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Indigenous Values, Cultural Safety and Improving Health Care
The case of Native Hawaiians
Laurie D McCubbin
Educational Leadership and Counseling Psychology, Washington State University, Pullman, Washington, United States of America
Article Text
Mana, also referred to as the life force of all things, is what underlies this paper. It is written from the perspectives of an academic, an Indigenous community member and a Native Hawaiian, and is best read from the 'pico,' the center or essence of who and what one is as a person, rather than isolated to the intellect of the mind. It is this feeling from the center that one can most easily grasp the plight of Native Hawaiians and where healing and change can occur. This paper is an expression of the voices of generations of Indigenous people who have not been understood or worse, trivialized, but who persist in sharing their viewpoints in order that future generations may be better served. What is at stake if this falls on deaf ears is not just miscommunication, but the continued loss of mana or life force from generations upon generations of people. This editorial is for those who are seeking to be understood and for health professionals who care enough to search for and find meaning in the cultural values of their clients. I encourage colleagues to read these articles with an open mind, not as another hurdle or challenge, but rather as an opportunity for the healing of past injustices and for the voices of one's ancestors to be heard again across the lands of the Pacific. This chorus of the collective voice of Indigenous peoples, if heard, can help change the plight of Native Hawaiians and Pacific Islanders and create its own mana or energy for healing.
As a Native Hawaiian psychologist, I have been asked by various professionals and organizations to talk about Native Hawaiian values and their connections to physical and mental health. A more important question is how can knowledge of cultural values help promote primary prevention and early detection of health issues facing Native Hawaiians today? Native Hawaiians, similar to many Indigenous populations across the globe, are at risk of multiple illnesses including depression, anxiety, suicide, obesity, diabetes, cancer, hypertension, cardiovascular disease and stroke. Recently, theoretical models have been developed (McCubbin & McCubbin 2005) and empirical research has investigated Native Hawaiians' world views and values, and their impact on health and health care (McCubbin 2006; Oneha 2001).
At the center of Native Hawaiian culture is the family system (also referred to as 'ohana in Hawaiian) and the interpersonal relationships which shape the processes by which culture practices and values are transmitted, maintained, nurtured and affirmed. The 'ohana or family system is at the pico or center of health and healing processes and must be understood in efforts to provide effective health care. Unlike the Western conceptualization of family - the nuclear family - the Native Hawaiian concept of family is expansive and inclusive of relatives, close family friends, children (including those who were informally adopted, also referred to as hanaied), and inclusive of relatives and ancestors who have passed on. Consequently the 'ohana has significant impact on health and cultural safety for -
- obtaining information about the client, including family history and a patient's symptoms;
- the connection between 'ohana, 'aina (land) and health; and
- the cultural understanding of the etiology of diseases.
Cultural safety is inclusive of the 'ohana system from which the identified patient draws support, clarification of the meaning of symptoms and, in many cases, treatment. The degree to which Western health care services and health care providers are accepted and trusted is determined by the 'ohana's world view of the services and providers. The 'ohana system plays a key role in determining cultural safety.
'Ohana affects how information is communicated to a health care provider. Ancestors' and relatives' stories about their experiences with Western medicine can affect the level of trust and safety a client may feel towards a health care provider. Historical trauma has ramifications in daily interactions within the health care system. In my experience, working with Indigenous peoples, each family has a narrative about health care and its experience with Western medicine. Some Indigenous families have stories about fear and anger towards Western medicine due to inadequate health care in the past, mistreatment in the relationship, and a lack of respect or understanding of the Native culture and Indigenous ways of knowing. For example, clients may communicate their family health history through dreams of ancestors and family members who have passed on. This may appear as irrelevant information to a health care provider who may communicate feelings of impatience or frustration when a patient presents this information. However the narrative may actually reveal a family's health history and health care experiences, both of which are vital in assessing the client's risk factors and their adherence to treatment protocol.
For example, a client discussed his reluctance to return to a physician because, on the previous occasion, the doctor had talked about him as if he were not in the room (referring to the client in the third person even though he was present in the conversation). This revelation is the building block of relationships at the very core of cultural trust, cultural understanding and cultural harmony. It is more than an expression of discontent or a judgment of the professional or clinic. As taught among the Indigenous people, relationships determine the course of service, the avenue of care and the foundation of treatment. All too often professionals will minimize or intellectualize the pico of relationships, not out of disrespect but due to disconnection with the 'meaning' of relationships, which is core or central to Indigenous people. The relationship, the pico of a treatment relationship, must be earned and its genuineness tested in order that this cultural safety can be established.
The Hawaiian practice of minimizing pain or distress - also referred to as the 'Ain't no big thing' syndrome (Howard 1974) - can present a formidable challenge to health care professions who are socialized to expect patients to articulate their pain levels, their need for relief and demands for treatment. Through years of socialization of minimizing symptoms and pain, Native Hawaiian patients may not issue a clear picture of their personal health status and, in failing to do so, may mask their true needs. I have experienced within my own family how different expectations of how information is communicated, a lack of understanding of the culture, and a lack of awareness of one's assumptions can lead to ineffective health care.
