Sociocultural factors influencing adolescent preference and use of native Hawaiian healers

Sociocultural factors influencing adolescent preference and use of native Hawaiian healers C. K. Bell, D. A. Goebert, N. N. Andrade, R. C. johnson, j. F. McDermott, E. S. Hishinuma, B. S. Carlton, j. A. Waldron, G. K. Makini, R. H. Miyamoto Native Hawaiian Mental Health Research Development Program (NHMHRDP), Department of Psychiatry, John A. Burns School of Medicine, University of Hawai'i, USA

SUMMARY. Objective: Few studies have examined the use of alternative therapies .among adolescents. This study examines the predictors of Native Hawaiian healer preference in the treatment of physical or emotional problems as well as the predictors of healer use. Design: This study is a longitudinal cross-sectional design. Setting: The survey was conducted in five high schools in Hawai'i. Participants: 1,322 high school students selected preference for and/or use of allopathic or alternative practitioners. Main outcome measures: Grade level, gender, ethnicity and cultural identity were used to predict healer preference. Healer preference, socioeconomic status and health status were used to predict healer use. Results: Identification with the Hawaiian culture was the strongest predictor of healer preference for both Hawaiian and non-Hawaiian adolescents. Mental health was also predictive of healer preference for non-Hawaiians. Healer use by Native Hawaiian adolescents was also predicted by Hawaiian cultural identity. Gender, grade level, and socioeconomic variables were not predictive of healer preference or use. Conclusion: Cultural identity plays a significant role in the preference and use of alternative practitioners, especially for minority adolescent populations. © 2002 Elsevier Science Ltd. All rights reserved.

INTRODUCTION

Cathy K. Bell Correspondence to: Cathy K. Bell, MD, Native Hawaiian Mental Health Research Development Program (NHMHRDP), Department of Psychiatry, 1356 Lusitana St., 4th Floor, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813. E-mail: [email protected] Preparation of this paper was supported by RCMI Supplement NIH Grant No. RR0361-06S I, NIMH Grant No. I R24 MHSOIS-OI, the Queen Emma Foundation, and the Native Hawaiian Center of Excellence.

Recent literature documents the increasing use of alternative medicine. Eisenberg et al. in 1993 1 defined alternative medicine as medical interventions that are not taught in U.S. medical schools or not widely available in U.S. hospitals. In their 1997 follow-up survey, 42.1 % of a large sample of Americans used alternative therapy within the past year, up from 33.8% since 1991. 2 A parallel phenomenon is the increasing awareness of the need for culturally competent care. 3 Cultural competence has been defined as a set ofknowledge-based and interpersonal skills that allow individuals to understand, appreciate and work with individuals from cultures other than their own. 4 Despite this emphasis physicians are often unaware of alternative practitioner use. 2 Research aimed at

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identifying sociocultural detenninants of alternative practitioner preference and use in different ethnic groups is needed. This study examines demographic and cultural factors that impact preference and use of indigenous healers in a multi-ethnic adolescent population. Studies intended to characterize use of alternative medicine across the world have been inconsistent in their findings regarding differences in preference and use as a result of age, education, health status, socioeconomic status and satisfaction with allopathic medicine,5-1 1 perhaps because of sampling differences. However, some findings have been replicated. Most studies have found that women use alternative medicine providers more than men. 5.9- 11 Those using alternative practitioners tend to have attitudes that are holistic, health promoting, and preventive. 8. 12- 13

