Conceptualizing a New System of Care in Hawai’i for Native Hawaiians and Substance Use

Abstract

Native Hawaiians of all age groups tend to show a higher prevalence of substance use than other ethnic groups in the state. Research shows that this inequitable health status results from several complex and interconnected social determinants of health, including historical trauma, discrimination, and lifestyle changes.

Before European contact, Native Hawaiians understood that balanced nutrition, physical activity, social relationships, and spirituality were fundamental to maintaining optimal health. Western influences triggered an imbalance in Native Hawaiian society, shifting the paradigm of Native Hawaiian family systems.

Historical and cultural trauma affect multiple generations and are linked to Native Hawaiian health disparities. Cultural trauma is defined as “the loss of identity and meaning that negatively affects group consciousness. It marks and changes them in fundamental and irreversible ways, often resulting in the loss of language, lifestyles, and values.” The remedy for cultural trauma is cultural reclamation. Historical trauma is defined as psychosocial trauma experienced by Indigenous groups as a result of colonization, war, genocide, or cultural, social, and political subjugation. These historical and cultural aspects have impacted and reached across generations of Native Hawaiians. The outcomes of these traumas are reflected in higher rates of health disparities, including mental health and addiction, which have affected the social determinants of health.

Current access to treatment and recovery is limited for Native Hawaiian residents with substance use problems. This article will look at a system of care that would reduce silos and incorporate cultural aspects to improve outcomes for Native Hawaiians receiving services. This article will also introduce an ‘āina- (land-) based model for creating healthy, thriving Native Hawaiian individuals, ‘ohana (family), communities, and care systems.

Background and Introduction

Native Hawaiians historically sought healing within their ‘ohana (family) systems. Prior to European contact, Native Hawaiians understood that lōkahi (harmony), which included balanced nutrition, physical activity, social relationships, and spirituality were fundamental to maintaining optimal health.^1-3 Native Hawaiian health has been illustrated in a lōkahi Triangle^1-3 as an equilateral triangle, with the apex labeled as Nā Akua (Gods/Goddesses/spirituality), and the base on one end labeled as kānaka (person) and the other as ‘āina (land).

Historical trauma is defined as psychosocial trauma experienced by Indigenous groups as a result of colonization, war, genocide, or cultural, social, and political subjugation.⁴ From the first European arrival in 1778, colonization, systematic oppression, and Western imperialism have led to a loss of traditional healing practices, and our [This article includes the first person voice from the lens of the Native Hawaiian authors and to acknowledge Indigenous ways of knowledge.] Native peoples were forced into Western treatment frameworks for matters that were historically addressed within the ‘ohana. Today, Native Hawaiians suffer from health disparities in chronic diseases⁵ and overrepresentation across all social services, including addiction services,⁶ incarceration for drug offenses, and offenses due to addiction diseases.⁷ Intergenerational substance use and incarceration impact individual, ‘ohana, keiki (children), and community health.

Disproportionate numbers of our Native population have been consistently overrepresented among those who are seeking or thrust into Western treatment for substance use disorders.⁶ Existing systems of care continue to assign treatment within the same Western frameworks leading to this consistent overrepresentation. In the present paper, we highlight key points from a chapter of the Hawai‘i Department of Health Alcohol and Drug Abuse Division (ADAD) State Plan which examines the roots of disparities in the intersections of Native Hawaiians and substance use and reimagines a system of care that would reduce silos and incorporate cultural aspects to improve outcomes for Native Hawaiians receiving services. For more background and context around the overall State Plan project, readers are referred to the introductory article of this special supplement.

