Has social work met its commitment to Native Hawaiians and other Pacific Islanders? A review of the periodical literature.

Mokuau, Noreen ; Garlock-Tuiali'i, Jessica ; Lee, Palama 等

Native Hawaiians and other Pacific Islanders (NHOPIs) contribute to the panoramic landscape of racial diversity in the United States. In 2000, NHOPIs were recognized by the U.S. Census Bureau (2001a) as a distinct racial group, along with other groups, including whites, blacks or African Americans, American Indians and Alaska Natives, and Asian Americans. People of Hispanic origin were also enumerated. Before 2000, NHOPIs were combined with Asian Americans in studies of race and ethnicity.

This first-time classification of NHOPIs in their own category is significant because all federal activities are guided by racial and ethnic standards established by the U.S. census. In particular, federal agencies' efforts to distribute funds; to issue grants; and to determine the social, economic, and physical health of populations in the United States must be in concordance with the census-designated racial and ethnic groups in the nation (U.S. Census Bureau, 1996).

Federal designation of NHOPI obligates the profession of social work with its historic commitment to cultural and ethnic diversity to generate and transmit knowledge on this population. Of particular importance is the ethical standard on cultural competence and social diversity contained in the NASW Code of Ethics (2000), which states that "social workers should obtain education about and seek to understand the nature of social diversity and oppression" (10. 7) as it pertains to many factors, including race and ethnicity. The purpose of this article is to assess the status of social work knowledge on NHOPIs by reviewing the periodical literature and to offer broad implications for social work.

NATIVE HAWAIIANS AND OTHER PACIFIC ISLANDERS

In 2000, Pacific Islanders composed 0.3 percent (874,000) of the total U.S. population (281 million), with more than 24 different ethnic groups identified (U.S. Census Bureau, 2001b). The largest groups consist of Native Hawaiians who are indigenous to the state of Hawaii (401,000), Samoans (133,000), and Chamorros (93,000), with other smaller groups such as Tongans, Fijians, Micronesians, and Maori. Of all the racial groups in the United States, Pacific Islanders have the largest number of people reporting membership in more than one racial or ethnic group, with 55 percent of the population noting multiracial heritages. Pacific Islanders tend to reside in the western region of the United States, especially in Hawaii, California, and Washington.

NHOPIs generally experience greater health disparities than does the U.S. population as a whole (Centers for Disease Control and Prevention [CDC], 2005; President's Advisory Commission on Asian Americans and Pacific Islanders, 2003). These disparities are complicated by socioeconomic realities such as low income, joblessness, and limited access to health care. For example, the disproportionate burden of cancer experienced by Native Hawaiians in Hawaii is compounded when viewed in the context of the high rates of poverty and unemployment and the low rates of health insurance within this population (Kanaiaupuni, Malone, & Ishibashi, 2005).

Although NHOPIs are a relatively small and invisible population in the United States, their federal classification, unique status as a diverse multiracial population, and impoverished condition provide compelling reasons for social workers to be informed about their circumstances. Knowledge provided in professional journals is an important source of education for social workers. Marsh and colleagues (2004) reported that articles and books by social work practitioners rank as the third most useful source of information for social workers, after "discussion of cases with other social workers" and "workshops on social work practice" (p. 533). Furthermore, they indicated that the most useful journal articles provide knowledge on population groups, social problems, and the effectiveness of practice.

For this article, we examined social work knowledge on NHOPIs as presented in the periodical literature published from 1995 to 2004. In particular, we examined information related to the descriptive analyses of this population, the social problems confronting them, and the practice models that are relevant for this population.

METHOD

We surveyed periodical literature in social work that focused on NHOPIs in the period from 1995 to 2004. To conduct a comprehensive survey, we used Social Work Abstracts, a database that contains more than 35,000 records of journal articles on social work and social welfare compiled from more than 400 journals, spanning a period from 1977 to the present. Produced by NASW, Social Work Abstracts is used as a "starting point for literature searches" (NASW, 2006). This database permitted us to expand the survey beyond the four or five journals most commonly examined in past periodical reviews (Fong & Mokuau, 1994; McMahon & Allen-Meares, 1992; Voorhis & Wagner, 2002).

