Challenges and lessons learned in implementing a community-academic partnership for drug prevention in a Native Hawaiian community

Abstract

Objective

The broad purpose of this project is to improve health in Native Hawaiian communities through the prevention of substance use. Our community-academic partnership (CAP) team developed an intervention called Puni Ke Ola for this purpose. This paper provides a brief overview of the intervention, then describes challenges and lessons learned in piloting Puni Ke Ola.

Methods

A single module of the Puni Ke Ola intervention was implemented, after which the intervention leaders (N=3) convened for a debriefing meeting. The information shared was content analyzed to identify challenges in implementation.

Results

Five challenges were identified: 1) timeline and schedule, 2) participant recruitment and sample size, 3) place-based intervention intensity and transportation, 4) communication, and 5) staff time and funding.

Conclusion

Challenges were reframed as lessons learned and organized under the overarching theme of Kapu Aloha. Kapu Aloha refers to the idea that practicing aloha (love and compassion) is sacred and extends to all of our interactions. By honoring this value, our CAP team managed a number of challenges throughout the implementation process, which also has implications for future implementation.

Introduction

The broad purpose of the Puni Ke Ola project is to improve health in Native Hawaiian communities through the prevention of substance use. Substance use represents a health disparity in our indigenous communities, with Native Hawaiian youth and adults carrying a greater burden than other ethnocultural groups. However, nationally recognized interventions have yet to be developed with, by, or for Native Hawaiian youth. To address this gap, our community-academic partnership (CAP) team is working to develop, implement, and test the effectiveness of a culture-as-intervention approach (1). In other words, we are shaping the intervention from the Native Hawaiian culture. The goal of this paper is to share lessons learned from our most recent experience of implementing the intervention. While our CAP team initially formed in 2006, and membership has evolved over time, this paper is a reflection of our work from 2015–2016.

Puni Ke Ola translates to life flourishes in a healthy community. The word puni³ was chosen deliberately to represent the idea of flourishing because older oli and mele (chants and songs) use the word in this manner. By using the word puni, the intervention is tied to a millennium of traditions that have allowed the Hawaiian people to thrive, in spite of over 200 years of recent colonization.

The Puni Ke Ola intervention recently was a featured exemplar in a theoretical literature review of culturally grounded intervention development (2). Puni Ke Ola is contributing to the shift in the prevention paradigm by moving beyond “surface structure” cultural adaptation toward “deep structure” cultural grounding (3,4). Although the first shift in the prevention paradigm from one-size-fits-all to surface structure adaptations was admirable, non-dominant cultural groups continue to demand authentic culturally grounded interventions that prioritize their own world views and respect their knowledge and ways of knowing (5–7).

Many effective prevention programs seek to implement school-based programs through conventional teacher-led curricula (8). On the other hand, our prior intervention development study indicated that rural Native Hawaiian youth advocate for learning environments that are integrated with, and not separated from, their communities’ approach to intergenerationally scaffolded adolescent development (9). That is to say, Hawaiian youth want to learn culturally important skills and knowledge inherent in place-based activities such as fishing, farming, or other land and water stewardship/guardianship with their families and alongside recognized educator-experts from these places. Youth who contributed to intervention development expressed that this strategy simultaneously would strengthen healthy living and contribute to cultural continuity. In essence, they see themselves as healers and leaders. Through our cultural auditing events, community forums in which our pilot studies are presented, critiqued, and validated, members of the community unequivocally have endorsed the strategy (10). Other researchers have found similar results. Empirical evidence indicates that Hawaiian cultural interventions are preferred among Hawaiian youth and adults (11,12) and an indigenous approach is effective for substance use and related problems among Hawaiian youth (11,13–16).

Overview of Puni Ke Ola Intervention Development and Pilot Feasibility Studies

Our initial intervention development study and the recent feasibility study adhered to participatory action research (PAR) principles. Initially, we had facilitated a youth-led social action campaign to promote the value of indigenous culture in drug prevention implemented in Hawaiian communities (9). Youth participants had identified key elements of a Native Hawaiian model for drug prevention, and then presented this information in a large community celebration to which local and state leaders attended. Through this event and subsequent cultural auditing, it was agreed that the photovoice process we were using should be retained as a way to link youth and community wellness with dynamic cultural continuity and leadership. Our approach to photovoice emphasizes multilayered insight, or kaona, in our photography to develop youth voice, leadership, empowerment, and ultimately drug-free living in a healthy community.