Observations and Rationale

Cultural trauma is defined as “the loss of identity and meaning that negatively affects group consciousness. It marks and changes them in fundamental and irreversible ways, often resulting in the loss of language, lifestyles, and values.”⁸ Our Native ‘ohana have become disconnected from their cultural heritage throughout generations. Many of these ‘ohana carry intergenerational trauma created by oppression and criminalization of the Native identity at the hands of those who colonized our island home. Further layers of complexity are added through the loss of land and abrupt lifestyle changes from subsistence living into a capitalistic environment, the ramifications of which created stark socioeconomic differences between Native Hawaiians and their Western counterparts. These differences have led to generations of poverty, houselessness, and mental health issues for Native Hawaiians that continue today.

The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) recognizes the unique nature and importance of cultural concepts of distress.⁹ However, a Native Hawaiian worldview has not yet been included in those listed. The Cultural Formulation Interview and supplemental modules in the DSM-5 provide a framework for assessment and a first step in approaching these areas through a broader lens. However, when in distress, seeking medical, behavioral/mental health, or substance use services, our Native people are treated by clinicians trained in predominantly Western ways. Therefore, clinicians working with Native individuals and families must be educated on our history, historical injustices, traumas, the impacts of colonization, traditional beliefs and practices, and understanding of the Hawaiian worldview.¹⁰

Paglinawan and colleagues maintain that the remedy for cultural trauma is cultural reclamation.¹¹ To develop effective, culturally focused approaches for working with Native Hawaiians, we must look i ka wā kahiko (to ancient times), to our kūpuna (elders), and to respected healers within our community to understand how ma’i (sickness) was approached during ancestral times. Hawaiian ma’i, Hawaiian illnesses, or ma’i kama‘āina, call for Hawaiian assessment, diagnosis, and treatment which is an ancient concept with deep roots in Hawaiian healing. Ma’i malihini or illnesses that stem from Western influence, such as infectious or chronic disease, could be treated through Western medicinal pathways. However, they are still best coupled with traditional kānaka health and well-being approaches to heal the spirit. For substance use, the root of this kind of ma’i is much deeper, and it could be understood almost as an amalgamation of ma’i kama‘āina and ma’i malihini. Understanding these concepts requires deep reflection and study (with practitioners of Hawaiian healing) of ma’i that contributes to an unhealthy kānaka environment, such as historical/intergenerational trauma and the loss of connection. Also, by understanding the root causes of ma’i kama‘āina , as well as the manifestation of addiction as a symptom of this deeper trauma12 practitioners can be better prepared to provide culturally focused interventions.

Loea Ho’oponopono Aunty Lynette Paglinawan, a revered haku ho’oponopono (cultural practitioner in the Native Hawaiian practice of healing families through forgiveness) and social worker who studied under Aunty Mary Puku’i (a revered cultural practitioner), offers us some of the most valuable insight into assessing Native Hawaiian individuals and ‘ohana.

Assessment and intake from a Western approach can be off-putting and invasive for some Native Hawaiians. Culturally, we must take a more Indigenous approach by “talking story” with the ‘ohana or individuals. Caseworkers must voice intentions, explaining “why questions may be asked and how they will be applied to the problem at hand.”¹³ During the intake or assessment process, it is also important to determine the best approach for our Native people to determine whether a culturally grounded healing would be most beneficial.

Similarly, there exists a gap in the development of culturally-focused interventions. Okamoto provides an assessment of the strengths and limitations of developing culturally focused interventions (Table 1).¹⁴ In summary, culturally grounded interventions provide a “ground-up” approach from a foundation of culture. Non-adaptation, surface-structure cultural adaptation interventions provide a “top-down” approach, altering the original model to add cultural components. Finally, deep-structure cultural adaptations use a “sprinkling in” approach of integrating culture into the intervention, providing “changes to images or phrases throughout its content or lessons, to align the program with familiar concepts or references of a specific cultural group.” Providers who utilize culturally-based treatment focusing on Native Hawaiians provide interventions in alignment with Okamoto’s categories. However, most providers lack the capacity to develop an evidence base that meets Western requirements, as illustrated in the limitations set by Okamoto et al.¹⁴

Table 1.

