OCR Document

Copyright @ eContent Management Pty Ltd. Contemporary :Nurse (2006-7) 23: 170-180.

I Despite assertions

if the importance if family in Indigenous cultures and its impact

on psychological and physical health, there remains a paucity

if

research and a lack

if measurement on Indigenous families' worldviews and their respective impact on well-being. The purpose

if

this investigation was to determine the relationship

between Indigenous family ethnic schema and individual wellbeing. The sample consisted

if 81 older adults (average age was 60.94 years old) with 77 Native Hawaiian and part-Native Hawaiian participants, and two Caucasian and two Asian participants with a Hawaiian partner or spouse. Family ethnic schema focusing on Indigenous values,

if

individual age, income and gender. Clinical implications if family

beliifs, expectations and priorities was found to explain higher levels

well-being independent if ethnic schema in terms if help-seeking behavior, treatment and adherencetl~ment are discussed.

Received 8 May 2006

Accepted 1 9 September 2006

Oneha 2001; Rezentes 1996). In many ethnic communities, the family has been viewed as the system LAURIE 'LAu' for intergenerational transmission of traditions in order D MCCUBBIN Assistant Professor to keep the culture and ethnic heritage alive (McCubbin, Dept of Educational Thompson, Thompson, Elver & McCubbin 1998). Leadership & Despite assertions of the importance of family on Counseling Psychology overall well-being (Kanaiaupuni 2004; Oneha 2001; Washington State Policy Analysis and System Evaluation 2005), there University Pullman WA, USA remains a paucity of research and a lack of measurement on Indigenous families' worldviews or schema and their BACKGROUND respective impact on well-being. Family schema is a system level construct defined as any scholars have noted the importance of family 'a structure of fundamental convictions, values, beliefs in Indigenous communities in main and expectations' (Mc taining Indigenous cultural identity, values and beliefs across generations (Kanahele 1986; Kana . iaupuni 2004; McCubbin & McCubbin 2005;

M

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C:J{ Volume 23, Issue 2, December 2006-]anuary 2007

The role of Indigenous family ethnic schema on well-being among Native Hawaiian families C:J{ Cubbin, Thompson & McCubbin 1996: 39). It is shaped and adopted by the family system over time and serves as the shared informational. framework against and through which family experiences and behaviors are processed and evaluated. Thus a family schema, expressed through the family's dispositional world view, includes cultural and ethnic beliefs and values and serves as a framework for guiding, shaping, and evaluating family behavior. Not only does a family's schema and its appraisal process give order, harmony, balance and stability to family life, it plays an influential role in shaping and legitimizing the family's old, established, newly instituted and maintained patterns of functioning as well as the family's problem solving and coping behaviors and patterns (McCubbin & McCubbin 2005); Thompson & McCubbin 1996: 39). Ultimately, family schemas playa key role in shaping the 'meaning' given to family situations and experiences which in turn facilitates coping and adaptation. The viability of family schema as a system construct is evident in the literature inclusive of explaining the variability in children's gender cognition (Tennenbaum 2002), family resilience (Hawley & Delraan 1996), family adaptation to brain injury (KosciulekI997), advancement of family system therapy (Dattilio 2005), treatment of overweight female adolescents (Turner, Rose & Cooper 2005), the assessment of a family with an asthmatic child (Masterson 1985) and intergenerational communication (Lin, Zhang & Harwood (2004). The purpose of this investigation is to advance this line of inquiry by examining the relationship between Indigenous family ethnic schema and family member well-being ?mong Native Hawaiians.

top or close to the top of every category of medical disease, social pathology, and psychological maladaptation (e.g. Davis et al. 2004; Hughes & Higuchi 2004; Ka'ano'i, Braun & Gotay 2004; Johnson, Oyama, LeMarchand & Wilkens 2004). Native Hawaiian adults have the highest prevalence rates of hypertension, diabetes, asthma and obesity in addition to the shortest life expectancy for any racial! ethnic group in the state (Davis et al. 2004; Johnson et al. 2004; Kaholokula, Haynes, Grandinetti & Chang 2006). Native Hawaiians also have high rates of suicide and suicide attempts especially among young men (Yuen, Nahulu, Hishinuma & Miyamoto 2000). Native Hawaiians also have high rates of substance abuse, depression and anxiety disorders compared to nonHawaiians (Andrade et al. 2006; Guerrero et al. 2003; Kaholokula et al. 2006; Marsella et al. 1995; Prescott et al. 1998). The predominant research focus in previous studies has been on the deficits of Native Hawaiians in comparison to their nonHawaiian and Anglo-European counterparts. Many other Indigenous populations in the Pacific are facing similar challenges and health risk factors with research following a similar pattern for uncovering what is wrong or deficient in these populations. In response to these challenges, Indigenous communities have come together to reclaim their land, identity, ethnic values and spiritual beliefs in order to strengthen themselves and their families and to promote their health and well-being. The movement of 'Indigenous ways of knowing' and re-embracing cultural strengths to help heal past historical injustices can be seen in multiple communities including the Native Hawaiians, American Indians, New Zealand Maori, and the Aboriginal peoples of Australia. This cultural renaissance of ethnic beliefs, values, customs, expectations and practices also has created a sense of pride and strength to help empower Indigenous peoples to create their own empirical investigations about their own people (McCubbin & McCub

