Adversity and resiliency in the lives of Native Hawaiian elders.

Browne, Colette V. ; Mokuau, Noreen ; Braun, Kathryn L. 等

The Hawaiian stands firmly in the present, with his back to the future and his eyes fixed upon the past, seeking historical answers to present-day dilemmas. Such an orientation is to the Hawaiian an eminently practical one, for the future is always unknown whereas the past is rich in glory and knowledge. (Kame'eleihiwa, 1986, pp. 28-29).

Regardless of their racial or ethnic origins or the state in which they live, disenfranchised and oppressed cultural populations across the United States have alarmingly similar social, health, and economic profiles. People indigenous to the lands that currently constitute the United States--Native Hawaiians, American Indians, and Alaska Natives--share a history of forced incorporation into the dominion and the trauma of colonized peoples. This history has contributed to shorter life expectancies and higher prevalence of a number of chronic diseases--diabetes, heart disease, and cancer--when comparing indigenous groups with majority populations in the United States (U.S. Department of Health and Human Services, 2000).

Native Hawaiians constituted less than 1 percent of the total U.S. population, about 401, 162 people, in 2000; approximately 60 percent resided in the state of Hawai'i. Of Native Hawaiians age 60 and older, about 20,994 live in Hawai'i, and 10,951 live in other U.S. states (U.S. Census Bureau, 2007). Nationally, Native Hawaiians as a group have higher mortality rates for cardiovascular disease and cancer than most other ethnic groups in the United States, and they rank second in prevalence of obesity (Fong, Braun, & Tsark, 2003). Rates for other social ills--substance abuse and child abuse--are highest among Native Hawaiians of all ethnic groups in Hawai'i (Mokuau, 2002). Specific to Native Hawaiian elders (na kapuna), data from Hawai'i suggest a number of serious social and health disparities--for example, poorer health, greater rates of disability, more problems with self-care, and an underutilization of services when compared with non-Hawaiian elders (Alu Like, 2005; Braun, Yang, Onaka, & Horiuchi, 1996; Mokuau, Browne, & Braun, 1998). About the same percentages (9 percent to 10 percent) of Native Hawaiian and U.S. elders live in poverty, but the per capita incomes for Native Hawaiians are significantly lower (Braun, Yee, Browne, & Mokuau, 2004). Scholars have offered a number of explanations: the historical impact of cultural trauma, poverty, inadequate access to health care (especially culturally responsive care), institutional and internalized racism, discrimination, and poor health practices (Mokuau, in press; Tsark, Blaisdell, & Aluli, 1998). Data about na kapuna who reside in the continental United States are nearly nonexistent (Braun et al., 2004). But there is another side to the lives of na kapuna, one that speaks to a resilient culture with enduring cultural values and traditions that promote health and family care (Braun et al., 2004; Mokuau, in press).

Building on the life course literature and resiliency theories, we propose a model that provides a context from which to analyze and understand the serious social and health disparities found in na kapuna. A number of culturally based solutions have been developed and implemented to address some of these well-documented social and health concerns, with positive results (Mokuau, in press; Mokuau, Browne, Choy, & Braun, 2008). Nonetheless, and although some progress has been made, the attainment of good health and well-being for all Native Hawaiians and specifically na kapuna has yet to be achieved.

Gerontology research has identified the biological, psychological, social, and other changes that occur with aging. We add to this discussion and argue that improving the health and well-being of Native Hawaiian elders requires that social workers take into account those cultural and historical markers and resiliency factors (for example, cultural values and traditions) that ultimately shape health and life trajectories. We introduce ola pono na kapuna, which is a practice model that incorporates cultural and historical markers and resiliency factors to explain the present and future health and social profiles of na kapuna. In the Hawaiian language, ola is defined as life, health, and well-being and pono is defined as perfect order (Pukui & Elbert, 1981). Thus, ola pono na kapuna aims to promote the life, health, and well-being of Native Hawaiian elders. In line with Hawaiian cosmography (Mokuau, in press), we define health broadly to include social and health issues rather than a sole focus on the absence of disease. We end with a discussion about implications for the profession, including a description of Ha Kapuna, National Resource Center for Native Hawaiian Elders, whose goal is the improvement of health and well-being for na kapuna.

