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Assessment and Priorities
for the Health and Well-Being
in Native Hawaiians and
Pacic Islanders
Department of Native Hawaiian Health
John A. Burns School of Medicine
University of Hawai‘i at Mānoa
2020
Assessment and Priorities for the Health and Well-Being
in Native Hawaiians and Pacific Islanders, 2020
Mele A. Look
Shelley Soong
J. Keawe’aimoku Kaholokula
© 2020 University of Hawai‘i, John A. Burns School of Medicine,
Department of Native Hawaiian Health
All rights reserved.
All inquiries should be addressed to:
Department of Native Hawaiian Health
University of Hawai‘i, John A. Burns School of Medicine
677 Ala Moana Blvd., Suite 1015
Honolulu, Hawai‘i 96813
Electronic copies of this report can be found at:
https://bit.ly/3cka5BK
Recommended citation:
Look, M.A., Soong S., Kaholokula, J.K. (2020). Assessment and Priorities
for Health and Well-Being in Native Hawaiians and Pacific Islanders.
Honolulu, HI. Department of Native Hawaiian Health,
John A. Burns School of Medicine, University of Hawai‘i.
Several institutions and individuals contributed illustrations to this
assessment. Photograph of Kamehameha Day March (2016) on cover
by Cindy Ellen Russell used with permission from Honolulu Star-
Advertiser; all rights reserved. Photograph of Queen Emma on cover
used with permission by Hawaii State Archives; all rights reserved.
Paintings Poi Pounder and Medicine Man on inside cover, and Tar o
Farmer on page 5 by Herb Kane used with permission by Herb K. Kane
LLC., which holds the copyright; all rights reserved. Death of Captain
Cook painting by John Cleveley (ca. 1784) on page 7 courtesy of
Collection of the Honolulu Museum of Art. Gift of Frances Damon
Holt in memory of John Dominis Holt, 1997 (26,262); all rights reserved.
Photograph of ‘Iolani Palace provisional government (1893) on page 7
courtesy of Hawaii State Archives; all rights reserved. Photograph on
page 8 KN-11352 Operation “Sailor Hat” (1965) courtesy of Naval
History and Heritage Command, Washington, DC. Photograph of
Centennial of U.S. Armed Invasion (1993) on page 8 by Bruce Asato,
courtesy of Honolulu Advertiser.
Design by Sara Saffery Design
Printed in Hawai‘i
CONTENTS
Preface
Introduction
Chapter 1: e Beginning of Inequity
Chapter 2: Health Inequities and Disparities
Coronary Heart Disease
Cancer
Cerebrovascular Disease (Stroke)
Diabetes
Other Chronic Diseases
Behavioral Health
Social Determinates of Health
COVID-19 Pandemic
Chapter 3: Striving for Health Equity
Nā Pou Kihi - e Corner Posts, A Hawaiian Framework for
Achieving Social and Health Equity
Culturally-relevant Programs
Culturally-adapted Programs
Culturally-grounded Programs
Promising Programs
Chapter 4: Recommendations
References
Mahalo and Acknowledgments
2
3
5
9
15
18
21
27
31
35
39
41
15
15
15
29
32
37
E ALA Ē
E ala ē, ka lā i ka hikina
I ka moana, ka moana hōhonu
Pi‘i i ka lewa, ka lewa nu‘u
I ka hikina, aia ka lā, e ala ē!
AWAKEN
Awaken, the sun in the east
From the ocean, the ocean deep
Climbing (to) the heaven, the heaven highest
In the east, there is the sun, Awaken!
2
PREFACE
his report is an update of the well-received Assessment and Priorities for Health and
Well-Being of Native Hawaiians and Pacific Peoples published in 2013. We, at the
University of Hawai‘i, John A. Burns School of Medicine, Department of Native Hawaiian
Health, together with the Queen’s Health Systems, have collaborated once again to provide
an updated broad summary of the health status and priorities of our Native Hawaiian and Pacic
Islander communities to enable community leaders, policymakers, academic institutions, and
other stakeholders make meaningful decisions and take informed actions.
Community leaders and organizations serving Native Hawaiians and Pacic Islanders (NHPI) have
shared with us that the 2013 report was particularly useful in explaining the causes and solutions
to health disparities to funders, researchers, clinicians, policymakers, and the leadership of our
healthcare systems. ey specically requested the addition of historical background information
to deepen the understanding of the root causes of health inequities. In addition to providing a
historical background in this report, we also assess the present health and well-being of NHPI and
describe current health inequities from the most current scientic papers and data sources. We also
share leading-edge, evidence-based solutions found in culturally-responsive programs and
approaches with a demonstrated appeal to NHPI communities, families, and individuals. In
conclusion, we oer recommendations and best practices for continuing work toward health equity.
T
3 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
Native Hawaiians remain an intelligent, vibrant, resilient, and united people, despite 127 years of occupation by the
United States.1,2 Throughout the Pacific, Island nations have endured and thrived in face of colonization, and
environmental destruction from foreign countries. But how has United States (U.S.) and other foreign intrusion
affected health? And how are Native Hawaiians and Pacific Islanders (NHPI) defined for health-related data
collection, analysis, and reporting?
Federal agencies frequently combine NHPI for the reporting and tracking of health-related data. Native Hawaiians continually
are the largest part of this group in the U.S. at 43 percent.3 NHPI is the fastest-growing racial/ethnic group in the nation.
Source: Hixson, Hepler, & Kim, 2012; U.S. Census 2018.
Figure 1: NHPI Population Changes, 2000–2018
1600000
1400000
1200000
1000000
800000
600000
400000
200000
0
2000
874,414
1.2 Million
1.5 Million
2010 2018
KEY POINTS
▶ THE PEOPLE
The population groups included as Native
Hawaiians and Pacic Islanders are all from
the Pacic Basin and include the three
main subregions of Polynesia, Micronesia,
and Melanesia.
▶ THE HISTORY
Since the arrival of Westerners to the
Hawaiian Islands two centuries ago, there
have been great disparities in health status
between Native Hawaiians and the U.S.
population.
▶ THE SITUATION TODAY
Scientists, clinicians, and scholars trace
the inequitable health status to several
complex and interconnected social determi-
nants of health, including historical trauma,
discrimination, and lifestyle changes.
INTRODUCTION
Introduction 4
Ho‘o moe wai kahi ke kao‘o
Let all travel together like water owing in one direction
The population groups included as NHPI are all from the
Pacific Basin and include the three main subregions of
Polynesia, Micronesia, and Melanesia. e largest Polynesian
groups are Native Hawaiians, Samoans, and Tongans.
The main groups from the Micronesian region include
Marshallese, Palauans, Chamorro, and Guamanians.
Fijians are among the Melanesians included as NHPI.
Although they share similar deep ancestry, each of these
Pacific Islander groups is culturally distinct in language,
histories, customs, and relationships with the United States.
This report focus is on Native Hawaiians,
the Indigenous people of Hawai‘i, who
continue to bear a disproportionate health
burden than overall racial and ethnic
populations.4
We acknowledge Hawaiians as their own race/ethnicity
and use the racial/ethnic label of “Native Hawaiian” and
“Hawaiian” interchangeably in this report. When available,
information for other Pacic Islanders is included either as
combined or separate categories.
Since the arrival of Westerners to the Hawaiian Islands two
centuries ago, there have been great disparities in health
status between Native Hawaiians and the U.S. population.
Historically, initial disparities arose from infectious disease
epidemics, such as smallpox, measles, and cholera. In
contemporary times the burden of health disparities comes
from chronic diseases, such as obesity, diabetes, and cardio-
vascular disease,4 and higher mortality rates due to cancer,
stroke, and diabetes.6,7
As with other racial and ethnic groups in the U.S. (e.g., Amer-
ican Indians and Alaska Natives, African Americans, and
Hispanics), and despite decades of federal and state initiatives
to achieve health equity,7,8 Native Hawaiians still experience
substantial health disparities.
