Native Hawaiian and Pacific Islander Elders: What Gerontologists Should Know

Abstract

Native Hawaiian and other Pacific Islanders (NHOPI) experience significant health disparities compared with other racial groups in the United States. Lower life expectancy has resulted in small proportions of elders in the population distribution of NHOPI, yet the number of NHOPI elders is growing. This article presents data on NHOPI elders and discusses possible reasons for continuing health disparities, including historical trauma, discrimination, changing lifestyle, and cultural values. We outline promising interventions with NHOPI and make suggestions for future research.

Native Hawaiian and Other Pacific Islander (NHOPI) Americans trace their ancestry to the islands of Polynesia, Micronesia, and Melanesia in the Pacific Ocean. In the United States, Pacific Islanders (PI) have long been aggregated with Asian Americans (AA) into a single racial group, abbreviated AAPI. In the aggregate, AAPI have a longer life expectancy, higher educational achievement, lower poverty rates, and better health indicators than most other minority groups in the United States (Shi & Stevens, 2010). However, this aggregation masks important differences between AA and NHOPI, as well as between distinct NHOPI groups, in longevity, cancer survival, mental health, and other indicators (Park, Braun, Horiuchi, Tottori, & Onaka, 2009; Stafford, 2010). Thus, researchers continue to advocate for the disaggregation of NHOPI groups from AA groups and, if statistically feasible, further disaggregation of NHOPI groups (Park et al., 2009; Siegel, 2012)

As the last known review of NHOPI elders was published in 2004 (Braun, Yee, Browne, & Mokuau, 2004), this article provides updated information on NHOPI elders, with particular attention given to the largest subgroups: Native Hawaiians, Samoans, Chamorros, and Micronesians. After a brief review of the historical context of NHOPI in the United States, we present data on demographic and health indicators, discuss possible reasons for poor health outcomes, outline promising intervention approaches, and make recommendations for future research.

Historical Context

Indigenous oral histories and records of early Western visitors to the Pacific indicate that NHOPI were once healthy and hardy peoples. However, with Western contact, natives contracted communicable diseases to which they had no immunity, witnessed dramatic changes in land tenure and social structures, and experienced suppression of their cultures and languages. (Hezel, 2010; Osorio, 2002).

For example, within 50 years of their arrival in Hawai’i, U.S. missionaries and businessmen had gained complete control of the economy. The Hawaiian nation was overthrown by the United States in 1893. The islands became a U.S. Territory in 1898 and a state in 1959. The United States gained control of Guam after the Spanish–American War in 1898 and of American Samoa with the Berlin Treaty of 1900 (Tsark, Cancer Council of the Pacific Islands, & Braun, 2007). The Commonwealth of the Northern Mariana Islands (CNMI), the Federated States of Micronesia (FSM), the Republic of the Marshall Islands (Marshalls), and the Republic of Belau (Palau) were put under U.S. protection following World War II.

All six island groups continue in legal relationships with the United States. American Samoa, Guam, and CNMI are U.S. flag territories. The FSM, Marshalls, and Palau are independent nations with treaty agreements with the United States. All six jurisdictions provide the U.S. military access to their lands and waters in return for economic aid and the right to freely migrate to the United States (Weaver, 2008). English is an official language, and the U.S. dollar is the legal currency (Tsark et al., 2007).

Population Characteristics

In the U.S. Census (2010), 1,225,195 people (0.4% of the total population) identified themselves as NHOPI. This included 540,013 people who reported NHOPI ancestry alone, and 685,182 who reported this race in combination with one or more other races (Table 1). The NHOPI label includes more than 50 groups with unique histories, languages, and cultures. The largest groups are Native Hawaiian (43%), Samoan (15%), Chamorro (12%), and Other Micronesian (6%). NHOPI reside in all 50 states, but the largest concentrations live in Hawai’i (29%), California (23%), Washington (6%), Texas (4%), New York (3%), Florida (3%), Utah (3%), and Nevada (3%). NHOPIs account for less than 1% of the population in most states, including California; however, they comprise 26% of the population of Hawai’i, 57% of the population of Guam (predominantly Chamorro), and 95% of the population of American Samoa (predominantly Samoan; U.S. Census Bureau, 2010).

Table 1.

