The Validation of a School-Based, Culturally Grounded Drug Prevention Curriculum for Rural Hawaiian Youth

Abstract

The purpose of this study was to validate a school-based, culturally grounded drug prevention curriculum for rural Native Hawaiian youth. Faculty and administrators from eight geographically dispersed middle, intermediate, or multi-level schools on Hawai‘i Island were interviewed on the cultural relevance and feasibility of implementation of the curriculum (Ho‘ouna Pono). While all participants appreciated the culturally specific content interwoven throughout the curriculum’s structure, several of them expressed concerns that the curriculum would compete with resources needed to implement Common Core national standards. Implications for the implementation, adoption, and sustainability of school-based prevention curricula are discussed.

In recent years, substance use has emerged as a major health concern for Native Hawaiian youth (Okamoto, 2011; Withy, Andaya, Mikami, & Yamada, 2007). These youth have been found to have significantly higher rates and earlier initiation into drug use compared with other major ethnic groups in Hawai‘i (Nigg, Anderson, Troumbley, Alam, & Keller, 2013; Okamoto, Kulis, Helm, Edwards, & Giroux, 2014). They have also been found to have an increased number of school absences, suspensions, and infractions (Hishinuma et al., 2006), and higher rates of unsafe sexual practices (Ramisetty-Mikler, Caetano, Goebert, & Nishimura, 2004) and suicidal behaviors (Else, Andrade, & Nahulu, 2007) associated with substance use. Despite these issues, there has been a lack of drug prevention or intervention programs tailored specifically for Native Hawaiian youth (Durand, Cook, Konishi, & Nigg, 2015; Edwards, Giroux, & Okamoto, 2010). More research is necessary to address this gap, in order to address substance use and related disorders for Native Hawaiian youth.

This study focuses on the validation of a school-based, culturally grounded drug prevention curriculum for rural Hawaiian youth. Prior research has described the development and preliminary effectiveness of a pilot version of the curriculum (Ho‘ouna Pono) in rural Hawai‘i (Okamoto, Kulis, Helm, Lauricella, & Valdez, 2016). The present study builds upon the Okamoto et al. study, by using Hawai‘i Island community stakeholders (e.g., school teachers, principals) to critique a revised and full-scale version of the curriculum prior to its island-wide implementation and evaluation. This study has implications for the development and feasibility of school-based, culturally grounded prevention curricula, and the implementation and sustainability of these curricula within rural, indigenous communities.

Literature Review

Culturally Grounded Health Promotion Curricula for Youth

Culturally grounded approaches toward health promotion place the culture of the participant at the center of the intervention. Interventions are designed based on the culture and social context of the targeted population (Marsiglia & Kulis, 2009). Several culturally grounded health promotion programs for youth have been developed in recent years, such as keepin’ it REAL (Hecht et al., 2003; Kulis et al., 2005; Marsiglia & Hecht, 2005), The Strong African American Families Program (Brody, Murry, Chen, Kogan, & Brown, 2006; Brody, Murry, Gerrard, et al., 2006), and the Seventh Generation Program (Moran & Bussey, 2007). These programs have focused on Mexican/Mexican American youth, African American youth, and American Indian youth, respectively. Despite the drug intervention needs of Native Hawaiian youth, there have been no culturally grounded, evidence-based drug prevention programs developed and evaluated specifically for this population outside of the intervention described in the present study (Durand et al., 2015; Rehuher, Hiramatsu, & Helm, 2008). This is a particular issue for rural Hawaiian youth, as substance use has been identified as a primary cause of health disparities in these youths’ communities (Withy et al., 2007). The inability to effectively address rural Hawaiian youths’ substance use is further compounded by the lack of services and/or poor coordination of services available for these youth in rural settings (Curtis, Waters, & Brindis, 2010; Withy et al., 2007). As a result, the development and implementation of the present curriculum fulfills a high community need, and has a potentially high scientific and health impact for rural, indigenous, and Pacific Islander youth (Okamoto, Kulis, Marsiglia, Holleran Steiker, & Dustman, 2014).

