Hawaiian Women Research Articles

High relapse rates and poor survival of native Hawaiian (NH) women with HER2-positive breast cancer.

e11116 Background: The Hawaii Tumor Registry reports of higher mortality rates and advanced disease at diagnosis for Native Hawaiian (NH) women with breast cancer may represent a biologically more aggressive cancer complimented by HER2 overexpression. This study investigates the association of HER2 overexpression potentiating NH breast cancer leading to early relapses and poor survival. Methods: This retrospective study analyzed data for women diagnosed with breast cancer from 2000-2005, and followed through 2007 (n=1488), at the Queen’s Medical Center in Honolulu, Hawaii. This study focused on three major ethnicities: NH (n=359), Japanese (JA; n=609) and Caucasian (CA; n=520) women. Demographics on tumor grade, stage, ER, PR, and HER2 expression were obtained from the hospital’s cancer registry. Cox regression models of 1) relapse; 2) death for these patients were used to evaluate the association of intrinsic breast cancer subtypes and ethnicities. Survival time was the interval between diagnosis and death or cessation of follow-up at 2007. Results: We compared the frequency distribution of tumor subtypes (Luminal A, Luminal B, HER2-positive, and Triple Negative). Triple Negative breast cancers were associated with increased risk of death for the NH women (Hazard Ratio (HR)=2.8, p=0.046) and JA (HR=2.2, p=0.052). HER2-positive breast cancers were associated with increased risk of death for NH (HR=2.6, p=0.044) and CA (HR=2.9, p= 0.018) women, but not for the JA women. In HER2+ tumors, we observed that there was a significant increase in the frequency of relapse for NH (23.6%) compared to JA (9.8%) or CA (10%) women. Cox regression analysis indicate that NH women are more likely to relapse (HR=3.28) compared to JA (HR=1.05) or CA (HR=1.2) women. Conclusions: These data illustrate the importance of cross-ethnic studies in understanding racial/ethnic based differences in breast cancer incidence and mortality. We observed that Her2 overexpression is associated with disproportionately higher relapse and mortality rates in NH women with breast cancer. An ethnicity - HER2 interaction is suggested by this data and further molecular studies are indicated.

Projecting Individualized Absolute Invasive Breast Cancer Risk in Asian and Pacific Islander American Women

The Breast Cancer Risk Assessment Tool (BCRAT) of the National Cancer Institute is widely used for estimating absolute risk of invasive breast cancer. However, the absolute risk estimates for Asian and Pacific Islander American (APA) women are based on data from white women. We developed a model for projecting absolute invasive breast cancer risk in APA women and compared its projections to those from BCRAT. Data from 589 women with breast cancer (case patients) and 952 women without breast cancer (control subjects) in the Asian American Breast Cancer Study were used to compute relative and attributable risks based on the age at menarche, number of affected mothers, sisters, and daughters, and number of previous benign biopsies. Absolute risks were obtained by combining this information with ethnicity-specific data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program and with US ethnicity-specific mortality data to create the Asian American Breast Cancer Study model (AABCS model). Independent data from APA women in the Women's Health Initiative (WHI) were used to check the calibration and discriminatory accuracy of the AABCS model. The AABCS model estimated absolute risk separately for Chinese, Japanese, Filipino, Hawaiian, Other Pacific Islander, and Other Asian women. Relative and attributable risks for APA women were comparable to those in BCRAT, but the AABCS model usually estimated lower-risk projections than BCRAT in Chinese and Filipino, but not in Hawaiian women, and not in every age and ethnic subgroup. The AABCS model underestimated absolute risk by 17% (95% confidence interval = 1% to 38%) in independent data from WHI, but APA women in the WHI had incidence rates approximately 18% higher than those estimated from the SEER program. The AABCS model was calibrated to ethnicity-specific incidence rates from the SEER program for projecting absolute invasive breast cancer risk and is preferable to BCRAT for counseling APA women.

