Exploring Culturally Specific Drug Resistance Strategies of Hawaiian Youth in Rural Communities

Abstract

This qualitative study examined the drug resistance strategies of Hawaiian youth residing in rural communities in Hawai`i. Forty seven youth participated in 14 focus groups which focused on the social and environmental context of drug use for these youth. The findings indicated that there were 47 references to resistance strategies used in drug offer situations. These strategies fell within two different categories: (1) overt/confrontational drug resistance strategies, and (2) non-confrontational drug resistance strategies. These strategies occurred within the community context of relational networks of ascribed and biological family members, and differed in frequency of use by gender. Implications for culturally grounded drug prevention programs for rural Hawaiian youth are discussed.

Youth drug resistance skills have been researched extensively since the early 1990's, and have been a core component of many substance use prevention programs (Tobler & Stratton, 1997). Overall, research has shown that prevention programs with a focus on drug resistance skills or strategies are a promising approach in reducing youth drug use, particularly when used in combination with other preventive approaches (Johnson et al., 1990; Botvin, Baker, Dusenbury, Botvin, & Diaz, 1995). However, much of this research has focused on predominantly Caucasian samples, and ethnocultural factors have not been examined in much depth. As a result, there is much to be learned about the unique, culturally specific ways in which minority youth populations resist drugs and alcohol. This information is important in order to address the growing problem of health disparities, including drug use and abuse (U.S. Department of Health and Human Services, 2003)

Guided by a resiliency framework (Waller, 2001), the purpose of this study was to examine the culturally specific drug resistance strategies used by Hawaiian youth in rural communities in Hawai`i. Rural communities in Hawai`i were the focus of this study, because recent research has shown that these communities have been disproportionately affected by drug use compared to their urban and semi-urban counterparts (Affonso, Shibuya, & Frueh, 2007; Withy, Andaya, Mikami, & Yamada, 2007). The goal of this study was to identify those skills that were most frequently accessed and accepted by these youth. These findings have implications for the development of drug prevention programs that are grounded in the living conditions in rural Hawai`i.

Native Hawaiian Youth and Drug Use

Similar to other indigenous youth populations, Native Hawaiian youth have demonstrated high rates of substance use/abuse, with significant adverse effects (Edwards, Giroux, & Okamoto, 2010). They have been found to report the highest lifetime and 30-day alcohol and other drug (ATOD) and tobacco use rates among various ethnic groups in Hawai`i (Glanz, Maskarinec, & Carlin, 2005; Lai & Saka, 2005; Mokuau, 2002; Wong, Klingle, & Price, 2004). Further, Ramisetty-Mikler, Caetano, Goebert, and Nishimura (2004) found that a higher proportion of Native Hawaiian youth initiated drinking by age 12 compared to Caucasian and other Asian Pacific Islander youths in Hawai`i. In terms of substance use effects, Wong et al. found that Native Hawaiian youth reported the highest need for drug and alcohol treatment, while Ramisetty-Mikler et al. found that substance use of Native Hawaiian youth was related to unsafe sexual practices. Clearly, there is a need for more culturally-focused empirical research in order to understand these alarming statistics and to inform drug prevention practices with rural Native Hawaiian youth.

Culturally Specific Drug Resistance Skills

Over the past two decades, there has been an increase in research focused on the drug resistance skills of minority youth populations (e.g., Hecht et al., 2003; Kulis, Marsiglia, Castillo, Becerra, & Nieri, 2008). Much of this research has been dedicated to the development and evaluation of culturally specific drug prevention programs (Castro & Nieri, 2010). At the core of these programs is training in specific drug resistance skills for minority youth. For example, a culturally focused version of Botvin's Life Skills Training program utilized Greek, Spanish, and African myths and stories reflecting contemporary inner-city culture as the context for teaching cognitive and behavioral skills to middle school aged youth (Botvin, Schinke, Epstein, & Diaz, 1994; Botvin, Schinke, Epstein, Diaz, & Botvin, 1995). More recently, a drug prevention program called keepin’ it R.E.A.L. has been developed for Mexican/Mexican American youth (Hecht et al., 2003; Kulis et al., 2005). The primary focus of the program is on teaching drug resistance skills using four strategies—refuse, explain, avoid, and leave—within the unique cultural and regional contexts of the Southwest U.S. (Hecht et al., 2003).

