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Transforming the Health of Native Hawaiian Men

Knehlani Transforming the Health of Native Hawaiian Men 3

Table of Contents
Introduction 5
Methodology 6
Part One: Historical Strengths 7
O Ka W Mamua (The Past) 7
Kne: Spirituality and Religion 7
Kne: The ina, Kai, and Resources 8
Kne: Family and Relationships 9
Kne: Education and Occupation 10
Kne: Leadership and Politics 11
Moohihia 12
Economic Transformations 12
Political Transformations 13
Social Transformations 14
Transformations in Hawaii during the Twentieth Century 15
Native Hawaiian Resiliency 16
Part Two: O Kia Au (The Present) 17
Demographics: The Kne Population in Hawaii 17
Social Determinants of Kne Health 18
Keiki 18
Ohana make-up 18
Education 20
Juvenile Crime 24
Mkua 24
Post-secondary Education 24
Economic Stability 26
Marital Status 28
Behavioral Risk Factors 28
Involvement with Criminal Justice System 31
Kpuna 31
Household Context 31
Preventive Services 32
Age and life expectancy 32
Health Outcomes 32
Mental Health 36
Morbidity 36
Further Conclusion and Recommendations 37
Discussion Questions 39
Works Cited 40
Part One: O Ka W Mamua 40
Part Two: O Kia Au 41
Acknowledgements 45

Knehlani Transforming the Health of Native Hawaiian Men

Copyright 2017. Office of Hawaiian Affairs. All Rights Reserved. No part of this report may be reproduced or
transmitted in whole or in part in any form without the express written permission of the Office of Hawaiian Affairs.
Suggested Citation: Office of Hawaiian Affairs. (2017). Knehlani Transforming the Health of Native Hawaiian Men. Honolulu, HI: Office of Hawaiian Affairs.
4 Knehlani Transforming the Health of Native Hawaiian Men
Knehlani Transforming the Health of Native Hawaiian Men 5

This report aims to provide a picture of traditional and contemporary wellbeing of kne,
Native Hawaiian men. Based on these descriptions, the report will also offer recommendations
to support the strength of future generations of kne. The focus here is on kne, specifically,
as we apply Hawaiian framework and methodology that incorporates a gendered perspective
of both the social, spiritual, and physical word. Both the study and the recommendations are
intended as starting points for additional research, discussions, and programming.
Part 1: O Ka W Mamua (The Past) starts with a depiction of the placement of kne in Native
Hawaiian society. This section will explore traditional Native Hawaiian culture and historical past.
It highlights strengths that contributed to the vitality of a thriving knaka iwi (Native Hawaiian)
nation, and also examines historical challenges that have negatively affected Native Hawaiians.
It looks at the traditional kuleana (responsibilities) and contributions of kne in Hawaiian soci-
ety as a foundation for pono (proper) action. This section will also examine the moohihia, the
chronology of historical difficulties which altered the traditional roles and contributions of kne.
Finally, the section will include an examination of the continued resilience of Native Hawaiian
kne. What you will see is that Native Hawaiian men had a significant place across both the
breadth and depth of Hawaiian culture, and a healthily functioning society spoke to healthy kne,
and vice versa. The idea of an individuals well-being is directly reflected in a healthy society. That
Hawaiian culture was able to flourish for hundreds of years, prior to western contact, is a testa-
ment to the ways Hawaiian society kept Hawaiians healthy, and in turn healthy Hawaiians were
able to tend their families, gods, avocations, and the ina (land).
The second part of this overview, Part 2: O Kia Au (The Present), seeks to also create a
similar narrativebut this one is based on data collected from various contemporary sources
of the health of kne, in relation to his socio-economic and other disparities. Obviously, these
two sections cannot be compared directly, but it is hoped that, together, they create their own
narrativeone of how rapid change in so many facets of a society has had long-lasting and
far-reaching effects, in ways that are both clear and can only be fully understood in relation to
other, shifting forces.
Throughout, we pose questions for your consideration, about ways your organization and
policymaking can affect real change for kne. Although your organization may not work directly
with some topics, we hope that using the social determinants of health (SDH) as a framework
will create links between seemingly disconnected points. This report then become a jumping-
off point for reflection and discussion. We also seek to highlight pathways of Native Hawaiian
resiliency, even in the face of adversity that threatened and threatens to collapse the Hawaiian
culture, as well as recommendations for future waysin policy, practice, and data collectionto
direct our energies and resources, in order to monitor, support, and enhance kne health.
6 Knehlani Transforming the Health of Native Hawaiian Men

This report makes significant usage of the Kkulu Hou Methodology, which was developed
by Dr. Kamanaopono Crabbe in 2009, and is rooted in the Native Hawaiian cultural practice of
umu hau phaku (rock-wall masonry). This practice was a fundamental aspect of constructing
ancient temples, shrines, fishponds, houses, and other structures. Umu hau phaku required
particular steps for gathering resources, site selection, construction planning, and skills train-
ing. The primary objective of the Kkulu Hou Methodology for research and reporting is fourfold:

To articulate the historical-cultural context of resilient and positive cultural strengths of

the Hawaiian heritage as a foundation of knowledge and practice;
To highlight the contemporary disparities in the conditions of Native Hawaiians based on
available data and research;
To provide critical analyses of systemic barriers and/or challenges with parallel solutions;
To make recommendations to improve the conditions of Native Hawaiians, their families
and communities, as well as the broader Native Hawaiian society or lhui.

It should be noted that first component of the report, O Ka W Mamua, is more narrative and
historically based, as opposed to data-driven. Thus, the sources of information include tradi-
tional oral accounts that were preserved as mookauhau (genealogies), moolelo (historical
narratives), and mele (songs and chants). Written historical accounts authored by foreigners at
contact were also analyzed for information relative to kne or societal well-being. These primary
sources record the long history of Native Hawaiians and were explored to affirm that Hawaiian
society consisted of thriving lands, resources, and peoples. Finally, the work of contemporary
scholars and academics were exhaustively researched and referenced where appropriate.
The second component of this report, O Kia Au, focuses on social determinates of health
which have been identified within current medical and social research literature. Data from nu-
merous sources were compiled to provide a context or overview of how social, economic, and
environment factors impact Native Hawaiian men in Hawaii. Major sources utilized include: the
U.S. Census Bureaus American Community Survey, the Hawaii State Department of Education,
State of Hawaii Department of Human Services Statistical Report on Child Abuse and Neglect,
the University of Hawaii Center on the Family Homelessness Services Utilization Report, and the
Hawaii State Department of Health Behavioral Risk Factor Survey System.
Finally, data on kne health outcomes are explored as the physical manifestations of the so-
cial determinates of health. Major sources of this information include Hawaii State Department
of Health Office of Health Status Monitory datasets and research from the University of Hawaii
Cancer Research Center. From all sources, the most recent data at the time of writing for Native
Hawaiian men was extracted and analyzed. In most cases, this selection includes data from
2014 or, where sample sizes were smaller, five-year estimates were used, which represents data
that was collected over a five-year period, as opposed to a point-in-time count. Other findings
reference data for the Native Hawaiian population at large. Unfortunately, in some cases data
specific to kne was not collected or was unable to be annualized due to small sample sizes. In
these instances, data for the larger Native Hawaiian population is referenced, along with data for
the total State male populationthe populations within which kne form a part. While specific
data for kne in regards to some topics are not available, these findings likely apply for kne also.
Knehlani Transforming the Health of Native Hawaiian Men 7

Part One: Historical Strengths

Note: The following sections are an abridged account of Mana K Kane: Native Hawaiian Mens
Wellbeing, a report prepared by Aha Kne in 2016, as well as information about the overthrow
of the Hawaiian monarchy and Hawaiis annexation from a 2011 internal OHA report. Aha Kne
is a non-profit organization whose mission is to strengthen the Native Hawaiian community
through nurturing and perpetuating the traditional male roles and responsibilities that con-
tribute to the physical, mental, spiritual, and social well-being of Native Hawaiian males, their
families, and communities.

O Ka W Mamua (The Past)

Kne, Native Hawaiian men, were an The Duality between Kne and Whine
integral part of the systems and structures One of the hallmarks of traditional Native
that contributed to the well-being of all Native Hawaiian spirituality and religion is that of
Hawaiians. Some academics estimate that the pono (balance) between complementary
population of Hawaii in the late 1700s was as forces. Dualities based on light and dark, land
large as 800,000 to 1 million people (Stannard, and sea, male and female, are presented in
1989). This abridged chapter is a historical ways that illustrate the importance of pono in
exploration of the traditional social, economic, the Hawaiian worldview (Tengan, 2008). The
and political roles of Native Hawaiian men in word pono has many meanings depending
Hawaiian society. on the context in which it is used: it can
The Moohihia section of this report refer to excellence, wellbeing, and balance
includes a critical examination of historical (Pukui & Elbert, 1986). Pono can also refer to
events that altered or challenged the ability of somethings true condition or nature, as well
Native Hawaiian men to maintain traditional as something that is perceived as necessary.
beliefs and practices within the context of the For Native Hawaiians, the balance embodied by
transformations within Hawaiian society during pono could be considered to be the essential,
the nineteenth and twentieth centuries. original state of something.
This discussion will be sub-divided into five Many Native Hawaiian beliefs and practices
areas of focus: reflected the values embodied in the divine
ancestors Papa and Wkea, as well as K
Kne: Spirituality and Religion and Hina. Paired, male and female mana
Kne: The ina, Kai, and Resources represented a balance and harmony that was
Kne: Family and Relationships considered vital in Hawaiian epistemologies.
Kne: Education and Occupation Without kne, whine would not be balanced,
Kne: Leadership and Politics and vice versa. Both masculine and feminine
mana were essential to wellbeing in traditional
Kne: Spirituality and Religion Hawaiian society.
From individual prayers offered before starting
everyday tasks, to formal rituals completed by Akua and Aumkua
chiefs and priests, spirituality and religion were In addition to the divine ancestors named
intertwined into every aspect of traditional in familiar genealogies like the Kumulipo, many
Native Hawaiian life. As compared to whine, other akua (gods) were significant to kne in
kne had very direct, active, and visible roles ancient Hawaiian society. The great number of
in ceremonial religious practices. This section gods in traditional Hawaiian religion has been
explores Native Hawaiian men and traditional described by foreign scholars as a pantheon,
spiritual beliefs and practices. while Native Hawaiians acknowledged the
8 Knehlani Transforming the Health of Native Hawaiian Men

mano (4,000), kini (40,000), lau (400,000) and including genealogy and rank, participation
lehu (great multitude, infinite) akua (Kanahele, in religious ceremonies, place of residence, or
1986). Not only were there a multitude of gods, familial observation of an individual.
there were rituals, prayers, and beliefs that The application of kapu also differed accor-
were specific to every area of life for Native ding to an individuals gender. In particular,
Hawaiians. Hawaiian society was characterized by the
Despite the existence of countless akua, ritual separation of the sexes through kapu
there were four male gods who were believed and social norms, which protected the spiritual
to be primary gods and who were invoked differences in male and female mana. Because
almost universally in rituals and ceremonies of their more active role in formal religious
conducted by all Native Hawaiians. These ceremonies, it was necessary for kne to
gods included K, Kne, Lono, and Kanaloa. maintain their spiritual sacredness through
Many gods served as models for the behavior the observation of kapu in ways that were not
of kne. In moolelo, the akua Kne and usually required of whine.
Kanaloa travelled throughout Hawaii and There were also specific rituals that were
pierced the ground in places where there performed for and by kne, including those
was no water to form springs; they also built that marked significant milestones or events
a fishpond in Honuaula (Helu 2, Ka Nupepa in the lives of Native Hawaiian men. These
Kuokoa, January 12, 1865). These life-giving included birth, betrothal, marriage, and death.
activities were imitated by generations of alii, Although celebrations and ceremonies were
many of whom sought to develop irrigation held for all kne, their complexity varied
systems and build fishponds as part of their according to a number of factors, including
kuleana (responsibilities) as rulers to ensure rank and genealogy (Valeri, 1985).
the wellbeing of people and lands under their One of the most significant ceremonies in
care. the life of a kne was known as k i mua, which
Gods were often specific to certain acti- described the transition of a young boy from
vities, skills, knowledge sets, and occupations. taking his meals common eating house where
In a newspaper article published on March 30, women and young children ate to the mens
1865 in Ka Nupepa Kuokoa, S. Ekaula listed the eating house (Malo, 1951). K i mua can
various aumkua specific to kahuna anan be translated to thrust into the mens eating
(sorcerous priests), poe kanu ai (farmers), house, (Pukui, Haertig & Lee, 1972). As part
lau lapaau (medicinal healers), kahuna heiau of the k i mua ceremony, a boy was given his
(temple priests), poe lawaia (fishermen), and first malo (loincloth), which served both as a
n alii (the chiefs). In this way, a kne was mark of his entrance to the hale mua and his
believed to have divine mentors and spiritual growth into manhood (Pukui, Haertig, & Lee,
guidance in every part of his life. 1972). A boy was also taught to humehume,
to tie or gird himself with a malo by his close
Kapu and Aikapu male relatives. Another important ceremony in
Kapu were sacred restrictions that served the lives of kne was the incision of the penis
as guidelines for spiritual and moral behavior (kahe ule).
in traditional Native Hawaiian society. There
were many different types of kapu. Certain Kne: The ina, Kai, and Resources
kapu were meant to prevent overuse of The deep relationship between kne
resources; for example a konohiki (land and the ina (lands) and kai (sea) is well
manager) could place a kapu on a specific documented in traditional oral history and
type of plant or fish if they were not abundant literature. Moolelo, mele, and mookauhau
or out of season (Malo, 1951). A kapu could be were part of a large body of knowledge main-
specific to a place or a resource, but could also tained by the rigorous intellectual traditions of
be specific to classes of people. Kapu were Native Hawaiians, whose studied observation
also put in place to protect the sacredness of of their surroundings allowed for a deep
gods, people, places, and objects. understanding of the systemic physical and
The number and severity of kapu was spiritual interactions of people, resources, and
applied differently in traditional Hawaiian environments.
society depending on a number of factors, In mele koihonua the Hawaiian Islands
Knehlani Transforming the Health of Native Hawaiian Men 9

were born as a result of mating between kuleana (reciprocal responsibility) resulted