Strengths and Limitations of Approaches in Developing Culturally Focused Interventions^a

Culturally grounded prevention intervention		Deep-structure cultural adaptation intervention		Non-adaptation/surface intervention
Strengths	Limitations	Strengths	Limitations	Strengths	Limitations
Community is engaged and invested in the development of the program	Time Consuming	Based on empirically supported intervention principles	Assumes the core components of an evidence-based program are applicable across cultural groups	Tests the applicability of generic/ universal prevention principles to unique groups	Often unacceptable to or disconnected from the community
Directly addresses core cultural constructs	Expensive	Balances length of time and costs to develop curriculum with the ability to bring the program to scale	Need to specify and retain the core prevention components for fidelities	Faster to develop, implement, and bring to scale	Can potentially avoid core cultural components
Core prevention components are derived organically (from the “ground up”) and can therefore be intertwined with core cultural components	Difficult to evaluate and replicate in similar settings	Engages the community, but within the parameters of a specific evidence-based program	May inadvertently alter core components and decrease their effectiveness	Based on empirically supported interventions, but with questionable “fit.”

^aUsed with permission from Okamoto et al.¹⁴

Indigenous ways of knowing provide evidence that predates any semblance of Western evidence, yet the Western way is somehow dominant today. An Indigenous evidence base has been established orally by passing down the knowledge of our people through traditional practices, storytelling, song, and much more. The Indigenous-based evidence, coupled with evidence from community-based participatory action research approaches, should be used to develop and measure the efficacy of culturally resonant/attuned interventions.

Current System of Care in Hawai’i

According to ADAD, Native Hawaiians were admitted to treatment 1358 times in 2017, which is 42.3% of the state total and the most of any ethnic group.¹⁵ This overrepresentation has been reflected throughout the past decade.⁶ In that same year, over 30% of Native Hawaiian admissions to ADAD treatment were referred via the criminal justice system, increasing to over 40% in 2020.¹⁶ Of those Native Hawaiians accessing services, over 40% indicated methamphetamine addiction as their primary substance of issue.¹⁶ This consistent overrepresentation further illustrates the ineffective nature of the Western treatment of Native peoples.

ADAD collects, uses, and develops fund allocations based on ethnicity data. Due to those efforts, ADAD can identify the disproportionate representation of Native Hawaiians receiving services for substance use in the state. Current policies allow for flexibility for treatment providers in set activities tailored to Native Hawaiians, thus allowing for the offering and inclusion of alternative treatment methods. However, the current gap exists in providers, cultural practitioners, and ADAD discussing and agreeing upon culturally resonant documentation and reporting of cultural services in clinical notes on how their treatment improves protective factors or reduces risk factors. This gap can be addressed by developing a culturally responsive system of care that uplifts and values Indigenous knowledge and cultural healing pathways.

The current system of care in Hawai‘i does include some providers who use varying degrees of culturally based or culturally adapted treatment and prevention programs. Treatment providers who contract with the ADAD adhere to the 5 Levels Of Care model established by the American Society of Addiction Medicine,¹⁷ which includes early intervention, outpatient, intensive outpatient, residential, and medically managed services.18 Most providers utilize Western interventions such as cognitive-behavioral therapy, dialectical behavior therapy, or 12-step programs (a model used for Alcoholics Anonymous/Narcotics Anonymous).

Treatment providers who employ utilization of culturally based treatment with a specific focus on Native Hawaiian values continue to find difficulty in billing for cultural services to ADAD, as well as including cultural services in treatment plans to accurately capture the successive impact that cultural reclamation can have on the individual, the ‘ohana, and the community. For Kānaka Maoli (Native Hawaiians), cultural reclamation can be defined as a spiritual/cultural healing process of a reawakening within the na’au (visceral mind) to deeper learning and understanding of the underlying reasons for their cultural beliefs, cultural practices, and their true identity as Kānaka Maoli.19 Learning about one’s history and cultural heritage, genealogy, and cultural morals and values, making ancestral connections, engaging in cultural practices (eg, working in the lo’i (taro field), dancing the hula) and learning to speak one’s language facilitates healing and cultivates cultural pride, which nurtures the development of a positive cultural identity and overall self-image.¹⁹ Most providers are dependent on outside funding to cover the costs of cultural practitioners to provide culturally-based healing, which only further silos culturally-based approaches from Western treatment constructs and places a burden on the provider to maintain 2 separate pathways of healing.

