Ho‘oilina Pono A‘e: Integrating Native Hawaiian Healing to Create a Just Legacy for the Next Generation

Abstract

Native healing practitioners have been incorporated into health centers serving large populations of Kānaka ‘Ōiwi (Native Hawaiians). However, no studies have examined their impact. A community based participatory research study at Waimanalo Health Center from 2017 to 2019 examined the added value of integrating native healing practices into primary care, including whether there is acceptability of the integration, cultural connectedness due to integration, and empowerment for patients, providers, and staff. Semi-structured interviews were conducted by the research team with 24 patients, providers and staff, and community residents. Through content analysis, 5 themes emerged. The integration of native healing practices provides an alternative to western medicine, recalls ancestral knowledge, focuses on the whole person, generates increased disclosure leading to behavior change, and is central to a decolonizing process. The findings support the integration of native healing practices providing added value in primary care.

Introduction

Indigenous healing practices and traditional healers exist throughout the Pacific Islands.¹ Upon the arrival of Captain James Cook in 1778, Kānaka ‘Ōiwi (Native Hawaiians) were described as healthy, fit, and athletic people. In Kānaka ‘Ōiwi culture, illness is considered to be derived from ma‘i or imbalance.² Thus, it is the healer’s role to find the source of the ma‘i in order to correct it. To Kānaka ‘Ōiwi, ola, or health/well-being, factors in the harmonious relationship between one’s mind, body, and spirit and how these components interact with the world.^2-3 Concepts such as ma‘i and ola are not always congruent with Western medical practices and may impact healthcare utilization. Effective health care for Kānaka ‘Ōiwi should consider patient perspectives of health and illness and can benefit from understanding and incorporating Indigenous healing practices into Western medicine.

Prior to the introduction of Western medicine, lā‘au lapa‘au (plant-based medicine) and lomilomi (massage) were used as forms of medicine/healing for Kānaka ‘Ōiwi. Both practices involve a spiritual, psychological, and a physical component to healing. The value of lōkahi (harmony) is central to understanding ola. It is achieved when physical, mental, and spiritual parts of a person are in balance, including relations with others, family, gods, and the environment.

Today, Kānaka ‘Ōiwi healing practices are experiencing a revitalization in contemporary Hawai‘i despite efforts at colonization evidenced by the outlawing of Kānaka ‘Ōiwi religious practices in 1830 and language in 1896.⁴ In 1905, Native Hawaiian healing practices and healers were forbidden by the government of the United States territory of Hawai‘i with punishments including fines and imprisonment.⁴ Cultural historical trauma has been identified as the psychological, physical, social, and cultural aftermath of colonialism many Indigenous peoples have experienced.⁵ Historical trauma and the negative impact it has on Indigenous communities has been consistently identified as an important cause of health inequities.^6-9 Through cultural historical trauma, Kānaka ‘Ōiwi have experienced structural and social stressors, including barriers to education, unemployment, and houselessness.¹⁰

Kānaka ‘Ōiwi, particularly those living in lower socioeconomic conditions, encounter many barriers to health care including a lack of: insurance, income, housing, childcare, transportation, and time due to school and work responsibilities.^11-12 Due to these barriers, some have turned to Kānaka ‘Ōiwi healing methods, but may be reluctant to share this with providers due to fear of judgment or discrimination.¹³ Providers may exhibit skepticism due to lack of experience with traditional healing methods or bias to western medicine.^14-15 These types of experiences can lead to alienation, nonadherence, or premature termination of services.^14,16

Integration of Traditional Healing Practices

A modest body of research exists on Kānaka ‘Ōiwi healing that recommends its integration with Western medicine. A pilot study from an O‘ahu clinic that delivered western and Kānaka ‘Ōiwi healing practices (especially lomilomi) showed that 76% of patients held the belief that improved health care can best be attained by using Indigenous and Western treatments together, and gave patients agency in choosing the treatment they wanted.¹⁵

In another study, Kānaka ‘Ōiwi who received both Western medicine and traditional healing were asked to compare and contrast their views of these different methods.¹⁷ The study found that Kānaka ‘Ōiwi saw Western medicine as professional, segmented, and scientific and traditional healing as personal, holistic, and spiritual/cultural. The study recommended that professionals of both healing disciplines collaborate for better health outcomes.