Papa and Wkea and their respective lovers. in self-restraint in the use of resources, and
In these chants, Papa and Wkea also had also cultivated a feeling social obligation to
a human daughter named Hoohokukalani. the larger community. Ultimately, these values
Desiring his daughter, Wkea mated with helped to protect land and marine resources
Hoohokukalani and they had a stillborn son, from overexploitation.
who was named Hloanakalaukapalili. He was Traditional resource management was
buried in the earth, and from his body grew characterized by extensive ike ina and ike kai
the first kalo (taro; Colocasia esculenta) plant. (knowledge and close familiarity with the land
Wkea and Hoohokukalani had a second child, and sea, respectively). Kne who were native to
Hloa, who is the chiefly ancestor of all Native an area carried unique cultural and historical
Hawaiians (Malo, 1898). For this reason, Native knowledge, which had been passed from one
Hawaiians considered themselves to be the generation to the next (McGregor, 2007). This
younger siblings of both the kalo plant and the knowledge of land and sea systems and cycles
Hawaiian Islands (Pukui, Haertig, & Lee, 1972). were important for gaining optimum resource
These familial relationships were reflected in yield; for this reason, certain crops were
the beliefs and practices surrounding mlama planted during specific moon phases to ensure
ina, or Hawaiian stewardship of lands, waters, that they would be ready for consumption in
and resources (Kameeleihiwa, 1997). the best possible times. Fishermen would
only catch fish in certain stages of growth, to
Fishing and Farming ensure that new generations of fish would be
One of the most poignant ways that kne born for future generations of knaka.
were linked to the land and sea was through
activities that were necessary for long term Kne: Family and Relationships
sustainability and survival; farming and fishing The cultural concept of piko (spiritual
were foremost among these activities. centers) demonstrated the importance of
While women also fished and farmed, men genealogy and familial relationships for kne
were the ones who usually engaged in the in traditional Native Hawaiian culture. Every
heavier and more physically intensive forms Native Hawaiian was believed to have three
of these activities. Spiritually, men were also piko, which connected him to past, present,
believed to be more appropriately suited to and future generations: his manawa (fontanel)
certain types of work, because of the mana connected him to his ancestors; his mai
they embodied. In this respect, men had (genitals) connected him to his descendants,
relationships and knowledge of the land and and his umbilicus connected him to the present
sea that was often specialized and different generation, parents, and blood relatives. Thus,
than that of women. the ohana was one of the most important
formative forces in the lives of kne.
Resource Management/
Traditional Hawaiian Stewardship Family Relationships
Trade and exchange between fishermen The importance of familial relationships
and farmers, and between the lowlands and is readily evident in Hawaiian culture. The
uplands, formed the basis of the traditional Hawaiian word for family, ohana, comes
Hawaiian economic system. To sustain their from the kalo plant: the main stalk of a kalo
communities and ensure that their farming is known as the oh. From this original plant,
and fishing activities would not exhaust the many new plants and clusters of kalo can be
resources of their lands, Native Hawaiian formed. Native Hawaiians believed families
men were instrumental resource managers were similar to kalo, in that they clustered
and stewards of the lands and sea. Kne around the same root or originating source
traditionally managed resources according (Pukui, Haertig, & Lee, 1976).
to spiritual and cultural values and practices, Although shared ancestry was an
employing extensive knowledge of physical important determining factor of ohana,
place. traditional Native Hawaiian families were not
The societal Native Hawaiian cultural and limited to a core nuclear unit. This expansive
spiritual values of mlama (to care for) and understanding of ohana included extended
10 Knehlani Transforming the Health of Native Hawaiian Men

family who were blood relations. Native was also an important site of mentoring by
Hawaiians also recognized important social male family members. In this setting, male
relationships of varying degrees with other children were guided by their fathers, uncles,
non-related members of the community. grandparents, and even elder brothers and
The concept of ohana also encompassed cousins in all manners of life and living. The
deceased ancestors, who often remained hale mua allowed a boys learning, discipline,
active in family affairs as aumkua. and modeling to occur within a close-knit
It was also the sacred kuleana of kne to community; such activities were undertaken
see to the physical and spiritual care of his with the support of the extended network of
family. Scholar Ty Tengan (2008) notes, On all kne, rather than in isolated nuclear family
levels, the responsibility for feeding both the units. Thus, the hale mua was one of the most
family and the gods fell on the shoulders of important facets of the ohana system which
men (p. 35). This responsibility encompassed shaped the lives of kne (Tengan, 2008).
all the processes associated with being able The family was such an important part of
to provide nourishment, including farming social organization in traditional Hawaiian
and fishing, preparation of food (such as the society, that Native Hawaiians developed
building of imu) and learning and observing ways to maintain familial harmony and
the necessary prayers and rituals involved in minimize discord. Hooponopono was a
those activities. In the hale mua, kne were ceremonial familial mediation meant for
responsible for making daily offerings and conflict resolution. If hooponopono and other
prayers on behalf of the entire ohana (family), methods of mediation failed, a ceremony
ritually feeding the gods in order to care for known as m ka piko (cutting the navel cord)
the ancestors (Pukui, Haertig & Lee, 1972). In could occur; this involved cutting all ties
recognition of mens roles as providers, Pukui between an individual and the family. For
(1986) notes that the word kua, which has Native Hawaiians, m ka piko was a terrible
connotations of a backbone or a support, was thing, because it cut a person off from the
also used to refer to a husband. support, aloha, and mana of his family (Pukui,
Haertig & Lee, 1972).
The Ohana as a Network of a Support
One of the most important functions of Kne: Education and Occupation
the ohana was as a network of support, which From the time of his birth, a Native
was present throughout the life of a Native Hawaiian man was groomed for familial and
Hawaiian men. Networks of kinship and aloha societal roles. From the general knowledges
sustained the growth of young boys into and skills necessary to survive, to the more
men, perpetuating a cycle that fostered the specialized knowledges that were specific
passage of knowledge and promoted learning to the deft practice of elevated occupations,
throughout a lifetime. kne were part of a genealogy of knowledge
The ohana played a role in the life of a that spanned generations.
kne even before he was born; it was believed
that the actions, health, and even diet of a The Nature of Traditional Education
pregnant woman would affect the disposition Education was not only an important means
and attributes of a child. Therefore, a woman of passing on traditional knowledge, but also a
would carefully follow the strictures of kahuna highly spiritual process which allowed kne to
pale keiki (midwives), with the support and gradually acquire mana. For this reason, kapu
care of her family and the community (Pukui, reinforced structure and protocol in education
Haertig, & Lee, 1972). and training.
The ohana system provided a safe Several lelo noeau illustrate Native
environment for learning. As a young child who Hawaiian educational values and methods
ate in the hale noa, a boy was cared for by his of learning: The first, Paa ka waha, hana
mother, female relatives, and other women ka lima, The mouth is shut, the hands are
of the village. Once a boy had undergone the doing stresses the importance of observation
k i mua ceremony, the hale mua became an without question and the importance of
important place of instruction and learning actually working to learn.
within the community of men. However, it
Knehlani Transforming the Health of Native Hawaiian Men 11

elements of stone masonry, meteorology,

Settings for Learning hydrology, botany, architecture, engineering,
Because general learning began in the hale and so on. The same scope and depth of
noa, members of the ohana were the first knowledge was necessary for kne to master
formal instructors of children. According to any given practice, field, or occupation.
Kamakau, the childs parents took a lesser role In addition to the common occupations
in the early nurturing of the child and rearing of fishers and farmers, there were more
was in the hands of the grandparents or their specialized esoteric occupations. Sometimes,
younger or older brothers and sisters, or other entrance to these occupations was limited
lateral relatives (hoahnau), or in the hands of by rank and genealogy, other times by family,
the lateral relatives of the parents (Kamakau, and natural skill or inclination. However, if a
1991, p. 26). boy demonstrated special talents or skills, he
In contrast to Euro-American education might be apprenticed to a relative or expert
models, young boys did not rely on a central for training in occupations such as prophecy
knowledgeable authority figure, such as a or healing (Pukui, Haertig, & Lee, 1972).
classroom teacher. Instead, they learned The complex structures of Hawaiian
from the community through listening to their society both allowed for and necessitated
elders and those more knowledgeable than the diversification and specialization of
themselves, observing particular tasks, and occupations among Native Hawaiian men.
eventually by doing said tasks themselves. No matter a mans occupation, however, high
While parents were important for these value was placed on deft and skilled practice
educational processes, a boys education was and knowledge.
conducted by the entire community. Cradled in
a familial network of the village, which included Kne: Leadership and Politics
extended family members, the community In many ways, kne were important leaders
was responsible for the education of all within Hawaiian society. For example, within the
children. The strong support of the extended makainana class, the eldest son was usually
family, as well as the specific guidance of a provided with an education and trained in ways
community of men found in villages, provided that would allow him to take over leadership of
support networks of kinship and aloha were the family and in the hale mua; this included
what sustained the growth of young boys into instruction in the proper observance of rituals
men, perpetuating a cycle that fostered safe and kapu, the care of others (including the
environments for learning. ancestors and family gods) as well as problem
resolution and mediation (Pukui, Haertig, and
Traditional Occupations Lee, 1972). However, within broader Hawaiian
Traditional Hawaiian education was cen- society, male alii had important responsibilities
tered on preparing kne to assume societal as sacred religious and political leaders.
and occupational roles. In a fishing village or
in a family of fishers for example, a boy would The Alii
learn knowledge specific to fishing; the same As a class, the alii were responsible for
was true of boys raised in families with other governance over the land, resources, and
occupations. people. Rank and related responsibility was
For male makainana, the most common stratified according to genealogy, and each
occupations were farmers and fishers; these class of chief had different responsibilities
individuals were responsible for feeding their within the political structures of Hawaiian
families and communities. However, there were society. For example, the alii nui or alii aimoku
also bird catchers, cordage makers, wood and (also later known as m) was the ruler of
stone carvers, and so on. Each occupation had an entire island or several moku (districts).
its own set of specialized knowledges, skills, Chiefs of lesser rank, known as kaukau alii
rituals, and gods. and konohiki were responsible for governance
Translated to modern professions, the tasks on smaller units of land for the alii nui.
skills and knowledge needed to simply grow The aha alii was a body of the highest
kalo for survival required kne to have working ranking chiefs who were distinguished by the
and sometimes expert knowledge of various use of a sacred cord called an aha. In addition
12 Knehlani Transforming the Health of Native Hawaiian Men

to its members being representative of the would impact Native Hawaiian men within the
highest mana, the aha alii was also a council Islands are complex, this report will highlight a
of chiefs, which provided political advice in number of the economic, social, and political
matters of governance, war, and diplomacy. transformations of the nineteenth and twentieth
Pono leadership was tied to mana. An alii centuries that had a particularly deep effect.
inherited the right to rule through genealogy,
as well as a specific set of kapu, which Economic Transformations
sanctified him as a sacred and religious leader Some of the most visible transformations of
(Malo, 1952). However, his decisions and Hawaiian society are reflected in the changing
actions regarding the care of his people, the structures of the Hawaiian economy during
expansion of territory, the apportionment of the nineteenth century. Whereas ancient
resources, were all factors which affected his Native Hawaiians maintained highly productive
ability to continue ruling. Kameeleihiwa (1999) economies that were carefully regulated by
describes two paths to mana for alii. The path the alii, Euro-American commercial ideals and
through Lono was accomplished through activity would redirect the basis of the Hawaiian
diplomacy and marriage. The path through K economy to one of capitalism and place a new
was accomplished through warfare. emphasis on the accumulation of wealth and
As sacred religious and political leaders, personal property (Hitch, 1992). Indeed, the
Native Hawaiians believed that it was the kuleana early commerce and industry in the islands,
of the alii to intercede in heavenly matters on which consisted primarily of the trade of furs
behalf of the people, much as it was the kuleana and sandalwood, would shift to whaling, sugar
of the kne to petition the gods on behalf of a and pineapple production, and eventually
makainana family. Famines, epidemics, or tourism over the course of two hundred years.
other troubles could be understood as resulting The far-reaching effects of commerce
in the displeasure of the gods with the ritual in the Islands are especially apparent in the
observations of an alii. increasing urbanization that occurred during
Furthermore, a good chief would ensure the the 1800s: the concentration of new economic
care of his people by facilitating the building opportunities in commercial trading centers,
of infrastructure, including heiau, irrigation such as Honolulu and Lhaina, would prompt
systems, agricultural systems, and fishponds. many Native Hawaiians to leave rural areas of
Issues of taxation were important, and an alii the islands, a process that would ultimately
would know when and how much to tax in ways alter ties among families, communities, and
that would not overburden the people. It was places (McGregor, 2007). Such population
believed that a wise and good chief could make shifts are evident in demographic statistics of
the land and resources themselves flourish, the nineteenth century. In 1850, Hawaii Island
and that the mana of a good alii was essential was the most populated island. By 1872, Oahu
to maintaining the wellbeing of the people. had become the most populous island with an
There are many oral histories surrounding estimated population of 20,671, as compared
the pono actions of alii, who served as models to the estimated population of 16,001 for
for leadership for future generations. Hawaii Island (Schmitt, 1989).
As farmers and fishermen whose labor
Moohihia produced the basis of subsistence, kne had
Beginning in the late 1700s, a series of traditionally provided enough food for their
changes at all levels of society would both families, communities, and the alii. However,
hinder and alter the ability of Native Hawaiians Tengan (2008) notes that during the nineteenth
to practice their culture, and in the historically century, Native Hawaiian men moved to cities
short span of 100 years, Hawaiian society and were engaged in wage work away from
would be fundamentally transformed. These their traditional communities. In the growing
changes would disrupt the succession and capitalist systems introduced by Europeans
flow of knowledge and support within Hawaiian and Americans, men were seen as the primary
society, creating breakages in the systems economic and political actors, and were much
that had preserved and perpetuated Native more directly involved in powerful mediums of
Hawaiian culture. imperialism. For this reason, men were often
Although the processes and events that more disconnected from traditional culture,
Knehlani Transforming the Health of Native Hawaiian Men 13