Abstract LB-442: The association of HER2/neu overexpression with relapse and poor survival in Native Hawaiian women with breast cancer

Abstract Cross-ethnic comparisons of data from the Hawai'i SEER Cancer Registry show that Native Hawaiian female breast cancer patients have the highest incidence and mortality among all ethnic populations in Hawai'i and Japanese had the lowest mortality. Factors that contribute to this disparity include socioeconomic status, access to healthcare, stage at diagnosis, and tumor biology. Breast cancer is a heterogeneous disease, with multiple subtypes based on histologic type, estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2/neu) expression profiles. This single institution-based retrospective study analyzed data for female patients diagnosed with breast cancer from 2000–2005 and followed through 2007 (n=1488) at the Queen's Medical Center in Honolulu, Hawai'i. This study focused on three major ethnic populations in Hawai'i: Native Hawaiian (n=359), Japanese (n=609) and Caucasian (n=520) women. Information on tumor stage, ER, PR, and HER2/neu expression were obtained from the hospital's cancer registry. Cox regression models of 1) relapse 2) death for breast cancer patients were used to evaluate the association with tumor subtype and ethnicity, adjusting for stage. Survival time was defined as the interval between diagnosis and the endpoint or cessation of follow-up at 2007. We compared the frequency distribution of intrinsic breast cancer subtypes [Luminal A (ER/PR+; HER2/neu−), Luminal B (ER/PR+; HER2/neu+), HER2/neu-positive (ER/PR−, HER2/neu+), and Triple Negative (ER/PR−, HER2/neu−)]. Native Hawaiian women had the lowest prevalence of Lum A subtype (69%) compared to Japanese (76%) and Caucasian women (72%). Native Hawaiian women had a higher prevalence of Lum B (14%) compared to Japanese (6%) and Caucasian (12%) women. Prevalence of Triple Negative and HER2/neu subtypes was similar for the three ethnic groups. There was a difference in survival associated with the intrinsic subtypes for the three ethnic groups. Triple Negative breast cancers were associated with increased risk of death for the Native Hawaiian (HR=2.8, p=0.046) and Japanese (Hazard Ratio (HR)=2.2, p=0.052) women. The HER2/neu-positive subtype was associated with increased risk of death for Native Hawaiian (HR=2.6, p=0.044) and Caucasian (HR = 2.9, p = 0.018) women, but not for the Japanese women. When we examined the outcome of relapse associated with HER2/neu overexpression, we observed Native Hawaiian (HR=3.28) women were more likely to relapse compared to Japanese (HR=1.05) or Caucasian (HR=1.2) women. We identified an association between differences in the prevalence of intrinsic subtypes, relapse and survival levels, and racial/ethnic background. These data illustrate the importance of cross-ethnic studies to increase our understanding of racial/ethnic based differences in breast cancer incidence and mortality in order to reduce disparities. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr LB-442. doi:10.1158/1538-7445.AM2011-LB-442

Testing the Feasibility of a Culturally Tailored Breast Cancer Screening Intervention with Native Hawaiian Women in Rural Churches

The authors report on the feasibility of delivering a church-based breast cancer screening intervention tailored on the cultural strengths of rural-dwelling Hawaiians. Native Hawaiian women are burdened by disproportionately high mortality from breast cancer, which is attributed to low participation in routine mammography. Mammography is proven to be an effective means for detecting disease at its earliest stages, when treatments are most likely to be successful. Culturally tailored screening programs may increase participation. Hawaiian initiatives call for screening innovations that integrate Hawaiian cultural strengths, including those related to spirituality and the extended family system. Before full-scale testing of tailored interventions, it is important to conduct feasibility studies that gauge community receptiveness to the proposed intervention and research methods. Study results establish the attractiveness and potential effectiveness of the authors' screening intervention. Recruitment exceeded targets, and retention rates were comparable to those of other randomized behavioral trials, confirming the value of reaching rural Hawaiian women through churches. Women appreciated the integrative approach of Hawaiian and faith-based values, and positive outcomes are suggested.This article may be relevant to social workers interested in culturally responsive, community-based interventions and to researchers conducting pilot studies and controlled trials of interventions adapted from evidence-based programs.