THEORETICAL PERSPECTIVES

Life Course Perspective

Gerontologists increasingly use the life course perspective as a way to understand old age as one phase of life and how this phase is shaped by events experienced and activities undertaken in the years leading up to old age (Moody, 2004). Age transitions, according to Riley (1994), are influenced by the complex interactions of personal biography and sociohistorical forces. As such, each person's "historical world" provides different opportunities and constraints; as a result, aging is experienced differently by age, ethnic, racial, economic, and geographical cohorts (Elder, 1994). Over the life course, cumulative adversity for some and cumulative advantage for others results in diverging trajectories and increasing inequality over time (Hatch, 2005). Three key points from Halfon and Hochstein's (2002) work on the life course and health are relevant to this discussion: (1) Different health trajectories are the product of cumulative risk and resiliency and protective factors and other influences that may be programmed into behaviors during critical and sensitive periods; (2) health is the consequence of numerous and interacting determinants that operate in various and changing contexts (for example, biological, behavioral, social, economic) over time and as the person develops and ages; and (3) the timing of historical events, in addition to biological, psychological, and cultural issues, influence the health of both individuals and populations.

Two additional concepts are important here in understanding the impact of history and other forces on people's lives. One is the identification of markers or transition points that are critical in an individual's life. The second key concept is cohort. This refers to those born during the same historical period, and leads to cohorts sharing certain values and perspectives (Elder, 1994).Both concepts demand that aging research be grounded historically. Two examples may illustrate these concepts. The lives of African Americans in the United States have been profoundly shaped by whether their birth cohort preceded or came after the 1960s civil rights era. Similarly, Japanese Americans whose families were forcefully moved to interment camps by the federal government when they were children during World War II experienced a number of traumas--loss of property, citizenship rights, and great discrimination--unlike the life experiences of their children.

Resiliency Theory

In addition to the life course literature, we draw from scholarship in resiliency theory, with its focus on underlying protective and recovery factors in health promotion. In contrast to a focus on adversities, deficits, and pathologies, so common in gerontology scholarship, resiliency theory draws from the strengths perspective, a philosophical standpoint that recognizes the inherent power and resilience of individuals and communities (Chapin, Nelson-Becker, & MacMillan, 2006; Saleebey, 1997). The resilience-enhancing approach is in concert with the ecological, or person-in-environment, perspective of the profession (Bronfenbrenner, 1979) as well as Hawaiian cosmography (Mokuau, in press). Both propose a holistic or holism perspective to understanding human behavior, well-being, and health, and both value sources of natural support within people's environments and communities (Borden, 1992; Cohen, Greene, Lee, Gonzalez, & Evans, 2006; H. I. McCubbin, Thompson, Thompson & Fromer, 1998; L. D. McCubbin, 2006-2007; Mokuau, in press).The contribution of Hawaiian cosmography to understanding human behavior, well-being, and health lies in its emphasis on the interconnections between all parts of the individual (biological, psychological, social, and spiritual) and the world (individual, family, community, land, and spiritual realm) (Mokuau, in press).

Becker and Newson (2005) saw resilience as a culturally specific philosophy and as an important adjunct to health in later life. Rather than viewing resiliency as a quality found only in an individual or a group of people, Native Hawaiian scholarship has consistently identified their cultural values and traditions as resiliency factors to their people (L. D. McCubbin, 2006-2007; Mokuau, in press). Returning to our focus on aging, a growing body of gerontological scholarship supports the positive impact of resilience on perceptions of "successful" aging, recovery from traumatic events, positive dying in later life, and coping with caregiving and personal disability (Gaugler, Kane, & Newcomer, 2007; Guthreil & Congress, 2000; Hardy, Concato, & Gill, 2004; Montross et al., 2006; Nakashima & Canda, 2005). Other scholars have found that cultural values help to promote resiliency among caregivers of elders with dementia (Allery et al., 2004; Braun & Browne, 1998).