The State also supports school and community-based youth prevention programs.¹⁸ Given the reliance on nationally endorsed evidence-based practices, the majority of youth substance use programs implemented in Hawai‘i have not been designed to support Native Hawaiian youth and communities specifically.²⁰ Two exceptions are the school-based Ho‘ouna Pono middle school drug prevention curriculum²¹ and the Hawaiian Homestead-based Puni Ke Ola adolescent substance use program.²² The National Institute on Drug Abuse funded Ho.ouna Pono Program which has been evaluated in a set of studies²³ and is currently working with their state partners to develop a sustainability strategy.²⁴ The Puni Ke Ola program has been supported through a variety of local and national sources in the intervention development²⁵ and feasibility phases,²⁶ aligns with a Culture-as-Health Framework,²⁷ and currently is funded by ADAD and Papa Ola lōkahi in preparation for multi-community implementation.

Interventions (Re-imagined)

Re-envisioning a culturally responsive system of care first requires us to identify parallel strengths and potentially detrimental differences that form the existing colonized/Western system’s foundation through the examination of 3 key areas: (1) Cultural perceptions of self; (2) Shifting to a cyclical continuum, and (3) the ahupua‘a model. Recent research indicates that re-envisioning treatment for the Native population, utilizing cultural reconnection, and methodologies that speak to Native perspectives, are more influential in creating positive health outcomes for Native peoples.⁵

Native Hawaiians need a sense of place to anchor values and balance life. Beyond Western practices, Native Hawaiians need to care for the ’āina, which they understand to deeply care for them. Native Hawaiians need the resiliency and protection that culture provides through language, traditions, and ceremonies, allowing ways to reconnect to ancestral knowledge and spirituality. Native Hawaiians need not become Western to heal.⁵

According to Papa Ola lōkahi and a Native Hawaiian Partnership, ’Imi Ke Ola Mau (a community collaboration Co-Occurring State Incentive Grant [COSIG]), for Native Hawaiians to heal, “[They] need a sense of self, retrieved from our past through ancestors, present through purpose, and future through descendants. [They] need our language, traditions, and ceremonies, which provide ways to reconnect to our spirituality and the concept of our source. [They] need the resiliency and protection our culture provides, in order to prevent relapse and redefine ourselves away from pathological diagnoses.”²⁸

Cultural Perceptions of Self

Current care systems addressing substance use are rooted in historically colonized systems, centered on Western approaches to individualistic care.²⁹ This individualistic and egocentric concept of the person can be contrasted with more sociocentric, ecocentric, or cosmocentric views, which understand the person in relation to the social world, the environment, and the cosmos.²⁹ The collective vs individual mindset within the Hawaiian worldview is dramatically different from Western approaches that are highly individualistic, and often do not account for historical and cultural trauma.

However, personal boundaries and understanding of self are not identical in every culture. The same methods used to treat and heal cultures rooted in individualism can be harmful to those rooted in various other cultural configurations of the self, such as Indigenous cultures. Ignoring the self’s internalized concept can leave the client with no way to reconcile their internal self-healing within the larger society’s connective tissue, those social interactions that sustain the self within the community, and their collective healing.²⁹ Each categorical perception of self varies in the ways the self is defined; the values underpin and characterize a healthy perception of the ideal self, the understanding of one’s role in specific actions or events, and associated healing systems.²⁹

Shifting to a Cyclical Continuum

On a traditional continuum of care, recovery is viewed as the phase after treatment. These individual areas can frequently become siloed, only concentrating on their specific prevention, treatment, or recovery areas. The depth of the recovery field often overlaps within the treatment area, as there are many pathways toward healing and recovery, and not all individuals in recovery have followed a path that involves clinical treatment. Recovery and healing are lifelong processes. Therefore, we must begin to re-envision the existing continuum of care, embrace culturally grounded approaches, and begin to see the entire continuum as cyclical rather than linear, with each area of focus informing the next.

