"Before we were Westernized, Native Hawaiians were very healthy, lean people," says Suzette Kaho'ohanohano, RN, health educator and clinical supervisor at Hui No Ke Ola Pono, a health care center for Native Hawaiians on the island of Maui. "We were fishers, we had land."
Today, few Native Hawaiians own land, much less cultivate crops or catch fish offshore. Often unable to afford fresh vegetables or fish, they eat an Americanized diet of fast food and are the world's number one consumers of Spam, the canned meat product high in saturated fat, sodium and cholesterol.
Unhealthy eating and a sedentary lifestyle have translated into big health problems for Native Hawaiians. Three-quarters of them are overweight, according to the Hawaii Department of Health. While Hawaii has the third lowest overall obesity rate in the nation (20.6%), the rate for the state's Native Hawaiian population is 39%—much higher than Mississippi, the most obese state, at 31.4%.
The outlook is similarly grim for other Pacific Islanders living in Hawaii, most of whom are immigrants from Samoa, Guam and Micronesia. Nafanua S. Braginsky, MSN, RN, a Samoan American nurse who is a lecturer at the University of Hawaii at Manoa School of Nursing, treats many Samoan patients at a clinic in Honolulu.
"We see a lot of big women," she says. "When we ask them to work on losing some weight, they say: ‘But I don't want to lose weight.' It's a culture where [you're not supposed to] be too skinny."
Obesity is only one of the many serious health problems Native Hawaiians and Pacific Islanders (NHPIs) are grappling with. They have high incidences of diabetes, hypertension, infant mortality and mental illness, to name just a few. Pacific Islanders also have high rates of tuberculosis and Hansen's disease (leprosy).
In contrast, NHPI women have comparatively low rates of breast and cervical cancer. But because they are much more likely to be diagnosed late, when the disease is already in an advanced stage, they have disproportionately high mortality rates, according to the American Cancer Society.
Lack of early detection and preventive care is a problem across the health spectrum for Native Hawaiians and Pacific Islanders. They have unusually low rates of cancer screening, immunizations and visits for prenatal care. A variety of studies has found that they visit the doctor less frequently than their Caucasian counterparts, seek care late in the course of a disease and are more likely to accept a serious disease as fatal, rather than try to fight it.
Yet in most cases, this low utilization of health care services is not due to lack of access. With the state's mandate that employers provide health insurance for all full-time workers, only 4.1% of Native Hawaiians are uninsured—lower than the rate for Hawaiians as a whole, the state health department reports. Unemployed Hawaiians can qualify for the state's Medicaid managed care program, Hawaii QUEST. But many do not apply and application processing can take months.
This long list of health disparities breaks the hearts of veteran Native Hawaiian nurses like Mary Frances Oneha, PhD, APRN, director of quality and performance at the Waianae Coast Comprehensive Health Center. The center provides health care services and outreach primarily to disadvantaged Native Hawaiians on the west coast of the island of Oahu. In her 17 years at the center, she says, "there has been an increase in screenings and more outreach, but I'm not sure they have resulted in better outcomes. I can't think of a significant health care indicator that has gotten better."
But Oneha has by no means given up hope. She is currently working on several research projects to improve Native Hawaiian health, including one that focuses on infant mortality risk reduction factors among pregnant women.
Asked to explain the poor health outcomes and underutilization of medical services, Native Hawaiian nurses at the front lines point to cultural trauma. Every Native Hawaiian is familiar with the events of 1893, when American and European plantation owners and missionaries, assisted by the U.S. Marines, invaded the palace of Queen Liliuokalani and seized control of the Hawaiian government. Hawaii was annexed by the United States five years later.
Like most Native Hawaiians, Kaho'ohanohano's ancestry comprises a mixture of races and ethnicities. Her background includes German, Polish, Irish and Russian heritage, but she feels the closest affinity with her Native Hawaiians roots. She says the near-destruction of the traditional Hawaiian culture has thrown Native Hawaiians off balance and had a devastating effect on their emotional and physical health, a process called "cultural wounding."