There has also been specific body of research examining the drug resistance skills of indigenous youth populations. Most of these skills are described in the context of drug prevention programs for these youth. Many of these programs focus on problem solving and communication skills training (e.g., Gilchrist, Schinke, Trimble, & Cvetkovich, 1987; Moran & Bussey, 2007; Schinke et al., 1988; Schinke, Schilling, & Gilchrist, 1986). Schinke et al. (1988), for example, tailored their program around skills of bicultural competence for American Indian youth (i.e., communication, coping, and discrimination skills). Gilchrist et al. described a skills enhancement intervention for American Indian youth focused on a culturally tailored problem solving model (SODAS). Inherent in most of these programs is the training in a set of drug resistance skills within the context of an indigenous youth culture.

Because much of the research on culturally specific resistance skills exists within the development and evaluation of drug prevention programs, the identification of many of these skills has evolved predominantly from experts in the field of drug prevention. Very few studies have examined the actual drug resistance skills used by minority youth populations in their own contexts (e.g., school, home, community). However, as part of a pre-prevention study, Okamoto, Hurdle, and Marsiglia (2001) examined the drug resistance strategies of American Indian youth of the Southwest, and found that these youth preferred non-confrontational strategies (e.g., redirecting the discussion away from the topic of drugs, avoiding or leaving the situation) over confrontational strategies (e.g., saying “no”). By using focus groups with Native youth, drug resistance strategies identified in the study were “grounded” in the realities of these youth, thereby providing a more relevant foundation for drug prevention programs than the use of theory alone.

The present study examines the drug resistance strategies of indigenous youth in rural Hawai`i. To date, there has been very little research focused specifically on drug resistance skills for these youth (Rehuher, Hiramatsu, & Helm, 2008). Rehuher et al. conducted an exhaustive literature search and found only one program based on rural Native Hawaiian culture, which is in its early stages of development and evaluation (Kim, Withy, Jackson, & Sekaguchi, 2007). Nonetheless, research suggests that resistance skills training for these youth may prevent future drug use. Withy, Lee, and Renger (2007) used stakeholder interviews to link the causes of substance abuse within the rural Hawaiian youth population to low self esteem, lack of self identity and life plan, and limited communication and conflict resolution skills. Consistent with this framework, the present study examines the way in which rural Hawaiian youth effectively managed conflict within drug related problem situations in order to resist drug offers. As a result, this study has implications for the development of culturally and regionally specific substance abuse prevention programs with Hawaiian youth. Future programs based on the perceptions of rural Hawaiian youth have the potential to provide essential resources for them to negotiate environmental challenges related to drug and alcohol use in their homes, schools and communities.

Method

Consistent with Okamoto et al.'s (2001) culturally grounded approach to identifying drug resistance strategies, qualitative methods were used in this study. Qualitative methods have recently been used in similar studies in rural areas of Hawai`i, because they promote community participation (Affonso et al., 2007) and investment (Withy et al., 2007).

Data Collection and Participants

Five rural middle schools participated in the study—four Big Island schools plus one pilot study school from a different island. Communities within the sample were included in recent research on health disparities in rural Hawai`i (Withy et al., 2007), and were considered rural by the Hawai`i Rural Health Association. Consistent with models of school/university/community partnerships (e.g., Spoth, 2007), youth were recruited in collaboration with school-based research liaisons. These were designated school staff members, such as counselors or health teachers, who assisted the university researchers in identifying students, distributing and collecting consent forms, and securing facilities to conduct the group interviews. The majority of participants were selected from a statewide database of enrolled students, which designated those students who were Hawaiian or Part Hawaiian in the participating schools. Fourteen focus “mini” groups (Morgan, 1997) with 2-5 Native Hawaiian middle school students per group were conducted (N = 47). Smaller (versus larger) groups were selected, because of the sensitive nature of the research and because they were more consistent with cultural norms of rural Hawaiian communities. In order to promote youths’ comfort in disclosing drug related information, homogeneity of group composition (Morgan, 1996; Zeller, 1993) was built into the research methodology. This was achieved in two ways. First, separate groups were held for girls (n = 26) and boys (n = 21), with group facilitators matching the gender of the youth participants. Second, efforts were made to create groups using naturally formed social cliques. Participants were in grades 6 (9%), 7 (53%) and 8 (38%). The average age of participating youth was 12.2 years. All students self-identified as Native Hawaiian, in addition to one or more Pacific, Asian American, Euro-American, and American Indian ethnocultural groups.

