Drug Offers as a Context for Violence Perpetration and Victimization

Abstract

Objective

Drug use has been linked empirically with aggression and violence among youth in national and State of Hawai`i samples. However, the nature of this link and its implications for prevention are unclear. Therefore, this paper explores the intersection of drugs with aggression and violence by using the drug offer context as the unit of analysis.

Method

Native Hawaiian youth are sampled because substance use rates tend to be higher and onset tends to be earlier than their non-Hawaiian peers. Fourteen sex-specific focus group discussions were held with rural Native Hawaiian middle school students (N=64). Students discussed what they thought they would do in terms of drug refusal strategies in a variety of drug offer contexts.

Results

While aggression and violence were perceived to be socially inappropriate, students nonetheless felt drug use would be less socially competent. Narrative analyses indicated aggression and violence were perceived to function as potential drug refusal strategies. As proximal drug resistance, aggression and violence perpetration served as an immediate deterrent to the drug offerer, and thus drug use. As distal drug resistance, victimization served as a rationale for avoiding drug using contexts.

Conclusions

Implications are discussed in terms of prevention policy and practice, specifically in terms of a school-based prevention curriculum. Future research in Hawaiian epistemology and gendered approaches are warranted.

Introduction

Native Hawaiian Youth and Drug Use

Native Hawaiian youth consistently represent the largest proportion of public school students in the State of Hawai‘i (Kamehameha Schools, 2009), and tend to reside in rural locations (Accountability Resource Center Hawai`i, 2004). Hawaiian youth have reported the highest rates of drug use among ethnic groups in Hawai‘i (Glanz, Maskarinec, & Carlin, 2005; Glanz, Mau, Steffen, Maskarinec, & Arriola, 2007; Mayeda, Hishinuma, Nishimura, Garcia-Santiago, & Mark, 2006; Mokuau, 2002; Wong, Klingle, & Price, 2004), particularly within rural areas (Lai & Saka, 2005). Compared to youth of other ethnocultural groups in Hawai`i, drug use onset tends to be earlier among Hawaiian youth (Lai & Saka, 2005; Ramisetty-Mikler, Caetano, Goebert, & Nishimura, 2004), and the consequences resulting from substance use tend to be more severe (Wong et al., 2004). While there have been substantial efforts in recent years to develop drug prevention programs focused on indigenous youth populations (Hawkins, Cummins, & Marlatt, 2004; Marlatt, Larimar, Mail, Hawkins, Cummins, Blume, 2003; Schinke, Tepavac, & Cole, 2000), very few have targeted Hawaiian youth (Edwards, Giroux, & Okamoto, 2010; Rehuher, Hiramatsu, & Helm, 2008).

Therefore, the broad purpose of this program of research is to develop socio-culturally relevant drug prevention focused on indigenous Hawaiian middle school students (Helm & Okamoto, 2013). The focus of this paper is more narrow however, as earlier research has indicated a need to explore the intersecting problem of substance use with aggression and violence (Okamoto, Helm, Giroux, Kaliades, et al., 2010). For the purpose of this research, middle school students include those students enrolled in 6^th, 7^th, and 8^th grades. The term middle school is used here to refer to schools that may use the term intermediate school; and may also include multi-grade campuses, e.g. K-12, K-8, 6-12, etc. Our focus on middle school students stems from locally and nationally recognized evidence indicating that universal or primary prevention is effective at this developmental age because most youth in these grades have not tried alcohol, tobacco, marijuana, or other drugs; and among those that have most of their use would be considered experimental rather than abusive or dependent (Nation, Crusto, Wandersman, et al, 2003). For example, unpublished data from our pre-prevention studies from the sampled schools indicate that the use of both alcohol and marijuana increases significantly between the 6^th and 7^th grade, making this an effective time to intervene. Furthermore, while effective drug prevention may begin as early as preschool, targeting middle school students requires a focus on social competence and skill building (US DHHS, 2003), which this program of research is designed to address.

