Gender Differences in Preferred Drug Resistance Strategies of Rural Native Hawaiian Youth

Abstract

This study examined the gender differences in preferred strategies used to resist drugs and alcohol for rural Native Hawaiian youth. Seventy-four youth (60% female) within eight different middle/intermediate or high schools participated in 15 different focus groups as part of a pilot/feasibility drug prevention study funded by the National Institute on Drug Abuse. Consistent with relational-cultural theory, qualitative findings indicated how female youth participants favored drug resistance strategies that maintained relational connectedness with the drug offerer, and how they considered the long-term relational consequences of different drug resistance strategies. Implications of these findings for indigenous- and gender-specific prevention are discussed.

Compared with other ethnocultural groups, research has shown that indigenous populations (i.e., American Indians, Alaska Natives, and Native Hawaiians) have disproportionally suffered adverse health consequences related to drug and alcohol abuse (Tann, Yabiku, Okamoto, & Yanow, 2007; Office of Applied Studies, 2009; Ta & Chen, 2008; Walters, Simoni, & Evans-Campbell, 2002). Studies also have indicated that substance abuse has disproportionately affected indigenous women (Ta & Chen, 2008; Walters et al., 2002). Indigenous women had the highest drug-induced mortality rate in 2007 (11.5 per 100,000 of all deaths; Center for Disease Control and Prevention, 2011), and have the highest perinatal risk related to substance use (Fuddy, Prince, & Tang, 2003; Indian Health Service, 1998–99) compared with women in other major ethnocultural groups. Despite these issues, there has been a lack of culture- and gender-focused substance abuse interventions described and evaluated in the scientific literature for indigenous populations (Hawkins, Cummins, & Marlatt, 2008; Mokuau, Garlock-Tuiali‘i, & Lee, 2008; Ta & Chen, 2008).

The purpose of this study is to examine gender differences in the preferred drug resistance strategies of one rural indigenous youth population (Native Hawaiian youth). This study used relational-cultural theory as framework for understanding culture- and gender-specific interactions within drug-related problem situations of rural Hawaiian youth. The theory was also used to understand the unique relational challenges experienced by Hawaiian girls within these situations. Examining gender differences in drug resistance strategies has implications to promote developmentally and culturally appropriate, gender-specific drug resistance skills training for indigenous youth, thereby informing ecologically relevant substance abuse prevention programs for these youth.

Dimensions of Indigenous- and Gender-Specific Youth Substance Use

While some research examining gender differences in the rates of substance use among indigenous youth has reported mixed findings (Hawkins et al., 2008), other studies have indicated significantly higher rates of substance use for indigenous girls compared with boys (Schinke, Tepevac, & Cole, 2000; Wallace et al., 2003). For example, using a large, nationally represented sample across 420 different schools, Wallace et al. examined ethnic and gender differences in illicit substance use for 8^th, 10^th, and 12^th grade students. Across all ethnic groups, substance use was found to be highest among American Indian girls in this study, with approximately 70 percent of these girls (compared with 54 percent of American Indian boys) having tried marijuana/hashish, 87 percent (compared with 81 percent) having tried alcohol, and 80 percent (compared with 69 percent) having tried cigarettes by the 12^th grade. Epidemiological studies focused on Alaska Native and Native Hawaiian girls have similarly found gender disparities in substance use rates, with these girls indicating higher usage of tobacco (Angstman et al., 2007; Glanz, Maskarinec, & Carlin, 2005; Glanz, Mau, Steffan, Maskarinec, & Arriola, 2007) and alcohol and marijuana (Mayeda, Hishinuma, Nishimura, Garcia-Santiago, & Mark, 2006) compared with their male counterparts.