What is the cause of these relentless disparities? Scientists,
clinicians, and other scholars trace the inequitable health
status to several complex and interconnected social deter-
minants of health, including historical trauma, discrimina-
tion, and lifestyle changes.9,10
What is historical trauma? Researchers have suggested that
Indigenous populations, particularly when they become a
minority population in their homeland, suer and endure
long-term negative effects from past blatant attempts to
eradicate their ancestors and way of life, remove them from
their ancestral lands, and enact compulsory and discrimina-
tory assimilation policies and strategies. Many of the past
transgressions and discriminatory practices have been insti-
tutionalized as structural racism in our current systems. Not
to mention the interpersonal racism that many Indigenous
communities endure regularly. Thus, historical trauma is
essentially a type of psychological wounding that can be
transmitted from one generation to the next and relived by
Indigenous peoples in both narrative forms and the lived
experiences of racism.11,12 e problems associated with his-
torical trauma are made worse by socioeconomic (e.g., hous-
ing, educational, and occupational disadvantages) and socio-
cultural challenges (i.e., ability to preserve cultural practices
and protect cultural and natural resources).13
To understand Native Hawaiian health,
it is important to understand the broader
historical and sociopolitical events and
contexts that have led to them. We rst
provide a post-Western contact historical over-
view of Native Hawaiians, because
this story is often overlooked in U.S. history
and is thus unfamiliar to many, especially
as it relates to achieving health equity. ◀
5 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
THE BEGINNINGS OF INEQUITY CHAPTER 1
It is estimated that when the British explorer Captain
James Cook first arrived in Hawai‘i in 1778, the native
population size was between 300,000 to 700,000.14-16
Writings by Cook and his officers, which marked
the start of sustained Western contact with Hawai‘i,
describe a vibrant and robust people who were physically,
emotionally, and spiritually healthy.17
KEY POINTS
▶ FOREIGN DISEASES
The inux of European, Ameri-
can, and Asian foreigners to
the islands resulted in a wave
of infectious disease epidemics.
Throughout most of the 1800s,
Hawai‘i was hit hard by cholera,
inuenza, mumps, measles,
whooping cough, and smallpox.
▶ THE OVERTHROW OF THE
MONARCHY
In 1893, a group of American
businessmen and mission-
ary descendants, forcefully
removed the reigning monarch
Queen Lili‘uokalani with the
backing of U.S. military.
▶ NATIVE HAWAIIAN HEALTH
CARE IMPROVEMENT ACT OF
1988
The Native Hawaiian Health
Care Improvement Act of
1988 was enacted after nearly
two decades of advocacy and
research documenting the
signicant health inequities
experienced by Native
Hawaiians.
Chapter 1: The Beginnings of Inequity 6
Everyday life in Hawai‘i up to this point was governed
by a system based on the notions of kapu (people,
places, and things held under strict regulation) and
noa (people, places, and things free of restriction).
It was essentially a resource management and public health
system that governed how land and ocean resources were
accessed and used as well as how people behaved, lived, and
treated others. A system that allowed for a well-ordered
communal society; a well-balanced, nutritious diet; and an
active lifestyle for holistic wellness and disease prevention.18,19
All that contributed to the overall health and well-being of
the native population as a people.
FOREIGN DISEASES
is system and the overall health and well-being of the native
population drastically changed following their contact with
Westerner settlers. Over the ensuing decades, the inux of
European, American, and Asian foreigners to the islands
brought with them waves of infectious disease epidemics.18
Throughout most of the 1800s, Hawai‘i was hit hard by
cholera, inuenza, mumps, measles, whooping cough, and
smallpox to name a few. Most aected were the native pop-
ulation who had no natural immunity to ward off these
diseases. ese epidemics decimated the Hawaiian popula-
tion such that by the late-1800s, the native population had
plummeted to about 30,000.14,18
LOSS OF LAND
While these epidemics were happening, Native Hawaiians
and their ali‘i (governing body) were beginning to lose
control over their government, lands, and businesses to
foreign inuence and interests. e Great Māhele of 1848 is
an example of the loss of control over land when an alien
concept of land privatization was introduced.18 is system,
pushed by foreign settlers, was entirely at odds with the
traditional and ancestral relationship Native Hawaiians have
with the land, which le many Native Hawaiians landless.20
Policies, such as e Great Māhele, were more about American
interests and the means to disenfranchise Native Hawaiians
from their ancestral lands, customary practices, and tradi-
tional economic systems.18 All of which have had deep and
lasting repercussions. Native political and economic control
was undermined as American culture and social policies
based on the preferences of conservative Puritan Christian
missionaries moved to the forefront. Also foundational to the
traumatization was that Hawaiian language and Hawaiian
cultural practices were deemed “primitive,” and oen “im-
moral” and the English language increasingly and ocially
replaced the Hawaiian language.21,22
Pilikia ho‘i kau a lohe mai
Troubles that [do not] hear
0
200000
400000
600000
800000
1000000
1200000
1400000
123 45
Population (thousands)
Other
Japanes e
Filip ino
Chine se
White
Hawaiian
Year
1778
1893-1898 2012
1400000
1200000
1000000
800000
600000
400000
200000
0
Other
Japanese
Filipino
Chinese
White
Hawaiian
1778 1893-1898 2012
Figure 2: Population estimates in Hawaiʻi, 1778-2012
Source: Bushnell, 1993; Stannard, 1989;
Nordyke, 1989; Hawai‘i DOH, 2020; Soong 2020
Population (thousands)
Year
7 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
INFLUX IN IMMIGRATION
From the mid-1800s to the early 1900s, foreign laborers from
China, Japan, Korea, and the Philippines were hired to work
in the plantation industries that dominated the islands.
Foreign laborers were needed because of the signicant native
population decline, but also because of Native Hawaiians’
disapproval of working on sugar plantations built upon
sacred ancestral lands. By the beginning of the 1900s, Amer-
ican and European foreigners and Asian laborers had over-
taken the native population, reducing them to minority
status in their homeland.18
THE OVERTHROW
e illegal overthrow of the Hawaiian nation in 1893 was the
culmination of the aforementioned events. In 1893, a group
of American businessmen and missionary descendants force-
fully removed the reigning monarch Queen Lili‘uokalani with
the backing of the U.S. military. e U.S. government’s initial
concern over its involvement gave way to political and mili-
tary interests in the strategic position of the islands and
extending U.S. inuence into the Pacic. e U.S. ignored
and suppressed the expressed opposition of the Hawaiian
nation’s citizens to the loss of independence. In fact, a petition
signed by 95 percent of the Native Hawaiian population
rejected annexation to the U.S.23 With the annexation to the
U.S. in 1898, the U.S. took without compensation 1.8 million
acres of the Hawaiian government and crown lands of the
mo nar chy. 18 Hawai‘i was designated a territory and by 1959,
the 50th state in the U.S.
THE HAWAIIAN RE-AWAKENING
e 1960s and 1970s saw a period of cultural awakening and
the revitalization of Hawaiian identity oen referred to as the
“Hawaiian Renaissance.” It was a momentous and vital
chapter of modern Hawaiian history, which included a
revival of traditional Hawaiian music, dance, language, and
ocean canoe voyaging, as well as political activism that sought
to bring about the re-evaluation of land use policies,
sovereignty, social justice and equity.24 One momentous
achievement from the period was grassroots activism that
brought an end to U.S. military bombing and control of
Kaho‘olawe, the eighth largest island of Hawai‘i.25 Notable
Native Hawaiian physician and health researcher, Dr. Emmett
Noa Aluli, was one of these early activists. He began his
involvement in protecting Native Hawaiian environmental
and health rights during his medical training on the rural
island of Moloka‘i in the 1970’s and it solidied as a lifelong
commitment. When describing Native Hawaiian health
equity, he is oen quoted as saying:
e health of
the land is the
health of the
people.
—Dr. Emmett Noa Aluli
HEALTHCARE IMPROVEMENTS
There were significant policy milestones during this
period to move toward equity between Native Hawaiians and
other populations, particularly in the areas of health,
education, and political self-determination. Of considerable
importance is the Native Hawaiian Health Care Improvement
Act of 1988, which was enacted aer nearly two decades of
advocacy and research documenting the signicant health
inequities experienced by Native Hawaiians.