whereas women were often the ones who access to the land and its resources.
preserved and reinforced it (Tengan, 2008). Political Transformations
Other economic activities would have large The political transformations in Hawaii
impacts on the lives of Native Hawaiian kne. during the nineteenth and twentieth century
The introduction of goods and materials (such were indeed revolutionary, particularly when
as flour, tinned foods, iron, glass, oil, and cloth) considering the scope of changes within
reduced the use of some traditional materials Native Hawaiian governance structures. For
and tools and increased mens integration in example, the transition from the traditional
the wage economy. The rise of sugar cultivation alii system of governance to a constitutional
in the islands would eliminate thousands of monarchy was astonishingly rapid. The
acres of forests and alter ecosystems. Sugar presence of a unified political entity that
plantations would affect the availability of spanned across the Islands was relatively new
agricultural land for kalo cultivation by diverting in the early nineteenth century. The formation
both land and resources, especially water of the monarchy within the Kamehameha
(Wilcox, 1997). Eventually the introduction lineage as a result of unification would lead
of pesticides, the switch in farming to cash to the development and strengthening of the
crops, the increasing use of monocropping, Hawaiian Kingdom government.
and the exhaustion of soil nutrients and would The 1819 breaking of the ai kapu (eating
devastate native agricultural practices. It would restrictions) and the subsequent ai noa
also foster immigration for sugar labor, and (free eating) by Liholiho, Kepolani, and
intermarriage with Native Hawaiians became Kaahumanu m (Kaahumanu and her
more common. The introduction of ranching supporters), transformed traditional sources
would have similarly devastating effects. of authority and shifted the traditional
During the reign of King Kamehameha III, relationships between the alii and the
a system was developed to mhele (divide makainana (members of the general
or portion) lands in the Islands that were populace) (Kameeleihiwa, 1992).
once held in common under alii and konohiki The 1820 arrival of the first company of
system. The land of Hawaii was divided into missionaries, who were sent by the American
individual parcels that could be held as fee Board of Commissioners for Foreign Missions
simple by private individuals. The body of (ABCFM), would also impact governance; a
legislation which are commonly known as number of Hawaiis most powerful alii nui
Mhele Acts were actually a series of laws that (high chiefs) embraced the religious doctrines
were enacted in stages, which were meant of the missionaries and moved to establish laws
to incorporate Western and Hawaiian legal based on Christianity, including edicts against
frameworks into the Kingdoms governance prostitution, polygamy, and adultery (Merry,
structures for the purpose of caring for the 2000). To some extent, the incorporation of
Native Hawaiian people. Although primarily Euro-American frameworks within Hawaiian
recognized as a system of land redistribution, laws (such as voting requirements), coupled
the Mhele also redistributed fishery rights. with other such factors (such as the increase
The Mhele process allowed for the in the number of non-Hawaiians in the Islands)
acquisition of private title to lands and would contribute to diminishing political
resources; although access and resource use participation among Native Hawaiians.
rights for Native Hawaiians were preserved in By the middle of the nineteenth century,
the laws surrounding the Mhele, these rights members of the Hawaiian government also
would be eroded by the practices of private began to consciously integrate Euro-American
landowners, through court cases and the secular legal frameworks within the Kingdoms
enforcement of laws in the judicial systems, governance structures (Osorio, 2002, p.
as well as in the transition of governance from 13). A Declaration of Rights was adopted by
the Kingdom of Hawaii to the Republic of Kamehameha III on June 7, 1839; it recognized
Hawaii, the Territory of Hawaii and the State a division and protection of rights between the
of Hawaii. In later years, particularly with the M (King) as sovereign, the chiefs, and the
erosion of many of the safeguards that were common people (McGregor, 2007).
in place within traditional Hawaiian society, The first Constitution of the Kingdom was
Native Hawaiians would increasingly lose adopted by Kamehameha III in 1840. The
14 Knehlani Transforming the Health of Native Hawaiian Men

creation and adoption of the Constitution United States, the Provisional Government
represented a voluntary shift from the formed the Republic of Hawaii in 1894
traditional alii system of governance towards (Coffman, 2009). Native Hawaiians would resist
a constitutional monarchy. The Constitution the Provisional Government and annexation
codified existing governmental structure by the United States during the mid-and
and practice, recognizing partially separated late 1890s through forming of political hui
executive, legislative and judicial branches, (groups), collecting Native petitions and
establishing a Supreme Court and a bicameral testimonies, and trying to encourage political
legislative body (Kingdom of Hawaii, 1840). advocacy among Native Hawaiians in Hawaii,
The Legislative Session of 1851 marked a the United States, and internationally. Despite
definitive shift in the governance structures the illegality of the overthrow, the lack of
of the Kingdom (Osorio, 1999). In particular, support for annexation from the majority of
non-Hawaiians were able to gain control of the Kingdoms population, and the presence
the authority of the House of Representatives of strong resistance movements, Hawaii was
in 1851, and although they remained annexed through a joint resolution of the U.S.
outnumbered by native representatives in Congress in 1898, during the administration
1851, their influence altered the form and of President William McKinley. By 1900, Hawaii
purpose of the legislature. It introduced new would become a U.S. territory without the
elements of governance to the Kingdom customary approval by a two-thirds majority
structure and drastically shifted the purpose of Congress (Coffman, 2009).
and form of Kingdom politics. For one thing,
the Constitution severely limited the authority Social Transformations
of the King and his ability to fulfill his traditional Many historians point to the breaking of
role as an alii. the 1819 ai kapu (eating restrictions) and the
In the transition of Hawaiian governance subsequent ai noa (free eating) by Liholiho,
to a constitutional monarchy during the Kepolani, and Kaahumanu m (Kaahumanu
nineteenth century, men became the primary and her supporters) as a seminal event in
political actors; although alii women had Hawaiian history that would greatly impact
served as kuhina nui (prime minister) and had the practice of the formal state religion.
been part of early House of nobles, they later However, despite the revolutionary nature of
would be excluded from political proceedings. the event, many Native Hawaiian makainana,
Additionally, only men were franchised under particularly in rural areas, maintained and
the constitutions. Over time, men who could perpetuated their practices and beliefs
not prove they owned land paid taxes, or (McGregor, 2007, p. 9).
were illiterate, were also excluded from voting Besides changing the demography of
(Lydecker, 1918). Hawaii, the influx of non-Hawaiians would
Agitation from sugar and commercial instigate a flood of ideas, beliefs, and practices
interests in the Kingdom, as well as those that would not only impact the traditional
with American nationalist proclivities, led practice of Native Hawaiian culture and
to increasing tensions within the Kingdom. history, but would also alter their value within
Eventually, this resulted in the 1887 Bayonet the Islands. The settlement of foreigners
Constitution, which would effectively strip in Hawaii began in the late 1700s; the
King Kalkaua of most of his executive powers escalation of travel and the establishment of
(Silva, 2004). In an effort to restore these regular trade routes within the Pacific Ocean
powers to the monarchy, Queen Liliuokalani led to the formation of small populations
attempted to promulgate a new constitution in of foreigners and beachcombers within the
January 1893, but was illegally overthrown in a Hawaiian Islands by the opening decades of
coup led by a group that included individuals the 1800s (Kamakau, 1992). This period also
heavily associated with American commercial marked the beginning of an extended period of
interests in the Islands. Stevens granted the Native Hawaiian diaspora, in which significant
so-called Provisional Government a measure portions of the Native Hawaiian population
of official U.S. recognition as the legitimate would move abroad (Chappell, 1997).
government of Hawaii (Silva, 2004). Following The growth of populations of foreign
a failed attempt to secure annexation by the nationals corresponded to the growing
Knehlani Transforming the Health of Native Hawaiian Men 15

commercial activities within the Islands, and

vice versa. For example, beginning in the 1850s Transformations in Hawaii
and 1860s, the massive importation of Chinese, during the Twentieth Century
Japanese, Filipino, Korean, Puerto Rican, and It is difficult to pinpoint which factors most
Portuguese contract laborers for the sugar contributed to the shifting value of a traditional
plantations would lead to the phenomenal Native Hawaiian cultural identity in Hawaii,
expansion and diversification of non-Hawaiian because the changes permeated society and
populations in Hawaii (Beechert, 1985). occurred over a period of two hundred years.
Missionaries would also impact the And, while many transformations that would
practice of Native Hawaiian culture (Hawaii affect the practice of Native Hawaiian culture
Mission Childrens Society, 1969). Instead of in the Islands would occur during the Kingdom
being educated by their families, boys were period in the nineteenth century, some of the
now educated in missionary-run classrooms greatest and most formidable would happen
by foreign teachers. Many missionaries and in the twentieth century.
their descendants would become involved The difference between the transform-
in Hawaiian politics and would participate in ations of the nineteenth century and those
economic ventures and commercial activities, of the twentieth is that many of the socio-
such as the purchase of land and investment cultural supports and protections that had
in the sugar plantations (Osorio, 2002; been in place during the Kingdom period
Kameeleihiwa, 1992; Silva, 2004). Some were severely diminished or fragmented
laws that were heavily influenced by Euro- during the twentieth century. During this
American religious and social mores outlawed time, fundamental paradigm shifts devalued
or discouraged the performance of certain and denigrated elements of Native Hawaiian
cultural activities, such as the practices of the identity, inhibiting the ability of Native
kahuna lau lapaau (Chai, 2005) and hula Hawaiians to practice their culture as they
(Silva, 2000). had under the protection of the Hawaiian
While the increase of non-Hawaiian monarchy. These transformations occurred in
populations in Hawaii during the nineteenth all political, economic, and social aspects of
century was remarkable, the decrease of the Native Hawaiian life. For example, English-only
Native Hawaiian population was even more instruction was established in 1896, which
dramatic and rapid. The introduction and Kaman and Wilson note had devastating
spread of highly infectious diseases, such effects on literacy, academic achievement,
as cholera, venereal diseases, smallpox, and and the use of standard English among Native
leprosy, would decimate the Native Hawaiian Hawaiians (in Benham and Heck, 1998, p.
population (Bushnell, 1993). Population loss 261). The legislation restricting the use of the
would complicate the transmission of ike ina Hawaiian language in schools would also have
pertaining to specific places, and was likely a a deep impact on wider Hawaiian society and
significant factor in the loss of historical and nearly extinguish Hawaiian-language fluency.
cultural knowledge. In turn, the loss of language would
As a result of the influx of foreigners and the impact the Native Hawaiian historiography
rapid depopulation of Native Hawaiians, non- and significantly alter conceptions of Native
Hawaiians would come to greatly outnumber Hawaiian culture (Nogelmeier, 2010). The
Native Hawaiians and part Hawaiians. An loss of the ability to practice self-governance,
analysis of the racial composition of the the presence of the American government
Hawaii population shows that by 1890, Native and military, and the growing importance of
Hawaiians and part Hawaiians collectively tourism would have similar effects on Hawaiian
made up about 45 percent of the total society. Cumulatively, these and other changes
population and non-Hawaiians the remainder. during the twentieth century would result in
By 1896, the gap was even wider. Native the transformation of Native Hawaiian culture
Hawaiians and part Hawaiians made up only from one that was practiced daily to one that
36 percent of the total population. Over time, must be actively recovered and revitalized.
the economic, social, and political activities
of foreign nationals would dominate Hawaiian
society, in large part as a result of the growth
of these non-Hawaiian communities.
16 Knehlani Transforming the Health of Native Hawaiian Men

Native Hawaiian Resiliency

Despite the existence of a series of historical difficulties and the impact of deep
transformations within Hawaiian society, Native Hawaiians have actively sought to preserve
and perpetuate their history and culture. For example, the significance of mookauhau was
maintained into the late 1800s: a Board of Genealogy was established in 1880 by King Kalkaua
and the Legislative Assembly of the Hawaiian Kingdom (Hawaiian Kingdom, 1880). It is also
important to remember that Native Hawaiians were able to rapidly adapt to many of the changes
occurring within society during the nineteenth century. One of the most poignant examples can
be seen in the proliferation of Native Hawaiian writings in the npepa, or Hawaiian-language
newspapers, as documented by Puakea Nogelmeier (2010):
In just over a century, from 1834 to 1948, Hawaiian writers filled 125,000 pages
in nearly 100 different newspapers with their writings. While literacy was at its
highest, Hawaiians embraced the Hawaiian-language newspapers as the main
venue for news, opinion, and national dialogue, but also as an acknowledged public
repository for history, cultural description, literature and lore.... The contents of
those papers span a period when noted historians, expert genealogists, skilled
storytellers, and cultural specialists were numerous, and their knowledge was
intentionally recorded in writing.
Knehlani Transforming the Health of Native Hawaiian Men 17

Part Two: O Kia Au (The Present)

Having examined the historical roles and responsibilities of Native Hawaiian kne (Native Hawai-
ian men) in traditional Hawaiian society, we turn now to a discussion of the contemporary state
of kne health and well-being. Within this discussion the larger social, economic, and cultural
context must also be considered, as these factors continue to determine the health and well-
being of Native Hawaiian men today.