The linkages between recovery and prevention lie in using one to inform the other through the feedback of successful outcomes, promoting mauli ola (well-being), and educating clients about making healthy, informed choices.²⁸ We can approach this shift toward a cyclical continuum through systems thinking as a way to see the phases along the continuum as interrelationships rather than as siloed components. This shift allows us to look for patterns of change rather than accepting static snapshots or defaulting to how it has always been.³⁰ From a culturally informed or holistic perspective, systems thinking can help us understand whether the purpose of the existing system is being accomplished and look for ways to create more equitable and resonating systems of care, thereby achieving better results with fewer resources in lasting ways.³⁰ Keeping this cyclical nature in mind, we can move toward a resiliency- and recovery-oriented care system where each phase informs one another, as seen in Figure 1 which spans the entire continuum of care.

Figure 1.

Kanaka (person) ‘Ohana (family) Kaiaulu (community)^a

^a Original unpublished figure created by the authors/Lilinoe Kauahikaua of Papa Ola Lokahi, and duplicated with permission 2021

At the center of Figure 1, the piko, we can see the depiction of self, ‘ohana, and community: 3 interrelated, interconnected healing targets. You cannot heal just one; all must be healthy for each to flourish. The Substance Abuse and Mental Health Services Administration explains that the resiliency- and recovery-oriented care system “is a coordinated network of community-based services and supports that is person-centered and builds on the strengths and resiliencies of individuals, families, and communities to achieve improved health and wellness outcomes for those at risk or experiencing issues with substance misuse.”³¹

The Recovery Ready Ecosystems Model (RREM) provides a model to increase recovery prevalence and focus on supporting and building recovery-informed infrastructure within communities.³² Collective healing of our communities is needed to combat intergenerational traumas that lead to stigma and NIMBYism (“not in my backyard”), which inhibit the healing of our Native people and their communities. The recovery-informed infrastructure allows for a backward mapping approach to building a culturally resonant system, beginning with what is working. Recovery through an RREM lens encompasses the many pathways to healing, including harm reduction, behavioral/mental health, reentry, peer recovery services, diversion courts, and many more. RREM provides an avenue of alignment with Indigenous, collective healing approaches.

Another way to acknowledge, value, and uplift the Indigenous experience is through culturally grounded peer support. Peer support can only be provided by someone with lived experience and provides a layer of support, empathy, and understanding unparalleled by other clinical support. Peer recovery specialists can be invaluable for our Native people, who often struggle with Western recovery spaces and language. Culturally grounded peer support services help address that dichotomy of individualism on the Western spectrum, with a more collectivist or holistic approach toward healing, ola, and the well-being of the whole environment. Recovery for many may even take the place of clinical treatment. We must support these services with the same vigor and intent as the areas of promotion, prevention, and treatment. A newly conceptualized healing journey for Native Hawaiians should utilize and uplift stories of resilience to resonate with, inform, educate, and empower those impacted, those who help navigate these systems, and those who choose to walk alongside the healing journey.