Chapter 1: The Beginnings of Inequity 8
A seminal report, E Ola Mau: e Native Hawaiian Needs
Study identied four key ndings:
1) Signicant disparity in rates of chronic disease.
2) Poor access to health services.
3) Shortage of Hawaiians as health professionals.
4) Preferences for culturally relevant programs and services.26,27
e Native Hawaiian Health Care Systems on the islands of
Hawai‘i, Maui, Moloka‘i, O‘ahu, and Kaua‘i, and their orga-
nizing entity Papa Ola Lokahi, were established under the
federal Act, as was a health professional scholarship program
for Native Hawaiians.26,27 At approximately the same time,
aer inequities in Native Hawaiian education achievements
were documented, federal legislation established the Native
Hawaiian Education Council, which provided funding for
various education-related endeavors, including Hawaiian
language immersion schools and culturally relevant educa-
tional curriculum.
APOLOGY RESOLUTION
In 1993, 100 years aer its illegal action, the U.S. Congress
passed a resolution that acknowledged and apologized for
the U.S. involvement of the unlawful overthrow of the right-
ful government of the Kingdom of Hawai‘i, the resolution
also acknowledged the devastating eects Hawai‘i’s historical
experiences had on the Hawaiian people. As noted by
Mokuau et al.22:
Although the overthrow of the Kingdom of Hawai‘i occurred
more than a century ago, historical loss of population, land,
culture, and self-identity have shaped the economic and
psychosocial landscapes of Hawai‘i’s people, and limits their
ability to actualize optimal health.
ACCESS TO EDUCATION AND ECONOMIC OPPORTUNITY
Similar to the Kingdom of Hawai‘i, other Pacific Island
nations came under control of foreign powers in the 1800s
and 1900s.28 To access educational and economic opportu-
nities, Pacic Islanders from these nations began emigra-
ting to Hawai‘i and the continental U.S. Samoans, for
example, emigrated from Sāmoa and American Sāmoa
(an incorporated territory of the U.S. since 1900) for agricul-
tural and factory work. Chamorro people/Guamanians
emigrated from the Northern Mariana Islands and Guam
(a territory of the U.S. since 1898).
MILITARY DESTRUCTION
From 1946 to 1958, the U.S. issued numerous destructive
nuclear weapons tests in the Pacic, specically the Marshall
Islands and Bikini and Enewetak Atolls, causing loss of life,
health, land, and resources.29 As a result of this devastation,
the U.S. attempted to “compensate” these Pacific Island
nations for killing their people and land through the
Compact of Free Association Act of 1985 (COFA). COFA,
a series of treaties between the U.S., the Federated States
of Micronesia, the Republic of Palau, and the Republic of
the Marshall Islands, allowed the U.S. exclusive military
access to these Pacic Island nations in exchange for provid-
ing them with health and education opportunities. The
U.S. government, however, has often not lived up to their
agreements under COFA. Medicaid coverage for many of
these Pacific Islanders has been revoked30, and military
occupation and damage from radiation, continues to disrupt
Micronesia’s traditional lifestyle leading to detrimental
chronic diseases.31,32 ◀
9 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
KEY POINTS
▶ CHRONIC DISEASES
Native Hawaiians continue to
see the onset of those chronic
diseases a decade earlier with
rates that are disturbingly three
times higher than overall
Hawai‘i State rates.
▶ DIABETES
In 2015, NHPI were 3.32
times more likely to die from
diabetes than the overall
Hawai‘i population.
▶ EDUCATION PROGRAMS
Diabetes education programs
have been one successful
approach to address diabetes
disparities and important
accomplishments have been
made in reaching Hawaiians.
▶ WEIGHT-RELATED DISEASE
Being overweight or obese are
major risk factors for cardiovas-
cular disease, hypertension,
diabetes, cancer, high blood
cholesterol, and sleep apnea.
HEALTH INEQUITIES AND DISPARITIES CHAPTER 2
As with other Indigenous U.S. populations, Native Hawaiians have a disturbingly higher rate of chronic diseases
than many other ethnic groups and the general population in Hawai‘i and the larger U.S.8,33 While the leading causes
of death are generally the same, the rates of Native Hawaiians aicted with chronic diseases are greater and occur a
decade earlier. ese rates are disturbingly three times greater than for the general population of Hawai‘i. is is
reected in the dierences in racial and ethnic longevity evident in past decades, a trend that persists. Compared to other racial
and ethnic groups in Hawai‘i, Native Hawaiians have the shortest life expectancy. Presented here are the leading causes of
death among NHPI and health conditions with dire disparity.
Figure 3. Leading Causes of Death for NHPI, 2015
05 0 100 150 200 250 300 350 400
Diabetes
Cancer
Congestive Heart Failure
Stroke
Coronary Heart Disease
Rates per 100,000
2.64 times higher
3.65 times higher
3.44 times higher
3.32 times higher
Overall State
of Hawai‘i
NHPI
1.96 times higher
Data Source: Hawai‘i DOH, 2020; Soong, 2020
Chapter 2: Health Inequities and Disparities 10
Chronic Diseases
CORONARY HEART DISEASE
Coronary heart disease is the most common type of cardio-
vascular disease and is the leading cause of death in the U.S.,
Hawai‘i, and among NHPI.6,33,35
Among ethnic and racial groups in Hawai‘i, the NHPI
coronary heart disease death rate was the highest (240.4 per
100,000 pop.), 2.64 times higher than the overall popula-
tion (66.1 per 100,000).
e NHPI mortality rate for congestive heart failure was also
the highest (63.9 per 100,000), 3.44 times higher than the
overall State of Hawai‘i population (14.4 per 100,000).
In Hawai‘i, compared to all other groups, Native Hawaiians
have the highest rates of the major behavioral risk factors
for heart disease, including unhealthy diet, physical inactiv-
ity, alcohol abuse, and tobacco use.
CANCER
Cancer is also a leading cause of death for Hawaiians. NHPI
have higher overall cancer death rates at 389.2 per 100,000,
more than any other group in Hawai‘i, and 1.96 times higher
than the overall population (131.4 per 100,000 pop.).
More NHPI die of specic cancer than any other racial or
ethnic group in the state; these cancers include colon,
lung, prostate, liver or bile duct, oropharyngeal, and breast
cancer.
Hawai‘i’s breast cancer death rate for NHPI women was 2.90
times higher than the overall population, the highest than
any other group (72.9 per 100,000 pop.), and Native Hawaiian
women have the lowest ve-year cancer survivorship than
the overall Hawai‘i population.
NHPI also have signicantly higher secondary admission
rates for endometrial cancer following hysterectomy com-
pared to other racial/ethnic groups.
What accounts for these cancer disparities? Health care
scientists and scholars identify many reasons for Native
Hawaiian health disparities including lack of culturally
appropriate interventions, late detection, diagnoses at more
advanced stages, genetic markers of tumor aggressiveness,
and a high prevalence of tobacco use.38,39
CEREBROVASCULAR DISEASE (STROKE)
Stroke is another leading cause of death for Native Hawaiians.
e stroke mortality rate for NHPI in 2015 (127.5 per 100,000
pop.) was higher than any other group in Hawai‘i, and 3.65
times higher than the overall population (37.4 per 100,000
pop.). At stroke onset, NHPI are younger—by approximate-
ly 10 years, and have a higher prevalence of stroke risk factors
such as diabetes, obesity, and hypertension, than Whites.
DIABETES
Another perilous area of large disparity is diabetes. In 2015,
NHPI were 3.32 times more likely to die from diabetes than
the overall Hawai‘i population.
In an age-adjusted comparison, approximately 62 NHPI
per 100,000 pop. die from diabetes, compared to 8 Whites,
13 Asians, and 14 people in the State overall.
e most common diabetes is Type 2 diabetes, and in Hawai‘i,
Hawaiians have a higher prevalence of Type 2 diabetes
compared to Whites and Japanese.
NHPI also have more complications related to diabetes. For
example, compared to other groups, NHPI have the highest
occurrence of chronic kidney disease and are most likely
to have end-stage renal disease induced by diabetes.
