Insights in Public Health

Abstract

This article briefly outlines a collaboration among communities on Hawai‘i Island and a university-based research team to develop, implement, and evaluate a school-based substance use prevention curriculum called Ho‘ouna Pono. In addition to providing a rationale for the project, the goal of this paper is fourfold. First, an overview of the Ho‘ouna Pono research results to date (2007–2013) is provided. Second, within this overview, the ways in which selected results informed program development are highlighted. Third, the curriculum is briefly described, and finally, the role of the students and community in the video production is described.

Background

Of grave concern across communities in Hawai‘i^1–4 and the scientific community^5–8 is the lack of evidence-based practice in substance use prevention targeting Hawaiian youth. Substance use and abuse contribute to significant and persistent health disparities among Native Hawaiians. Hawaiian youth initiate drug use earlier than their non-Hawaiian peers,^9,10 and report higher use rates.¹¹ Although there are national registries recommended to communities for identifying rigorously developed and tested drug prevention practices,^12–13 a paucity of options exist for indigenous Hawaiian communities.^6,8 Specifically, nationally recognized evidence-based practices have not been culturally grounded in Hawaiian epistemology,^5–6,8 despite the fact that substance use and abuse has been a serious health concern among Native Hawaiians for decades.^10,14–18

Project Rationale

Empirical evidence indicates that Hawaiian cultural interventions are preferred among Hawaiian adults and youth,^19–20 and an indigenous approach is effective for substance use and related problems among Hawaiian youth.^{5–6,8,20–21} Therefore, Native Hawaiian communities may need to develop their own contextually-relevant evidence-based practices.^1–3,6 This article briefly outlines such a collaboration among communities on Hawai‘i Island and a research team affiliated with Hawai‘i Pacific University and the University of Hawai‘i who are developing a middle school curriculum (6th, 7th, 8th grades) to prevent substance use. The individual studies in this program of research each have been reviewed and approved by the Department of Education, Systems Accountability Office; University of Hawai‘i Human Studies Program; and Hawai‘i Pacific University IRB Committee. These studies have been published elsewhere, and the reader is referred to those articles for additional methodological details, and greater depth and breadth of results and their implications.

Ho‘ouna Pono Research

Program development has focused on rural middle school-aged adolescents by using an eco-developmental^22–24 approach to defining etiology and risk and protective factors. The intervention development phase, which started in 2006, concluded recently in 2012. The current implementation phase is underway with a pilot study to determine feasibility and effect size of the proposed intervention (2012–2014). A summary of the initiatives and their most salient results are provided here. Demographic characteristics for each study are provided in Table 1. All participating schools are public schools located in rural areas, and include youth in middle school (grades 6–8), except for K01 (K01 refers to the National Institute on Drug Abuse grant number: K01 DA019884) study 4; the sampling frame for school-communities has remained the same from 2007 to present. For K01 Study 4, adults and older youth participated. In addition, we included high school aged youth in R34 (R34 refers to the National Institute on Drug Abuse grant number: R34 DA031306) Study 1.

Table 1.

Demographic Characteristics for Each Study

Study	Schools	Focus Groups	Youth	% Girls	% Native Hawaiian*
K01 -Study 1	n=5	n=14	n=47	55% girls	100%#
K01 -Study 2	n=7	survey	n=249	59% girls	78%*
K01 -Study 3	n=7	n=14	n=64	50% girls	95%#
K01 -Study 4	n=11 schools and community organization	survey	n=138	62% girls and women	33%
R34 -Study 1	n=8	n=15	n=74	60% girls	88%#
R34 -Study 2 (expected)	n=6	survey	n=350	50% girls	60%

Studies oversampled (*) or exclusively (#) sampled for Native Hawaiian youth

• K01 Study 1 - 2007. Focus group interviews with girls and boys indicated a variety of situations in which drugs - defined as alcohol, tobacco, marijuana, and other drugs - had been offered.^{1–2,25–27} Study 1 results were used to develop the Hawai‘i Youth Drug Offer Survey (HYDOS).²⁸ Drugs most commonly offered in these scenarios were beer, hard liquor, marijuana, or cigarettes, which reflects the extant literature for this age group. 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. However, 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.¹ This has implications for drug prevention, because the prevailing paradigm emphasizes direct offers.

• K01 Study 2 - 2008. HYDOS was administered to Hawaiian and non-Hawaiian youth to determine frequency of exposure to drug offers, and difficulty in refusing drugs in these situations.^28–31 Native Hawaiian youth indicated a higher frequency of exposure to drug offers, but rated the difficulty to refuse to be lower than their non-Hawaiian peers. Among the Hawaiian youth, girls indicated more frequent exposure to drug offers and more difficulty in refusing compared to boys.²⁹ Also among Hawaiian youth, three factors accounted for 63% of the variance: peer pressure (23%), family offers and context (21%), and unanticipated drug offers (19%).²⁸ The family factor has implications for prevention, in that most prevention programs focus on peer-to-peer offers. For Hawaiian youth, prevention must also highlight the need for refusal skills with family members. This finding is corroborated by Studies 1 and 3.