Research also has identified gender-specific ecological risk factors for substance abuse of indigenous youth populations. These studies have examined gender differences in the exposure to offers to use substances for American Indian (Dixon Rayle et al., 2006; Kulis, Okamoto, Dixon Rayle, & Sen, 2006) and Native Hawaiian (Okamoto, Kulis, Helm, Edwards, & Giroux, 2010, in press) youth. These studies also examined the perceived difficulty that these youth have experienced in dealing with these situations. In particular, Dixon Rayle et al. and Okamoto, Kulis, et al. (2010) found that, compared with their male counterparts, American Indian and Native Hawaiian girls (respectively) were exposed significantly more often to drug offers by peers and family members, and found it significantly more difficult to resist those offers. Gender-specific research on indigenous youth has provided limited insight to account for these quantitative findings. Okamoto, Kulis, et al. (2010) recently indicated several reasons that may have accounted for Hawaiian girls’ higher exposure to offers to use substances (e.g., earlier initiation into substance use compared with boys). However, this study was limited in elucidating the reasons related to the perceived difficulty that these girls had experienced in dealing with drug offers.

Relational-Cultural Theory as a Framework for Understanding Substance Use Risk of Indigenous Girls

Relational-cultural theory (RCT) evolved from clinical practice in the 1970’s, and at that time, was characterized by the centrality of relationships in women’s lives (Comstock et al., 2008). A central tenet of the theory is that women grow “through and toward” connection with others, and that significant relationships are central to women’s sense of meaning and well-being (Jordan, 2001, 2008). West (2005) expanded upon Jordan’s early theoretical principles by linking them directly to feminist theory building, while Comstock et al. elucidated the implications of RCT to counseling and direct practice. According to RCT, relational development occurs across the life span, and is linked to individuals’ racial, cultural, and social identities (Comstock et al., 2008). In effect, psychological “disorders” become less about the individual and more about the relational and cultural context (West, 2005; Comstock et al., 2008). Disorders evolve more from culture-based relational disconnections between individuals, rather than problems or issues within the individual. West suggested that RCT had strong implications for the development of preventative interventions, including gender-specific interventions for youth in the school setting.

In order to apply RCT to the lives of indigenous girls, it is important to understand their unique relational and cultural contexts. Some research has described these unique contexts for American Indian and Native Hawaiian youth, and how these contexts may function to intensify both risk and protection for substance use for these youth (Hurdle, Okamoto, & Miles, 2003; Waller, Okamoto, Miles, & Hurdle, 2003; Okamoto, Helm, Po‘a-Kekuawela, Chin, & Nebre 2009). Specifically, these studies described close-knit networks of biological and ascribed family members within the home, school, and community for these youth, and how these networks functioned as strong influences for or against the use of illicit substances. In other words, research has emphasized that indigenous youth live within a cultural context which both values and is characterized by close, interconnected relational networks, and that these networks function as both ecological risk and protection. For indigenous girls, RCT would suggest that the demand to stay relationally “connected” is particularly strong, as both gender and culture intersect to provide these girls with a sense of meaning and well-being through their significant relationships.

RCT can be used to understand indigenous girls’ perceived difficulty in refusing offers to use illicit substances from peers and family members found in recent empirical research (Dixon Rayle et al, 2006; Okamoto, Kulis, et al., 2010). The theory suggests that indigenous girls’ perceived difficulty in dealing with drug offers may be an outgrowth of balancing harmony within significant relationships and the goal of abstaining in the use of illicit substances. This difficulty may place these girls at increased risk for substance use, particularly when the ability to effectively refuse substances threatens the harmony within a significant relationship. RCT suggests that indigenous girls may feel increased social pressure to accept drugs and/or alcohol in order to mitigate discord or conflict in the relationship with the drug offerer, particularly since relational disconnection is incongruent with their culture- and gender-based norms and values.

In the present study, qualitative methods were used to examine the gender-specific considerations and preferences in drug resistance strategies for rural Native Hawaiian youth. Research has indicated that rural youth have higher alcohol use rates compared with their urban counterparts (Swaim & Stanley, 2011), with rural minority youth having particularly elevated risks toward substance use (Curtis, Waters, & Brindis, 2010). The analysis in this study elucidated the ways in which Hawaiian girls balanced relational- and health-related demands or expectations within various ecological settings (i.e., the home, school, or community). Using RCT as a framework for understanding the narratives of the youth participants, the findings also helped to elucidate the reasons behind indigenous girls’ perceived difficulty in refusing offers to use substances found in earlier studies (Dixon Rayle et al., 2006; Okamoto, Kulis, et al., 2010).

