Participatory Drug Prevention Research in Rural Hawai`i With Native Hawaiian Middle School Students

Abstract

Background/Objectives

This paper describes a prevention study focused on the drug use scenarios encountered by Native Hawaiian youth. Priorities from communities on the Big Island of Hawai`i helped to shape the qualitative data collection and analysis of middle school students participating in the study.

Methods

Forty-seven youth from five different schools were interviewed in small, gender-specific focus groups during lunch hour or after school.

Results

The findings indicated that youth were exposed to drug offers that were direct–relational or indirect–contextual in nature. Direct–relational offers were didactic exchanges where drugs or alcohol were offered from one individual to another (e.g., “Do you want some beer?”). Indirect–contextual offers reflected complex exchanges among individuals, where drugs or alcohol were involved, but not offered directly (e.g., “Do you want to hang out with us?”).

Conclusions

Implications are discussed regarding drug prevention research and programs that highlight indirect–contextual drug offers that are place based and culturally grounded.

Promoting Social Competence and Resilience among Native Hawaiian Youth (PSCR) is a prevention study examining environmental contexts of alcohol, tobacco, and other drug offers to middle school-aged Native Hawaiian youth in rural Hawai`i. By using an ecological and participatory model, the intent is to develop comprehensive and authentic strategies for drug use resistance that are place based and culture based. Native Hawaiian youth have reported high rates of substance use with significant adverse effects. For example, Hawaiian youth have reported the highest rate of substance use among ethnic groups in Hawai`i,¹ and the highest need for drug and alcohol treatment.² Although there have been substantial efforts in recent years toward developing drug prevention programs focused on indigenous youth populations,^3–6 very few have targeted Hawaiian youth.⁷ erefore, the need for Native Hawaiian informed drug prevention is warranted, particularly in rural areas where Hawaiian youth tend to reside.⁸

Although this project was not initially proposed as participatory research, the lead investigators believe that participatory practices are essential to quality research and sustainable community wellness. Our concept of participatory research is founded on social justice work with marginalized, colonized, and otherwise oppressed populations globally,^9,10 in the United States^11,12 and Hawai`i,^13–18 and emphasizes participatory practices in knowledge construction and ownership.^19,20 Therefore, we have been reshaping the project around participatory principles of practice.

Prevention partnerships in rural Hawai`i are fundamental to Native Hawaiian health. For example, with few exceptions, Hawaiian students account for 35% or more of rural schools’ total student population.<sup>3</sup> Because rural communities in Hawai`i tend to be underserved in terms of health and related prevention services, the research team agreed that the first step was to partner with rural community groups. Although our role as prevention scientists may differ from the community practitioners or educators with whom we were seeking to collaborate, we ultimately share the same goal of eliminating drug-related health and educational disparities and the differential burden born by Native Hawaiian communities.

Rural Hawaiian communities often are overlooked in health research owing to logistical challenges experienced by the university-based researcher. Challenges stem from the fact that most researchers are affiliated with universities in urban Honolulu, on the island of O`ahu. Working with rural communities generally requires added travel time and expense. Despite this, we felt the importance of working in rural Hawai`i far outweighed these challenges.

METHODS

The PSCR project incorporates a mixed methodology over a 5-year period. The focus of this paper is Phase 1 (2007–2008), during which students identified environmental demands for drug use specific to their community, school, and family contexts (for more information, refer to a recently published description of the overall study²¹). Research procedures were approved by the Institutional Review Boards at the University of Hawai`i, Hawai`i Pacific University, and the State of Hawai`i Department of Education.

Developing Partnerships

Given the conceptual emphasis on place-based cultural relevance,⁷ we focused our work on rural locales within a specific geographic location. Serendipitously, while the research team was formulating rural partnership plans, the Hawai`i County Prosecuting Attorney’s office invited the principal investigator to work with their geographic community on the island of Hawai`i (also known as the “Big Island”). This invitation stemmed from the community’s frustration in utilizing various prevention programs with little or no lasting effects, or that had little relevance to the culture and values of the youth and families in Hawai`i and the Pacific. Further, our lead community partner explained that as funding levels decreased, federal regulations for grants increasingly demanded implementation of “best practices.” However, despite their extensive search, the Prosecuting Attorney’s office found these programs did not address cultural components that are a part of their history and current every day lives.

The community–university partnership was solidified through mutual respect between the researchers and community representatives, and a common goal of strengthening the community through youth drug prevention. Further, the PSCR project was consistent with the County of Hawai`i’s recent comprehensive plan to reduce juvenile delinquency.²² The Prosecuting Attorney’s office facilitated the partnership among the academic team and public school administrators who had expressed interest in reducing drug problems. After reviewing project information, several schools joined the study. For this phase of the research, it was agreed that school names would not be released.