ahupua‘a Model

Our Native people thrived in Hawai‘i for centuries before Western contact. Native Hawaiians developed a complex resource management system through the ahupua‘a system, a land division of interconnected systems stretching from the mountain to the sea. The ahupua‘a model provides a framework to implement cultural interventions at various places within the ahupua‘a to effectively provide healing that impacts not only the individual but their ‘ohana and community as well. Interventions within the metaphorical framework would aim to effectively decrease the intergenerational transmission of risk factors (intergenerational/historical/cultural trauma, colonization, poverty, oppression, loss of traditional healing practices, criminalization of Native identity, loss of land, and family/community history of use/incarceration) and increase the intergenerational transmission of protective/resiliency factors (‘ohana relationships, cultural wisdom, traditional healing, community connection, mo‘okūauhau [genealogy], ‘āina, respect for kupuna, and culture). The model draws from Dr. Keawe Kaholokula’s model of the social and cultural determinants of health and their relation to Mauli Ola (health).³³ Our ahupua‘a stretched ma uka a i kai (mountain to sea), connected through wai (water), which flowed through each system section to bring life. Wai ran through our lo‘i (kalo patch), and loko i‘a (fishponds), and down into the ocean, where it evaporates and becomes ua (rain) to once again fall from the lani (sky), run through our nāhele (forests), and down throughout the rest of the ahupua‘a. No one system functioned independently. Kānaka, our people, tended these systems knowing that resources were finite and the land must flourish for us to survive. He ali‘i ka ‘āina, he kawa ke kānaka,³⁴ the land is chief, and us its servant.

Looking at the lo‘i system, within our ahupua‘a system, I ka wa kahiko (ancient times), if these systems were not functioning correctly, or not healthy, and if those who mālama (to take care of) these spaces were not ma‘a (accustomed, used to, familiar) to this understanding, no one would be fed. Lo‘i is the Native Hawaiian’s agricultural system using terraces along the hillsides. They developed complex systems, similar to water paddies, to grow their staple food of kalo (taro) along the valleys. We should understand the external impact on this substantive system. We can understand kalo as a reflection of ourselves, of hāloa, our ancestor, our root, both metaphorically and physically. We conceptualize this new system of care, one where Native people can thrive and pursue healing pathways that embrace, empower, and value an Indigenous worldview. We achieve this by recognizing interconnections within systems and understanding how feedback from each area along the continuum of care impacts and informs other system areas as a whole, much like the ahupua‘a.

As we visualize the system through this culturally informed and holistic lens, we must also acknowledge that current data often aggregates ethnicities, is disparity-focused, and has a history of portraying Native/Indigenous populations by showing what is wrong. Therefore, the ahupua‘a model (Figure 2) provides a metaphorical model to understand collective healing through a Native lens and embraces a recovery perspective that recognizes substance use as a symptom of a larger trauma. The ahupua‘a is a living, breathing example of a thriving, healthy Native system. Through this model, practitioners can identify the root causes of trauma, and develop effective culturally informed interventions to engage in collective healing from trauma and celebrate resiliency outcomes.

Figure 2.

The Impacts of Colonization on Ahupua‘a. Conceptualization by Lilinoe Kauahikaua and Papa Ola Lōkahi V3.0^a

^a Original Copyrighted Unpublished figure created by Kimo Apaka and edited by the authors and duplicated with permission 2022.

With the help of our Indigenous cousins, we continue to explore the manifestations of deeper trauma within ourselves, ‘ohana, and communities through the model of a Healing ahupua‘a, inspired by the Healing Forest model created by White Bison.^35,36

Pre-contact, our ahupua‘a were healthy and existed in a harmonious relationship, tended by kānaka (Native people) who understood that each interconnected system within the ahupua‘a must be healthy for all to thrive. However, Figure 2 outlines the impacts of colonization, racial/cultural traumas, negative socio-economic impact, the criminalization, and subsequent loss of the Native identity has had on Native Hawaiian individuals, ‘ohana, and communities. These impacts are carried through the ahupua‘a system as risk factors impacting generations.

We visualize these risk factors entering our ahupua‘a through the ua or rain. This ‘eha, or pain/trauma, is passed down from generation to generation and compounded by unresolved grief. All of this ‘eha creates layers of huhū (anger), hewa (guilt), hilahila (shame), and maka‘u (fear), which enter into our ahupua‘a just as the metaphorical rain feeds into the soil. We look at the systems and visualize the ‘eha (pain/trauma) impacting the soil to understand the pollution and other toxins that have found their way into our environment and continue to impact our systems through the environmental water cycle cyclically. The potentially unhealthy/impacted soil would then run off into the kahawai (river) and be carried downstream, impacting the rest of our interconnected systems. But, just as trauma is passed down generationally, our ancestors pass down the strengths and resilience (as seen in the ua).