Demographics: Hawaiians. 62.8% of Native Hawaiians

The Kne Population in Hawaii in the State lived in Honolulu County,
As previously illustrated, there was a 18.9% lived in Hawaii County, 12.7%
considerable decline in the Native Hawaiian lived in Maui County (including
population throughout the 1800s. However, Kalawao), and 5.6% lived in Kauai
beginning in the 1900s the Native Hawaiian County.
population began to stabilize, and then grow. Of the 289,970 Native Hawaiians in
Naturally, kne population figures also followed Hawaii, 145,849 or 50.3% were kne,
this trend. While not comparable to population with a median age 26.3 years. The
figures from previous years, the new population median age for the 681,243 State
figures for 2000 and 2010 showed a further males was 37.2 years.
increase in the kne population: In 2010, there were 527,077 Native
Hawaiians in the United States: 45%
Of the 1,360,301 State population, living in the Continental U.S. and 55% in
Percent of289,970
Hawaiian Population
were Native by Gender Hawaii.
Native Hawaiian Male State Male

0.1% 90 years and over 0.5%

0.3% 85 to 89 years 1.1%
0.7% 80 to 84 years 1.7%
1.1% 75 to 79 years 2.2%
1.6% 70 to 74 years 2.8%
2.6% 65 to 69 years 4.2%
3.5% 60 to 64 years 6.0%
4.6% 55 to 59 years 6.8%
Male Population in
5.5% 50 to 54 years 7.2%
Hawaii by Age and
6.1% 45 to 49 years 7.1%
Native Hawaiian
5.9% 40 to 44 years 6.6% status
6.0% 35 to 39 years 6.5% Note. Adapted from (U.S.
Census Bureau, 2010a)
6.6% 30 to 34 years 6.6%
7.5% 25 to 29 years 7.4%
7.9% 20 to 24 years 7.6%
9.6% 15 to 19 years 6.5%
9.4% 10 to 14 years 6.1%
10.2% 5 to 9 years 6.3%
10.9% Under 5 years 6.6%
10% 8% 6% 4% 2% 0% 0% 2% 4% 6% 8% 10%

Note. Adapted from (U.S. Census Bureau, 2010a)

18 Knehlani Transforming the Health of Native Hawaiian Men

261,907 (49.7%) of Native Hawaiians effective solution in improving the health of

in the U.S. were kne. Their median age kne will likely require targeted strategies in
was 25.8 years. many of these areas. These health areas are all
The kne age-distribution plot connected to one another, and efforts towards
resembles a pyramid with a wide base, improving kne health as a whole will likely
which indicates a higher fertility rate. require improvements in the various parts.
Percentwise, the kne population was The structure of this second section of the
larger than the State male population report mirrors a knes lifecycle, starting from
before it reached parity between prenatal and familial health through morbidity,
30-34 years of age. From that point, and highlights significant health factors and
the trend reversed, with the largest figures. It concludes with examples of Native
percentage point difference (2.5%) Hawaiian resiliency and recommendations
between 60-64 years of age. The peak for policymaking and other factors that can
indicates a higher mortality rate. The positively affect kne health and well-being.
State male age-distribution plot is
more rectangular below 65 years and Keiki
tapers at the top, indicating a more Health begins before birth during hookau-
stationary population (U.S. Census hua (gestation); social determinants can affect
Bureau, 2010a). health resources for the hpai (pregnant)
makuahine (mother). Keiki (childs) early years
Social Determinants can be conceptualized in three phases: infancy,
of Kne Health childhood, and adolescence. The financial and
Although individuals generally strive to social resources at a familys disposal can
achieve health and well-being, not everyone enhance or inhibit their ability to provide keiki
has the same opportunities to make health- (children) with nurturing and stimulating envi-
Social promoting choices. Even with great motivation, ronments conducive to cognitive and
Determinants of the barriers to health can be too great for behavioral development. The effects of educ-
Kne Health individuals to overcome. Health behaviors, ation and income impact health at all
Using the lens of the quality and affordable medical care, genetic stages of life, but are most profound during
social determinants makeup, and physical and social environments childhood. pio (adolescents) are generally
of health (SDH), are critical in understanding an individuals a healthy group, and when pio experience
what are the ability to be healthy. These factors are better adverse health outcomes, the causes can be
interconnected known as the social determinants of health preventable. (Office of Hawaiian Affairs, 2015).)
elements your (SDH).
organization The social determinants of health describe Ohana make-up
addresses? the complex and interconnected structures, The ohana continues to be the center of
circumstances, environments, institutions, and Native Hawaiian identity. In 2014, there were
systems that contribute to the health or harm 52,686 Native Hawaiian families in Hawaii.
of individuals and communities. Some of the Native Hawaiian families made up 16.8% of
Keiki most commonly cited factors to impact long families in the State of Hawaii, and had an
How can your term health and well-being are early childhood average family size of 4.06 people (U.S. Census
organization work to experiences, educational attainment, employ- Bureau, 2014a).
address the health ment, income, housing, culture, public policy,
and well-being of social and familial support networks, built and Larger Families
keiki kne? physical environments, and access to health Empirical national studies have long
care and social services. Leading national and supported the theory that family size is
international organizations recognize the com- negatively associated with childrens education,
bination of these determinants is the most due to the impact of decreased parental time
important influence on individual and popu- and financial resources. Newer studies, however,
lation health outcomes (Office of Hawaiian indicate this association may vary by different
Affairs, 2015). cultural conditions, such as communities with
Thus, the multiple variables discussed high levels of collectivism, where parents share
in the following sections interact in complex responsibility for raising children with many
and multifaceted ways; such that any lasting, relatives (Chilhaya and Styrc, 2015).
Knehlani Transforming the Health of Native Hawaiian Men 19

Additional research is necessary to parent, while of Native Hawaiian families

determine if the presence of more children 39% are single-parent. Specially, 28%
in Native Hawaiian families and households is of Native Hawaiian families were single-
also negatively associated with education and mother and 11% were single-father.
other social determinate of health, or if these Additionally, in 2014, of the 4,201 Native
impacts are mitigated by Native Hawaiian Hawaiian women who had given birth
traditions of extended family involvement and in the past 12 months, 2,514 or 60%
support. were unmarried. This figure compares
with 32% of the total State (U.S. Census
The total State average family size was Bureau, 2014a).
3.61, considerably smaller than those
of Native Hawaiians. This figure includes Multi-Generational Living
members of the household who are not Since the Great Recession of 2008, multi-
related by birth, adoption, or marriage. generational living across the United States
Of these families, 17,228 or 32.7% has grown in popularity. In Native Hawaiian
had children younger than 18 years, communities, however, these household
in comparison with 27.3% of the total structures are consistent with traditional
State family households (U.S. Census practices which emphasized the importance
Bureau, 2014a). of ohana and kpuna (grandparent). Current
research indicates three-generation living
Single Parent Families as a protective factor in early childhood
The number of parents in a household can experiences (Kamehameha Schools, 2014).
impede a familys ability to provide resources This setting includes the keiki, mkua
for its keiki. In 2014, the Hawaii median family (parents), and kpuna living together in one
income for single-father households was home, as opposed to skipped- generation
68% that of a married couples, while single- households in which kpuna are the primary
Single Parent
mother households median family income caregivers and the mkua is absent. National
was 56% that of married couple families (U.S. research on skipped-generation households
In what ways can
Census Bureau, 2014a). Additionally, current indicates that these children might face
your approach
research on fatherhood in Hawaii concluded additional risk factors, which can negatively
change or vary
that fathering matters because it is related impact their future health (Scommergna,
towards improving
to important outcomes of children, including 2012).
the situation of
cognitive, social, and behavioral. Both the
single parents?
quantity and quality of father involvement In 2014, 8.6% of the Native Hawaiian
appear to be important in shaping child population over the age of 30 lived with
outcomes, above and beyond the contribution their moopuna (grandchildren).
of mothers (Lewin-Bizan, 2015). National 37.2% of these kpuna were financially
research suggests that the absence of stable responsible for their moopunas basic
fathers from childrens lives has particularly needs, such as food, shelter, and day
significant adverse consequences for boys care. This responsibility may indicate a
psychosocial development and educational skipped-generation household.
achievement (Autor and Wasserman, 2013). By comparison, of the total State
Thus, many future social determinates of population over the age of 30, 6.4%
mens health, such as education, occupation, lived with their grandchild(ren); 25.3%
and earnings, can be affected by the early of whom were responsible for the
childhood experience of family structure. child(ren)s basic needs.
Additionally, 19.1% of Native Hawaiian
Data on the ohana makeup for Native households included other relatives
Hawaiian households from 2014 not related to the householder by
demonstrate that Native Hawaiian keiki birth, marriage, or adoption, compared
are more likely to come from single- to 14.2% for the State (U.S. Census
parent households than other keiki in Bureau, 2014a).
the State of Hawaii. 26% of families in
the total State population are single-
20 Knehlani Transforming the Health of Native Hawaiian Men

Abuse/Neglect Education
Countless national and international There are many long-term health effects
studies confirm that sustained childhood of education that reach into adulthood,
experiences of abuse or neglect also including improved cognitive development,
have long-term consequences for mental improved social-emotional development, and
and physical health, as well as for social general health knowledge. Improved cognitive
adjustment, academic achievements, and development is associated with greater
subsequent employment histories. Adults academic achievement, which translates
with a history of childhood abuse have been into better employment opportunities and
found to suffer from significantly more health higher earning potential. Improved social-
conditions, and mental health effects include emotional development is associated with
depressive disorders, anxiety disorders, drug decreased propensity for risk-taking, stress,
abuse, and suicidal behavior (Moore, McDonald absenteeism from school, and self-regulation.
& McHugh-Dillon, 2015; Cashmore & Shakel, General health knowledge informs students
2013; McLeod et al., 2014; Macmillan, 2009; of health promoting and risky behaviors.
Norman et al., 2012; Reeve & van Gool, 2013; High educational attainment predisposes
Zielinski, 2009). the recipient to a higher health trajectory.
Limited research points to links between These individuals report lower chronic and
boys experience of abuse or neglect in child- acute disease burden, independent of basic
hood and increased rates of substance abuse, demographic and employment indicators
sexual transmitted diseases, and perpetration (Office of Hawaiian Affairs, 2015).
of domestic violence in adulthood. Far more
studies focused on the effects of child abuse School Enrollment in Kindergarten through
and neglect in women, making it difficult to Twelfth Grade
compare differences between men and women Historically, the State of Hawaii has one
as less is known on the effects of child abuse of the highest percent of students enrolled in
and neglect on men (Springer, 2007). private schools nationwide. Factors which may
Although Native Hawaiian keiki kne (boys) influence a students school enrollment may
experience increased protective factors due include family income, parent educational
to cultural values and traditional practices, attainment, race, ethnicity, religious affiliation,
Abuse/Neglect current social, economic, and political condi- and Hawaii State Department of Education
How can your tions (such as financial insecurity and unem- (DOE) School Quality rating. The long-term
organization address ployment) create disproportionately high levels impact of private education in comparison to
the need to reduce of child abuse and neglect within Native Hawaiian DOE education has not been determined.
the incidence and households (Kamehameha Schools, 2014).
prevalence of In 2015, Native Hawaiians constituted
childhood abuse and In 2014, 31% of all children in Hawaii 26.1% of male students in the DOE
neglect? were Native Hawaiian, yet Native system, including charter schools (24,659
Hawaiian keiki constituted 42.6% of all of 94,590 male students) (DOE, 2015).
confirmed victims of abuse and neglect Of these Native Hawaiian male
in Hawaii (State of Hawaii, Dept. of students, 70.2% were classified as
Human Services, 2014), a dramatic economically disadvantaged, as
over-representation (U.S. Census indicated through their eligibility
Bureau, 2014a). for the federal free/reduced lunch
Notably, though, confirmed cases of program (DOE, 2015).
Native Hawaiian child abuse and neglect Although not directly comparable
have decreased from 1,456 cases in with the information from 2015, data
2000 to 600 in 2014 (State of Hawaii, from the 2010 U.S. Census indicated
Dept. of Human Services, 2014). that 14.8% of Native Hawaiian male
Although data are not available specific students in kindergarten thorough
to Native Hawaiian boys, in the total twelfth grade were enrolled in private
State population boys constituted 46.8% school and 85.2% were enrolled in DOE
of confirmed victims (State of Hawaii, schools (calculated from U.S. Census
Dept. of Human Services, 2014). Bureau, 2010b).
10% 8% 6% 4% 2% 0% 0% 2% 4% 6% 8% 10%

Note. Adapted from (U.S. Census Bureau, 2010a)

Knehlani Transforming the Health of Native Hawaiian Men 21

Reading Proficiency, by Gender and Native Hawaiian Status, SY2015

Proficient Non-Proficient


72.5 58.7 52.8 39.1 58.1 44.4

Reading Proficiency,
by Gender and Native
Hawaiian Status,
Notes. Calculated from
(DOE, 2015).

