cultural literacy !

Intimate Partner Violence: Modifying an Internet-Based Safety Decision Aid

to a New Zealand Context

AMANDA M. YOUNG-HAUSER University of the Free State (UFS), Bloemfontein, South Africa

KAREN B. EDEN Oregon Health & Science University, Portland, Oregon, USA

DENISE WILSON and JANE KOZIOL-MCLAIN Auckland University of Technology, Auckland, New Zealand

Women experiencing intimate partner violence face complex deci- sions in navigating their safety. In a feasibility study, we examined the suitability of an intimate partner violence interactive online decision aid developed in the United States for its application in New Zealand, particularly with regard to cultural appropriateness. We conducted focus group sessions with women who experienced partner violence and focus group sessions with service providers. Women completed the U.S. online decision aid tool and provided feedback on the safety decision criteria, content, and design. Con- sidering the findings from the focus group sessions the decision aid was modified. We reflect on the process of balancing women’s stor- ies with technical limitations and constraints of a replication study.

KEYWORDS computer-assisted decision making, cultural appro- priateness, domestic violence, focus group, internet, intimate partner violence, usability inspection

Received February 24, 2014; accepted July 8, 2014. Address correspondence to Amanda M. Young-Hauser, Department of Sociology, Faculty

of the Humanities, University of the Free State (UFS), Bloemfontein, South Africa. E-mail: [email protected]

Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wths.

Journal of Technology in Human Services, 32:297–311, 2014 Copyright # Taylor & Francis Group, LLC ISSN: 1522-8835 print=1522-8991 online DOI: 10.1080/15228835.2014.967905

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Safety planning is the most widely recommended intervention for women who experience intimate partner violence (IPV; Davies, Lyon, & Monti-Catania, 1998; Hardesty & Campbell, 2004; McFarlane et al., 2004). The challenge is to provide women with the knowledge, skills, and tools to plan and implement a safety plan tailored to their complex situations. A woman’s considerations may include access to safe housing, financial resources, social support, custody of children, and maintaining confidentiality (Glass, Eden, Bloom, & Perrin, 2010). Help-seeking behaviors often depend on whether women who experience IPV recognize their experience of abuse or violence as ‘‘serious,’’ or that it is negatively impacting on their children (Fanslow & Robinson, 2010; Glass et al., 2010). An Internet-based decision aid tool was recently developed in the United States to help women plan for safety and seek community resources (Glass et al., 2010). Interacting with an online program allows women the opportunity to explore their situation at a convenient time and safe place, and without the need to disclose their situ- ation to another person until they choose to do so. In preparation for a rep- lication study of the U.S. decision aid in New Zealand, focus group sessions were carried out to examine the extent of modification needed to provide women in New Zealand with a quality and culturally appropriate tool.

DECISION AID TOOL

Glass and colleagues (2010) developed a unique online Internet-based decision aid tool to help women plan for their own safety and their children’s safety, and to decrease exposure to repeat IPV. The tool includes three com- ponents: a safety priority setting activity, an assessment of risk (Danger Assessment) and an individualized safety action plan. Originally, decision aids were designed to facilitate ‘‘close-call’’ health treatment or screening decisions that involve the consideration of benefits, loss, and uncertainty (O’Connor, Bennett, Stacey, & Barry, 2009; Stacey, Bennett, & Barry, 2011). In the broad- est sense, decision aids facilitate decision-making processes in conflicting situations by providing alternatives and assisting in planning the next steps.

The decision aid designed for women in the United States included an activity to help women set priorities for safety. This safety priority setting activity is based on a multicriteria decision model (Glass et al., 2010). The women indicated the importance of the following five components: (a) having resources (includes employment, housing, and safe childcare); (b) keeping privacy (includes the priority to keep relationship issues private from family, friends, work, and community resources); (c) feelings for partner (includes feelings of love and concern for partner); (d) concern for own safety (includes physical, emotional, and spiritual safety); and (e) child’s or children’s well- being. Using a sliding bar, women made pairwise comparisons (Figure 1) to determine the relative importance in the context of their personal lives.

