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Substance abuse among Native Hawaiian women in the United States: a review of current literature and recommendations for future research.

Substance abuse is a problem that adversely impacts society at micro and macro levels. Furthermore, substance abuse costs society approximately $67 billion every year including costs "related to crime, medical care, drug abuse treatment, social welfare programs, and time lost from work" (NIDA 1999). The 2005 National Survey on Drug Use and Health indicated that 22.2 million people aged 12 years or older years old met substance dependence or abuse criteria in the past year (SAMHSA 2006). During that same year, 23.2 million people aged 12 years or older needed substance abuse treatment, but only 3.9 million of these people received treatment (SAMHSA 2006). There is, hence, a huge gap between the number of people who need treatment and those who actually receive it.

Additionally, there are gender differences when it comes to rates of dependence, abuse and treatment entry. In 2005, males were more likely than females to report current illicit substance abuse, with the former at 10.2% versus the latter at 6.1% respectively (SAMHSA 2006). Also, 58.1% of males were current alcohol drinkers versus 45.9% of females (SAMHSA 2006). However, substance-dependent females are less likely to enter treatment than men (NIDA 2006). While there has been research about gender differences and substance abuse treatment, very little is known about subpopulations such as Native Hawaiian women.

DESCRIPTION OF NATIVE HAWAIIANS

According to the 2000 U.S. Census, there were nearly 141,000 Native Hawaiians in the U.S. (Leigh & Jimenez 2002). Native Hawaiians (NH) were the largest Pacific Islander population, comprising 35% of all Pacific Islanders (e.g. Native Hawaiians, Samoans, Tongans, Guamanians). There were many persons, however, who identified themselves as NH and another race, and NH are the fastest growing racial/ethnic group in Hawaii.

In the past 200 years, the NH population has experienced significant social changes that have affected their livelihoods and challenged their traditions (Leigh & Jimenez 2002; Takeuchi, Leaf & Kuo 1988). NH own less than 1% of the land in Hawaii, and their health status is largely determined by their socioeconomic status (Leigh & Jimenez 2002). Overall, NH have poorer health outcomes compared to other groups in Hawaii (Cheng & Ho 2002; Leigh & Jimenez 2002). Although a large number of NH have public health insurance, they are less likely to have health insurance compared with non-Hawaiians in Hawaii (Cheng & Ho 2002). Also, NH often use traditional medicine before seeking Western medicine (Leigh & Jimenez 2002).

Substance abuse is problematic for the NH population. According to the Hawaii State Department of Health, Hawaii's rate of heavy alcohol use was consistently higher than the national average in the 1990s, and as of 2006 was one and a half times higher than the United States average (HMSA Foundation 2005). The same source also contends that the rate of illicit substance use is higher in Hawaii than the United States average. As an example, approximately 20% of NH adults reported drug use in the past month whereas approximately 5% of adults in the U.S. reported drug use in the prior month. Regarding adult need for treatment, the 1995 Hawai'i Adult Household Survey of Substance Use and Treatment Needs indicated that close to 9% of adults residing in Hawaii were in need of both alcohol and illicit substance abuse treatment (Hawaii State Department of Health 2008) Clearly, this area warrants examination.

STUDY GOAL

Substance abuse is a significant public health problem facing our nation; however, published research regarding NH women remains largely unexplored. The goal of this article is to assess present knowledge about substance abuse among NH women. The findings will assist in addressing a significant priority area--health disparities among racial/ ethnic minority women (US DHHS 2005a, b).

METHODS

Search Methods

The search strategy for this article involved a search of the published literature utilizing the inclusion and exclusion criteria described below. We searched three computerized databases (PubMed, PsycARTICLES, and CINAHL) for published articles. The key words "Asian," "Pacific Islander," "NH," were used in combination (e.g., "and") with the following key words in these three computerized databases: "mental health," "mental disorders," "substance use," "substance abuse," "drug," "alcohol," "women," "health," "substances," "services," "help," "care," "treatment," "United States."

Other information sources included reference lists in articles, and consultation with field experts for other known published articles that were not found from the other sources. Published articles were read if the title and/or abstract of the article appeared to fulfill the search criteria. A published article's title and/or abstract was deemed relevant if it involved a study that was conducted in the U.S., included NH women, and was related to substance abuse and/or utilization of substance abuse treatment-related services.

After retrieval of the articles, each was read thoroughly to further determine whether it met the search criteria and should be included in this literature review. All articles that included Asian and Pacific Islander (API) or Asian women were included in the literature review if it was unclear whether NH were included in the "API" or "Asian" race/ ethnicity categories.

Inclusion Criteria

All published articles through December 31, 2006 that included studies that were conducted in the U.S. were retrieved. The population of interest was NH women; however, articles that included NH women under "Asian" or "API" women were also retrieved and reviewed. Types of publications included original research articles and review articles. Only articles that were written in the English language were included.

Exclusion Criteria

Commentaries and studies that only briefly mentioned substance abuse were excluded from this literature review. Also, articles that focused on the findings from clinical trials and/or the effects of certain medications or drugs on patients were also excluded. Substance abuse was restricted to problem alcohol use and illicit drug use, not tobacco use.

RESULTS

Of the 136 articles that were retrieved and reviewed, three existing review articles and 13 nonreview articles met the inclusion and exclusion criteria for this literature review. Table 1 provides a summary of the prevalence of substance abuse and use of services among NH women. Table 2 provides a summary of the prevalence of substance abuse and use of services among NH and Asian women. Both tables provide a summary of the articles' findings, including study aims, description of sample and study design, and summary of the main results.

This section presents findings by (1) prevalence of substance abuse and utilization of services among NH and (2) prevalence of substance abuse and utilization of services among NH, Asian and other Pacific Islander women.

