�anau wasinspiring for kaimahi. Although measurement ofchanges in knowledge or awareness among wh�anau wasout of scope of this evaluation, kaimahi reported

observing that the approach created awareness amongwh�anau about hazards in the home:

Wh�anau didn’t realise the potential consequences of thehazards in their homes because it had never beenexplained to them. They never thought about hazardsbecause it is the ‘norm’ in wh�anau homes (that is, it isnormal to have these ‘hazards’ in the home as they arenot perceived nor recognised as hazards). So this pro-gramme was great in that sense that it explained whathazards are and created this awareness for wh�anau. It wasan eye opener for wh�anau about potential hazards intheir homes.

The upskilling of wh�anau promoted tino rangatira-tanga in protecting whakapapa. This capacity building ofwh�anau also meant that the providers could “call onwh�anau that we already have engaged to do the mahiand be facilitators of the programme. They are applyingthis teaching and these practices within their homes.”The approach aimed to be inclusive of all wh�anaumembers, from tamariki to t�unohunohu, who couldtake action to minimise, eliminate, isolate or reducehazards.

‘Low or no cost’ solutions to hazards in the home‘My Home is My Marae’ is predicated on implementing‘low or no cost’ solutions to hazards in the home.Comments from wh�anau captured in project documen-tation stated that “financial costs were the greatestbarrier to change” (Tamaki Makaurau M�aori Women’sWelfare League, 2016). The ability for wh�anau to reducehazards in their home with little or no financial cost wasa key strength of this approach, particularly whenaddressing hazards in low-income households.Hazard auditing in Far North whare showed that 76%

of the hazards identified and recorded in the whare ofwh�anau could be resolved through ‘low or no cost’ solu-tions (368 of 481 hazards). 23% of the hazards encoun-tered could not be resolved through low or no costsolutions (113 hazards). These unresolved hazardsrequired a high-cost solution such as plumbing andelectrical work (16% or 79 of 481 hazards), otherunspecified solutions (6% or 30 of 481 hazards) or hadno solution identified (1% or 4 of 481 hazards).Unfortunately, these data were not available for SouthAuckland.

DISCUSSIONThis evaluation explored critical success factors of ACC’s‘My Home is My Marae’ injury prevention approachand identified mana tangata and man�akitanga,k�anohi-ki-te-k�anohi, capacity building and the imple-mentation of ‘low or no cost’ solutions as integral to theapproach and engagement of wh�anau and/or M�aoricommunities. The evaluation also aimed to understandthese factors in the context of what is known to work

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well for M�aori in injury prevention, and M�aori modelsof health and well-being.Having the ‘right people’ to support and deliver ‘My

Home is My Marae’ extended from strong M�aori leader-ship at ACC who facilitated buy-in from provider organi-sations, to frontline staff who were locally informed,present and connected. As trainers, advocates and keyconduits between ACC and M�aori providers, M�aorileaders at ACC are a key support system for kaimahi.Coggan et al14 emphasise the importance of strongM�aori support networks and cultural competency ofproject co-ordinators. Their evaluation of the WaitakereCommunity Injury Prevention Project highlighted thepivotal role the M�aori Coordinator played in buildingstrong support networks for the project at the localmarae. The current evaluation showed that without keyM�aori representation at ACC, providers would have beenreluctant to participate. The networks, relationships andtrust that the injury prevention consultants were able toleverage to secure provider involvement in ‘My Home isMy Marae’ were a key strength of this approach.However, this same strength also presents a challengefor the future growth of ‘My Home is My Marae’.Increased M�aori representation at ACC is needed toenable succession planning, growth and increased sus-tainability of the approach.Beyond M�aori leadership, kaimahi—equipped with

their care and passion for communities, and local knowl-edge, language and connection—delivered home safetymessages with credibility. A previous evaluation of theNg�ati Porou Community Injury Prevention Project high-lighted the importance of staff having strong communityties.15 The project involved working with a rural M�aoricommunity in the North Island to deliver road safetycampaigns, alcohol and drug programmes and familyviolence initiatives. It connected with M�aori(k�anohi-ki-te-k�anohi) in hui at various local settings suchas marae, M�aori immersion schools and sports clubs andachieved a significant increase in awareness of injuryprevention among participating wh�anau: (pre 17% andpost 25%, p>0.05). Post-intervention, wh�anau were morelikely to agree that alcohol-related injuries are prevent-able (pre 2%, post 10%). Evaluators positioned theestablishment of strong community ties as pivotal to theproject’s success.15

