Abstract
The lack of emphasis on disease prevention in the fa’aSamoa, the Samoan way of life, may contribute to low cancer screening rates. However, other aspects of the culture, such as the respect of matai (chiefs) and faifeau (pastors) could be incorporated into cancer prevention programs aimed at improving cancer control among Samoans.
Background
The Samoan way of life, or the fa’aSamoa, is a collection of practices and rituals by which Samoans conduct their lives. The purpose of this study was to explore in the possible influence of the fa’aSamoa on cancer prevention practices.
Methods
The investigators conducted six focus groups; three in Carson, California and three in Pago Pago, American Samoa among 60 men from the communities, matai (chiefs), faifeau (pastors). Using a discussion guide, bilingual Samoan moderators asked questions about the fa’aSamoa, how traditional cultural practices might influence cancer prevention, and whether certain aspects of the fa’aSamoa could be incorporated into cancer screening programs to improve screening rates. Through qualitative content analysis, the investigators identified major themes and came to a consensus about them.
Results
The mean age of the 60 participants was 61 years, all were married, 50 were born in American Samoa, and 10 were born in the Independent State of Samoa. Among the themes, three were particularly important. First, participants confirmed that the fa’aSamoa remains an important concept in Samoan life. Second, they believed that disease prevention was not an integral part of the fa’aSamoa. Indeed, traditionally modesty and reluctance to discuss personal issues may inhibit use of screening services. Despite these a beliefs, a third theme emerged. Because of the influence of the matai and faifeau in the fa’aSamoa, participants stressed that seeking input from these leaders could improve cancer prevention programs.
Conclusion
The lack of emphasis on disease prevention in the fa’aSamoa may contribute to low cancer screening rates. However, other aspects of the culture, such as the respect for matai and faifeau could be incorporated into cancer prevention programs aimed at improving cancer control among Samoans.
Keywords: Cancer prevention and control, special populations, Pacific Islanders, cancer education, Samoans
Introduction
Cancer is second only to cardiovascular disease as the leading cause of death in American Samoans (1). Moreover, the diagnosis of cancer is made at younger ages and in more advanced stages among American Samoans than in non-Latino Whites (2,3). Recent research has pointed out the need for improved cancer control programs for American Samoans (4). Many Samoans do not believe that there is much one can do to prevent cancer (4), and they have low use of recommended cancer screening services (5,6). Complicating matters, until recently there were no culturally appropriate cancer education materials in the Samoan language made available to this population (7).
To put the current study into perspective, it is important to review some of the aspects of traditional Samoan culture. The fa’aSamoa is a unique way of life that distinguishes the Samoan community from the rest of the Pacific Island counterparts (1,8). The fa’aSamoa revolves around many native traditions including: the chief (matai) system, religious beliefs (talitonuga), dietary habits (mea’ai), and family and village social functions (fa’alavelave) such as funerals and weddings, and chiefly title bestowal ceremonies (saofa’i).
The basic social and political unit of Samoan society is the village (nu’u) (8). All traditions and beliefs are formed within this concept. The way Samoans conduct their lives is directly influenced by the way the village perceives their behaviors. From the concept of nu’u came the aiga (family), the foundation of the fa’aSamoa. Much emphasis is placed on conducting one’s life to benefit the greater good of the aiga (8). Indeed, many of the beliefs and cultural practices are formed and utilized in the aiga
The matai system is the oldest Polynesian system of governing aiga and nu’u (8). The matai delegates social responsibilities and seeks to ensure that family members participate in fa’alavelave and contribute to both the aiga and the nu’u. For example, if a death occurs in the family, it is the matai’s responsibility to contact relatives (close and extended) in Samoa, Hawaii, and California. The matai then makes the arrangements with the funeral home, coordinates the buying of food and supplies, and keeps a detailed account of contributions. A family meeting is called for the local aiga to decide on the amount of money and goods it wishes to give as a group to the family in mourning (8).
The church is an intrinsic component of Samoan life. In 1830, missionaries from the London Missionary Society introduced Christianity, which spread rapidly throughout Samoa, displaced many native religious beliefs and practices. The aiga is deeply rooted in the spiritual, having long abandoned polytheism in favor of monotheism. from the pagan beliefs in different gods to the more recent belief in one God. When families migrated from the Samoan islands to Hawaii and California, the church became the focus of community activities taking the place of the nu’u in these new environments. In effect, it became an urban village with deacons assuming the role of talking chiefs (tulfale) and faifeau (pastors) that of high or paramount chiefs (alii). As in traditional villages, pastors are well-respected in the communities.