27.5 41.3 47.2 60.9 41.9 55.6

Male Female Male Female Male Female
Native Hawaiian Non-Hawaiian All Students

In comparison,
Notes. Calculated from (DOE,18.1%
2015).of non-Hawaiian the new system reports results within four
male students in Hawaii were enrolled categories, including Exceeded Standard,
in private schools, and 81.9% were Met Standard, Nearly Met Standard, and
enrolled in DOE schools. Across the Did Not Meet Standard. As in any evaluation
nation, 10.3% of male students were based on standardized achievement tests,
enrolled in private schools, and 89.7% this discussion must consider the inherent
in DOE schools (calculated from U.S. limitations of this form of assessment. Many
Census Bureau, 2010). education scholars suggest that standardized
Math Proficiency by Gender and Native Hawaiian Status, SY2015
assessment methods are culturally bias and Standardized
Kamehameha Schools is thelargest Native Non-Proficient
Proficient skew results by actually measuring test-taking Educational
Hawaiian-serving private school in the State. skills rather than educational achievement. Achievement
100% Within a comparable time period, an annual The following data on Native Hawaiian student Tests
average of 5,369 Native Hawaiian students test results is presented within the larger How can your
were enrolled at Kamehameha Schools context of these debates. organization impact
campuses (calculated from Kamehameha kne youth within
Schools, 2011). If 50%
73.70 70.60of these students
56.10 52.10
Reading 60.80 57.10 Hawaiis educational
are assumed male, these averages equate In 2015, 27.5% of all Native Hawaiian system?
with 7.5% of Native Hawaiian male students male students tested were proficient
statewide and 50.9% of Native Hawaiian male in reading.
private school students. A higher percent of Native Hawaiian
female students tested proficient
Standardized Educational Achievement Tests in reading than Native Hawaiian
In school year 2014 2015 the Hawaii male students, by 13.8 percentage
State DOE fully implemented a new standard- points.
ized achievement test system: The Smarter A higher percent of non-Hawaiian
26.30 29.40
Balanced Assessments. This system was 43.90 47.90 39.20 tested proficient
male students 42.90 in
designed to align the new Hawaii Common reading than Native Hawaiian male
Core Standards and measure whether students, by 19.7 percentage points.
0% students are on track for college and career (DOE, 2015)
Male Female
readiness. These tests are administered Male Female
Math Male Female
in grades three through eight and 11. Like In 2015, 26.3% of all Native Hawaiian
Native Hawaiian
previous standardized tests used in the Non-Hawaiian
DOE, All Students
male students tested were proficient

Notes. Calculated from (DOE, 2015).

22 Knehlani Transforming the Health of Native Hawaiian Men

Math Proficiency by Gender and Native Hawaiian Status, SY2015

Math Proficiency by Gender and Native Hawaiian Status, SY2015
Proficient Non-Proficient
Proficient Non-Proficient

73.70 70.60 56.10 52.10 60.80 57.10

Math Proficiency by 73.70 70.60 56.10 52.10 60.80 57.10
Gender and Native
Hawaiian Status,
SY2015 50%
Notes. Calculated from
(DOE, 2015).

26.30 29.40 43.90 47.90 39.20 42.90

26.30 29.40 43.90 47.90 39.20 42.90

0% Male Female Male Female Male Female
Male Female Male Female Male Female
Native Hawaiian Non-Hawaiian All Students
Native Hawaiian Non-Hawaiian All Students
Notes. Calculated from (DOE, 2015).
in math. (DOE, 2015).
Notes. Calculated from
A higher (DOE, of
percent 2015).
Native Hawaiian
female students tested proficient Science (The Hawaii State
in math than Native Hawaiian male Assessments are still used for science
students, by 3.1 percentage points. and are administered in grades 4 and 8)
A higher percent of non-Hawaiian In 2015, 34.2% of all Native Hawaiian
male students tested proficient in male students tested were proficient
Science Proficiency, by Gender
math than Native andmale
Hawaiian Native Hawaiian Status, SY2015
in science.
Science Proficiency, by Gender and Native
students, by 17.6 percentage points. Hawaiian Status,
A higher SY2015
percent of Native Hawaiian
Proficient Non-Proficient
Proficient Non-Proficient

65.80 67.40 47.10 50.50 52.30 55.10

65.80 67.40 47.10 50.50 52.30 55.10

Science Proficiency, 65.8% 67.4% 47.1% 50.5% 52.3% 55.1%

by Gender and Native
Hawaiian Status,
Notes. Calculated from
(DOE, 2015).
34.20 32.60 52.90 49.50 47.70 44.90
34.20 32.60 52.90 49.50 47.70 44.90

0% 34.2% 32.6% 52.9% 49.5% 47.7% 44.9%

0% Male Female Male Female Male Female
Male Female Male Female Male Female
Native Hawaiian Non-Hawaiian All Students
Native Hawaiian Non-Hawaiian All Students
Notes. Calculated from (DOE, 2015).
Notes. Calculated from (DOE, 2015).
Knehlani Transforming the Health of Native Hawaiian Men 23

Enrollment of Male Students, by School Type and Native Hawaiian Status, SY2015
Charter: Hawaiian-Focused Charter: Other DOE


91.5 95.8 94.7

Enrollment of Male
Students, by School
Type and Native
Hawaiian Status,
Notes. Calculated from
(DOE, 2015).

2.4 0.8 2.2

6.1 3.4 3.1
Native Hawaiian Non-Hawaiian All Male

Notes. Calculated
malefrom (DOE, 2015).
students tested proficient in
science than Native Hawaiian female Data on graduation rates are reported
male students, by 1.6 percentage by ethnicity or gender, not as a
points. combination. In 2014, Native Hawaiian
A higher percent of non-Hawaiian students in the Hawaii State DOE had a
male students tested proficient in graduation rate of 77.8%, in comparison
science than Native Hawaiian male to the total student rate of 82.1%. In
Population of Hawaii with a Bachelor's Degree or2014,
students, by 18.7 percentage points. male students in the Hawaii
(DOE, 2015) State DOE had a graduation rate of
by Gender and Native Hawaiian Status, 2005-2014 79.1%, in comparison to the female
student rate of 85.2% (DOE, 2016).
Graduation from High Total Male Population
School Native Hawaiian Male considering
When Native Hawaiian Female
the total population
35% According to research from the U.S. of Hawaii of 25 years or older,
Centers for Disease Control, education is one however, an equal portion of Native
of the strongest predictors of health. There Hawaiian men have attained a high 30.0%
30%are numerous ways completing a high school school diploma or higher. In 2014,
education can impact health outcomes. First, 92.9% of Native Hawaiian men had
it has a direct correlation of levels of future attained this level of education. This
25%income, as high school completion is also the rate is comparable to 92.2% of Native
gateway into college, which offers even greater Hawaiian women and 92.5% of the total
benefits than high school alone. Second, male 18.2%
(U.S. Census Bureau,
18.9% 17.8%
high school education facilitates healthier
16.6% 2014a).
14.3% choices by 15.0% 15.6% access
offering learners 15.3% 16.0%
These results may suggest that Native
15%to health information and tools to acquire help Hawaiian male students are not
and resources, such as smoking cessation completing high school on time, 15.4%but15.0%
programs. Third, people are able to acquire
13.3% eventually gain their diploma
12.8% by age 25.
12.0% strengthen social networks, 12.5% 11.8%
10%social support,
and mitigate social stressors; simply 10.4% put, Connection to Native Hawaiian Epistemology
the more education people have, the more and Traditional Practices
5%social support they have. Finally, education Although by several measures of academic
people to 2006
gain a 2007
sense of 2008 2009 achievement,
control over 2010 2011 2012
Native Hawaiian 2013 2014
male students
their lives, an outcome associated with better appear to be lagging behind their peers in
Notes. Adapted
health from (U.S.and
(Freudenberg Census Bureau,
Ruglis, 2007). 2014a) the Hawaii DOE system, alternative systems
24 Knehlani Transforming the Health of Native Hawaiian Men

provide educational opportunities which may offenses on the Crime Index (murder
address these disparities. Many Hawaiian- and non-negligent homicide, forcible
focus charter schools offer cultural-based rape, robbery, aggravated assault,
education, which can be defined as a holistic burglary, motor vehicle theft, larceny-
and comprehensive application of culturally theft, and arson). The majority of the
relevant education and referred to education arrests were for crimes related to
approaches that are ground in a particular larceny-thefts.
cultural worldview (Kanaiaupuni, 2010)in Between 2000 and 2014, however, there
this case, a Native Hawaiian worldview. was a 61% decrease of Native Hawaiian
Recent studies found that the use of cul- juveniles arrested for Part I offenses.
ture-based education strategies by teachers In 2014, 1,750 Native Hawaiian juveniles
and school systems is linked with education were arrested for Part II offenses,
outcomes of Native Hawaiian students. First, which represented 30% of total arrests.
strategies positively impact student socio- Crimes related to runaways accounted
emotional well-being, which are directly related for the highest number of these arrests
to current health outcomes, including identity, (34%).
self-efficacy, social relationships. Second, From 2003 - 2012, Native Hawaiian
enhanced socio-emotional well-being, in youth accounted for:
turn, positively affects math and reading test The highest number of individual
scores, which is a predictor of future health juvenile arrests (26,788 or 34% of all
outcome. juvenile arrests).
The highest number of total juvenile
8.5% of all Native Hawaiian male arrests (60,685 or 37% of 161,901
students (or one out of every 12 total juvenile arrests).
students) is enrolled in a charter The highest number of juveniles
school, in comparison to 4.2% of non- confined to the Hawaii Youth
Hawaiian male students. Correctional Facility (802 or 55% of
6.1% all Native Hawaiian male 1,470 total juveniles).
students are enrolled in a Hawaiian- (Hawaii State Department of the Attorney
focused charter school, over twice General, 2003 2014)
Juvenile Crime the percentage of non-Hawaiian male
In what ways can students (3.4%). Mkua
your organization The vast majority of Native Hawaiian Aging can also be viewed as two phases,
combat the male students, however, are enrolled adulthood and elderhood. Mkua (adults)
prevalence and in a mainstream DOE school (91.5%). and kpuna (older adults) are also vulnerable
incidence of keiki (DOE, 2015) to stressors and social conditionsin their
kne involvement in case, though, the concern becomes how the
the criminal justice Juvenile Crime accumulation of these circumstances over time
system? Juvenile crime can be seen as both an lead to chronic diseases, which then have to
outcome of early childhood social determinates be managed. Some stressors common among
of health, and a factor contributing to adult mkua include working long or irregular hours,
barriers to well-being. Recent research dealing with daily parental responsibilities, or
demonstrates the over-representation of caring for older family members. Long-term
Native Hawaiians in the criminal justice systems exposure to these stressors can put mkua
(Umemoto et al., 2012). These disparities are at higher risk for injuries, digestive problems,
reportedly the effect of the social, political, hypertension, obesity, or heart disease.
and economic conditions which increase the The social determinants of health impact
prevalence of antisocial and criminal behavior individuals in similar ways, but manifest
among Native Hawaiian youth, as well as the themselves differently at each stage of life.
results of institutional bias.
Post-secondary Education
In 2014, 391 Native Hawaiian One of the most significant factors in the
juvenilesrepresenting 31% of total future of a young adult is their level of educational
arrestswere arrested for Part I attainment. Research has shown that there are
Notes. Calculated from (DOE, 2015).

Population of Hawaii with a Bachelor's Degree or Higher,

Knehlani Transforming the Health of Native Hawaiian Men 25
by Gender and Native Hawaiian Status, 2005-2014

Total Male Population Native Hawaiian Male Native Hawaiian Female

Total Male Population Native Hawaiian Male Native Hawaiian Female Population of Hawaii
Population of Hawaii with a Bachelor's Degree or Higher, with a Bachelors
by Gender and Native Hawaiian Status, 2005-2014 30.0% Degree or Higher, by
28.3% Gender and Native
Total Male Population Native Hawaiian Male Native Hawaiian Female 30.0% Hawaiian Status,
2005-2014 (as
35% a percent of the
30.0% population 25 Years
28.3% and Older)
30% 18.4% 18.9% 17.8%
20% 18.2% 30.0%
Notes. Adapted from (U.S.
16.6% 16.0%
Census Bureau, 2014a)
14.3% 15.6% 15.3%
15% 15.0%
15.4% 15.0%
14.6% 13.3% 12.8% 18.9% 17.8%
20% 12.0% 12.5% 18.2%
11.8% 18.4%
10% 16.6%
15.6% 10.4%
15.3% 16.0%
14.3% 15.0%
5% 15.4% 15.0%
14.6% 2006 14.3%2007 13.3%
2008 2009 2010 2011 2012 2013 2014
12.5% 12.8%
12.0% 11.8%
not Adapted
Notes. only economic advantages
from (U.S. for individuals
Census Bureau, 2014a) higher, half as many as the total male
who obtain college degrees in comparison to population in the State.
those with high school diplomas only, but also The percent of Native Hawaiian men
increased well-being in terms of health and civic 25 years and over with a bachelors
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
engagement (Day and Newburger 2002; Dee degree or higher increased by only 0.4
Notes. Ross and
Adapted Wu(U.S.
from 1996). The higher
Census the2014a)
Bureau, level of percentage points from 2005, while the
education an individual attains, the higher their percent of the total male population
future income, enabling them to purchase better increased by 1.7 percentage points.
Male Unemployment in Hawaii, by Age
housing in safer neighborhoods, healthier food, and Native
TheHawaiian Status,
percent of Native 2006-2010
Hawaiian men 25
better medical care and health insurance; each years and over with a bachelors degree
Non-Hawaiian Hawaiian
of these factors is associated with improved or higher continued to be lower than the
health. Native Hawaiian female population from Post-secondary
0.00 75 years 0.01
In 2014, 15% of Native Hawaiian men 2006 to 2014. (U.S. Census Bureau, Education
Male Unemployment
25 and older hadin Hawaii, by Age
0.01 degree
a bachelors 70and
or to 74Native Hawaiian Status, 2006-2010
2014a) In what ways can
0.03 65 to 69 0.02 your organization
Non-Hawaiian Hawaiian
help promote post-
0.06 62 to 64 0.03
secondary education
0.05 75
and 0.01
0.06 amongst kne?
0.14 70
55 to 74
to 59 0.00
0.32 65
45 to
to 69
54 0.02
0.33 62
35 to 64
to 44 0.03
0.14 60to
30 and
34 0.06
0.23 55 to
25 to 29
59 0.12
0.45 Male Unemployment
0.13 45
22 to
to 54
24 0.57
0.42 in Hawaii, by Age
and Native Hawaiian
0.05 35 to 44
20 and 0.62
0.39 Status, 2006-2010
0.21 30
16 to
to 34
19 0.37
0.76 Notes. Adapted from (U.S.
Census Bureau, 2014a)
1.00% 0.80% 0.60% 0.40% 0.23
0.20% 0.00%25 to 290.00% 0.45
0.20% 0.40% 0.60% 0.80% 1.00%