Substance Abuse and Utilization of Services Among Native Hawaiians (Table 1)

There was one article that focused on the NH population but did not present findings by gender. It was a review article, and the data for the published findings were derived from a 1985 data source (Blaisdell 1993). This review article reported that NH have the highest prevalence (28.3%) of acute alcohol drinking in Hawaii, according to the 1989 U.S. Centers for Disease Control's Behavioral Risk Factor Surveillance System. Also, NH were ranked second for current alcohol use behind Caucasians in 1979, according to two reports focusing on NH mental health (the 1985 E Ola Mu NH Health Needs Study Mental Health Task Force Report and the 1987 volume of Contemporary Issues in Mental Health Research in the Pacific Islands). However, among alcohol abusers receiving alcohol treatment services, 19.4% were NH compared with 40.6% who were Caucasians.

According to these two reports, NH have the highest prevalence of narcotic abuse (15%). However, among substance abusers in treatment facilities in Hawaii in 1979, 22.3% were NH compared with 49.1% who were Caucasians.

Substance Abuse and Utilization of Services Among Native Hawaiian and Asian Women (Table 2)

The remaining articles are summarized in Table 2. Most of the articles did not distinguish their findings by NH ethnicity, gender (e.g., women), or both (NH women). The following section summarizes the main findings of the articles as they relate to substance abuse and use of services among NH women. This section includes four subsections, which are organized by the population studied or included in the articles: NH women; women but not separately by NH ethnicity; NH ethnicity but not separately by gender; and other articles.

Native Hawaiian Women

One cross-sectional study examined the health care utilization patterns among women in Hawaii (n = 332) and found the prevalence of substance abuse among NH women to be 13.8% (vs. 8.8% Japanese and 11.1% Filipina) (Blaisdell-Brennan & Goebert 2001). In the same study, NH women were less likely to have seen a provider in the past year, less likely to have insurance, and more likely to have visited the emergency department.

Moreover, another study that included college students (n = 541) in Hawaii found high rates of current/former alcohol use among Hawaiian/part-Hawaiian (87.5%) females compared with rates of 53.6% for Chinese, 84.6% for Europeans, 53.7% for Filipinas and 67% for Japanese females (Danko et al. 1988).

Another study that looked at perinatal substance use and poor pregnancy outcomes among high-risk women (n = 2,750) in Hawaii found that Hawaiians/part-Hawaiians (19%) had a significantly higher prevalence of alcohol use compared with non-Hawaiians (12%) (Fuddy, Prince & Tang 2003). Hawaiian/part-Hawaiian women (11%) also had a significantly higher prevalence of illicit drug use compared with non-Hawaiian women (7%). After controlling for demographic factors, Hawaiian/part-Hawaiian women were one and a half times more likely to drink alcohol compared with non-Hawaiian women. Furthermore, among Hawaiian/ part-Hawaiian women, those who used alcohol and other drugs (14.8%) had significantly different preterm rates compared with those who did not use any substances (5.5%). For those who used at least one substance, the preterm rate was 10% (p < 0.01) and the low birth weight rate was 12% (p < 0.01) compared to women with no substance use, who had a preterm rate of 5.5% and a low birth weight rate of 6.6%, respectively.

Women but not Separately by Native Hawaiian Ethnicity

A recent article that utilized data from the 2002 National Epidemiologic Survey on Alcohol and Related Conditions, which is comprised of a representative sample of U.S. adults 18 years or older, included 1,517 pregnant women (including eight Native Hawaiians/Other Pacific Islanders (NHOPI)) and 10,576 nonpregnant women (including 42 NHOPI) in their study (Caetano et al. 2006). NHOPI pregnant women were not included in the analysis due to a small sample size. Nevertheless, among nonpregnant women, NHOPI had the highest rate of alcohol dependence (over 12%), but the second highest rate of ex-drinkers and abstainers (52.5%) compared to other racial groups.

Another cross-sectional study that examined the association between psychosocial risk factors and alcohol or other drug use among adult female recipients (n = 150) of public assistance in Hawaii included Hawaiians/part-Hawaiians in their sample (27%) (Delva & Kameoka 1999). However, the study did not present results by ethnic group. The main findings included a high prevalence of alcohol use (65%) and other drug use (e.g., 20% marijuana, 12% methamphetamine, and 10% cocaine, respectively) in the past 12 months. This study also found that alcohol use in the past 12 months was associated with mental health problems, and drug use in the past 12 months was significantly associated with aggressiveness, lack of social support and history of family cohesion. Also, greater alcohol use was significantly associated with having a greater number of relatives with alcohol/other drug use and increased aggressiveness.

In another article, findings compared prevalence and trends of alcohol abuse/dependence in the U.S. by racial group and gender (Grant et al. 2004). However, findings specific to NH women were not presented. Similarly, an article that utilized data from the 1988 National Health Interview Survey to provide estimates of the prevalence of family history of alcoholism did not present findings specific to NH women (Harford 1992).

In addition to the quantitative studies described above, there were also qualitative studies conducted in this area of substance abuse among women that included NH. Two of the three qualitative studies, which were conducted by the same authors, interviewed 21 women who were participants in a culturally based, women-centered residential treatment program for pregnant and postpartum women in Hawaii in 1998 (Morelli, Fong & Oliveira 2001; Morelli & Fong 2000). The majority of the study participants were Hawaiian/part-Hawaiian (81%) and the rest were Asian. Additionally, most of the women (80%) were substance-free at the time of the study, although the methods used to determine this are not shared. The treatment program was "designed to address barriers that often prevent Asian and Pacific Islander women from engaging and completing treatment" (Morelli, Fong & Oliveira 2001: 263).

The first study asked the women to describe the kupunas's role in substance abuse treatment (Morelli & Fong 2000). In Hawaiian culture, kupunas are grandparents or elders who can provide support to women who abuse substances. A majority of the women (87%) had positive assessments of kupunas' participation or role in the program. The women said that the kupunas were helpful in helping them heal through Hawaiian cultural practices, developing parenting skills, supporting the relationship between parent and child, educating them about Hawaii's culture, and providing counsel.

The second qualitative study asked the participants about their substance abuse treatment experience with the program (Morelli, Fong & Oliveira 2001). This study found the following to be very important in participants' treatment experience: being able to trust that the staff would not use their past substance abuse against them, and participating in a Hawaiian-deep cultural therapy. This therapy is comprised of ho'oponopono (conflict resolution), deep culture or storytelling, lo'i (taro patch), and Lomilomi, a form of massage therapy.