• K01 Study 3 - 2009. Focus groups were held in which youth brainstormed possible socio-culturally competent drug refusal strategies to the 15 most frequent and difficult drug offers as defined from Study 2, and then youth described the pros and cons as well as rationales for the variety of refusals.^32–34 These responses and associated drug offers were collated as primary or secondary responses, and incorporated into a web-based survey for Study 4. Primary drug resistance strategies are a single response, or first part of a two part response; while secondary drug resistance strategies were those that were used in tandem with the primary drug resistance strategies. A response type may be used as a primary response, or a secondary response. Over half of the responses reflecting primary drug resistance strategies fell into three different categories (“refuse”, “explain”, or “angry refusal”), while over half of the responses reflecting secondary drug resistance strategies represented one category (“explain”). Implications for prevention focus on the finding that variations in the frequency of using different strategies were based on the type of drug offerer (family versus friends/peers).³²

• K01 Study 4 - 2010. Community stakeholder guidance was sought prior to making the final determination about which socioculturally competent responses would be taught through the drug prevention curriculum.^35–36 A series of school and community workshops were held with older adolescents, educators, parents, drug prevention and treatment professionals, and cultural leaders. Following each workshop, participants were invited to provide their input via a web-based survey. Community stakeholders rated “refuse” and “explain” as the best responses, and aggressive or violent responses as the worst.³⁶ However, there were age differences in that youth participants endorsed non-confrontational/avoidant and aggressive responses significantly more than the adult participants. This may reflect their reality, in that youth in prior studies also indicated that aggressive responses may be required when other refusal strategies do not work.

• R34 Study 1 - 2011-2012. The prevention intervention has been designed as a school-based curriculum, enhanced with videos depicting drug offers and drug refusal options. As part of curriculum development, youth participated in focus group discussions for the purpose of adapting and validating video scripts to make them more realistic. Youth affirmed the situations described in the scripts, and suggested changes to make the scripts more culturally specific.³⁷ In the scripts where drug offerers were a parent or peer/friend, the participants appeared to favor non-confrontational drug resistance strategies. Such strategies may be a method by which rural Hawaiian youth preserve their social relationships with peers and friends in the school setting and relational harmony within the family system.

• R34 Study 2 & 3 - 2012–2014. Participating schools have been randomly assigned to either the intervention or comparison group. Pre- and post-intervention surveys have been or will be administered during the second semester of the 2012–2013 academic year in both intervention and comparisons schools. Surveys ask about ethnicity & culture; risk & protective factors, including drug use; and resistance strategies. Follow up surveys will be collected at 6 months and 12 months at both intervention and comparison schools.

The Curriculum

Intervention schools participate in the video-enhanced curriculum, which includes a teacher's manual that aligns with Hawai‘i Content and Performance Standards in Health Education. (These standards can be accessed online: http://165.248.30.40/hcpsv3/search_results.jsp?contentarea=Health&gradecourse=6-8&strand=&showbenchmark=benchmark&showspa=spa&showrubric=rubric&Go%21=Submit), as well as national education standards for middle school grades. Comparison schools participate in the standard health education curriculum. For the pilot test, seven lessons are delivered once weekly for seven weeks. Lessons are based on the drug offers identified in Study 1 and Study 2, and the drug refusal options identified in Study 3 and Study 4. Each lesson follows a similar pattern. To begin, a video is shown depicting a drug offer, and three possible drug refusal options, often incorporating refusing, explaining, and other nuances that emerged from Study 3. Next, critical thinking skills have been designed to emphasize key terms and concepts in drug prevention and Hawaiian culture, and these are depicted in the video. Finally, applied practice activities have been designed to enhance skill acquisition with respect to the drug refusal options seen in the video, as well as those the youth generate on their own. Practice activities include role playing for example, and other small group co-learning. Table 2 outlines several examples of the drug offer situations depicted in the videos, along with still shots from the videos. While these examples only show alcohol offers, the other situations not shown involve marijuana offers.

Table 2.

Sample Drug Offer Situations & Video Stills

Video Title	Drug Offer Situation	Still Photography from Video production
Paina	You are at a family party where the adults have coolers full of beer. They are getting drunk, so you and your cousins can take a beer without the adults noticing. One of your cousins says to you, “Let's grab one.”
Pulehu	Your dad, uncles, papa, and dad's friends are making pulehu in the yard, and you are with them. Your mom is inside the house. They are drinking a lot of beer, probably already drunk. Your dad offers you a beer.
Vodka Recess	Your friends bring vodka to school and mix it with juice. They are drinking it on campus during recess. They offer you some.

Community Contributions

Of note is the tremendous generosity of the many Hawai‘i Island community members who volunteered their time and talents during the video production phase. Youth and adults were cast in each video, and for the most part they were amateur and first-time actors/actresses. With exception to the professional producer - Matt Yamashita of Quazifilms Media, and the professional freelance cameraman - Randy Mills, the production crew consisted of student volunteers from nearby schools with video production curricula. An opening night celebration was held in their honor at UH-Hilo so that the talent, crew, and their families would have an opportunity to view their videos post-production, after which the audience was invited to name the curriculum. “Ho‘ouna Pono” was selected among a number of excellent options, and signifies sending forth or enveloping oneself in doing/making the right choice. The name was recommended along with a honu icon, because the turtle's shell suggests a protective envelope around one's being.

Next Steps

The next steps in program development will focus on two primary aspects. First, we will use results from this pilot phase to improve the existing curriculum. These results will be shared with our community partners later this year, as well as in several scholarly venues (eg, national academic meetings, peer-reviewed publications). We also are in the process of formalizing the community advisory board so that we can learn more about the schools and communities where the majority of Native Hawaiian middle school youth reside, which will improve the research design and curricular content and implementation. Second, we plan to scale up the intervention to include more sessions (pilot phase includes 7 sessions), as well as to use a larger sampling frame.