Voices of Native Hawaiian Women

Using a community based participatory approach, individual interviews and focus groups were conducted with Native Hawaiian women to understand their cultural perceptions, responses, and needs regarding intimate partner violence (IPV). Semi-structured interview guides were used for both interviews. The overriding theme derived from content analysis is that IPV "starts in the home," it is learned in the family and in the community. Visible injuries requiring emergency care is commonly perceived as IPV. The response to IPV included a primary theme of "defend the collective." Intimate partner violence is understood to be a "family matter," dealt within the family or by oneself. Native Hawaiian women who participated in this study sought to re-connect or establish relationships with self, others, spirit, natural elements, cultural practices, and community. Responding to IPV requires an understanding of cultural perceptions, responses, and needs of Native Hawaiians, with implications for families and communities. The needs expressed by Native Hawaiian participants reflect what they need to access "health." Implications for health care providers require understanding how best to facilitate an individual's access to "health" vs. access to "health care."

"You Have Been Very Thoughtful Today": The Significance of Gratitude and Reciprocity in Missionary-Hawaiian Gift Exchange

In October 1819 the first company of American missionaries set sail for the Hawaiian Islands with the express intent of converting its inhabitants to Christianity. The missionaries earnestly believed that they might provide Hawaiian Islanders with the dual gifts of civilization and salvation and were eager to set about the work of bestowing them. Missionaries were surprised to discover that Hawaiians had gifts of their own to bestow, interrupting the missionary agenda almost from the moment of their arrival. Exploring the unspoken and often symbolic language of gifts, this article offers a re-examination of early Hawaiian-missionary contact to argue that Hawaiian and missionary women—who situated themselves at the very center of the exchange of things—were powerful figures in this missionary and colonial drama.

The Pacific Muse: Exotic Femininity and the Colonial Pacific (review)

Reviewed by: The Pacific Muse: Exotic Femininity and the Colonial Pacific Susan Y. Najita The Pacific Muse: Exotic Femininity and the Colonial Pacific. By Patty O'Brien. Seattle: University of Washington Press, 2006. 338 pp. $25.00 (paper). In her recent book, The Pacific Muse: Exotic Femininity and the Colonial Pacific, Patty O'Brien has provided an extensive and expansive discussion of the fetishistic image of island women whose ubiquity in popular culture is at once instantly recognizable and entirely clichéed. O'Brien defines the "Pacific muse" as that "stereotype of exotic femininity" that involves the representation of Pacific Island women as "little brown gal"—exotic, youthful, "unself-consciously naked," "physically perfect, passive, and pleasing" (p. 5). The Pacific muse is a "portal" through which the Pacific past—its historical myths, meanings, and representations—might be viewed. Not only does the notion of the muse reveal how colonial representations of island women "fed the making of Pacific history"; it also shows how this history, in turn, "fed colonial representations" (pp. 4–5). Hence, O'Brien examines the accounts of explorers, beachcombers, missionaries, whalers, sealers, and convicts for their representations of indigenous women while also showing how those documents served as the basis for fictional, poetic, musical, artistic, and other representations. These creative forms fed the further production of expectations and assumptions about the Pacific that contributed to later colonial projects. (So perhaps while the notion of the "Pacific muse" grates to those who acknowledge the gendered critique of the concept of the muse, in many senses it is an appropriate term.) The muse image emerges out of, on the one hand, the accounts of voyages of exploration and contact beginning in the 1760s (in particular landings in Tahiti and what would become French Polynesia), and on the other, a harkening back to the representations of women in the Hellenic revival of the late eighteenth and early nineteenth centuries. O'Brien deftly charts the transformation of this image over the nineteenth and into the twentieth centuries. She positions [End Page 531] the Pacific muse in relation to anxieties about colonial masculinity and white femininity, showing how the image "contrasts" with and also "absorbs" the latter (p. 4). O'Brien's book contributes to the burgeoning field of studies of gender and sexuality in Pacific Studies at the same time that it broadens the feminist critique of constructions of sexuality and gender to include locations such as the Pacific, a location that is often thought of mistakenly as merely a geographical extension (or derivative) of other colonial sites. Chapter 4, which looks at the notions of noble and ignoble savages, is particularly important because it furthers our understanding of how these concepts were produced beyond the highly masculine notion of "the savage." O'Brien persuasively examines how Western judgments about Pacific Islander women's bodies as either nubile or maternal bodies were being produced in relation to Enlightenment ideas of women. The geographical terrain of The Pacific Muse is broad, incorporating typical images of exotic femininity associated with Polynesia as well as constructions of Aboriginal women, those of the western Pacific islands, and those of Micronesia. At times, this geographical sweep leads to a re-inscription of the type. Thus, for example, the only significant discussion of Hawaiian women comes in the chapter in which O'Brien discusses the incompatible notions of European and Hawaiian feminine beauty. In the process, figures such as Ka'ahumanu or Kīna'u are reclaimed from their infamous "girth" in the following way: "Powerful Hawaiian women such as [these], whose girth was often a point of interest, were revered and courted by the American missionaries of the islands, because their influence depended upon these women.… Transient observers had no need for such diplomacy" (p. 201). The passage reveals a tendency on O'Brien's part to provide brief, summative answers to explain the complexity of Ka'ahumanu and Kīna'u's significance which went far beyond mere "influence" (p. 201). These historical figures become opportunities to reinscribe the Western approach to women as objects of men's evaluative and amorous affections. But perhaps this is the result of O'Brien's particular approach, a...