Some components of Hawaiian-deep cultural therapy warrant further explanation (Mokuau 2002). Ho'oponopono is a family-based treatment approach that occurs in stages. This process involves identifying the problem, discussing feelings about the problem, apologizing for the problem, receiving forgiveness for the problem, and finally, releasing the problem. A community leader, respected elder, or family member, facilitates this process. Lo'I refers to tending to the taro patch. While a participant plants, weeds, and harvests the taro, they learn about Hawaii's cultural past through an elder's storytelling. Taro has been thought of as the first sibling of humans, which suggests that working with taro is caring for ancestors and future family members.

The third qualitative study involved interviews with 31 incarcerated women (including 19 NH/part-Hawaiians) to better understand the unmet needs and situations or factors that played a role in the behavior that led to their incarceration (Stein 2001). This study provided the background information that NH women made up less than 10% of Hawaii's population yet comprised of up to 40% of Hawaii's incarcerated women. Results indicated that a majority of women interviewed were incarcerated for a drug-related offense (90%). Most women reported being addicted to an illegal substance during the time of last arrest (97%), and recognized that they had a substance abuse problem during or before the time of their arrest (71%).

The majority of these women also experienced violence (87%; e.g., rape, physical or sexual abuse as a child) in their life (Stein 2001). More than a quarter reported having been diagnosed with a mental disorder (eight, or 26%), and seven out of the eight women had a co-occurring mental and substance abuse disorder. Also, at the time of arrest, 43% of participants had a stable living situation. The problems in their lives affected the women in various ways including depression, anger and suicidality.

In addition, 58% (n = 18) of the women had received substance abuse treatment in the past (Stein 2001). Of these women, 16 reported receiving treatment an average of two and a half times and the rest "many times" (Stein 2001). The majority of the women who reported receiving treatment (n = 16) felt that their treatment was successful, although the definition of treatment varied among the women. Intensity of treatment varied, and some considered self-help groups such as Alcoholics Anonymous.

Native Hawaiian Ethnicity but not Separately by Gender

Furthermore, one cross-sectional study in Hawaii using data from the 1982 Hawaii Alcohol, Drug and Mental Health Survey examined the lifetime prevalence of drug use among adults from five ethnic groups (n = 2,503) including NH/part-Hawaiians (19%) (McLaughlin et al. 1987). This study found that compared with Asian ethnic groups (Chinese, Japanese, and Filipino), Caucasians and Hawaiian/ part-Hawaiians have higher lifetime prevalence of drug use.

Other Articles

The remaining articles included NH in the analyses but they were included in the racial category "Asians and NHOPI," had insufficient sample sizes to analyze the data by NH ethnicity, and/or did not present or discuss gender differences (Price et al. 2002; Zhang & Snowden 1999; Kuramoto 1994; Ja & Aoki 1993).

DISCUSSION

Summary of Findings

Overall, the majority of the articles reviewed did not present results by gender-ethnic group (e.g., NH women). Of the 16 articles, two did not present differences by gender (Blaisdell 1993; McLaughlin et al. 1987), seven did not distinguish by NH ethnicity (Caetano et al. 2006; Grant et al. 2004; Stein 2001; Delva & Kameoka 1999; Harford 1992; Morelli, Fong & Oliveira 2001; Morelli & Fong 2000), and four did not distinguish by either gender or NH ethnicity (Price et al. 2002; Zhang & Snowden 1999; Kuramoto 1994; Ja & Aoki 1993). The remaining articles distinguished and/or discussed NH women specifically in their findings (Fuddy, Prince & Tang 2003; Blaisdell-Brennan & Goebert 2001; Danko et al. 1988). Clearly there is a dearth of substance abuse data on NH women.

This literature review suggested a high prevalence of substance abuse among NH women. For instance, a majority of incarcerated NH women were arrested for drug-related offenses and had an addiction to an illicit substance during the time of the last arrest (Stein 2001). Qualitative studies have discovered that incarcerated NH women were highly likely to also have a co-occurring mental disorder (Stein 2001).

Another study that included NH (but did not provide results specifically for NH women) found the prevalence of current/former alcohol use among Hawaiian/part-Hawaiian college students to be 87.5% (Danko et al. 1988). Prevalence of acute alcohol drinking (five or more drinks one or more times in the past month) was 28.3% (Blaisdell 1993). Factors related to alcohol use included being widowed and depressed (McLaughlin et al. 1987). Prevalence of other drug use ranged from 15% (narcotic use; Blaisdell 1993) to 28.4% (marijuana/hashish use; McLaughlin et al. 1987). Factors related to other drug use among NH included younger age and being separated/divorced (McLaughlin et al. 1987).

Strengths and Limitations

Strengths. This study provides a unique contribution to the literature. To our knowledge, this is the first article that summarizes current understanding about NH women's use of substances and background characteristics associated with addiction. Moreover, it identifies substance abuse treatment characteristics that are important to NH women.

Limitations. It is important to acknowledge that the authors of the articles that were reviewed may have been limited in their ability to examine specific differences by NH ethnicity and gender (e.g., females). However, the goal of this literature review was to contribute important knowledge specific to NH women; this group that has been historically understudied, and our findings support this point.

Some of the findings of this literature review consisted of articles that were published a number of years ago. However, this fact supports the need for future research in an understudied area. Such research will expand understanding of the needs related to substance abuse treatment services for NH women.

Recommendations for Future Research

NH women had significantly lower health care utilization rates compared to other racial/ethnic groups (including Caucasians) and were less likely to have seen a health care provider in the past year (Blaisdell-Brennan & Goebert 2001). Although NH women were less likely to have health insurance compared to other groups, this does not completely explain the underutilization of services among NH women. There were limited studies, however, that distinguished the types of health care used (e.g., substance abuse treatment); this information helps in understanding the factors behind this underutilization as well as which factors help to facilitate the decision-making process for NH women in seeking treatment for substance use disorders.