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The decision aid was developed as on online tool, recognizing that dis- closing abuse is a major challenge (Spangaro, Zwi, Poulos, & Man, 2010). Safety advocates testing the online-computerized decision aid in the United States commented that it provided ‘‘a sense of privacy not always found with even the most supportive person’’ (Glass et al., 2010, p. 1954). While the intent of the computer-based decision aid is to reduce women’s decisional conflict related to an abusive relationship and to increase safety-seeking behaviors that lead to reduced exposure to violence and improved well-being, women need to be able to access the tool in a safe place. The decision aid’s preamble stresses the importance of selecting a safe environment (e.g., accessing the decision aid on a computer located in a space away from the abusive partner). The preamble also provides information on how to clear the cache account in the computer. The emergency exit bar that extends across the computer screen allows for instant withdrawal from the online tool.

THE NEW ZEALAND CONTEXT

The decision aid was developed for a North American population and trans- lated into Spanish to serve the Hispanic population (Glass et al., 2010). We would not assume that the tool would necessarily be appropriate for women living outside the United States. New Zealand has a unique history with the settler’s culture regarded as ‘‘dominant by power, history and majority,’’ while the ‘‘Māori [indigenous] culture is dominant by a longer history, by legacy and by its strength of survival’’ (Ritchie, 1995, p. 6). The Treaty of Waitangi is the founding document that defines the relationship between the Crown and

FIGURE 1 Screenshot of a sample pairwise comparison.

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New Zealand’s indigenous population, making it imperative to ensure that we considered Māori women’s needs with regard to the decision aid. Both crime victim surveys and population based surveys in New Zealand indicate over- representation of Māori women in IPV statistics (Fanslow & Robinson, 2010; Koziol-McLain, Rameka, Giddings, Fyfe, & Gardiner, 2007; Morris, Reilly, Berry, & Ransom, 2003). Haaken (2010) considers this overrepresentation a consequence of colonization, commenting that it ‘‘cuts deeply into the tissue of everyday life’’ (p. 39) and impacts on indigenous populations globally, with New Zealand being no exception. Colonization and racism together have eroded traditional social and family structures and, along with poverty, urba- nization and other determinants of health, disproportionally affect Māori in New Zealand (Kruger et al., 2004).

Although biculturalism signifies the relationships with Māori, New Zealand has become increasingly ethnically diverse over time. Among the 4.4 million people living in New Zealand, the population census showed that 2,609,589 people identified as European; 565,329 as Māori; 265,974 Pacific Peoples; 354,549 Asians; and 34,746 Middle East=Latin America=Africa (Statistics New Zealand, 2006). There is agreement that communicating pro- grams in a culturally appropriate manner can be more effective when tailored to the population they serve (Sanders Thompson, Cavazos-Rehg, & Jupka, 2008). To promote health programs in culturally appropriate ways, Kreuter and colleagues (2003, p. 135) proposed five strategies. The strategies seek to package materials or programs ‘‘in ways likely to appeal to a given group’’ (Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2003, p. 135); refer to epidemiological data relevant to a specific population; use the lan- guage of the target group; draw on the experience of the target group; and consider the wider sociocultural context of the specific group. The challenge was to modify the decision aid in a manner that the tool appeals and is useful to all women in New Zealand. In particular, we considered the needs of Māori women. As collective people, their intimate relationships are ‘‘developed and constructed within the relational, cultural, social, historical and political con- texts’’ (King, Young-Hauser, Li, Rua, & Nikora, 2012, p. 94). This became also evident in discussions with Pasifika women whose couple relationship was enmeshed in complex extended family dynamics.

The Internet is considered an important source of information and has become an essential resource for many New Zealanders. Internet access is increasingly commonplace in homes and workplaces in New Zealand (Statistics New Zealand, 2006). According to the World Internet Project, 83% of New Zealanders use the Internet (Smith, Smith, & Sherman, 2009). However, it is important to note that not everyone has Internet access, with nonusers more likely to be in the older age group or lower income group (Smith et al., 2009). Those living in urban areas spend more time online compared to those living in rural areas. In addition, people with a higher income rated their ability to use the Internet as superior than those with lower incomes. Smith and colleagues

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(2009) also observed that fewer Māori and Pasifika people used the Internet at home (80% compared to 95% of Europeans and Asians; Smith et al., 2009). However, the use of cell phone amongst the Māori population (72%) is higher than for the non-Māori population (62%), particularly for Māori between the ages of 15 and 24 (Te Puni Kōkiri, 2010).