OLA PONO NA KUPUNA (LIFE AND HEALTH OF OUR ELDERS)

Social and health disparities call for new strategies on behalf of Native Hawaiian elders. To accomplish this, social workers must be knowledgeable about how contact with Western civilization triggered dramatic declines to the health and well-being of the Hawaiian people and about significant resilience-oriented responses from Hawaiian leaders (Mokuau, in press). The components of Ola Pono Na Kapuna--a life course and resiliency model--with population cohorts and key historical periods are presented in Table 1. The historical periods include markers representing challenges (adversities) to Native Hawaiian well-being and markers demonstrating cultural resilience. Birth cohorts range from those born between 1905 and 1914 (who would be in their 100s today) to those born between 1955 and 1964 (the oldest of whom will turn 60 in 2015). The model offers reasons for the different social and health trajectories found among Native Hawaiian cohorts and underscores the need for the social work profession to intervene simultaneously on micro, meso, and macro levels to meet the needs of na kapuna. This is a broad discussion and, while noting similarities in cohorts, variations caution us to not stereotype or generalize a population or person.

KEY HISTORICAL EVENTS

What follows is a summary of key historical events that affect Native Hawaiian elders today. We summarize these events in four 30-year periods--pre-1915, from 1915 to 1945, from 1945 to 1975, and post-1975. Our first marker is pre-1915 because understanding the health of na kapuna requires knowledge of Hawaiians' colonial past (Mokuau, in press).

Pre-1915

Polynesians, voyaging northward from Tahiti, established a society in the Hawaiian Islands about 1,000 years ago. At the time of first contact with the West in 1778, Hawaiians had a sophisticated culture and a population of at least 300,000 (Stannard, 1989). The Hawaiian worldview emphasized collective affiliation and the interdependence of the individual, family, community, environment, and transcendent realms (Mokuau, in press). A number of adversities followed western contact, including the abolishment of native religion (1819), changing land ownership in favor of non-Hawaiians (Mahele) (1848), and the decline of the native population to 40,000 due to Western diseases to which they had no immunity (1890). Plantation laborers were imported from China (1852),Japan (1880), the Philippines (1905), and other countries. To safeguard U.S. economic interests, the U.S. military overthrew the Hawaiian monarchy in 1893 (Apology Resolution, 1993).

There were also episodes of resiliency during this time of decline. Native Hawaiian monarchs (ali'i) did not passively accept these dangers to their people, and they established legacies to counter these harms. Queen Emma founded the Queen's Hospital in 1859 to care for indigent sick Hawaiians and others and St. Andrew's Priory in 1867 for the education of Hawaiian girls; King Lunalilo created Lunalilo Home in 1883 to care for elderly Hawaiians; Princess Bernice Pauahi Bishop set up the Kamehameha Schools in 1887 to educate Hawaiian children; and Queen Lili 'uokalani's trust of 1909 established the Children's Center for Hawaiian orphans and destitute children.

1915 to 1945

Elder cohorts born in this time period--those in their 60s, 70s, 80s and 90s today--were strongly affected by the decimation of the Hawaiian population and culture through personal experience of the effects and through stories told to them by the parents and grandparents. They lived through the adversities around World War I, the subsequent depression, and World War II, when Hawai'i was bombed (1941) and held under martial law (1941 to 1945). The negative impact of these events is seen clearly in Hawai'i population statistics: Native Hawaiians constituted about 20 percent of the state's population in 2000 but only 10 percent of the 60+ population, suggesting that many in this cohort have died before reaching old age (U.S. Census Bureau, 2007). Nonetheless, continued reflections of cultural resiliency were evident. Most notable was the establishment of the Department of Hawaiian Homelands in 1921, which was supported through U.S. congressional enactment to provide housing to Native Hawaiians.

1945 to 1975

Those born in this timeframe--who are now in their 30s, 40s, 50s and early 60s--have seen a rapidly changing Hawai'i. Hawai'i became the 50th U.S. state in 1959, and with the popularization of air travel, tourism and land development increased. This lead to major political and economic changes; descendents of plantation laborers rose to high positions in business, labor, and government, and land costs and costs of living rose dramatically. Similar to non-Hawaiians in this cohort, many middle-age Native Hawaiians have experienced much more personal freedom than their parents and grandparents. This lifestyle has come with a price--new adversities around the increasing need for all family members to work (many at multiple jobs) and the escalating prevalence of obesity, hypertension, cancer, and heart disease (Fong et al., 2003). As with other periods, there were episodes of resiliency. The post-World War II period saw the restoration and expansion of educational opportunities. Most significantly, a renaissance of Hawaiian culture emerged with a rebirthing and reaffirmation of Native Hawaiian culture and native language, huh, spirituality and healing traditions such as lomi lomi (massage), la'au (herbs), and ho 'oponopono ("to set right"), a family-centered practice.