Through local M�aori providers, the delivery of homesafety messages for ‘My Home is My Marae’ reflects a ‘forand by M�aori’ approach that enhances wh�anau engage-ment and importantly assists in (re)building ACC’s rela-tionship and reputation with M�aori communities. This isparticularly significant given the distrust of ACC amongM�aori communities.4 A systematic review by Klassenet al16 showed that injury prevention programmes aregenerally more effective when they are tailored to addressunique community characteristics, such as ethnicity andsocioeconomic status. The ‘My Home is My Marae’approach achieves this through localisation of M�aori pro-viders with strong community ties, but provides nationally

standardised ACC resources (eg, checklist and teachingaids). This evaluation identified an opportunity for injuryprevention initiatives to authorise tailoring of resourcesto address unique community needs, effectively (1)increasing provider autonomy to develop or amendresources, and further (2) supporting increased visibilityof provider organisations (eg, through incorporation ofprovider organisation branding).Brewin and Coggan15 also attributed the success of

the Ng�ati Porou Community Injury Prevention pro-gramme to how the project addressed M�aori aspirations.While ‘My Home is My Marae’ creates strong communityties through the contracting of frontline delivery to localM�aori providers, the approach fails to connect with/address higher level M�aori aspirations for improved well-being and reduced health inequities experienced byM�aori communities. A focus on ‘low or no cost’ solu-tions enables wh�anau to address minor householdhazards in an affordable way. However, broader socialcauses impacting the state of housing and health andwell-being of wh�anau are not addressed within the scopeand resources for ‘My Home is My Marae’. Observationsof poverty and poor housing states experienced by somewh�anau are carried on the wairua of kaimahi whom,beyond their contracted roles, continue to act as advo-cates for wh�anau to have high costs hazards and/or sub-standard housing addressed. Typically, this requires theattention and involvement of stakeholders outside thewh�anau (such as landlords) and support for wh�anau tonavigate government agencies.Through home safety auditing, kaimahi aimed to

increase wh�anau knowledge of hazards in their whare sothat these can be effectively reduced, isolated or elimi-nated (‘capacity building’). This multifaceted approachto intervention addresses behavioural (knowledge andawareness of wh�anau to reduce or eliminate hazards)and environmental (changes made in whare) dimen-sions. This reflects, to some extent, a more holisticapproach to health that better aligns with M�aoriapproaches and understandings of health and well-being. Towner and Doswell’s research1 was not specificto wh�anau, but highlighted the importance of stimulat-ing cultural change through a mix of environmentaland behavioural intervention for injury prevention. Thatis, community-based injury prevention efforts shouldaim to create/build knowledge, but also act on knowl-edge or create environmental changes. A New Zealandstudy17 that measured falls at home requiring medicaltreatment (per person, per year) attributed environ-mental changes in homes, including the fastening of“handrails along outside steps and internal stairs, grabrails for bathrooms, outside lighting, edging for outsidesteps, and slip-resistant surfacing for outside areas suchas decks and porches” (p. 231), to a 26% reduction inthe rate of injuries caused by falls at home per year.Cherrington and Masters18 provided a review of M�aori

models of health in previous work prepared for injuryprevention at ACC and identified three models—Te

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Whare Tapa Wh�a, Ng�a Pou Mana and Te Wheke—whichare regarded as emulating tikanga practices.Cherrington and Masters identified common features ofmodels and frameworks to be a focus on holisticapproaches and “acknowledgement of wairuatanga (spir-ituality) and wh�anau (family)” [ref. 18, p. 2]. Drawingfrom these M�aori models of health, ‘My Home is MyMarae’ takes a preventative approach that is wh�anauinclusive (reflecting the hauora of the wh�anau), wh�anauempowering (improving knowledge and awareness ofwh�anau to reduce, eliminate or isolate hazards in theirwhare), environmental (making changes in the home—te oa turoa) and physical (reducing the risk or incidenceand/or severity of injury in the home—te taha tinana).The aim of empowering and motivating wh�anau is par-ticularly aligned to dimensions of te taha wh�anau(family well-being) and whanaungatanga (the extendedwh�anau and social interactions).From previous research, we concluded that the ‘My