Drug Use and Violence

A critical area for improvement in drug prevention programming is the intersection of drug use and violence (Banyard, Cross, & Modecki, 2006; Brady, & Donenburg, 2006; CESAR, 2008; CESAR, 2010; Kulig, Hall, & Kalischuk, 2006; Tschann, Flores, Pasch, & VanOss Marin, 2005). There are a variety of definitions for aggression and violence. Broad categories include physical violence, including sexual violence, and emotional or psychological violence including the use of social electronic media to exert power and control (Baker & Helm, 2011). The Center's for Disease Control and Injury Prevention have adopted a definition of youth violence, borrowed from Dahlberg & Krug's 2002 World Health Organization report, to include the intentional use of physical force or power, both actual or threatened (CDC, 2013). In addition to victimization and perpetration, children's exposure to violence has been deemed a national crisis affecting approximately two-thirds of the nation's youth, and refers to both threatened and perceived violence (Listenbee, Torre, Boyle, et al, 2012). Bullying and other forms of aggression among children and youth also are public health concerns (Hamburger, Basile, & Vivolo, 2011).

Large-scale epidemiological research indicates that as drug use increases, violence increases (Farell, Sullivan, Esposito, Meyer, & Valis, 2005; Mulvey, Schubert, & Chassin, 2010; Pavkov, Travis, Fox, King, & Cross, 2010; Rainone, Schmeidler, Frank, & Smith, 2006; Substance Abuse and Mental Health Services Administration, 2006). In examining the co-occurrence of drug use and violence more deeply, a large sample of urban minority middle school students participated in a randomized clinical trial studying effectiveness of a drug prevention program on aggression and delinquency (Lynne-Landsman, Graber, Nichols, & Botvin, 2011). In addition to analyzing for group trajectories in substance use, aggression, and delinquency, temporal associations in the patterns of change were analyzed. Analyses indicated that while aggression and delinquency predicted substance use, substance use did not predict either aggression or delinquency. The authors suggest that aggression and delinquency prevention during childhood and early adolescence may deter future substance use.

Research in Hawai`i and among Hawaiian populations shows similar trends as national reports of the co-occurrence of substance use and violence (Austin, 2004; Baker, Hishinuma, Chang, & Nixon, 2010; Goebert, Caetano, Nishimura, Ramisetty-Mikler, 2004; Hishinuma et al., 2005; Zaha, Helm, Baker, Hayes, 2012). In a subsample analysis of youth identifying as Hawaiian, Pacific, Asian American, or Caucasian, analyses of Hawai`i Youth Risk Behavior Survey data indicated that alcohol use and violence perpetration and victimization were correlated (Goebert et al., 2004). Among Hawai`i adolescents, a positive correlation was found between violence perpetration, substance use, and life stress (Baker et al., 2010). Similarly, in a study of substance use and dating abuse among Hawai‘i youth, odds ratio calculations indicated that substance use is associated with an increased likelihood of reporting victimization (Zaha et al, 2012). Among Native Hawaiian youth, substance use has been found to be a robust predictor of a variety of school problems and health risk behaviors, including violence (Hishinuma et al., 2005). Among older adolescents and adults of Native Hawaiian ancestry living in rural Hawai‘i, violence was significantly correlated with drug use, and witnessing violence was significantly correlated with a variety of drug use patterns (Austin, 2004). Among Native Hawaiian adults, violence and drug use were described as occurring in the same setting, both within the family and in the community (Austin, 2004).

Finally, our preliminary analyses of drug resistance strategies among rural Native Hawaiian middle school students indicated that violence and aggression were among the more common responses to hypothetical drug offer contexts (Okamoto, Helm, Giroux, Kaliades, et al., 2010). Early communication research in compliance-resistance and cigarette smoking had focused on the peer relationship (Reardon, Sussman, Flay, 1989), as has much of the drug prevention research and practice since. Our program of research among Native Hawaiian youth has indicated that immediate and extended family drug offers may be particularly challenging (Okamoto, Helm, Po'a-Kekuawela, Nebre, & Chin, 2009). In the subsequent aforementioned study of drug offer context responses, youth responded to 15 drug related problem situations. Responses reflecting primary (N=420) and secondary (N=89) drug resistance strategies were identified by the youth, which were qualitatively collapsed into 16 different categories. From these 509 responses, 16.7% were coded as “angry refusal”, as defined as refusal with an angry tone, often laced with profanity (e.g., “Get the hell away from me!”); and 7.9% were coded as aggressive refusal, as defined as refusal that incorporates the threat or act of physical violence (e.g., “Get the hell away from me, or I'll punch you in the face.”). The current study builds on this preliminary analysis.