Native Hawaiians discharged with a diabetes diagnosis
had the second-highest number of lower-extremity amputa-
tions, with amputations occurring at a younger age.
Preventable hospitalization rates due to diabetes are also
signicantly higher for Hawaiian males as compared to White
males, even after adjusting for ethnicity-related rates of
diabetes and other demographic factors.
Diabetes education programs have
been one successful approach to address
diabetes disparities and important accom-
plishments have been made in reaching
Hawaiians. Native Hawaiians are more
likely to receive formal diabetes education
(74%) than the overall population (57%).33
11 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
Other Chronic Diseases
OBESITY
Being overweight or obese are major risk factors for cardio-
vascular disease, hypertension, diabetes, cancer, high blood
cholesterol, and sleep apnea. ese diseases, which oen
come on before age 60, are widespread among the Native
Hawaiian population.
Native Hawaiians (43%) and other Pacic Islanders (54%)
have the highest prevalence of obesity (dened as BMI ≥30)
in Hawai‘i compared to White (21%), Chinese (13%), Filipino
(19 %), and Japanese (19%).33
NHPI teens and young adults in Hawai‘i also follow this trend
in obesity disparities. Teens who are Native Hawaiian (19%)
or another Pacic Islander (44%) have the highest prevalence
of obesity compared to Japanese (5%), White (7%), Filipino
(15%), and the overall Hawai‘i teen population (14%).33
A 2012 study that examined obesity among 18- to 24-year-
olds in rural Hawai‘i determined 30% of NHPI young adults
were obese, compared to just 10% of Asians and 9%
of Whites.46
ASTHMA
More Native Hawaiians, both men and women, have asthma
than any other group in the state.36 In 2009, about one in four
Hawaiian children had asthma (25%), compared to the state-
wide average of 17%.47 Smoking is a risk factor for asthma,
and more Native Hawaiian males are current smokers (21%)
than overall males throughout the state (17%).36
Behavioral Health
Native Hawaiians have among the highest incidences of
behavioral health problems of all racial and ethnic groups in
the U.S. ese behavioral health problems include depres-
sion,48 anxiety,49 suicide,50 substance use,51 family adversity
(e.g., family disruption, family criminality, and poor family
health),52 adverse childhood experiences,53 and serious psy-
chological distress.8
Native Hawaiians also report more trauma (such as depres-
sion, anxiety, post-traumatic stress disorder, and sleep distur-
bances) resulting from accidents and abuse throughout their
life than do other racial/ethnic groups in the state.54
Native Hawaiians living in Hawai‘i have a higher prevalence
of depression (13%) than the state’s overall population (8%).48
Suicide,55 substance use,56 and aggression57 are associated with
Figure 4. People with Diabetes who Received Diabetes Education by Race/Ethnicity in Hawaii, 2016
Race/Ethnicity
People with diabetes who receive formal diabetes education
Percent (%)
Native Hawaiian 74.2
60.8
43.9
White
Japanese
Filipino
Overall
Source: Hawai‘i DOH, 2020
57.8
57.4
Chapter 2: Health Inequities and Disparities 12
depression in Native Hawaiians. The overall suicide rate
among Native Hawaiians ages 15–44 is the highest compared
to all of Hawai'i's major ethnic groups.47
Social Determinate of Health
Social determinants of health are the conditions in which
people are born, grow, live, play, work, and age.58 Social
determinants of health include factors like socioeconomic
status, education level, neighborhood and physical environ-
ment, employment, social support, access to health care.
Among the most challenging social determinants of health
for Native Hawaiians are education, economic well-being,
and crime/incarceration.
Education
In 2017, the Oce of Hawaiian Aairs (OHA) reported that
fewer Native Hawaiian students (compared to non-Hawaiian
students) were procient in reading, math, and science on
the Hawai‘i Department of Education’s Standardized Educa-
tional Achievement Test.36 According to a 2014 report by
Kamehameha Schools, Hawaiians in the public school system
had the lowest rates of timely graduation of all major ethnic
groups in Hawai‘i.47 In the same year, they also reported that,
compared to other groups in Hawai‘i, Native Hawaiians were
the least likely to be enrolled in college and attain a bachelor’s
degree.47
Economic Well-Being
Native Hawaiians had the highest rates of using public assis-
tance and homeless services, and the highest rate of poverty
among Hawai‘i’s major ethnic groups.47 Also, Native
Hawaiians had the highest unemployment rate among major
ethnic groups in the state,47 and had lower average annual
earnings than statewide averages for both males and
females.59
Crime Incarceration
Native Hawaiians’ arrest rates for violent crime, aggravated
assault, robbery, and drug manufacturing or sales are higher
than statewide averages.47 Native Hawaiians are also overrep-
resented in Hawai‘i’s prison population. For example, in 2012,
when Native Hawaiians made up only about 18% of Hawai‘i’s
total adult population, they accounted for 43% of the state’s
female prison population and 36% of the state’s male prison
population.59
Figure 5. Adults Who Are Obese (BMI ≥ 30) in Hawai‘i by Race/Ethnicity, 2015
54.1
21.1 18.8 18.8
23.8
Percent (%)
Race/Ethnicity
Other Pacic
Islanders
Hawaiian White Japanese Filipino Chinese Overall
60
45
30
15
0
Source: Hawai‘i DOH, 2020
42.7
12.5
13 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
COVID-19 Pandemic
e COVID-19 pandemic has brought another layer of health
inequities for NHPI. e eects of COVID-19 on the health
of NHPI is still emerging; however, current data suggest a
disproportionate burden of illness among NHPI residing on
the continent compared to other racial and ethnic groups.
High rates of pre-existing chronic diseases (e.g., cardio-
vascular disease, cancer, diabetes) make NHPI especially
vulnerable in public health emergencies like the current
COVID-19 outbreak. Because of these existing health
disparities, NHPI are faced with a higher chance of severe
symptoms and hospitalization due to COVID-19 than other
racial and ethnic groups.
Behavioral health issues among NHPI due to COVID-19 has
also become an increasing concern. e negative psycho-
social eects of shelter in place and social distancing mea-
sures adds to the preexisting behavioral health issues among
NHPI. ese eects include depression, anxiety, stress, and
an increase in harmful behavior to self and others (e.g., sui-
cidal behaviors and interpersonal violence).
Health dierences between NHPI and other racial and ethnic
groups are often attributed to socioeconomic-related
vulnerabilities that are more common among NHPI than
other racial and ethnic groups. In public health emergencies
such as COVID-19, these vulnerabilities can also create a
barrier for NHPI to access the resources they need to prepare
for and respond to such a pandemic.60 For example, NHPI
are more likely than other racial and ethnic groups in
Hawai‘i to live in large multi-generational households and
densely populated neighborhoods. Also, almost 1 in 4 Native
Hawaiians work in essential jobs (e.g., service-related indus-
try, healthcare, security, military).
The best way to prevent COVID-19 infection is to avoid
being exposed to the virus, however, these factors places
NHPI in direct and frequent face-to-face contact with
many other people, and increases chance of exposure to
COVID-19. ◀
Source: Haynes et al. Circulation. At the Heart of the Matter, Volume: 142, Issue: 2,
Pages: 105-107, DOI: (10.1161/CIRCULATIONAHA.120.048126). © 2020 American Heart Association, Inc.
