USING PHOTOVOICE WITH YOUTH TO DEVELOP A DRUG PREVENTION PROGRAM IN A RURAL HAWAIIAN COMMUNITY

Abstract

Introduction

Substance use represents a significant and persistent health disparity among Native Hawaiian youth and communities. A community-university participatory action research project was conducted to develop a Native Hawaiian model of drug prevention.

Methods

Ten youth participated in eight Photovoice focus groups. Focus group transcripts and the youths’ SHOWED (see, happening, our, why, empower, do) worksheets were analyzed.

Results

Emergent analyses are described regarding focus group theme identification and the meaning of each theme. Youth-selected exemplary photographs and researcher-selected exemplary quotations are provided.

Implications

Native Hawaiian drug prevention will be place-based in culturally significant community locations, experiential, and guided by multigenerational teaching and learning.

INTRODUCTION

Prior to colonization, Hawai`i was a globally recognized independent nation. The overthrow of the Hawaiian monarchy in 1893 marked the official beginning of an ongoing process of colonization in Hawai`i, which is recognized to have begun in 1778 when English Captain James Cook arrived there. Since this time, the U.S. and other international interests have dominated the social, economic, legal, and health and wellness systems in the islands. The Indigenous people of Hawai`i, also referred to as Kānaka Maoli or Native Hawaiians, initially suffered greatly as the population was decimated by foreign disease, then disenfranchised through religious, geopolitical, and socioeconomic colonization (e.g., Liu, Blaisdell, & Aitaoto, 2008; McCubbin & Marsella, 2009). Currently, Kānaka Maoli account for approximately 20% of the (now) U.S. state of Hawai`i population, though there are rural communities in which the Kānaka Maoli population exceeds 60%. A history of colonization followed by rapid and enduring health disparities is not unique to the Indigenous people of Hawai`i, as demonstrated across First Nations populations in each of the continents.

Indigeneity and Substance Use

Among the various health disparities that may be attributable to the colonization of Indigenous populations is substance use (e.g., Bassett, Tsosie, & Nannauck, 2012; Brave Heart, Chase, Elkins, & Altschul, 2011; Liu et al., 2008; Walters, Simoni, & Evans-Campbell, 2002). These and other examples are based in the experiences of Alaska Natives, American Indians, First Nations peoples in Canada, Maori in Aotearoa, Aboriginals in Australia, Indigenous peoples from Mexico through Central and South America, and Kanaka Maoli (e.g. Allen et al., 2006; Hazel & Mohatt, 2001; Kaholokula, Nacapoy, & Dang, 2009; Kulis, Dustman, Brown, & Martinez, 2013; Smith, 1999). As with other Indigenous populations worldwide, Kānaka Maoli adults and youth suffer disproportionately from substance use-related problems. To focus this paper: Hawaiian youth initiate drug use earlier, report more frequent offers, and report higher use rates than their non-Hawaiian peers (Lai & Saka, 2005; Okamoto, Helm, Giroux, Edwards, & Kulis, 2010; Ramisetty-Mikler, Caetano, Goebert, & Nishimura, 2004; Wong, Klingle, & Price, 2004).

Rurality and Substance Use

Further complicating this heavy burden, the majority of Native Hawaiian youth reside in rural communities throughout the state of Hawai`i (Accountability Resource Center Hawai`i, 2011) where health resources, including high-quality drug prevention programs tend to be limited. Although rural prevention is becoming a national priority through emerging federal legislation (the Affordable Care Act), researchers on youth drug prevention historically have underrepresented rural populations in their samples, thereby creating a dearth of knowledge specific to these populations. On a national level, higher prevalence rates of alcohol and other drug use have been indicated among rural youth (Gilvarry, 2000; Pruitt, 2009; Substance Abuse and Mental Health Administration [SAMHSA], 2004). Differences in health risks among adolescents have indicated a consistent pattern, with rural students at most risk (Atav & Spencer, 2002; Colby et al., 2013).