E Ola Mau: The Native Hawaiian Health Needs Study recommends the integration of traditional healing and Western medicine in clinics that serve Kānaka ‘Ōiwi.¹⁸ The report expands on this recommendation by mentioning different approaches to integration ranging from networking to co-treatment, all working towards the goals of increasing communication between western providers and traditional healers, and improving health care for Kānaka ‘Ōiwi.

There is growing evidence that culturally relevant interventions can have an impact on diet, blood sugar, blood pressure, cholesterol, and cultural identity.^19-21 The integration of Western and Indigenous healing has also been studied in other cultures, including First Nations in Canada, Africa, and Asia.^{14 22-25} Findings from these studies demonstrate that this integration has shown to be effective, needed and preferred among Indigenous patients. However, fewer studies have examined the benefits and challenges of integration among Kānaka ‘Ōiwi in Hawai‘i.

Study Objectives

The objective of this study was to further the literature on the integration of Indigenous and Western healing practices in Hawai.i among Kānaka ‘Ōiwi. This study investigated 1 model of integration occurring at Waimānalo Health Center (WHC) on the island of O‘ahu. The objectives were to identify the impact of integrated services on the patient experience, further understand the process of integrating Indigenous and Western healing (including barriers), and potentially provide information about the critical components of integration for Kānaka ‘Ōiwi.

To meet these objectives, a 7-member community advisory board (CAB) was formed consisting of patients, staff, and community leaders. The group met monthly for the first 6 months of the study and then quarterly thereafter. Prior to developing the protocols for the study, the authors engaged the CAB in discussions of the potential impact of integrated services to frame the study and guide the work through the research process. From these discussions, a conceptual model for understanding the patient experience emerged. The model posited that first, if the implementation of integrated services is successful, there will be a greater sense of acceptability by both patients and providers. Subsequently, if acceptability is achieved, this will result in a deeper sense of cultural connectedness. In this case, both patients and providers would feel more connected to Kānaka ‘Ōiwi culture and understand its relevance to wellbeing. The model further hypothesized that if acceptability and cultural connectedness occurs, there will be an increase in patient activation or empowerment among patients and providers (Figure 1). These concepts refer to patients being activated to take charge of their own health, and providers observing these behaviors among their patients. And finally, if empowerment is achieved, there is a greater potential for patients to continue to seek services and over time, improve their health status. Based on this conceptual model, the CAB developed a set of interview questions reflecting these stages (Table 1). Key informant interviews were used to further validate the CAB’s conceptual model and fully understand the patient experience with integration.

Figure 1.

Conceptual Model of Integrated Services Developed by Community Advisory Board

Table 1.

Native Hawaiian Healing Interview Questions

	Question asked of:
Questions reflecting acceptability and cultural connectedness:
1. Do patients feel more connected to their providers and the clinic?	Patients
2. Do providers, staff, and administration have a greater sense of connectedness to Kānaka ’Ōiwi cultural values and practices?	Providers/Staff
3. Is the clinic viewed as being more connected to the cultural values and practices of the community and Kānaka ’Ōiwi in general?	Community; Kūpuna
Questions reflecting patient empowerment:
1. Do patients abide by their medical regimens at an increased rate?	Provider/Staff; Patients
2. Do providers promote integrative and team-based approaches to care that include Indigenous healing?	Provider/Staff
3. Does the clinic promote the sustainability of these integrative services?	Patients; Provider/Staff; Community; Kūpuna
4. Do large systems, for example, healthcare systems, insurers, and the government, support the integration of Indigenous healing?	Provider/Staff
5. Is there a diffusion of Indigenous healing practices that is used within the community?	Patients; Community