HEALTH STATUS OF NATIVE HAWAIIANS The plight of Native Hawaiians in the state of Hawaii has been well documented. Research has found Native Hawaiian adults are either at the

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Volume 23, Issue 2, December 2006-January 2007 C:J{

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, CJ( Laurie 'Lali' D McCubbin '" I.,' i

bin 2005; Policy Analysis and System Evaluation 2003).

FAMILY IN NATIVE HAWAIIAN CULTURE At the center of Native Hawaiian culture is the family system or 'ohana and the interpersonal relationships which shape the, processes by which cultural practices and values are transmitted, maintained, nurtured and affirmed. The "ohana' or family system is at the pi co or center of health and healing processes. Therefore 'ohana is a strong source of support and identity in Hawaiian culture. A person's 'ohana can consist of extended family as well as informal relationships such as friends, and family members of friends (Kanahele 1986; Pukui & Elbert 1986; Rezentes 1996). 'ohana encompasses not only kin but also those members who are closely tied to the extended family who provide support or that the 'ohana is currently supporting emotionally, physically, and/or financially. The Native Hawaiian concept of self is grounded in social relationships (Handy & Pukui 1972) and tied to the view that the individual, society and nature are inseparable and key to psychological and physical health. Such relational and emotional bonds that shape the' ohana and its worldview have implications for psychological functioning and well-being (Kanaiaupuni 2004).

RESEARCH ON INDIGENOUS FAMILIES The study of Indigenous families has been traditionally guided by theories and measures developed and advanced by social and behavioral scientists committed to western conceptualizations and metrics (e.g. Henslin 1980; 1985; Olson & Defain 2002). The few theory building and systematic efforts to produce reliable and valid instruments for Indigenous families have unveiled a host of challenges which demand attention and commitment to measuring cultural dimensions of these families across multiethnic Indigenous communities.

172

FAMILY

SCHEMA

AND

FAMILY

ETHNIC SCHEMA The concept of family schema is a construct that has been applied to Indigenous peoples to quantitatively measure values and spiritual beliefs (McCubbin & McCubbin 2005: McCubbin, Thompson & McCubbin 1996). Family schema is the structure or identity of a family consisting of shared values, beliefs, goals, expectations and priorities. Family ethnic schema focuses on the family's worldview involving cultural and ethnic values. This includes respecting and maintaining one's ethnic heritage, honoring and respecting one's elders, caring for the land and valuing the meaning of dance, language and music in order to keep the culture alive for generations. The central function of family ethnic schema is the development of family meanings of crises and experiences through the framework of cultural values, expectations, spirituality, nature and time. Family ethnic schema has been used in research to determine the multifaceted conceptualization of family in Indigenous cultures and its impact on family resilience, hardiness, and adaptation (McCubbin & McCubbin 2005). Researchers with the Family Stress, Coping and Health Project (McCubbin et al. 1998) investigated the role of family ethnic schema on family resilience among Native Hawaiian families. They found that family ethnic schema attenuates the severity of family dysfunction and plays a catalytic role in family resilience through indirect effects on family problem solving, family sense of coherence and family hardiness. Although these findings are promising, there remains a paucity of empirical research on the effects of family ethnic schema at the family member level focusing on psychological functioning. This investigation attempts to address this gap in the literature by investigating the role of the 'ohana, inclusive of the family's ethnic values, spiritual beliefs, and their relationship to the land, on a family member's psychological well-being. The purpose of this exploratory investigation

CJ( Volume 23, Issue 2, December 2006-January 2007

The role ofIndigenous family ethnic schema on well-being among Native Hawaiian families