The Development of Ho‘ouna Pono

The Ho‘ouna Pono curriculum was developed through a multi-university and community partnership funded through the National Institute on Drug Abuse. The foundation for the pilot version of the curriculum was established through a mixed-methods, multiphasic study focused on the social and cultural context of substance use initiation for rural Hawaiian youth (Okamoto, Helm, et al., 2014). Youth in this study identified drug-related problem situations in their homes, schools, and communities, and socially and culturally relevant responses to these situations (Helm et al., 2008; Okamoto, Helm, Giroux, Edwards, & Kulis, 2010; Okamoto, Helm, Giroux, Kaliades, et al., 2010). These situations and responses were used to create the storylines for culturally grounded videos (Okamoto, Helm, McClain, & Dinson, 2012), which served as the core of the prevention curriculum. Interactive classroom activities and exercises were used to promote students’ discussion of videotaped responses to drug offers depicted in the situations. Theoretically, the curriculum was based on ecodevelopmental theory, which emphasizes that the development and behavior of an individual is shaped by their relationship to their environment (Coatsworth et al., 2002; Perrino, Gonzalez-Soldevilla, Pantin, & Szapocznik, 2000; Szapocznik & Coatsworth, 1999). As an outgrowth of this theory, social and environmental demands toward drug use were realistically depicted in the Ho‘ouna Pono videos, and functioned as the core components within the curriculum. Each lesson in the curriculum was aligned with the Hawai‘i Content and Performance Standards (HCPS) for Health—Grades 6–8 (Hawai‘i State Department of Education, 2005), which are state-level academic standards being implemented alongside the national-level Common Core standards in the state of Hawai‘i. Preliminary quasi-experimental analysis of the curriculum found that it reduced interpersonal conflict and promoted the use of non-confrontational drug resistance strategies, particularly for girls (Okamoto et al., 2016).

The Present Study

The present study is the first step in bringing the development and evaluation of the curriculum to scale. Based on the pilot study results, existing videos and lessons were revised and re-edited, and two new videos and lessons were created (see Table 1). The revised version of the curriculum was sent to school-based community stakeholders on Hawai‘i Island for review and critique specific to the value and relevance of the curriculum content, and its feasibility for implementation in the public schools. A similar process of curriculum validation was successfully utilized in the development of another evidence-based, culturally grounded drug prevention curriculum for Mexican/Mexican American youth (Gosin, Dustman, Drapeau, & Harthun, 2003). The present study describes the results from the qualitative analysis of the community stakeholders’ feedback on the curriculum. The findings from this study were used to make necessary modifications to the curriculum prior to its island-wide implementation and evaluation.

Table 1.

Ho‘ouna Pono Lessons and Primary Content Areas

Lesson	Title	Video	Primary Content Areas
1	Introduction to Ho‘ouna Pono	Introduction/“Behind the Scenes”+	Introduction to the curriculum and to key prevention concepts
2	Is it Worth the Risk? +	Oh Brother	Risk assessment Assertive versus aggressive refusal as a resistance strategy Empathy toward the drug offerer as a resistance strategy Health consequences of substance use
3	Explain Yourself	Kanikapila Invite	Assertive versus aggressive refusal as a resistance strategy Explanations for refusal as a resistance strategy
4	Solve the Problem	Pulehu	Using resistance strategies within a problem-solving approach to dealing with drug offers Using avoidance and leaving the situation as resistance strategies Gender socialization and its effect on drug resistance strategies
5	Help Your Friend	Vodka Recess	Involving others in drug-related problem situations as a resistance strategy Assertive refusal strategies
6	Is it Normal?	Pā‘ina	Personal, descriptive, and injunctive norms Redirection and leaving the situation as drug resistance strategies
7	ACT Now*	Bully Boy*	Drug refusal in bullying situations Gender differences in bullying
8	It’s a Date*	One Time*	Drug refusal in dating situations Non-confrontational resistance strategies Social consequences of chronic drug use
9	Putting it All Together+	N/A	Summary of the curriculum Post-test