Our previous research suggested that cancer prevention efforts based upon the fa’aSamoa have the potential to improve cancer control in this population. For example, a recent study found that American Samoans believed that failure to follow the fa’aSamoa could lead to cancer and that a return to the fa’aSamoa could prevent cancer (9). Within this context, this study will evaluate current beliefs about the fa’aSamoa, the impact of the fa’aSamoa on use of cancer screening services, and the potential for incorporating certain aspects of the fa’aSamoa into cancer prevention and control programs.
Methods
To answer the research questions, the investigators conducted focus groups with Samoan men in California and American Samoa. The advantages of focus group methodology for needs assessment and program development are multi-faceted. The methodology is a socially oriented research procedure that permits the moderators to probe for responses (10). Moreover, focus groups are consistent with the Samoan culture that includes an oral tradition and face-to-face meetings (fono) in which information is exchanged with a high degree of reliability (11). The University of California, Irvine Human Subjects Review Committee approved the research protocol.
The research settings were Carson, California and Pago Pago, American Samoa. With a population of 12,836 American Samoans, Los Angeles County, where Carson is located, is home to the largest concentration of this racial/ethnic group outside of the Territory of American Samoa which has a population of 57,291 (12).
The investigators chose focus group participants from each of the following groups: men from the community, matai, and faifeau. We chose to interview men in this pilot study because of the important role they play in traditional Samoan culture. Focus group participants were selected from lists that were kept by the Office of Samoan Affairs in Carson and the Native American Samoan Advisory Council in American Samoa. These community-based groups have worked closely with Samoan communities.
In addition to being a community member, matai, or faifeau,, criteria for participation included being a self-reported Samoan, having no history of cancer, and being 50 years of age or older. We chose the age criteria because men of that age group would likely be well versed about the fa’aSamoa and because screening for important cancers in men, such as prostate and colorectal cancer, begin at age 50. Potential participants were contacted by telephone to explain the study and to request participation.
We conducted six focus groups: two with community men, two with matai, and two with faifeau. One focus group with each type of participant took place in Carson, California and the other one occurred in Pago Pago, American Samao. Each focus group had from 8–12 participants. The sessions were conducted at a Samoan church in Carson and at the American Samoa Community College in Pago Pago.
Investigators experienced in focus group methodology trained moderators to conduct the sessions. Two male bilingual (Samoan and English) Samoan moderators conducted the focus groups, with one moderator conducting the discussion and the second moderator functioning as a note taker. After obtaining informed verbal consent, the moderators conducted and audiotaped the focus group sessions. The moderators reviewed their notes at the end of each session. Each focus group lasted for approximately two hours.
The sessions began with a prayer as is the custom for all Samoan meetings. After the prayer, the moderator obtained basic demographic data including age, marital status, and country of origin. Next, using a discussion guide, he asked general questions about the fa’aSamoa such as: What is the fa’aSamoa? What are the components of the fa’aSamoa? How does religion influence the the fa’aSamoa? What are the matai roles in the fa’aSamoa? What are the faifeau roles in the fa’aSamoa? The next set of questions addressed what the participants believed about the influence of the fa’aSamoa on the use of cancer screening and early detection services. The moderator asked questions such as: Does the fa’aSamoa influence cancer prevention practices? If so, how? Finally, the moderators explored whether participants believed that the fa’aSamoa could be incorporated into a program to increase the use of cancer prevention services. If so, how?
Bilingual certified translators transcribed the audiotapes verbatim. In general, the moderators conducted the focus groups in Samoan; however, participants used the English language during parts of the sessions. For those parts conducted in Samoan, the transcribers translated the transcripts into English. Using content analysis, the investigators read the transcripts multiple times and identified major ideas or themes and came to a consensus about them. They tested the trustworthiness of the findings by discussing them with some of the original focus group members – who confirmed the findings.
Results
Sixty men participated in the focus groups. The mean age was 61 years, all were married, 50 were born in American Samoa, and 10 were born in the Independent State of Samoa. The investigators identified several major themes from the transcripts of the focus groups (Table 1). The themes are discussed below in answer to the following questions: What is the fa’aSamoa? What influence does the fa’aSamoa have on the use of cancer prevention services? Could certain aspects of the fa’aSamoa be used to improve use of cancer screening services?