This issue is complicated even further for rural Hawaiian youth, as there is a documented lack of evidence-based substance abuse prevention programs developed for them (Edwards, Giroux, & Okamoto, 2010; Rehuher, Hiramatsu, & Helm, 2008). Together, these studies point to the need for substance use prevention and research that account for deep structure cultural designs (Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999) for rural, Indigenous, and medically underserved communities. Deep structure cultural designs in prevention often engage the community or population in identifying the core culturally grounded components around which the intervention is built (see also Okamoto, Kulis, Marsiglia, Holleran Steiker, Dustman, 2014). In contrast, surface structure cultural designs are characterized by prevention programs that retain the core epistemology of the program, and are modified only to change things such as language (house to hale or casa) or symbols (such as an apple tree to a palm tree).

Hawaiian Culture and Positive Youth Development

Despite the persistent problem among Indigenous youth and rural Native Hawaiian youth in particular, nationally recognized evidence-based practices that are culturally grounded in Hawaiian epistemology do not exist in youth substance use prevention (Edwards et al., 2010; Rehuher et al., 2008). On the other hand, empirical evidence indicates that Hawaiian cultural interventions are preferred among Hawaiian adults and youth, and an Indigenous approach is effective for substance use and related problems among Hawaiian youth, as well as for promoting positive youth development (PYD; Irwin & Adler, 2008; Tibbetts, Medeiros, & Ng-Osorio, 2009; Trinidad, 2009; Withy, Lee, & Renger, 2007). PYD addresses the science-practice gap in drug-related problems experienced by Indigenous Hawaiian communities. As a strengths-based approach (Damon, 2004), the PYD paradigm has the potential to support Indigenous communities that advocate for repositioning culture as an asset around which prevention and promotion may occur. In addition to promoting bonding, resilience, and competence, PYD fosters aspects of adolescent development (Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2004) that align well with the ecology of Native Hawaiian well-being (McGregor et al., 2003). In particular, PYD fosters spiritual well-being, which Hawaiians often refer to as `uhane, and which encompasses aumakua (family deities), akua (gods), and kupuna (ancestors).

Community-based Participatory Action Research

Furthermore, participatory action research (PAR) is an approach that recognizes the sociopolitical origins of health, and the disproportionate impact of substance use and related problems on disenfranchised groups such as rural Indigenous populations, including Hawaiians (Freire, 1998a; Freire, 1998b; Said, 1978; Trask, 1987). Historically, PAR evolved from consciousness-raising activities among disenfranchised rural agricultural and other laborers to move people to act on their own behalf for social justice (Freire, 1998b). While community-engaged research varies in the balance of power among community and academic entities, community-based participatory research (CBPR) most closely resembles the historical intents of PAR while adhering to traditional conceptualizations of scientific rigor (Israel, Eng, Schulz, & Parker, 2005; Minkler & Wallerstein, 2003; Viswanathan et al., 2004).

Photovoice is a CBPR technique gaining in popularity since the 1990s among adolescent and prevention researchers. The idea is to place “cameras in the hands of community people so that they may visually represent and communicate to others their lived experiences” in order “to elicit emotions, feelings, and insights about topics that may be shrouded in silence” (Lopez, Eng, Robinson, & Wang, 2005, page 326). While some CBPR projects with youth are more community-located than participatory (Jacquez, Vaughn, & Wagner, 2013), Photovoice inherently enhances the participatory process in that community members who have identified a concern use photography to represent and define the issue from their own perspective, including the social action that stems from their work. Photovoice may be considered a decolonizing method because control of knowledge construction is, at least in part, in the hands of the participants. In addition, Photovoice is well suited for exploratory research in health disparities (Lopez et al., 2005), such as the intersection of indigeneity, rurality, PYD, and substance use because the knowledge gained is based in the community’s view, which often has not been documented previously, has been marginalized, or, in some cases, has been banned from public use. In fact, the community endorsed Photovoice as a valid research technique because they already had been using video and photography to protect and perpetuate the Hawaiian culture. Photovoice was viewed as part of this process.

Present Study

The purpose of the research was to use theory and concepts from the PYD paradigm and PAR approaches to guide the development of a Native Hawaiian model of drug prevention. By repositioning Hawaiian epistemology as the core component for intervention design, this study strives to decolonize prevention science (Bruner, 1990; Cochran et al., 2008; Meyer, 2008; Mohatt & Thomas, 2006; Smith, 1999). Hawaiian epistemology will be incorporated into future implementation and evaluation work in several areas: development and examination of the intervention itself (what the intervention is and what is delivered), process (how it is delivered), and outcome (intended levels of change).