C~

is to determine the effect of family ethnic schema on information about participants' age, gender, income, individual well-being. This study hypothesizes that ethnicity and race. higher levels of family ethnic schema will predict higher levels of well-being independent of gender, age and Family ethnic schema Family Ethnic Schema (FSCH-E;McCubbin, Thompson, income. Elver & Carpenter 1992) measures the degree to which a METHODS family has cultivated a family's worldview and identity that includes cultural and ethnic values. The FSCH-E is Sample a 34item instrument which measures a family's identity, The initial sample consisted of 94 adults who were values, beliefs, rules and boundaries within a cultural! attendees at an annual convention of a national ethnic values context. Examples of items are 'In our community civic clubs association for family we believe that if we destroy the land, water and Native Hawaiians and who were participants of the air, we are hurting ourselves'; 'In our family we do a lot convention's health screening program. The to hold onto our ethnic and. cultural identity'; 'We medical team invited the author to be a part of the believe that the land we live on is an important part of screening and evaluation process with the goal of who we are' and 'We teach our children to listen to our gaining greater understanding of the factors which can elders and their opinions.' Each item is rated on a 4 point explain the variability in the health status of the Likert scale (O=False, Hawaiian population which has been traditionally 1 = Mostly False, 2=Mostly True, 3=True). Scores on resistant to seek health care services. The study sample the FSCH-E are detei"mined by summing the responses consisted of 81 of the 34 items. Higher scores indicate greater family adults, 16 (19.75%) males and 65(80.25%) females. The ethnic schema whereas lower scores indicate lower average age was 60.94 years old (SO 13.67) with a ratings of family ethnic schema. Previous studies range of 22 to 89 years old. The median income was involving Native Hawaiians ranging in income (n= 141) $20,000 to $39,000 USO with a range from under have found the internal reliability to be .87 (McCubbin, $20,000 to over $100,000 USO. Thirty-nine or nearly H.I. et al. 1996). The Cronbach's alpha for this sample half (48. 1 %) of the participants identified themselves was. 78. as being solely Native Hawaiian. Thirty eight (46.9%) participants identified themselves as Hawaiian and either one or two other ethnicities. Therefore over three fourths of the sample (n=77; 95%) were either Hawaiian or PartHawaiian. Two participants (2.5%) reported they Individual well-being were Caucasian, one (1.25 %) reported being of The 8-item Family Member Well-being Index Japanese ancestry, and one (1.25%) indicated being of (McCubbin & Patterson 1983) was designed to both Japanese and Filipino ancestry. These four determine the degree to which a family member is participants (5%) were not of Hawaiian ancestry but adjusted in terms of his/her health, emotions, and social participated because they were part of the' ohana in life. (McCubbin et al. 1995). The family member's having a partner or spouse of Hawaiian ancestry. overall well-being (physically, emotionally and Instruments socially) is based on a biopsychosocial view of health. Each item is rated on a 10 point Likert scale with opposite descriptive words on each end related to the question. For example, 'How concerned or worried are you about your health have you been [in the past Demographics month]?' with 'Not concerned'

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A demographic survey was developed to obtain Volume 23, Issue 2, December 2006-January 2007 C~

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C:J( Laurie 'Lali' D McCubbin at one end (0) and 'Very concerned' at the other (10). Another example of anitem is 'How sad have you been' with 'not sad at all 0' to 'very sad 10.' Six items (1,2,5,6,7 and 8) were reverse scored, therefore all items are scored in the same direction with higher scores indicating greater well-being. Past studies have found the internal reliability to be .85 (McCubbin et al. 1996). The measure has also been found to be valid for families in rural areas, executive families, and military families with diverse backgrounds (McCubbin et al. 1996). The reliability in this study sample was. 73.

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Procedure The author served as a psychologist and a member of the health screening team at the convention. The health screening protocol involved participants entering a room organized into 'health checkup' stations where participants could receive diabetes testing, nutrition information, cancer information, family resilience screening and BMI assessments. The station designated as 'family resilience assessment' offered participants the opportunity to complete a survey consisting of the demographic sheet, family ethnic schema measure and the family member well-being measure. The survey took 15 to 20 minutes to complete. An estimated one third of the conference attendees participated in the health screening program. Each participant was mailed an individual profile indicating their personal scores on family resilience factors which he or she can share with their family and health care provider(s).