⁺Revised or re-edited content

^*New content

Method

Participants and Procedures

All research procedures were approved by the Institutional Review Boards at Hawai‘i Pacific University, the University of Hawai‘i at Mānoa, and the State of Hawai‘i Department of Education. Fourteen faculty or staff members, each from a different public or public-charter middle, intermediate, or multi-level school on Hawai‘i Island, were sent a complete draft version of the curriculum (nine lessons and eight videos) two weeks prior to a scheduled interview. Due to time and resource restrictions, only eight of these individuals were asked and agreed to participate in this study. The phase of the project described in the present study needed to be completed in early Summer 2016, in order to finalize the curriculum prior to its implementation and full-scale evaluation in early Fall 2016. Subsequently, we only solicited faculty or staff members from the early phases of data collection to participate in the present study, in order to complete data management and analysis of interviews in advance of the final curriculum revision. The participants’ demographics are outlined in Table 2. These faculty or staff members worked at schools within rural communities that were geographically dispersed across the island, and that had a higher percentage of families receiving public assistance compared to the State (Accountability Resource Center Hawai‘i, 2015). In order to obtain detailed feedback on the Ho‘ouna Pono curriculum, participants were asked a series of questions focused on the relevance, feasibility, and implementation of the curriculum within their respective schools (see the semi-structured interview schedule in Table 3). Each interview lasted approximately 60 minutes. Each participant received a 20-dollar gift card for their participation in the study.

Table 2.

Participant Demographics (N = 8)

Gender	Male	37.5%
	Female	62.5%
Age	31–40	12.5%
	41–50	37.5%
	51–60	37.5%
	61–70	12.5%
Ethnicity	White	62.5%
	Multiracial	37.5%
Job Position	Principal/Vice Principal	37.5%
	Teacher	25.0%
	Counselor/School-Based Behavioral Health	37.5%
Years with DOE	6–10	12.5%
	11–20	62.5%
	21–30	25.0%
Highest Education Level	Master’s Degree	87.5%
	Doctoral Degree	12.5%

Table 3.

Semi-Structured Interview Schedule

Ho‘ouna Pono Drug Prevention Curriculum Validation Semi-Structured Interview Schedule
1.	What are your overall impressions of the Ho’ouna Pono Curriculum?
2.	How well does the curriculum reflect the lives of the youth that you work with or teach?
3.	How well do you think the curriculum would engage the youth that you work with or teach?
4.	How easily do you see the curriculum fitting in with the current academic structure?
5	What might be some issues in implementing the curriculum in the classroom setting? How might these issues be addressed?
6	What are ways that you would improve the curriculum? Are there content areas that are missing? Are there content areas that are not necessary?
7	What types of support will teachers need to administer the curriculum successfully?

Data Analysis

All interviews were audio recorded and transcribed verbatim by a member of the research team. This team consisted of two health promotion researchers affiliated with two large universities in the Pacific, and two student research assistants in social work. To ensure data quality, transcripts were reviewed for accuracy by at least two different research team members. A comprehensive set of emergent open codes (Strauss & Corbin, 1990) were collaboratively identified by three research team members, and were imported into a computer-assisted qualitative data analysis software program (NVivo, 2010). NVivo is one of several code-based, theory-building programs that allow the researcher to represent relationships among codes or build higher-order classifications (Weitzman, 2000). In order to establish intercoder reliability and validity, three members of the research team collectively coded one transcript, in order to clarify the definition and parameters of all of the codes. Then, all subsequent transcripts were separately coded by at least two of these research team members. A consensus coding technique was employed in this study, in which the content, length, and placement of narrative units were mutually agreed upon by the team members. Narrative segments that were not identically coded by the team members were identified, discussed, and justified for inclusion or exclusion in the data set. This process entailed explaining how the content and length of discrepant narrative units were consistent or inconsistent with the definition of the code, until consensus was achieved. Upon establishing intercoder reliability and validity, an analysis of the feedback of the Ho‘ouna Pono Curriculum Teacher Training Manual (Version 2) was conducted, in order to examine the relevance of the content and issues related to the implementation of the curriculum in public schools on Hawai‘i Island.

Results

The primary themes identified by the participants reflected the curriculum’s content and characteristics, and the potential school-level impacts of the curriculum. Despite overall positive feedback for the curriculum, participants also discussed potential systemic challenges to its implementation.

Curriculum Characteristics

All participants had positive responses to the organization and structure of the curriculum. In particular, participants appreciated the Hawai‘i Island cultural focus interwoven throughout the curriculum’s structure. Participant 1, for example, commented on the cultural validity of the videos in the curriculum.