Methods

Study Design

This exploratory study was approved by the Association of Asian Pacific Community Health Organizations Institutional Review Board (1711-AAPCHO-01N-California-HooilinaPonoAe). A total of 24 adult participants were recruited for the study as described in Table 2. Providers and staff were purposely sampled from those who referred patients to or interacted with the Kānaka ‘Ōiwi healing practitioner and interviewed by a non-WHC researcher. A WHC non-patient care research team member reached out to patients who had a visit with a healing practitioner to determine interest in study participation. Community members were recruited from health promotion classes or events at the health center. Kūpuna (honored elders) who were healing practitioners were invited by the research team healing practitioner to be a part of this study.

Three lead researchers, 2 of whom were WHC staff, including the Kānaka ‘Ōiwi healing practitioner, conducted the interviews. Participants provided informed consent to the researcher prior to the interview. Interviews were about 1 hour long and were audiotaped and transcribed. Demographic participant data was obtained prior to or immediately after the interview. Demographic data for patients and community residents included, race, age, gender, residency, and education. There were several education categories including traditional knowledge, referring to traditional knowledge passed on to the participant from kupuna. Demographic data for staff included, race, age, sex, residency, length of time at WHC, length of time in Hawai‘i, profession, and education. Each participant received a $20 grocery gift card for their participation.

Using a directed approach to content analysis, data were initially analyzed deductively using pre-defined, CAB-developed constructs as guidance for initial code categories/themes (ie, Integration, Acceptability, Cultural Connectedness, Patient Activation/Empowerment). Text was analyzed for the presence of code categories, as well as the meaning and relationship between code categories using the Dedoose software (Dedoose Version 9.0.17, Sociocultural Research Consultants, LLC, Los Angeles, CA, dedoose.com).^26-27 The generalization and abstraction of data within the code categories were used to formulate our results. For reliability and validity, all interviews were double-coded, by lead researchers and students, and all inconsistencies were discussed and rectified.

The sampling was completed when the analysis reached saturation, in all subgroups, with regard to these themes. The hypotheses were first, participants will be familiar with and will demonstrate acceptance of Kānaka ‘Ōiwi healing practices. Second, participants will demonstrate cultural connection through Kānaka ‘Ōiwi healing practices. Next, patients will experience a sense of activation and empowerment over their health care needs, including regular clinic attendance, adherence to treatment regimens, improved self-efficacy in their management of acute and chronic illness, and patient satisfaction. Finally, it was hypothesized that through this model of integration, positive changes in patient health outcomes will be observed.

Results

The results are divided by each of the components of the conceptual model. Overall, the evidence supported the model among all study participants and all participants endorsed the role of integration in promoting patient wellbeing. Below, are emerging themes that developed from the interview questions within the components.

Integration

All patients and providers interviewed shared the importance of integrating Kānaka ‘Ōiwi healing practices. For the majority of patients, practicing Indigenous healing methods continues the tradition of education and the passing of ‘ike kūpuna (ancestral knowledge). Participants noted that integration restores Indigenous knowledge and cultural practices to the community. For example, a community resident stated:

“We have the Western medicine, but if you can go into the natural, that’s a lot better, you will need the guidance for it, you cannot just take what you see people saying, ‘oh this herb is good, …,’there’s no way of really knowing for sure until you get the education.”

Patients had varying degrees of understanding Kānaka ‘Ōiwi healing practices, with some having extensive knowledge and others having mostly memories of family using various plants and healing practices. They recalled seeing these plants growing in their yards as youths. Those with less knowledge reported that having a Kānaka ‘Ōiwi healing practitioner gave them access to knowing how to grow and use Indigenous plants. In addition to patients, providers (n=4) expressed enjoyment in learning alternative forms of care, including Kānaka ‘Ōiwi healing practices, and building a more open and trusting relationship with patients through integrated services.