Method

Data from this study came from a multi-year pilot/feasibility drug prevention study funded by the National Institute on Drug Abuse, in which youth participants were asked to adapt and/or validate narrative scripts to be used to create culturally grounded drug prevention videos. All research procedures were approved by the Institutional Review Boards at Hawai‘i Pacific University, the University of Hawai‘i at Mānoa, and the State of Hawai‘i Department of Education.

Sampling and Participants

Six middle or intermediate schools and two high schools within two of the three public school complex areas on the Island of Hawai‘i participated in this study. Participating schools were located in low-income, rural communities. These communities had populations less than 50,000, and had a higher percentage of families receiving public assistance compared to the State (Accountability Resource Center Hawai‘i, 2010). Participant recruitment for the study was conducted in collaboration with School-Based Research Liaisons. These Liaisons were typically school staff members, such as teachers or school counselors, who had long-standing professional relationships with the university-based research team from a prior multi-year pre-prevention study. The liaisons assisted in the recruitment of Hawaiian students, and responded to student and parent questions about the study. They also assisted in the distribution and collection of parental consent forms from the students, and secured space within their respective schools for the focus group discussions.

Seventy-four youth participated in the study. Sixty percent of the youth participants were female, and their mean age was 13.21 years (SD = 2.17). The mean number of youth participating per school was 9.25 (SD = 2.76). The majority of these youth were in the 7^th grade (38%), followed by the 8^th grade (22%), 12^th grade (18%), 6^th grade (11%), 11^th grade (7%), and the 9^th and 10^th grades (1% each). In terms of ethnicity, approximately 88% of the youth indicated they were Hawaiian or part-Hawaiian; however, the majority of these youth also identified with additional ethnocultural groups, such as Chinese (42%), Filipino (54%), Portuguese (49%), and White (41%). Of the youth that indicated they were Hawaiian or part-Hawaiian, 80 percent of them indicated that they primarily identified with their Hawaiian background over their other ethnic backgrounds.

Procedures

Youth participated in one of 15 gender-specific focus groups (2–10 youth per group; M = 4.63, SD = 2.33), and the gender of the group facilitators matched that of the youth participants. The goal of these groups was to adapt and/or validate seven different narrative scripts to be used to film culturally grounded drug prevention videos focused on rural Hawaiian youth. Each script outlined a brief vignette based upon a drug-related problem situation developed and validated from prior research (Okamoto, Helm, Giroux, Edwards, & Kulis, 2010). Table 1 outlines the script names, associated drug-related problem situations, and the gender composition of the groups that adapted and/or validated each script. Following each situation, each script also outlined three different types of responses for drug refusal, such as avoiding the situation or saying “no”. The drug refusal responses corresponding to each scripted situation also had been developed and validated in prior research (Okamoto, Helm, Giroux, Kaliades, et al., 2010; Okamoto, Helm, Giroux, & Kaliades, 2011).The semi-structured interview schedule used for the focus groups is presented in Table 2. Participants were informed to keep all youth disclosures in the group setting confidential. Because we audio recorded the interviews, youth were asked to use pre-selected pseudonyms to refer to one’s self and others participating in the group discussions, as well as to use pseudonyms to refer to individuals in their stories.

Table 1.

Narrative Script Names, Drug-Related Problem Situations, and Group Gender

Script Name	Situation	Group Gender
Bacardi Party	Your friends bring Bacardi to school and mix it with juice. They are drinking it on campus during recess. They offer you some.	Female
Bully Boy	A big, bulky boy in school is known to be the leader of a group of "tough kids," who fight and do drugs. He approaches you one day at recess and asks you if you'd like to hang out with his group.	Male
Kanikapila Invite	On the nights that there is a full moon lots of the older kids like to go out at night because they can kanikapila and smoke marijuana and drink beer outside. Your older cousin invites you to come along.	Male
Oh Brother	Your older brother enters your bedroom, closes the door, and asks you if you’d like to smoke some weed.	Male
One Time	You are with a girl/boy you like and some other friends. They are all hiding in the bushes and smoking weed. They ask you if you want to try some. After you say no, they say, "Just try this once, it's cool."	Female
Pā‘ina	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."	Female
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.	Male and Female

Table 2.