PURPOSE OF THE STUDY

This article is based on a feasibility study carried out in preparation for testing the decision aid in New Zealand. The purpose was to test the decision aid from a user’s point of view for its utility, satisfaction, and aesthetics. We exam- ined the extent of modification needed to make the tool culturally appropriate and meaningful to women in New Zealand. In particular we sought to gain an understanding of cultural appropriateness from our participants’ points of view. Focus group sessions were conducted and the resulting conversations shaped our understanding of cultural appropriateness. The sessions also served to explore diverse ethnic understandings and needs of IPV-related issues. Specifically, cultural appropriateness was seen to encompass language appropriate to New Zealand; a design to reflect a New Zealand identity; and examples that represent New Zealand women’s experiences of domestic viol- ence. This article summarizes the findings of the focus group sessions. We dis- cuss the balance required in order to incorporate these findings to modify the U.S. decision aid into a New Zealand specific tool. We also consider technical limitations and the constraints of a replication study.

METHOD

To examine the suitability of this online safety decision aid for women in New Zealand, we conducted focus group sessions. As an assessment of end-user usability (Bias, 1994) and utility (Jónsdóttir Johannessen & Hornbæk, 2013) participants included women who worked as IPV-related service providers, and women who experienced physical, sexual, and psychological or emotional abuse by a partner (male or female). The concept of usability inspection involv- ing end-users to use the interface (Bias, 1994; Nielsen, 1994) and to provide feedback on the design, usability and utility informed the research design. Participants were 16 years of age or older. To recruit participants we drew on an existing network of service providers who connected us with potential part- icipants. The participants were contacted by phone and the first author told them about the opportunity to enroll in the study. During the call the first author also screened whether the participant (and children) would be safe during the study.

The University’s Ethics Committee approved the research. Focus group sessions were conducted in a University’s computer lab and in the office of a nongovernmental organization. Transport was provided where necessary

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and a child care service was offered. Following consent and the gathering of demographic data, the focus group sessions included two activities. The participants used a demonstration version of the decision aid. They completed baseline measures (Table 1), and were provided a safety plan. Supplied with paper and pen, participants took notes of impressions, thoughts, ideas, ques- tions, and concerns that arose during their use of the decision aid. During the second activity, participants discussed their experience of using the decision aid, their impressions of the decision aid’s usefulness, design, user friendliness, and the value of the priority-setting activity. Conversations were digitally recorded and transcribed verbatim by the first author who supplemented the data with field notes taken during and immediately following the focus group sessions. Drawing on Corbin and Strauss’s (2008) analytic tools and on Braun and Clarke (2006), the first author identified, grouped, and documented themes within and across focus groups to examine and analyze the responses. During a weeklong workshop in New Zealand attended by nine local and international collaborates (including experts in IPV in New Zealand, a Māori cultural advisor, a computer expert, a statistician, and the U.S. decision aid developer) the results of the content of the focus groups were reviewed. The group discussed the con- tent of the U.S. safety decision aid screen-by-screen for face validity by users in New Zealand. The team worked on the process of interpretation and fairness that balances all stakeholders’ views and concerns (cf. Lincoln, Lynham, & Guba, 2011, p. 122). We used pseudonyms to protect participants’ identities.

FINDINGS

We undertook seven focus group sessions; five with women who had experi- enced IPV in the past (N¼14) and two sessions with service providers (N¼6). Sessions were stopped when we reached saturation (few new themes were emerging). We noted that some service providers also disclosed a history of abuse, affording them a dual role. The overall participants’ age

TABLE 1 Scales used in the Decision Aid

Mental health outcomes . CESD-R (Depression Scale) . PCL-C (PTSD Checklist - Civilian Version) . AUDIT (Alcohol Use Disorders Identification Test) . DAST (Drug Abuse Screening Tool)

IPV exposure . SVAWS (Severity of Violence Against Women Scale) . WEB (Women’s Experiences With Battering)

Decision process and safety seeking behaviors . Decisional Conflict Scale . Safety Checklist

Risk assessment . Danger Assessment (Risk factors for intimate partner homicide) . Danger Assessment–R (For women in same-sex relationships)

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ranged between 16 to 63 years. The mean age was 40.75 years: 50.83 years for service providers (age range from 25 to 63; Table 2), versus 36.43 years for women who experienced abuse (age range 16 to 60 years; Table 3). All service providers’ first language was English and they rated their English proficiency as excellent. English was not the first language for two women who experi- enced IPV (Table 3); they rated their English proficiency as good and very good. Only one participant (woman who experienced IPV) had minimal com- puter skills and did not have an e-mail address.