Female Disclosure of HIV-Positive Serostatus to Sex Partners: A Two-City Study

The aims of this article are (1) to describe the prevalence of disclosure of HIV serostatus to sex partners among a racially/ethnically diverse sample of HIV-positive women living in Hawai'i and Seattle, Washington; and (2) to examine factors related to disclosure and condom use with those sex partners. HIV-positive women have difficulties consistently disclosing serostatus to sex partners and using condoms. Little is known about the disclosure practices of women from Hawai'i or Seattle. A cross-sectional design with convenience and snowball sampling was used, and up to three recent sex partner experiences were assessed among the HIV-positive participants (N = 84). A total of 133 recent sex partners were reported, with disclosure and condom use frequencies of 75.2 and 59.9%, respectively. Women who knew when it was safe to disclose were more likely to disclose. Women who disclosed to recent sex partners were less likely to use condoms, while those in casual/anonymous partnerships were more likely to use condoms. Hawaiian/part Hawaiian women had the lowest proportion of condom use. Health care personnel should routinely discuss disclosure and sexual transmission risk behaviors with seropositive women and offer strategies to enhance condom use, especially among those in committed partnerships. Culturally tailored interventions focused on strengthening efficacy beliefs for disclosure and condom use in Native Hawaiians are needed.

Navigating Uncharted Oceans of Meaning:Kaonaas Historical and Interpretive Method

I ka ‘ōlelo nō ke ola, I ka ‘ōlelo nō ka make. In speech there is life, in speech death.—Hawaiian proverb ('ōlelo no'eau)“With You is My Life, with You My Death.” With these Words, the American Missionary Rev. William Richards Placed Himself Under the protection of the‘aha’ ōlelo, a Hawaiian chiefly council composed of the highest-rankingali'iin the Sandwich Islands. On the afternoon of 26 November 1827, Richards defended himself before the ‘ahaagainst a charge of libel brought by the English consul, Richard Charlton. Charlton had argued with Richards over a letter the minister had written to his Boston-based employers, the American Board of Commissioners for Foreign Missions (ABCFM). The letter, written in October 1825, contained the news that an English captain, William Buckle, had purchased a Hawaiian woman from a chiefess. The problem was not the letter itself but the fact that it had been made public, through American newspapers. It would take the news two years to make its way back to the islands from New England, a world two oceans and six months’ sail away. The purchase of the woman, according to Charlton, was slavery and constituted a violation of British piracy law (qtd. in Richards, Letter to Evarts, 6 Dec. 1827). When Richards refused to sign an oath swearing to the veracity of his letter, Charlton accused the missionary of libel. Now both parties had come before the‘aha ‘ōleloto argue their cases. The question before the chiefs was whether or not the American Richards should be turned over to Charlton to face the charge in front of an English jury.

Abstract LB-392: Ethnic/racial differences in bladder cancer risk: the Multiethnic Cohort