I thought that they were very [good]. I was very impressed at the level of the kids’ ability to come across genuine [in the videos] and of course the way in which Matt [the director] put the [videos] together. The way they were scripted was very genuine. And the [youth actors] did a great job and that, of course, will bite right into the other kids as they watch it, because you can really feel the emotion when you’re looking at ‘em. And I loved the cross-section of where the vignettes occurred. I mean, awesome, awesome, awesome. I mean, a lot of the time people don’t want to talk about what’s happening at the house and the party on the weekend. And so I thought the videos were excellent.

Seven of the participants appreciated the culturally specific focus of the activities and lessons in the curriculum. For example, Participant 2 describes the value of the Culture Wall activity in the curriculum. This activity was intended to draw parallels between concepts, locations, and landmarks specific to Hawai‘i Island with traditional prevention concepts.

The activities are real good. [The curriculum] calls on the [kids] to bring up some of the academic vocabulary that [we discussed earlier], and I mentioned to you about the Culture Wall. I like how that is interwoven throughout all the lessons. Like every lesson, you wanna add to your Culture Wall, because the kids are real big [on culture], especially with our school. We’re 44% Hawaiian or part-Hawaiian, or at least that’s what they identify themselves as. Having the Culture Wall there keeps it relevant, I think, as opposed to just having academic vocabulary. ‘Cause the Culture Wall is a different thing from academic vocabulary, but you have them kind of side by side, and I can see some of the parallels [on] how understanding the culture helps you understand some of the vocabulary. I like how the Culture Wall [was] interwoven throughout all the lessons.

A focus of the Ho‘ouna Pono curriculum is on the impact of interpersonal relationships on the selection and use of drug resistance strategies. Four of the participants specifically commented on the relational focus of the curriculum. Participant 3 described why the focus on interpersonal relationships in the curriculum is consistent with the norms and values of her community.

I think here, it’s kind of like a little family, you know? Everybody knows everybody. Everybody either lives next to each other, they’re your cousin or they’re [another family member], you know what I mean? It’s just very close knit, so everybody knows how your family does things. [The kids] kind of just know how everybody operates, and so I think it feels very family connected [here], even though they may not be [blood] related. So, when you look at the lessons, I just thought, “oh, this is kind of [fits], they’ll feel like they were at home,” you know? And it kind of would be comfortable for them. That’s the feeling I got when I looked at it.

System Impacts and Considerations

All participants suggested that the Ho‘ouna Pono curriculum had value at the school level. For example, two administrators indicated that the curriculum was consistent with school-wide adopted pedagogical approaches that encouraged student interaction and critical thinking (e.g., AVID strategies). Because of this, they felt that the curriculum could be implemented throughout an entire grade level to provide a uniform structure for standards-based education. Participant 3 described the school-wide value of the curriculum.

I don’t know how much the average teacher knows about drug education or current best practice. You’re looking at a standard and figuring out “okay, I guess I’ll talk to them about this”. You know, that’s hard. I think our teachers do their best, but having this [curriculum], I think, would make things really kind of clear and more accurate. So sometimes we will have discussions at the teacher level, right? And [if] we’re talking about the health curriculum, one teacher [might] say, ‘Well, I was gonna talk about this,’ and another teacher will go, ‘No, I don’t think you should cover [that]’. I think this [curriculum] removes [these decisions] from the personal, “what we think about things,” and more [toward] what’s been researched and what are best practices.

However, other participants indicated that the curriculum’s narrower focus on a subset of health education (substance abuse prevention) could create issues with its implementation. Participant 4 described how curricula that are not writing or math intensive are not prioritized very highly within the Department of Education, because they do not teach directly to the national-level, standards-based tests.

Okay, how easily do you see the curriculum fitting in with the current academic structure? That’s [become] a little more challenging, because we are, of course, always focused on the test. It’s really the whole environment here [that] is always about the test. And so, through no fault of the curriculum at all, it becomes challenging [to implement] just because, if it’s not math or language arts, [the Department of Education doesn’t] support it as much.

Participant 4 further goes on to warn that successful implementation of the curriculum may require mandates and enforcement at a higher administrative level.

What types of support will teachers need to administer the curriculum successfully? Well, of course, you need the administrators’ [support]. You really need the support of the higher ups to kind of pull open that time frame, because everybody’s crunched for time to do any kind of curriculum. And everyone’s complaining that they don’t have enough time to do what they already have on their plate. Unfortunately, it’s still a very top down system. If you could get the top folks to pry open more [time], they will [help to implement the curriculum successfully].