Native Hawaiian and Other Pacific Islander Population (N = 1,225,195) in the United States by Detailed Group

Detailed group	N (%)
Polynesian
Native Hawaiian	527,077 (43.0)
Samoan	184,077 (15.0)
Tongan	57,183 (4.7)
Tahitian	5,062 (0.4)
Tokelauan	925 (0.1)
Unspecified	9,153 (0.7)
Micronesian
Guamanian or Chamorro	147,798 (12.1)
Mariana Islander	391
Saipanese	1,031 (0.1)
Palauan	7,450 (0.6)
Carolinian	521
Kosraean	906 (0.1)
Pohnpeian	2,060 (0.2)
Chuukese	4,211 (0.3)
Yapese	1,018 (0.1)
Marshallese	22,434 (1.8)
I-Kiribati	401
Other Micronesian	29,112 (2.4)
Melanesian
Fijian	32,304 (2.6)
Papua New Guinean	416
Solomon Islander	122
Ni-Vanuatu	91
Unspecified	222
Other/unspecified	240,179 (19.6)
Total	1,225,195 (100)

Elders do not comprise a large percentage of NHOPI populations. According to the U.S. Census (2010), only 5.6% of NHOPIs in the United States are aged 65 and older, compared with about 13% of the general population. Elders comprise only 5% of Guam’s population and less than 4% of American Samoa’s population (U.S. Census Bureau, 2010). In Hawai’i, Native Hawaiians comprised 24.3% of the total state population in 2008, but only 12.6% of residents aged 60+ are Native Hawaiian (Ka’opua, Braun, Browne, Mokuau, & Park, 2011). According to the 2010U.S. Census, 16.4% of NHOPI households include an elder, compared with 24.9% of U.S. households (Table 2). Only 11.7% of NHOPI aged 65+ are head of household (compared with 22.1% of elders in the overall population), and only 16.5% of NHOPI elders own their homes (compared with 26.3% of elders in the overall population). NHOPI elders, however, are less likely to live alone; only 13.4% of older NHOPI men (vs. 18.3% of older men in the general population) and 19.8% of older NHOPI women (vs. 34.2% older women in the general population) do so.

Table 2.

Comparison of Native Hawaiian and Other Pacific Islanders (NHOPI) and Total U.S. Population on Median Age and Household Characteristics: 2010

Characteristics	NHOPI population (N = 1,225,195)	Total U.S. population (N = 308,745,538)
	n (%)	n (%)
Median age (years)	26.5	37.2
Aged 65+
Total	68,225 (5.6)	40,267,984 (13.0)
Men	30,369 (2.5)	17,362,960 (5.6)
Women	37,856 (3.1)	22,905,024 (7.4)
Households	319,873 (100.0)	116,716,292 (100.0)
Households w/individuals aged 65+	52,313 (16.4)	29,091,122 (24.9)
Householder aged 65+	37,298 (11.7)	25,819,386 (22.1)
Householder living alone aged 65+
Men	4,057 (13.4)	3,171,724 (18.3)
Women	7,512 (19.8)	7,823,965 (34.2)
Average household size	3.38	2.58
Average family size	3.86	3.14
Home owner (any age)	149,262 (46.7)	75,987,074 (65.1)
Aged 65+	24,575 (16.5)	20,006,616 (26.3)
Renter (any age)	170,611 (53.3)	40,730,218 (34.9)
Aged 65+	12,723 (7.5)	5,813,190 (14.3)

Disability levels of NHOPI (39%) and U.S. elders (37%) are very similar. However, NHOPI elders have among the lowest per capita incomes and highest poverty rates of all American ethnic groups. Specifically, 12.6% of these NHOPI live in poverty (compared with 9.3% of elders in the general population), and the per capita incomes for NHOPIs are significantly lower ($18,562 for NHOPI elders vs. $26,708 for elders overall; Table 3). English is not the first language of 45.9% of NHOPI elders (compared with 13.9% of elders in the general population), and 13.8% of NHOPI elders report that they do not speak English well or at all (compared with 5.3% of elders in the general population).

Table 3.