Abstract Few studies have examined differences in bladder cancer risk among ethnic groups in the United States. We investigated racial/ethnic differences in bladder cancer risk and cancer stage and risk factors for bladder cancer among 189,998 African-American, Japanese-American, Latino, Native Hawaiian, and White men and women in the Multiethnic Cohort Study. We included 880 incident cases of bladder cancer (685 males and 195 females) identified in the cohort over an 11-year period, between baseline (1993 through 1996) and 2004. Data on known/potential risk factors for bladder cancer were obtained from the baseline questionnaire. Among many potential risk factors examined, only cigarette smoking-related variables (e.g. cigarette dose, years of smoking, pack-years, and years since quitting) were significantly associated with risk of bladder cancer in both men and women; the associations were observed in all five racial/ethnic groups. Racial/ethnic differences in bladder cancer risk were observed in men (P<0.0001) and women (P=0.001). Whites, by far, had the highest risk of bladder cancer compared to other racial/ethnic groups; the relative risks (RRs) (vs. Whites) were 0.65 [95% confidence intervals (CI): 0.53, 0.80] for African Americans, 0.63 (95%CI: 0.46, 0.86) for Native Hawaiians, 0.59 (95%CI: 0.49, 0.69) for Japanese, and 0.41 (95%CI: 0.33, 0.50) for Latinos. After adjustment for cigarette dose, the RRs were 0.69 (95%CI: 0.56, 0.85) for African Americans, 0.65 (95%CI: 0.47, 0.89) for Native Hawaiians, 0.62 (95%CI: 0.52, 0.73) for Japanese, and 0.48 (95%CI: 0.38, 0.59) for Latinos. Similar results were obtained when other smoking variables were considered for adjustment. Although Whites had the highest risk of developing bladder cancer, African-American (P=0.007) and Latino (P=0.008) women were more likely to be diagnosed with advanced disease. Among current and former cigarette smokers, regardless of their smoking dose, Whites were more susceptible to bladder cancer than African Americans, Hawaiians, Japanese, and Latinos. Results from this study suggest that differences in self-reported smoking characteristics among men and women of different races/ethnicities do not fully explain interethnic differences in bladder cancer risk. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr LB-392.

Abstract 1827: Ethnic differences in the association between body mass and risk of colorectal cancer in the multiethnic cohort

Abstract Introduction. Higher body mass has been associated with elevated risk of developing colorectal cancer. However, limited prospective data are available as to whether the association differs among ethnic groups with varying degrees of susceptibility for central obesity and obesity-related metabolic diseases. We investigated potential ethnic heterogeneity in the body mass-colorectal cancer association in the Multiethnic Cohort. Methods. Baseline self-reported data were obtained on height, weight, physical activity, diet, and other risk factors from a population-based sample of over 96,810 men and 118,441 women in Hawaii and Los Angeles who were of Caucasian, African, Japanese, Latino, and Native Hawaiian ancestry and were 45-75 years old in 1993. By December 2006, 1,575 male and 1,316 female incident colorectal cancer cases were ascertained from linkage with SEER registries. The associations of interest were estimated by multivariable-adjusted Cox proportional hazards models with age as the time metric. Results. Prevalence of obesity at baseline (body mass index (BMI) ≥ 30) ranged from 8% in Japanese to 36% in Native Hawaiian men and from 6% in Japanese to 35-37% in African American and Native Hawaiian women. Baseline BMI was positively associated with colorectal cancer risk in men (hazard ratio (HR) for BMI ≥ 30 compared with 18.5-22.9 = 1.50 (95% confidence interval: 1.32, 1.70)) and women (HR = 1.50 (1.33, 1.70)). When examined by sex and ethnicity, men of Caucasian (HR = 1.80 (1.36, 2.39)), African (HR = 2.17 (1.48, 3.16)), and Japanese (HR = 1.80 (1.44, 2.25)) ancestry showed a positive association, whereas Latino and Native Hawaiian men showed a null association (p-interaction = 0.11). In women, the association was strongest among Native Hawaiians (HR = 2.39 (1.24, 4.60)) and Japanese Americans (HR = 2.21 (1.75, 2.79)), followed by Latinas (HR = 1.67 (1.15, 2.41)) and Caucasians (HR = 1.38 (1.07, 1.77)), while it was null among African Americans (p-interaction = 0.12). Conclusions. These findings from a large follow-up study of diverse ethnic make-up suggest sex- and ethnicity-related heterogeneity in the body mass-colorectal cancer association, which would be important to consider for understanding the etiology and identifying higher-risk groups for intervention. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 1827.