During her final days, my aunt experienced significant physical pain. Her daughter, in nursing school at the time, observed her mother's movements, indicating discomfort and distress. Upon inquiry, the nurse noted that the patient had 'not asked for pain medication'. The daughter assisted the nurse in understanding her mother's propensities to avoid revealing needs, not wanting to impose on the medical team and her reliance on her 'ohana to communicate her needs.
The value of understanding the cultural role of the 'ohana in these matters can help create a safety zone for the client to express her real needs. There is a paradoxical conflict between the professional's desire to empower and respect the patient's right to make decisions and to respect and honor the cultural norms of communication within the 'ohana system. Cultural liaisons or advocates within the Indigenous community can be helpful in navigating these differing communication styles.
Alignment of western based policies with cultural based practices is a continuous issue and struggle among Native Hawaiians. The regional concept of health care, designed for the eight islands of the state of Hawaii, places specialized health care services in major urban settings, calling for patients in need of specialized care to be transported to another island. Flying by air to another island to visit hospitalized family members is expensive and time-consuming so critically ill patients are often alone and without family support. In addition, the 'ohana can have a spiritual connection to the 'aina that can affect their spiritual, psychological and physical health of (Oneha 2001). This value presents a challenge for patients and their supporters to achieve congruency in health care policies that remove the patient from his/her major network of support and their primary energy source for healing (eg their ancestral land) and can increase feelings of mistrust, fear, anger and frustration with the medical field. What may seem like a simple logistical decision, moving a patient to a different facility, may also put a patient at risk of feeling unsafe and isolated, if one does not understand, minimizes or fails to recognize this value and the need for a sense of belonging and safety within one's 'ohana, community and land.
McGrath et al (2006) provides insight into Indigenous peoples' understanding of the etiology of cancer and its relationship to interpersonal discord. Indigenous peoples' perspective of health is associated with being in harmony and connected to one's land, one's kin and the spiritual world (Fenwick 2006). Native Hawaiians also have a similar view of disease. Disease develops when disharmony, discord or transgressions in interpersonal relationships occur (McCubbin, Ishikawa & McCubbin in press). Native Hawaiian healers have two different etiologies of illness: ma' i mai waho and ma' i ma loko (Pukui, Handy & Livermore 1934). Ma'i mai waho refers to sickness caused by outside forces such as spirits or gods. Ma' i ma loko refers to sickness from within, originating from the family, such as grudges or family discord. For these illnesses, traditional healing practices such as faith healing and ho'oponopono or conflict resolution can be conducted within the 'ohana system to treat the cause of the illness(es). These Native treatment practices can be conducted in conjunction with Western treatment. The integration of both medical practices can help a client feel respected and safe, rather than placing the Indigenous client in a struggle between choosing his/her own cultural practices and Western medicine, which can result in feelings of mistrust, displacement and isolation.
The concept of 'ohana and its connection to the 'aina can greatly assist the design and implementation of community health services. For example, the annual convention of the Association of Hawaiian Civic Clubs incorporates a two-day health screening program conducted by a team of doctors, nurses, psychologists, and nutritionists, all with ties to the Native Hawaiian community. This health screening includes testing for diabetes, cholesterol, obesity, high blood pressure, mental health issues and other 'health risk' factors associated with the Hawaiian people. For some convention attendees, this may be the only time they will visit with health care providers. The health care providers, being active members within civic clubs, and being Hawaiian or connected to the Hawaiian culture, can create a sense of familiarity as part of the larger 'ohana community. The people conducting the screening (eg nurses, doctors, psychologists and nutritionists) can also go through screening demonstrating a collaborative, equalitarian process for all members in the organization. The conference attendees may also feel a sense of kinship with the health care providers as they may have had similar experiences and concerns within their own 'ohana and in dealing with delivery of health care services.
Nursing as a discipline has been a leader in promoting a biopsychosocial and spiritual view of health to guide the delivery of culturally competent care. Nurses have consistently been at the forefront in obtaining important health information and building trusting relationships with their patients. Incorporating cultural values in the health care process can lead to more effective prevention and early detection programs within an Indigenous community, holistic healing treatments inclusive of biomedical, psychological, emotional and spiritual interventions and Indigenous healing practices. Commonalities of the interconnections between the family, interpersonal relationships, vitality of the land, and physical and psychological well-being can be seen across Indigenous cultures and may represent an archetype that health care providers need to consider while simultaneously gaining a better understanding of intergroup and intragroup differences within these cultures. This special issue on cultural safety is vital in incorporating Indigenous values into systems of health care access, treatment and delivery of services. By integrating cultural worldviews and Indigenous healing practices, one can learn to respect and understand Native Hawaiians and other Pacific Islanders' pico and mana, to assist in the healing and protection of Indigenous cultures for future generations.
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