Comparison of Native Hawaiian and Other Pacific Islander (NHOPI) Elders and U.S. Elders on Income, English-speaking Ability, and Disabilities

Characteristics	NHOPI population (n = 540,013)	Total U.S. population (N = 281,421,906)
	n (%)	n (%)
Population aged 65+	31,213 (5.8)	40,267,984 (14.3)
Income below poverty aged 65+	3,935 (12.6)	3,730,456 (9.3)
Per capita income	$18,562	$26,708
English-speaking ability among elders (%)
English is only language	54.1	86.1
English is not first language:	45.9	13.9
Very well	21.2	5.8
Well	11.0	2.8
Not Well	9.6	3.0
Not at all	4.2	2.3
Individuals aged 65+ with a disability	39.1	36.6

Health

Although residents of Hawai’i have the greatest longevity of all 50 states, there are differences across ethnic groups. Native Hawaiians and Samoans have the shortest life expectancies of the state’s seven major ethnic groups, 9–13 years shorter than life expectancy for Chinese, Japanese, and Korean residents and 5–8 years shorter than for Caucasians and Filipinos (Park et al., 2009). Median age is a reflection of life expectancy, and the median age of NHOPI in the United States is 10 years younger than for the U.S. population as a whole (27.1 years vs. 37.6 years; U.S. Census Bureau, 2010). The median age of NHOPIs in the United States is similar to the median population age in American Samoa (28.3 years) and Guam (29.9 years) but older than the median population age in the FSM (23.8 years) and the Marshalls (22.2 years; U.S. Central Intelligence Agency, 2013).

Data from the National Cancer Institute’s 14 Surveillance, Epidemiology, and End Results sites suggest that NHOPI subgroups in the U.S. have higher cancer incidence and mortality than non-Hispanic Whites and Asian subgroups (Miller, Chu, Hanky, & Ries, 2008). Specifically, Native Hawaiian men have especially high mortality from prostate, lung, and colorectal cancers. Samoan men have especially high mortality from prostate, lung, liver, and stomach cancers. Native Hawaiian and Samoan women have especially high mortality from breast and lung cancers (Miller et al., 2008). Cancer registry data from the other Pacific jurisdictions indicate that cancer is the second leading cause of death, and the most commonly detected malignancies are breast, lung and bronchus, prostate, colorectal, liver, and cervical (Buenconsejo-Lum, Navasca, Jeong, Wong, & Torris, 2014).

The Centers for Disease Control and Prevention estimate the age-adjusted percentage of diabetes among NHOPI adults as 23.7%, compared with 7.6% for non-Hispanic Whites (Schiller, Lucas, Ward, & Peregoy, 2012). In a household survey with data on 2,522 Hawai’i migrants from the FSM and the Marshalls, 35% of participants aged 40+ reported having diabetes (Pobutsky, Krupitsky, & Yamada, 2009). Forty-seven percent of the adult population of American Samoa is reported to have diabetes (Ichiho, Roby, Ponausuia, & Aitaoto, 2013). In Guam, the Chamorro population has higher rates of diabetes than Asian and Caucasian residents, and Chamorros with diabetes were found to be at greater risk for heart disease and stroke than their nondiabetic counterparts (Inouye, Li, Davis, & Arakaki, 2012). The prevalence of overweight and obesity also is high among NHOPI adults, estimated at 61.1% in Guam, 93% in American Samoa, 78.5% for Native Hawaiian in Hawai’i, (Ichiho, Gillan, & Aitaoto, 2013; Ichiho, Roby, et al., 2013).

The prevalence of Alzheimer’s disease (AD) is growing among U.S. adults. Prevalence in 2010 was estimated at 4.7 million individuals aged 65+, projected to increase to 13.8 million in 2050 (Hebert, Weuve, Scherr, & Evans, 2013). Very little information exists on the prevalence of dementia in NHOPI in the United States. However, several dementia-related studies have been conducted on Guam because of the high prevalence of amyotrophic lateral sclerosis and Parkinsonism–dementia complex (PDC) reported in the 1950s among the Chamorro residents. A population-based survey of Chamorros aged 65+ on Guam suggested a point prevalence of all-cause dementia on February 1, 2004 of 12.2%, including 8.8% Guam dementia (clinically equivalent to AD), 1.5% PDC, 1.3% pure vascular dementia, and 0.6% other. As in other communities, dementia prevalence rose exponentially with age (Galasko et al., 2007).