Participants also expressed how integration of Kānaka ‘Ōiwi healing practices fills gaps in care that exist when culturally relevant care is not available. Patients expressed satisfaction and trust in the clinic when integration brings culture specific care to patients, as a patient responded:

“I get more than that when I come here, … It’s just not take 2 [pills], they really show that they care for me.”

Acceptance

According to the model, integration leads to the second component: acceptance. All patients were open to and even interested in learning more about Kānaka ‘Ōiwi healing and saw value in incorporating these healing methods into their health routines. Patients stated they value these methods as they are natural, cost effective, and present fewer side effects compared to western medicine. A patient shared:

“The relief that I get honestly, I no need pain pills. With her [cultural practitioner] treatment, the tension of the pain, the pressure, the depression of the pain, ooh, sore, when she do her number on me, oh, the relief I get! I can live.”

“The practices, I take it home with me and exercise and practice that advice. It’s important that we not only hear advice but do it.”

Among patients, acceptance demonstrates that the benefits of integration are acknowledged which is exemplified by their willingness to utilize, receive, and learn more about Kānaka ‘Ōiwi healing methods. Acceptance was widely expressed by patients and providers alike during the interviews. A provider noted:

“With the Native Hawaiian culture being integrated into it, it’s gonna only get better. People want the traditional, they are tired of the iPads and all that kind stuff.”

Interviews with clinic patients and providers revealed not only that acceptance of Kānaka ‘Ōiwi healing practices increased through integration, but that acceptance of Western medicine may have also increased. Analysis of interview responses revealed that acceptance of and trust in Western medicine may increase when Western medical providers work in collaboration with already trusted, culturally familiar, Kānaka ‘Ōiwi healers. One provider described observing this in patients:

“… folks who not necessarily feel comfortable if we were just providing medicine or providing psychology, they feel really comfortable in talking and they see [the cultural practitioner] and they are almost immediately at ease, and are just more willing to just converse.”

Cultural Connectedness

The integration and acceptance of Kānaka ‘Ōiwi healing practices into primary care creates an avenue for a deeper connection to Native Hawaiian history, practices, and values as well as brings awareness to the cultural interaction that has influenced the rocky relationship between western medicine and Indigenous peoples. Four sub-categories of cultural connectedness that convey the importance of culture in this community were identified through the interviews: (1) Recollection brings memories to the forefront, generating pride in patients and their family’s ancestral knowledge, (2) Revitalization of cultural practices that have been considered sacred wisdom and passed down through generations are legitimized through integration, (3) Respect for cultural values that support a holistic and self-sufficient approach to health, and (4) Culture (Western) to culture (Kānaka ‘Ōiwi) interaction realizes that patients are caring for their health in the ways they know how and changes the way providers interact with their patients. It breaks barriers to care that Kānaka ‘Ōiwi have experienced. One provider remarked,

“I think it’s also made me aware of the fact that so many patients really do kind of their own lā‘au that they grew up with at home. So they have some understanding and knowledge of that.”

A patient recalled:

“… it [Kānaka ‘Ōiwi healing services] actually validates what I [learned from Tūtū Lady]. For my family, I knew the genealogy of the teachers.”

Empowerment

An important aspect of integrating native healing practices for patients is that integration not only helps alleviate the physical, but strengthens the mind and spirit of the patients, giving them sufficient capacity to proactively make positive changes to improve their health. One patient, who is also a parent, reported making dramatic changes in their family diet and encouraged their children to engage in different sports to prevent obesity and chronic illnesses that adversely affected many kūpuna. In the interviews, multiple health providers reflected the excitement in seeing the positive changes patients are making to enhance the health status of both themselves and their families:

“I do see greater motivation. I see a lot of families make dramatic changes, they made this poultice, they tried it, and they are so excited… when you see families making these changes, it is so rewarding, and its empowering for the families.”