Figure 6. Coronavirus (COVID-19) Health Disparities and Solutions,60 2020
15 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
STRIVING FOR HEALTH EQUITY CHAPTER 3
Because Native Hawaiians, as a group, experience
signicant health disparities, it is imperative that
we work expeditiously toward health equity. From
a Western lens, “health equity” is oen understood
as simply the absence of systematic disparities in health
between dierent racial/ethnic groups.61 A Native Hawaiian
way of thinking about health equity is quite dierent.62
The Hawaiian worldview of individual
health is inclusive of physical, spiritual,
emotional, and mental spheres.63,64
On a macro-level, community health
is closely associated with the important
Hawaiian values of lōkahi (harmony) and
pono (equity) in the relationship between
kānaka (mankind, both self and others),
‘āina (land), and nā akua (gods, spirits).18,64
Historical trauma, the psychological distress and associated
issues resulting from loss, oppression, and cultural disruption
for Hawaiians have been described by Native Hawaiian
psychologist-researchers in various ways. Rezentes identies
the Kaumaha (heavy, sad, depressed) Syndrome.65 Crabbe
discusses, that in contemporary times Hawaiians share a
“collective sadness and moral outrage” and hō‘ino‘ino (abuse,
inure) or broken-spirit.66 These psychologists point to
continuous oppression, and cultural discord from traditional
Hawaiian values, practices and beliefs. To achieve health
equity for Native Hawaiians, the Hawaiian community and
their knowledge, both cultural and ancestral, must be
prioritized.67 The ability of Hawaiians to adhere to their
ancestral knowledge is central to their identity and social
relations, and is intimately tied to their physical and emotional
well-being.62
Also crucial is spirituality, which in kāhiko (ancient) times
was not a second thought but a way of life. Research shows
that spiritual and social well-being are important to the
overall well-being of Native Hawaiians living with chronic
disease, despite any physical limitations caused by the
disease.68
KEY POINTS
▶ INTEGRATED HEALTH
The Hawaiian worldview of individual
health is inclusive of physical, spiritual,
emotional, and mental spheres.
▶ ACHIEVING HEALTH EQUITY
To achieve health equity for the Hawaiian
community, knowledge, both cultural and
ancestral, must be prioritized.
▶ COLLECTIVISM AND CULTURE
Studies with NHPI often identify the impor-
tance of extended family systems, values of
cooperation and collectivism, pride in cultur-
al heritage and traditions, and spirituality.
Chapter 3: Striving for Health Equity 16
Mai kapae i ke a‘o a ka mākua, aia he ola malaila
Do not set aside the teachings of one’s parents for there is life there
NĀ POU KIHI - e Corner Posts
A Hawaiian Framework for Achieving Social and Health Equity
Systemic change in political, educational, economic, and social systems is required to realize improvements in Native Hawaiian
health. What Hawaiian scientist-scholar Kaholokula proposes, is a framework for Native Hawaiian well-being that synthesizes
cultural values, health equity research, Indigenous scholarship, and social determinants. Like the corner posts in a solid house,
each of the elements are fundamental, and it is their integrated strength that establishes the structure. It should be noted that
the examples provided in the descriptions below oen seek to address more than a single pou kihi (corner post).69,70
KE AO ‘ŌIWI – Indigenous Cultural Space
is corner post seeks to rmly establish Indigenous cultural spaces
for Native Hawaiians to exercise prerogatives and aspirations, and
express cultural identity without discrimination or prejudice.
Specically, the goal would be to revitalize: ‘ōlelo Hawai‘i (Hawaiian
language), cultural practices, protocol, beliefs, values, and traditions
and cultural-based education.
Examples include: Hawaiian language immersion schools, Maoli
Arts Month (MAMo), Nā ‘Ōiwi Television, and Kānehūnamoku
Voyaging Academy. Cultural revitalization, cultural safety and a
supportive environment that uplis a strong positive Hawaiian
identity will help mend the cross-generational trauma and lessen
the stressors associated with chronic physical and mental diseases.
KA WAI OLA – Social Justice
is corner post is about ensuring fair treatment and equitable
share of the benefits as well as burdens of society. Ka Wai Ola
recognizes that education, political power, social-economic status
all inuence health and well-being. Examples include: Partners
in Development, MA‘O Farms, Ho‘okua‘āina’s Kūkuluhou
Mentorship, and Ma Ka Hana Ka ‘Ike (hanabuild.org), and the
newly formed Aloha ‘Āina party.
KA MĀLAMA ‘ĀINA – Environmental Stewardship
Concepts of aloha ‘āina (love for the land) and mālama ‘āina (caring
for the land) are fundamental to Hawaiian view of personal health.
Further, Hawaiians believe personal health is intimately and
reciprocally linked to the wellbeing of their ‘ohana (family, friends,
and community) and ‘āin a (land).
Goals for this corner post include: access to nature/natural environ-
ment, food sovereignty, restoration of Native ora and fauna, and
protection of spiritual sites. Examples include: Waipā, Kaho‘olawe,
Kauluakalana, Kū Maoli Ola, Limu Hui, KUA, and Kū Ki‘ai Mauna
(Maunakea protectors) movement.
KA ‘AI PONO – Healthy Consumption
The term ‘ai pono refers to eating healthy and healthy lifestyle
choices, it includes moderating consumption of food, as well as
natural and manufactured resources, technology, and other
conveniences of daily living.
What might Ka ‘Ai Pono look like? Poi would commonly be a baby‘s
rst food and on the dinner table every night along with fresh sh
and produce grown in Hawai‘i. Examples include: Lunalilo Home,
Kōkua Foundation, Kōkua Kalihi Valley’s Ho‘oulu ‘Āina, Waianu
Farm and Ka‘ala Farm.
KA WAI OLA
KA MĀLAMA ‘ĀINA
KE AO ‘ŌIWI
KA ‘AI PONO
17 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
Creating Solutions
Health intervention programs designed to prevent and manage illnesses is one approach to begin to address health inequities
and disparities. When health programs are aligned with the cultural values, perspectives, and preferred modes of living of a
specic population, they are known as culturally responsive programs.71,72 e landmark E Ola Mau Report and subsequent
research, has called for culturally relevant and responsive programs as one meaningful approach to achieve health equity for
Native Hawaiians. It has taken decades to create, develop, implement, and evaluate health programs that have cultural relevance.
ey include evidence-based culturally-adapted programs; culturally-grounded programs; as well as promising programs.
1CULTURALLY-ADAPTED PROGRAMSAAAA AAA
As part of a national movement to improve health
disparities and overall quality and accountability of
health care services, the U.S. government has called for
implementing evidence-based programs to promote
health.73,74 Programs must show evidence, through an
accepted research process, that distinct health improvements
were achieved. An increasing reliance on such proven
programs, though, leaves Indigenous communities at a
disadvantage because there are very limited numbers of such
programs and interventions designed by or for Indigenous
peoples.75-78 Community researchers and educators have,
therefore, relied on culturally adapting evidence-based
programs for Pacic populations.78-81
Adapting an evidence-based program means carefully
considering cultural factors that may, directly or indirectly,
be associated with health-related behaviors and how (or
whether) a community accepts and adopts the program.
Studies with Native Hawaiians and Pacific Islanders, for
instance, oen identify the importance of extended family
systems, values of cooperation and collectivism, pride in
cultural heritage and traditions, and spirituality.68,82
Pacic peoples also frequently mention an insensitivity to the
nuances of different Pacific populations. For example,
Micronesians are a fast-growing Pacic Islander group made
up of individuals from multiple island nations, each with a
distinct language and its family structures and traditions. For
programs and materials to be culturally appropriate and
successful, program planners must understand these various
cultures and subcultures within the Pacic.
When adapting an evidence-based
program, recognizing community agency
and adapting health interventions for the
specic, targeted community can improve
both the efcacy and sustainability of
positive health outcomes.80,83
Chapter 3: Striving for Health Equity 18
Ke Ku‘una Na‘au Program
BEHAVIORAL HEALTH
In 2016, recognizing the need to reduce unnecessary
hospital readmissions among Native Hawaiians, e Queen’s
Medical Center, Hawai‘i’s largest tertiary care hospital which
was founded by Hawaiian royalty over 160 years ago, imple-
mented the Ke Ku‘una Na‘au Program (KKN), a culturally-
adapted patient navigation behavioral health program
focused on reducing hospital readmissions for socially and
economically vulnerable Native Hawaiian adults.85
OVERVIEW
▶ Navigators understand the key pathways to community-
clinical linkages and help patients to obtain essential
resources. They support patients with a safe transition after
discharge, and also assist patients in obtaining resources
to support their ongoing recovery and healing.
▶ Navigators understand that for their Hawaiian patients,
lōkahi (harmony) between the spiritual realm, mankind, and
the environment is critical to recovery and health and that the
Hawaiian view of creating individual health and well-being
is inclusive of all realms: body, mind, and spirit.