We can understand the interconnected ahupua‘a systems as our care systems, our ‘ohana, and our communities. In understanding care systems and approaches to healing within the larger continuum, we focus on the lo‘i as ‘āina-based model to visualize the internal and external impacts of trauma and the manifesting symptom of substance use on our lāhui ecosystem. As the unhealthy soil enters into our lo‘i, it becomes that which feeds the next generation of kalo or hāloa that emerges from it.

Today, we may have generations of people born with internal ‘eha buried deep within them. If the ‘eha begins to bubble up to the surface, it can manifest in many different ways in our kalo; anger, violence, substance use, etc, giving way to an unhealthy ahupua‘a. However, we can remember that our strengths and cultural resilience are also contained in the ua and soil. In that case, we see a path forward in cleaning our water of the risk factors to improve and increase our protective/resilience factors for generations to come.

We can imagine that, while working in the lo‘i one day, we find a kalo that is sick (manifesting trauma as addiction). First, we must look around to the other kalo to find the source of the sickness. Are the other kalo sick? Is the whole lo‘i sick? How could this sickness be getting in? We must look up the interconnected ‘auwai (canal) and the kahawai for the source of this sickness, this pollution, this ‘eha. If we cannot find the source of this ma‘i, this sickness, and we instead decide we will just take that one kalo out, heal it, and then put it back into that potentially unhealthy environment, it will only get sick again.

This metaphor illustrates we will face the same result we began with if we decide to solve the problem on the surface that we see. We need to put in the work to address the root of the problem, look far enough up the system, and dig deep enough to find the source that creates the unhealthy environment.

Recognizing how Native Hawaiians experience the self through ecocentric, cosmocentric, and sociocentric definitions provides a lens for understanding and developing more impactful and effective interactions for Native people are implemented through the ahupua‘a framework. Thereby cleaning our wai as it traverses throughout our interconnected systems and is reborn through the water cycle to fall as ua once again, reducing risk factors and increasing protective factors. This increase in protective factors will contribute to the healthy lo‘i and ahupua‘a through the soil waiwai (rich) with lōkahi (balance), mauli ola (health), mana (spiritual energy), and pilina (connection/bonds), foundational values for a thriving lāhui kānaka (Native Hawaiian people), as seen on the right side of the image (Figure 2). The ahupua‘a conceptual framework is intended to develop and grow as the framework is embraced and actualized across systems and care spaces.

Embracing a more culturally grounded approach would effectively provide a paradigm shift in how society and individuals see themselves. Imagine the empowerment of nurturing and uplifting these unique gifts contained within Native Hawaiian protective/resiliency factors and the impact or effect they would have on someone’s life, how they grew up, and how they perceive themselves. By understanding the multiple threads impacting their lives, a more robust, comprehensive (holistic) approach that incorporates (blends) the interventions used will have more value for this Native person.

Recommendations

Table 2 displays proposed recommendations to guide the initial steps toward implementing of a newly conceptualized system. These recommendations were based on the synthesis of the existing literature and available data, but also Indigenous knowledge and feedback from our stakeholder groups.

Conclusion

Current culturally grounded interventions have struggled for some time to meet the requirements for evidence-based interventions and assessments required by Requests for Proposals (RFP’s) and Grant applications. These methods often do not align with culturally grounded intervention programs which tend to be more fluid in approach as each intervention is tailored to the individual and family. It is also impractical to assess the successive impact of cultural interventions through standard Western assessment.