Ethical considerations The procedure for following ethical guidelines was twofold: (a) to obtain permission from the civic club association to conduct the research and (b) human subjects approval process at Washington State University. Upon invitation to participate in the health screening program, the investigator met with the President of the association and the Chair of the health committee

174

one year prior to the convention to obtain permission from within the organization (i.e. the civic club association) for data collection. Examples of the survey were sent to the President of the organization and the Chair of the health committee for approval of the protocol. Permission was also obtained from the President to share the findings of this research in aggregate form for publication. Results were also shared to the entire membership of the organization at the proceeding annual convention. Feedback about the presentation and how participants would like the information shared in the public domain was sought in a hui (group gathering) during the convention. It was mandatory that the investigator and any research assistants were longstanding members of the association and Indigenous (Native Hawaiian) themselves. These standards were met. The Internal Review Board at the university granted permission for the investigator to collect data among the convention's participants. Individual consent forms were signed by participants and collected prior to the participants' filling out the survey. Participants were also informed of their individual rights such as confidentiality and that all information from the data collected would be presented solely in aggregate form. Participants could also withdraw at any time during the process. Participants were also given the contact information of the investigator, the university department and the university's Internal Review Board to address any questions or concerns they may have about the project.

RESULTS First, the descriptive statistics for the demographic variables and the two main study variabIes (family ethnic .schema and family member well-being) were calculated. Second, a correlation matrix was constructed to determine the relationships between all the study variables (age, gender, income, family ethnic schema and family member well-being). To determine the

C:J( Volume 23, Issue, 2, December 2006-]anuary 2007

Th~ role ofIndigenous family ethnic schema on well-being among Native Hawaiian families C:J( unique contribution of family ethnic schema to explaining the variability in the criterion of well-being, a hierarchical regression analysis was conducted with Step 1 including the demographic variables: age, gender and income; and Step 2 consisted of the total score on the family ethnic schema measure. The outcome variable was family member well-being. The mean score for the family ethnic schema as 88.15 (SD 9.71) with a range of61 to 95 (possible range 0 to 102). The sample mean for the family member well-being was 46.94 (SD 11.56) with a range from 13 to 76 (possible range 0 to 80). Most participants scored in the moderate range. Using a one tailed test, significant positive correlations were found between age (r .246; P .013) and family member well-being; older participants reported higher family member well-being. Family ethnic schema was positively related to family member wellbeing (r =.296; p = .004); participants who reported higher family ethnic schema reported higher well-being. No other significant correlations were found between the study variables.

=

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ings in treating demographic variables as a group (F = 2.62, df = 3,77, P = .057). How ever analysis of the individual contributions of the demographic variables as measured by the beta weights isolated age (B = .22, t 2.34, P .022). as the only independent explanatory variable. (see Table 1). The second step of the hierarchical regression analysis was intended to determine the unique contribution of family schema. After controlling for demographic factors, Family eth nic schema emerged as a significant predictor of family member well-being (F = 8.67, df 1, 76, P .004). Family ethnic schema (B .37, t 2.95, P .004) accounted for an additional and significant 9.3 percent of the total variance explained while controlling for age, gender and income. In total, the demographic factors and family schema combined explained a total of 18.5% of the variance of the criterion of family wellbeing (see Table 1).

=

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DISCUSSION

Family ethnic schema and health and well-being

Hypothesis testing

The hierarchical regression analysis with a forced entry The combination of age (being older) combined with a of the control variables of age, gender and income strong ethnic schema (e.g. cultivation of the family's identity, values, beliefs, rules and revealed non-significant find

TABLE 1: HIERARCHICAL REGRESSION ANALYSIS WITH DEMOGRAPHIC VARIABLES AND FAMILY ETHNIC SCHEMA IN EXPLAINING THE VARIABILITY IN INDIVIDUAL WELL-BEING AS THE OUTCOME FACTOR

R2 Beta SEB B ---------------------------------------------------------------------------------Variable Step 1 Age* Gender Income

.22 -2.62 .83

.092

.254

3.14 .57

-.09 .16

.09

.25

Step 21 Age

.214

Gender

-3.78

3.02

-.13

Income

.79

.54

.15

Family Ethnic Schema 1

.37

.12

.31

R2

.09 2

.092

.185

.093*

* p < .05 1 Family ethnic schema accounted for an additional 9.3 and of the total variance explained while controlling for age, gender and income.