Sources of Information that Promote Breast and Cervical Cancer Knowledge and Screening Among Native Hawaiians in Southern California

Breast and cervical cancers are the second and fourth leading causes of cancer death among Asian and Pacific Islander women. Despite screening exams that can detect these cancers early and increase survival, racial and ethnic populations continue to be disproportionately affected. This study examined the sources of information and their impacts on cancer screening compliance among native Hawaiians in Orange County, California. A community-based participatory research approach was used to conceive, design, implement, and analyze data. A relatively small proportion of the study's native Hawaiian women were compliant with recommended breast and cervical cancer screenings, and their screening rates were below the national Healthy People 2010 standards. Knowledge of screening procedures, seeking advice from a doctor, and obtaining information from internet medical sites were associated with higher rates of compliance with cancer-screening procedures.

Patterns of regular use of mammography—Body weight and ethnicity: The Multiethnic Cohort

To describe the association between body mass index (BMI) and frequency of regular mammography over an approximate 6-year period after controlling for the influence of demographic factors, behavioral factors, and medical history. This association was examined overall and by race/ethnicity in a multiethnic cohort of women including African American, Japanese American, Hispanic, Native Hawaiian, and non-Hispanic White women. Analysis of 81,722 women from the Hawaii and Los Angeles Multiethnic Cohort (MEC) using unconditional logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (CIs) for the association between BMI and regular annual or biennial (every 1-2 years) mammography overall and by race/ethnicity. Overall, 36% of MEC women reported regular annual mammography over an approximate 6-year period of follow-up. African American, Hispanic, and Native Hawaiian women had significantly lower annual and biennial mammography use compared to White women even after controlling for age, education, family history, BMI, menopausal status, and hormone therapy. Women who were overweight (OR = 0.96; 95% CI 0.92-1.01) or obese (OR = 0.88; 95% CI 0.84-0.93) were less likely to have regular annual mammography compared to women of normal weight. Similar findings were noted among women who had mammograms every 1-2 years (biennial). BMI is associated with the frequency of regular annual and biennial mammography in multiethnic women, especially among women who are overweight and obese. Culturally sensitive educational strategies that promote healthy behaviors toward regular mammography and maintenance of normal BMI are warranted.

Abstract B26: Cancer prevention clinical trials: Assessing for disparities in recruitment in Hawaii

Abstract A key concern of clinical trials of cancer is improving the participation rates of minority populations that are often underrepresented and have high rates of disease. In particular, identifying the underlying factors that contribute to the underrepresentation of minorities is essential for developing improved recruitment strategies—this is especially important for prevention trials of cancer that may ultimately translate to reducing the burden of disease in the population. To identify disparities in cancer prevention trials in Hawaii, we compared participation rates across racial/ethnic groups for breast and prostate cancer prevention trials. We then examined the methods of recruitment for each trial. The following four prevention trials were included in our assessment: the Breast Cancer Prevention Trial (BCPT), the Prostate Cancer Prevention Trial (PCPT), and the Study of Tamoxifen and Raloxifene (STAR). We identified gender differences in the participation rates of Native Hawaiians. Among 272 female participants in the STAR and BCPT trials, 10.3% (n = 28) were Native Hawaiian. In contrast, among 213 male participants in the SELECT and PCPT studies, only 5.2% (n = 11) were Native Hawaiian. The ethnic breakdown of the state during the approximate time of recruitment (2000) was as follows: African American 2.4%, Caucasian 24.3%, Chinese 7.4%, Filipino 16.5%, Hawaiian 19.8%, Japanese 18.9%, Korean 2.4%, Other ethnicities 8.4% (US Census, 2000). In these trials differing recruitment strategies were used. For example, in the SELECT trial a targeted direct mailing campaign to men 50 years of age or older (27.6% of sample), whereas in the STAR trial physician referral was the primary source of participation (59.0%). While these analyses do not speak to what specific strategies were most beneficial for a given racial/ethnic group, it is important to note that there was a higher likelihood of recruiting Native Hawaiian women when they were referred to the trial by their physician. Understanding the importance of the relationship between the study participant and the referral agent is just one strategy that will be examined in our future work. Researchers attempting to recruit African Americans at a rate of 20% for clinical trials (Cook at al., 2005) found that a diligent effort aimed at expanding the eligibility recruitment for African American men and the provision of more resources to particularly target this group were strategies that helped decrease disparities in recruitment. Given the multi-ethnic and multi-cultural nature of Hawai'i there are a wide range of practices and beliefs that need to be considered and incorporated in clinical trial recruitment. Our ultimate goal is to improve the participation rates of Native Hawaiians in clinical trials of cancer prevention. Citation Information: Cancer Prev Res 2010;3(1 Suppl):B26.