Discussion

This study focused on the validation of the Ho‘ouna Pono curriculum by school-based community stakeholders on Hawai‘i Island. Participating stakeholders indicated that the curriculum had both pedagogical and health promotion value for Hawai‘i Island middle/intermediate schools, and had potential to support the Department of Education’s emphasis on state-level educational standards through its direct alignment with HCPS. The participants’ narratives reaffirmed the importance of the culturally specific content in prevention. In this case, participants placed emphasis on close-knit, interpersonal relationships of Hawaiian youth described in prior studies (Bills, Okamoto, & Helm, 2016; Okamoto, Helm, Po‘a-Kekuawela, Chin, & Nebre, 2009). Despite overall enthusiasm for the curriculum, participants also expressed concerns centered on alignment of the curriculum to address some standards specific to Common Core, such as math and writing skills. Because the curriculum is not intended to be writing intensive or exclusively academic, some stakeholders feared that it could lose priority with the DOE, jeopardizing successful implementation in certain schools.

Implications for Practice

The findings from this study have implications for the feasibility of culturally grounded prevention curricula in rural, indigenous communities, as well as the adoption, implementation, and sustainability of similar curricula in those communities. They highlight how health promotion curricula in public schools may lose implementation priority if they are not explicitly aligned with state and national academic standards. This is in contrast to school-based prevention curricula developed in years prior to standards-based education, where the potential health impact of the curriculum could solely generate motivation toward its school-based implementation. The challenge for contemporary school-based prevention curricula similar to Ho‘ouna Pono is to balance the health promotion aspects of the curriculum with the academic needs and Common Core requirements of the public school system. In some ways, these are conflicting goals. If prevention curricula such as Ho‘ouna Pono became math or writing intensive, will the health promotion message become blunted in students’ efforts to correct math errors or writing mechanics in order to get a good grade? Despite this concern, this study suggests that the proper balance between academic standards and health promotion goals becomes paramount for the successful implementation of modern-day, school-based, youth prevention curricula. For example, the inclusion of optional writing assignments, such as those requiring youth to argue for the most effective drug resistance strategies, or math assignments, such as those incorporating statistics on drug using or abstinent youth, may help to fulfill current Common Core academic standards. As suggested by Participant 4, addressing these standards in prevention could elevate the curriculum to a higher priority level for upper-level educational administrators, setting the stage for successful implementation of the curriculum at the school level. A similar “top-down” approach may also support the long-term adoption and sustainability of these types of curricula within public school systems.

Despite these systemic concerns, this study points to the importance of grounding prevention messages and content in the worldviews of the rural and indigenous youth. Okamoto, Kulis, et al. (2014) described how culturally grounding prevention curricula is important to establish core content for an indigenous prevention science, particularly for under-researched indigenous populations. This study expands upon the literature by describing how these efforts resonated beyond the targeted youth populations, through acknowledgement by school faculty and administrators. They recognized the unique value of culturally grounded prevention focused on Hawai‘i Island youth, and the potential of these curricula to engage local youth and subsequently ameliorate substance use and abuse.

Limitations of the Study

There were several limitations of this study. A small convenience sample was utilized, which may or may not have been representative of the views of the faculty or administrators in the sampled schools. The findings may also have been influenced by regional sociodemographic variability. Specifically, Participant 4 described significant ethnic and socioeconomic differences in the student populations on the east versus the west side of the island, which may have affected faculty or administrators’ perceptions of the curriculum in different schools, as well as the transferability of the curriculum across the different regions. Finally, the findings may not transfer to public schools located on other islands in the state, and to those schools within urban areas.

Conclusions

Using in-depth interviews with community stakeholders in eight geographically dispersed schools on Hawai‘i Island, this study described the content validation process of a culturally grounded drug prevention curriculum in rural Hawai‘i. Stakeholders were enthusiastic about the curriculum’s potential to engage youth through its culturally specific content, and acknowledged its alignment with state-level health standards and language arts (e.g., vocabulary). However, they also suggested that more explicit alignment toward national-level Common Core standards may be indicated. Future drug prevention and health promotion curricula in the public school setting may need to consider the balance between effective communication of prevention messaging with the incorporation of academic standards and content. This would ensure that the necessary health promotion messaging is communicated effectively, while also ensuring successful implementation, adoption, and sustainability of the curriculum in public schools.