Puni Ke Ola was fortunate to have been selected for funding to implement a pilot version of the intervention during the 2015–2016 school year. The RCMI Translational Research Network (RTRN) affords small competitive grants to faculty members affiliated with Research Centers in Minority Institutions. The comprehensive purpose of the RTRN is to improve minority health and reduce ethno-cultural and geographic health disparities. Of the RCMIs across the United States, 18 are part of the RTRN. Among these are the University of Hawai`i, where the university PI is based, and the University of Puerto Rico, where the RTRN academic collaborator is based. Albeit, separated in two different oceans with two different cultural heritages, we felt the collaborative link between Hawai`i and Puerto Rico was purposeful given our island geographies and colonial contexts.

With the RTRN Small Grant funding, we conducted a feasibility study of a single module of the intervention, the idea being that each module would continue for about one lunar cycle⁴, and would focus on a specific place-based and culturally immersed skill set. We had the honor of collaborating with an historic fishpond to learn about loko i`a, or traditional Hawaiian aquaculture (17) alongside the site’s Kia`i Loko (guardians of the fishpond, local experts who coordinate and are caretakers the fishpond). While this fishpond was built and maintained for centuries to feed the people of its ahupua`a (land division from mountain to sea), for the past several decades it has been restored as a center for ecological learning with youth, families, community members, and guests.

Given its emphasis on education, this loko i`a was a superb environment for implementing the foundational part of the intervention: hands-on, culturally immersive field trips which included photography, referred to as huaka`i (journey, voyage). Figure 1 depicts photographs of the fishpond selected from the youths’ portfolios. After each huaka`i, we convened group discussion to reflect upon the ways in which Native Hawaiian values, beliefs, and practices promote overall health and drug-free living, referred to as ho`āla (to waken, rise up, revive, or summons).

Figure 1.

Fishpond photographed by Puni Ke Ola youth leaders.

Intervention Description

Puni Ke Ola consists of four activities. Activity 1 involves two parts, an `Ohana Night (family) and the haumāna training (student, apprentice, participant). For `Ohana Nights, haumāna and family are invited to a dinner meeting to learn about the project, at which time informed consent is obtained (active parental consent and youth assent). Haumāna training features drug prevention, positive youth development, and photovoice, a form of participatory photography addressing a community identified social justice issue (18, 19).

Activity 2 (huaka`i) and activity 3 (ho`āla) are linked through photovoice. Huaka`i are hosted by local experts who introduce haumāna to a culturally significant site and lead skill building activities during which youth take photos. Haumāna are chaperoned by Puni Ke Ola staff who facilitate the subsequent ho`āla, small group discussions based on photos. Critical pedagogy is used during ho`āla to link huaka`i cultural knowledge and skill to drug prevention and positive youth development. Ho`āla draw on narrative theory (20, 21), Freirean participatory action research (22, 23), and the SHOWED technique (24), which is common in photovoice.

Activity 4 is a culminating social action community celebration, referred to as ho`ike. Ho`ike means to make known or to show, with the root word `ike signifying knowing, perceiving, and understanding. Haumāna highlight what they have learned about drug prevention from having participated in huaka`i and ho`āla. In addition to inviting family and friends, haumāna invite local and statewide leaders in youth substance use and adolescent health.

Materials and Methods

Sample

The goal of this paper is to highlight lessons learned in implementing the intervention. Therefore, as part of the larger implementation documentation study, adult leaders (N=3) involved implementing Puni Ke Ola contributed data for the analysis presented here. This includes the two principal investigators from the university and the community who facilitated the ho`āla, as well as a community-based culture leader from the fishpond that hosted the huaka`i. The community participants are respected cultural practitioners and Native Hawaiian leaders, while the university participant is known as a researcher in community-based culturally-informed drug prevention. This study was reviewed and approved by the university’s institutional review board.

Data Collection and Analysis

Data were collected during a post-intervention debriefing meeting in Spring 2016. The debriefing interview questions are listed below, and the conversation was audio recorded. The debriefing was content analyzed to identify challenges to implementation. The analysis and corresponding reflection was conducted by the two principal investigators (co-authors).

1. We are developing a Native Hawaiian model of drug prevention based on Hawaiian cultural practices, beliefs, values, and ways of knowing. Given your vast experience in [specify area of expertise], what do you consider to be the most important things to include.

2. In developing a Native Hawaiian model of drug prevention, Native Hawaiian youth clearly indicated that knowledge and health occurs through relationships. They particularly emphasized relationships with kupuna [elders] and relationships with the environment. Please share your thoughts about this, as a way to help us ensure our prevention is done correctly.

3. Please share your thoughts about drug prevention from a Hawaiian perspective.

4. Please share your mana`o [thoughts, insights, knowledge] on other things you think will be important for preventing drugs and for improving wellbeing in Hawaiian communities.