In addition to increasing prevalence of chronic diseases and associated risk factors, a small percentage of NHOPI elders from the Western Pacific (especially the FSM and the Marshalls) migrate to the United States with active tuberculosis, Hansen’s disease, and other communicable diseases (Pobutsky et al., 2009).

Mental Health

There is a shortage of mental health research on NHOPI elders. Klest, Freyd, & Foynes (2013) analyzed data from 833 members of an ethnically diverse longitudinal cohort study in Hawai’i. Cohort members of Native Hawaiian ethnicity and poorer socioeconomic status reported greater trauma exposure over the life course and greater symptoms than did individuals of other race/ethnic backgrounds and individuals from higher socioeconomic levels. Also, experience of trauma correlated inversely with self-rated health (Klest, Freyd, Hampson, & Dubanoski, 2013). In an analysis of Behavioral Risk Factor Surveillance System data in Hawai’i, Aczon-Armstrong and colleagues (2013) found that the prevalence of severe or moderately severe depression was 4.8% among Native Hawaiians and other Pacific Islanders, almost twice as high as the state prevalence (2.7%) and 3 times higher than the prevalence for Asians in Hawai’i (1.5%). However, the rate of suicide among Native Hawaiians aged 65+ is about half that of Caucasian elders in Hawai’i, and suicide rates also appear low among elders in American Samoa, the FSM, Guam, and Micronesia (Else, Andrade, & Nahulu, 2007).

Discussion

A number of reasons for poor health outcomes among NHOPI adults and elders have been hypothesized, including colonization/historical trauma, discrimination, loss of traditional healthy lifestyles, lack of experience with accessible health care, and cultural values.

The forced assimilation of NHOPI homelands by colonizers obviously contributed to the health inequalities they currently experience. Several researchers speak to historical trauma, which links the experience of colonization to health and social problems across multiple generations (Braveheart & Debruyn, 1998; Evans-Campbell, 2008; Sotero, 2006). Specifically, colonized people usually are exposed to foreign disease and lose vitality and life, along with land, language, culture, and power in their homelands (United Nations, 2008). Children and grandchildren of the colonized generation are affected by the original trauma through exposure to their dispossessed parents and grandparents, who may transmit feelings of racial inferiority. Colonizers impose their own social and political structures, into which their own progeny fit, but these structures serve to marginalize native peoples. Active and passive forms of discrimination promote intergenerational marginalization, keeping indigenous people at or near the bottom of economic and social hierarchies. Thus, “populations historically subjected to long-term, mass trauma exhibit a higher prevalence of disease even several generations after the original trauma occurred” (Sotero, 2006, p. 94).

A self-governance movement among Native Hawaiians blossomed in the 1970s, igniting a revival of the Hawaiian language and culture (Marsella, Oliveira, Plummer, & Crabbe, 1995). This also paved the way for the U.S. government to formally apologize for the overthrow of the Hawaiian monarchy. However, many Hawaiians have internalized damaging social stereotyping, leading to feelings of shame about their cultural history. An examination of perceived racism in 146 adult Native Hawaiians found that Native Hawaiians perceiving high levels of racism had significantly higher systolic blood pressure than those reporting lower levels (Kaholokula, Grandinetti, Keller, Nacapoy, Kingi, & Mau, 2012).

With colonization came a shift in lifestyle as subsistence fishing and agriculture were replaced by large-scale industrial agriculture (e.g., sugar and pineapple plantations) and fishing for export (Cassel, 2010). Militarization also accompanied colonization. Enlistment in the military became an avenue for native men and women to ensure the survival of their families, and NHOPI today are overrepresented in the U.S. military by a factor of 250 (Kane, 2005). Residents of Guam and the FSM were rescued by the U.S. military from tortuous living conditions under the Japanese prior to World War II, but the military also brought tobacco and foods high in refined sugar, salt, and fat, which supplanted traditional foods (Cassel, 2010). Residents of the Marshalls witnessed the detonation of more than 67U.S. thermonuclear weapons, which contaminated large areas of traditional fishing and planting grounds (Yamada & Pobutsky, 2009). Even today, the U.S. military owns about 21% of Hawai’i and 29% of Guam, offering employment opportunities for local residents but restricting their access to large areas of land and ocean.