Table 1.
Themes
| 1. The fa’aSamoa is important in the lives of Samoans. It consists of: |
| • Chief system |
| • Religious beliefs |
| • Family |
| • Villages |
| • Churches |
| • Cultural traditions such as family interruptions |
| 2. The fa’aSamoa may have a negative influence of use of cancer prevention services because of: |
| • Lack of emphasis on prevention |
| • Modesty |
| • Shame |
| • Respect |
| • Embarrassment |
| 3. Matai and faifeau should be included in cancer screening programs. |
What is the fa’aSamoa?
As illustrated by comments from the participants below, there was a general consensus among all focus group participants that the fa’aSamoa referred to the culture of the Samoan people. However, the men from the community discussed the fa’aSamoa in general terms, while the matai tended to stress the role of the chiefs in Samoan society, and the pastors stressed the importance of religion.
Comments from the community men included:
“The fa’aSamoa is our culture. It is the way we behave and act. It is respect, how we talk, righteous behaviors, royal conduct since we are descendents of kings, and servitude. These are just some of the things that encompass the fa’aSamoa.”
“The fa’aSamoa is what we use to describe people from Samoa, just like if you were from America, we would say fa’aAmerica. It is just a term used to describe people from their different backgrounds.”
In response a question about differences in the fa’aSamoa between American Samoa and the mainland United States, one man said:
“It is the exact same. They are one in the same. The only difference here is that there are no villages and major chiefs. It is the same, in the sense that when there are familial interruptions, than we will use the same the fa’aSamoa that is practiced in the islands. If something were to happen to the pastor’s daughter in Samoa, that offending family’s house would be burned down, all their animals would be slaughtered. But here we can’t do the same because of the law. In Samoa, if a teacher were to spank a student, they aren’t sued by the family like they are here.”
Comments from the matai included:
“Well as I said before, it all started from the top. In Samoa they have family, a clan of people that should be headed by a matai. The family is governed by the High Chief. He also governs the lands. He has the last saying. There are other chiefs of the family as well, but they are relegated to serving under the High Chief and assist in ensuring the well being of the family under the care of the High Chief. One day, they too will become a High Chief, but only after servitude. If there is a funeral or a wedding, then you will see the fa’aSamoa at its purest…”
“…We all know from the beginning of life that everything in the fa’aSamoa begins with the family. In the family we raise and begin to mold the conduct of our children out in the world. It is the way we represent ourselves before others, within our families, villages, and in the world. Just like setting a table for dinner, the fa’aSamoa teaches a child how to behave and act in a manner that is acceptable, like in setting the table, certain plates, utensils, and glasses are put forth, this is the fa’aSamoa.”
“The first thing is let’s not beat around the bush, in my mind the person that dictates the the fa’aSamoa is the high chief. The pastor’s role is the pulpit, but when it comes to the affairs of the fa’aSamoa in the families and villages, it is under the jurisdiction of the chief. The chief is the head of the family, he leads the family. Only one person dictates the fa’aSamoa, and that is the chief. The chief is where the fa’aSamoa and culture begins and ends. The fa’aSamoa goes through the chiefs who between them dictate and determines the direction of the fa’aSamoa.”
Comments from the faifeau included:
“The traditions and customs of our country, we can't do away with. We can't change them either. God created the world. He divided the world into different languages, like Samoan. He also gave each, traditions and customs to live by. These are the things that are important in Samoa; its traditions and customs. They're a way by which Samoans relate to each other. It's relational. But what's most important is a life of worship. Samoans relate to each other through their traditions and customs. From these comes a life of respect. This life is centered on God. Everything is one because of God's name and purpose…”
“The fa’aSamoa is how one carries himself, it is something that is passed from generation to generation and will continue on till eternity. I also believe that this is one area that the new male generation is trying to change as well. But to me, I don’t think it works that easily. You can’t just barge in and change the fa’aSamoa. This is one of the reasons that Samoans are held in high esteem, because they have an identity that goes way back in history.”
“The fa’aSamoa is one of the highest regards no matter where one travels. Samoans are prideful and take great pride in who they are and where they come from. They never want to be put down by anyone, because they are descendents of royalty. There is no other culture around the world that compares to the Samoan culture.“
What influence does the fa’aSamoa have on the use of cancer prevention services?