As this brief review of drug and violence trends shows, substance use and violence often go hand-in-hand, both among national samples and among rural Hawaiian samples. Furthermore, recent research has shown that youth perceive aggression and violence as a drug refusal strategy across a variety of drug offer contexts (Okamoto, Helm, Giroux, Kaliades, et al., 2010; Pristas & Rosenberg, 2010). While there is empirical support for the temporal link between substance use on the one hand, and aggression and violence on the other (e.g. Lynn-Landsman, et al, 2011), it is still not clear how this may co-occur in specific contexts. The purpose of the present study is to explore this link more deeply in terms of the drug offer context. Specifically, this study examines the 1) targets, 2) types, and 3) functionality of aggression and violence in drug offer contexts as described by rural Hawaiian middle school students.

Methods

Procedures for this study 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. Prior to initiating data collection, active parental consent and active youth assent was obtained.

Research Participants

Communities participating in this study were geographically concentrated within two of the three public school complex areas on Hawai`i Island, and comprised 88% of all public middle schools within the sampling frame. Seven middle schools participated in this study. Students were recruited in collaboration with school-based liaisons, meaning we were assisted by school staff who were able to distribute and collect parental permission forms among Native Hawaiian students enrolled on their campus. A total of 64 youth participated, from grades 6 (11%), 7 (42%), and 8 (47%). Half of the participants were girls (50%). The mean age was 12.58 years (SD = 0.612). The majority (95%) of youth identified as Native Hawaiian, including part-Hawaiian. Youth who participated received a gift card worth $5.00 for a local vendor.

Data Collection

Youth participated in sex-specific focus groups. The sex of the group's facilitator matched that of the participants. Fourteen focus groups were held (seven female and seven male), each lasting approximately 90 minutes, and consisted of three parts.

Part 1 - Elicitation Activity

Youth were asked to generate responses (e.g. brain storming) to a specified drug offer situation. These situations had been developed from narratives of rural Hawaiian youth (Helm et al., 2008; Okamoto, Helm, Po`a-Kekuawela, Nebre, & Chin, 2010; Okamoto, Helm, Po`a-Kekuawela, Nebre, & Chin, 2009; Po`a-Kekuawela, Okamoto, Helm, Nebre, & Chin, 2009), and were subjected to a series of test development and validation procedures that indicated they are the most frequently experienced and difficult for middle-school students to deal with in their homes, schools, and/or communities (Okamoto, Helm, Giroux, Edwards, & Kulis, 2010; Okamoto, Kulis, Helm, Edwards, & Giroux, 2010; Okamoto, Kulis, Helm, Giroux, Edwards, in press).

Part 2 - Rank Order

Youth rank-ordered the responses based on perceived efficacy for drug refusal. Youth were asked questions such as, “Which one of these responses is the best response to the (drug offer) situation, in terms of preventing you from using drugs and/or alcohol?” or “Of the responses you came up with, what would you do first (second, third, etc.) in this situation?” The process concluded with prompts such as, “Which one of these responses is the worst one, which might result in your use of drugs and/or alcohol in the situation?”

Part 3 - Group Discussion

The group discussion was interwoven with the ranking activity. The facilitator asked group members to explain their rationales for selecting a response as the best or worst. Facilitators asked for clarifications, for example would the rank change if the drug offerer had been a family member rather than a peer, if the location had been at home as opposed to school, or if the offerer had been a male versus female. Group discussions were audio recorded and transcribed verbatim. Discussion transcripts were subsequently coded and analyzed.

Data Management and Analyses

Results reported here use the facilitators’ first and last initial to indicate their comments, where as the youth were assigned pseudonyms. Transcripts were analyzed in stages, based on grounded theory (Patton, 2002; Ponterotto, 2010; Strauss & Corbin, 1990). First, lead researchers inductively identified patterns in the narratives for open coding. A coding structure was developed from these emergent themes. Next, each transcript was coded and added to the digital database (NVivo software; QSR International, 2008). Axial and selective coding were conducted by identifying themes related to drug resistance strategies.