Overall, participants commented positively on the decision aid. In terms of usability, two technology features were considered outstanding: the emergency exit area that extends across the width of the computer screen; and the ability to exit the website and resume the decision aid at a later stage.

We noted distinct patterns between the comments made by the service provider and the women’s focus group sessions. The former discussed the decision aid more analytically and critically, while the latter drew on recent personal experiences of IPV, which they brought into the discussions. The fol- lowing core themes emerged: length of decision aid and emotional reaction to questions, children’s safety plan, validating individual experiences of IPV to include both physical and psychological abuse, and language and design.

Length of Decision Aid and Emotional Reaction to Questions

Service providers considered the length and content of the decision aid to have a potential impact on women’s emotional and psychological well-being. They proposed pop-up banners with positive encouragements and to enlist the support of a friend or advocate while doing the decision aid. The women did not echo these concerns, even though some experienced the decision aid as lengthy and tiring. ‘‘I think that’s the key the thoroughness, it is hugely hol- istic, it covers lots of different things’’ suggested Mahia. The comprehensive decision aid resulted in a ‘‘wake-up call’’ (Beth) and a ‘‘reality check’’ for Abbey that ‘‘make[s] you think what you are doing to yourself.’’ Abbey and Beth considered this process as painful but necessary realization that set the context for the violence in their relationships.

Two women left the room to take a cigarette break while doing the decision aid. Abbey was only halfway through the tool when she stopped

TABLE 2 Age, Ethnicity, and First Language of Service Provider Focus Groups

Age Ethnicity First language

63 NZ European English 25 NZ European=Filipino English 48 NZ European English 60 Māori English 62 NZ European English 47 NZ European English

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because: ‘‘It makes you reflect on everything you have done, and everything that is happening. It’s like a light bulb doing this [the decision aid].’’ Doing the decision aid also evoked memories of Abbey’s violent upbringing. She referred to her own violent outbursts of ‘‘yelling, swearing, throwing things around’’ that now are reflected in her young daughter’s conduct.

Emotional reactions varied in intensity across the different assessments. The ‘‘Drag to calendar’’ exercise (Figure 2) in which women are asked to indi- cate discrete abusive acts and their severity (slap, punch, or beating, for example) on a calendar (Campbell, Webster, & Glass, 2008) evoked mixed feel- ings. Some participants (service providers and women) suggested the calendar to be too emotional to recall individual instances of violence. Leigh left some questions unanswered because she was not ready ‘‘to go there.’’ Despite invok- ing unpleasant memories Aileen liked the calendar:

That was, yep, it brought back memories, because it has been two years since I have left my abusive husband, but that brings up things. You know, in these past few weeks actually I have been reverting back to the guilt and back to the feeling sorry for him etc., slightly, not in a big way. And I think this has been really good for me because it has brought back the reasons why I couldn’t stay, really strongly. It has been good.

Most women underestimated the danger they were exposed to and scored high on the risk assessment (cf. Glass et al., 2010). Aileen captured other participants’ experiences of violence that has been normalized:

I am shocked at the severity rating scale because I think that you just tend to learn to live with a lot of things if you have been in an abusive relation- ship for a long time. You don’t realise how serious it is.

TABLE 3 Age, Ethnicity, First Language and Children of Women’s Focus Groups

Age Ethnicity First language Children at home Age of children

37 Māori=Samoan English 1 1 year 6 months 22 NZ European English 1 5 years 41 Chinese Mandarin=Cantonese 1 5 years 41 Korean Korean 1 1 year 4 months 16 NZ European English 0 N=A 38 Māori English 3 3, 10, 16 years 60 Māori English 0 N=A 38 Māori English 1 17 years 38 NZ European English 3 1, 11, 14 years 27 Cook Island Māori English 3 2, 9, 9 (not twins) years 28 Tongan English 2 2, 4 years 48 Māori English 1 16 years 29 NZ European= Samoan English 2 4, 10 years 47 South Africa English 2 15, 17 years