There were a variety of opinions regarding the influence of the fa’aSamoa on cancer prevention services. The minority believed that there was no influence. However, a more common perception was that the fa’aSamoa provided a negative influence because of the tendency of Samoans to avoid talking about private issues, such as prostate cancer screening, even among family members. There were no important differences between the views of the community men, matai, and faifeau regarding this issue. The comments below are typical of the responses from focus group participants.
“I don’t think the fa’aSamoa has a role in health care. I think it’s just the nature of the person to get checked. There are some who eat sparingly not only Samoans but also other groups. Some are just embarrassed with things like this. Who wants to have others look at their private parts? Unless you are someone who likes to go get checked by nurses like one of the pastors here. But it’s just the nature of the person. So, I don’t think the fa’aSamoa has a role in this. It’s just the embarrassment of the people. However, if you are close to your people/ congregation, whether you are Samoan, White, Mexican, it’s your duty because you want to live.”
“There is this belief especially for Samoans, when they are sick, first they go and do what they want to do because they don’t know what next to do. They rather do what makes them happy than to face something unknown. Its only when they are near their death bed that they seek treatment.”
“I don’t know how to put it, but Samoans are ashamed to have word come out that they have cancer. But now days, many know of this illness, it’s not like HIV and AIDS, if they were told they have this, they wouldn’t want anyone to know. It’s because of pride that they refuse treatment so that people wouldn’t find out what they have. But nowadays, I think they cannot hide it anymore. It’s more common nowadays. No more pride, because people know there’s treatment. Then and now there are different ways of receiving treatment. They didn’t have boats and cars to get to doctors, so the chief and family decide to seek treatment, everyone is involved.
“This is another problem with the culture, refusal to talk about private matters because it is tabooed. Samoans are very respectful, even to death, thus don’t won’t discuss these things even with their daughters. So if you don’t go and see a doctor but hide it, it is because of the culture.”
“Why the Samoan is ashamed to get screening for a disease? I think we understand the meaning of the fa’aSamoa as explained by the pastors, but I believe the fa’aSamoa you're looking for has to do with diseases. Samoans are ashamed out of respect for the doctor, he's careful about what to say to the doctor, he's careful about what words to use. He's afraid to say that he has a certain disease because he doesn't know what to say.”
“That the fa’aSamoa is based on fear; the person is embarrassed because it suggests that he lacks respect. So what one needs to do is put aside the fa’aSamoa for that time and do what is necessary for his good in regards to screening for the disease. Recall the Samoan is about respect, but if we put that in the context of disease, the doctor is without respect. But the doctor really isn't concerned about any custom. The custom is not this or that; he's looking at the individual's best interest. But the fa’aSamoa is, respect for the doctor. One shouldn't be ashamed. That's my help”
Could certain aspects of the fa’aSamoa be used to improve use of cancer screening services?
As with the question above, there were differing opinions regarding whether an emphasis on the fa’aSamoa could improve cancer-screening services. However, the majority opinion was that it could by enlisting the help of matai and faifeau. The following comments are illustrative of the responses.
“It can. What I mean is that the culture through the chiefs can influence an individual to get a prostate exam. The chief will go over to the family’s house and speak with them with regards to the illness or the exam. The chief can use his authority as the leader of the family to encourage this individual to go and seek treatment or take the exam. A chief can do these things. Even if it is a young man, he can walk to the parents and encourage the parents to take their child for treatment.”
“The problem with getting people to seek treatment is that they need to be told by someone of authority and respect like a pastor or chief before they even consider going. Otherwise, they will do what they please until it becomes too late. This has been the mode of operation for our people.”
“Here in the States because we don’t have villages, if the pastor makes an announcement and asks the congregation to go get treatment, the congregation will follow, but in Samoa, it’s the role of the high chief to so. So here, the voice of the pastor is important in getting people mobilized to seek treatment.”
“I agree with the last comment. We as pastors should not be limited to just the Bible. Like it states in the Bible, a man shall not become an animal and that another man should not have relations with another man but with a woman. This is what we need to teach the people. To abide and live according to what is written in the bible.”