Exploratory in nature, this study identified critical factors needed to develop the foundation of an efficacious prevention program from the perspective of rural Hawaiian youth. This phase of the project represents pre-prevention research designed to identify key concepts and elements in youth substance use prevention by answering this question: What are the Hawaiian cultural values, beliefs, and practices that may guide program design, implementation, and evaluation of youth substance use prevention; and how do Indigenous ways of knowing, or Hawaiian epistemology, guide the inquiry process?

METHODS

Ethics

This research was approved by the Institutional Review Board of the University of Hawai`i. In addition, as is becoming customary among Indigenous communities, an elders’ meeting was held in which ethical standards expected of the university were detailed for the university researchers. For example, community members were concerned about ownership of knowledge. All parties agreed that knowledge gained from the study would not be owned by the researchers, though we would be permitted to co-author peer-reviewed and other publications which may involve copyright of disseminated knowledge products. These standards are revisited in regular meetings among the university-based principal investigator (PI; Helm—science and research lead), the community-based co-PI (Lee—community director/coordinator), and the culture mentor (Hanakahi—language, kaona, and cultural practices specialist; liaison with other elders) for this project.

Sampling Frame and Participants

The community-based co-PI served as the onsite Program Director and recruited youth who had demonstrated leadership in drug prevention among their peers and in their school and community (based on his direct and indirect involvement in these activities). These haumana (pupil, apprentice) were encouraged to invite their friends to join the project. The goal was to recruit 8–12 haumana to participate in the Photovoice project. Ultimately, 10 youth were recruited: 6 girls and 4 boys, ranging from 12 to 18 years of age. We held an orientation meeting for the haumana and their families to explain the overall purpose and approach, and to ensure that families were fully informed and supported their children. At the conclusion of the `ohana night (family night), all 10 of the youth joined the project, at which time consent and assent forms were completed.

Throughout the project duration, we learned that several haumana were fluent or nearly fluent, whereas others had a basic knowledge and use of the Hawaiian language. Similarly, some haumana were deeply engaged in living and practicing the Hawaiian culture on a daily basis, whereas others practiced only with extended family on a regular, but not daily, basis.

Procedures

The Photovoice project involved three basic aspects: training, Photovoice focus group discussions, and social action. First, haumana were loaned high-quality point-and-shoot digital cameras for the duration of the Photovoice project and were trained in basic photography, image ethics (Wang & Redwood-Jones, 2001), and storytelling, including using the SHOWED technique (described below) for group discussion of photos (Wallerstein, 2004). For the image ethics session, we reviewed (1) privacy issues as they related to the photographer and the photographed; the concept of privacy in terms of private space, protection of disclosure, and protection from false light; and (2) ethical process, such as asking to take a photo and using consent/assent forms. Haumana also were allowed to take personal photos and post them on Facebook, Instagram, etc.; we did not ask about whether they did so. Photos became a part of the research project only if the youth chose to share them in the group and if they met image ethics standards.

According to the SHOWED technique (see, happening, our, why, empower, and do; refer to Appendix A), participants not only describe what they see in their photos in a literal sense, but also articulate what was happening when the photo was taken, how it affects them, and why an issue has arisen, as well as discuss issues of empowerment and ultimately move towards social action. Training included discussion of substance use and drug prevention, as well as Hawaiian culture and wellness, as these were the broad themes for the Photovoice project. We also introduced the concept of epistemology.

Second, haumana participated in Photovoice focus group discussions based on their photos. Discussions were co-facilitated by the university-based PI and the community-based co-PI, both of whom have extensive experience conducting youth group interviews for research and clinical purposes. A total of eight sessions were held for this project. Haumana were compensated with snacks and beverages and provided a $10 money order at each session. Each session included time for signing in, snacks, and uploading one or two photos. Each haumana selected which of her/his own photos to share with the group, and the session facilitators verified with the youth that image ethics were followed. (In cases where image ethics were not followed, the photos were not used.). Then haumana completed a SHOWED worksheet, typically writing two to three sentences for each aspect. Next, each haumana orally described his/her photo(s). Finally, the haumana selected one or two photos from among their group to discuss in greater detail. Based on this deeper conversation, additional themes arose which led to the photography assignment for the next week. In this way, issue selection emerged from the haumanas’ discussions. The themes and photos, with selected quotations from the focus group discussions, are described in the results.