Post-1975

Present day na kapuna were already middle aged at the time of the beginning of the Native Hawaiian cultural renaissance. The adverse effects of decades of skyrocketing land prices have fueled economic stress on families and increased out-migration among Native Hawaiians. As a result, some of today's na kapuna wonder whether they should stay in Hawai'i or follow children and grandchildren to other states. Resiliency events, however, continue to be evident. These events include the 1978 Hawai'i State Constitutional Convention that laid the groundwork for the return of federal lands (such as the island of Kaho'olawe, which had been confiscated by the U.S. military for target practice), the creation of the Office of Hawaiian Affairs, and the instruction of Hawaiian language in public schools. In 1988, the Native Hawaiian Health Care Improvement Act (P.L. 102-396) established Native Hawaiian primary and preventive health care programs in rural communities (where many Native Hawaiians live) as well as a scholarship program for Native Hawaiians entering health professions. In 1993, the U.S. government formally apologized for the 1893 overthrow (Apology Resolution, 1993), and new legislation on self-determination was introduced to the U.S. Congress (S. 147, 2005).We hope that recognition of the positive and resilient traits and contributions of Hawaiian culture will be coupled with an improved standard of living for Native Hawaiians born during this time period so that they can age well and live long.

HEALTH AND SOCIAL PROFILES OF NA KUPUNA

Life course scholarship assumes that aging and its many meanings are shaped not only by the aging process, but also by the timing of historical, cultural, and other events and experiences (George, 2007; Halfon & Hochstein, 2002; Jackson & Chapeleski, 2000). In this article, we have described how Native Hawaiian history reflects moments of adversity and resiliency. In this section, we return to the three-point framework of Halfon and Hochstein (2002) to reflect on the effect of these historical events and cultural markers on the health and social profiles of Native Hawaiian elders. Halfon and Hochstein's first point was that health trajectories are the product of cumulative risk and protective (resiliency) factors programmed into behaviors during critical and sensitive periods. The historical events experienced by today's na kapuna have had an adverse effect, earlier through the decimation of the people and marginalization of culture, and today through the family disintegration effects of the economy. We suggest that these factors, together with the effects of aging and personal biography, have lead to the poor social and health outcomes of today's na kapuna. The oldest kapuna--those 65 years of age--are generally poorer and have more health problems compared with "younger" kapuna (those who are in their 50s and 60s) who grew to adulthood in a later time line. This health pattern is similar to that of the nation in general, with older cohorts experiencing poorer economic and physical health and greater poverty rates compared with the "younger" aged individuals (Dunkle & Jeon, 2006). The importance of a historical time line is more evident, however, when considering that surviving na kupuna are less healthy than elders of other ethnicities in Hawai'i and that they underuse needed services (Braun et al., 2004).

Halfon and Hochstein's (2002) second point--that numerous and interacting influences and determinants on health change over time--lends some hope for Native Hawaiian elders in the future. We identified examples of resiliency, primarily embodied in the continuation of cultural practices and traditions and programs that countered the negative effects of colonization. One of the effects of the Hawaiian cultural renaissance that began in the late 1970s and continues today is the development and delivery of indigenous health services for Native Hawaiians provided through the previously discussed Native Hawaiian Health Care Improvement Act that developed a statewide health care system with a focus on the unique and urgent needs of Native Hawaiians in Hawai'i. This act's objective is to raise the health status of Native Hawaiians living in Hawai'i to the highest possible level through the provision of comprehensive health promotion, disease prevention, and primary health services. Research to date on life expectancy in Hawai'i, however, documents that Native Hawaiians remain a population at risk (Park, Braun, Horiuchi, Tottori, & Onaka, in press). Exactly what effect indigenous and other services have on the health and well-being of na kapuna, and their impact on future cohorts that are increasingly multiethnic, will be an important focus for future research.