▶ Ke Ku‘una Na‘au Program is innovative, meaningful, and
unique to Hawai‘i as QMC was Hawai‘i’s rst acute care
hospital to implement the use of community health workers
into its health delivery system in this way.
“I love having the opportunity of working 1-on-1, having a connection,
and building a trusting relationship. I provide support and care with the
intentions to create a healthier and enhanced quality of life for our patients.
Simply providing the resources they need, like helping patients obtain food
stamps is very rewarding for me. It makes me happy that I can make them
happy. My approach is simple: I am present with open arms, humble heart,
open mind, caring thoughts and prayers, honesty, and consistency.”
—Anthony Hereari‘i Negrillo, Patient Community Navigator.84
The program name, Ke Ku‘una Na‘au, is
translated as “to put one’s mind and heart at
ease,” which is a key goal for the program‘s
Patient Community Navigators.85
KKN oers culturally-relevant and sensitive care to target the
social needs of Native Hawaiians employing highly eective
non-clinical community health workers as Patient Commu-
nity Navigators.
ese Navigators are included as members of a patient’s direct
clinical care team, and their role is to serve as the patient’s
liaisons between the hospital and community services.84
Navigators understand the key pathways to community-
clinical linkages and help patients to obtain essential
resources. ey support patients with a safe transition aer
discharge, and also assist patients in obtaining resources to
support their ongoing recovery and healing.84 Every Navigator
has deep community and Hawaiian cultural knowledge that
facilitates their caseload of 10–12 patients, and oen requires
daily contact with each patient.
Key Hawaiian values and practices are foundational to the
KKN program. ese values include: kōkua which translates
as, to help, care for, aid, assistance, relief, to be a helper,
counselor, and comforter and pilina which means relation-
ship, union, connection and is central to the development of
trust. Navigators understand that for their Hawaiian patients,
lōkahi between the spiritual realm, mankind, and the envi-
19 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
ronment is critical to recovery and health and that the
Hawaiian view of creating individual health and well-
being is inclusive of all realms: body, mind, and spirit.64,84
Similar to traditional patient navigator services, the KKN
program provides support through the entire hospitalization,
and post-discharge for a minimum of 30 days. KKN Naviga-
tors oen build a deep relationship with their patients that
goes far beyond the ocial program.84 It is this type of pilina
that has been important to impacting avoidable re-hospital-
izations. As shared by Patient Community Navigator, Kehau
Pu‘ou, navigators take pride in their kuleana (responsibility)
to serve their kūpuna (elders) and the Native Hawaiian
community:84
“Being chosen to carry this kuleana is truly a privilege.
It is an honor to represent my kūpuna and the mission
and vision they set forth. It is an honor to represent
my kūpuna and the mission and vision they set forth.
That alone is truly something our team holds at the
forefront. We, as Navigators, are mission-driven and
grounded in our kūpuna. This kuleana allows us to
aloha our patients at the bedside. It is the rst contact
we have with them to form a relationship. From
there, the journey begins.”
KKN is innovative, meaningful, and unique to Hawai‘i. e
Queen’s Medical Center was Hawai‘i’s rst acute care hospital
to implement the use of community health workers into its
health delivery system in this way.84 KKN has successfully
met community needs by reducing readmission rates among
Native Hawaiian adults, improving their quality of life, and
making positive impactful changes to the persistent, unmet
healthcare needs in the Native Hawaiian community.85
e program’s success has been attributed to:
1) Removing barriers to community resources.
2) Building trusting relationships.
3) Using Native Hawaiian values in practice.85
kōkua ▶ pilina ▶ lōkahi
help union harmony
e program emphasizes collaboration across clinical and
non-clinical workforces, and focuses on the importance of
cultural adaptations and relevance.84 As shared by Patient
Community Navigator, Damien Hanakeawe:84
“Because of the cultural trauma that has happened to
Hawaiians, a lot of the kūpuna have a difcult time
trusting Western institutions, especially when it
involves health and healing. For Hawaiians, hospitals
are often viewed as places devoid of culture and life,
where people come to die, sterile institutions lled
with people that don’t look like them or talk like them.
All they see are medical staff with an agenda, whether
it is taking vitals or checking a pain scale. For us as
navigators, in the beginning, it is very important that
we skip all that. It is more benecial that we create a
connection that is rooted in our
Hawaiianness.”
The KKN program now serves as a model and began
expanding to other populations and locations. ◀
Chapter 3: Striving for Health Equity 20
PILI ‘Ohana, Healthy Lifestyle Program
WEIGHT-LOSS AND MAINTENANCE
The Partnership for Improving Lifestyle Intervention (PILI)
‘Ohana Program is a weight-loss maintenance program that
oers culturally-adapted and community-placed program
lessons designed to improve diet, physical activity, time, and
stress management for Native Hawaiians and Pacic Islanders.
PILI does not only focus on weight management but also
teaches lifestyle changes, such as spending more quality time
with one’s family and community. e program aims to change
how participants view their health.
Gatherings take place in a group setting, which provides a
safety net for participants supporting one another while
learning the benets of healthy lifestyle choices. at fosters
a supportive environment that allows participants to engage
in actively improving their health.86 Both scientists and com-
munity members strongly endorse the program. As shared
by Cappy A. Solatorio, PILI ‘Ohana program facilitator:
OVERVIEW
▶ PILI does not only focus on weight management but also
teaches lifestyle changes, such as spending more quality
time with one’s family and community. The program aims
to change how participants view their health.
▶ The program is designed to reflect traditional Hawaiian
beliefs about health and well-being. Healthcare is no longer
just between a patient and physician but is also between an
individual’s family, neighbors, and community members.
This evidence-based program was built
upon a strong community collaborations
and used a scientically tested community-
based research partnership framework in
all phases from development through
implementation. It was adapted from a
landmark study, the National Diabetes
Prevention Program,87 as a weight-loss
maintenance program specically for
Pacic populations.
A partnership of seven community, academic, and state
organizations developed and tested the program to integrate
community wisdom and expertise as well as scientific
methods to provide a viable option to address the risk of
chronic diseases in Native Hawaiians and other Pacific
people. More than just a health intervention, PILI also aims
to increase community capacity by empowering communities
to engage with academic science researchers in meaningful
ways about issues that aect them. Community members
served alongside academic researchers as co-investigators,
and play an active role in planning, decision-making, and
carrying out all research activities.
In addition to being ecacious through rigorous scientic
testing, PILI’s cultural-congruence and eectiveness have also
been demonstrated and evaluated in real-world settings by
community peer educators from other partnering commu-
nity-based organizations.80
PILI ‘Ohana is designed to
reflect traditional Hawaiian
beliefs about health and well-
being. Community members
and leaders are not only
researchers but also individu-
als addressing their health,
as healthcare traditionally
begins in one’s own home and
"PILI ‘Ohana was really wonderful. What was so
wonderful was the camaraderie. All of us together,
encouraging one another, and the stories everyone
shared. I still see a lot of the people, and a lot
of them have kept the weight off. It was such
a success. Very rewarding.”
—Cappy A. Solatorio, PILI ’Ohana program facilitator
21 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
community. Healthcare is no longer just between a patient
and physician but is also between an individual’s family,
neighbors, and community members.
A key element of the program is facilitating the relationships
and connections between participants. ese connections are
fundamental to Hawaiian cultural values and also facilitate
engagement and retention. As participants described, “We
looked forward to meeting each other week aer week,” said
one participant. “We couldn’t get enough of each other.” Not
only do the program participants build trust and account-
ability, but they share personal and relatable accounts of their
changing lifestyle habits. Ultimately, participants realize they
are not alone in improving their lifestyle. By looking at and
returning to traditional wisdom, PILI puts health back into
the hands of a community by helping its members learn to
be accountable to each other. ◀
“Losing weight together and participating in the
[eight-mile] Great Aloha Run together was my
most memorable memory of PILI.”
—PILI ‘Ohana participant
“Everyone ended the class with a great sense
of camaraderie from helping and encouraging
each other to lose weight.”