During these discussions, youth did not always agree with one another (although disagreements did not occur often, as the facilitation focused on sharing personal views and building upon these viewpoints, as opposed to agreeing or disagreeing with one another’s views). Managing the flow of conversation and keeping youth Photovoice participants on track can be challenging; therefore, we used basic focus group ground rules, established with the youth during orientation and revisited during each session as needed (e.g., taking turns speaking, respect, confidentiality, honesty).

The third aspect of the Photovoice project was our community celebration, which served as our social action event for this phase of the project. Approximately 75 family, friends, and dignitaries from local and statewide public and private organizations were invited. Dignitaries were invited based on their position or role as a decision-maker with the power to promote the use of Indigenous epistemology as a core aspect of PYD, adolescent and community health, and substance use prevention. Photos presented in this article were shared by the haumana at this public event.

Data Management and Analyses

Focus group discussions were digitally audio recorded and were facilitated mainly in English and Hawai`i Creole English (usually referred to as Pidgin, also referred to as Pidgin English or Hawaiian Pidgin), though Hawaiian language also was used. Discussions were transcribed verbatim, retaining English, Pidgin, and Hawaiian (with English translations or paraphrases in brackets as necessary). The SHOWED worksheets also were digitally archived. The emergent analyses from the focus group discussions are presented here. Thus, the lead theme for each of the eight sessions is listed, described briefly, depicted visually in the photo, and elucidated through selected quotations from discussions and SHOWED worksheets.

RESULTS

Themes presented here are emergent, with the exception of the first theme which was provided by the PIs. Emergent analyses were identified in vivo at the conclusion of each session. This process was necessary because haumana needed to know what the next photo assignment was, so part of each session was devoted to discussing and agreeing on the next theme. Table 1 outlines the sequence of focus groups, with respective themes and youth-selected exemplary photographs.

Table 1.

Sequence of Focus Group Interviews for In Vivo Themes and Photographs

Focus Group Sequence	In Vivo Themes	Photographs
1	Theme 1: What are the Hawaiian values, beliefs, practices, ways of knowing that we know and use, and that would be important to include in a model of Native Hawaiian drug prevention?	(No photograph for session 1)
2	Theme 2: What do we see that's not working or not supportive of Hawaiian culture, and what do we see that is?
3	Theme 3: Talk to your Kupuna (elders) to find inspiration about Native Hawaiian values
4 & 5	Theme 4: What are the strengths and resources in (our community) from the past, currently here in the present, and that we want to carry forward for the future?
6	Theme 5: How do you and/or your 'ohana (family) resolve conflict, looking to Hawaiian epistemology
7	Theme 6: Thinking about the Native Hawaiian model of drug prevention that we are building, what are the Hawaiian sources of strength to help kids when they are vulnerable?
8	Theme 7: Again, thinking about the Native Hawaiian Model of drug prevention that we are building, what does mana (spiritual power) feel like and where in yourself do you feel it?

Theme 1: What are the Hawaiian values, beliefs, practices, ways of knowing that we know and use, and that would be important to include in a model of Native Hawaiian drug prevention?

There is no photo for the first theme, as the discussion served to inspire the haumana to take photos of values, beliefs, practices, and ways of knowing that would be important to include in the Native Hawaiian model of drug prevention. Haumana converged on several points during the first session: aloha (love, compassion, charity; also a greeting—see quotations below), malama (caring) and malama ka `āina (caring for land and earth, stewardship), hō`ihi (respect, especially toward kupuna [elders]), and kuleana (responsibility), as well as reciprocity in relationships across these values:

Aloha is, we share aloha a lot on this island. But we don’t just share it; we also instantly learn that the second we are born. When we’re kids we just learn aloha. And before you can even say the word, you are pretty much showing the action. Action speaks louder than words.

Helping out others without even asking for anything in return. ’Cause a lot of people do that, especially, like you saw today [university PI had been injured in an accident so the haumana carried her things, helped her sit comfortably, etc]. Knowing that when we need help, we know that someone else is going to help us without asking for any, anything in return. Like we help them, they help you, back and forth, back and forth. That’s how it always is around [here].

The haumana also discussed substance use and drugs in the community. Although the facilitator initially used the term “disgrace,” the youth agreed and said it was shameful. When asked about what was disgraceful, the haumana indicated that people lose their values, especially aloha. They explained that people lose self-respect and respect for others, that family problems result, and that people even lose their families because of drug use. This exchange led to a brief discussion on right and wrong, which was picked up as the next Photovoice focus group theme.