Articles from journals were selected if the title, abstract, subject heading, or heading word contained the following key words: Pacific Islander, Native Hawaiian, Samoan, and Chamorro or Guamanian. In searching for these key words, we used the technique called truncation in which records were retrieved that contain "the search terms and all possible suffix variations of a root word (for example, Guam, Guamanian, Guamanians) (Ovid Technologies Field Guide, 2005). The use of truncation allowed for both author and journal input. We selected only full-length articles and excluded dissertations, letters, and editorials.

We evaluated articles using content analysis. Content analysis is a method of textual analysis that compresses many words of text into fewer content categories on the basis of objective and systematic rules (Berelson, 1952; Krippendorff, 1980; Stemler, 2001). It underscores the importance of coding and the categorizing of data. We initially used a priori coding to establish categories emphasizing topics that were ranked as most useful to social workers (Marsh et al., 2004): population, social problems, and practice. Three researchers independently reviewed the articles and applied the coding to the data. The researchers compared and discussed their findings and reconciled differences over the course of several meetings. Patton (2002) suggested that this part of content analysis is particularly important because different people can have different views when looking at the same set of data. After reviewing the articles, revisions in coding were made to accommodate the data, and subcategories were identified. Thus, the subcategories were identified on the basis of their prominence and the frequency with which they were mentioned in the articles.

We coded each article according to its primary content focus. In the category labeled "population," we identified the following subcategories: Asian and Pacific Islanders, Native Hawaiians, Samoans, and Chamorros or Guamanians. In the category of "social problems," we identified the subcategories of cultural conflict, health, and elder care. We revised the category "practice" to "cultural competence" with specific reference to cultural values and practice. The subcategories within cultural competence include practice with individuals, families and groups, and communities. Several articles addressed overarching themes. For example, some articles addressed both social problems and culturally competent interventions. However, researchers remained attentive to the primary focus of articles to maximize some level of exclusivity and to code accordingly. Researchers checked the reliability of the coding to ensure that 95 percent agreement had been achieved and applied the coding on a large-scale basis.

RESULTS

A total of 32 articles were found in 23 different journals published from 1995 to 2004 (see Table 1). This represents 0.64 percent of the 5,010 articles published in these social work journals. Most journals had only one article that discussed NHOPIs, but one journal had five articles. Circulation rates ranged from fewer than 200 to more than 150,000 subscribers; although most journals had fewer than 1,000 subscribers.

Population Focus

In the 32 articles reviewed, 17 articles (53 percent) used the rubric "Asian and Pacific Islanders" and aggregated information on NHOPIs with the larger, and equally diverse, Asian American population (see Table 2). Asian Americans constitute 4.2 percent of the nation's population and comprise diverse subgroups, including Asian Indian, Chinese, Filipino, Japanese, and Vietnamese (U.S Census Bureau, 2001a). In presenting aggregated information, these articles tend to describe a homogenous people rather than distinctive populations. When specific subgroups were identified under the umbrella term "Asian and Pacific Islander," they were likely to be of Asian descent such as Chinese and Vietnamese.

The other 15 articles (47 percent) in the survey disaggregated NHOPIs from Asian Americans. There were nine articles (28 percent) on Native Hawaiians, four articles (13 percent) on Samoans, and two articles (6 percent) on Chamorro/Guamanians.

Social Problems

Sixteen of the 32 articles (50 percent) had a primary focus on social problems. Within the category of social problems, themes that emerged were as follows: cultural conflict and social change; health, with an emphasis on HIV/AIDS, mental health, and substance abuse; and challenges particular to aging and caregiving.

Cultural conflict was cited in eight of the 32 articles (25 percent) that addressed the erosion of cultural worldviews and values. Six of the articles (19 percent) attributed the erosion of cultural worldviews and values to social changes wrought by colonization, racism, and acculturation. These social changes were typically described in the articles as "modernization," "urbanization," and "tourism." The articles indicated that this loss contributed to personal problems such as difficulties in identity formation and social problems such as the loss of employment. Two articles (6 percent) on cultural conflict focused on issues of inequity when racial differences were glossed over.