Research that explores NH women's barriers to seeking mental health services is limited, but there has been documentation of the presence of cultural barriers in the NH culture when trying to promote and change health behaviors, which may present as similar barriers to substance abuse services. For instance, "efforts from outsiders to bring about behavior changes are viewed by NH as infringements on their traditions, which value integration, balance, and continuity among person, nature, and spiritual world" and NH may oppose change for this reason itself (Leigh & Jimenez 2002: 10). Two other cultural factors that may act as a barrier to seeking health services are illness interpretation and mistrust of health providers. First, the NH culture may view illnesses as disharmonious, which interfere with the Hawaiian culture of preservation of harmony; thus, NH may try to underrate the illness in order to preserve harmony (Leigh & Jimenez 2002). Second, NH may also be mistrustful of Western healthcare providers due to past experiences (Leigh & Jimenez 2002). Exploration of these cultural influences on substance use will help substance abuse treatment providers better serve this population.

In addition to recognizing the barriers to seeking substance abuse treatment services, it is also important to learn what factors serve as facilitators to accessing care for substance abuse among substance-abusing or -dependent NH women. One factor that should be investigated is 'ohana, a Hawaiian term that refers to the extended family. 'Ohana in the NH culture is the "center of all relationships" (Nahulu et al. 1996) and may play an important role in treatment-seeking behaviors for NH women. Also, kupunas appeared to play a significant role in creating positive experiences for NH women in a substance abuse treatment program; this also merits further special attention.

There are other cultural factors that have not been as extensively explored in the NH population. For instance, an important question to examine is whether ethnicity-specific substance abuse treatment programs (having providers from the same cultural/ethnic background) make a difference among the NH population. Takeuchi and colleagues (1995) found that Asian Americans who went to ethnicity-specific mental health programs were almost 15 times more likely to return after the first session compared to Asian Americans who went to mainstream ("Caucasian") programs, but it was not clear whether this had an impact on the treatment outcomes. A limitation of this study is that it did not include NH in the sample (Takeuchi, Sue & Yeh 1995); it would be interesting to see whether offering ethnic-specific substance abuse programs for NH women would serve as a potential facilitator to seeking services.

Two of the articles reviewed were literature reviews on drug abuse research conducted among Asians and Pacific Islanders (Kuramoto 1994; Ja & Aoki 1993). Both found that there was limited drug abuse prevention research on these populations and on institutional and community barriers to substance abuse treatment (e.g., cultural bias, denial, lack of knowledge). Kuramoto (1994) suggested that the lack of substance abuse data strongly supported the model minority myth, which results in a perception of little substance abuse treatment needs for Asians and Pacific Islanders. He also concluded that there was a lack of culturally competent services available and the majority of API were in prison for drug-related offenses.

Furthermore, the drug abuse treatment system in the U.S. is poorly equipped to meet the needs of racial and ethnic minorities, and these groups have been generally underserved in these systems (US DHHS 1999). A recommended method for determining whether a racial or ethnic minority group is experiencing problems accessing substance abuse treatment services is to "examine their utilization of services in relation to their need for services" (US DHHS 1999). Based on the results discussed here, there appears to be a high need among NH, but a low utilization rate of services. The present findings show that there are clear needs among the NH population. Further exploration in this area is essential in order to improve the health and well-being of NH and to thereby reduce health care disparities in the United States.

Finally, in order to move the knowledge base about NH women forward, it seems important to adopt the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) ten recommendations for the improvement of research with a minority focus, which are as follows: (1) support for secondary analysis of existing datasets, (2) identification of race/ethnicity in databases, (3) research on cultural variations within ethnic/racial groups, (4) research on effects of migration and immigration on alcohol, (5) treatment and prevention research, with a focus on cultural issues, (6) need for small-scale studies, (7) need for ethnographic research, (8) minority expert collaboration, (9) liaison between minority alcohol researchers, NIAAA, National Institute on Drug Abuse, and 1(0) training support for minority researchers (Kuramoto 1994). If researchers are mindful of these recommendations, perhaps understanding of how to better provide culturally appropriate substance abuse treatment for NH women can be improved.

REFERENCES

Blaisdell-Brennan, H.K. & Goebert, D. 2001. Health care utilization among women on O'ahu: implications for Native Hawaiian women. Pacific Health Dialog: A Publication of the Pacific Basin 8 (2): 274-9.

Blaisdell, R.K. 1993. Health status of kanaka maoli (indigenous Hawaiians). Asian American and Pacific Islander Journal of Health 1(2): 116-60.

Caetano, R.; Ramisetty-Mikler, S.; Floyd, L.R. & McGrath, C. 2006. The epidemiology of drinking among women of child-bearing age. Alcoholism: Clinical and Experimental Research 30 (6): 1023-30.

Cheng, S.M. & Ho, T.L. 2002. A Portrait of Race and Ethnicity in Hawaii: An Analysis of Social and Economic Outcomes of Hawaii's People. Honolulu: Pacific American Research Center.

Danko, G.P.; Johnson, R.C.; Nagoshi, C.T.; Yuen, S.H.; Gidley, J.E. & Ahn, M. 1988. Judgments of "normal" and "problem" alcohol use as related to reported alcohol consumption. Alcoholism: Clinical and Experimental Research 12 (6): 760-68.

Delva, J. & Kameoka, V.A. 1999. Risk for alcohol and drug abuse among ethnically diverse female recipients of public assistance. Ethnicity and Disease 9 (2): 237-45.

Fuddy, L.J.; Prince, C.B. & Tang, M.C. 2003. Perinatal substance use among high risk women in Hawaii: Patterns and impact on pregnancy outcomes. Asian American and Pacific Islander Journal of Health 10 (1): 50-57.

Grant, B.F.; Dawson, D.A.; Stinson, F.S.; Chou, S.P.; Dufour, M.C. & Pickering, R.P. 2004. The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States, 1991-1992 and 2001-2002. Drug and Alcohol Dependence 74 (3): 223-34.

Harford, T.C. 1992. Family history of alcoholism in the United States: Prevalence and demographic characteristics. British Journal of Addiction 87 (6): 931-35.