0.13 22 to 24 0.42
Notes. Adapted from (U.S. Census Bureau, 2014a)
0.05 20 and 0.39
0.21 16 to 19 0.76
1.00% 0.80% 0.60% 0.40% 0.20% 0.00% 0.00% 0.20% 0.40% 0.60% 0.80% 1.00%

Notes. Adapted from (U.S. Census Bureau, 2014a)

Median Individual Earnings in Hawaii, by Gender and Hawaiian Status, 2005 - 2014
26 Knehlani Transforming the Health of Native Hawaiian Men

Median Individual Earnings in Hawaii, by Gender and Hawaiian Status, 2005 - 2014
Hawaii State: Native Hawaiian: Hawaii State: Native Hawaiian:
Male Male Female Female

$50K $48,440
$45,577 $45,911 $45,443 $45,748
$41,821 $41,821 $41,811
$41,238 $44,194
$43,740 $42,826
$38,870 $42,832
Median Individual $40K $40,618 $40,259 $38,040 $40,370 $40,162
Earnings in Hawaii, $35,471
by Gender and $33,780 $36,709 $35,977 $36,707
$35K $32,305
Hawaiian Status, $35,596 $35,725

2005 - 2014 $32,739 $33,008

Notes. Adapted from (U.S. $32,378 $32,135 $31,950
Census Bureau, 2014a) $30K $30,872


2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Notes. AdaptedStability
Economic from (U.S. Census Bureau, 2014a) Earnings
Because of its high cost of living, Hawaii poses
a great economic challenge for not only Native In 2014, the average annual earnings
Hawaiians, but all residents. With the nations of Native Hawaiian men was $41,811;
highest food and electricity costs, householders this figure is 89.4% of the average of all
must make difficult choices to select which men statewide ($46,786).
bills get paid every month. Parents working long From 2005 to 2014, Native Hawaiian
hours may be too exhausted from working a long male average annual earnings
Economic Male shift toOccupational
cook nutritiousRepresentation
meals, and instead in relyHawaii, by NativebyHawaiian
increased 2.9%, whileStatus,
the earnings of
Stability 2006 on cheap,-2010 high-calorie
as percentfood. of
all menwithout
in occupationallinmen statewide increased 13.5% and
In terms of economic health insurance cannot receive preventive the earnings of Native Hawaiian women
shifts over time, services or seek care when they fall ill. The closest Native Hawaiianincrease
Non18.3%. (U.S. Census Bureau,
how can the State primary care physician may be an hour away by 2014a)
address the report bus, making the visit costly and time-consuming.
Material moving 33.43 66.57
findings that are Families unable to pay monthly mortgages or rent Occupation
linked to kne Laware enforcement
left to moveworkers
in withincluding supervisors 31.08 68.92
other family members or
refighting and prevention and seek other
other protective shelter,
service creating
workers crowded
including living spaces.
supervisors 27.44 In the most72.56 recent data, from 2006
With barely enough financial resources for daily through 2010, Native Hawaiian men
Construction and extraction 27.22 72.82
living expenses, planning for the future becomes comprised 17.6% of the total male
nearly impossible,Transportation
leaving peopleoccupations 27.1
with the ability 72.9 but were over-represented
to only respond to urgent
Farming, fishing,needs. Research
and forestry 22.61 in moving materials (33.4%), law
findings on unemployment rates, earning levels, enforcement (31.1%), firefighters
occupation, commuting Personal care
times, and service
poverty 20.86
rates, and (27.4), 79.13
construction and extraction
Building and grounds indicate thatand
cleaning Native Hawaiian men
maintenance 20 (27.2%),80and transportation (27.1%)
are disparately affected by economic factors. occupations.
Community and social service 19.73 80.27
During this same time period,
Unemployment Production 18.95 Native 81.05
Hawaiian men had the lowest
In the most recent data, from 2006
Installation, maintenance, and repair through18.42 representation
81.58 in legal (5.5%), life/
2010, 3.8% of Native Hawaiian men were physical/ social service (6.8%),
unemployed, Office and administrative
compared with 2.1% ofsupport
all men 17.35
in health 82.65
technologists and technicians
Hawaii (U.S. Census Bureau, 2010c).
Healthcare support 16.57 (7.4%),83.43
health diagnosis and treating
practitioners (7.7%), and business and
Food preparation and serving related 14.72 85.28

Arts, design, entertainment, sports, and media 13.57 86.43

Education, training, and library 11.62 88.38

Architecture and engineering 11.24 88.76

Knehlani Transforming the Health of Native Hawaiian Men 27
Male Occupational Representation in Hawaii, by Native Hawaiian Status,
2006 -2010 as percent of all men in occupation in Hawaii)
Native Hawaiian Non Hawaiian

Material moving 33.43 66.57

Law enforcement workers including supervisors 31.08 68.92

Firefighting and prevention and other protective service workers including supervisors 27.44 72.56

Construction and extraction 27.22 72.82

Transportation occupations 27.1 72.9

Farming, fishing, and forestry 22.61 77.39

Personal care and service 20.86 79.13

Building and grounds cleaning and maintenance 20 80

Community and social service 19.73 80.27

Male Occupational
Production 18.95 81.05
Representation in
Installation, maintenance, and repair 18.42 81.58
Hawaii, by Native
Office and administrative support 17.35 82.65
Hawaiian Status,
Healthcare support 16.57 83.43 2006 -2010 as
Food preparation and serving related 14.72 85.28 percent of all men
Arts, design, entertainment, sports, and media 13.57 86.43 in occupation in
Education, training, and library 11.62 88.38 Hawaii)
Notes. Adapted from (U.S.
Architecture and engineering 11.24 88.76
Census Bureau, 2010d)
Sales and related 11.08 88.92

Management 10.6 89.4

Computer and mathematical 8.91 91.09

Business and financial 8.73 91.27

Health diagnosis and treating practitioners and other technical 7.67 92.33

Health technologists and technicians 7.44 92.56

Life, physical, and social science 5.75 93.25

Legal 5.51 93.49

0 20 40 60 80 100

Notes. Adapted from (U.S. Census Bureau, 2014a)

financial occupations (8.7%). on housing costs. Households that spend

(U.S. Census Bureau, 2010d) more are considered cost-burdened because
they have less to spend on other necessities
Commuting (HUD, 2014), such as nutritious food and
health care.
On average, Native Hawaiian men spend In 2014, 55% of Native Hawaiian households
30.1 minutes a day traveling to work. who rent their homes were considered cost-
Therefore, it can be estimated that they burdened and 35% of those who own their
spend 60.2 minutes traveling to and homes (U.S. Census Bureau, 2014a). These
from work, which equates to 5.1 hours figures were lower than total State percent-
a week and 260.9 hours, or over 1.5 ages, even though as previously mentioned
weeks a year. Native Hawaiian household income was consi-
On average, Native Hawaiian men spend derably less. These differences may be attri-
3.4 more minutes a day traveling to buted to the higher rates of Native Hawaiian
work each day, than non-Hawaiian men. households doubling-up (multiple families
Therefore, it can be estimated that living together to share costs) and the selection
they spend an additional 6.8 minutes of housing in lower cost neighborhoods. Thus,
traveling to and from work, which although income is saved on direct housing
equates to an additional 34 minutes a costs, Native Hawaiian household may experi-
week and 29.5 hours a year. ence related negative health outcomes due
(U.S. Census Bureau, 2014b) to factors such as lack of appropriate green
space for activity and longer commuting
Housing times.
The Department of Housing and Urban
Development definition of affordability is for a Poverty Status in the Past 12 Months
household to pay no more than 30% of income Between 2006 and 2010, 12.1% of Native
28 Knehlani Transforming the Health of Native Hawaiian Men
Average Travel Time to Work in minutes, by Gender and
Native Hawaiian Status, 2014
Male Female

30% 29.30 28.50
28.20 27.30
Average Travel Time
to Work in minutes, 25%
by Gender and Native
Hawaiian Status,
Notes. Adapted from (U.S.
Census Bureau, 2014b) 15%



Native Hawaiian Non-Hawaiian Total

Notes. Adapted from (U.S. Census Bureau, 2014a)

Hawaiians had income in the past 12 months divorced, 1.9% were widowed, and 0.9% were
below the poverty level. Of these, 45.8% were separated. Percentages for total State male
kne and 54.2% were whine (U.S. Census were 9.2 percentage points lower for never
Bureau, 2010e). married, 9.8 percentage points higher for now
married, and comparable for divorced, widowed
Homelessness or separated (U.S. Census Bureau, 2014a).
Data onService
Homeless Native Hawaiian
Clients male homeless
in Hawaii, by Native Hawaiian Status, 2011 - 2015
service clients are not currently reported Behavioral Risk Factors
within the Homeless Service Utilization
Nonor the
Hawaiian Several
Native lifestyle behaviors can, over time,
State Point-in-Time Count Reports. Generally lead to a variety of health issues. This section
speaking, Native Hawaiians in total were over- explores these behaviors.
represented in the population of homeless
service clients: they comprised 30.5% of Nutrition
clients in 2015
as compared to 20.8% of the
The Behavioral4,241
Risk Factor Surveillance
population. System (BRFSS) collects and reports on these
Over 5 years (2011 - 2016) the number nutritional data for Native Hawaiians, including
of total homeless service clients has fruit, vegetable, and soda consumption, which
increased by 5.3%, while the number assist in analyzing behavioral health choices.
8000 of Native
10,225Hawaiian homeless
10,037service 9,733 10,041 10,400
clients has increased by 14.6%. Daily frequency of total vegetable
Male homeless service clients are also consumption for 2015 did not show
over-represented; they comprise 57.0% differences between kne and all
of the total homeless service client men statewide, with 17.4% of kne
population in 2015. (Yuan, 2014) consuming the recommended three
or more vegetables per day (HHDW,
Marital Status 2016b). Further data indicated no
In 2014, there were 108,091 kne age considerable differences across races
15 0 and older (50.5% of Native Hawaiian for daily frequency of fruit consumption.
2001 2012 2013 2014 2015
population, 15 and older). 47.1% were never However, kne did have one of the
Notes. 40.5%
Adapted were
from now2014)
(Yuan, married, 9.6% were higher rates of soda consumption as
Knehlani Transforming the Health of Native Hawaiian Men 29

Homeless Service Clients in Hawaii, by Native Hawaiian Status, 2011 - 2015

Non Hawaiian Native Hawaiian


3,975 3,943 3,906 4,241 4,554 Homeless Service

Clients in Hawaii,
by Native Hawaiian
Status, 2011 - 2015
Notes. Adapted from
8000 10,225 10,037 9,733 10,041 10,400 (Yuan, 2014)


2001 2012 2013 2014 2015

Notes. Adapted from (Yuan,

compared to the2014)
other racial/ethnic the highest group to use e-cigarettes
groups in the State of Hawaii: 24.6% of (30.3%) (HHDW, 2016a).
kne consumed one or more sodas per
day (HHDW, 2016b). Alcohol Use/Drunk Driving
Existing studies regarding the way alcohol
Tobacco Use/Smoking consumption affects years of life by race and
Native Hawaiians have historically been sex have found that interventions need to be
challenged with high rates of tobacco use. 2015 specifically suited to the targeted subgroups
Risk Behaviors by Race-Ethnicity in Hawaii Binge Drinking: 2013
data from the three category smoking report of the population.
from the Behavioral Risk Factor Surveillance
40%Survey (BRFSS) classifies individuals into one Binge drinking is defined by the U.S.
of three categories: Current Smoker, Former Centers for Disease Control and
35%Smoker, 32.6
and Never Smoked. Prevention as four or more drinks for
women and five or more drinks for men
30% As of 2015, the kne rate of 21.6% on an occasion in the past thirty days.
current smokers exceeded the total 25.8 26.6
In 2015, kne had the highest risk
25% male rate of average of 17.7% (HHDW, behaviors for binge drinking (32.6%)
2016b). among all major ethnic groupssix
20% Through a comparison across gender percentage points higher than all men
of the 2015 data, it can be seen that statewide.
within the Native Hawaiian community Additional data from 2015 show that
15% 12.1
the kne rate (21.6%) also exceeds the kne have higher rates of heavy alcohol
whine (18.5%) (HHDW, 2016b). There consumption (drinking more than
10% is evidence that smoking behaviors (as two drinks per day for men). 13.5%
may be the case with many detrimental of kne experienced heavy alcohol
5% health behaviors) are being transmitted consumption.
across generations. The high rate of In 2014, 10.2% of kne reported
0% tobacco and smoking prevalence with having driven under the influence, as
Native Hawaiian
Native Caucasian
Hawaiian Filipino
adults persists within Chinese
compared toJapanese
5.3% for the State of Hawaii
total State.
Native Hawaiian youth. In 2015, Native (HHDW, 2016a).
Hawaiians under the age of eighteen
Notes. Adapted from (Yuan, 2014)
were the second highest group to
smoke in high school (19.2%)and

35% 32.6
30 Knehlani Transforming the Health of Native Hawaiian Men
Risk Behaviors by Race-Ethnicity in25.8
Hawaii Binge Drinking: 2013 26.6
35% 32.6
15% 29.1 12.1
Risk Behaviors by 30%
25.8 26.6
Race-Ethnicity in 10% 24.8
Hawaii Binge 25%
Drinking: 2015 5%
Source. HHDW. 2016a 20%
15% Native Hawaiian Caucasian Filipino Chinese
12.1 Japanese State of Hawaii

Notes. Adapted from (Yuan, 2014)