Native Hawaiian healers

225

Additionally, individuals with illnesses that have younger age groups have not been contrasted. Adoan associated psychological component or psy- .lescence is a unique developmental period during chiatric illnesses tend to use alternative healing which identity formation occurs. As such, identifimethods to a greater extent. 2,6--9,1l-12 Finally, be- cation with aspects of different cultures may occur lief in efficacy of alternative treatmene-s is an ex- as teens struggle with the formation of a cultural tremely common finding among alternative care identity. Cultural identity has been defined in many different but related ways. One common definition users. Several studies on alternative medicine have is the values, attitudes, beliefs, and customs assofocused on cultural factors, concluding that in- ciated with a given ethnic group.20 As part of the dividuals who identify with a particular non- formation of a cultural identity, as well as inwestern culture are more likely to use alterna- dividuation away from parental influence, altertive healing practices. 13-16 However, cross-cultural native healing methods may be explored. This studies of the use of alternative therapies have community-based study examines sociocultural produced surprising results. Predominantly Cau- variables affecting alternative healing practices in casian populations surveyed in Australia and the a multi-ethnic adolescent population. It compares United States demonstrate greater use of alterna- Native Hawaiian youth with other ethnic groups tive therapies than non-Caucasian populations,2,17 since Native Hawaiians are known for their relaStudies in minority populations within the United tively poor mental and physical health compared States reveal interesting findings as well. Among to other ethnic groupS.14,21-24 A theoretical model Mexican-Americans, only 4.2% of 3,623 individ- predicting healer preference and use was designed uals reported consulting a curandero, an indige- based on the aforementioned literature and is denous folk medicine practitioner,15 and a study picted in Figure 1. We hypothesize that (a) adolescents who idenon Navaho Indians revealed a preference for physicians compared to an indigenous health tify with the Hawaiian culture, especially those provider. 18 who practice Hawaiian customs, will be more Few studies have characterized use of Native likely to prefer a Native Hawaiian healer; (b) feHawaiian healers or kii hUlla. The Native Hawaiian males will prefer and use healers more than males; healer refers to an individual trained in one ofmany and (c) healer use will be predicted by identificaNative Hawaiian healing traditions and practices. tion with the Hawaiian culture, perceived illness, The most common type of healer is the kahuna access to care, and healer preference. Hi' au lapa' au, who treats common ills with plants and plant extracts. Others include kahuna hii hii (faith healer), lomilomi (massage), and METHODS ho' oponopono (' setting things right,' family/group therapy). In traditional Hawai'i, the kii huna were The Native Hawaiian Mental Health Research forced to restrict their practice to family and Development Program (NHMHRDP) conducted a friends. The majority of healers live in Native cross-sequential (i.e. longitudinal cross-sectional) Hawaiian rural communities throughout the state, study ofmore than 7,000 high school students from Recently, with the increased use of indigenous 1992 to 1996, and was developed in collaboration and alternative healing practices nationwide, ka with the National Center for American Indian and huna are once again sharing their knowledge and Alaska Native Mental Health Research Program. 25 healing practices with others. In addition, there The data from the 1993-94 school year analyzed is a statewide emphasis towards integrating tradi- herein included the largest sample and the most tional healing and Western medicine to improve culture-related questions. the health of Native Hawaiians. Snyder found that 90% who sought Native Participants Hawaiian healers did so for psychosocial problems, including adjustment, relationship, or oc- This study inCludes 1,322 students that secupational difficulties. I I Judd examined Hawaiian lected either allopathic or alternative practitionherbal healing, finding that some use native healing ers. There were 844 Native Hawaiians (hereafter, as a last resort, while others use it complementarily Hawaiians). Pure and part-Hawaiians were inor alternatively for milder illnesses. 19 Predictors of cluded in the Hawaiian group, since the numuse were familiarity and trust in the healer 11 ,19 and ber of pure Hawaiians was small. There were female genderY We demonstrated that 8.2% of 478 non-Hawaiians, including Caucasian(n = 44), Native Hawaiian adolescents used healers com- Filipino (n = 72), Japanese (n = 92), Mixed/Nonpared to 79.7% who saw a physician or nurse, Hawaiian (n = 255), and Other (n = 15). supporting the finding that indigenous populations tend to use allopathic approaches for most of their Procedures health needs. 14 While studies have examined sociocultural in- Parents/guardians and students were given written fluences on alternative practices among adults, notification of the nature and purpose of the study

226

Complementary Therapies in Medicine

Access

Health Status

Fig. I

Theoretical model predicting healer preference and use.

and were asked to return a post card if they did not wish their child to participate. Students who provided their assent on the day of administration were given the Hawaiian High Schools Health Survey in their homeroom. Teachers read the provided instructions to the students before the survey was distributed. Completion of the questionnaire took approximately 45 minutes. Based on the enrollments during those school years, the estimated response rate was 60% in the five high schools.

