FormalPara Key Points

  • Culturally grounded cancer prevention projects can be effective for men and women.

  • Dialogue between project participants can inform project enhancement.

  • Grounding projects in local communities can support project sustainability.

Native Hawaiians have populated the Hawaiian Islands since about 300 CE [1]. They descend from an ancient oceanic people, whose migration from northwestern Malaysia to Hawai‘i began as early as 1600 BCE, taking a southern course from Malaysia through parts of the south Pacific before taking a northerly course to the Hawaiian Islands [1]. From the original colony, Hawaiians established approximately 18 settlements over several centuries, populating eight major islands in the archipelago. For almost a millennium and a half, Native Hawaiians remained isolated by the Pacific Ocean, situated many miles north of established voyaging routes. When British Sea Captain James Cook, the first recorded Western visitor, arrived at Waimea Bay on the island of Kaua‘i in 1778 [2], he estimated the Native Hawaiian population numbered almost one million [3]. According to the 2000 US Census, full- and part-blooded Hawaiians comprise 19.25% of Hawai‘i’s total population of 1,244,898 [4].

Exposure to Western contagious illnesses, lifestyles, and foods has caused higher mortality among Native Hawaiians from cancer, type 2 diabetes, heart disease, and other chronic conditions, and Native Hawaiians have the shortest life expectancy among Hawai‘i’s major ethnic groups [5]. These conditions are attributed to certain barriers to seeking healthcare identified in the 1985 E Ola Mau study, which persist today—including challenges to accessing primary and specialty care, lack of availability of services including traditional healing, and the ways Native Hawaiians are treated by healthcare providers and systems [6].

In 1995, with a grant from the US Department of Health and Human Services as part of its 1990 Health Goals for the Nation, the American Cancer Society (ACS) assembled the Native Hawaiian Breast Cancer Sub-Committee. The committee, comprised of community health advocates representing a number of community agencies and individual Native Hawaiian women, facilitated efforts to increase awareness of the benefits of early detection of breast cancer.

Native Hawaiian women continue to have higher breast cancer incidence and mortality rates than any of Hawai‘i’s four other major ethnic populations (Caucasian, Japanese, Filipino, and Chinese). In addition, they have the third highest breast cancer mortality rate in the USA [7].

Developing Culturally Appropriate Health Settings

The ACS Native Hawaiian Sub-Committee conducted three focus groups with Native Hawaiian women and key informants to identify healthcare-seeking behaviors, perceived and real barriers, healthcare concerns, and possible solutions to improve health services. The results revealed barriers to care that included insensitive and inappropriate communication, lack of privacy, and poor healthcare environments. Concerns and potential solutions were organized into short-, mid-, and long-term projects, funded by the Office of Hawaiian Affairs, Longs Drug Stores, and the R.E. Black Foundation.

The short-term project involved creating medical chart reminders that read “Mammograms Due,” printed on sticky label notepads, to cue physicians to tell patients, “Your mammogram is due. Please see the nurse to schedule an appointment.”

The medium-term project consisted of four public service announcements featuring Native Hawaiian cancer survivors and using material culture (e.g., the pahu (drum)) to increase awareness of the importance of annual mammograms and early breast cancer detection.

In 2000, only 5.5% of physicians in Hawai‘i and 7% of nurses were of Native Hawaiian ancestry [4]. This suggests that healthcare might not be sensitive to the cultural customs and needs of Native Hawaiians. Therefore, the long-term project consisted of developing training for health professionals to positively influence attitudes, communication styles, and the clinic environment, to foster cultural awareness and understanding among medical professionals providing healthcare to Native Hawaiian women. The training included:

  • A 20-minute video, Caring for Native Hawaiian Women: Understanding Cultural Values in the Treatment of Breast Health, explaining aspects of Native Hawaiian spirituality, perceptions, customs, traditions, and values.

  • A manual, Ka Lōkahi Wāhine: The Healthy Balance of Women, including sections on (1) interpersonal communication, (2) creating a healing environment, (3) guidelines for simplifying communication, and (4) a glossary of Hawaiian words and phrases.