—PILI ‘Ohana participant
Chapter 3: Striving for Health Equity 22
2CULTURALLY-GROUNDED PROGRAMSAAAA AA
For over 30 years, it has been well documented that
Native Hawaiians prefer, and experts have recom-
mended, culturally-relevant health programs and services
to address health needs and issues. Although more is needed,
many culturally-adapted health programs for Native Hawaiians
have been put place in community and institutional settings.
Culturally-grounded programs are rarer.
Grounding a program in the culture, and focusing on culture-
centeredness, means using agency, power, and language to
draw from a culture’s strengths and promote healthy changes
in its communities.88 For Native Hawaiians, an individual’s
health and well-being are related to the health of family,
community, and environment.89 To improve Hawaiian health,
then, health interventions must promote loyalty, unity, and
reciprocity within Hawaiian communities, and they must
emphasize family and family-like support.86
One way to develop a culturally-grounded
health program is for it to be based on a
cultural practice, and to build, weave, and
emphasize aspects that can have specic
health benets. In this way, the strengths
of cultural and western medical knowledge
can be brought together.
23 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
Ola Hou i ka Hula, Heart Health Program
RESTORING HEART HEALTH
Building on ten years of ground-breaking research
conducted through the University of Hawai‘i at Mānoa John
A. Burns School of Medicine’s, Department of Native Hawaiian
Health found that implementing a health intervention based
in the iconic dance of hula signicantly improved hyperten-
sion in Native Hawaiian participants.
Working closely with many kumu hula (hula experts and
educators) and Native Hawaiian community leaders, the
medical school’s scientists developed and implemented the
Ola Hou i ka Hula (Restore Health rough Hula) program,
initially as cardiac rehabilitation for individuals recovering
OVERVIEW
▶ The Hawaiian community asked the scientists not to only
focus on disease, but to nd ways to restore heart health
before people got really sick.
▶ Hula experts explain that this cultural dance incorporates the
integrated Hawaiian view of health where aspects of physical,
mental, and spiritual development are involved.
▶ So far, 53 kumu hula and others have been trained and more
than 16 organizations including community health centers,
now offer the Ola Hou program, either specically for hyper-
tension management or general heart health and disease
prevention.
“I don’t want to say I would be dead, but I would have probably
had a heart attack or stroke by now, because I know exactly what
I didn’t do. I didn’t exercise until I came to the program.
I didn’t think I could.”
—Arma Oana, Ola Hou i ka Hula participant
from heart bypass surgery.90,91 en the Hawaiian communi-
ty asked the scientists not to only focus on disease, but to nd
ways to restore heart health before people got really sick. It
was decided to begin with hypertension, a risk factor that too
oen leads to heart disease and stroke. e collaboration of
Chapter 3: Striving for Health Equity 24
scientists, and kumu hula, worked on how indigenous and
medical knowledge could be brought together.
To develop and test this innovative and leading-edge solution,
medical school researchers worked with six communi-
ty-based organizations serving Native Hawaiians to identify
263 Hawaiians who were under their doctor’s care for hyper-
tension, chronic high blood pressure, and were still unable
to make health improvements. Hawaiians from eight com-
munities on three islands participated in a research eort to
evaluate how the Ola Hou i ka Hula program could improve
hypertension management. During the six-month program,
participants received three hours of culturally relevant
heart health education, which included information on diet,
exercise, and the use of medications.
ose attending the hour-long hula classes went twice a week
for three months, followed by one lesson per month for three
additional months and self-directed hula practice. ey also
participated in activities that reinforced hypertension educa-
tion and healthy behaviors. All participants continued their
usual medical treatment during the study.92
e results were quite positive. What had been poorly man-
aged hypertension improved considerably, lowering down
two levels of risk through participation in the program.92,93
This is even more remarkable given that the best proven
non-medication treatments of hypertension, such as diet,
sodium reduction, physical activity are shown at comparable
or lesser amounts of improvement.
Traditional hula training incorporates Hawaiian values such
as familial relationships, cooperation, and aloha—ongoing
kindness and acceptance of others. Hula experts explain that
this cultural dance incorporates the integrated Hawaiian view
of health where aspects of physical, mental, and spiritual
development are involved.63,94 Researchers and kumu hula
believe traditional hālau hula (hula school) training incor-
porates important components that go beyond just physical
activity, including social support, and stress management, to
improve blood pressure. On Hawai‘i Island, rural Hilo
resident Mari Martin described her joy and success with
the program:
“I have always told my family that I would like to
go back to dancing hula, as that was a passion of
mine when I was growing up, and I later had to
stop, not by my choice. I have hypertension and
Type 2 diabetes, and have been having the worst
time trying to incorporate physical activity into my
lifestyle. Having the chance to dance hula again
has been so awesome. I look forward to the hula
class where I am surrounded by other women
who want to learn hula, learn how to take care of
their hypertension, have tness, but most of all
fellowship with each other. I can honestly say this
program has helped with getting me back into
physical activity that I was lacking and has also
helped me to take care of me.”
e decade long collaboration of the kumu hula, medical
school scientists, and Hawaiian leaders also committed them-
selves to build capacity for the Ola Hou program to be
widely oered. So far, 53 kumu hula and others have been
trained and more than 16 organizations including commu-
nity health centers, now oer the Ola Hou program, either
specically for hypertension management or general heart
health and disease prevention. e popularity of the program
is evident. At Kōkua Kalihi Valley Comprehensive Family
Services, a community health center, clinician Sheryl
Yoshimura exclaimed:
“Our patients love it! It has become a “super-
support group.” They not only help each other,
they want to share the hula at our clinic communi-
ty events, at family celebrations, and holiday
gatherings. Our doctors are even writing in-house
prescriptions that say the patient should join the
Ola Hou hula class.”
Restore Health Through Hula
25 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
Results of this successful, largest-ever health treatment study
involving Native Hawaiians were presented at the 2019
National American Heart Association meeting. As shared by
Eduardo Sanchez, the American Heart Association’s Chief
Medical Ocer for Prevention:
“This study is a great example of how interven-
tions can be more effective when they are tailored
for cultural relevance to participants. Not only are
individuals achieving health-promoting levels of
physical activity, they are also having fun, engag-
ing in a valued cultural practice, and connecting
with their community in the group classes—all
important for well-being.” ◀
e collaboration of scientists, and kumu hula,
worked on how indigenous and medical knowledge
could be brought together.
Chapter 4: Recommendations 26Chapter 3: Striving for Health Equity 26
3PROMISING PROGRAMSAAAAAAAAAAAA AA
Culturally-grounded health programs can and have
been successfully grown from the community through
commitment, enthusiasm, and resolve. In Hawaiian commu-
nities, there is great interest in programs related to aloha ‘āina
and mālama ‘āina.95,96 Native Hawaiian scientists and scholars
continue to advocate that cultural knowledge and practices
are a critical component to addressing Hawaiian health
equity. 22,96 ey emphasize the need for place-based strategies,
and those rooted in the Hawaiian integrated world view of
health and wellness.9,22,38,96
While grassroots community efforts have
developed an array of promising health
promotion intervention programs, they
have not yet been tested in a scientic
evaluation, so they do not presently
qualify as “evidence-based.” However,
they draw wide interest and support
and represent the potential for a wide
contribution to establishing health equity.
27 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
Board and Stone Program
WELLNESS AND FAMILY UNITY
The Keiki O Ka ‘Āina Family Learning Centers established the
Board and Stone Program under the direction of
cultural practitioner Earl Kawa‘a.97,98 A place-based, family-
centered cultural practice class, “Board and Stone” is a
promising program that promotes health equity through
encouraging wellness and family unity.99 Emphasizing
cultural traditions, language, and values, families together
learn how to make poi, the primary Hawaiian food staple,
using very traditional practices, including making tradi-
tional, hand-carved Hawaiian implements pa wili ‘ai (board)
“It brought us together as a family. We took turns. Where she [my wife]
struggled, she left it for me; and if I struggled, I left it for my son. We all
shared and took turns. It was a family project. Even carving the pōhaku
[stone], it was wonderful. It really brought us closer as a family.”
– Board and Stone participant in Kalihi Valley99
OVERVIEW
▶ By standards of a health-related program, the Board and
Stone Program is phenomenally popular with over 9,000
people having completed the program over the past 10 years.