Measures All measures were part of the Hawaiian High Schools Health Survey, a self-report questionnaire. The questionnaire asked about demographics, academic performance, mental health, family environment, major life events, family and friends support, and identification with the Hawaiian culture. It was designed to measure the prevalence of psychopathology in a community sample as well as to evaluate the relationships among independent (e.g., gender, ethnicity, age), mediating (e.g., illness, cultural identity, healer availability) and outcome variables (e.g., health-provider preference and use).

Demographic variables Four demographic variables were included: (a) ethnicity (Hawaiian, non-Hawaiian), (b) gender, (c) grade level (9th-12th), and (d) socioeconomic measures. For the socioeconomic measures, participants were asked to mark the response that corresponded to the highest educational level of the main wage earner in their family-(a) less than high-school, (b) high-school graduate or equivalent, (c) some college, and (d) college graduate

or higher. Family income was assessed by asking the source of income of the main wage earner in the family-(a) full-time, (b) self-employment, part-time employment or retirement; and (c) unemployment, welfare, or disability. The education categories were based on the assumption that each increase in level would reflect increased aptitude and subsequently earning potential. Income level cut-offs were chosen to differentiate those who would either be provided free health care due to poverty or through their employers, and those in the middle group who might not be able to afford conventional health care.

Hawaiian cultural identity This term is used to describe individuals who identify with the traditional Hawaiian culture, including Hawaiian customs, beliefs, and practices. This domain included the cultural dimensions from two composite variables, the Hawaiian Culture Scale (see below) and a measure of the importance or value attributed to the Hawaiian culture. Given that different rating scales were used to measure the constructs, the ratings for each variable were converted to z-scores (where the mean = 0.0 and standard deviation = 1.0). An individual's overall Hawaiian cultural identity indicator was the mean of his or her respective z-scores.

Hawaiian culture scale (HeS) This is a newly constructed instrument to measure identification with the Hawaiian culture for adolescents. The HCS has seven subscales: (a) Lifestyles (8 items; traditional lifestyles with particular emphasis on food gathering and preparationa primarily male activity in traditional Hawaiian culture); (b) Customs (II items; spiritual and

227

Native Hawaiian healers

religious traditions and rituals of Hawaiians); (c) Activities (10 items; social gatherings, events, and activities that perpetuate Hawaiian dance, music, sports, and arts); (d) Folklore (5 items; traditional stories and beliefs of Hawaiian mythic heroes, heroines, and superstitions); (e) CauseslLocations (3 items; political causes involving land, water, and fishing rights at three locations on Oahu, the most populated island); (t) Causes/Access (2 items; political causes involving access to the ocean and mountains); (g) Language Proficiency (2 items; understand and speak the Hawaiian language). Students were asked to rate themselves in these areas using a 3-point scale, except for the Language Proficiency factor. 22 In the case of the latter, this 5-point measure was rescaled to a 3-point dimension to coincide with the other subscales. Importance of the Hawaiian culture (value) Students ranked two questions on a 5-point scale: (a) 'How much do you value Hawaiian beliefs, behaviors, and attitudes?' and (b) 'How important is it to you to maintain Hawaiian cultural traditions?' These two questions were among the best singleitem cultural predictors of Hawaiian ethnicity.22 This indicator of Hawaiian values was based on the mean of these two 5-point scales. Mental health Four symptom scales were used to measure mental health: (a) Center for Epidemiologic Studies Depression (CES-D);26 (b) Spielberger StateTrait Anxiety Inventory,27 utilizing only the State subscale; (c) Braver Aggressiveness Dimension Scale;28 and (d) 6 face-valid questions from the Substance Abuse Subtle Screening InventoryAdolescent version. 29 Two questions were also used: (a) 'During the last month, how much has your mental (emotional) health worried or concerned you?' rated on a 5-point scale; and (b) 'When did you last have counselling or any other mental health service?' rated on a 5-point scale. The overall composite mental health score was derived using the mean of the converted z-scores for each of the variables. Correlations between individual items and the composite mental health variable ranged from 0.14 to 0.82, suggesting that individual items represent different, but related, components of mental health. Physical health Physical health comprised three questions rated on a 5-point scale: (a) worry or concern about physical health; (b) comparative health with peers; and (c) absenteeism. Correlations between individual items and the composite physical health variable (which was based on the mean of the respective zscores) ranged from 0.17 to 0.69, suggesting that individual items represent different, but related, components of physical health.