Native Hawaiian Caucasian Filipino Chinese Japanese State of Hawaii

Notes. Adapted from (Yuan, 2014)

Incarceration of Native Hawaiians as a percentage of the
Community Minimum Medium Close Maximum Unclassified Total
state prison Male
Female MalebyFemale
Male classification andMale
Female Male Female sex,Female
2012Male Female Male Female
Incarceration of Native Hawaiian 35.6% 34.5% 36.8% 45.8% 38.1% 41.3% 35.2% 62.5% 34.6% 42.9% 44.5% 40.0% 37.0% 40.0%
Non-Hawaiian 64.4% 65.5% 63.2% 54.2%
Native 61.9%
58.7% 64.8% Non-Hawaiian
37.5% 65.4% 57.1% 55.5% 60.0% 63.0% 60.0%
Native Hawaiians
as a percentage 100%
of the State
prison population, 90%
by custody Incarceration
64.4 65.5
of Native
63.2 54.2
61.9 58.7
as a percentage
64.8 37.5
of the
65.4 57.1 55.5 60.0 63.0 60.0

classification and 80% prison population, by custody classification and sex, 2012
sex, 2012 70%
Source. Ka Huakai: Native Native Hawaiian Non-Hawaiian
Hawaiian Educational
Assessment. 2012.
64.4 65.5 63.2 54.2 61.9 58.7 64.8 37.5 65.4 57.1 55.5 60.0 63.0 60.0
35.6 34.5 36.8 45.8 38.1 41.3 35.2 62.5 34.6 42.9 44.5 40.0 37.0 40.0
Male Female Male Female Male Female Male Female Male Female Male Female Male Female
35.6 34.5 36.8 45.8 38.1 41.3 35.2 62.5 34.6 42.9 44.5 40.0 37.0 40.0
Community Minimum Medium Close Maximum Unclassified Total
20%The five custody levels shown are defined by the Hawaii Department of Public Safety (2012) as follows:
Notes. Adapted
Community: for inmatesfrom (Yuan,
who have 24 months2014)
or less to serve on their sentence and are eligible to participate [in] furlough programs, extended furlough, or residential
transitional living facilities. Minimum: for inmates with less than 48 months until their parole eligibility date; who have demonstrated through institutional conduct
that they can function with minimal supervision in a correctional setting, or in the community under direct supervision. Medium: for inmates who have more than 48
months to their parole eligibility date; whose institutional conduct and adjustment require frequent supervision/intervention. Close: for those who have minimum
sentences of 21 years or more, who are serious escape risks or have chronic behavioral/management problems. Maximum: inmates who are chronically disruptive,
violent, predatory or are a threat to the safe operation of a facility.
Native Hawaiians are over-represented in the Hawaii prison population. In 2012, Native Hawaiians constituted 17.7% of the total adult population in Hawaii,
Male Female Male Female Male Female Male Female Male Female Male Female Male Female
while in the male prison population Native Hawaiians accounted for 37.0% and in the female prison population 40.0%.
Even within more secure custody levels of close of maximum, Native Hawaiian men account for a lower percent of the population than Native Hawaiian women.
These findings Minimum
are consistent with Medium
those of the 2006 Disparate Close
Treatment of Native Hawaiians inMaximum
the Criminal JusticeUnclassified Totalthat
System report, which concluded
while both Native Hawaiian men and women are disproportionately represented in the criminal justice system, the disparity was less for women. In these data,
44% of incarcerated women were Native Hawaiian, while 37% of incarcerated men were Native Hawaiian.
Notes. Adapted from (Yuan, 2014)
Knehlani Transforming the Health of Native Hawaiian Men 31

Involvement with high healthcare costs, low retirement rates,

Criminal Justice System increased dietary complications due to health
In 2014, 1,962 Native Hawaiian adults conditions requiring nutritional support or
were arrested for Part I offenses on the multiple medications, and the desire to age
Crime Index (i.e., murder, forcible rape, in place with limited financial resources.
robbery, aggravated assault, burglary, Kpuna kane have a life expectancy shorter
larceny-theft, motor vehicle theft, and than the total State population.
arson). This was 31% of the States
6,300 arrests; the second highest racial Household Context
group after Whites (2,215 or 35%). Many kpuna kne in Hawaii continue to live
Larceny-theft accounted for 1,100 or in their communities, outside of institutions,
56% of arrests, followed by aggravated and rely on themselves, family, and services
assault (259 or 13%). Arson was lowest to keep them healthy; and this lifestyle is
(2%). Larceny-theft was consistently considered to be the most desirable. Studies
the highest for both Native Hawaiians have shown that nearly one out of every six
and the State arrest populations from adults is a caregiver to an older adult, but
2000 - 2014. these studies also acknowledge that there
In 2014, 9,837 Native Hawaiian is very limited information about the needs
adults (27%) were arrested for of these kpuna and their family caregivers
seven categories of Part II offenses. (Browne et al., 2011).
These comprise all other offenses
characterized by type: violent, property- As recorded in the most recent U.S.
related, drug manufacturing/sale, Census in 2010, Native Hawaiians
drug possession, gambling, and other 65 years and older constitute only
crimes. This was the second highest of 7.3% of the total Native Hawaiian
11 racial groups after Whites (35% or population in Hawaii. However, 23.7%
12,902 of 36,587 State arrests). of Native Hawaiian households include
From the most recent incarceration a kpuna member. Although the total
reports available by ethnicity and State population had almost twice the
gender (2012), Native Hawaiians were percentage of older adults (14.3%)
over-represented in Hawaiis prison as the Native Hawaiian population, Age and life
population. While Native Hawaiian men the percentages of households to expectancy
accounted for 17.7% of total adult include an older adult member was How can we, as a
population in Hawaii, they were 37% of only 6.6 percentage points higher lhui, raise the life
the male prison population. (30.3%). These figures indicate that expectancy for all
Of the five classes of custody (i.e., Native Hawaiian kpuna are living in kne? What would
Community, Minimum, Medium, Close households at greater rates than the be needed to reform
and Maximum), Native Hawaiians make total State population. in the current
up 35.6%, 36.8%, 38.1%, 35.2%, and A larger percent of Native Hawaiian health care system
34.6% of the population, respectively. kpuna kne lived their moopuna to improve kne
(Kamehameha Schools. 2011) (8.4%), in comparison to the total State health?
older adult population (5.3%). 2.6%
Kpuna of Native Hawaiian kpuna kne were
Kpuna kne (male Native Hawaiian older also financially responsible for their
adults) hold a unique and highly respected moopunas basic needs, such as food,
place in Native Hawaiian communities today shelter, and day care, which is twice
as leaders of the ohana, as well as keepers of the percentage of the total State adult
knowledge and traditions. Kpuna, however, population (1.3%).
often experience increased health, social, Conversely, Native Hawaiian kpuna
and economic vulnerabilities. Many of these kne living alone comprised 1.8% of
concerns can be traced to social determinants Native Hawaiian households; less than
of health, which kpuna kne were exposed the percent total State male older
to earlier in their lives, and many are related adults (2.7%) and kpuna whine (3%).
to kpunas current needs. Many of these
needs are related to high poverty rates,
32 Knehlani Transforming the Health of Native Hawaiian Men

Preventive Services U.S. average of 77 years. This trend of

To keep Native Hawaiian kpuna kne higher life expectancy in Hawaii versus
healthy, services that provide preventive care the U.S. was established since 1950.
must be accessible. Core preventive care Native Hawaiian life expectancy was
services include a flu shot within the year, 74.3 years; kne 71.5 years and whine
pneumonia vaccination ever, and either a 77.1 years. Of six race-ethnicities,
colonoscopy/sigmoidoscopy in ten years or Native Hawaiians had the shortest life
Fecal Occult Blood Test (FOCT) within the year. expectancy. (Health Trends in Hawaii,
In 2014, 30.6% of Native Hawaiian male
kpuna (65 years and older) received Health Outcomes
the necessary core preventive health The physical manifestations on an
services. This percentage compares individual of the social determinants of
with 37.8% of the total State male older health can manifest in many ways. This
adult population and 27.6% of kpuna section explores some of the leading serious
whine (for whom core services include adverse health effects afflicting the Hawaiian
a mammogram within two years). community.
(HHDW. 2016a)
Age and life expectancy Generally speaking, the Native Hawaiian
For kpuna, mobility, or the ability to community is particularly challenged with being
effectively and safely move in the environment overweight and obese. A greater understanding
is essential to health and well-being. Impaired of the Native Hawaiian obesity problem is
mobility can cause mental distress from complimented by recent academic research.
the inability to independently perform daily One such study, published in the Hawaii
activities, access goods and services, and Journal of Medicine and Public Health
interact with ohana. The physical problems conducted by Dr. Laura McCubbin, PhD.
associated from limitations in mobility include and Mapuana Antonio M.P.H.investigated
depression, cardiovascular (heart) disease, whether social stigmas as manifested in
Health Outcomes cancer, and injuries. perceived discrimination is a contributing
What are good factor to the adverse health outcome of
examples of The kne population had 40% (26% being overweight or obese. This study also
existing approaches State) under the age of 20, 15.4% explains that the variability in health risks of
that should be between the ages of 20-29 (15.0% obesity/overweight Native Hawaiians may be
drawn upon in the State) and 6.4% (13% State) 65 and more fully understood and addressed as the
development of a older, signifying high birth and death combination and interacting influence of both
framework to create rates and lower life expectancies. risk and protective factors rather than a single
positive health In 2013, of the total Native Hawaiian negative causal influence of discrimination
outcomes? resident deaths (1,693), 54% or 918 complemented by controlling other variables.
were kne and 46% were whine.
Resident males died at a higher rate The obesity rates for both Native
(AAMR Age Adjusted Mortality Rates) Hawaiian kne and whine are high, but
than females. the obesity rates of kne much higher
In 2000, life expectancy at birth in (45.7%) (outside of the margins of
Hawaii was 80 years, compared to the error) relative to whine (36.1%).
Knehlani Transforming the Health of Native Hawaiian Men 33

Logistic regression analyses of Other Pacific Islanders. In this year of

confirmed a negative influence of measurement, 82.7% of kne were considered
overt discrimination in explaining overweight or obese, based on the body mass
the variability in obesity/overweight index (BMI); in comparison to 66.0% of all men
in Native Hawaiians. There were Statewide (HHDW, 2016b).
statistically significant demographic
predictors which varied in the nature Asthma
of their association, but could be A related outcome connected to high
used to present an at-risk profile. tobacco use is asthma.
Specifically, being male (OR=2.73),
between the ages of 35 and 54 (OR = The most recent data from 2012
1.29), having a household income of documents Native Hawaiians with the
$35,000 or less (OR = 2.45), and living highest prevalence of asthma in the
in the Hawaiian Islands 620 years State of Hawaii at 16.3%. While specific
(OR = 1.29) were positively related to data about kne with asthma is not
being obese/overweight. Thus, kne currently available, combined male/
may be particularly susceptible to female data demonstrates that asthma
obesity if they have lived in Hawaii for a prevalence among Native Hawaiians
considerable time, are poor, and generally is higher (as a percentage)
are between 35 and 54 years of age when compared to all other races within
(McCubbin & Antonio). the State of Hawaii.
Data from the aggregated years 2011-
Data from 2015 reflects that kne 2014, show that whine are more likely
continue to have a higher prevalence of being to currently have asthma compared to
overweight or obese than other racial groups kne.
in the State of Hawaii, with the exception

Compared to the rates from the State of Hawaii, kne had slightly higher rates of hypertension in
2011 and 2013. However, because the confidence intervals do overlap, it is difficult to ascertain
with absolute certainty that the kne rate for hypertension.

2011 2013 Combined Data

Health Indicator Gender Race/Ethnicity Percent Lower CI (95%) Upper CI (95%)
Male Native Hawaiian 33.6% 28.8% 38.4%
Male State of Hawaii 29.2% 27.6% 30.7%
34 Knehlani Transforming the Health of Native Hawaiian Men

High Cholesterol
Compared to the rates from the State of Hawaii, kne had slightly lower rates of high cholesterol
for 2011 and 2013. The difference is marginal, and once again, the confidence intervals overlap.
Diabetes & Pre-Diabetes
2011 & 2013 Combined Data
Health Indicator Gender Race/Ethnicity Percent Lower CI (95%) Upper CI (95%)
Male Native Hawaiian 36.1% 30.5% 41.6%
High Cholesterol
Male State of Hawaii 37.7% 35.8% 39.6%

Both kne and whine diabetes and pre-diabetes rates are relatively comparable to one another
for both categories, for the aggregated years 2011 through 2014.
Heart Attack
Health Indicator Gender Race/Ethnicity Percent Lower CI (95%) Upper CI (95%)
Male Native Hawaiian 10.6% 8.3% 12.8%
Female Native Hawaiian 11.2% 9.4% 12.9%

Health Indicator Gender Race/Ethnicity Percent Lower CI (95%) Upper CI (95%)
Male Native Hawaiian 11.9% 9.7% 14.0%
Female Native Hawaiian 11.7% 9.8% 13.6%

Data from the aggregated years 2011-2014, show that kne are only slightly more likely to have
ever had a heart attack compared to whine. Differences may not be notable or significant, given
that the confidence intervals overlap.