It’s a disgrace to the Hawaiian culture because, like nowadays, like how at every party there is alcohol. It kind of becomes like people see it as becoming, it became a part of our culture’ cause everyone, a lot of people do it, and, and. Like Hawaiians back in the day they never, they didn’t do that. They didn’t have alcohol to drink. They didn’t need it.

Theme 2: What do we see that’s not working or not supportive of Hawaiian culture, and what do we see that is?

Based on the first session, it was evident that we needed to return to the basics of what is considered right and wrong (pono and hihia; see Table 1), then move to more abstract and deeper issues. The word pono and its derivatives (e.g., ho`oponopono, the practice of making right) are commonly used in the Hawaiian language and in Pidgin. They are heard in everyday parlance in Hawai`i, including among standard English speakers, as pono is a pervasive value. Hihia is a less commonly used term, but the meaning is quite universal. Hihia refers to entanglements that occur when wrongdoing is not corrected. The discussion of pono included nature, natural beauty, medicinal plants, caring for nature, health and wellness, and being a role model for health and wellness. Hihia centered on when people don’t malama ka `āina (take care of land), cigarette smoking, which may lead to cancers and other health problems, and loss of cultural traditions and related health problems. The overall conversation highlighted the tie between the natural environment, individual and community well-being, and the importance of role models who pass cultural traditions across and within generations.

We’re the next generation, right? So we’re going to be the ones passing down the values next. Like, our parents passed on values to us. And if it’s good then it’s our, it’s our job to pass it on to our kids, so. And the more, and if we all, like if all the kids in our generation had good values, we would be passing down good values for the next generation. …Be the example, and like, like plant it like, if you be the example then other people are going to follow you. Like, if, if, they’re um, if they realize that what your doing is good and they might want to do it too.

[referring to photograph with a pile of cigarette butts] People were smoking and just throwing them [butts] to the floor when they’re done, without throwing them away. [It’s important] because it’s not taking care of our `āina.

(Refer to Table 1, Theme 2 for photographs)

Theme 3: Talk to your kupuna to find inspiration about Native Hawaiian values

At the end of the second session, the haumana seemed to be struggling with the depth of the discussion the facilitators desired and their individual knowledge and ability to discuss the full breadth of the related issues. While part of this struggle may have been developmental, in that younger haumana were emerging socially, emotionally, and cognitively into this type of reflective discussion, the facilitators believed that all haumana would benefit from listening to their kupuna speak of Native Hawaiian cultural practices, beliefs, and ways of knowing. (Kupuna are one’s grandparents, though the term encompasses elders across a variety of familial and social relationships, including one’s ancestors.) In addition, during the first two sessions, haumana had indicated that hō`ihi toward kupuna (respect toward elders and ancestors) is a core value. This idea yielded rich discussion, ranging from family traditions of growing kalo (taro, a staple of the Hawaiian diet) and the importance of kalo in Hawaiian ontology, to showing respect to kupuna by caring for their land. Exemplary quotations point to the importance of the past informing the present. The particular value, action, and way of knowing that epitomized intergenerationality were pono, malama, and ho`ihi. These values also are passed between humans and the earth, sky, and waters.

That was in an old placement where Kings and Queens used to come and stay [by the bayfront]. And nobody’s been watching it or watering it so it’s just died out and people are just throwing their rubbish down. So our class is cleaning it up. …Because there’s kupunas there [referring to spiritual presence]. And everybody goes there to look at it and it’s all dried up and dead…. Like, when people come over and they see it, they cannot feel the kupuna there. But we would clean it up and you would feel it. (Refer to Table 1, Theme 3 for photograph of youth cleaning the old placement, which appears to be a barren oceanfront park)

Theme 4: What are the strengths and resources (in our community) from the past, currently here in the present, and that we want to carry forward for the future?

The concept of past, present, and future was a dominant cross-cutting theme in the first three sessions, as exemplified in the last quotation above. As a result, it became the Photovoice topic for the next session. The depth of discussion was more profound by this time, so the topic was continued for two sessions. Initially, the haumana acknowledged their region of Hawai`i as something culturally unique, traditional, and thus revered for its authenticity toward Hawaiian culture. Their rural cultural strength also was connected to what one youth explained as “…there’s probably a higher percentage of people who are still like, or who are Native Hawaiian like living here.” This sentiment set the tone for the rest of the conversation, which also picked up on themes presented in prior sessions.