Results: Implementation Challenges

While we achieved our implementation goal to facilitate a single module of Puni Ke Ola, there were a number of challenges. These challenges included a short time line and scheduling conflicts, difficulty with participant recruitment and sample size, hindered intervention intensity due to transportation problems, onerous communication with participants, and limited staff time and modest funding. Each of these challenges resulted from a number of factors, as depicted in Table 1. For example, regarding the timeline and schedule, we had planned for a twelve month project but needed to complete it in ten months instead. This primarily impacted the start-up phase, which included the time during which participant recruitment was to occur. Due to scheduling conflicts (e.g. school schedules, holidays, prior commitments), we also were not able to implement the activity following the lunar cycle as planned.

Table 1.

Challenges & Lessons

Content Analysis Themes		Implications: Lessons Learned
Challenge	Details	Kapu Aloha
Time line, Schedule	Proposed start up for first two months of project, but notice of award was received two months into one-year project, so timeline for activities was constricted. Proposed single module (about one lunar cycle), but due to delayed start date, we encountered scheduling problems: end-of-year holidays, existing commitments of kids, families, staff.	Be Flexible: We stretched the one-month module to four months to accommodate schedules, while still attending to lunar cycles.
Participant Recruitment, Sample Size	Rural Native Hawaiian communities tend to be small in population size. We aimed to enroll 15 to 20 youth leaders (~5% of youth in the region), but enrolled only eight. Nine youth came to our first `Ohana Night (family meeting, recruitment and orientation event), seven of whom participated, half of whom were referred by a partner organization, the other half by word of mouth. Second `Ohana Night did not draw new participants. Coordinating with other after school programs was useful, but competing schedules limited additional enrollment to one new student.	Be Persistent: Identify and work with a variety of community organizations, and adjust intervention schedule to meet participants’ needs.
Place-based Intervention Intensity & Transportation	The intervention is placed-based in the community; however public transportation in rural communities is limited to a small number of routes with few operational hours. We identified community partners who may have been in a position to provide transportation free of charge to youth so that the cultural immersion activities could be day-long activities rather than half-day, but resources were not available.	Be Creative: The local public transportation company added a stop at the cultural immersion site on specified days. The site is on the bus route, so no fees were required, and the youth already ride for free given their student status.
Communication	Our pilot project budget did not include an onsite office, so communication with kids and families was difficult and required extensive unanticipated staff time. In addition, not all families have telephones or regular access to social media, so face-to-face communication was required, but time consuming and necessarily inconsistent.	Be Present: We communicated by all means available to ensure that kids, families, Puni Ke Ola staff remained informed. We all had to go with the natural ebb and flow of small rural community life.
Staff Time & Funding	While we were very fortunate to be selected for the RTRN Small Grant Award, we did not have access to other funds to support the staff time required to facilitate all aspects of the project.	Be Committed: Adult leaders fulfilled their responsibilities by working pro bono, however, this is not a long term solution. Future grants need to compensate staff time, especially considering Kapu Aloha is based on relationships that occur over time.

Participant recruitment presented a number of anticipated and unanticipated challenges. An anticipated challenge is related to the fact that Native Hawaiian communities tend to be located in rural and remote areas with small populations from which to recruit participants. Our goal was to enroll 15 to 20 haumana, or about 5% of the youth residents. The project coordinates Ohana Nights for families and youth to learn about the project. Although these meetings were advertised widely, only nine youth attended with their family members. A second Ohana Night did not draw new participants. Coordinating with other youth organizations was useful, but competing schedules limited participation and the ultimate sample size of participating haumana.

The Puni Ke Ola intervention is place-based in culturally significant locations in the community. The intervention did not include funds for transportation, rather relied on the public transit system. Public transit in rural communities tends to be limited to a small number of routes with few operational hours. Although the intervention intensity would have benefitted from a full day for the cultural immersion huaka`i, the public transit route and schedule supported a half day huaka`i.

Communication proved to be onerous for several reasons. The budget did not include an onsite office, so communication with the haumāna was not streamlined. Rather it required an extensive time commitment because not all families had reliable phone service nor access to social media due to rural connectivity and household finances. In addition to electronic communication, face-to-face communication was quite time consuming.

A final challenge was related to the amount of staff time needed relative to the available funding. Although additional resources were leveraged in the community so that the Puni Ke Ola project could be implemented (e.g. public transit), the project did not have access to funds beyond those provided by the RTRN Small Grant Award for the research. As a result, adult leaders were not adequately compensated for the time required to coordinate the implementation.