The research team collectively coded one transcript to clarify the initial definition and parameters of each code and to ensure the team consistently identified narrative units. A narrative unit was defined as a “chunk” of conversation with a clear beginning and end for a particular theme. Subsequent transcripts were coded by one lead researcher and one or more research associates. In terms of inter-rater reliability, we used a consensus coding technique (rather than calculating numerical concordance among coders): narrative segments that were not identically coded by research team members were discussed by the team and justified for inclusion or exclusion in the code's data set. Code definitions evolved around the narrative content, so the digital data and codebook were continuously updated.

Thematic analyses broadly highlighted the contexts of substance use and responses to drug offers among rural Native Hawaiian youth in order to develop contextually relevant substance use prevention (Okamoto, Helm, Giroux, Kaliades, et al., 2010). While other important themes have been reported elsewhere, the purpose of this paper is to elucidate the theme of aggression (including profanity) and violence.

Results

Youths’ responses described here reflect their perceptions about what they think they would do, and may or may not be based on actual experience in these drug offer situations. Extensive quotes are provided, and it should be noted that youth participants speak both standard and pidgin English. Of the 17 drug resistance strategies initially identified (Okamoto, Helm, Giroux, Kaliades, et al., 2010) aggression and violence were described by girls and boys across each of the seven school-communities in which the 14 focus group interviews were facilitated (Table 1). Aggression and violence were referenced an average of 10 times per interview, with an average of 31% of the content in each group discussion focused on this theme (with a stronger emphasis made among girls’ groups as compared to boys’). These data indicate that violence and aggression may be considered legitimate concerns in substance use prevention among rural Native Hawaiian youth, and thus warrant deeper narrative analyses as presented below.

Table 1.

The Context of Drug Offers: Aggression and Violence.

Target of Aggression/Violence	Type of Aggression/Violence	Function of Aggression/Violence
inanimate object	verbal aggression	proximal resistance, perpetration
person	physical threats	distal resistance, victimization
	physical violence

Theme 1: Target of Aggression and Violence

Youth distinguished between aggressive and violent acts directed toward inanimate objects from acts directed at people or other living beings. For example, slapping a person who offers beer was considered more inappropriate than “slap[ing] the beer out of his hand”. In response to a drug offer, participants distinguished between using profanity in a non-directive way versus name-calling. For example, responding to a drug offer by saying “f--- that shit” or “I'm not in the f-ing mood” was considered less inappropriate than, “I would tell my cousin to f--- off”, “Get away I don't want to be stupid like you”, or “Burn in hell”.

Theme 2: Type of Aggression and Violence

Youths’ narratives highlighted three types of aggression and violence used in the context of drug resistance. First, verbal aggression, as listed above, was described frequently and at great length. Examples included insults, sarcasm, name-calling, and profanity. To create more or less emphasis, the youth described using tone of voice, facial expressions, and physical gestures in combination with statements such as, “Are you crazy!”, “You must be high!”, and “Brah, you one dumb idiot”. Second, verbal aggression extended beyond this to include threats of physical violence. Threats were uttered as stand-alone statements, or in combination with verbal aggression or further explanation. Threats included, “I going lick you [hit, punch, beat up], retard”, “I would say, ‘You is gone’”, “You want me to slap you in your head, because I just said no”, and “No, put it away or I'll crack that bong on your head.”

By rank ordering their respective group's lists of drug resistance strategies, the youth located verbal aggression and threats of physical violence at the bottom, “last”, or worst response. While these were considered less socio-culturally competent than non-aggressive and non-violent strategies, participants felt that making a threat is a way to emphasize verbally assertive refusals that had not been effective in deterring the drug offerer. In this example, “Wonder Woman” tempers the threat by suggesting that the drug is making the drug offerer do something wrong, and that it can result in loss of friends:

Wonder Woman: Well that makes it the last thing because you are just telling them, “you like me slap you in the head, I just told you I am over with this conversation” [uses strong tone].

SH: So you are using a really strong voice.

Wonder Woman: “You see what marijuana is making you do to you, it is making you keep asking people [to use drugs] and it is not making you have that much good friends” [still using strong voice]. Because they are getting irritated that you keep begging them to smoke but they no like because it is bad for you. That is what I think it means.