Semi-Structured Interview Schedule

What did you think about the situation described in this script? Are youth in this community exposed to these types of situations? Describe in as much detail as possible the setting in which you see this situation occurring. Where would this situation occur in your community? Who do you see as being present in the situation? Who is involved in the discussion and who is in the background? When do you see this situation occurring in your community? What do you think about the dialogue described in the script? How would you change the language to fit in with the way kids in this community talk? Are there things that were not included in the script that, if included, would make the dialogue more consistent with the way kids in this community talk or act (e.g., additional language, non-verbal reactions, etc.)? Based on responses to Questions 1–3, facilitators will make some on-the-spot revisions to the narrative script. After this has been finished, select the same group participants to read the parts of the revised script. What do you think about the changes that were made to the script? Are there any other changes that should be made to make the script more consistent with the way kids talk and act in this community? How do you think kids in this community would react to a video vignette using this script, if it was presented as part of a drug prevention program in your school?

Data Analysis

All interviews were audio recorded and transcribed verbatim by a member of the research team. As an added layer of research protection, participants’ self-selected pseudonyms were replaced by a researcher-selected pseudonym in the analyzed transcript and disseminated data. To ensure data quality, each transcript was reviewed for accuracy by at least two different research team members. Following this process, a comprehensive set of open codes (Strauss & Corbin, 1990) was identified by the Principal and Co-Principal Investigators, and was imported into a qualitative research data analysis program (NVivo, 2010). NVivo 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 intercoder reliability and validity, all members of the research team collectively coded one transcript, in order to clarify the definition and parameters of each of the codes. Then, all subsequent transcripts were separately coded and cross-checked 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. As an additional validation check, after all transcripts were coded and entered into NVivo, the content of conceptually complex codes was again reviewed and validated by the research team. This allowed for further clarification and verification of the code content. Upon establishing intercoder reliability and validity, an analysis of the changes to the narrative scripts suggested by the youth participants was conducted. Gender differences were systematically examined within each of the codes, including differences in content and the manner in which male and female youth participants discussed the drug-related problem situations and their associated responses depicted in each of the scripts.

Results

Across all focus groups, 54% of the narrative content came from boys’ groups, while 46% of the content came from girls’ groups. The primary gender differences for the youth participants were evident in the discussion and/or modification of proposed responses to drug offers described in each of the scripts. Male participants were more inclined to endorse and/or describe responses that “disconnected” the protagonist in the script from the drug offerer more abruptly (e.g., “[S]he would leave the situation”), while female participants were more inclined to endorse and/or describe methods to stay relationally “connected” in the situation, despite the drug offer occurring (e.g., “Next time”, “not now, maybe later”). As an example of a disconnected response to a drug offer, several boys described how the female youth protagonist in “Pulehu” should react to her father’s offer to drink beer with him. In this script, a 13 year old girl (Ku‘u) is offered a beer by her father in front of several uncles and a grandfather. The boys compared her actions with how they would behave in this type of situation.

Facilitator: So how would you feel [if your father offered you beer]?

Reptile: Awkward.

Jax: Uncomfortable.

Facilitator: Awkward, uncomfortable. How do you act when you feel uncomfortable? If somebody makes you feel uncomfortable and they ask you to do something, how do you act?

Reptile: I[’d] go in the house.

Jax: I[’d] walk away.

Facilitator: You’d walk away?

Reptile: I[’d] go to my room and play games.

Facilitator: How do you react immediately? Do you just look at them and then just turn and walk away? Or, do you-

Jax: [Interrupts] I just look at somebody else. No, my dad’s really strict, so I would just sit down, but not too close to [him].

Facilitator: And it sounds like you would kinda look away too, you just said, so you would sit down kind of close to him and look away. So would you say anything, right at that moment?

Jax: I[‘d] say “Dad, I go play games. I go play game[s].”

In contrast to the refusal strategy endorsed by the boys, girls who validated “Pulehu” felt differently about how Ku‘u should respond to her father’s alcohol offer. Their suggested response illustrated concern for the father’s well-being, and an attempt to stay relationally connected with him.