Healer preference Provider preference was determined by asking participants whom they would prefer to see for mental or emotional problems. This question required the participants to choose between a doctor, nurse, Native Hawaiian healer, teacher or school counselor, or minister. Participants were included in the healer preference group if they selected healer for their provider of choice. Those who left the item blank, chose more than one, or selected to see a teacher, counselor, or minister were excluded. Those who chose a physician or a nurse were included in the non-healer group. Healer use Participants were asked how many times they had seen a Native Hawaiian healer in the last six months, using a 5-point scale. Participants were included in the healer use group if they saw a healer at least once.

Statistical analyses Rates of healer preference and use were determined by gender, ethnicity, socioeconomic status and school for Hawaiians, non-Hawaiians, and the combined group using univariate analyses. Multiple logistic analyses were conducted to predict healer preference and use for Hawaiians, nonHawaiians, and the combined group. The first analysis identified the predictors of healer preference. Both individual variables (gender, grade level) and composite variables (Hawaiian cultural identity, mental health and physical health) were used. A second analyzed the individual cultural identity variables separately, to identify the most influential determinants of healer preference. The variables used in determining healer preference were also used in determining healer use. In addition, wage earner's education, wage earner's employment and healer preference were used. All analyses were conducted with SAS version 7.

RESULTS Demographic variables and prevalence rates The sample description is given in Table 1. Hawaiians comprised 63.8% of the study population. Thirty-four percent of Hawaiians and 8.6% ofnon-Hawaiians preferred healers (X 2 [1] = 104.23, P < 0.0001). Of females, 27% preferred healers, compared to 22.3% of males (X 2 [1] = 4.07, P < 0.05). Adolescents whose main wage earners were college graduates were less likely to prefer healers (X 2 [3] = 10.74, P < 0.05). There were no signifiqmt differences by grade level or main wage earner's source of income. Of Hawaiians 13.5% and of non-Hawaiians 3.6%

228 Complementary Therapies in Medicine Table I Demographk data on healer preference and use patterns

Preference

Demographic variable

Level

Ethnicity

Use

N

%

N

%

Hawaiian Non-Hawaiian

285 41

33.8% 8.6%

114 17

13.5% 3.6%

Gender

Male Female

153 172

22.3% 27.1%

74 56

10.8% 8.8%

Grade level

9th 10th 11th 12th

99 86 74 66

25.6% 24.6% 24.4% 23.7%

51 38 19 22

13.2% 10.9% 6.3% 7.9%

Main wage earner's education level

Less than high school High school gradute Some college College graduate

34 9/ 84 95

26.4% 29.9% 27.6% 20.3%

18 36 27 37

14.0% /1.8% 8.9% 7.9%

Main wage earner's employment status

Unemployed. disability, welfare Part-time, retired, self-employed Full-time

28 61 223

36.4% 23.8% 24.7%

8 25 88

10.4% 9.8% 9.8%

used healers (X 2 [1] = 33.85, P < 0.001). Twelve percent of ninth and tenth graders saw healers, compared to only 7% of eleventh and twelfth graders (x 2 [3] = 1O.81,p < 0.05). There were no significant differences by gender or socioeconomic status.

Models for Preference Identification with the Hawaiian culture was the strongest predictor of healer preference for Hawaiians and non-Hawaiians (X 2 [1] = 200.69,PB < 0.001). For non-Hawaiians, mental health (X 2 [1] =7.45,PB < 0.05) was also predictive (see Table 2). Simultaneous multiple logistic regression analysis was used to predict the unique variance ofindividual components of cultural identity. Valuing the Hawaiian culture was the most predictive of healer preference for Hawaiian and non-Hawaiians combined (X 2 [1] = 66.69, PB < 0.001). Folklore was also predictive for Hawaiians (see Table 3).