Hawaiian Culture Propped High with Meaning: The Lei Hoaka in Victoria Nalani Kneubuhl's Emmalehua

Hawaiian Culture Propped High with Meaning The Lei Hoaka in Victoria Nalani Kneubuhl’s Emmalehua Stefani Overman-­ Tsai Victoria Nalani Kneubuhl, a postcolonial playwright of Sa­ moan, Hawaiian, and Caucasian descent, unveils the challenges Hawaiian Ameri­ can women face in their construction of an identity that embraces their heritage, yet still allows comfortable social movement within the dominant U.S. culture present in Hawai’i. Three of Kneubuhl ’s published plays can easily be categorized as postcolonial. In Emmalehua Kneubuhl specifically traces complicated issues of Ameri­ can-­ iza­ tion prevalent in Hawai’i in the 1950s through the negotiation of a specific stage prop, a lei hoaka.1 Kneubuhl’s play is not simply a history lesson of Hawai’i’s past. Instead, the playwright weaves history with current struggles native Hawaiians experience with Ameri­ canization and the consequences of centuries of colonization. Using traditional and ancient practices, Kneubuhl traces the trials of the protagonist, Emma, and her family as they each struggle to encourage each other not to for­ get their heritage and give into Ameri­ canization. This essay will examine the playwright’s use of an ancient lei hoaka and how it highlights the complications for native Hawaiians in a postcolonial society. Many props are used to signify how characters are reacquainted with their Hawaiian heritage in Emmalehua. Many of those props will be discussed in this essay, but it is the lei hoaka that is particularly interesting in a consideration of how postcolonialism is addressed. In the first scene of the play Emma hears the call of Laka, the goddess of hula, after ignoring her grandmother and hula for several years. The call of Laka is transferred from her dreams to her consciousness and the audience by a Greek-­ like chorus and the lost lei hoaka that Emma finds in her closet. 84 S te f a n i O v e r ma n - ­ T sa i This specific lei hoaka, a crescent-­ shaped necklace adorned with human hair and a black boar’s tooth, once belonged to Emma’s grandmother and holds significant spiritual importance in its association with hula.2 Once it is brought out in the open, the lei hoaka becomes an active participant in developing the characters of two half-­ Hawaiian women in the play, Emma and her younger half-­ sister, Maelyn. The prop passes hands between the two women, revealing their personal views of their heritage , their passion for hula, and their relationship with each other. The development of Emma’s and Maelyn’s characters via the negotiation for the lei hoaka presents postcolonial issues of reviving lost cultural practices before they are forgotten or buried under the imperialistic changes that come with Ameri­ canization. Kneubuhl uses the lei hoaka as a metaphorical and physical example of Emma’s rich hula roots, a reminder of her spiritual strength and her responsibility to her family. As a prop, the lei hoaka is able to transcend function and becomes a significant cultural and postcolonial sign. The power of an object as a sign is what makes props in a play useful as storytelling devices, because a prop can have more visual power as a sign onstage than in ordinary life. In Great Reckonings in Little Rooms, Bert O. States asserts that objects become signs when they enter “illusionary space and time.”3 This notion of how objects become representations can lead us to consider objects onstage, such as props, as specific and purposeful plot mechanisms used by the playwright to reveal tidbits of information when language is simply not enough for the descriptive job at hand. Props take on characteristics and reveal important information that the playwright wishes the viewer to recognize. Andrew Sofer’s book The Stage Life of Props is a useful guide when considering a prop’s performative power because an object transcends function when it is placed onstage and “manipulated” by actors.4 How a prop is manipulated in performance may reveal socioeconomic messages, including cultural practices, identity construction, and the reintegration of heritage into one’s everyday life. The structure of the play Emmalehua also manipulates the lei hoaka and raises it above simple decoration. For outsiders to...

Cultural Identity and Conceptualization of Depression among Native Hawaiian Women

This study seeks to understand how Native Hawaiian (NH) women identified themselves culturally and conceptualized the causes of depression, and whether there was an association between these two constructs. Among the thirty NH women who were interviewed, a quarter had a high degree of depression symptoms, and a majority expressed a strong/shared identification/affinity with their culture. Our findings suggest that social stressors that contribute to the depressive symptoms of NH women could be, in part, linked to acculturation-related factors associated with U.S. occupation of Hawai‘i and their social status as native people. Future research should examine this relationship further.