[referring to his photograph of a kalo plant] That is someone that has been passed down, that has been part of the family gene. First to have one taro, you have to have the one before it. … Like the last time I said [kalo] represents the human race, like, and if that one dies, like…We should take care of the plants as we take care of ourselves because without the plants we won’t be able to live.

The haumana discussed the connection among language, cultural and genealogical continuity, knowing and ways of knowing, sovereignty, and colonization while thinking about the past, the present, and the future. In this and other sessions, the haumana believed that colonization, loss of language, and the decimation of the Kanaka Maoli had been started by Captain Cook and sustained by missionaries. Revitalizing the language was highly valued among the youth, both currently and moving into the future, as it is linked with the natural environment. This feeling was contrasted with the time when Hawaiians were punished for speaking their language.

I chose this, this picture because there’s two, two traditions in it. The language and the kalo. [There is] a boy and a kalo plant. … He’s pulling weeds. Taking care of the plant. Both are important but, the tradition that I chose was the language and for me, to me language is important because it was banned before. And now we have the opportunity to learn it and carry on the language. And this kid is in preschool, so I think it’s cool that they’re starting young. And on the shirt says, “E ola mau ka `olelo Hawai`i” which means, “long live the Hawaiian language.” (Refer to Table 1, Theme 4, for photograph of kalo plant)

Theme 5: How do you and/or your `ohana (family) resolve conflict, looking to Hawaiian epistemology?

This theme arose from the prior session during which the haumana had emphasized malama ka `āina (taking care of the land). They had explained that problems were weeds that need to be removed from one’s life, similar to the way the farmer tends lo`i kalo (taro patch), so the weeds will not choke the plant. We wanted to explore the concept of problem solving more deeply, and anchored it to how youth problem solve in their families. This conversation uncovered the challenges that youth have in dealing with personal, familial, and social conflicts, and the feelings of vulnerability that result. A photograph of one participant’s ukulele was used to highlight the practice of ho`opono, to clear himself of conflict as a way to prepare to handle conflicts with others through ho`oponopono (to make right through a social process of guided problem solving).

Like how I was saying before, instead of talking with my mom about problems and stuff, I sit down and play my ukulele and sing and write new songs. Get my mind off the problems that’s going on. That’s what I do. And when I no more really, anybody for talk to, just sit down and play. Makes you feel better after that. But then again, you’re not really getting anywhere because you’re not talking with your family. But I think through music I can get out my feelings. And express myself little bit. That’s why I took this picture.

(Refer to Table 1, Focus Group 6, Theme 5, for photograph of ukulele)

While the haumana agreed ho`opono was an important part of being well and staying well, they expressed that youth often feel isolated and may have difficulty finding their way through all the “weeds.” The haumana selected a second photograph to represent this aspect of theme 5, in which two kukui leaves (a tree which symbolizes guiding light and leadership) surrounded by other leaves signify the struggle youth have in being and becoming pono, and the potential for vulnerability when youth feel isolated.

There’s that one different person. I guess there’s two. …And all around here, the [other leaves] are facing their stem at them, because they are so different. And you have to let go of something because you want them to come back to you. Because you are doing something wrong, they don’t want to come by you because you could be turning everything negative, from a positive. Yeah. Like in math, a negative plus a positive can be negative. Yeah, you have to be positive…and you can plus them together.

(Refer to Table 1, Focus Group 6, Theme 5 for photograph of kukui leaves)

Theme 6: Thinking about the Native Hawaiian model of drug prevention that we are building, what are the Hawaiian sources of strength to help kids when they are vulnerable?

The final two sessions were facilitated as a way to bring the haumana back to the overarching aim of the Photovoice project; that is, to create a Native Hawaiian model of drug prevention. The “sources of strength” theme stemmed directly from the prior group discussion when haumana explained that, in moments of vulnerability, youth turn to drugs as a way of coping with problems, and because of peer pressure and community norms endorsing drugs.