Discussion

In this study, it was hypothesized that through the integration of Kānaka ‘Ōiwi healing practices, there would be a positive change in the patient, provider and community experience at WHC. It was hypothesized that this would occur through greater acceptance, increased cultural connectedness, and patient activation and empowerment. Although this study is cross-sectional and thus is not designed to study change over time, patients and providers consistently supported the integration of Native Hawaiian healing practices and positive experiences in acceptance, connectedness, and empowerment because of integration. For example, patients spoke often of wanting to utilize and learn more about Native healing practices.

Acceptance and acceptability of health care is an important component of health care access. Acceptability includes how well patient and provider health beliefs align, the quality and extent of conversation between patient and provider, and how health care systems and services are provided and organized. Increasing the acceptability of health care is crucial in the journey towards health equity.²⁸

Culture’s role in the acceptance of health care is corroborated by Kānaka ‘Ōiwi elders and their family members.²⁹ The current research suggests that when cultural values have a prominent place in the health care of Kānaka ‘Ōiwi, health care was acceptable to patients. Other research suggests that feelings of cultural connectedness may be important agents of health improvement for indigenous populations. For example, meta-synthesis of research studies working with various Indigenous communities of North America found that cultural continuity was correlated with health outcomes such as a sense of holistic wellness, feelings of belonging, trauma healing, and even lower rates of chronic disease and other illnesses.³⁰

A significant body of health care research exists on the importance of empowerment. Empowerment, in the context of individuals and communities, refers to the realization of self-determination and control over one’s circumstances, and the subsequent actions that follow such realizations.^31-32 A study on integrated Western and Aboriginal health care in Canada found that as a result of utilizing traditional healing methods, patients seemed to have a greater sense of empowerment, much like patients in our study implied.²³

Limitations

There are several limitations from this study including the small sample size and self-reports of individual experiences. Next, findings are not generalizable to other integrated primary practices beyond the WHC as the study sampled only patients/providers who had previously been referred or had contact with a Kānaka ‘Ōiwi healing practitioner. The results may not be generalizable to patients who would decline such a referral, or providers who would decline to make such a referral. In addition, integrating Kānaka ‘Ōiwi healing into the Western setting of primary care can impact and shorten the amount of time available to deliver traditional healing practices. Having the Kānaka ‘Ōiwi healing practitioner conduct the kūpuna interviews, although culturally appropriate, may be perceived as biased. Finally, while potentially effective, we acknowledge that native healing practices will not cure all ills. Despite these limitations, the authors believe this study contributes greatly to the literature on the integration of Kānaka ‘Ōiwi healing into primary care.

Conclusion

There is a need to examine the processes in which Kānaka ‘Ōiwi healing services are rendered to ensure that the traditions are kept intact. Kānaka ‘Ōiwi healing is holistic, takes time, and should be just as valued as Western medicine.

Table 2.

Participant Demographics (N=24)

Participant Characteristic	Providers/Staff n (%)	Patients n (%)	Community Residents n (%)
Total participants	8 (33)	10 (42)	6 (25)
Kānaka ’Ōiwi	4 (17)	10 (42)	5 (21)
Female	7 (29)	6 (25)	5 (21)
Age range	29-64	45-70	51-71
Years living in Waimānalo	1-15	9-50	20-61
Received lomilomi or lā’au lapa’aua from WHC	NA	10 (42)	0
Education
High school only	0	5 (21)	5 (21)
Some college	3 (13)	4 (17)	0
More than 4 years of college	5 (21)	4 (17)	0
More than 4 years of college	5 (21)	1 (4)	1 (4)
Traditional knowledge	2 (8)	8 (33)	1 (4)

^aLomilomi, a traditional Native Hawaiian holistic massage. Lā’au lapa’au, a traditional Native Hawaiian holistic practice using native plants as medicine.

Abbreviations and Acronyms

CAB

community advisory board

WHC

Waimanalo Health Center

Conflict of Interest

None of the authors identify a conflict of interest.