"Native Hawaiians [sank into a collective] depression when we lost our land, our culture and our language," she explains. "We turned to alcohol and tobacco. To me, it's a lot like what happened to the American Indians."
Now Native Hawaiians are a minority in their own land, unnoticed by tourists in the beachfront hotels. According to the most recent U.S. Census, there are only about 260,000 Native Hawaiians in the state, or about 15% of the population. That's fewer than the number of Japanese Americans living in Hawaii and only slightly more than Hawaiians of Filipino descent.
Oneha, whose ethnic background reflects successive migrations to Hawaii (English, Scottish and Chinese), agrees that Native Hawaiians' poor health "has to do with the history, the historical trauma that we've been through. There is a cumulative experience that people bring with them [from generation to generation]."
Pacific Islanders have also experienced the impact of Western influences on their traditional way of life. But unlike Native Hawaiians, their small island societies have managed to hold on to their languages and much of their culture.
Thanks to wide-open borders between these islands and the United States, some 28,000 Pacific Islanders have migrated to Hawaii. So have thousands of people from the U.S. territories of Guam and American Samoa, who have no entry restrictions because they are U.S. citizens. There are currently 16,000 Samoans and 4,000 Guamanians living in Hawaii, the Census Bureau reports.
America's borders are also open to people from the former U.S. trust territory of Micronesia, some 8,000 of whom now live in Hawaii. While one part of this territory, the Commonwealth of the Northern Mariana Islands, remains American, the rest has spun off into three independent nations: the Federated States of Micronesia, the Republic of Palau and the Republic of the Marshall Islands, where the U.S. conducted extensive nuclear weapons testing from 1946 to 1958. Under treaties with these nations, called the Compacts of Free Association, their citizens can enter the United States without visas or time limits.
Unlike Native Hawaiians, who share a common language and culture, Pacific Islanders in Hawaii are a fragmented population who speak many languages and come from many different islands with totally different customs and cultural beliefs. As many as 20 different languages are spoken at health centers in Hawaii.
All of this adds up to frustrating challenges for Hawaiian health professionals trying to provide care to Pacific Islander patients. In an article published in the California Journal of Health Promotion, researchers from the Hawaii Department of Health and the University of Hawaii noted that "health care providers [in Hawaii] almost universally regard Micronesians as ‘difficult' patients." Not only are there cultural barriers, they wrote, but many of these patients change residences frequently and go back to their homelands, making screening and follow-up "problematic."
Under the Compacts, Micronesians are eligible for Hawaiian Medicaid, which has spent an estimated $100 million on health care for them over the years. Prodded by state health officials, the federal government finally agreed in 2004 to pay the Hawaii Medicaid program $10.5 million for Micronesian care, but the contribution falls short of the full $18 million their care actually cost.
Not surprisingly, Native Hawaiian and Pacific Islander nurses are at the forefront of the state's efforts to improve health outcomes for NHPI patients and communities. Many of these nurses are involved in interventions that tap into Native Hawaiian cultural traditions—traditions that patients are in many cases reconnecting with.
To break down barriers and establish trust, nurses take advantage of Native Hawaiian concepts like ohana (close connections to family and friends). Patients are encouraged to bring family members into examination rooms, which actually improves compliance. Similarly, patients are urged to draw on their shared cultural values to help each other stay healthy. A study conducted in the 1990s found that when groups of Native Hawaiian women used traditional Hawaiian values like kokua (proactive helping), aloha (compassion) and pili (bonding as family), more of them sought screening for breast and cervical cancer.
This emphasis on providing culturally competent care is epitomized by the Native Hawaiian Health Care Systems, a group of wellness and outreach centers created under the Native Hawaiian Health Care Act of 1988 and partly funded by a grant from the federal Health Resources and Services Administration (HRSA).
"Native Hawaiians have often felt that the Western health system did not understand or value their beliefs and practices," says Dianne Ishida, PhD, MA, MSN, RN, an associate professor at the University of Hawaii at Manoa School of Nursing. "That's why it was important to create a Native Hawaiian health system."