Two haumana discussed the banana plant (Refer to Table 1, Focus Group 7, Theme 6 for photograph). Unlike other life forms that can grow from seeds or propagated from cuttings independent of the parent plant, banana must grow as shoots directly from the original plant until it is somewhat mature and can nourish itself. In this way, the banana plant and its progeny are like humans. The boy is referring to himself as a child trying to grow up, in the safety of his family but also moving out into the world where it is difficult to be pono and a challenge to carry one’s kuleana (responsibility). In addition to one’s family in the present world, the youth relied on their kupuna (ancestors) to fulfill their kuleana.

Boy explains: I took a picture of [banana plant] because every time when I do something bad, it dies. And by keeping on doing bad, it dies again. When I do good, it helps out like when you water [the banana plant], it grows good, back good again. …I am going to have to change to make the plant change, grow back better. I think good things are saying sorry [when I am not pono]. And making it better.

Girl responds: Yeah, kind of like he said, like in order to make the plant grow. Or like, he’s the plant, so in order to make yourself grow better then you have to do good things. But then, if you do bad things then you don’t necessarily die, but like, like he said that if you don’t water it or you don’t weed it then it gets overgrown and then the plant dies. So, yeah you just have to do the right thing in order for it to grow.

Theme 7: Again, thinking about the Native Hawaiian model of drug prevention that we are building, what does mana (spiritual power) feel like and where in yourself do you feel it?

At the conclusion of the prior discussion, haumana indicated that mana (spiritual power) is what makes them feel strong, and that it is felt in the na`au (gut, as opposed to only in one’s mind). The haumana elaborated on this theme during the final session. Some haumana noted that mana feels like light glowing at various levels of luminosity. They also provided contrasting examples of what it is like when one does not feel mana.

It’s just a strength to make you get up and do stuff [but] if you’re mana is down you’re like, you feel sick or something, or you just depressed… It comes from inside of you I guess. Yeah.

You confused, like you don’t know where you are. You stand on cliff, you walk off the cliff. …Just like when you’re in the night time you cannot see nothing, nothing guiding you. Just like when you by the cliff, if it’s night time it’s easier for you to fall off the cliff because you can’t see nothing.

The power of mana was embodied in the photograph of a shore break ocean wave (Refer to Table 1, Focus Group 8, Theme 7). The quotation is from a SHOWED worksheet, and solidifies the intersection of nature, knowledge, and culturally grounded well-being.

Happening. The wave is barreling in. It’s heaving and strong.

Our. This picture shows what mana might feel or look like. It’s strong and can push you in the right direction.

Why. This might have become an issue… new technology … causes us to be less out in the natural environment doing the things that are part of our Hawaiian culture.

Empowerment. Bringing this knowledge to a person by placing in an environment and work on their observant skills and then oli [chant], feeling something from within.

Do. Since I know how some people don’t know what mana feels like I think that they should know what it feels like and how they can use this positive energy and use it well.

DISCUSSION

Summary

A Photovoice project among Hawaiian youth residing in a largely Hawaiian community was conducted as an initial step in building a Native Hawaiian model of drug prevention. Working with a single group of haumana repeatedly over 6 months through eight focus group discussions allowed for a depth and breadth of discussion not often achieved among adolescents. Allowing future themes to emerge from each discussion modeled concepts of PYD, in that haumana directed the flow and content of the conversation. Through the focus group discussion themes, haumana highlighted values, beliefs, practices, and ways of knowing that they believed belong in the prevention model.

Limitations

Analyses presented here are emergent themes developed in vivo at the conclusion of each session. Future analyses will be needed to explore the data more systematically and in greater depth. Although there were eight focus group discussions, these data represent the experiences and viewpoints of a single group of ten haumana. Cultural auditing with the larger community will be important for validating results prior to developing the prevention model (Trimble & Fisher, 2006).

The extent to which the results of this study are replicable among other Native Hawaiian youth and communities may be limited. The community involved in the study is somewhat unique in that Hawaiian values and practices are dominant (though they are no longer dominant across the state). As a result, the participating haumana may have greater access to Hawaiian culture as it is currently lived and as it has been practiced historically. In fact, this is one of the reasons the community supported the project, because it is considered a leader in living the Hawaiian culture and language. On the other hand, the results may be generalizable to other Native Hawaiian youth and communities who wish to use decolonizing approaches to substance use prevention.