Interviews were held at school, either during lunch, recess, or after school, and lasted from 40-60 minutes. The groups began with a discussion “starter” question (Morgan, 1997), in which students were asked to imagine a scenario where someone important to them had offered them drugs or alcohol. This question led students to describe real situations in which drugs had been offered to them or someone they knew, and to share their views on the extent of the drug problem in their school or community and what could be done about it. Particular attention was given to the time, place, drug offerer, and drugs used in specific situations described by the youth. Students were also asked about the ways in which cultural values, practices, and beliefs help middle school youth resist alcohol, marijuana, cigarettes, and other drugs.

Participants were informed to keep all youth disclosures in the group setting confidential. Because the interviews were audio taped, participants were asked to use self-selected pseudonyms to refer to one's self and others in the group discussion, and to individuals described in their stories. Active parental consent and student assent were obtained for all participants in the study. All research procedures were approved by the Institutional Review Boards at Hawai`i Pacific University, University of Hawai`i at Mānoa, and the Hawai`i Department of Education.

Data Analysis

All interviews were audio recorded and transcribed verbatim by a member of the research team. Transcripts were then reviewed for accuracy by a different research team member. A comprehensive set of open codes (Strauss & Corbin, 1990) were identified by the Principal and Co-Principal Investigators, and were imported into a qualitative research data analysis program (N Vivo). N Vivo is one of several code-based theory-building programs that allow the researcher to represent relationships among codes or build higher-order classifications (Weitzman, 2000). In order to establish interrater reliability and validity, all members of the research team collectively coded one transcript, in order to clarify the definition and parameters of all of the codes. Then, all subsequent interview transcripts were separately coded by at least two different research team members. Narrative segments that were not identically coded by the team members were identified, discussed, and justified for inclusion or exclusion in the data set. Coding iterations continued until there was consensus by all members of the team coding each transcript. Upon establishing interrater reliability and validity, a content analysis of the resistance strategies code was conducted, which examined each group's responses based on gender, grade, primary resistance strategy employed in each response, and secondary resistance strategies employed in each response.

Results

All 14 focus groups referenced resistance strategies in their discussions, and the mean percentage of coverage for the code was 20.2¹. There were 47 references to real drug offers by participants in the study. The majority of the strategies used within these offers fell within two different categories: (1) Overt/confrontational methods of drug resistance (22 references), and (2) non-confrontational methods of drug resistance (17 references). Seven of the references focused on seeking social support from friends or family members in drug related problem situations, while one of the references focused on participating in extracurricular activities as a method of drug resistance. Overt/confrontational methods of drug resistance included saying “no” to drug offers, verbal confrontations related to drug offers (e.g., “How can you drink that?”), and aggressive acts of resistance (e.g., fighting). Non-confrontational methods of drug resistance included walking away from the drug offer situation, changing the subject of a discussion away from the topic of drugs or alcohol, and making excuses or lying to avoid using drugs. A gender difference was evident in these two categories, with females describing the use of overt/confrontational methods more often than male participants (16 versus 6 references) and males describing the use of non-confrontational methods more often than female participants (11 versus 6 references).

Overt/Confrontational Drug Resistance

Participants described several examples of overt or confrontational drug resistance strategies in the focus group discussions. Three primary types of these strategies were described by participants—(1) saying “no”, (2) verbally confronting the offerer, and (3) using aggression as drug resistance. One female participant described the challenges of saying “no” to drug offers in the context of close relational networks in her community. Her fear of physical consequences related to drug use ultimately compelled her to say “no” to the drug offer.