Facilitator: Okay, so it sounds like all of you guys would be [feeling] some level of discomfort [and] fear [if your father offered you a beer], or I think you said feel[ing] scared, confused, [and] pressured.

Dakota: Empathy.

Facilitator: Empathy. Okay, so then what do you think Ku‘u should do in this situation? How would she behave in this situation?

Cutie: She would like, tell her dad, [uncles, and grandfather] that she doesn’t wanna drink. And that she wanna just listen, like, talk with them instead.

The theme of relational connectedness was also evident in other scripts validated by girls’ focus groups. For example, in “Pā‘ina”, several girls discussed the merits of two different responses to a drug offer from a cousin—diverting the topic away from drug use by suggesting to the offerer that they go play a game with other cousins (Response 2) or leaving the situation and going inside to watch television (Response 3). “Candy” describes how Response 2 allows her to help her cousin who is offering her alcohol, supporting the importance of staying relationally connected with him as a potential intervention strategy.

Facilitator: So what’s the difference between the second response and the third response?

Candy: ‘Cause the second response, she[‘s] going to try and [get] them [to] not drink. And, the third response, she’s just going to let them go and she[‘s] not going to know what’s going to happen.

Facilitator: Oh, okay. So, [do] you guys follow what Candy’s saying? Explain it [again]. I want to make sure I understand.

Candy: The second response is better than the third, because [in] the third [response], she[‘s] just going to leave them outside and she[‘s] not going to know what’s going to happen. And, [in] the second [response], she’s going to help them in not making them drink, and she’s going to help them have fun.

The importance of staying relationally connected in drug resistance for girls also extended to scripts with peers as drug offerers. In “One Time”, a group of older adolescents described how the female youth protagonist (Kiana) should refuse a marijuana offer from a boy with whom she just met and shares a mutual attraction (Eric). The group participants debated whether Kiana should refuse the offer by saying “no thanks, I’m cool.” They debated various responses which conveyed refusal, but also suggested the potential for drug use in the future, so as to not “cut off” the relationship.

Sherrie: I like the “No thanks, I’m cool.” Like, she’s trying to flirt with him at the same time ‘cause she does like him, you know. Like, or “no thanks”, not “I’m cool” but something else. Not “No thanks”.

Cammie: “I’m good.”

Sherrie: “I’m fine.”

Facilitator: I think what you’re picking up on, Sherrie, is that she does like this boy. So she wants to keep him [around her].

Sherrie: Yeah, keep him there but not like push him away on the side like “No thanks, I’m cool.”

Facilitator: So you’re thinking that way is okay. But then the suggestion that you made, you don’t want to totally like kick the guy off the [curb]. But what you said can work if you say it.

Sherrie: Yeah, in a different way.

Facilitator: You could do something, too, in your voice, if you want.

Bertha: She could be like “Noooo, next time.”

Sherrie: Yeah “next time.”

Bertha: ‘Cause then he’ll, he would be like [asking] again.

Sherrie: And the next time would be like again, “No, no, next time.”

Bertha: Yeah. She’ll be like “No, no, not right now, next time.”

Orchid: ‘Cause there’s people there too. So like-

Pearl: [Interrupts] She doesn’t want, she doesn’t want his friends to be like, “Brah, drop her, man.”

Orchid: [Referencing an extracurricular activity] She could be like “Nah, I gotta practice, you know.”

Data further suggested that female participants were more aware and/or concerned of the long-term ramifications of their interactions to their relational networks during drug refusal. This was exemplified in “Pearl’s” statement that Kiana in “One Time” should choose a refusal strategy which would minimize Eric’s friends from pressuring him away from dating her in the future (i.e., “Brah, drop her, man.”). Also demonstrating insight related to the long-term relational impact of drug refusal strategies, female participants who validated “Bacardi Party” described how responses to drug offers which involved telling an adult authority figure at school about the offer might be construed as “tattle-tailing” and could eventually lead to a fight among peers. Overall, female youth participants expressed insight related to the impact that specific drug resistance strategies could have had on their relationship with the drug offerer, as well as with their relationships with individuals who are in the offerer’s social network.

