FormalPara Key Points

  • The Association of Native Hawaiian Physicians has provided first aid and health screening at the Hoʻokuikahi i Puʻukoholā annual cultural gathering for many years.

  • By engaging in the community’s culture, the doctors have been able to open doors and establish trust.

  • Kukākukā (talk story) sessions are a great tool for encouraging Native Hawaiians to do cancer screening.

  • Bringing the tools of Western medicine to cultural activities and important gatherings of Indigenous people to improve health is something we believe can be done with other Indigenous groups.

Hoʻokuikahi i Puʻukoholā has been an annual cultural gathering on Hawaiʻi Island since 1972, where cultural activities and strict Native Hawaiian protocol are practiced. Ohua (groups) that attend are mainly Native Hawaiian men, who typically do not use Western medicine for their healthcare needs. It is a gathering where “living history” is perpetuated [1].

ʻAhahui o nā Kauka (the Association of Native Hawaiian Physicians or AONK) first attended Puʻukoholā (Hawaiʻi Island) during a cultural huakaʻi (trip) in 2004. Subsequently, AONK representatives were invited to the upcoming Hoʻokuikahi i Puʻukoholā, mainly to provide first aid during activities such as a “sham battle” (mock fighting with spears covered with padding). Having doctors there proved to be helpful, not only for the purposes of providing first aid but also for the general wellbeing of all participants. August is the hottest month of the year in Hawaiʻi, and participants follow strict Hawaiian protocol, including kapu (avoiding certain activities such as eating specific foods), often with many hours spent in ceremony. Medical problems ranged from simple injuries (such as cuts, bruises, and sprains/strains) to more urgent problems such as heat exhaustion and heat stroke. Per cultural protocol, males must be tended by male doctors, and females need to be tended by females. Since 2004, the AONK has provided both kane (male) and wahine (female) kauka (doctors). Over the years, AONK activities have expanded from first aid and urgent care to health screenings and educational talks. In return, AONK members have learned and participated in Native Hawaiian protocols and rituals, including the performance of oli (chants) used when entering the heiau (temple).

In recent years, the AONK health screening activities have become more prominent in response to the significant health disparities experienced by Native Hawaiians (NH), especially type 2 diabetes, cardiovascular disease (CVD), and cancer. NH typically experience disease at a younger age (such as with CVD, which presents 10 years earlier than in their Caucasian counterparts) [2]. Cancer is the second leading cause of death in Hawaiʻi, accounting for about 2500 deaths each year (124.1 deaths/100,000 age-adjusted population) [3, 4]. NHs have the highest rates of mortality for all cancers, including breast, lung, colorectal, and pancreatic cancers compared to any ethnic group in Hawaiʻi. In the second place, Japanese males have higher mortality rates of colorectal and pancreatic cancers with Filipino males leading the way with lung cancer, compared to other ethnicities in Hawaiʻi [3].

Trust from the Community: Health Screening

As AONK continued to provide first aid at Hoʻokuikahi i Puʻukoholā and discussed health issues with different ohua (groups), we learned that participants wanted information about how to improve their health. As the community started to feel comfortable having the AONK team around, they started to ask questions and lay the groundwork for our screening activities, which have now been embedded within the event. Because of the leaders’ encouragement, young NH men, usually a hard-to-reach group, now actively participate in the screening.

We offer a range of screening activities, including body mass index (BMI) measurement, blood pressure, cholesterol, blood sugar, and skin cancer screening. We found that many participants believe the brown skin of Native Hawaiians means they have little chance of developing skin cancer and therefore they don’t need sunscreen. At the exit interview with the kauka (doctor), we discuss further cancer screening and the prevention of breast, cervical, prostate, and lung cancers. We provide participants with instructions for follow-up with their doctors or, if needed, provide assistance in finding a doctor. Figure 5.1 shows some of our field clinic experiences.

Fig. 5.1
4 photos under the title, Kauka reviewing health screening results with participants at Puukohola. Top, a photo of 9 people posing for the camera. Bottom, 3 photos feature 2 different people in each photo sitting on either side of a table and speaking.

The exit interview: clinic in the field. (Photos: M.A. Cardejon (top) and D. Carpenter (bottom row))

Full size image

Over the years, AONK has worked with Papa Ola Lokahi (Native Hawaiian Health Care System) to bring in other groups of educators and healthcare providers, including the University of Hawaiʻi (UH) at Mānoa John A. Burns School of Medicine, Department of Native Hawaiian Health, Native Hawaiian Center of Excellence (NHCOE), Hui Mālama Ola Nā ʻŌiwi (NH Health Care System on Hawaiʻi Island), UH Hilo Daniel K. Inouye College of Pharmacy, Hawaiʻi Island Family Medicine Residency Program, and Chaminade University School of Nursing.

Kukākukā (Talk Story) Sessions

During Hoʻokuikahi i Puʻukoholā, we were asked to have some kukākukā (talk story) sessions with participants, with kauka wahine (female doctors) addressing women and kauka kane (male doctors) addressing men. In safe spaces, we talk about health disparities experienced by NH and the importance and impact of screening. We also provide time for questions and concerns. Participants share stories, some very personal, about their own or family members’ bouts with cancer, fears of getting cancer, prevention, and what can be done to help them. A prominent topic for deep discussion is caring for oneself in order to care for others—which is a topic not previously discussed among these participants. These conversations provide a catalyst for many to accept the need for health screening. Each year, many participants return to report on their lifestyle changes and physician follow-up.

Lessons Learned and Implications

We are members and past presidents of the AONK and faculty at the John A. Burns School of Medicine who have been privileged to be part of Hoʻokuikahi i Puʻukoholā for almost 20 years. We continue to provide education and service and, through health screening and exit interviews, we help navigate participants through the healthcare system to prevent illnesses, including cancer. Over the years, we have diagnosed diabetes, hyperlipidemia, hypertension, and skin cancer.

We have learned these key lessons from Hoʻokuikahi i Puʻukoholā:

  1. 1.

    An invitation from the community and, in our case, the cultural groups that are stewards of Puʻukoholā was essential. With this we gained legitimacy and, with leadership encouragement, we were able to reach out to a population of NH that does not normally trust Western medicine.

  2. 2.

    Cultural orientation of all Western practitioners involved in health screening and first aid in the NH communities is imperative. For NHs in this setting, this would include an attitude of respect, humility, and professionalism, as well as knowledge of culture and history, kapu (activities or foods being avoided), and NH protocol specific to Hoʻokuikahi i Puʻukoholā. Having our kauka (doctors) follow protocol helped to build trust.

  3. 3.

    The kukākukā (talk story) sessions are especially important. These sessions allow for safe spaces to share stories, provide information, and discuss the need for prevention, which is key to optimal health of our Indigenous people. We were encouraged to hear in subsequent years stories from the participants who shared what they learned with family and friends and had helped to change lives.

We believe that this model of bringing the tools of Western medicine to cultural activities and important gatherings of Indigenous people to improve health can be undertaken with other Indigenous groups. Especially when addressing scary topics such as cancer, it is critical to allow for safe spaces to share stories and make it easy to access screening and information. We believe similar programs can be successful with other Indigenous groups as we all try to improve the cancer health disparities impacting our communities.

We would like to thank all our partners, including those already mentioned as well as the National Park Service at Puʻukoholā, Na Aikane o Puʻukoholā, Na Papa Kanaka o Puʻukoholā, and Na Waʻa Lalani. Partial support came from funds from the Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS), grant number D34HP16044 and title Native Hawaiian Center of Excellence. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS, or the US Government.