Health was cited as a social problem in five of 32 articles (16 percent).Three of the articles (9 percent) focused on HIV/AIDS with some consensus that the incidence rate remains relatively low among this population. However, concerns exist because the rates of infection are steadily increasing among Asian and Pacific Islander men who have sex with men. Of the remaining two articles related to health, one (3 percent) described the multiple problems associated with polysubstance use among Asian and Pacific Islander adolescents, and one (3 percent) focused on mental health consequences of unexpected life events of women in Guam.

Social issues related to aging and caregiving were highlighted in three of the 32 articles (9 percent). These articles identified problems, such as dementia, that are associated with aging and the need for home health care and long-term care for Asian and Pacific Islander populations. These articles indicated that Asian and Pacific Islanders have lower utilization rates of formal services when compared with other ethnic groups and attributed this to cultural perceptions of caregiving and help-seeking behaviors.

Cultural Competence

Of the 32 articles reviewed, 16 (50 percent) had a primary focus on cultural competence. All 16 articles promoted some understanding of cultural values, and 15 articles specifically identified worldviews and values emphasizing a collectivist orientation. Cultural illustrations of the collectivist orientation include lokahi (unity) for Native Hawaiians, inafa'maolek (cooperation) for Chamorros, and fa'a Samoa (the Samoan way) for Samoans. An excerpt from a Samoan poem poignantly captures the collectivist orientation:

 'I' does not exist.
 I am not.
 My self belongs not to me because T does not
 exist.
 'I' is always 'we.' (Fiegel, cited in Nagler, 1999,
 p. 551)

All 16 articles discussed the importance of cultural values in the development or demonstration of culturally competent interventions, skills, and services. These articles promoted the inclusion of culturally diverse principles and paradigms in social services and specifically advocated for the integration of Western models of social services with cultural or indigenous models. These articles overwhelmingly emphasized practice with families and communities, with one article focusing on clinical work with Samoan individuals.

Nine articles emphasized work with families. Of these, the most references, three articles (9 percent), described the indigenous intervention, ho'oponopono, an approach in Native Hawaiian culture typically used with families but also with relevance for group work practice. Two articles (6 percent) illustrated the incorporation of cultural values for working with Chamorro families (for example, tao'tao'mona--ancestral spirits) and Samoan families (for example, aiga potopoto--extended family). Other articles, four (13 percent), broadly addressed the importance of the family for Asian populations.

Six articles (19 percent) described community-based practice with its emphasis on community participation in the design of culturally competent services. Two of these articles (6 percent) focused on community-based interventions for Native Hawaiians, a nutrition program for Native Hawaiians that used cultural foods (for example, taro, fish, and seaweed), and a community development project for Native Hawaiians predicated on cultural principles of self-sufficiency. Another article (3 percent) examined a parent training program for Samoan and other Asian and Pacific Islander families that included bilingual trainers. Three other articles (9 percent) described community programs for Asian and Pacific Islanders in regard to HIV/AIDS health education and prevention and economic reform.

It is important to note that six (19 percent) articles also addressed provider and institutional characteristics that promote working with Pacific Islander populations. These articles addressed the importance of the provider being aware of cultural biases that he or she may hold, being open to working with culturally diverse populations, and having a willingness to learn about the backgrounds of Pacific Islander populations.

DISCUSSION AND IMPLICATIONS FOR SOCIAL WORK

Although the U.S. Census Bureau (2001b) recognizes NHOPIs as a distinctive racial minority population, knowledge on these populations remains limited in the social work periodical literature. Of the 5,010 articles published from 1995 to 2004 in 23 social work journals, only 32 (0.64 percent) had content on Pacific Islanders. Social Work, the journal with the largest circulation, with more than 150,000 subscribers (NASW, 2005), produced five articles, with the remaining articles being distributed in 22 other periodicals, most of which have a limited circulation of 1,000 subscribers or fewer.

Of these 32 articles, 17 (53 percent) used the rubric "Asian and Pacific Islander" and aggregated NHOPIs with Asian Americans into a single racial classification. Aggregating information in this manner is harmful if it conceals distinctive differences between NHOPIs and Asian Americans in regard to unique histories, languages, values, and cultural traditions (Shinagawa et al., 1999). Many of these articles presented Asian Americans and Pacific Islanders as a homogenous group and neglected to describe variations between the two populations. When specific groups were identified, most often they were of Asian descent such as Chinese and Vietnamese.