Hawaii State Department of Health. 2008. 1995 Hawai'i Adult Household Survey of Substance Use and Treatment Needs. Retrieved from http:/hawaii.gov/health/substance-abuse/prevention-treatment/ survey/adsurv.htm

HMSA Foundation. 2005. Health Trends in Hawaii: A Profile of the Healthcare System. Seventh Ed. Retrieved from www.healthtrends.org

Ja, D.Y. & Aoki, B. 1993. Substance abuse treatment: Cultural barriers in the Asian-American community. Journal of Psychoactive Drugs 25 (1): 61-71.

Kuramoto, F.H. 1994. Drug abuse prevention research concerns in Asian and Pacific Islander populations. In: A. Cazares & L. Beatty (Eds.) Scientific Methods for Prevention Intervention Research. NIDA Research Monograph #139. Rockville, MD: NIDA.

Leigh, W.A. & Jimenez, M.A. 2002. Factors affecting the health of women of color. Women of Color Health Data Book. Bethesda: Office of the Director, National Institute of Health.

McLaughlin, D.G.; Raymond, J.S.; Murakami, S.R. & Goebert, D. 1987. Drug use among Asian Americans in Hawaii. Journal of Psychoactive Drugs 19 (1): 85-94.

Mokuau, N. 2002. Culturally based interventions for substance use and child abuse among native Hawaiians. Public Health Reports 117 (Suppl 1):S82-87.

Morelli, P.T.T. & Fong, R. 2000. The role of Hawaiian elders in substance abuse treatment among Asian/Pacific Islander women. In: J. Delva (Ed.) Substance Abuse Issues Among Families in Diverse Populations: Haworth Press.

Morelli, P.T.; Fong, R. & Oliveira, J. 2001. Culturally competent substance abuse treatment for Asian/Pacific Islander women. Journal of Human Behavior in the Social Environment 3 (3/4): 263-80.

Nahulu, L.B.; Andrade, N.N.; Makini, G.K., Jr.; Yuen, N.Y.; McDermott, J.F., Jr.; Danko, G.P.; Johnson, R.C. & Waldron, J.A. 1996. Psychosocial risk and protective influences in Hawaiian adolescent psychopathology. Cultural Diversity and Mental Health 2 (2): 107-14.

National Institute on Drug Abuse (NIDA). 2006. Women and substance abuse. NIDA News Scan: NIDA Addiction Research News October 13: 1-4.

National Institute on Drug Abuse (NIDA).1999. NIDA InfoFacts: Drug Addiction Treatment Methods. Rockville, MD: NIDA.

Price, R.K.; Risk, N.K.; Wong, M.M. & Klingle, R.S. 2002. Substance use and abuse by Asian Americans and Pacific Islanders: Preliminary results from four national epidemiologic studies. Public Health Reports 117 Suppl 1:S39-50.

Stein, L.Y. 2001. The psychosocial needs of Hawaiian women incarcerated for drug-related crimes. Journal of Social Work Practice in the Addictions 1 (4): 47-69.

Substance Abuse and Mental Health Services Administration (SAMHSA). 2006. Results from the 2005 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies.

Takeuchi, D.T.; Leaf, P.J. & Kuo, H.S. 1988. Ethnic differences in the perception of barriers to help-seeking. Social Psychiatry and Psychiatric Epidemiology 23 (4): 273-80.

Takeuchi, D.T.; Sue, S. & Yeh, M. 1995. Return rates and outcomes from ethnicity-specific mental health programs in Los Angeles. American Journal of Public Health 85 (5): 638-43.

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Please address correspondence and reprint requests to Van M. Ta, Ph.D., Assistant Professor, University of Hawaii at Manoa, Department of Public Health Sciences, 1960 East-West Rd., D104AA, Honolulu, HI 96822. Phone: (808) 956-5767, fax: (808) 956-5818, email: vanta@hawaii.edu

Van M. Ta, Ph.D., M.P.H. * & TeChieh Chen, B.A. **

([dagger]) The original dissertation research for this study was conducted at the Johns Hopkins University Bloomberg School of Public Health. Final editing for and draft of this publication were supported by the National Institute of Drug Abuse (NIDA) University of California San Francisco Treatment Research Center Grant (P50 DA09253) and the NIDA Training Grant (T32 DA07250).

* Assistant Professor, University of Hawaii at Manoa, Department of Public Health Sciences, Honolulu, HI.

** Clinical Psychology Graduate Student, Purdue University, Department of Psychological Sciences, West Lafayette, IN.
TABLE 1
Prevalence of Substance Abuse & Utilization of Services Among Native
Hawaiians

Study Study Aims Study Sample/ Design

Blaisdell 1993 * Summarize indigenous Review of available
(Review article) Hawaiians' present literature and unpublished
 health status with information
 historical background
 Data sources include: State
 of Hawaii Vital Statistics,
 Health Surveillance Program,
 Tumor Registry, U.S. Census
 and 1985 E Ola Mau NH
 Health Needs Study Medical
 Task Force Report

Study Results

Blaisdell 1993 * NH continually have low SES. Some alarming findings
(Review article) include: NH have highest mortality rates, Years of
 Productive Life Lost rate, crude birth rate,
 infant mortality rate.

 NH with highest prevalence (28.3%) of acute alcohol
 drinking (5 + drinks 1 + times in past month). NH
 ranked second for current alcohol use behind
 Caucasians in 1979. However, among alcohol abusers
 receiving alcohol treatment services, 19.4% were
 NH vs. 40.6% Caucasians.

 NH with highest rate of narcotic abuse (15%). Among
 drug abusers in treatment facilities in 1979, 22.3%
 were NH vs. 49.1 % Caucasians.

 "The data support hypothesis of cultural conflict,
 social disruption, and impaired self-image (p.135).

 Availability of health services concentrated in
 Honolohu. higher % of NH reside on neighbor islands.
 Rural residents and neighboring islands are at a
 disadvantage due to fewer available care. In 1992,
 less than 3% of licensed medical doctors in Hawaii
 were NH.