While assertiveness was considered socio-culturally competent, participants shared stories demonstrating that it did not always work; and therefore may not be a realistic “best” response. The following quote from “Glam” and “Darma” illustrates how youth struggle to balance assertiveness with effectiveness:

SH: What about “stop following me”? Would that be at the top? [girls indicate no]

Glam: No, because stop following me sound[s] just like you would tell... I tell my brother that all the time. It's not really powerful.

Darma: It's just like saying I want candy, but you're not gonna get it.

Finally, the third type of violence and aggression described in the context of drug offers was physical violence. Physical violence included pushing or slapping someone as an initial reaction to a drug offer, or fighting off someone who may be using force as part of the drug offer. Examples of physical violence targeting the drug included, “I would grab [marijuana] and slap her with it” and “Whack [the beer] out of the hand.” Targeting the drug offerer was also suggested, such as, “Punch them in the choppers”, “Give ‘em a slap and tell them to wake up”, and “I would grab the beer bottle and crack it on their head.” In this quote, several boys weighed the pros and cons of verbal aggression compared to physical violence:

SO: You're saying that “Slap ‘em and run” isn't a good response because it's gonna cause a fight?

Conan: Yeah, kind of.

Kaleo: It all depends on how old he is. [Laughs]...

Centipede: Well, it's, that you like slapping some sense into him, I guess? So, he'll like, think about it for a second, yeah. But then you also wanna run away in case he...

Nightcrawler: I would just say, “No way you crazy idiot”, because it's better saying it, not doing anything physically, ‘cause, he might beat you up. If he was your cousin, he probably would beat you up. And...plus, after just saying “No way you crazy idiot”, you could probably just walk away right after that.

Girls also considered the benefits and risks of using aggression and violence in drug refusal. In general, girls expressed that polite assertiveness may be insufficient for drug refusal, thus necessitating verbal aggression; however it may lead to violent retaliation. Furthermore, some contexts were perceived to be particularly risky because adults may not be able to provide safety in drug use contexts, as explained by girls in the following discussion.

Darma: Because “stop following me” is just like playing and stuff. But if you say “shut the hell up and get away from me” because like he keeps on asking you “you want a drink, you want a drink, you want a drink” [acting out how the cousin would sound].

Lucy: But say your cousin might not listen.

Dakota: What if you shove ‘em in the face?

Darma: But still, if you defend yourself, if you say it loud enough then somebody will come and defend you back.

Lucy: Not if they're all drunk.

Darma: No, there would, there would be somebody that would be there to listen to you.

Lucy: It's probably like the kids that drive their parents’ home.

Theme 3: Function of Violence

Youth highlighted two basic pathways in which aggression and violence may function as drug resistance. Most examples involved violence perpetration as a direct and immediate deterrent to ward off the drug offerer. However, youth felt this was a “last resort” due to likely retaliation and violence escalation, as described in the last three quotes. Although each group agreed that aggression and violence perpetration are not socio-culturally competent skills, these were seen as the lesser of two evils – using drugs is worse than using aggression or violence. One girl put it succinctly—“But even if you swear - that's not as bad as somebody doing drugs. Which one is more worse? You're just telling them to leave you alone”.

Despite the functionality of violence perpetration as a drug resistance strategy, youths’ narratives indicated that violence begets violence. If a youth perpetrates aggression and violence as drug resistance, a likely result is that s/he will become a victim of retaliatory violence, partially aggravated by the possibility that the drug offerer is impaired by drug use. Students also acknowledged the potential for becoming a victim of violence as a result of simply being in a drug use context, and not only as retaliation to their own aggression and violence. The following quote from a girls’ group exemplifies violence victimization as drug resistance. These girls explained that an effective strategy is to say that your parents won't let you go to a party where there will be drinking, not because of the drinking, but because of the likelihood of becoming a victim:

Taffy: ‘Cause [at the party] they drunk.... ‘Cause everybody stay acting stupid and all that.

Baby: And when you drinking you come violent. Just like, no care. You say any kine stuff that you don't mean.

Taffy: Yeah. They don't know what they saying.

Mercury: Yeah.

Taffy: Oh no, I was telling a story....We was at my cousin's graduation party and then everybody was all drinking. And we was about to leave at 4 o'clock in the morning. And then had all these [ethnic group] guys in the back, was acting all dumb, and my uncle told them for leave. And then, um, all the [ethnic group] guys went go in the back, find all knives. But they couldn't find so, they went crack the glass bottle.