Models of use Cultural identity was the strongest predictor of healer use (X 2 [1] =46.31,PB < 0.001) among Hawaiian adolescents (see Table 4). Healer preference was also predictive within the Hawaiian group. None of the independent variables were found to be predictive of healer use for the nonHawaiian teens.

DISCUSSION This is the first large-scale, community-based study that examines adolescent preference and use patterns in indigenous healing practices. While

most adolescents in our sample preferred physicians, 24.7% preferred native healers and 9.9% saw a healer within the last six months. As expected, Hawaiian teens preferred and saw healers more than non-Hawaiians (33.8% vs 8.6% and 13.5% vs 3.6%, respectively). Contrary to our hypotheses, there were no gender differences in healer preference and use. There were notable differences in preference and use patterns between Hawaiians and nonHawaiians. For Hawaiians, Hawaiian cultural identity significantly predicts healer preference. The Hawaiian culture, like Hawaiian healing, is strongly rooted in spirituality and the connection between the mind, body and soul. 30 It is no surprise then that those who are strongly rooted in the culture are more likely to prefer Hawaiian healing that is holistic over allopathic medicine that tends to be more disease oriented. Of all the cultural identity variables, valuing the Hawaiian culture and folklore were the only significant predictors. Contrary to our hypothesis, participation and/or knowledge of the Hawaiian culture were not predictive. This may reflect the renewed appreciation of the Hawaiian culture that characterized the Hawaiian renaissance that began in the 1960s. Despite the interest in the culture, traditional customs may not be as much a part of a teen's modem lifestyle due to the denigration of Hawaiian beliefs, practices and religious rituals that occurred in the past. As a result, adolescents may typically learn about Hawaiian folklore; however, they may not participate in traditional customs. These customs may have been more prevalent in Hawaiian civilization prior to Western contact, or are in present times taught and practiced in early adulthood, as opposed to adolescence. In terms of healer use, Hawaiian cultural identity and healer preference were predictive for

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1.64 0.18 0.18 -0.04

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0.96 0.92

110.85*** 1.82 1.68

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X2 (1)

2.33 1.31 1.06

7.39 0.83

Odds ratio

Non-Hawaiians

1.27-4.27 .62-2.81 .77-1.47

3.71-14.72 .45-1.51

Odds ratio 95%CI

0.88 0.22 0.53

Hawaiian values Lifestyles Customs Activities Folklore Causes/location Causes/access Language Total model (df = 8)

*Ps < 0.05; **PS < 0.01; ***PS < 0.001.

0.17

0.64 -0.06 0,04

om

(3

PREDICTOR

Odds ratio 2.41 1.25 1.70 1.01 1.89 0.94 1.04 1.19

X2 (1)

49.26***

1.96 4.19 0.00 9.39*

0.12 0.07 2.30 190.76***

Hawaiians

1.02-2.82 .62-1.62 1.26-2.84 .68-1.31 .78-1.38 .95-1.49

1.88-3.08 .92-1.71

Odds ratio 95%CI 0.87 -0.45 0.80 0.39 0.61 0.58 0.27 0.31

(3

1.27 1.64 0.51 1.79 1.75 0.90 0.98 68.62***

13.38**

X2 (1)

2.39 0.64 2.22 1.48 1.84 1.79 1.31 1.36

Odds ratio

Non-Hawaiians

.74-2.51

1.50-3.82 .29-1.39 .65-7.57 .51-4.30 .75-4.49 .76-4.23 .75-2.28

Odds ratio 95%CI

Table 3 Influence of cultural id¢ntity variables on healer preference by ethnidty using multiple logisti¢l"¢gression analyll¢s

*PS < 0.05; **PS < 0.01; ***Ps < 0.001.