Facilitator (S.H.): So you were telling some of your story before, Jane. Did you want to give some more details? You said you were with another eighth grade kid, was that a boy or a girl?

Jane: Girl.

S.H.: Uh-huh, and that was one of your friends?

Jane:Well, yeah, kind of. ‘Cause her mom was my mom's best friend, so I met her [and] then we started being friends.

S.H.: OK, how'd that make you feel when she offered [you beer]?

Jane:Scared. I didn't really know what it was, and I didn't know what was gonna happen if I took it or something. So I just said, “No.”

Some participants described situations where youth would verbally challenge the drug using behavior of the offerer in an effort to help them to stop using drugs.

S.H.: [What] about the kids who have chosen to not use marijuana? What do you think they tell to the other kids who are using?

Mindy: Don't do it.

Kari: Or, [they] just say, “You should quit, it's bad for your health.”

Chrissy: And have fun living the rest of your short life.

Finally, some participants described aggressive acts as a method of drug resistance. Some of them described taking the drugs or alcohol and throwing it away or destroying it in front of the offerer. As an extreme example of aggressive drug resistance, “Dana” described slapping as a method for deterring drug use.

S.H.: What do you do in those situations [when] you're hearing kids talk about [smoking marijuana], but they're not offering it?

Dana: If it's [a] family [member] using, I walk up to them and I slap them. ‘Cause then they don't really know what it means [when you smoke]. Then, I explain it to them and then they stop talking about it because they know they're not supposed to be talking about it.

Even when participants described hypothetical ways of dealing with drug offers, they often referenced aggressive behaviors. While it was not a common occurrence, in several cases, youth referred to violence as a method of drug resistance.

S.O.: Are there ways in which you can avoid using drugs after you've been offered? How do you deal with that situation?

Jason: You just walk away, tell an adult or something.

Kenny: Say “no”.

S.O.: Say “no” or walk away?

Jason: Lick ‘em li’ that².

Kenny: Yeah.

Michael: Kill ‘em, nah.

Non-Confrontational Drug Resistance

Participants also described non-confrontational acts of drug resistance in the focus group discussions. Three primary types of non-confrontational drug resistance strategies were described by participants—(1) avoidance/walking away, (2) using proximity to a protective family member for drug resistance, and (3) using Hawaiian cultural practices as drug resistance. As an example of avoidance/walking away, a male participant described how he witnessed his older brother becoming addicted to drugs as his brother began to socialize with drug users in high school. He described the efforts of his family to deter his brother's drug use, and the effect his brother's addiction had on him and his family. This led to a discussion of how he plans to resist drug use as he prepares to transition to high school.

Facilitator (S.O.): Wow. So, that must be scary for you, thinking about [your brother] and what's happened to him. Then, you're going to be going to high school as well, so you're going to be exposed to that same kind of environment, right?

Ross: Right

S.O.: So you probably have thought of how to stay away from those guys, right?

Ross: Yeah.

S.O.: What are you going to try to do?

Ross: I'm gonna try to stay away from them and make sure that I do all my work in school. And, if anybody offers me [drugs], I'm just gonna walk away and [not] say anything to them.

S.O.: It sounds [like] the main strategy all [of] you guys use is walking away from the situation, yeah? Why is it that that's the one you guys go to first? Why is that the best thing to do?

Bo: ‘Cause you want to stay out of it, and you don't want any part of it. Just walk away.

In several situations, drug offers were embedded in the social context of the participants. There appeared to be a strong social demand for drug use in these cases, and “walking away” seemed to be the resistance strategy of choice for the participants. For example, “Honeygirl” described how she employed “walking away” from drug offers at a community event.

We [were] getting together at [this community center]. [There was] a Friday night dance, and had all [these] guys smoking marijuana outside. And, then they was like, “Oh wassup Honeygirl, what, you like some?” I [was thinking] “Oh no, I not that stupid.” They started asking me all kinds [of] questions. I never [did anything], I walk[ed] away.