* Cannot distinguish most findings by gender

Abbreviations: Native Hawaiians (NH); Socioeconomic status (SES).

TABLE 2
Prevalence of Substance Abuse & Utilization of Substance Abuse
Services Among Native Hawaiian (NH) and Asian Women

Study Study Aims Study Sample/Design

Blaisdell- Examine health care Cluster sampling used
Brennan & utilization patterns among from 8 shopping centers
Goebert 2001 women in Hawaii & on Oahu.
 comparisons among ethnic
 groups 332 women (including
 21.6% Japanese, 18.5%
 NH, 11.9% Filipina).
 Limited to
 English-speaking women.

Caetano et al. Estimate prevalence of Subjects drawn from 2002
2006 ** drinking, binge drinking, National Epidemiologic
 alcohol abuse and Survey on Alcohol and
 dependence, & identify Related Conditions who
 factors associated with responded to the
 heavier drinking among pregnancy questions.
 women of child-bearing
 age. n = 1,517 pregnant
 women (including 8 NHOPI)
 & 10,576 non-pregnant
 women (including 42
 NHOPI).

 Other races included
 Asians, Blacks,
 Hispanics, Native
 Americans/Alaskan
 Natives, Mixed Races,
 and Caucasians.

Danko et al. Obtain alcohol use Participants recruited in
1988 data and judgments of psychology courses at
 "normal" and "problem" University of Hawaii and
 alcohol use. Windward Community
 College.

 n = 541 female respondents
 including 28 Chinese, 136
 European, 41 Filipina, 72
 Hawaiian/part-Hawaiian,
 and
 264 Japanese.

Delva & Examine psychosocial risk Cross-sectional study.
Kameoka factors & association with
1999 ** alcohol/other drugs Participants recruited
 from six public
 assistance program
 units of Hawaii
 Department of
 Health Services.

 Self-report data.

 n = 150 adult female
 recipients of public
 assistance including
 27% Hawaiian/
 part-Hawaiian, 7%
 Japanese, 1% Samoan, 5%
 Filipina.

Fuddy, Prince Examine association High-risk women in Hawaii
& Tang 2003 between perinatal who had live births
 substance use & poor during 1994-95 and
 pregnancy outcomes enrolled in Hawaii's
 Perinatal Support
 Services program

 Hawaiian/part-Hawaiian (n
 = 1,721) including 20.6%
 Caucasian, 17.8%
 Filipina, 6.9% Samoan,
 3% Japanese

 Self-report data

Grant et al. Determine prevalence & Data derived from
2004 ** trends of alcohol abuse/ National Institute on
 dependence in U.S. Alcohol Abuse and
 Alcoholism's (NIAAA)
 2001-02 National
 Epidemiologic Survey
 on Alcohol and related
 Conditions (NFSARC) (n =
 43,093) & NIAAA's
 1991-92 National
 Longitudinal
 Alcohol Epidemiologic
 Survey (NLAES)
 (n = 42,862)

 Both NESARC & NLAES
 consisted of
 face-to-face
 interviews with
 respondents aged 18+
 years residing in
 non-institutionalized
 population in
 U.S.

 DSM-IV used as diagnostic
 instrument for alcohol
 abuse & alcohol
 dependence for both
 NESARC & NLAES.

Harford Provide U.S. estimates Data derived from 1988
1992 ** of prevalence of family National Health Interview
 history of alcoholism Survey (NHIS)

 Sample (n = 43,809)
 consisted of 18+ years
 old

 Respondents were asked if
 they had relatives who
 were problem drinkers or
 alcoholics. NHIS did not
 provide formal criteria
 for alcoholics/problem
 drinkers, however.

Ja & Aoki Summarize issues Review literature of
1993 *** concerning cultural present state of
(Review barriers with substance knowledge.
article) abuse among Asian
 Americans

Kuramoto Describe drug abuse Review literature on
1994 *** prevention research issues substance abuse research
(Review among API conducted among API in
article) U.S.

McLaughlin et Determine lifetime Data derived from a
al. 1987 * prevalence of drug use cross-sectional survey
 within five ethnic groups called the Hawaii
 Alcohol, Drug and Mental
 Review psychosocial Health Survey.
 predictors of drug use
 Face-to-face structured
 interview conducted with
 one person, 18+ years
 old, from each
 household (n = 2,503
 including 19% Native
 Hawaiian/part-Hawaiian;
 29% Caucasian; 4%
 Chinese; 22% Japanese;
 11% Filipino); 56%
 females

 Interview questions:

 1) Drug use--prevalence
 of 10 different
 drugs.

 2) Alcohol use--a) Type
 of drinker; b) alcohol
 consumption level

Morelli, Fong Examine the substance Data derived from
& Oliveira abuse treatment participants in a
2001 narratives of API women culturally based,
 participating in the women-centered
 program residential treatment
 program in Hawaii (called
 Na Wahine Makalapua).

 21 API women participated
 in semi-structured
 interviews (2-4 hours) in
 1998 (2 years after the
 demonstration project
 closed). Women were
 Native Hawaiian/part
 Hawaiian (81%) and
 Asian (19%)

Morelli & Fong Describe Kupuna's Data derived from
2000 (Hawaiian for family participants in a
 elders or grandparents) culturally based,
 role and Hawaiian women-centered
 practices as facilitators residential treatment
 in the healing of pregnant program in Hawaii
 and postpartum API (called Na Wahine
 women. Makalapua).

 15 of the 21 API women
 who participated in
 semistructured
 interviews (2-4 hours) in
 1998 (two years after the
 demonstration project
 closed). Women were
 Native Hawaiian/Hawaiian
 (81 %) and Asian (19%)

Price et al. Assess substance abuse Study analyzed four
2002 *** among API & Caucasians. national surveys:

 Examine the role of 1) 1999 National
 acculturation & SES with Household Survey on
 substance abuse Drug Abuse (NHSDA99)
 (n = 66,706)

 2) 1992 National
 Longitudinal Alcohol
 Epidemiologic Survey
 (NLAES92) (n = 42,862)

 3 & 4) 1995 National
 Longitudinal Study of
 Adolescent Health
 In-School & In-Home
 surveys (Add Health
 S95, Add Health H95)
 (n = 90,118, n =
 20,745, respectively)

 Substance abuse measures
 restricted to most
 commonly used drugs.