Taffy: They went crack them, and then they went stab my uncle.

SH: And that's because why?

Taffy: Drinking.

Baby: Drinking is bad.

Boys also described avoiding violence victimization as a drug resistance strategy. The situation was described as, “You're at home having dinner with your family. Your parents are drinking beer with dinner and your mom offers you some.”

SO: “I would walk away to somewhere safe”. Why is that number four [middle rank]?

Batman: They won't kick your butt.

Kobe: No, because they're drunk, they don't know what they're doing, and they offer you some. And you say, “no ways, I'm not.” They come and try and force you, whack you and stuff. So they're all drunk and getting kind of crazy. So you got to go to your room, and lock yourself in, somewhere safe.

SO: So, somewhere safe would be your bedroom? Where else is somewhere safe?

Batman: My grandma's house.

Joseph: Run down the street.... My friend's.

Bow Wow: Yeah, my friend's or my cousin's house.

Bart: Also that is a good reason because you don't want to make them like mad. They're all drunk and don't know what they're doing. They might go crazy, cuckoo. You should just like get up and walk to somewhere safe.

Violence perpetration was conceptualized as an immediate and direct deterrent, even if as a last resort. Victimization was conceptualized as a reason to avoid drug-related contexts in the first place, and thus served as an indirect deterrent. In this sense, violence perpetration had proximal functional value, whereas violence victimization had distal functional value.

Conclusion

Key Findings

These results indicate that youth perceive the drug offer and related drug use as a form of rules transgression. The Native Hawaiian youth who participated in this series of focus group discussions perceived drug offer contexts as situations in which aggression and violence may be necessary strategies for drug refusal. Narrative analyses indicated important nuances with implications for preventionists and prevention researchers in the fields of substance use and abuse as well as violence. Although participants converged on the idea that neither drug use nor aggression and violence are socially competent, socially competent responses were perceived to be ineffective in some situations, thus aggression and violence were perceived as the lesser of two evils.

Analyses indicated three main points. First, aggression and violence directed at a person was perceived to be less appropriate than violence directed at an object. Second, aggression and violence were seen as a last resort after more socio-culturally competent responses are used. Yet verbal aggression, threats of violence, and physical violence were perceived to be more competent than succumbing to a drug offer. Finally, aggression and violence functioned proximally through violence perpetration, and distally through violence victimization.

Limitations

This study was designed to identify possible responses to hypothetical drug offers to rural Native Hawaiian youth. These responses represent what the youth think they would say or do, and may not represent what they actually would say or do. Furthermore, implications drawn from these results may have limited applicability to rural Native Hawaiian youth.

Research Implications

These findings support and extend the epidemiological and risk and protective factor research linking drugs with aggression and violence, as reviewed above. While these prior studies indicate that violence and drug use are positively related, these studies did not clarify whether drug use and violence occur in the same context, nor how this may occur. The results presented here are based on qualitative analyses of focus group interview data in which youth described what they think they would do in response to specified drug offers.

Results presented here suggest a temporal link between drug offer contexts and aggression and violence, though these cross-sectional data cannot show a definitive temporal link. A recent study corroborates this temporal link between drugs and aggression and violence to some extent. For example, in a survey of 309 high school students regarding their anticipated behavioral and emotional response to drug offers, results indicated several subscales or category of response. Verbal and physical aggression toward the offerer was one of the five responses (also included inform others, deception, verbal & nonverbal refusal, and deflection; Pristas & Rosenberg, 2010). As with the qualitative study presented here, the survey results indicated that aggression was endorsed less frequently than other options (Pristas & Rosenberg, 2010). Future qualitative research may need to sample youth who have been offered drugs (as opposed to a convenience sample of the general school population), and ask them to describe specific examples in which socially competent responses were not effective, and the way in which aggression and/or violence may have deterred the drug offerer.