Health Indicator Gender Race/Ethnicity Percent Lower CI (95%) Upper CI (95%)

Coronary Heart Male Native Hawaiian 4.7% 3.6% 5.9%

(ever) Female Native Hawaiian 3.5% 2.5% 4.6%

Data from the aggregated years 2011-2014, show that whine are only slightly more likely to
have ever had a stroke compared to kne. Differences may not be notable or significant, given
that the confidence intervals overlap.
Health Indicator Gender Race/Ethnicity Percent Lower CI (95%) Upper CI (95%)

Stroke Male Native Hawaiian 3.4% 2.5% 4.4%

(ever) Female Native Hawaiian 3.6% 2.6% 4.7%

Although data exists for both incidenceany diagnosis of contracting cancerand for
mortalitya scenario where cancer leads to death, the data for cancer specific to kne are
available for the State of Hawaii, but have not been updated in nearly a decade.
The kne incidence rate becomes particularly troubling when the mortality rate for kne
Knehlani Transforming the Health of Native Hawaiian Men 35

Race-Ethnicity Male Female
Incidence Count Incidence Rate Incidence Count Incidence Rate
Native Hawaiian 369 479.6 441 447.8
White 980 542.4 767 413.6
Table 7.122a Average
Chinese 186 423.5 166 317.3 Annual Incidence &
Filipino 403 466.8 336 341.4 Mortality Counts &
Japanese 842 476.3 776 363.9 Rates for All Cancer
Sites by Gender and
Total, All Races 2,967 485.7 2,684 382.2
Source: Hawaii State,
Mortality University of Hawaii,
Cancer Research Center
Race-Ethnicity Male Female of Hawaii , Hawaii Tumor
Mortality Count Mortality Rate Mortality Count Mortality Rate Registry, Hawaii Cancer
Facts & Figures 2010.
Native Hawaiian 173 231.7 162 171
White 336 198.2 252 133.6
Chinese 68 154.4 61 107.2
Filipino 158 178.7 95 98.3
Japanese 337 187.1 273 109.9
Total, All Races 1,158 192 912 124.7

Note: Invasive cases only, in-situ cases are excluded. Counts are 6 year average annual, rounded to the nearest whole.
All races include race/ethnic groups listed plus all other race/ethnic groups combined.
Rates are average annual and are per 100,000 population, age-adjusted to the 2000 U.S. standard population.

is also considered. Taken together, we get a clearer picture. For whatever reason, kne are
contracting cancer at the second highest rate, but dying from it with the highest mortality rate
of all groups broken down by race and sex (in 2010).

Perhaps shedding a little light on why incidence and mortality rates may be so high is one
statistic on prostate cancer. Compared to all other ethnic groups, kne have the lowest rate of
early stage prostate cancer, and the highest rate of late stage prostate cancer. One potential
reason for explaining this outcome lies in detection. If detection happens later for kne, then
cancer is likely more advanced. Admittedly, drawing broad conclusions on one outcome must be
done with caution. Nevertheless, this trend is particularly instructive. If this trend were reversed,
it could potentially lead to parity with other ethnicities regarding early, late, and un-staged
cancer rates. Understanding why kne are not as participatory in detection will be an important
component to determining and strategizing potential solutions.

Data from the aggregated years 2011-2014, show that whine are more likely to have ever
had cancer compared to kne. This is keeping with the general trend of men having lower
rates of ever having cancer compared to women, throughout the State of Hawaii overall.
The five leading cancer sites for mortality for kne from the most recently recorded years
of 2000-2005: Lung and Bronchus (31.3%), Colon and Rectum (10.1%), Prostate (6.1%),
Pancreas (5.6%), and Liver (5.3%).
36 Knehlani Transforming the Health of Native Hawaiian Men

Trends for lung and bronchus cancer Morbidity

during the years 2000-2005 indicate There are many health challenges facing
that this type of cancer kills more kne the kne population. Data specific to kne
than any other. In fact, this trend had demonstrates that the kne population has
remained unchanged since 1975. grown over time and stabilized, that kne have
Referring to incidence, the event when high suicide rates, and high rates of heavy
cancer is contracted and detected, alcohol consumption. In regards to cancer,
kne have a higher rate of incidence the leading cancer site for kne is lung and
than every female group, and every bronchus cancerwhich kne contract more
other male group with the exception than any other race; kne also have the second
of White males, who have the highest highest incidence rate of cancer and the
incidence rate of all (from 2010). highest mortality rate of cancer. Kne have the
Kne had the second lowest rate of lowest rate of early stage prostate cancer, and
Ever Had a Prostate-Specific Antigen the highest rate of late stage prostate cancer.
(PSA) Test (Among Men Age 40+) in In regards to cancer prevention, kne have the
2013 and have the lowest rates among lowest rates among all other ethnicities for
all other ethnicities for PSA tests within Prostate Specific Antigen (PSA) tests within
the past two years. This is specific the past two years, with kne overall being
evidence demonstrating that kne are significantly less likely to participate in both
not as engaged in cancer detection cancer prevention and treatment trials.
behaviors. Clinical trials also confirm that kne cancer
prevention behaviors can be improved. A
Mental Health recent 2015 study by Bantum, et. al found that
kne were significantly less likely to participate
Data from 2015 shows that kne are in both cancer prevention and treatment trials
more likely to report six or more days than wahine (Native Hawaiian females), and
of bad mental health in the past 30 that both groupskne and wahine alikehad
days (18.6%) than total men statewide the lowest proportion of participation in cancer
(12.9%). (HHDW, 2016b) Kne also clinical trials in comparison to White and Asian
have slightly higher rates of depression American men and women in Hawaii. These
Morbidity disorder (12.4%) as compared to total findings identify both gender and ethnic/
How can your men statewide (9.0%) (HHDW, 2016b). racial gaps in clinical trials conducted in the
organization help In the State of Hawaii, both the entire State of Hawaii with cancer participants. This
with early detection male population (nearly double that of serves as another piece of evidence indicating
of health risks and the female) and the Native Hawaiian the need for future cancer research to
illnesses amongst population and Other Pacific Islander investigate the relationship between factors
kne? What effective generally (nearly double that of the like race and culture with distinct participation
interventions can second highest ethnic group) are demographics. Such research may inform
improve their health both much more likely to commit promotional strategies that increase trial
and well-being? suicide, as measured by the Age- participation, with the hopeful prospect of
Adjusted Mortality Rate per 100,000 decreasing cancer incidence and increasing
(AAMR). Kne susceptibility to suicide quality of life for kne diagnosed with cancer.
and the factors that influence such
negative outcomes need to be better
understood, and promptly addressed
from a prevention lens (HHDW, 2016c).
Knehlani Transforming the Health of Native Hawaiian Men 37

Conclusion and Recommendations

In many ways, the situation looks grim. Native Hawaiians are more likely to come from
single parent homes; have high rates of child abuse and neglect; a higher prevalence of being
overweight or obese with the highest risk factors associated with obesity; and with high rates
of tobacco use.
Complicating a deep understanding of kne health is the absence of holistic research that
would otherwise complement already-existing information. There is much that we do not know.
For example, there is little data on illicit drug use. Diet and nutrition data could be expanded to
include comprehensive nutritional examination surveys of traditional diets. It would be especially
helpful to understand the why that motivates many of these outcomes. For example, why are
kne behaviors sometimes at odds with their own best interests, especially in cancer prevention
and treatment?
Support from schools, government, and other institutions could include the following:

Better policies

Basic public health research methodologies and indigenous ways of knowing should be
incorporated into State policy planning.
Policies that address children and adolescents should be improved to go upstream, to
consider causal and associated risk factors.
HRS 226-20 should be implemented in specific policies. The Hawaii State Planning Act
was amended to codify a commitment to addressing the health disparities and social
determinants of health (SDH) of Native Hawaiians, other Pacific islanders, and Filipinos.

Better programs

Public-private partnerships can be created, which convene to outline a master plan for
the well-being of kne. This plan will focus on reducing kne inequities through policies,
programs, and practice for the State of Hawaii.
Expand ohana-based programming that looks at prevention and interventions through a
family-based model, especially to address multigenerational patterns of SDH disparities.

Better research/evaluation or data

Advanced research, assessment, and evaluation can be conducted, to understand Hawaiian

indicators for connectedness to traditional interventions, especially those outlined in O Ka
W Mamua.
Estimates suggest that investments to improve educational achievement can save more
lives than can medical advances. According to a recent review by Cutler and Lleras-Muney
(3), policies that increase educational attainment could have a large effect on population
health. To realize these possibilities, public health researchers need to develop new
conceptual and analytic approaches to studying the reciprocal relationships between
health and education and consider education as an arena for intervention as well as a
marker or moderator for social position (Office of Hawaiian Affairs, 2015).
The above work could be conducted with non-profit, culturally based organizations (such
as Aha Kne).
38 Knehlani Transforming the Health of Native Hawaiian Men

Better collaboration

We can showcase how collaborations between OHA and Aha Kne show laulima and
collective effort to uplift the community needs. This report is an example of how a
collective effort can make important progress.
State agencies can improve data sharing and data disaggregation for advanced analysis,
to make data-informed decisions and deployment of resources.

Better practice

A statewide study could produce a complete, statewide data set (which included
information on cultural practices and values, etc.), which then would enable researchers to
start making correlations between various SDH. This study could include data collection by
age group and gender, as this report is outlined, and could be conducted cross-agency (for
example, by: OHA, DOH, DOE, DHS, DPS, UH, and DBEDT).

This report is somewhat unique as it begins to paint a more complete picture of the Native
Hawaiian male experience in Hawaii. If we were able to include indicators of cultural connection,
this picture would become even clearer. This report might be able to lend some insight into how
and why kne health needs more holistic interventions, departing from a more traditional, siloed
approach of education, early detection, and treatment. In fact, it goes back to the fact that we
need to support the whole person and positive experience throughout his entire life.
Knehlani Transforming the Health of Native Hawaiian Men 39

Further Discussion Questions

Which aspects of kne well-being are of interest or apply to your


After reading this report, what ecological factor is the most important to
address about kne well-being?

How does having healthy kne positively affect the entire State?

How can your organization address kne well-being for kne of all ages?

In what ways can you work with outside organizations on Native Hawaiian
mens health?

In what ways can this report be used by your organization to achieve greater
health outcomes for Native Hawaiian males?

Who or what organizations need to be part of your planning for next steps
towards greater kne health?

What should be the next steps for the current administration to develop and
implement a shared outcomes framework for ohana-centered wellness?
40 Knehlani Transforming the Health of Native Hawaiian Men

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of Total by State at Diagnosis by Race-Ethnicity, Invasive Cancers, Selected Sites
in Hawaii: 2000-2005. Retrieved from:
University of Hawaii, Cancer Research Center of Hawaii. (2010). Average Annual Incidence &
Mortality Counts & Rates for All Cancer Sites by Gender and Race-Ethnicity in Hawaii:
2000-2005. Retrieved from:
U.S. Census Bureau (2010a). Table QT-P2 Single Years of Age and Sex 2010. (See comments
page for URL)
U.S. Census Bureau (2010b). Table B14002, Sex by School Enrollment by Level of School
by Type of School for the Population 3 Years and Over, 2006 2010 American
Community Survey 5-year estimates. Retrieved from http://factfinder.census.
U.S. Census Bureau (2010c). Table B23001, Sex by Age by Employment Status for the
Population 16 Years and Older, 2006 2010 American Community Survey 5-year
estimates. Retrieved from
U.S. Census Bureau (2010d). Table C24010, Sex by Occupation for the Civilian Employed
Population 16 Years and Over, 2006 2010 American Community Survey 5-year
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44 Knehlani Transforming the Health of Native Hawaiian Men

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Knehlani Transforming the Health of Native Hawaiian Men 45

About this report
Knehlani Transforming the Health of Native Hawaiian Men is the first in a series of
reports by the Office of Hawaiian Affairs on the health of Native Hawaiians. According to scholar
Dr. Pua Kanahele, Knehlani literally means, The fire that ignites the sky, and is the name
of Peles father. In the context of this report, h is transformative energy, the heat that is
necessary to generate life on earth (water systems, food systems etc); lani is symbolic of the
ideal state of health; and Kne represents the connection of akua to kanaka.

Part One: Historical Strengths is adopted from Mana K Kne: Native Hawaiian Mens
Wellbeing, a report written by Aha Kne, a non-profit organization whose mission is to
strengthen the Native Hawaiian community through nurturing and perpetuating the
traditional male roles and responsibilities that contribute to the physical, mental, spiritual, and
social well-being of Native Hawaiian males, their families, and communities.

Cover art and illustrations by Solomon RN Enos.

The kukui glyph was also designed by Enos, The kukui is a kinolau form of Kamapuaa; pairing it
with makawalu (eight eyes)which encourages seeing something in several, dynamic ways
speaks of enlightened, masculine energy that is understood through many lenses.

About the Office of Hawaiian Affairs

Hooulu Lhui Aloha To Raise a Beloved Nation. OHAs vision statement blends the
thoughts and leadership of both King Kalkaua, and his sister, Queen Liliuokalani. Both faced
tumultuous times as we do today, and met their challenges head on. Hooulu Lhui was King
Kalkauas motto. Aloha expresses the high values of Queen Liliuokalani.
Mission Statement
To mlama (protect) Hawaiis people and environmental resources and OHAs assets, toward
ensuring the perpetuation of the culture, the enhancement of lifestyle, and the protection of
entitlements of Native Hawaiians, while enabling the building of a strong and healthy Hawaiian
people and nation, recognized nationally and internationally.
The Office of Hawaiian Affairs is a public agency with a high degree of autonomy. OHA is
responsible for improving the well-being of Native Hawaiians.
OHA is governed by a Board of Trustees made up of nine members who are elected statewide
for four-year terms to set policy for the agency.
OHA is administered by a Ka Pouhana (Chief Executive Officer) who is appointed by the Board
of Trustees to oversee a staff of about 170 people.
Mana is Our Legacy, Mauli Ola is Our Destiny
E hookanaka.
Be a man.
(said by Kamehameha to his
son Liholiho on his deathbed)

lelo Noeau #290.

48 Knehlani Transforming the Health of Native Hawaiian Men

Empowering Hawaiians, Strengthening Hawaii

560 N. Nimitz Hwy., Ste. 200 Honolulu, HI 96817 808.594.1888