Halfon and Hochstein's final point--that it is the timing and sequence of these events that influence the health of individuals and populations--acknowledges the greater importance of earlier stages in shaping health in the later years. The decimation of the Native Hawaiian culture has negatively affected the health of the older cohort; whereas the advocacy that emanates from the cultural renaissance, most evident in the post- 1975 cohort, may prove beneficial. These multiple and interacting influences on health and well-being underscore the need for social workers to have the necessary skills to intervene simultaneously on micro, meso, and macro levels.

SOCIAL WORK PRACTICE AND RESEARCH WITH NA KOPUNA

Social work practice and research with Native Hawaiian elders should include the provision of culturally based and appropriate counseling and other services that acknowledge historical and cultural markers and resiliency factors on well-being, the adoption of community-based participatory approaches to community organizing, and increased study on social, health, and economic disparities of native elders.

The time line mentioned in this article allows the profession to consider these complex influences on health and well-being and to conceptualize their links to services and health delivery implications. Today's na kapuna experienced childhood and young adulthood when social and health care services were primarily Western. Culturally based solutions may have been provided by family members, but as a rule they were rarely offered or legitimized by government or health care organizations. The subsequent lack of trust and suspicion among Native Hawaiians for some services suggests one reason for their low utilization rates of Western models of care (Fong et al., 2003). One implication is that na kapuna are often in need of primary health care and preventive health care--the provision of good health practices and disease prevention--but this care may be required at earlier ages compared with their non-Hawaiian counterparts because of shorter life expectancies. The cohort born from 1915 to 1945 grew to adulthood when some service models began to adopt principles of cultural competence in addition to those that adopted more Western models. Their attitudes toward accessing services may be mixed--a lack of trust of some Western models and a growing sense of cultural pride and legal entitlement, with accompanying preferences for services grounded in their culture.

For those born after 1945 and through 1954, federal and community support increased for health and social services using culturally responsive solutions, indigenous models, and community-based participatory approaches. What these models have in common are core elements that include spirituality, cultural values and practices, and the inclusion of Hawaiians in the design, implementation, and evaluation of these interventions. The use of these values and practices implies that the wisdom of na kapuna and the Native Hawaiian historical past are incorporated into solutions for the health and human services problems that confront Hawaiians in contemporary society (Mokuau, in press).

Culturally based practice solutions can be found at various levels of intervention. At the micro level of practice, examples might include incorporation of Hawaiian spirituality in working with individuals with health issues (Braun, Mokuau, Hunt, Ka'ano'i, & Gotay, 2002; Braun, Tsark, Santos, Aitaoto, & Chong, 2006). At the family level of intervention, examples include ho'oponopono, a family-centered social work model that identifies, prevents, and resolves problems (Mokuau, 1990), and the "Ohana intervention, a culturally based family-oriented solution that addresses issues of family support for Native Hawaiian women with cancer (Mokuau, Braun, Wong, Higuchi, & Gotay, 2008). At the community level is 'Imi Hale--Native Hawaiian Cancer Network in Hawai'i funded by the National Cancer Institute. This community capacity-building program, involving the participation and leadership of Native Hawaiians on all levels of design and delivery of services, supports the health and education of Native Hawaiians in social work and other professions. In so doing, 'Imi Hale is building a cadre of indigenous professionals committed to decreasing social and health disparities through the development of strategies to improve access and the provision of culturally competent practice with Native Hawaiians (Braun et al., 2006; Fong et al., 2003). Indigenous leaders involved in this and other community-based efforts are healing their own communities, and social workers assist when invited to do so with their skills in advocacy, grant writing, research, and legislative testimony. At the macro level of policy change, the Native Hawaiian Health Care Improvement Act promotes social justice through its delivery of primary health and preventive care in five community-based island health systems to help Native Hawaiians live long and healthy lives.

Research continues to play a critical role in addressing the disparate social and health outcomes and improve the access and delivery of services to Native Hawaiian elders. Especially for those cohorts born after 1965, the need will continue for study on social, health, and economic disparities and the effectiveness of culturally responsive solutions to the problems of the aged population. Moreover, the need to acknowledge Native Hawaiian heterogeneity and its implications for the development of principles for practice and models of care in social work and other professions will become an increasingly important focus.