The dangerous implication for social workers who rely on aggregated information is that it provides them with misleading information that might lead to inaccurate assessments of problems and could hinder the development of interventions that are culturally competent. For example, the issues of an immigrant community such as Vietnamese (for example, language barriers and acculturation) are vastly different from those of a native community such as Native Hawaiians (for example, colonization), and to presume their similarity on the basis of aggregated information would jeopardize social workers' rendering of assistance. Thus, it is vitally important to promote and use disaggregated information on Native Hawaiians and other Pacific Islander populations to optimize effective services.

Of the 32 articles, 15 (47 percent) focused on NHOPIs, with specific attention to the largest subgroups: Native Hawaiians, Samoans, and Chamorros/Guamanians. Although Pacific Islanders have the largest number of people in the United States reporting multiracial heritages (U.S. Census Bureau, 2001b), none of the articles in this survey described this unique characteristic. The themes that emerged in this literature review focused on the problems challenging this population and prescriptions for cultural competence in the social services.

Social Problems

There are multiple problems that confront NHOPIs. Half of the articles in this survey focused on social problems confronting this population. In particular, problems related to cultural conflict, poor health (HIV/AIDS, mental health, substance abuse), and caregiving of the elderly population were discussed. In general, there is evidence in other literature that highlights these problem areas for NHOPIs (Lee, 2002; Mokuau, 1999).

NHOPIs are besieged by numerous other problems that were not identified in this periodical survey. There are multiple reports generated at both state and national levels that describe the disproportionate burden that this population experiences in regard to their overall health. Including this kind of information in the periodical literature is essential and can inform social work practice. For example, information from the CDC (2005) indicates that NHOPIs are more at risk of developing and dying from cancer, heart disease, diabetes, and other diseases than are others in the U.S. population. Overall, Native Hawaiians have a higher age-adjusted death rate at 901 per 100,000 when compared with the U.S. population at 524 per 100,000 (Ghosh, 2003). One implication for social work is to generate a knowledge base on health disparities among this population in the profession's periodical literature so that we can better understand its effects within the population. A second implication would be to examine practice models that emphasize the cultural importance of familial relationships and networking with the community in addressing issues of health disparities of Pacific Islanders (Mokuau, 2002).

Cultural Competence

The development and demonstration of cultural competence emerges as an important theme when working with NHOPIs. Of the 32 articles, 16 (50 percent) emphasized knowledge of Pacific Islanders in regard to cultural worldviews and values, promoted the application of interventions for culturally competent practice, or both. In addition, attention was paid to the provider and institutional characteristics in enhancing multicultural services. In general, these findings are consistent with the literature on cultural competence, which states that professionals and institutions should be guided by knowledge of diverse cultural groups, behavioral skills for practice with the culturally diverse, and attitudes that promote openness and respect for diversity (Fong & Furuto, 2001; Green, 1999; Lum, 2003; Lynch & Hanson, 2004).

The collective/group orientation (versus an individual orientation) was consistently highlighted as the single most important worldview shared by NHOPIs. A collectivist orientation minimizes the focus on the individual and emphasizes social networks with the family and community. In emphasizing group identity for many Pacific Islanders, one article indicated that social work's emphasis on "self-determination" may be a culturally biased interpretation that is inappropriate for a population that prizes interdependence over independence (Ewalt & Mokuau, 1995).

In line with the collective/group orientation, the articles focusing on cultural competence emphasized practice with families and communities, with minimal attention to work with individuals. Most often, reference was made to incorporating cultural values (for example, tao'tao'mona--Chamorro ancestral/familial spirits) into practice. There were also frequent references regarding the application of culturally based models of practice (for example, ho'oponopono--family and groupwork) in work with NHOPIs. The inclusion of cultural values and culturally based models of practice into the social services epitomizes cultural competence in that diverse populations are empowered to use their own interventions for resolving their problems. As such, these culturally based models reflect a strengths perspective in that positive attributes of the cultural group are integrated into the approach (Mokuau, 2002).