Community partners have influenced the research design, implementation, and dissemination of findings. First, interview questions were rephrased with input from school personnel. The structure of our focus groups consisted of a handful of lead questions with several follow-up or probe questions. Community partners helped the research team to identify culturally relevant follow-up questions appropriate to the specific rural communities.

Second, student recruitment was guided by school principals and school liaisons. We worked mainly with a principal-designated research liaison in each school—a teacher or counselor most familiar with Native Hawaiian students, families, and organizations in their school community. The liaisons’ role consisted of (1) serving as the primary contact for communication and activities between the university research team and the school, students and families, and community, (2) assisting with student recruitment, and (3) coordinating focus group interviews.

Finally, the research team has discussed preliminary findings with partners as a means to understand their implications. Although it is recommended that academic–community health partners develop this process at the outset of their project,²³ additional aspects of the partnership roles and responsibilities are continuously emerging in this study. Most important, we have collaboratively developed the methods, improved our understanding of the findings and implications for prevention, and chosen appropriate school and community dissemination methods.

Research Participants

Five rural middle schools participated in Phase 1 of this study. Student participants were recruited with assistance from each school’s liaison. Fourteen small focus group interviews were conducted. Separate groups were held for girls (n = 26) and boys (n = 21), for a total of 47 participants. Participants were in grades six (9%), seven (53%), or eight (38%), and were designated intermediate or middle school students. All students self-identified as Native Hawaiian, and were of mixed ethnocultural backgrounds including Pacific (e.g., Tahitian, Samoan), Asian American (e.g., Japanese, Korean), Euro-American (e.g., Portuguese), and American Indian ethnocultural groups.

Data Collection and Analysis

For each semistructured interview, the facilitator role was filled by a lead researcher, and a research assistant served as a note taker. Interviews were held at school, ranged from 40 to 60 minutes, were audio-recorded and transcribed verbatim. The interview note taker created the initial transcript, which was subsequently edited by a member of the research team, and finally reviewed for accuracy by the interview facilitator. Interviews consisted of these four open-ended questions, and as appropriate, probing questions were asked to promote more detail in the group discussions.

1. Have you (or anyone your age) been offered alcohol, cigarettes, marijuana, or other drugs?

2. Do you think drug use is a problem in your school or community?

3. Is it hard to resist drug offers?

4. If your parents found out that you were using drugs, how would you feel; what would they do?

Analyses occurred in stages, based on grounded theory.^24,25 Our initial stage centered on “open coding,” whereby the lead researchers inductively identified emergent patterns in the narratives. The next stage involved using these emergent themes to develop the coding structure. Next, each transcript was then coded and added to the digital database (NVivo²⁶ software) for further analyses to validate and expand this structure. Axial and selective coding were conducted by identifying themes in the types of drug offer scenarios and their relationship with higher order constructs.

All members of the research team were trained by collectively coding one transcript to clarify the initial definition and parameters of each code. Subsequent transcripts were coded by one lead researcher, both of whom are experienced qualitative researchers,^27–31 and one or more research associates. For each transcript, narrative segments that were not identically coded by research team members were discussed and justified for inclusion or exclusion in the code’s data set. Once the coding team reached consensus about a specified transcript, it was imported into NVivo. As expected in qualitative analyses based on grounded theory, code definitions evolved around the narrative content. As a result, the codebook was continuously updated (about which coding team members were informed).

PRELIMINARY RESULTS

Preliminary analyses reported here concern the drug offer scenario code, and represent one part of the data generated from this study regarding drug offer scenarios. A total of 171 drug offers scenarios were described. These fell into three distinct categories: (1) actively seeking drugs (n = 4 [2%]); (2) direct–relational offers (n = 81 [47%]); and (3) indirect–contextual offers (n = 86 [50%]). Drugs most commonly offered in these scenarios were beer, hard liquor, marijuana, or cigarettes.

Participants distinguished between situations in which they actively sought alcohol, cigarettes, and other drugs from those in which drugs were offered to them. Across all 14 interviews, we found only four situations in which participants actively sought drugs as a coping mechanism for family or dating relationship problems. Of these four, only one was an actual event in which one participant described a real situation where she actively sought drugs for this purpose. The other three situations were described as reasons why a youth might want to seek drugs (e.g., as a coping mechanism for family or dating relationship problems) and were hypothetical in nature.

