Native Hawaiian and Pacific Islander Youth Substance Use Prevention in Rural Hawai‘i

Background

On February 7, 2024, a 12-year old student in a rural public school on Hawai‘i Island was found unresponsive on a bench. Accounts from other students gave conflicting reports, but it is believed the student used an e-cigarette device before she became unresponsive, or potentially ate a cookie laced with some type of substance.¹ This troubling event underscores the continued reality of a significant public health concern in Hawai‘i, notably in rural communities – youth substance use.^2–3 National and local public health data consistently demonstrate that Native Hawaiian and Pacific Islander (NHPI) youth have disproportionately high rates of substance use and substance use disorder.^4–5 Rural Hawaiian youth are particularly at-risk because they reside in areas with elevated rates of use and are exposed to high-risk social environments, such as family offers to use substances and the normalization of marijuana use.^3,6–7

Substance use initiation often occurs during adolescence, about age 13 or younger.⁸ Early initiation of substance use is commonly associated with problematic substance use, such as substance use disorders, highlighting the critical need for research identifying the risk and protective factors for youth, and for efforts focused on youth substance use prevention. Overall in Hawai‘i, the substances most often reported for early initiation are alcohol, marijuana, e-cigarettes, and tobacco cigarettes.⁸ An initial peak for early initiation of alcohol occurs at about 8 years of age, with a later peak at about age 13.⁸ Initiation of marijuana, e-cigarette, and tobacco cigarette use occurs around age 13, while the peak for binge drinking primarily begins to occur about the age of 15–16.⁸ According to the 2019–2020 Hawai‘i Student Alcohol, Tobacco, and Other Drug (ATOD) Survey, among ethnic groups in Hawai‘i, NHPI youth report the highest rate of cigarette and e-cigarette use, disproportionately high rates of moderate-to-heavy e-cigarette use, marijuana use, and binge drinking, as well as the highest need for substance use treatment.⁸

Youth substance use can increase the risk for injuries, violence, and disease, and it is often associated with sexual risk behaviors, poor mental health, and suicidality.² Preventing youth substance use can reduce these risks as well as the risk for later use of substances and the development of a substance use disorder.^2,5 NHPI rural youth, with their unique cultural and social context, face specific challenges in substance use prevention, particularly related to familial relationships.^3,9 Etiological studies have found that Hawaiian youth interact significantly more with their family members and receive more family support than their non-Hawaiian counterparts, findings that are consistent with the ‘ohana (family) oriented value system centered within the Native Hawaiian culture.^10–12 These findings suggest that family factors play an important and influential role in the lives of Native Hawaiian youth and highlight the strong possibility that substance using behaviors among Native Hawaiian youth exist within a relational context.^10–12 Research with these youth reveal that family factors significantly contribute to their substance use decision-making, including both decisions to engage and decisions to abstain from substance use.

Parental influences on youths’ substance use, such as parental monitoring and parent/child conflict, are particularly significant for NHPI youth.⁷ According to the 2019–2020 ATOD data, one of the strongest protective factors for youth is clear rules and consequences within the family about alcohol and drug use.⁸ These findings demonstrate that it is critical to examine family factors that promote NHPI youth substance use resistance strategies, because these strategies have direct implications for youth substance use prevention.³ However, few studies have specifically examined familial influences on NHPI youths’ substance use decision-making and behaviors in rural Hawaiian communities.^3,13–14 More culturally focused research is needed to examine these familial factors, especially parental influences, that contribute to substance use resistance for these youth and ways to meaningfully incorporate these factors into effective family-based substance use interventions.

Pilot Study

One current study seeking to examine these familial factors is titled, “Parental Influences in Youths’ Tobacco and Drug Use Resistance in Rural Hawai‘i.” This pilot study is funded through Ola HAWAII (5U54MD007601-37), UH Mānoa’s Research Centers in Minority Institutions (RCMI) Specialized Center and is led by a Native Hawaiian community researcher and Assistant Professor at Thompson School of Social Work and Public Health. A community based participatory research (CBPR) approach is utilized throughout the study design to insure the equitable representation of both academic and community expertise. Through individual, semi-structured interviews with parents of Native Hawaiian students on Hawai‘i Island, and an innovative focus group called a Citizens’ Panel,¹⁵ this study seeks to identify parental influences on rural NHPI youths’ resistance to tobacco and other substances.

The experimental plan for this project is guided by an innovative, multifaceted methodology that applies core CBPR principles, including co-learning, local relevance, mutual benefit, and long-term committment.¹⁵ The study utilizes semi-structured interviews with Hawai‘i Island parents or caregivers of Native Hawaiian youth, and a subsequent deliberative focus group (Citizens’ Panel) consisting of Hawai‘i Island parents or caregivers of Native Hawaiian youth and Native Hawaiian serving community-based service providers. The Citizens’ Panel is a novel methodology that has been employed as the primary methodology in 2 federally funded projects in which the researchers aimed to better engage underrepresented groups in order to encourage stakeholders’ input and decisions in the research process.¹⁵ This CBPR approach engages public expertise and knowledge of community health needs, risks, and priorities to tailor public health research and interventions for greater relevance and impact on disadvantaged communities. It offers a systematic method for obtaining rich community insight into health disparities, shaping community-informed solutions, and affords disadvantaged communities influence over public health decision-making to stimulate grassroots change and health equity. The purpose of the individual interviews is to explore the role of parents in promoting youth substance use resistance, and the purpose of the Citizens’ Panel is to rank order the identified parent priority areas. The goal of the study is to identify components that can be used as a foundation to develop future culturally grounded, family-based substance use prevention curricula.

This proposed study not only aims to improve NHPI health, but also reduce ethnic and geographic disparities in health by conducting community-driven, socio-behavioral, and translational research on rural Hawai‘i Island. Additionally, it seeks to identify culturally relevant parent and caregiver priorities to support Native Hawaiian youth resistance strategies that can be incorporated into a future family centered, evidence-based, culturally grounded youth substance use prevention curriculum.

Conclusion

Research with rural NHPI youth demonstrates that substance use, including tobacco product use behaviors, are strongly influenced by their social context, particularly close relational networks of biological and ascribed (hanai) family members.^9,12,16 The closeness and intensity of these familial interactions across numerous social relationships function to magnify both risk and protection for these youth, with immediate and extended family members providing both exposure to or protection from illicit substances in the home, school, and community environments.^9,16 Though substance use for NHPI youth may be influenced by multiple factors, family factors seem to play a key and influential role in the use and resistance of substances for these youth.^3,9

Research gaps remain which can inform effective prevention practices incorporating culturally relevant parent and caregiver supports for youth drug resistance strategies. This study will aid in addressing a gap in the culturally focused prevention literature and has important implications for complimenting existing school- and community-based youth-focused prevention interventions with the goal of reducing the health disparities seen in NHPI youth populations.