Discussion: A Reflection on Challenges and Lessons Learned

Upon further reflection, the content analysis revealed challenges which our CAP team managed by being flexible, persistent, creative, physically present, and committed. We reframed these challenges as lessons learned for future implementation (Table 1, column 3). First, to manage the timeline and schedule, we needed to be flexible. It became evident that implementing a Puni Ke Ola module in a single lunar cycle during the school year was not feasible. Instead, we stretched the module across the academic year to accommodate the participants’ schedules, while still attending to the lunar phases. Second, we realized that participant recruitment and retention (and study sample size) required persistence. By identifying a variety of organizations with whom to work, particularly Native Hawaiian youth organizations, we expect to enroll larger groups of haumāna in the future. Third, by creatively leveraging existing local resources (e.g. public transit), the huaka`i intervention intensity was maintained even though field trips were shortened to a partial day. To preserve immersion intensity in the future, the intervention will need to include field trip transportation funds. Fourth, by being physically present, participant retention and coordination was possible despite the lack of an onsite office, and onerous rural communication (limited cel phone and internet coverage). Finally, due to the aforementioned challenges, staff time exceeded the budget and required a level of commitment above and beyond. For future feasibility, grant funding will need to include a larger allocation for staff time.

Taken together, these lessons are organized under an overarching theme of “Kapu Aloha and Cultural Integrity.” Kapu has several meanings, and in this case it refers to the sacredness of aloha. Aloha also has many meanings, and broadly refers to sharing love and compassion for all beings. In other words, by practicing kapu aloha we may embrace the value system through which we collaborate across our various professional disciplines, areas of expertise, resource access and control, etc., for the collective good of the community. This is critical, because the concept of Puni Ke Ola is to perpetuate cultural integrity by wrapping the intervention philosophy and practices around Hawaiian values. This means we promote an inclusive `ohana (family) based values system to sustain whole community wellbeing. While we worked very hard to create an intervention that asserts kapu aloha, we also recognized the need to work even harder to affirm kapu aloha in the way in which our CAP team operates across the academic community divide, as well as within the academy and within the community.

But, it isn’t easy! In fact, collaboration is inherently problematic when western academic institutions partner with rural and indigenous communities, especially given historical and ongoing marginalization, disenfranchisement, and colonization. Academic institutions are highly segmented and compartmentalized, which makes practicing kapu aloha tenuous in the academy, let alone beyond. Not only are universities set up as independent ivory tower silos, the public health systems which oversee substance use intervention development; efficacy and effectiveness testing; implementation and service delivery; and program evaluation and other dissemination efforts often are removed from public participation. Further complicating this is our view that education extends beyond the classroom walls by adhering to a critical pedagogy that allows kids to be learners and leaders as a way to address social injustices undergirding problems like substance use. By extension, we believe that drug prevention needs to incorporate positive youth development so our haumāna (student, apprentice) recognize themselves as leaders and healers for themselves, their peers, families, and communities.

We acknowledge that these positions often do not align with western education and health systems that frequently position students and patients/clients (and educators and health care providers) as passive recipients rather than agents of change for healing and leading community health. Even with this potential for philosophical misalignment, our obvious community partners for a successful Puni Ke Ola pilot implementation encompass organizations in the traditional education and health sectors – schools, afterschool programs, and the like. The kapu aloha spirit sustained us through these challenges (summarized in Table 1).

Undeterred by these challenges and with the kapu aloha spirit as our guide, the pilot intervention was a success in terms of implementing a single module of the intervention. Our Spring 2016 Community Celebration stands as testament. Approximately 60 family, friends, and local dignitaries attended the celebration during which each youth shared selected photos from her/his portfolio and explained her/his view of culture-as-intervention. They related this to drug prevention and positive youth development through kaona, ka`ao, and mo`olelo (layers of meaning, legends, oral history) that they learned and reinforced through the huaka`i and ho`āla. Their thought provoking and emotionally moving presentations included formal speeches enhanced by their beautiful photographs of these places and activities. The agenda for the evening included a welcoming oli (chant); a catered art show in which haumāna presented their portfolios; prepared speeches by each youth based on their selected photograph and associated kaona; the sharing of community leader and `ohana insights gained from the haumāna presentations; and a closing oli in which all youth were invited to join.

Community members shared affirmations that ranged from pride and hope, to ideas for future directions and expansion, to invitations to present in other forums in which local and state dignitaries will be present. Most inspirational were the young people in attendance, some of whom disclosed personal and familial trials and tribulations with drugs, and who voiced a commitment to join Puni Ke Ola “next time.” They expressed wanting to take charge of their lives the way haumāna had demonstrated. It was gratifying to see that by honoring the aloha spirit, others may envision a future in which life flourishes in a drug free and healthy community, despite adversity.

In conclusion, the Puni Ke Ola CAP team uses a participatory action research stance. PAR has its roots in social justice movements through which residents transform themselves to become change leaders for the collective good of their communities (22,23). The Puni Ke Ola youth leaders are doing this, as seen in the 2016 Community Celebration. By reviewing our (Puni Ke Ola adult leaders) own PAR practices, we have learned that what makes the difference is kapu aloha.