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The decision criteria brought renewed clarity to feelings of guilt and ambiguity. Earlier in the conversation Aileen offered her interpretation of ‘‘feelings for my partner’’ (in the priority setting activity, see Figure 1) as feel- ings of love: ‘‘oh yes, about feelings for partner, I think again, my impression was that they [decision aid] were talking about loving your partner despite the abuse. In my case, my feeling for my partner was guilt, really, really strong guilt.’’ This was a dimension that she felt was not captured in the decision aid. Pacific Island women in particular located IPV within the larger family and conversations uncovered complex family dynamics that added extra dimensions to IPV, the couple relationship, family pressure, feelings of guilt and shame that prevented Lavinia from disclosing the abuse. Extended families, traditional values, religion, respect for elders and marriage vows functioned to silence the women. Recounts of intrafamilial abuse and alcohol problems spoke to wider issues of domestic violence. Lavinia was critical of the decision aid because she felt that cultural factors and barriers to help seeking behaviors remained unaddressed. Raised in South Africa, Aileen also reflected on feelings of guilt, influenced by her upbringing and fluctuating in intensity over time as described earlier.

Children’s Safety Plan

Service providers considered the children’s safety plan to be too broad and the generic recommendations age inappropriate, potentially putting children

FIGURE 2 Screen shot of drag to calendar activity.

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at risk. Alternate pathways to frame children’s safety plan according to children’s age groups were proposed. Sharing similar sentiments, Aileen pro- posed that the children’s safety instructions were tailored for younger children and not useful advice for her teenage children. Beth found the plan to get chil- dren to a safe place useful, saying ‘‘I wouldn’t have thought to go through actually a step-by-step drill with my kid for violence. So those things were really helpful, because that stuff I could have done with my 14 year old.’’ A disabled child added complexity to framing children’s safety plan as in the case of Meg (service provider who experienced IPV) who said that her boy would be unable to follow her instructions.

Validating Individual Experiences of IPV to Include Both Physical and Psychological Abuse

Service providers and women considered some baseline instrument questions (see Table 1 for scales) too narrow and not reflecting the spectrum of women’s experiences of abuse. Participants debated the use of weapons other than guns (Severity of Violence Against Women Scales [SVAWS]) that have the potential to inflict harm. As a way to personalize the experience, it was suggested to ask broad questions, insert a drop-down menu that offers more examples, or offer a blank space to type unique experiences. With a focus on lethality assessment, service providers felt that psychological abuse was not well captured in the decision aid. Failing to address psychological abuse could potentially alienate women (who only experience psychological abuse) and exclude them from using the decision aid.

Language and Design

Most participants preferred the decision aid to reflect a New Zealand identity in terms of idioms, English spelling and the design. The U.S. version uses photos depicting women and women with children, photos that were con- sidered powerful and effective by most participants. Ruihi questioned the appropriateness of displaying smiling faces in a grim situation: ‘‘it [IPV] is not a happy, smiley matter, really.’’ To signify a distinct New Zealand charac- ter, it was proposed that the photos should reflect the ‘‘kind of cultural, ethnic mix that we have here in New Zealand’’ (Tina) and to include indigenous symbols in the web design, like the kowhaiwhai panels.

1

Although the literacy level was judged appropriate, some specific terms were considered problematic. Despite public campaigns to de-stigmatize mental illness in New Zealand (Vaughan & Hansen, 2004), the term ‘‘mental,’’ as in ‘‘mental health’’ used in the depression scale invoked discomfort. Ruihi explained that ‘‘from a Māori perspective one can’t be without the other so I think you kind of need to encapsulate the holistic wellness rather than specific to mental, physical, spiritual, just trying to maybe capture all.’’ Participants in

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Ruihi’s focus group suggested the use of an alternative term such as ‘‘wellness’’ or ‘‘mental well-being.’’

DISCUSSION

The purpose of the feasibility study was to explore the extent of modification necessary to make a U.S.-developed decision aid appropriate for use in New Zealand. These considerations are located within the constraints of a repli- cation study, technical matters, and financial boundaries and are the sub- stance of this article. A discussion on the dialectic of theory and application is outside the scope of this article. As we have outlined earlier, New Zealand’s population is culturally diverse and we tested a cross section of representative users. It is critical that health is responsive to Māori because of the partnership principle of the Treaty of Waitangi (Hudson, Milne, Reynols, Russell, & Smith, n.d.). The difficulty arises as to how to do justice to and best accommodate these various aspects in one tool. Participants contextualized their experi- ences through the sharing of individual stories, which were also imbued with cultural practices and understandings. This was particularly evident in the focus groups with Māori and Pasifika women. The latter group highlighted the complexity of intimate relationships where shame, guilt, substance abuse, religion, and family pressures become part of IPV. These wider problems of IPV are not well addressed in the decision aid tool where the focus is on an individual woman, and her and her children’s safety.