In 2006, Ha Kupuna--National Resource Center for Native Hawaiian Elders--was established with funding from the Administration on Aging (Choy, Mokuau, Braun, & Browne, 2008). It aims to improve access to and delivery of services to Native Hawaiian elders and their caregivers in Hawai'i and the United States through the development and dissemination of knowledge about health and long-term care. Predicated on principles of community-based participatory research, the center's emphasis is on cultural values, the mobilization of community knowledge and involvement, and social change to improve well-being and health of current and future populations of na kapuna (Mokuau, Browne, Choy, & Braun, 2008).

CONCLUSION

Native Hawaiian elders face a number of health and social disparities compared with their nonnative counterparts in Hawai'i and across the United States. We presented a model based in life course and resiliency theories that provides a context for understanding these disparities. As suggested by the model, key cultural and historical markers work in concert with personal biography and normal aging changes to shape social and health outcomes. This underscores the need for social workers to intervene simultaneously at various levels to help na kapuna transition well into old age. At all levels, these solutions must be centered in Native Hawaiian history, culture, and values to respond to the real health issues faced by na kapuna, their families, and the community at large.

Original manuscript received May 3, 2007

Final revision received January 22, 2009

Accepted February 11, 2009

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Colette V. Browne, DrPH, MSW, is professor, Myron B. Thompson School of Social Work, University of Hawai'i at Manoa, and co-investigator, Ha Kapuna (National Resource Center on Native Hawaiian Elders). Noreen Mokuau, DSW, MSW, is professor of social work and co-investigator, of Ha Kapuna. Kathryn L. Braun, DrPH, MPH, is professor of social work and public health and co-investigator of Ha Kapuna. Send correspondence to Colette Browne, School of Social Work, University of Hawai'i, 1800 East-West Rd, Henke 137, Honolulu, HI 96822; e-mail cbrowne@hawaii.edu.

Table 1: Cohort and Historical Markers in the Lives of Native
Hawaiian Elders

 Population Cohorts
Key
Historical Born Born
Periods Events 1905-1915 1915-1924

Prior to * Illness and depopulation Age 0-10
1915 of Native Hawaiians
 * Mahele
 * Overthrow of Hawaiian
 Queen Lili'uokalani
 * Labor imports
 * Ala'i trusts

1915- * World War I Age 10-20 Age 0-10
1924 * Dept. of Hawaiian
 Homelands
1925- * Depression Age 20-30 Age 10-20
1934

1935- * World War II Age 30-40 Age 20-30
1944

1945- * GI Bill Age 40-50 Age 30-40
1954

1955- * Statehood Age 50-60# Age 40-50
1964 * Land development
 * Mass tourism

1965- * Land development Age 60-70# Age 50-60#
1974 continues

1975- * Cultural Renaissance Age 70-80# Age 60-70#
1984 (language, hula, spiritual
 practices, etc.)
 * Constitutional
 Convention

1985- * Housing price boom Age 80-90# Age 70-80#
1994 * Native Hawaiian Health
 Care Improvement Act
 * Apology Bill of 1993

1995- * Outmigration of Native Age 90-100# Age 80-90#
2004 Hawaiians
 * Boomer lifestyle
 * Akaka bills

 Population Cohorts
Key
Historical Born Born Born Born
Periods 1925-1934 1935-1944 1945-1954 1955-1964

Prior to
1915

1915-
1924

1925- Age 0-10
1934

1935- Age 10-20 Age 0-10
1944

1945- Age 20-30 Age 10-20 Age 0-10
1954

1955- Age 30-40 Age 20-30 Age 10-20 Age 0-10
1964

1965- Age 40-50 Age 30-40 Age 20-30 Age 10-20
1974

1975- Age 50-60# Age 40-50 Age 30-40 Age 20-30
1984

1985- Age 60-70# Age 50-60# Age 40-50 Age 30-40
1994

1995- Age 70-80# Age 60-70# Age 50-60# Age 40-50
2004

Note: Shaded areas denote middle and older adulthood.

Note: Shaded areas denote middle and older adulthood is
indicated with #.