▶ The program leads with Hawaiian cultural training to
empower families to perpetuate and connect with their
culture as well as improving overall health and well-being.
▶ Consistently, the program found that cultural grounding
was intrinsic to participants’ empowerment to make
improvements in their lives and families.
▶ “The class helped me to come to a realization that I gotta
do something now to help myself to live longer.”
and pōhaku (stone pounder), which are used to pound
cooked kalo (taro root) into poi.
Kalo has a deep spiritual signicance to Native Hawaiians for
many reasons, one explanation is found in a Hawaiian origin
story, that explains the rst kalo plant was an elder sibling to
man. This ties to key Hawaiian values and practices that
require older siblings to care for those younger. In turn,
younger siblings must honor, care for, respect, and abide by
their elders. Embedded in this cultural belief and practice is
the understanding that when Hawaiians care for kalo and the
‘āi n a (land), in turn, they will provide food, shelter, and
everything necessary to sustain health and well-being.20
By standards of a health-related program,
the Board and Stone program is
phenomenally popular with over 9,000
people that have completed the program
over the past 10 years. Even more
unprecedented is it is primarily promoted
only by word-of-mouth, and continues to
have wait-lists at sites.
e Board and Stone has grown from being a program into
a movement and has created an increased desire to have the
healthy complex carbohydrate of kalo and poi as a regular
part of the family’s diet.99
Chapter 3: Striving for Health Equity 28
Culminating ho‘ ike
When Board and Stone began monthly poi pounding events,
they used 200 lbs. of kalo per month. Demand increased, and
Board and Stone now orders up to four to ve times more
kalo, 800–1,000 lbs. each month, thereby encouraging the
farming of kalo. Along with increased access to this tradi-
tional practice and food, there is also an increase in the num-
ber of Board and Stone alaka‘i (leaders) with the knowledge,
skills, and passion to lead and train others.99
The program leads with Hawaiian cultural training to
empower families to perpetuate and connect with their
culture as well as improving overall health and well-being.
This approach to family strengthening, shifts personal
perspectives, and helps individuals as well as the family unit
to redene themselves.99 Dynamically, the simplistic process
of making tools to pound a traditional food becomes for
many participants dramatic, rewarding, and life-changing.
e program culminates in a ho‘ike, a tradition of sharing
and showcasing knowledge and skills learned. A pivotal part
of the ho‘ike is when each family shows their board and stone,
and uses the cultural protocol and knowledge they learned
to share a story of their accomplishment and lessons learned.
A woman from O‘ahu who attended the class described the
deep transformation she saw in her husband as a father and
partner:97
“In the past, my husband would go to the beach
or forest alone every chance he had. After taking
the board and stone class, he took [lead instruc-
tor] Kawa‘a’s teaching to heart willingly; and the
light within him began to turn on. My husband
began taking our three girls and me to the
mountains and beach, and now we go all the
time. I fell in love with him all over again.”
Consistently, the program found that cultural grounding
was intrinsic to participants’ empowerment to make
improvements in their lives and families. A man from O‘ahu
shared his new awareness and resolve this way:99
“The class helped me to come to a realization that
I gotta do something now to help myself to live
longer. Even just the kalo, it tells me that we have
good things coming from our culture that was
helpful to our ancestors, and if I can change to be
more healthy for my family, then I can help them.
We can do something now by taking care of our
health now.” ◀
29 Assessment and Priorities for the Health and Well-being in Native Hawaiians and Pacic Islanders, 2020
RECOMMENDATIONS CHAPTER 4
Health inequities continue to exist for
Native Hawaiians and Pacic Islanders.
Because culture is such a signicant part of
what distinguishes a population, especially
Indigenous communities, disease prevention,
treatment, and management programs must
be culturally-responsive at their core and
the cornerstone of health promotion.
The case studies described previously can serve as
templates for developing culturally relevant health
programs for Native Hawaiian communities and
Pacic Island peoples. Developing new culturally
relevant evidence-based programs or other promising
programs is needed. Health equity will be achieved in part
with eective, sustainable, and culturally responsive health
intervention programs—which, as a bonus, also help to
revitalize cultural practices and empowers communities.
SYSTEMATIC CHANGEAAAAAAAAAAAAAAAAAAAAAAAAAA
Systematic change in political, educational, economic, and
social systems is required to realize improvements in
Native Hawaiian health. What Hawaiian scientist-scholar
Kaholokula proposes, is a framework for Native Hawaiian
well-being that synthesizes cultural values, health equity
research, Indigenous scholarship, and social determinants.
Application of this Hawaiian framework “Nā Pou Kihi” has
the potential to address health disparities and increase health
and well-being among Native Hawaiians through eective
programs implemented in the community.
COLLABORATION
To establish these programs, health scientists, commu-
nities, and cultural practitioners must come together. It is
through the collaboration and the integration of knowledge
and experiences that breakthroughs can be made. For
example, it’s important to know that Hawaiians seek, evaluate,
Chapter 4: Recommendations 30
and accept or reject a program based on whether they believe
aloha exists in the program, not just staff behavior but
intrinsically within the theory, approach, and materials.
While people outside the Hawaiian culture may understand
the term “aloha” as merely a greeting, it also refers to love,
affection, compassion, mercy, sympathy, pity, kindness,
sentiment, grace, and charity.100 To Hawaiians, the values of
aloha, ‘ohana, and ‘āina are complex foundations of life.65
CULTURALLY GROUNDED HEALTH PROGRAMSAAAAAAAA
It is essential to correctly interpret the meaning and
understand a group’s values, practices, and beliefs when
creating culturally responsive and grounded health programs
for Native Hawaiians. is is important with Pacic Islander
communities, too, who generally prefer a face-to-face or
similar type of direct interaction. When adopting or
developing interventions, groups should use methods and
evaluations that not only promote good health but are also
grounded in cultural values and practices signicant to the
community. It is important to consider and measure factors
important to the community when developing a program’s
evaluation methods, as well.72
THE IMPORTANCE OF FAMILY
Families and their extended households of Pacic peoples
must be able to participate together for culturally responsive
programs to have positive outcomes. Families have their
networks of interpersonal relationships, which are strong
sources of support and identity and help shape self-
determination and decision-making for Native Hawaiian
and Pacic Islanders.101
Organizations do exist that are dedicated to providing
education, research, and health services for Hawaiians, but
we must continue building capacity in how we understand
and perpetuate Pacific history, languages, practices, and
beliefs. ◀
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37
is publication by the University of Hawai‘i, John A. Burns School of Medicine Department of Native Hawaiian Health was
made possible by funds from e Queen’s Health Systems. e content is solely the responsibility of the authors and does not
necessarily represent the ocial views of the funder.
We would like to express our mahalo to Sara Saery for seeing our vision and bringing essence and life to this publication
through graphic design. We also extend a mahalo piha to all those who provided support and kōkua (help and assistance) in
obtaining photographs for this publication: Kai Markell (cover; preface); Kai Adams (cover); Kaleomanuiwa Wong and
Kauluakalana (pages 26-30); Hālau Mōhala ‘Ilima (page 29); Hawai‘i State Archives (cover; page 7); Herbert K. Kane LLC
(inside cover, page 5); Honolulu Museum of Art (page 7); Honolulu Star-Advertiser (cover; page 8); Kamaka‘aina Seipp (pages
14, 31); Kim Birnie (page 7); Nicasello Photography (pages 17, 23); University of Hawai‘i at Mānoa’s College of Tropical
Agriculture and Human Resources (pages 15, 16); and the John A. Burns School of Medicine Communications (pages 22, 30).
We also express our sincere mahalo to Earl Kawa‘a and Momi Akana for their assistance in the Board and Stone section of this
publication. To all the Ulu Network organizations who have been our collaborators and partners over the past 17 years, we
extend our deepest appreciation for your dedication and commitment to community.
MAHALO AND ACKNOWLEDGMENTS
Kūlia i ka nu‘u. Strive for Exellence.
..
University of Hawai‘i
John A. Burns School of Medicine
677 Ala Moana Blvd., Suite 1015
Honolulu, Hawai‘i 96813