The bulk of participants’ narratives indicated a distinction between direct–relational and indirect–contextual drug offers. Direct–relational offers occurred in nearly half of all drug offer scenarios, in which a specific individual explicitly offered drugs to the participant. Direct–relational offers were made at school, apparently during a free period (e.g., recess, on the way to school, after school), as well as in one’s own home or the home of a relative or friend. Direct–relational offers were made by close friends and classmates, same-age and slightly older cousins, and adult family, including parents, grandparents, aunts, and uncles. Below are typical examples of direct–relational scenarios, one within the free-period context at school and the second within a family context.

“Chrissy” (eighth-grade girl): Well we were walking around [recess at school] and I kinda had a feeling they had alcohol, ‘cause I could smell it. But then, I didn’t do anything. And I was just walking with them. And they offered me a drink, but I said no. And then after I got tired of walking, I went by my friends [and siblings], by the classes, and that’s all.

“Joe” (seventh-grade boy): Actually [it] was one of my [older cousins]. We all was at this party and then when I was walking, he stop[ped] and asked me to try take one drink of beer. And, [I] told him that I gotta go, but he kept following me and asking me to drink beer.

In indirect–contextual offer scenarios, no explicit drug offer occurred. Rather, narratives suggested that middle school youth often find themselves (wittingly or unwittingly) in situations in which alcohol, marijuana, or cigarettes are being used. The drug offer is made implicitly by the drug-using context itself, not by a particular person. The youths’ narratives suggest that a latent expectation for drug use is implicit within the specific social and cultural context. Although the offer is unexpressed in direct terms, it is nonetheless present, according to the youths’ narratives. These, indirect–contextual offers fell into two categories based on whether the situation was described as avoidable (80%) or not. Avoidable indirect–contextual offers generally occurred within the peer context, such as at school during recess. Unavoidable scenarios generally occurred within the family context, such as when parents were drinking beer or smoking cigarettes, or when other respected adults in the home were using.

One such scenario was described by two eighth-grade girls, and was representative of other focus groups. The girls were explaining why kids their age do not consider alcohol a big problem as compared with cigarette smoking. Their explanation revealed a typical indirect–contextual drug offer.

“Hoku”: I think they think that about alcohol because like they feel that everyone should try it, everyone should drink it, alcohol’s the best, alcohol’s like.

“Lani”: And it’s a lot easier to get than cigarettes….’Cause, like, if your parents them is drinking and like everybody around you is drunk and they don’t really pay attention to what’s going on.

“Hoku”: You can just grab it.

“Lani”: You can just [go] right into the cooler and grab ‘em right out, take ‘em to your friends and start drinking. And cigarettes is in a pack and they might count the cigarettes and whatever…. Yeah, they probably carry it around with them.

The following quote from a group of seventh- and eighth-grade boys indicates that subtle exposure to drug-involved peers and family may create ambivalence among some youth about the dangers or risks of drug use. Although one of the boys hints at associating drug use with being bad (i.e., “my cousin hangs out with all the bad kids”), he seems hesitant about whether this makes his cousin bad by association, and then by extension whether drug use is bad. This uncertainty was expressed in a variety of ways across several groups, and seems to predispose participants to indirect–contextual offers because they want or have to maintain their social and familial relationships.

Facilitator: Do you guys have situations where friends ask you if you want to use drugs or alcohol?

“Michael”: What if they smoke like whatever, but they don’t offer? Does that still count?

“Kenny”: [I have] two cousins, a brother and sister, [who do drugs].

Facilitator: Have they offered you drugs or alcohol before?

“Kenny”: No, but he has like…all weed in his room. He’s in high school already…. They hang out with all their friends that smoke. And yeah, he hangs, my cousin hangs out with all the bad kids that shoplift and all that, yeah. But, he doesn’t [shoplift], he only smokes.

Indirect–contextual offers seem to occur in more overt ways among peers in community settings. For example, an eighth-grade girl described a situation where her friend was asked by some older boys to drink and smoke with them at an athletic event. Knowing this, she joined her friend. She was not explicitly offered alcohol or marijuana, but a drug-using context clearly was evident.

“Sunny”: Yeah. And, so me and my friend… we was hanging with these boys from our team and they all had snuck like weed and hards and stuff into [the race location] …. After that race finished we was all just hanging out under the tent and they asked my friend if she wanted to go drink, and she said yeah. So, she asked me if I wanted to come, and I yeah went. And then we was all just drinking like a lot, but yeah. It wasn’t that bad.

The situation described was avoidable; she knew the other kids would be drinking and smoking, and thus she could have declined to go. At first glance, the next situation seems similarly avoidable. The eighth-grade participant could have declined to “sneak out” in the middle of the night because she may have been able to deduce that alcohol and marijuana would be available. But her story suggested that, although she knowingly left the house without permission, her plans did not include drugs. Once in the situation, she was essentially stuck with the group, which included “burning and drinking.”