“Lani” described the use of “walking away” during family parties where alcohol use is unmonitored and prevalent.

Yeah, I've been at parties [with] all my cousins. They[`re] not even of age yet, but my dad [and other adult family members], they just like [to] offer [drugs and alcohol], because they [are] stressed out. So, I just walk away. I walk away kind of frustrated, knowing that they [are] trying to get my cousins to drink and stuff.

“Bo” also described how he tried to employ “walking away” from a drug related problem situation that involved his older cousin. However, when this was not effective, he used another family member to protect himself from pressure to use drugs.

S.O.: So, Bo you said you had a real experience with drugs. Can you tell us what [happened]?

Bo: Well, actually [it] was [with] one of my relatives. We all [were] at this party and then when I was walking, [my cousin] stop[ped] and asked me to try [and] take one drink of beer. And I told him that I gotta go, but he kept following me and asking me to drink beer.

S.O.: So, what did you do in that situation?

Bo: I kept walking until I found one of my older cousins and I stayed by him. So, then my other cousin walked away.

Similar to “Bo”, many participants managed their proximity around a protective individual in order to resist drug offers. Most often, protection was sought from a close family member. “Skullz” described how he used his father as protection from a drug offer during a family gathering.

S.O.: Have any of you been offered [drugs or alcohol]?

Skullz: Nods head indicating “yes”.

S.O.: Skullz, you said you have?

Skullz: By my auntie's boyfriend. [It] was on New Year's Eve last year, and he was drunk and I was sitting next to my mom. She [went to] the restroom, and then he offered me beer. I said no, and then I walked away to go next to my dad, ‘cause he was poppin’ fireworks.

“Tehani” described how she makes sure that she surrounds herself with supportive cousins when attending events where drugs or alcohol might be present, in order to protect herself from potential drug offers during these events.

Tehani: I'm usually with my cousin when I go [to the community dances]. I gotta make sure [my] cousin's there.

S.H.: So, you have somebody who's watching out for you.

Tehani: Yeah, I have three or four cousins there who watch over me. My cousin [who is female], she [is] the one [who] watches me the most. My other [male] cousin—he just goes out with his friends. He's going to care if I get into [a] fight or something.

Finally, in some of the more rural areas, Hawaiian cultural practices were used as a form of non-confrontational drug resistance. “Don” described his use of “throwing net” (an indigenous form of fishing in Hawai`i) when he and his friend were offered beer by an adult family member.

S.O.: Can you tell me about your situation?

Don: Well, [we were] at a beach, and my friends’ uncle was drunk and was offering all kinds of beer. And, we said no. ‘Cause we know he was drunk and we didn't wanna follow anything, or else somebody [was] going to get hurt.

S.O.: So, what did you do in that situation?

Don: We said no, and [were] trying to get him off the subject. Like, we [went to] go “throw net” in that area, so he would get [beer] off of [his] mind and then try to focus on what to do.

S.O.: How did that work?

Don: It worked just fine. Once we caught fish, he forgot all about it.

Discussion

Using qualitative methods, this study examined the drug resistance strategies of Hawaiian youth in rural communities. The results revealed overt/confrontational and non-confrontational forms of drug resistance used by the participants, which functioned within the unique cultural context of rural Hawai`i. Similar non-confrontational acts have also been described as preferred drug resistance strategies of American Indian youth (Okamoto et al., 2001). The strategies described by the participants highlighted several points. First, their strategies were influenced by the close relational networks of biological and ascribed family members within their communities. For example, aggressive acts of drug resistance were used to protect themselves as well as other family members from drug use. Non-confrontational acts of drug resistance, such as walking away, were used to preserve family relationships while avoiding drug use. These findings are consistent with the family oriented value system (i.e., ‘ohana system) that is characteristic of the Native Hawaiian culture (Miike, 1996). It is also consistent with, prior research, which has shown how familial networks can intensify both risk and protection related to drug use of American Indian (Waller, Okamoto, Miles, & Hurdle, 2003) and Native Hawaiian (Okamoto, Helm, Kekuawela, Chin, & Nebre, 2008) youth. Subsequently, the relative success of the resistance strategies described in this study depended upon the drug use acceptance levels of the familial networks in the community. Youth with many drug abstinent family members were able to find social support for their resistance strategies, and were successful in using them. Conversely, youth with many drug-using family members may not receive support for their drug resistance efforts, and may be at higher risk for drug use than peers with drug abstinent family members.