Implications for Indigenous Hawaiian Practices and Ways of Knowing

Preliminary emergent analyses indicate that haumana participated in the project to make a contribution as leaders and role models in their community. Haumana want their voices heard and want to make a difference in their community; they believe that Hawaiian values, practices, beliefs, protocols, and disciplines are necessary in activities that occur in their community; and that their generation must lead by example by joining other communities’ leaders to end substance use problems. Their understanding of wellness and prevention is derived from their experiences with the natural environment, spirituality, and family from the past, to the present, and carried to future generations. All of these elements are tied to becoming familiar with and/or fluent in the Hawaiian language in order to understand mo`olelo (historical knowledge) embedded in mele (songs), oli (chant), and hō`ailona (reading signs in nature).

A framework for the Native Hawaiian model of drug prevention is becoming evident. First, we will continue to use a strengths-based model as suggested in PYD. Furthermore, the framework will be community-based and experiential, and will include a didactic component to encourage critical thinking, dialog, and writing. Experiential activities will be place-based and facilitated by a cadre of cultural experts, referred to as hulu kupuna. In this way, intergenerational teaching and learning will occur from hulu kupuna to `opio (expert elders to adolescents).

In debriefing sessions, haumana also indicated that the photography component should be retained because it was fun and useful in facilitating critical thinking, dialog, and writing. These findings are consistent with recent research in Hawai`i among Native Hawaiian students, in which youth enrolled in culture-based programs reported higher levels of cultural connectedness and other positive developmental assets (e.g., Hawaiian language, connections to the `āina [land, earth; includes waters and skies] and `ohana, connections to Hawaiian cultural values and practices; Tibbetts et al., 2009). Similar findings have been reported in studies of American Indian youth participating in drug prevention programs in the U.S. Southwest in which spirituality, storytelling, respect, generational roles, language, and a place-based concept referred to as home were valued (Dustman & Kulis, 2013).

In our original university-community meetings to discuss ethical standards, we had considered data ownership and data protection. Given the constraints of both the university and the community, we identified cultural auditing as a technique that balanced the two interests. Cultural auditing refers to the idea that the people who contributed the data should have an opportunity to examine the data and guide the process by which they are analyzed and used (Trimble & Fisher, 2006). In preparation for community-based cultural auditing, the university-based research team conducted a systematic content analysis. Opio (youth), makua (adults), and kupuna (elders) have participated in a series of cultural auditing activities in 2013–2014.

CONCLUSION

Local, state, and federally funded grants and contracts often require the use of evidence-based practices for youth drug prevention (see the national Registry of Evidence Programs and Practices [NREPP]; SAMHSA, 2013). Prevention science has made great strides in the past several decades to demonstrate that prevention works (Perl, 2013). The criteria by which programs are deemed effective have been articulated clearly (Flay et al., 2005). As a result, national repositories of evidence-based practices such as NREPP represent an important scientific and technologic advancement in the field of health and wellness. However, these practices often have been viewed as another form of colonialism among Indigenous practitioners. Indigenous and minority communities are left behind because the vast majority of nationally endorsed evidence-based practices have not included them in efficacy and effectiveness trials (Rehuher et al., 2008). Using national rather than local practices silences Indigenous knowledge and ways of knowing (see Cochran et al., 2008). There has been a paradigm shift in prevention science over the past decade toward conducting cultural adaptation studies and, more recently, deep structure cultural adaptations (e.g., Kulis & Dustman, 2013). However, adapted programs retain the core components of the original program based on the cultural group that participated in the initial intervention development and effectiveness trials, and these core components become the foundation for the new program used with the new cultural group. In other words, the core values, beliefs, and practices around which a culturally adapted program was built may not represent the new culture in which the adaptation is used (see also Okamoto et al., 2014).

Given the role of colonialism as historical and current cultural traumas that contribute to present-day substance use problems in Indigenous communities, we have opted to develop our own program on our own terms. Instead of marginalizing Hawaiian knowledge and ways of knowing, we have privileged them. In challenging the current prevention science and practice paradigm, we have selected decolonizing methodologies to reposition Hawaiian epistemology as the core around which drug prevention is built and the process through which drug prevention in a Hawaiian community is researched (Smith, 1999). In doing so, we have used principles of PYD because it is a strengths-based paradigm, and Photovoice as a community-based PAR strategy because it acknowledges sociopolitical inequities and embraces social justice aims.

Appendix A

Sample SHOWED Worksheet used in Focus Group Sessions