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C:J( Laurie 'Lali' D McCubbin boundaries within an ethnic context) explains the variability in the individual's overall sense of well-being (physically, emotionally and socially). Consistent with prior investigations with Native Hawaiians (McCubbin, H.I. et al. 1998), family ethnic schema emerged as a significant explanatory factor in positive adaptation. In this investigation, positive adaptation refers to the individual family member's physical, emotional and social well-being. Higher levels of family ethnic schema were inversely related to levels of anxiety, tension, depression, anger and fear but positively related to higher levels of energy and vitality. The findings renders empirical support for the assertion that the' ohana and its values, beliefs, expectations and priorities can have a positive impact on emotional and psychological well-being (McCubbin & McCubbin 2005; Policy Analysis and System Evaluation 2005). Valuing one's cultural and ethnic identity within the family system, connection with the spiritual! ancestral world and the land, and respect for elders may be at the core (pica) of Indigenous families which helps them to maintain a sense of balance or harmony which in turn may affect physical, social and emotional health.

FAMILY ETHNIC SCHEMA AND FAMILY SENSE OF MEANING Other studies point to family schema as a central component in the development of the family's sense of meaning in the face of crises or stressors such as traumatic brain injury (Kosciulek 1997), coping with a child with asthma (Masterson 1985) and obesity (Turner et al. 2005). This 'meaning making' may help families to overcome adversity and render clarity to the confrontation with and management of health issues in a larger context. Conceptualizing events or stressors through the lens of culture within the family can include (a) framing the stressor or situation within the family's ethnic values and expectations, (b) placing the situa- tion within the family's ethnic/ spiritual belief system, (c) examining the situation from a long

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term framework rather than solely on the short term consequences and (d) looking at situations within the family in terms of culture, i.e. interpersonal order of things including harmony with nature, family and the community (McCubbin et al. 1996). Family ethnic schema may also help explain overall individual wellbeing by providing the individual with a context or meaning-making framework in order to feel a sense of control, balance and harmony with both expected and unexpected life events. This 'meaning-making' may allow a person to navigate life's challenges including dealing with social injustices and historical trauma. However more research is needed in relation to these unique stressors facing Indigenous families and their impact on family adaptation and individual well-being. The relationship between age and family ethnic schema deserves further examination. Although outside of confirmation in this investigation there is reason to hypothesize that there is a developmental pathway between ethnic schema and age; as a person gets older, ethnic schema within the life cycle may gain clarity and value. In many cultures and particularly in Indigenous cultures, elders as their knowledge and acquired wisdom increases are perceived as having a special role in the community accompanied by greater respect and value. Therefore, the systematic study of individuals in the latter stages of life, as they transition through the Generativity and Integrity (Erikson, Erik~on, & Kivnick 1986) stages of the life cycle should be inclusive of ethnic schema as both a protective and a recovery factor in the individuals' coping and adaptation with life stressors and strains. Furthermore, 'meaning making', fostered by ethnic schema may well be an integral part of adaptation and life satisfaction, particularly during the later years. Along side the preponderance of research on ethnic identity in adolescence (Phinney 1990, 1992), family ethnic schema may add a new dimension in understanding the role c"ulture

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IMPLICATIONS FOR NURSING plays in later adulthood as having an impact on one's PRACTICE sense of integrity and being a part of an extended chain Family ethnic schema provides an understanding of the of human existence (Vaillant 1994) . worldview of Indigenous families as a unit and how families conceptualize and understand stressors such as family illness within a cultural and ethnic framework. IMPLICATIONS FOR FUTURE Family schema can also provide insight in evaluating a RESEARCH family's appraisal process in order to understand the family's coping behaviors. This concept provides a lens More research is needed with various Indigenous that provides the foundation upon which decisions families including Native Americans and Native peoples about health care are made including seeking health of Australia and New Zealand to determine if family care services (Indigenous or 'western' practice), ethnic schema is a valid and reliable measure across treatment protocol and adherence to treatment. Nash, Indigenous cultures. In addition, obtaining a larger Meiklejohn and Sacre (2006) assert that health services sample size with more male participants may yield can only be culturally safe and responsive if the different findings and include multiple dimensions services are congruent with the Indigenous culture's within the domain of family ethnic schema that may values, beliefs and practices and that the services are affect well-being, adaptation and resilience. One limiput in a context that is culturally meaningful. tation of this study is that all the participants were Indigenous perspectives need to be considered in the members of a civic club organization founded on the context of culturally safe collaborative care when identity and values of the Native Hawaiian culture. working with Indigenous peoples (Nash et al. 2006). Therefore the sample in this study may have higher Unsafe cultural practice can occur if one is not aware scores on family ethnic schema because of their of a family's schema which can be deeply rooted within affiliation with this organization when compared to one's ethnicity and culture and may be a key Hawaiians who are not members. Another limitation of component in a family's ways of coping and appraisal the study is the broad definition of well-being primarily process in dealing with health issues as a family unit. focused on the absence of negative emotions (e.g. In addition, generalizations about Indigenous families depression, anxiety, anger, and fear) and only on limited without considering the heterogeneity within Indigepositive factors (e.g. vitality and energy). nous groups may lead to erroneous assumptions and Future investigations should include more stereotypes and unsafe practices in health care. Family descriptive and clearly delineated frameworks of ethnic schema provides a tool that can shed some light overall well-being to understand better the relationship on the variation and heterogeneity across Indigenous between family ethnic schema and individual well- families and individual member's perceptions about being. It should also be noted that the family ethnic cultural values, beliefs and practices which may vary schema as based solely on one person's perspective. greatly within a family unit. Differing levels of family More comprehensive research including family ethnic schema among individual family members may constellations and multiple family members' also help in understanding family con perspectives may yield some interesting yet complex flict and discord around the treatment of a family member findings. Because family ethnic schema is in its who becomes seriously ill. beginning stages of development as a construct it is Understanding Indigenous family ethnic schema can important to distinguish its unique contribution on well- be a key element in building rela being from family support and ethnic identity. .