The types of drug resistance strategies used by the youth in this study varied by gender. Girls described the use of overt/confrontational resistance strategies more often than boys, while boys described the use of non-confrontational strategies more often than girls. This difference might be accounted for by the stronger verbal skills of Hawaiian girls, which allowed them to articulate their negative feelings about drugs more clearly and directly than boys. However, resistance strategies focused on non-confrontational communication patterns are consistent with social norms of certain Indigenous youth (Green, 1999), suggesting that these forms of drug resistance might become communicative competencies that rural Hawaiian youth could use in specific situations (Okamoto et al., 2001). More research is necessary to understand the gender differences related to drug resistance of Native Hawaiian youth.

Implications for Prevention

This study has implications for the development of culturally grounded prevention interventions with rural Hawaiian youth. Training in drug resistance skills or strategies for these youth should focus on their use within supportive social networks, and specifically within the context of interconnected family relationships. For example, several of the youth paired overt and non-confrontational forms of drug resistance with seeking social support from another family member (e.g., “Bo”). In this way, the protective functions of familial relationships are utilized alongside other resistance strategies. Focusing on non-confrontational forms of drug resistance is also a unique aspect of drug prevention for indigenous youth. This approach enables youth to manage their own behavior while preserving their connections with their peer group or family members (Okamoto et al., 2001). In this way, non-confrontational drug resistance may function as a valuable conflict management skill for Hawaiian youth in rural communities. According to practitioners and stakeholders interviewed for the Withy et al. (2007) study, skills for conflict management are essential in order to prevent drug use of these youth. While prevention programs employing non-confrontational drug resistance strategies may differ from the bulk of the programs that focus on overt refusal skills, the findings suggest that the ability to avoid confrontation in drug resistance may be particularly important within the close knit rural communities in Hawai`i.

From a broader perspective, prevention programs built upon pragmatic drug resistance strategies of rural Hawaiian youth have the potential to contribute to the growing movement toward nationally recognized evidence based practices. Rehuher et al. (2008) found a lack of these practices designed by or for Native Hawaiians. Further, Matsuoka (2007) argued that existing evidence based practices are “decontextualized,” and therefore have limited applicability to the Hawaiian population. The present study is an attempt to infuse Hawaiian culture and context into the “core” of drug prevention efforts, thereby enhancing both the fidelity and fit of these interventions (Castro, Becerra, & Martinez, 2004).

Limitations of the Study

There were several limitations of this study. A convenience sample was utilized, which may or may not have been representative of the views of the youth population in the sampled communities. Also, due to the sensitive nature of the topic, in depth interviews, rather than focus groups, might have been a more appropriate approach in order to yield richer, more valid data. However, in order to address this methodological critique, group homogeneity and small group size were incorporated in order to promote youths’ active participation in the groups. Further, participants stated that the use of pseudonyms enhanced the anonymity of group members, increasing their engagement in the group. Finally, the findings of this study may lack transferability not only to the general population of Hawaiian youth in Hawai`i, but to those who reside in rural communities outside of the sampling frame.

Conclusions

Resistance skills have long been a staple of drug prevention programs for youth. However, there have been very few studies that have focused on the actual resistance skills or strategies utilized by these youth. This study attempted to examine the resistance strategies used by rural Hawaiian youth, in order to inform future culturally grounded prevention interventions. Future prevention programs can translate these strategies into culturally relevant resistance skills for rural Hawaiian youth, allowing these youth to negotiate environmental demands related to drug use more effectively. These programs should also involve family members as a part of their skill building programs.