Home is My Marae’ approach aligns well with what isknown to work for M�aori in injury prevention for severalaspects including leveraging strong community ties,being whanau inclusive, creating and sharing aware-ness/knowledge, maintaining strong M�aori leadershipand delivering a multifaceted intervention which simul-taneously addresses environmental and behaviouraldimensions (educating and acting). Key challenges andopportunities for the future development of ‘My Homeis My Marae’ identified in this article include increasedM�aori leadership at ACC, resourcing to address Maoriaspirations of ‘My Home is My Marae’ and tailoring ofresources to address unique community needs.There were some limitations to our Kaupapa M�aori

evaluation of ‘My Home is My Marae’ trials. In manyinstances, kaimahi shared the perspectives or experiencesof wh�anau, but the evaluation did not involve the directparticipation of wh�anau who had completed home safetyaudits alongside kaimahi. In addition, provider organisa-tions that participated in this evaluation were selected byACC and it is possible that provider organisations notinvolved in the evaluation could have had differentexperiences that were not captured. While low or no costsolutions used in this programme were identified aspotentially highly cost-effective for ACC, a specific cost–benefit analysis was not carried out—this may be a direc-tion for future research. Finally, incomplete quantitativedata in Excel spreadsheets meant that it was not possibleto draw robust conclusions regarding the reach of theprogramme and also presented difficulties in being ableto compare different patterns in the hazards identifiedacross Far North and South Auckland regions.

CONCLUSIONS‘My Home is My Marae’ is a multifaceted approach tointervention that addresses behavioural (knowledgeand awareness of wh�anau to reduce or eliminatehazards) and environmental (changes made in whare)

dimensions. The M�aori leadership and mana tangata ofACC’s injury prevention consultants acting as conduitsbetween ACC and provider organisations, and securingprovider’s engagement, were key strategic factors forsuccess. Programme delivery by local M�aori organisa-tions provided the opportunity to integrate injury pre-vention in other health promotion activities by theseorganisations; facilitating a holistic rather than isolatedresponse to wh�anau needs.‘My Home is My Marae’ reflects a holistic approach to

injury prevention which (to varying extents) aligns withM�aori tikanga and M�aori models of health and well-being—specifically in that the approach is wh�anau inclu-sive (reflecting the hauora of the wh�anau), wh�anauempowering (improving knowledge and awareness ofwh�anau to reduce, eliminate or isolate hazards in theirwhare), environmental (making changes in the home—te oa turoa) and physical (reducing the risk or incidenceand/or severity of injury in the home—te taha tinana).Injury prevention or health promotion approaches thatseek to engage with wh�anau and/or M�aori communitieswould benefit from realising critical success factors of‘My Home is My Marae’.

Acknowledgements The authors express a deep appreciation to kaik�orerofrom provider organisations who contributed to this evaluation k�orero—fromManagement to kaimahi who deliver the approach in the whare of wh�anau.Your passion and enthusiasm to support wh�anau is an inspiration to theevaluation team and an asset to ACC and M�aori communities. They also thankwh�anau who so courageously let kaimahi into their homes to tackle hazardshead on and make changes for the safety of our wh�anau—kuia, kororua,p�akeke, tamariki and mokopuna. Heoi an�o kia ACC m�o o koutou tino tautoko Ite nei kaupapa whakahirahira “Ko t�oku kainga, t�oku marae”. Kia ora an�o ACCm�o o koutou tautoko I tenei waitara me te whakanui I te kaupapa. No reira, hemihi mahana an�o kia t�atou katoa.

Contributors This article has been principally developed by the Research andEvaluation Office of Ko Awatea, Counties Manukau Health: BH, DM, LL andLV. ML also contributed to the article development. AE-H of OTS Consultingwas the Kaupapa M�aori consultant for this evaluation. BH managed theevaluation process including the development of participant documents, dataanalysis, evaluation reporting and partnerships with stakeholders. ML was theinterviewer for the evaluation and also contributed to the development ofinformation sheets, co-analysed interview data and reviewed evaluationreporting. LV developed the evaluation framework in partnership with ACC andreviewed evaluation reporting. DM drafted the paper and analysed home auditdata. AE-H provided cultural knowledge and support as a kaupapa Maoriexpert and ensured integrity of information sheets, evaluation processes andevaluation reporting. LL reviewed all evaluation documents.

Funding The kaupapa M�aori evaluation of ‘My Home is My Marae’ was fundedand supported by the Accident Compensation Corporation (ACC),Wellington, New Zealand. Views and/or conclusions in this report are drawnfrom the analyses of evaluation data completed by Ko Awatea’s Researchand Evaluation Office (Counties Manukau Health) and may not reflect theposition of ACC.

Competing interests The authors declare that they have no competinginterests.

Ethics approval Ethical approval to conduct this evaluation was granted byThe ACC Ethics Committee. The ACC Ethics Committee is made up of a mix ofACC staff and external representatives who review ACC’s research methods toensure the rights and interests of ACC clients and stakeholders are protected.All participating kaik�orero provided written informed consent to participate inthis evaluation.

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Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement ‘My Home is My Marae’ data are not available fromKo Awatea. Interested parties should refer to ACC with data requests. NewZealand injury data are publically available from http://www.acc.co.nz/about-acc/statistics/.

Open Access This is an Open Access article distributed in accordance withthe Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, providedthe original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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