Trinidad and Andrade have suggested a critical analysis of these findings from a more nuanced indigenous perspective (Trinidad, 2009; N. Andrade, personal communication, November 19, 2010). For example, Hawaiian epistemology distinguishes between two forms of knowledge and meaning making that guide action. Naua‘o refers to deeply felt beliefs that are revealed through critical thinking and dialog, where as ‘ike refers to the more immediately available factual knowledge. Viewed from this perspective, it may be that violence as a drug resistance strategy represents ‘ike knowing, which may align with first order change prevention. Likewise, understanding the context of drug offers/drug use as contexts which incite violence may align more closely with naua‘o knowing and second order prevention approaches. In addition, the concept of pono is a core value in Hawaiian culture, and refers to balance and harmony. Pono has external manifestations, in which kū (anger, hostility, aggression, violence) is balanced with lono (healing, regeneration, growth, birth, peace). Internal manifestations of pono are expressed as lokahi within an individual, as aloha among individuals at a relational level, and as ‘ohana at the larger group level. Future qualitative research may elucidate how Hawaiian epistemology can inform both first order and second order drug use and violence prevention, as has been suggested elsewhere (Trinidad, 2009; Akeo et al., 2008).

Finally, additional gender analyses of these data are warranted. Compared to boys, girls devoted approximately twice as much of their discussions to themes of violence and aggression. To impact drug use as a health disparity among Native Hawaiians, it may be important to move beyond considering the meaning of drugs and violence among rural Hawaiian youth, toward the gender specificity of these phenomena with rural Native Hawaiian girls.

Practice and Policy Implications

Implications of epidemiology and risk/protective factor research emphasize individual level behaviors, and thus call for first order change (Dalton, Elias, & Wandersman, 2007). First order change may include teaching drug resistance skills to individual students so that they may expand their repertoire and competence in using verbally assertive drug refusal, as opposed to aggression and violence. The research presented here suggests that first order prevention efforts may need to acknowledge that aggression and violence as a drug resistance strategy may be perceived by youth as preferable to drug use.

This is an important point for the field of health promotion and prevention; that intervention developers must identify and incorporate these multiple viewpoints in the intervention so that the intervention may be effective. For example, in a study of sixth grade students who participated in video-taped refusal skills role play scenarios designed to assess ability to refuse peer pressure, results indicated that perceptions of competent refusal depended on the assessor's age (Nichols, Birnel, Graber, Brooks-Gunn, & Botvin, 2010). Junior high school students and adult graduate students differed in their perceptions of competent refusal, with the youth endorsing strategies considered to be ineffective by adult-derived programmatic standards (Nichols, Birnel, Graber, Brooks-Gunn, & Botvin, 2010). Not only is it important to identify and include differences in developmental perspectives, culturally grounded perspectives are critical (Kulis, Jumper Reeves, Dustman, & O'Neill, 2011). While minority and indigenous youth may employ similar drug refusal strategies as majority youth in many instances, there are important nuances as suggested in the study presented here and elsewhere (Kulis & Brown, 2011; Kulis, Dustman, Brown, & Martinez, 2013; Kulis, et al, 2011).

With respect to the drug prevention curriculum developed from the broader program of research in which this study is a part, an explicit component of the school-based intervention includes critical thinking and skill building around assertiveness rather than aggression and violence (Okamoto, Helm, Dustman, 2013). For example, intervention schools participating in the video-enhanced curriculum during the pilot test phase (2012-2013 school year) progressed through the seven lessons, delivered once weekly for seven weeks. Each lesson followed a similar pattern. To begin, a video was shown depicting a drug offer, and three possible drug refusal options. Among these refusal options, verbally assertive responses are depicted. Next, critical thinking skills have been designed to emphasize key terms and concepts in drug prevention and Hawaiian culture, which are depicted in the video. Part of this includes explicit discussion of assertiveness, anger, aggression, and violence. 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. The teacher's role was to facilitate both critical thinking discussions as well as practice activities, including when youth highlight aggression and violence.

In addition to considering the individual as the target of intervention, this research emphasizes the need to consider the drug offer context as a unit of analysis and target of intervention. This requires a shift in the prevention framework from first order to second order change (Dalton et al., 2007). For example, reducing and eliminating youths’ exposure to drug offers serves a dual purpose of minimizing substance use and aggression and violence. Eliminating youths’ exposure to drug offers may require structural or policies changes in schools and communities, as well as with in peer and family dynamics. Future school and community based work will focus on these types of second order practice and policy changes.