 No formal measures of
 acculturation in surveys.
 Study used indicators to
 assess acculturation
 (e.g. foreign-born;
 language spoken at
 home; immigration
 patterns; SES).

Stein 2001 ** Better understand the Study conducted at T.J.
 unmet needs & situation/ Mahoney & Associates,
 factors that played a role a program for females
 in the behavior that led in transition back to the
 to incarceration among community from prison.
 non-violent,
 substance-abusing women. 31 incarcerated women
 were interviewed
 (including 19 Native
 Hawaiian/part-Hawaiian).

Zhang & Examine lifetime Data derived from the
Snowden prevalence of substance Epidemiological Catchment
1999 *** use disorders among Area (ECA) study in U.S.
 various ethnic groups
 Data analyzed with full
 sample (five sites) & one
 ECA site, Los Angeles.
 Both include adult males
 & females.

 Full sample (n = 18,152):
 69.5% Caucasian, 1.9% API

 Los Angeles sample
 (n = 2939): 44.6%
 Caucasian, 7.1 % API

Study Results

Blaisdell- Prevalence of substance abuse: 13.8% NH, 8.8%
Brennan & Japanese, 11.1% Filipina.
Goebert 2001
 NH were less likely to have seen a provider in pass
 year, less likely to have insurance, and more likely
 to visit the emergency department.

Caetano et al. NHOPI pregnant women not included in analysis
2006 ** due to small sample size.

 Among nonpregnant women NHOPI have the highest
 rate of alcohol dependence (over 12%) compared
 with other races. Rate for total sample was 4%.

 1) NHOPI have the second highest rate of
 ex-drinkers and abstainers (nearly 53%) after
 Asians (55%).

 2) NHOPI have lower rates of alcohol abuse,
 binge drinking, and drinking compared with
 the rates of the total sample.

 3) No significant difference in the odds ratio for
 heavier drinking between NHOPI and
 Caucasians.

Danko et al. Prevalence of current/former alcohol use: 53.6%
1988 of Chinese, 84.6% of European, 53.7% of Filipina
 87.5% of Hawaiian/part-Hawaiian, & 67% of
 Japanese

 Ethnic differences in consumption are similar to
 ethnic differences in norms. High correlation
 between group means in quantity and frequency
 of alcohol use and group means in self and
 cultural judgments of normal alcohol use.

Delva & Prevalence of alcohol use in past 12 months: 65%.
Kameoka Prevalence of drug use in past 12 months: 20%
1999 ** reported marijuana use, 12% methamphetamine
 use, & 10% cocaine use.

 Alcohol use in past 12 months associated with
 mental health problems (p < 0.05).

 Drug use in past 12 months associated with
 aggressiveness (p < 0.05), lack of social support
 (p < 0.05), & family cohesion (p < 0.05).

 Greater alcohol use associated with greater #
 relatives with alcohol/other drugs use (p < 0.05)
 and increased aggressiveness (p < 0.05).

 Prediction of alcohol/other drugs problems
 associated with increased mental health problems
 (p < 0.05) and increased aggressiveness (p < 0.01)

Fuddy, Prince Significant difference in prevalence of alcohol use
& Tang 2003 and illicit drug use between groups:

 1) Alcohol use: Hawaiian/part-Hawaiian
 (19.1%) and non-Hawaiian (12%) (p < 0.001)

 2) Illicit drug use: Hawaiian/part-Hawaiian
 (10.9%) and non-Hawaiian (6.7%) (p < 0.001)

 Compared to non-Hawaiian women, Hawaiian/part-Hawaiian
 women were more 1.5 times more likely
 to drink alcohol (p < 0.01), after controlling for
 demographic factors.

 Among Hawaiian/part-Hawaiian women, those who
 used alcohol and drugs had a preterm rate of 15%
 (p < 0.01) compared to less than 6% of women who
 did not use any substances. For those who used at
 least one substance, the preterm rate was 10%
 (p < 0.01) and low birth weight rate of 12% (p <
 0.01) compared to women with no substance use.

Grant et al. Prevalence of alcohol abuse (AAB): 2001-02
2004 **
 1) Overall, AAB 12-month prevalence was
 4.7% (representing 9.7 million adults)

 2) Overall, significant difference of AAB
 prevalence between males & females (6.9%
 and 2.6%, respectively). Not statistically
 significant among API.

 3) Among females, Caucasians had significantly
 higher AAB rate vs. API.

 4) Overall, % of AAB decreased with each
 successively older age group.

 5) Among API females, % AAB for age groups
 were: 4.6% 18-29 years old; less than 1 %
 30-44 years old; less than 1 % 45-64 years old.

 Prevalence of alcohol dependence (AD): 2001-02

 1) Overall, 12-month prevalence of AD was
 3.8% (representing 7.9 million adults).

 2) Overall, rates significantly greater for males
 vs. females, but not among API.

 3) Overall, 1.3% AD among API females.

 4) Overall, % of AD decreased with each
 successively older age group.

 Trends of AAB between 1991-92 & 2001-02

 1) % AAB significantly increased between
 1991-92 (3%) & 2001-02 (4.7%).

 2) Among API females, % AAB was less than
 1% (1991-92) & 1.1% (2001-02).

 3) Among API females aged 18-29, % AAB
 was less than 1% (1991-92) & 3.9%
 (2001-02) (p < 0.05).

 Trends of AD between 1991-92 & 2001-02

 1) % AD significantly decreased between 1991-92
 (more than 4%) & 2001-02 (less than 4%).

 2) Among API females, % AD was 1 % (1991-92)
 and 1% (2001-02) (not statistically significant).

Harford Among total sample, nearly 38% reported family
1992 ** history of alcoholism (36.1% of male & 38.8% of
 female).