Research suggests that most NHOPI from areas outside Hawai’i migrate to the United States in search of better opportunities for education, employment, and health care (Aitaoto, Braun, Estrella, Epeluk, & Tsark, 2012; Choi, 2008). Elders who have migrated to the United States from American Samoa and the Western Pacific may be encountering health care that is very different from their homelands. For example, Choi (2008) interviewed Marshallese in Hawai’i and found that many migrants did not seek health care until they perceived a health crisis. This practice may stem from the very limited availability of health services, especially preventive health services, on their home islands, as found through research on cancer and diabetes care across this region (Buenconsejo-Lum et al., 2014; Hubbell, Luce, & McMullin, 2005; Ichiho, Gillan, et al., 2013; Ichiho, Roby, et al., 2013; Tsark et al., 2007).

Cultural values (enduring philosophies that influence social structures) can have a significant effect on beliefs about health and well-being. Most Pacific cultures place individuals within the context of the larger group (e.g., the family, clan, and village), the physical environment within which they live, and their church structures. Traditional Samoan culture (known as faaSamoa or the Samoan way) is rooted in strong family dynamics, a powerful tie to the land, a deep reverence for the church, and a respect for both reciprocity and authority (Aitaoto, Braun, Dang, & Soa, 2007; Cassel, 2010). As a result, Samoans may link poor health to disharmony across these domains, as well as to aitu or spirits (Hubbell et al., 2005). Many Hawaiians believe that good health is a reflection of one’s ability to balance responsibilities to the group, the land, and the spiritual world (including ancestors and family gods; Braun et al., 2004). Chamorro culture places great importance on family, community, nature, spirituality, and communal society (De Frutos & De la Rosa, 2012), with some believing that illness is caused by island spirits (Balajadia, Wenzel, Huh, Sweningson, & Hubbell, 2008).

Qualitative research findings suggest that NHOPI families expect to care for their elders (Browne, Mokuau, Ka’opua, Kim, Higuchi, & Braun, 2014; McLaughlin & Braun, 1998). In Samoan communities, elders are responsible for imparting traditional Samoan culture onto a younger generation and assisting them to traverse their American and Samoan identities (Vakalahi, 2012). Hawaiian elders are valued for their link to the past and their transmission of Hawaiian language and traditions to younger generations (Browne et al., 2014). Also, and in contradiction to Western views of aging as decline, NHOPI tend to think positively about aging, as growing old signifies a period in one’s life where one can slow down and have loved ones take care of him/her (Tauiliili, Delva, & Browne, 2008). Rehabilitation professionals have noted that NHOPI elders’ belief that family will (and should) care for them can thwart efforts to help elders regain function following stroke or hip fracture (Braun, Mokuau, & Tsark, 1997). Nonetheless, optimistic views aging and dependency contrast with Western views and may help explain lower rates of suicide among older NHOPI than Whites (Else et al., 2007).

Promising Practices With NHOPI Elders

Strategies to reduce disparities experienced by NHOPI elders include increasing access to care, tailoring programs to NHOPI groups, and improving the cultural sensitivity of providers.

Increasing NHOPI access to care is critical. Although the Affordable Care Act and Medicaid expansion programs are bringing insurance coverage to more populations in need, including NHOPI, it is important to note that Hawai’i has been allowed to restrict the type and amount of services covered under Medicaid for residents from the FSM, Marshalls, and Palau (Shek & Yamada, 2011). The U.S. Health Services and Resources Administration funds a system of Federally Qualified Health Centers across the United States and Native Hawaiian Health Care Systems (in Hawai’i). These are designed to provide free or low-cost care, and many of these are located in communities in which NHOPI are concentrated. These entities employ community health workers and navigators that can help increase access to care (Braun et al., 2012).

Programs that have been tailored to NHOPI populations have been successful in improving NHOPI health care utilization. Especially useful are interventions that reflect NHOPI values related to family, community, and church. For example, Native Hawaiian women responded well to a church-based program in which breast cancer screening messages were delivered from the pulpit (Ka’opua, Park, Ward, & Braun, 2011). A family-focused intervention was shown to help Native Hawaiian cancer patients cope with and complete treatment (Mokuau, Braun, & Dannigales, 2012). Interventions using lay navigators were shown to increase cancer screening participation in Native Hawaiians (Braun et al., 2012) and Micronesians (Aitaoto et al., 2012). In developing culturally responsive services and promoting them to NHOPI elders, it is important to use designs and photos that are attractive to the ethnic group, to present evidence of the relevance of the problem to the culture, to incorporate words and phrases from the group’s language, and to reflect the group’s cultural values and context (Kreuter, Lukwago, Bucholtz, Clark, Sanders-Thompson, 2003).