Cultural Identity and Conceptualization of Depression among Native Hawaiian Women

This study seeks to understand how Native Hawaiian (NH) women identified themselves culturally and conceptualized the causes of depression, and whether there was an association between these two constructs. Among the thirty NH women who were interviewed, a quarter had a high degree of depression symptoms, and a majority expressed a strong/shared identification/affinity with their culture. Our findings suggest that social stressors that contribute to the depressive symptoms of NH women could be, in part, linked to acculturation-related factors associated with U.S. occupation of Hawai'i and their social status as native people. Future research should examine this relationship further.

Dietary Patterns and Risk for Diabetes

OBJECTIVEThe high diabetes incidence among Japanese Americans and Native Hawaiians cannot be explained by BMI. Therefore, we examined the influence of three dietary patterns of “fat and meat,” “vegetables,” and “fruit and milk” on diabetes risk in the Hawaii component of the Multiethnic Cohort with 29,759 Caucasians, 35,244 Japanese Americans, and 10,509 Native Hawaiians.RESEARCH DESIGN AND METHODSSubjects aged 45–75 years completed a baseline food frequency questionnaire. After 14 years of follow-up, 8,587 subjects with incident diabetes were identified through self-reports or health plan linkages. Risk was assessed using Cox regression stratified by age and adjusted for ethnicity, BMI, physical activity, education, total energy, smoking, alcohol intake, marital status, and hypertension.RESULTSFat and meat was significantly associated with diabetes risk in men (hazard ratio 1.40 [95% CI 1.23–1.60], Ptrend < 0.0001) and women (1.22 [1.06–1.40], Ptrend = 0.004) when extreme quintiles were compared. Except in Hawaiian women, the magnitude of the risk was similar across ethnic groups although not always significant. After stratification by BMI, fat and meat remained a predictor of disease primarily among overweight men and among overweight Japanese women. Vegetables lowered diabetes risk in men (0.86 [0.77–0.95], Ptrend = 0.004) but not in women, whereas fruit and milk seemed to be more beneficial in women (0.85 [0.76–0.96], Ptrend = 0.005) than in men (0.92 [0.83–1.02], Ptrend = 0.04).CONCLUSIONSFoods high in meat and fat appear to confer a higher diabetes risk in all ethnic groups, whereas the effects of other dietary patterns vary by sex and ethnicity.

Listening to Leoiki: Engaging Sources in Hawaiian History

This paper challenges the perception of "silence" of Hawaiian women in the sex trade in 1820s Hawai'i by focusing on the sale of a Hawaiian woman, Leoiki—whose name means "little voice"—by a chiefess to a British whale ship captain in 1825. Working with family genealogies, depositions, American missionary correspondence, and other sources written in Hawaiian, this paper explores how the important principles of kuleana and kapu function within Leoiki's story as well as essential focal points for a Hawaiian historian's gathering and interpretation of sources. In writing this kind of history, this paper also sets out a new methodology that is interpretively consistent with traditional Hawaiian modes of remembering and perpetuating history.

Substance Abuse Among Native Hawaiian Women in the United States: A Review of Current Literature and Recommendations for Future Research

Information about and understanding of Native Hawaiian substance abuse and utilization of substance abuse treatment services is limited. This article reviews the literature on the prevalence and factors associated with substance abuse and use of health services among Native Hawaiian women in the U.S. The literature review included three review and 13 nonreview articles that were published through December 2006. The majority of the articles reviewed did not present findings by gender-ethnic group. The review of the literature suggested a high prevalence of substance abuse, especially among those who were incarcerated. Risk factors for substance abuse included not being married and young age. Native Hawaiian women also had significantly lower health care utilization rates compared to other groups, and were less likely to have seen a health care provider in the past year. Programs should consider involving Kupunas (“elders”) in the design and implementation of culturally appropriate programs in order to better serve the needs of Native Hawaiian women. Further research is needed about the rates of substance abuse and barriers and facilitators to treatment so that effective and culturally competent treatment can be provided for this population.