 Among API women (n = 439):

 1) 15.5% with family history of alcoholism (vs.
 40.2% among Caucasian women)

 2) 7.9% with 2nd and/or 3rd degree relatives
 only (vs. 14.9% among Caucasian women)

 3) 6.2% with 1st degree relatives only (vs.
 15.8% among Caucasian women)

 4) 1.4% with 1st, 2nd, and/or 3rd degree
 relatives (vs. 9.5% among Caucasian women)

Ja & Aoki Present state of knowledge:
1993 *** 1) Not much data exist in the area of substance
(Review abuse among Asian Americans
article)
 2) Present data suggest that Asian Americans
 have lower rates of substance abuse

 3) Lower rates of substance abuse associated
 with metabolic/genetic factors

 4) However, this knowledge may not be
 accurate due to study designs of past research
 (e.g. inadequate sample size, including controls)
 and heterogeneity of Asian Americans (e.g.
 findings tend to be broadly applied to Asian
 Americans, but may not be applicable to
 specific Asian Americans subgroups).

 5) Institutional & community barriers to treatment
 (e.g. cultural bias, denial, lack of knowledge)

Kuramoto Limited drug abuse prevention research on API.
1994 *** Lack of substance abuse data strongly support the
(Review model minority myth, which results in a perception
article) of little substance abuse treatment needs for API.
 Some findings:

 1) Use of marijuana and cocaine more present
 in assimilated API & recent immigrants.
 Possible reasons for this include peer pressure,
 misunderstandings concerning U.S.'s laws of
 substance abuse and cultural norms in the
 immigrants' native countries.

 2) Lack of culturally competent services.

 3) Alcohol consumption among Pacific Islanders
 (e.g. Samoan) is higher than U.S. average.

 4) Majority of API in prison for drug-related
 offenses.

McLaughlin et Prevalence:
al. 1987 *
 1) Compared with Caucasians & Native
 Hawaiian/part-Hawaiian, Asian Americans
 overall had less lifetime prevalence of drug use

 2) Compared with Caucasians & Native
 Hawaiian/part-Hawaiian, Chinese Americans
 had lower drug use.

 3) Compared with Caucasians & Native
 Hawaiian/part-Hawaiian, Asian Americans
 had lower alcohol use in past year.

 4) Native Hawaiian/part-Hawaiian had lower
 alcohol use vs. Caucasians.

 Predictors of use:

 1) Age is significant predictor of overall drug
 use (e.g. cocaine & marijuana use higher
 among younger respondents across all groups)

 2) Education not a significant predictor with
 any drug use.

 3) Lower incomes significant with only use of
 marijuana/hashish & cocaine

 4) Generally, not being married is associated
 with all types of drug use.

Morelli, Fong Treatment program was designed to address
& Oliveira barriers that often prevent API women from
2001 engaging & completing treatment.

 Analysis of interviews found the following as very
 important to their treatment experience: Being able
 to trust that the staff would not use their past
 substance abuse against them and participation in
 a Hawaiian--deep cultural therapy (which integrated
 Hawaiian values & traditional healing).

 80% of women were substance-free at the time
 of the study.

Morelli & Fong The API women were participants in a culturally
2000 based substance abuse treatment program in Hawaii.

 87% of women had positive assessments of kupunas'
 participation/role. Women said kupunas were helpful
 in helping them heal through Hawaiian cultural
 practices, developing parenting skills, supporting the
 relationship between parent and child, educating them
 about Hawaii's culture, and providing counsel
 and paying attention to them.

Price et al. % API
2002 ***
 1) NHSDA99--less than 4%;

 2) NLAES92--2.3%;

 3) Add Health S95--5.1%;

 4) Add Health H95--6.6%.

 % Female

 1) NHSDA99--51.9%;

 2) NLAES92--58.4%;

 3) Add Health S95--49.5%;

 4) Add Health H95--50.5%.

 % 18+ years old

 1) NHSDA99--62%;

 2) NLAES92--100%;

 3) Add Health S95--86.2%;

 4) Add Health H95--86.6%.

 Compared with other racial groups, API had
 lowest substance abuse rate.

 Results limited to Caucasian & Asian Americans

Stein 2001 ** Background: NH women make up <10% of
 Hawaii's population yet make up 40% of Hawaii's
 incarcerated women.

 Results: 90% of women were incarcerated for a
 drug-related offense. 97% of women said they were
 addicted to an illegal substance during the time of
 last arrest. 71% of women recognized they had a
 substance abuse problem during or before time of
 arrest. 58% (n=18) of women had received treatment
 for substance abuse in past. Of these, 16 received
 treatment average of 2.5 times and two others
 many times. 16 women also felt their treatment
 was successful (authors state that interpretation of
 this finding is not clear since meaning of treatment
 varies among individuals).

 Seven women had a co-occurring substance abuse
 disorder along with mental health disorder.

Zhang & Lifetime prevalence of:
Snowden
1999 *** 1) Drug: a) Full sample: 6% Caucasian, 2.3% API;
 b) Los Angeles sample: 11.7% Caucasian, 2.1%
 API

 2) Alcohol: a) Full sample: 12.7% Caucasian,
 7.1 % API; b) Los Angeles sample: 14.5%
 Caucasian; 7.1 % API

 Odds ratios for API (vs. Caucasians) (95% CI):

 1) Drug: a) Full sample: 0.26 (0.11, 0.63);
 b) Los Angeles sample: 0.14 (0.05, 0.39)

 2) Alcohol: a) Full sample: 0.49 (0.33, 0.74); b)
 Los Angeles sample: 0.45 (0.28, 0.70)

* Cannot distinguish most findings by gender

** Cannot distinguish most findings by Native Hawaiian ethnicity

*** Cannot distinguish most findings by gender and Native Hawaiian
ethnicity

abbreviations: Asians and Pacific Islanders (API); Diagnostic and
Statistical Manual of Mental Disorders, 4th Edition (DSM-M; Native
Hawaiians (NH); Native Hawaiians/Other Pacific Islanders (NHOPI);
Socineconomic stains (SRS).
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Article Details
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Author:Ta, Van M.; Chen, TeChieh
Publication:Journal of Psychoactive Drugs
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2008
Words:7911
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