Finally, providers need to improve their sensitivity to diverse cultures. In working with NHOPI elders, it is important first to establish a personal connection (Mau, 2010). This may be achieved by finding something in common, for example, living in the same community, identifying a mutual acquaintance, or sharing a feeling in common (such as excitement over a birth in the family). Asking about the elder’s home island can demonstrate interest in and respect for the elder’s ancestry and experiences. This connection helps establish trust and facilitates clinical and research interactions.

Two critical interview skills are to listen actively and to delay judgment about what the client is relating. Both are tenets of motivational interviewing, an approach to problem solving that encourages the client to define his/her issues, debate advantages and disadvantages of various solutions, set his/her own goals, and gain accountability for behaviors. This approach appears to be more successful than lecture-style approaches to patient care (Simmons & Wolever, 2013). NHOPI elders also may want to involve family in health care visits and decision making (McLaughlin & Braun, 1998), and often family can be enlisted to help elders get to appointments and follow treatment advice (Mau, 2010).

To prevent miscommunication and unintentional insults, providers should ask NHOPI elders about preferred forms of address (Mau, 2010). Some older NHOPI women may prefer to be called “auntie” or by their first name, whereas others may prefer a formal address (e.g., Mrs. Kealoha). When NHOPI elders are hospitalized, it is a good idea to ask the older adult which family member(s) will be helping with decision making, if any (McLaughlin & Braun, 1998). Some NHOPI cultures greet with a hug, whereas others do not; take the lead from the client and family about touching. Some NHOPI cultures find it offensive to speak the names of some body parts. Start with an apology if you need to ask about breasts or genitals, and ask permission before conducting a physical exam (Mau, 2010). Because some NHOPI cultures have gender boundaries, using same-sex providers is advised (Aitaoto et al., 2007).

It is important to gauge the English-language proficiency and health literacy of NHOPI clients. As noted earlier, 13.8% of NHOPI elders report that they do not speak English well or at all, and providers who work with indigenous populations—both indigenous and nonindigenous—often do not speak the native language or know the culture (Braun, Browne, Ka’opua, Kim, & Mokuau, 2014). As with other indigenous peoples, NHOPI health beliefs are carried in the native language, challenging clinicians and researchers to assure conceptual equivalence of health information, as well as respect for cultural norms (Tuck, 2009).

Critical Gaps

To better serve these groups and develop relevant policies and programs, more research is needed on NHOPI elders in the United States and its Pacific jurisdictions. Physical and mental health issues must be examined and detailed by age, sex, income, culture, and acculturation, whereas experience with acculturation and discrimination must be evaluated and cross-referenced to understand the interaction of these factors. The life course perspective suggests that policymakers and providers advocate for strategies that reduce economic disparities, as well as discriminatory practices, and promote NHOPI health across the life span (Browne, Mokuau, & Braun, 2009). Due to vast differences in health outcomes between NHOPI and AA, the practice of aggregating data from these groups must stop (Ka’opua et al., 2011; Park et al., 2009). Oversampling of NHOPI during the U.S. Census is needed to provide valid information on this group. As the NHOPI label encompasses more than 50 Pacific Islander cultural groups, further disaggregation of data on the groups subsumed under this label is important. Concurrently, more culturally tailored interventions should be designed and tested, and more research is needed on how to increase the cultural sensitivity of providers working with diverse cultural populations.

Conclusion

Although we were challenged by limitations in ethnic-specific NHOPI data, we conclude that NHOPI populations experience health disparities, and these are related to cultural, geographical, linguistic, political, and socioeconomic factors. More research is needed to better understand older NHOPI and the best ways to increase their health and well-being.

Funding

This project was supported, in part, by grant number 90OI0006/01 from the U.S. Administration on Aging, Department of Health and Human Services to Hā Kūpuna National Resource Center for Native Hawaiian Elders and by grant number U54CA153459 from the National Cancer Institute’s Center to Reduce Cancer Health Disparities to ‘Imi Hale Native Hawaiian Cancer Network.