Some of the more serious and insightful responses around this theme came from female focus group participants who validated “Pulehu”. These participants expressed overall concern related to how adult family members might perceive Ku‘u’s refusal to drink alcohol with her father.

Boo Boo: I would feel pressured because that’s your family and you don’t want to like [does not finish statement], and it’s with your uncle guys and stuff. [Repeats a little bit louder] I would feel pressured because it’s your dad and your uncle guys.

Facilitator: What do you mean by pressured?

Boo Boo: Like maybe, just ‘cause they might find it offensive that you don’t want to drink beer, but they do. And that they think bad about it and stuff.

Later in the group discussion, these participants expressed concern specifically about the impact of one of Ku‘u’s responses to her father’s alcohol offer, in which she yells to her mother “Look what dad gave me!” The girls in this focus group described how this response might affect her father’s relationship with her mother, and subsequently her relationship with her father (Kana).

Facilitator: [Reading the script] So Kana hands her the beer he just cracked open. Ku‘u looks down hesitantly at the beer in her hand, then she looks back towards the house and yells out-

Laverne and Cutie [as Ku‘u]: Mom, look what dad gave me!

Facilitator: And Ku‘u holds up the beer and her [mother walks out and stands] out of the door with her hands on her hips. Alright, what do you think about that one?

Beyonce: Her dad’s in trouble.

Facilitator: Dad’s in trouble. Okay. Go ahead Dakota.

Dakota: I was just gonna say that, like, that decision she made could start problems between her mom and her dad, and then she could start getting abused by her dad because we still don’t know what kind of person he is.

Conversely, several of the boys who validated “Pulehu” did not seem to express as much concern toward Ku‘u’s response to her father’s alcohol offer. On the surface, they seemed to minimize the impact or extent of the problems that this response might have caused to Ku‘u’s family.

Facilitator: Okay, so response two, Kana says, “E Ku‘u, relax and have a beer with us.” And then, Kana hands her the beer he just cracked open. Ku‘u looks down hesitantly at the beer in her hand, then she looks back towards the house and yells out, “Mom, look what dad gave me!” Ku‘u holds up the beer. Her Mom steps out of the door with her hands on her hips. What do you think about that response?

Kolohe: [Laughs] I think that’s very realistic.

Facilitator: Oh, you think this is realistic, that this could happen?

Kolohe: Yeah.

Reptile: ‘Cause then, you know, mother[‘s] gonna get like mad.

Facilitator: Would this cause more problems within the family?

Jax: No.

Reptile: Yeah.

Kolohe: Only with the dad, mom and dad.

Discussion

In order to elucidate recent findings related to ecological risk for drug use for indigenous girls (Dixon Rayle et al., 2006; Okamoto, Kulis, et al., 2010), this article examined gender differences in preferred drug resistance strategies for rural Hawaiian youth participating in a culturally-grounded drug prevention pilot/feasibility study. Analysis of the modifications to the narrative scripts described by the youth participants indicated distinct gender differences, and supported the theoretical principles of relational-cultural theory. Compared with female focus group participants, male participants were more likely to endorse drug resistance strategies which relationally disconnected the youth protagonist from the drug offerer in the script. These strategies allowed the protagonist to eliminate personal risk of substance use in the short term, but eventually may result in adverse relational consequences. Conversely, the female youth participants appeared to favor resistance strategies which maintained a connection to the drug offerer. They considered the long-term relational consequences of their actions and behaviors, and appeared to balance the need to maintain relational and social harmony with the goal of drug abstinence.