“We pastors are the doctors of the Bible. We are also the doctors of healthy behaviors and lifestyles because we are the ones leading the church. A church cannot grow if they are unhealthy. We shouldn’t stop at ensuring a healthy spiritual life, but also a healthy worldly life. Health comes from the word balance. We need to balance what we do in the churches with what we do in the world. A balance needs to be set for all things. We are the heads of the culture because the churches act as villages by which our people come together, thus as pastors we must lead our people spiritually as well as physically.”
“A pastor role is to educate boys and girls of the church and spreading positive information to all the people. I am thankful for this afternoon and the opportunity to this discuss this much-needed issue. No matter how big or small we need to get checked. However, this role should not be limited only to pastors but to matai as well. Matai and family leaders need to encourage these changes as well. They need to tell their families what needs to be done.”
“I agree with one of the participants in that yes the fa’aSamoa does have an influence on cancer screening. It may be difficult, because these are habits that we’ve had for generations. When an individual is sick, they will hide their sickness because they are ashamed that others will find out. It’s my business and not yours. But you can influence this through education to overcome these perceptions and beliefs. So that people can come out of hiding and embrace their illnesses not out of fear, but to be able to live a longer life. The fa’aSamoa can help this providing an avenue by which the education and training of the community can be implemented.”
Discussion
Our findings confirmed the importance of the fa’aSamoa to Samoans in California as well as those residing in the Territory. These findings are consistent with prior research regarding this population (1,8,9,13), In advancing the literature, the results suggest that the fa’aSamoa may have a negative influence on cancer screening practices but also indicate that certain aspects of the fa’aSamoa, specifically the traditional roles of matai and faifeau, could be incorporated into cancer prevention and control programs.
The study participants pointed out that an emphasis on prevention was not part of the fa’aSamoa. Traditionally, Samoans viewed preventive practice as the ability to maintain good health without consulting a doctor (8). Samoans did not seek health care intervention for things they considered small that wouldn’t necessarily interfere with one’s normal routine. Samoans have learned to have a high tolerance for pain, because there is much pride associated with good health. This pride is translated into a strong status among ones family and within the village. Anything less could lead to criticism and the ultimate disgrace of being weak and feeble, unable to care for the family and the village (8).
Moreover, the participants noted that Samoans are traditionally modest and reluctant even to discuss personal issues. The idea of seeing a doctor for examination of the rectum for prostate cancer, for example, would not be considered in the traditional culture. Widely available cancer screening tests for prostate, breast, and cervical cancer have very personal and tabooed implications for Samoans, for these parts are meant only to be touched and viewed by the individual themselves and/or their significant others. The question of an outsider looking in is a major issue in screening and early detection.
On the other hand, the results indicate that aspects of the fa’aSamoa could be incorporated into cancer prevention and detection interventions. In American Samoa, the matai are respected leaders of the villages, while in many ways, the faifeau play this role and the church replaces the village for Samoans on the mainland (14). The focus group members believed that matai and faifeau should expand their leadership roles to include encouraging more cancer education and increased use of cancer screening tests. They felt that such efforts would be well accepted by the Samoan community and would lead to improved cancer control.
Several limitations of the study should be mentioned. First, the nature of qualitative research is to explore what is presented, as opposed to counting how often something is present. Thus, we did not provide proportions of respondents who responded in one way or another. Second, reliability and validity are not concepts that can be directly taken from quantitative research and applied to qualitative research. Qualitative investigators often address these concepts through the ‘trustworthiness” of the results. We addressed trustworthiness by providing the results to members of the focus groups and asking them to comment on them. Finally, the results of the focus groups may not be generalizable to the whole American Samoan community. Additional population based surveys would be necessary to determine the generalizability of the results.
In conclusion, the fa’aSamoa remains the revered way of life for Samoans. Future cancer prevention and control efforts should consider including the leaders of the fa’aSamoa, matai and faifeau, in the programs. Since these leaders are not likely to be well versed in cancer screening recommendations, they could be targeted for cancer education themselves prior to involvement with cancer control interventions. Moreover, their other duties may preclude their active involvement as educators in such programs. This role could be assumed by Samoan health professionals with the matai and faifeau encouraging the population to participate.
Acknowledgments
Sources of support: Supported in part by grants from the National Cancer Institute (U01 CA64434 and P30 CA62203). The contents of the manuscript are solely the responsibility of the authors and do not necessarily represent the views of the funding agency.
Footnotes
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