Each of the five main Hawaiian islands has a separate system. Hui No Ke Ola Pono, the system for Maui, offers disease prevention and health promotion programs, nutritional education and counseling, wellness classes and community health screenings.
Janice Fernandez, RN, a Native Hawaiian nurse who runs a hypertension and stroke program at the center, says some patients do not readily accept her recommendations. "Sometimes Native Hawaiians are really hard-headed," she explains. "If they are not ready [to make the necessary lifestyle changes], they're not going to accept it." Some patients, she adds, have dropped out of the program, then reappeared a year or two later.
Hui No Ke Ola Pono also offers traditional Hawaiian healing methods, including lomilomi, a form of massage, and hooponopono, family conferences in which relationships are set right through prayer, discussion, confession and forgiveness.
Kaho'ohanohano, the lead clinical supervisor for the Maui system, says the nutrition courses try to accommodate Native Hawaiian tastes. "For example, they should not be eating Spam, but if they insist, we show them how to cook it healthier. Instead of frying it, they can steam it." Participants are also given opportunities to taste healthy foods and are taken on shopping trips to grocery stores.
Given Native Hawaiians' distrust of Western medicine, it makes sense to take small steps. Rather than impose a strict diet, Ke Ola Mamo, the Native Hawaiian Health Care System for Oahu, helped middle-aged and elderly patients lose 5% of their body weight through lifestyle modifications, such as taking walks. Participants wanted "to do things their way," says Donna Palakiko, RN, MS, programs administrator for the Oahu system. "We [Native Hawaiians] don't really take well to being told what to do."
She adds that Native Hawaiians often keep their opinions to themselves, so nurses need to pick up non-verbal cues, such as a patient making a face.
Pacific Islanders are also eligible to receive care from the Native Hawaiian Health Care Systems, but many of them don't take advantage of this opportunity. So the Maui system is reaching out to them by partnering with local churches and other trusted organizations in the PI community. When Fernandez provided health screenings to 125 Micronesians at a church-sponsored outreach event, she found that more than half of them had high blood pressure or diabetes and most had not signed up for Medicaid. Even by NHPI standards, "it was very disheartening," she says.
Church-based outreach programs have been very successful in raising community awareness about health issues, Hawaiian nurses report. For example, Samoan pastors have been trained to present cancer as a palagi (white man's illness) to differentiate it from a Samoan spiritual illness, which cannot be cured.
At the Waianae Coast Comprehensive Health Center, nurses are reaching out to homeless Native Hawaiians living on the beaches. Partly due to a lack of affordable housing, an estimated 2,000 people live on beaches and other unsheltered areas on Oahu alone.
The nurses bring hygiene products, blankets and donated clothes. "We try to meet their needs and their goals," says Yvette Budoit-Alop, RN. "In the short term, that means food, shelter and clothing. In the long term, it means being ready to get off the beach."
Being Native Hawaiian herself helps her establish rapport with them—at least to some extent. She uses "talk story," an informal way of conversing using Hawaiian pidgin slang. One person will share a story, and the others corroborate or add to it. But the homeless people are still wary. "It takes a while for them to trust us," Budoit-Alop says. "We saw one mother with kids out on the beach for a year before she requested shelter."
Even though there is a great need for more nurses like Budoit-Alop who can provide culturally knowledgeable care to the NHPI population, very few Native Hawaiians enter nursing. To try to increase Native Hawaiian enrollments, nursing schools like the University of Hawaii at Manoa on Oahu are doing their own community outreach, sending representatives into local high schools to develop students' interest in nursing, help students become academically prepared for nursing school and find financial aid for them.
Outside of Oahu, it is difficult for Native Hawaiians to pursue their education. Kaho'ohanohano says she earned her associate's degree in nursing from Maui Community College, but then had to get her BSN degree online through the University of Phoenix, because there were no such programs on Maui.
She believes Native Hawaiian nurses can make an important contribution to improving the health outlook for her people, because "we are actually the bridges between the traditional Hawaiian culture and the Americanized world. We are trying to incorporate the Hawaiian culture into Western medicine."