“Wilma”: And we were at my cousin’s house and then we snuck out. We didn’t sneak out; we went outside to the park. And like, it was just me and my cousin and three other friends[s]. And we [were] hanging out, and then my friend’s ex-boyfriend [and his friend] came to the park, to meet us. And they brought, hards and weed and whatever. My friend was all depressed about something, so, she started burning [smoking marijuana] and my cousin started burning and then my other friend started burning. And then we [were] all burning and drinking.

On the other hand, most of the unavoidable situations were those in which the youth was required to be at a particular place, usually with family members or at school, and the drug use scenario was not avoidable (e.g., parents were using or kids using in the bathrooms). Taken together, these indirect–contextual and direct–relational drug offer scenarios suggested that participants are exposed to alcohol, cigarettes, and marijuana frequently.

DISCUSSION

As suggested in the introduction, factors contributing to elevated drug use rates for Hawaiian youth compared with other youth populations are a complex issue.^1–7 is study suggests that the combination of both direct and indirect drug offers within the environment of rural Hawaiian youth may partially account for disparities in drug use rates.

The current study highlights qualitative findings from focus groups with rural Hawaiian youth. We identified two predominant types of drug offers, direct–relational and indirect –contextual. Direct–relational drug offers are explicit offers made by one person to another. Indirect–contextual drug offers are embedded within a drug using scenario, in which no explicit offer is made. Indirect–contextual offers were further distinguished by whether the scenario was avoidable or not. This is an important finding for drug prevention science and practice because previous work has focused primarily on direct drug offers (e.g., “just say no” campaigns), rather than on indirect–contextual ones.

These findings suggest that much of the middle school participants’ time at school, in the home (their own, a friend’s, or a relative’s), and in their communities is spent in subtle and not-so-subtle decisions about drug use. The extent to which this is true will be explored in upcoming phases of the research. For example, the administration of a survey in the next phase will encompass a broader sample of Native Hawaiian and other students from these rural communities, and will assess the frequency with which students encounter both direct–relational and indirect–contextual drug offer scenarios at home, school, and in the community among their peers and family.

Prevention programs focused on indirect offers might train youth to effectively deal with situations where the demand or expectation for drug use is implicit within the specific social and cultural context of the youth. The youths’ narratives indicated that the indirect–contextual drug offer is a latent expectation. There is no direct offer of drugs or alcohol, so there is no rejection either. Therefore, an aspect of drug resistance skills in these scenarios may involve teaching youth to anticipate these kinds of situations, and then to reject the situation in avoidable cases and the “offer” in unavoidable ones. Clearly, within these types of situations, drug resistance training would become much more complex, and will need to be guided by the social and cultural norms of the community. Subsequent phases of the PSCR research have been planned with these aspects in mind.

Our findings are limited in two main ways. First, in this study actively seeking drugs seemed to be an uncommon phenomenon. However, this may have been a product of the data collection process: We asked youth whether they had been offered drugs, not whether they seek to use drugs.

Second, the sample is not representative; it was purposive. Youth who were not comfortable speaking candidly in small groups did not participate, and based on principals’ choice, not all schools within the district of our sampling frame participated in the study. We acknowledge that an unrepresentative sample cannot generate all of the possible drug use scenarios that might be generalizable to all youth across each community in this rural district. This limitation was also acknowledged by community members when we disseminated and discussed findings in several community forums. On the other hand, collectively we agreed that this did not detract from the goal of the project. That is, we wanted to gain a better understanding of the environmental contexts of alcohol, tobacco, and other drug offers made to middle school-aged Native Hawaiian youth in rural Hawai`i. The findings presented here, despite the sampling limitations, have provided a more nuanced picture of these environmental demands, with some unexpected results (i.e., the salience of indirect–contextual offers). These findings have set the foundation for future survey research in which we will sample more students from the majority of the communities within this rural district. Equally important, our collaborative efforts have aimed to increase community members’ understanding of research methods partially as a way to increase community participation; and likewise this has improved the research team’s capacity to address the diverse community interests in youth drug prevention.

CONCLUSION

The prevailing paradigm in prevention science favors large-scale research that generalizes to other people or communities. Yet, this project has been guided by the community’s need for regional and cultural specificity—a practice that, in many ways, is inconsistent with the prevailing paradigm of prevention science. Grounding our study within a specific place and culture was possible because of mutually consistent values among the participating academic, school, and community partners. We feel this approach is necessary because of its potential for enhancing effective prevention programs for Native Hawaiian youth.