By March 2004, over 300 health professionals, including physicians, nurses, health educators, homecare therapists, and providers had received training. Native Hawaiian women involved in this effort frequently reminded the group that Hawaiian men also needed health attention. Native Hawaiian men have the highest mortality rates for lung bronchus and colorectal cancers among the five major ethnic groups of Hawai‘i. The ACS Native Hawaiian Sub-Committee, therefore, broadened its focus and negotiated a name change to the Native Hawaiian Cancer Committee (NHCC) of the ACS. With the limited funding ($5000) remaining from various grants, the committee turned its attention to the health of Native Hawaiian kāne (man/men). Since then, a group of dedicated individuals and organizations, including community physicians, the University of Hawai‘i Cancer Center, the Department of Health, Ke Ola Mamo (Oahu’s Native Hawaiian Health Care System), and the ACS, have worked to improve the health and wellbeing of Native Hawaiian kāne.

Many of the chronic health challenges facing Native Hawaiian men, such as type 2 diabetes, cardiovascular disease, and certain cancers, result from systemic inequalities that prevent doctor visits and deprioritize healthcare. High rates of chronic illnesses and behaviors result in higher risk of death for Native Hawaiians, particularly for Native Hawaiian men. For instance, while Native Hawaiian men have the lowest incidence of prostate cancer in Hawai‘i compared to non-Hawaiians, they have the second highest mortality rate. Currently, Native Hawaiian men have the second-highest number of cases of diagnosed advanced-stage prostate cancer compared to the general male population of Hawai‘i [8]. This suggests the need for education to promote overall health, identify cancer in its early stages, and reduce disproportionate rates of mortality among Native Hawaiian men.

Statewide Discussion Groups for Men

To understand the attitudes, beliefs, and health-seeking behaviors of Native Hawaiian men, the NHCC conducted a first round of research from October 2002 to August 2003. This involved focus groups in four geographic areas on O‘ahu, Hawai‘i, consisting of 54 Native Hawaiian male participants, ranging in age from 22 to 75. The participants discussed their attitudes and beliefs about overall health, their provider and care-type preferences when seeking healthcare, and perceived barriers to engaging in healthcare services and programs. They also expressed the critical importance of Native Hawaiian cultural values and practices to their access and acceptance of healthcare [9]. The findings highlighted the importance of creating culturally appropriate methods to protect and promote the health of Native Hawaiian men. As it considered actionable insights from the study, the NHCC transitioned from the ACS to Ke Ola Mamo, the Native Hawaiian Health Care System for the island of O‘ahu and renamed the project No Ke Ola Pono o Nā Kāne (for the good health of men), or the Kāne Project.

Developing Resources for Men

The Kāne Project developed health education resources for Native Hawaiian men based on the study findings. The NHCC was aware that Native Hawaiian men (and probably men in general) are hesitant to share personal and family concerns in group settings, especially when women are present. The NHCC was also aware that, except in limited situations, contemporary society does not support men-only talking groups. However, there are abundant examples in Hawaiian history, traditions, and culture to inform culturally tailored interventions. The concept of the Hale Mua or kāne meeting house provided an overarching framework of how to advance men’s health dialogue. Traditionally, the Hale Mua was a significant institution in Hawaiian society where men’s educational, leadership, and spiritual and religious roles and responsibilities were learned, reinforced, and passed on to future generations [10, 11]. It was also a place where kāne discussed their role in community governance and health.

In 2005, the Kāne Project created and pilot-tested its first health education module on overall Native Hawaiian male health in a series of kāne-only hui kūkākūkā (focused group dialogue sessions) patterned after the Hale Mua. The module included a video recording of Dr. Richard Kekuni Blaisdell, one of the founders of the project and an advocate for Native Hawaiian health and wellbeing. At the end of the module, kāne were asked to write down and commit to one actionable behavior they would change in the subsequent 3 months to improve their health. These commitments were collected, and, after 3 months, an NHCC team of Native Hawaiian kauka (physicians) checked in with participants about their behavioral commitments.

To adhere to the fidelity of the module and to aid in data collection across multiple sites, a large, durable flip chart was designed by NHCC male cultural advisors. As a tool to promote health education among men, the front of the flipchart contained information, questions, and cultural images viewable by participants, while the back was viewable only to the alaka‘i (facilitator) and included a script to follow. Each session also had a kōkua (assistant to the alaka‘i) and a notetaker and audio recorder.

Building Out and Scaling the Educational Model

During the pilot test and preliminary data collection, the NHCC discussed what they were learning from men during discussion sessions. Rapid feedback loops helped to evaluate the focus group process and provided a touchpoint on how well the intervention was received. Overwhelmingly, men shared their health concerns and offered each other solutions. While health dialogue was a mark of success, the NHCC knew that subsequent modules needed to include a Native Hawaiian kauka (physician) to provide an immediate response to the men’s health questions. Based on the pilot study, the NHCC scaled out the model by developing subsequent cancer-specific modules to address the high incidence and prevalence of cancer among Native Hawaiian men.