Cultural identity Physical health Mental health Gender Grade level Total model (df= 5)

PREDICTOR

Odds ratio

Hawaiians

Table 2 Predictors of adolescent healer preference by ethnidty

0.03 0.07 0.21

0.13 0.60 0.17 0.63

0.89

(3

0.29 0.00 -0.06

1.84 0.13

(3

0.04 0.31 4.08 361.10***

6.32 0.59 11.16**

0.77

66.69***

X2 (1)

5.41 0.00 0.79 323.39***

200.69*** 1.15

X2 (1)

2.43 1.14 1.82 1.18 1.87 1.03 1.07 1.24

Odds ratio

Combined

1.00 0.94

6.30 1.14 1.34

Odds ratio

Combined

1.30-2.71 .76-1.40 .84-1.38 1.01-1.53

1.14-2.89 .77-1.81

1.96-3.06 .85-1.51

Odds ratio 95%CI

4.89-8.13 .90-1.44 1.05-1.71 .75-1.35 .83-1.07

Odds ratio 95%CI

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Hawaiians. Gender, grade level, health status and socioeconomic status dId not predict healer use. For non-Hawaiians, Hawaiian cultural identity and mental health were predictive of healer preference. Valuing the Hawaiian culture was the only significant predictor of all the cultural identity variables. As mentioned above, the Hawaiian culture supports a holistic and spiritual approach towards health and wellness. Thus the finding that non-Hawaiians who identify with and value the Hawaiian culture also prefer Hawaiian healing, a form of alternative medicine, is not surprising and supported by the literature (8, 12-13, 31). Hawaiian healing and other alternative medicine may appeal to individuals, regardless of ethnicity, who are dissatisfied with allopathic medicine. Native Hawaiian healing may be efficacious in treating certain chronic and psychosomatic illnesses that do not respond well to allopathic approaches. Surprisingly, no predictors of healer use among non-Hawaiians were identified in this study. There were substantially fewer non-Hawaiians compared to Hawaiians that preferred and used healers. Perhaps the numbers were too small to reach significance. In addition, the fact that these non-Hawaiian families decide to live in these Native Hawaiian communities makes them a unique population, and other factors may influence their healer use. For example, peers or families living nearby may have connections to Native Hawaiian healers and may refer these individuals to them. As a result, access may be more important than the predictors that were used in this study. It will be important to look into this issue further, since the adult literature suggests that the appeal of alternative healing practices crosses ethnic groups. There are study limitations that require consideration. Schools located in communities with large numbers of Hawaiians were chosen to ensure adequate Hawaiians and may not reflect the general population of adolescents in Hawai'i. Additionally, standardized measures of socioeconomic status were not used, and it is difficult to generalize the findings to other populations. Healer use was a forced-choice question, and therefore complementary use of a Hawaiian healer and physician could not be determined. This is important since complementary use ofHawaiian healing may be more common than exclusive use of Hawaiian healers, and because of the recent interest in the integration ofallopathic and alternative healing practices. Finally, although our theoretical model implies that cultural identity predicts healer preference, which in tum predicts healer use, it is just as likely that healer use impacts one's cultural identity and healer preference. In actuality, all these factors most likely affect each other bidirectionally and causality would be very difficult to discern. Despite these limitations, these findings contribute to the existing knowledge base on the impact of ethnicity, culture, gender, illness,

Native Hawaiian healers

and access on alternative medicine preference and use in an understudied ethnic minority adolescent population. This community-based study demonstrates the importance of cultural identity in seeking alternative care in multi-ethnic adolescents. Having a value system that is congruent to those typified by alternative practices is important in determining preference and use of alternative healing practices. Further studies are needed to assess the efficacy of alternative and complementary approaches in treating illnesses in both ethnic majority and minority adolescents, especially for illnesses that have not responded well to allopathic medicine. ACKNOVVLEDGEMENTS The authors wish to thank: Nanette Judd, PhD, Patrice ML Tim Sing, MD, Marie Place, Anita Arce, the other researchers and staff of the Native Hawaiian Mental Health Research Development Program (NHMHRDP), and the Native Hawaiian Center of Excellence.

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