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C:Jf Laurie 'Lali' 0 McCubbin tionships and establishing a sense of trust and safety between health care providers and Indigenous clients. Being aware of ethnic values and beliefs can help health care providers understand their clients' worldviews and shape intervention and prevention programs. Cultural and ethnic worldviews can shape how Indigenous clients contextualize illnesses, diseases or health problems within the family. In addition family ethnic schema may also influence help seeking behavior and adherence to treatment plans. It can also address the heterogeneity within Indigenous families and avoid making generalizations and s.tereotypes across all Indigenous families. More research is needed to understand the complex nature of culture and ethnicity and its effects on health care programs and treatments when working with Indigenous peoples. This study yields some promising findings of strengths found within a family's cultural schema which may help promote overall health and well-being among Indigenous peoples and their respective families.

schemas: a cognitive-behavior perspective. Journal if Marital and Family Therapy 31 (1): 15-30.

Davis J, Busch J, Hammatt Z, Novotny R, Harrigan R, Grandinetti A and Easa D (2004) The relationship between ethnicity and obesity in Asian and Pacific Islander populations. A literature review. Ethnicity and Disease 14( 1): 111-118. Erikson EH, Erikson JM and Kivnick HQ (1986) Vital involvement in old age: The experience if old age in our time. New York: Norton. Guerrero AP, Hishinuma ES, Andrade NN, Bell CK, Kurahara DK, Lee TG, Turner H, Andrus J, Yuen NY and Stokes AJ (2003) Demographic and clinical characteristics of adolescents in Hawaii with obsessive compulsive disorder. Archives if Pediatrics and Adolescent Medicine 157(7): 665-670. Handy ES and Pukui MK (1972) The Polynesian family system in Ka'u. Boston MA:Tuttle. Hawley HR and DeHaan L (1996).Toward a defini tion of family resilience: Integrating life-span and family perspectives, Family Process 35(3): 283-191. Henslin J (Ed.) (1985) Marriage and family in a changing society. New York: The Free Press. Henslin J (Ed.) (1980) Marriage and family in a changing society. New York: The Free Press. Hishinuma ES, Johnson RC, Carlton BS, Andrade NN,

Acknowledgements

Nishimura ST, Goebert DA,Yuen NY, Wegner EL, Makini

This study was made possible by the members of the GK, Nahulu LB, Else IR and Chang JY (2004) Native Hawaiian community and their commitment to Demographic and social variables associated with the civic clubs. In addition the author would like to psychiatric and schoolrelated indicators for Asian/Pacific thank President Antonette Lee (National Association of Islander adolescents. The International Journal if Social Psychiatry 50(4): 301-318. Hawaiian Civic Clubs) and Dr Claire Hughes for their Hughes C and Higuchi P (2004) Ka LokahiWahine: A leadership and vision in promoting the health of Native culturally based training for health professionals. Pacific Hawaiians. Health Dialog 11(2): 166-169.

Johnson DB, Oyama N, LeMarchand L and Wilkens L (2004) Native Hawaiians mortality, morbidity, and lifestyle:

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