Dissemination of the Project

In 2010, the NHCC secured modest funding from the Office of Hawaiian Affairs (OHA) to develop subsequent cancer modules and a statewide dissemination plan. Informed by the pilot testing, the NHCC adopted a peer-led implementation model. Community kāne were recruited as volunteers to deliver cancer prevention interventions using a “train-the-trainer” approach. The trainers in this case were committee members from the 2008 project, who trained other Native Hawaiian men from different communities to deliver sessions. Additionally, kauka were enlisted to provide the medical expertise needed during the sessions.

In 2016, additional funding from the Hawai‘i Medical Service Association (HMSA), Hawai‘i’s Blue Cross Blue Shield insurance provider, and the Hawai‘i Department of Health’s Comprehensive Cancer Control Program facilitated extension to the islands of Lāna‘i, Moloka‘i, Kaua‘i, Hawai‘i, Maui, Ni‘ihau, and rural areas of O‘ahu. The first set of modules included topics on overall health, lung cancer, colorectal cancer, and oro−/nasopharyngeal cancer. The colorectal module also included the distribution of fecal immunochemical tests (FIT) to participants aged 50 years and older, with a small financial incentive to complete the test. Over the following 3 years, the project reached ~400 Native Hawaiian men who attended 1 of 43 educational sessions, with 79% of the 149 kāne over age 50 reporting they were up to date with colon cancer screening recommendations. The impacts of efforts to increase cancer prevention and early detection and improve the overall health of Native Hawaiian men continue [12].

Discussion-Informed Project Enhancement

As part of our cancer prevention educational activities, kāne-only hui kūkākūkā (focused group dialogue sessions) informed iterative improvement of the project’s design and delivery. Discussion topics included knowledge, attitudes, and behaviors surrounding emergent risk for illness among men and identified non-health topics of concern. During the sessions, kāne expressed the need to identify, compile, and share dwindling traditional knowledge and cultural practices. Major themes included consistent and robust dialogue about the role of kāne in the modern Hawaiian family, including building capacities as men and family leaders to transmit cultural and traditional knowledge to younger generations. Other discussions emphasized the importance of protecting the ‘āina (land) and the importance of kalo (taro) in Hawaiian culture, centered on the Hawaiian value of mālama ‘āina (to love and respect the land) and claiming stewardship. Participants viewed the loss of land stewardship as a result of Western influences, specifically the overthrow of the Hawaiian Kingdom, which prevented Native Hawaiians from growing culturally important crops such as kalo, a dietary staple. The participants discussed specific activities, such as meal preparation and healthy foods, which served to build the robust physiques of Hawaiians in former times, and the importance of maintaining balance between physical, mental, and spiritual health as a part of traditional Hawaiian culture.

Cultural Modules Added

These discussions highlighted the importance of incorporating topics of concern into the existing project. The NHCC and project staff developed cultural modules to address these emergent issues, including (1) a session on modernizing the preparation of healthy traditional Hawaiian food, or ‘ai pono (eating well), (2) a module on the traditional practice of kaula (cordage binding) to preserve knowledge of methods that were historically important in building robust infrastructure in the absence of metal, (3) a module on loko i‘a (fish ponds) that demonstrated historical sustainable eco-friendly fish farming, and (4) a module on pule (prayer) and the importance of maintaining a balance between physical, mental, and spiritual health. These new modules were contextually grounded in the theme of maintaining good health and delivered via video recordings by renowned Hawaiian cultural practitioners, capturing this cultural heritage for posterity.

Next Steps and Sustainability

In 2021, the project was renamed Kū Ola (upright and purposeful living) with guidance and support from the NHCC. With funding from the Hawai’i Community Foundation, the scope of this new project expanded, seeking to build the capacity of all Native Hawaiians to learn, incorporate, and disseminate key cultural concepts and practices as part of overall health and wellbeing. We continue to enlist new community partners and have begun expanding capacity at the community level. We intend to build a lasting example of how Native Hawaiian communities can continue to thrive. Our long-term goal is to establish and build upon relevant science, link scientific discovery with pragmatic engagement and health promotion in the Native Hawaiian community, and build the capacity of communities to support and extend the purposeful and joyful lives of Native Hawaiians.