The current Western definition of evidence-based interventions^37,38 are practices or programs with peer-reviewed, documented empirical evidence of effectiveness. But what does this mean for culturally grounded interventions? The current Western dominant paradigm of evidence base prioritizes research, peer review, and randomized controlled trials. However, we cannot continue to adhere to this Western dominant paradigm, which heavily bases itself on the assumption that research in the social sciences is essentially the same as natural sciences.³⁷

Western research looks for themes formulated together to produce “laws” or one size fits all, blanket approaches to social issues.³⁸ “This way of understanding people and their struggles has become dominant in a very particular economic and cultural milieu, one that, despite the forces of globalization, is alien to many communities around the world. Its materialist and individualist focus means that it is often a specifically inappropriate vehicle to use with Indigenous communities.”³⁹

A newly conceptualized journey of healing for Native Hawaiians should utilize and uplift stories of resilience to resonate with, inform, educate, and empower those impacted, those who help navigate these systems, and those who choose to walk alongside the healing journey.

Therefore, our recommended approach is centered around healing the ahupua‘a system through culturally grounded programs that allow for tailored interventions that meet the specific needs of individuals and families living within the healthy, thriving ahupua‘a system.

Table 2.

Recommendations to Guide the Initial Steps toward Implementation of a Newly Conceptualized System^a

1. Infrastructure Development	Reporting Standards - Create a network within Native Hawaiian communities across the State to increase engagement capacity (accountability and ongoing feedback loop). Inter-agency - With other State departments, develop a cross-discipline group to focus on creating inter-agency engagement strategies (protocols) and outcomes (procedures) (i.e., specialty cultural court). - Identify areas where language and processes can be updated to shift the narrative and create a more inclusive space for integrating Native Hawaiian values and beliefs. Peer Support - Value and uplift lived experience - Develop culturally grounded, resonant, inclusive, and supportive peer spaces for Indigenous people on their healing journey from substance use. - Create reimbursement pathways for care systems employing peers.
2. Data Collection & Disaggregation	Data Disaggregation - Address the need for data sovereignty that allows Native Hawaiians to develop data collected for, by, and about us. - Create mechanisms that identify culturally relevant data collection. - Develop culturally anchored evaluation tools that state-funded treatment programs use related to the efficacy of programming specific to Native Hawaiians.
3. Funding & Monitoring/Oversight	Funding - Track federal dollars that are sought after and awarded to the State of Hawai‘i where Native Hawaiians (and or other marginalized groups indicated on request for proposal) are targeted, and create a clear plan for accountability and meaningfulness of programming. - Analyze spending on Native Hawaiian programs throughout the department. - Create a policy oversight position to develop criteria and monitor cultural adherence. Advisory Council - Establish a council of relevant partners (providers, government, stakeholders) to monitor compliance and review accountability of funds and programming related to Native Hawaiians. - Convene a group of Native Hawaiian health and well-being specialists from across the state to provide feedback and guidance on the process of funding.

^aDr. Sheri Daniels, Papa Ola Lōkahi (2021)

Abbreviations and Acronyms

ADAD

Hawai’i State Department of Health Alcohol and Drug Abuse Division

DSM-5

Diagnostic and Statistical Manual of Mental Disorders 5th Edition

RREM

Recovery Ready Ecosystems Model

Conflict of Interest

None of the authors identify a conflict of interest.

Notice of Duplicate Publication

This article is based on the draft version of a chapter from the Hawai‘i State Department of Health Alcohol and Drug Abuse Division (ADAD) State Plan, and all or a majority of the contents within will be subsequently also reproduced in the corresponding chapter of the final version of the ADAD State Plan (https://health.hawaii.gov/substance-abuse/state-plan/). While the ADAD State Plan may later be modified as a living document following its release, the material and content found in this article represents a snapshot of the highlights of the ADAD State Plan at the time of the article’s publication.

Funding

Support for the writing, coordination, and publication of this special supplement and for the State Plan for a System of Care was provided by the Hawai‘i State Department of Health Alcohol and Drug Abuse Division (ADAD).