The main topics we gleaned from the focus group sessions can be grouped into: length and content of the decision aid and its emotional impact; children’s safety plan; validating individual experiences of IPV to include physical abuse and psychological abuse; and language and design. Some of these aspects, for example, the adaption of the language and the design, were more easily incorporated into the New Zealand version of the decision aid. Peripheral strategies, one of the five categories used by health communication researchers, seek to make materials more familiar by drawing on photo- graphs, images, colors or fonts to package the content (Kreuter et al., 2003; Sanders Thompson et al., 2008). Thus, a design that is authentic to New Zealand was adapted, which will enhance the tool’s appeal to women living in this country, while also contributing to its cultural appropriateness.

Emotional reactions to the content of the tool seem unavoidable. In a study asking women about their experience of IPV screening in the health care setting, women spoke of the screening triggering ‘‘painful memories,’’ yet were adamant that screening continue (Koziol-McLain, Giddings, Rameka, & Fyfe, 2008). However, it is our duty to minimize the impact and ensure the safety of women by offering various safety strategies. Thus, the suggestion to incorporate messages in the form of pop-ups to acknowledge the women’s courage to do the decision aid, to reassure that they are doing alright, to

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remind them to take a break, to refer to the comprehensive list of resources, to seek professional help or to enlist the support of a friend were integrated in the New Zealand version of the tool.

The decision aid offers a thorough, holistic, and lengthy assessment with the benefits experienced by the women outweighing the concerns of the service providers. It was noted that younger participants completed the decision aid faster, which may suggest well-developed computer knowledge in younger participants. While this observation is speculative—we did not examine whether participants answered all questions in the decision aid sur- veys—it is in keeping with research suggesting that younger people in New Zealand are more digitally involved and confident, and that Internet abilities are reduced in older-age cohorts (Smith et al., 2009).

The need for a carefully compiled children safety plan was substantiated by the fact that 85% of the women (who experienced IPV) had children living with them. The safety plan was revised and modified to include age-appropriate recommendations and to reflect New Zealand child care practices and policies.

All women in this study welcomed the online decision aid tool that allows women to engage with a sensitive topic in private and without the need to disclose until they decide to do so. The findings of the focus group sessions provided the platform for modifying the decision aid into a cultu- rally appropriate tool that benefits women in New Zealand. While we endea- vored to maximize the range of women’s experiences and to adapt these to an appropriate New Zealand context we have to work within the boundaries of existing scales and measurements (see Table 1). Domestic violence is not only widespread but also enmeshed in layers of complexities, including women with disabilities who experience IPV, immigrants or women with a refugee status. Women with disabilities might experience more challenges to access a safe computer, or to operate a keyboard and mouse if they have fine motor difficulties. On the other hand, immigrants or women with a refugee status might struggle with the language. At this point, the New Zealand version of the decision aid is only available in English thus assuming basic English literacy. An audio function is available in New Zealand English to render the tool linguistically appropriate (Kreuter et al., 2003) to a New Zealand context.

The focus group discussions provided rich material and illustrated the importance of tailoring an intervention to a local context, but they also cre- ated tension because of aspects and concerns that cannot be fully incorpor- ate into the decision aid. For example, women with disabilities who experience IPV often face additional challenges pertaining to accessing or doing the decision aid tool. A proposed division into a physical abuse and psychological abuse path to authenticate women’s diverse experiences of abuse would deviate too much from the U.S. version, the study that is replicated. Based on the gathered evidence, the decision aid was modified

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into a cross-culturally appropriate tool to benefit New Zealand women who experience IPV. In the next phase, the modified decision aid will be tested for its usability and utility.

FUNDING

Funding for this project was provided by the Health Research Council (11=516).

NOTE

1. Kowhaiwhai panels contain symbolic patterns to convey messages or stories.

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