While the need to stay relationally connected in the midst of drug-related problem situations for Hawaiian girls is consistent with relational-cultural theory, it also may account for the perceived difficulty that indigenous girls have expressed in dealing with these situations found in prior research (Dixon Rayle et al., 2006; Okamoto, Kulis, et al., 2010). Developmentally, indigenous pre-adolescent girls may be more aware of the social and relational consequences of different drug refusal strategies than their male counterparts. Because of this awareness, these girls may not see relational disconnection as an option in drug-related problem situations, as this may be perceived as culturally disrespectful or may lead to problems within their close-knit social network. In some cases, female focus groups participants described how relational connectedness in drug resistance with family members could even function as an intervention strategy, emphasizing the social responsibility that some of these girls experienced in preventing the substance use of family members. In any case, the qualitative findings strongly suggested that indigenous girls are compelled to engage in interactions with significant individuals who are offering them drugs, while simultaneously meeting the conflicting goals of maintaining social and relational harmony with these individuals and personally abstaining from drug use. Balancing all of these considerations represents an enormous challenge for these girls.

Implications for Indigenous- and Gender-Specific Practice

Examining gender differences in preferred drug resistance strategies has implications to promote developmentally and culturally appropriate, gender-specific resistance skills training for rural Hawaiian youth. Historically, drug prevention interventions have focused on instrumental means to meet individualistic goals related to abstinence (e.g., “just say no”). While prevention research has largely identified these skills as overly simplistic and ineffective (Tobler & Stratton, 1997), they are particularly inappropriate for girls (indigenous or non-indigenous), as they fail to consider the culture- and gender-based relational consequences of these types of responses. The findings from this study suggest that resistance skills which focus solely on meeting individualistic goals towards drug abstinence (e.g., walking away) may not be appropriate for indigenous girls. As suggested by RCT, drug resistance skills must equally balance the goals of relational connectedness and drug abstinence, particularly for indigenous girls within close-knit rural communities. Further, gender- and indigenous-specific drug prevention may need to much more contextual and relational in nature, and thereby will most likely be highly complex. This is particularly the case for drug offers from adult family members (e.g., parents). For example, an emerging video-based, culturally grounded drug prevention program for rural Hawaiian youth demonstrates how the female protagonist in “Pulehu” (Ku‘u) uses a series of verbal and non-verbal interactions with her father and other protective adults to maintain her positive relationship with her father, while simultaneously protecting herself from drinking beer with him (Okamoto, Helm, McClain, & Dinson, in press). The intent of this approach is to demonstrate how Ku‘u is able to use her culture-based relational networks as protection against substance use. Training in balancing drug abstinence with relational consequences is currently being developed for a school-based prevention curriculum to be delivered by teachers, but these types of skills have been adapted to other settings (e.g, social service agencies) in prior research (Holleran-Steiker, 2008). Drug prevention programs for other indigenous youth populations may need to similarly reflect realistic gender-specific problem situations, and unique ways in which indigenous girls deal effectively with them.

Limitations of the Study

There were several limitations to this study. Because data from this study came from a pilot/feasibility drug prevention study focused on Native Hawaiian youth on the Island of Hawai‘i, the results may lack transferability to Hawaiian girls on other islands, or to indigenous girls on the Mainland U.S. Furthermore, the topic of drug use can be sensitive in nature, affecting the level of comfort or amount of disclosure in a focus group setting. However, because the focus of these groups was on validating scripts based hypothetical drug-related problem situations, and not on intrusive topics such as past personal substance use, lack of comfort or disclosure in the group setting for these youth did not appear to be an issue. Finally, because active parental consent was required for all youth participating in the study, the sample may have been influenced by a selection bias. Youth with more extensive personal or familial substance abuse histories may not have been granted permission to participate in the study, due to their parents’ concern that these histories might be disclosed in the focus groups. As a result, preferred drug resistance strategies of Hawaiian girls with more extensive drug use histories may not have been reflected in the youths’ narratives.

Conclusions

Despite these limitations, this study builds upon prior gender-specific theory and practice by examining the preferred ways in which Hawaiian girls manage offers to use substances by peers and family members. Coupled with the framework of relational-cultural theory, the findings suggest that drug prevention interventions for Hawaiian youth should target the relational and cultural context (rather than the individual) as a primary focus of the intervention (West, 2005). Future research should examine the relational connectedness of Native Hawaiian girls within drug-related problems situations more closely, including subthemes that might provide more insights on the aspects or nature of relational connectedness with these youth. The findings from this study may have implications for the development of gender-specific drug prevention programs for other indigenous youth populations, particularly those within rural or reservation communities.