Conclusion

This survey of periodical literature published from 1995 to 2004 suggests that the profession of social work is demonstrating a commitment to NHOPIs by beginning to establish a knowledge base but that refinement and expansion of knowledge is still needed. With its historic obligation to social and cultural diversity, social work is uniquely positioned to further its commitment to NHOPIs in several ways. First, to assist social workers in their work with Pacific Islanders, we need to increase the number of journal publications that provide information on the population. In line with the survey by Marsh et al. (2004), which reported on the types of knowledge that social workers deem important, articles should include descriptions of the population, social problems, and the effectiveness of practice. Second, to ensure that social workers receive accurate information, we must disaggregate data and distinguish Asian Americans from NHOPIs. Proper identification and understanding of these two populations as well as the ethnic subgroups subsumed within the Pacific Islander classification will improve the accuracy of our assessments and the effectiveness of our interventions. Third, we must ensure that a knowledge base on NHOPIs be anchored in cultural values and culturally based models of practice. Findings from our periodical review emphasized integrating cultural values and culturally based models into practice as the means to epitomize cultural competence. If the gold standard, as presented in the NASW Code of Ethics (2000), is to have social workers be competent in social and cultural diversity, then we must increase our vigilance in establishing a knowledge base on NHOPIs in our periodical literature.

Original manuscript received December 20, 2005

Final revision received October 10, 2006

Accepted February 8, 2007

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Noreen Mokuau, DSW, is professor, School of Social Work, University of Hawaii, 1800 East-West Road, Henke Hall 126A, Honolulu, HI 96822; e-mail: noreen@hawaii.edu. Jessica Garlock-Tuiali'i, MSW, LSW, is project coordinator, Hawaii Child Welfare Education Collaboration and doctoral student, and Palama Lee, MSW, LSW, QCSW, is director, Native Hawaiian Health Scholarship Program of Papa Ola Lokahi and doctoral student, School of Social Work, University of Hawaii, Honolulu. The authors acknowledge Christine Cipolla for her assistance in the periodical literature search.

Table 1: Year of Publication, by
Population Focus and Journal

 Populations
Year Focus Journal Title

1995 NH Social Work
1995 NH Health and Social Work
1996 C/G Asia Pacific Journal of Social Work
1997 API Social Work
1997 S Child Adolescent Social Work Journal
1997 C/G Child Welfare
1998 API Health and Social Work
1998 API Health and Social Work
1998 NH Social Development Issues
1999 API Journal of Multicultural Social Work
1999 API Journal of Social Service Research
2000 API Cultural Diversity and Mental Health
2000 NH Journal of Child Adolescent Group
 Therapy
2001 API Journal of Community Practice
2001 S Journal of Family Social Work
2001 API Journal of Gerontological Social Work
2001 NH Journal of Social Work Practice in the
 Addictions
2001 S Smith College Studies in Social Work
2002 S Journal of Poverty
2002 API Journal of Poverty
2002 NH Social Thought
2002 API Social Work with Groups
2002 API Women and Health
2002 NH Social Work
2003 API AIDS Education Prevention
2003 API AIDS Education Prevention
2003 API AIDS Education Prevention
2004 NH Social Work
2004 API Journal of Adolescence
2004 API Journal of Human Behavior in the
 Social Environment
2004 API Journal of Social Work Education

Note: API =Asian and Pacific Islanders. NH = Native Hawaiians.
S = Samoans. C/G = Chamorros/Guamanians.

Table 2: Number of Articles, by Thematic Content
for Native, Hawaiians and Pacific Islanders

 Population Focus

 Asian/Pacific Native
Theme/Subtheme Islanders Hawaiians Samoans

Social problems
 Cultural conflict 2 4 1
 Health 5 0 0
 Elder care 3 0 0
Cultural competence
 Individuals 0 0 1
 Families/groups 4 3 1
 Communities 3 2 1

Total 17 9 4

 Population Focus

 Chamorros/
Theme/Subtheme Guamanians Total

Social problems
 Cultural conflict 1 8
 Health 0 5
 Elder care 0 3
Cultural competence
 Individuals 0 1
 Families/groups 1 9
 Communities 0 6

Total 2 32