Development of a Family Intervention for

Native Hawaiian Women with Cancer:

A Pilot Study
Noreen Mokuau, Kathryn L. Braun, Linda K. Wong, Paula Higuchi, and Carolyn C. Gotay

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Native Hawaiian women have high cancer rates and low survival rates. As with other women,
a major source of support for Native Hawaiian women is their families. This pilot study reports
on the feasibility of providing and measuring a culturally appropriate intervention designed
to help Native Hawaiian women and their families deal with cancer. The feasibility evaluation
indicated that a major strength of the intervention was its incorporation of Hawaiian values
and practices, and a major limitation reflected the difficulties in recruiting Native Hawaiians
for research studies. Despite the small sample size, the six Native Hawaiian women and their
10 family members in the intervention group showed improved self-efficacy and coping
when compared with the four Native Hawaiian women and their eight family members in
the control group. Pilot study data established the feasibility and potential effectiveness of this
culturally tailored intervention for Native Hawaiians, and feasibility findings will be useful in
designing follow-up studies. Steps taken to incorporate cultural values into an intervention also
provide a model for other social workers in developing culturally appropriate interventions for
minority populations.
Key words: culture; feasibility study; Hawai‘i; kinship networks; oncology services; social values

A lthough cancer is the second leading cause

of death in the United States (American
Cancer Society [ACS], 2004), there have
been notable reductions in deaths associated with this
disease. In the 1930s, less than 20 percent of cancer
patients were living five years after their treatment
(ACS, 2003–2004).Today, however, improvements in
the treatment of cancer have allowed more people
to survive this devastating disease. Approximately
62 percent of cancer survivors are expected to live
at least five years after their diagnosis (ACS, 2003),
and it is projected that the number of survivors will
increase steadily over the coming years (Centers for
Disease Control and Prevention and Lance Arm-
strong Foundation [CDC & LAF], 2004).
Despite the decline in deaths from cancer, some
groups have not fully benefited from the advances
in medical technology and treatment. One such
group is Native Hawaiians, a group indigenous to
the islands of Hawai‘i. Native Hawaiian women’s
health disparities are evidenced by their high cancer
rates and low survival rates. In the state of Hawai‘i,
Native Hawaiian women, when compared with
other ethnic and racial groups, have the highest death
rates for all cancers combined (Tsark, 1998) and, in
particular, are diagnosed at significantly younger
ages and later stages for breast cancer (Braun, Fong,
Gotay, Pagano, & Chong, 2005). When compared
with other ethnic and racial groups in the United
States, they have the second highest mortality rates
for all cancers combined (Tsark, 1998). Their five-
year survival rate from 1990 to 1995 was 53 percent
(Tsark, 1998).
Numerous factors contribute to these rates for
Native Hawaiians, including late detection and
diagnoses at more advanced stages, high prevalence
of behavioral risk factors, and genetic markers of
tumor aggressiveness (Braun et al., 2005). However,
one factor receiving increasing attention relates to
the lack of culturally appropriate interventions,
particularly those that focus on the family (Ka´opua,
Gotay, Hannum, & Bunghanoy, 2005).
Native Hawaiian women, as with other women,
typically experience their cancer in the context of
their families.There is a growing body of literature
that documents the effects of cancer not only on the

Mokuau,
CCC Braun, Wong,
Code: 0037-8046/08 Higuchi,
$3.00 ©2008 and Gotay
National Association / AWorkers
of Social Family Intervention for Native Hawaiian Women with Cancer 
patient, but also on the entire family (Baider, Cooper,
& De-Nour, 2000;Veach, Nicholas, & Barton, 2002).
The importance of family in dealing with cancer
has led the National Cancer Institute to expand its
definition of “cancer survivor” to include caregivers
and family members as well as the person diagnosed
with cancer (CDC & LAF, 2004).
The inclusion of the family in “survivorship”
and the subsequent need to explore family support
as a resource in dealing with cancer are of vital
importance. Evidence demonstrates that family
support as a resource can help the cancer patient
cope with the illness and, in the best circumstances,
reinforce the patient’s efforts to stay healthy (Bloom,
2000; Keller, Henrich, Sellschopp, & Beutel, 1996;
Lichtman & Taylor, 1986).The types of support that
can be rendered by families include informational,
tangible, and emotional support. Informational sup-
port refers to the provision of knowledge relevant
to the cancer experience. Tangible support refers to
specific assistance that others may provide to the
cancer patient, such as child care and transportation
to a medical appointment. Emotional support is the
demonstration of caring and reassuring thoughts and
behaviors.The body of literature on family support,
unfortunately, excludes an examination of special
populations such as Native Hawaiians.
Native Hawaiians
As in other ethnic groups (Bloom, 2000; Keller et
al., 1996), family (`ohana in the Hawaiian language)
is a primary resource for Native Hawaiians who
experience cancer. Consistent with the general lit-
erature, focus groups with Native Hawaiian female
cancer patients and their `ohana identified three
key needs—easy access to information, tangible as-
sistance with physical care, and emotional attention
(Braun, Mokuau, Hunt, Ka´anoi, & Gotay, 2002).
We learned that, although Native Hawaiian
`ohana strive to provide the best level of care for
their ill member, deficits in knowledge, informa-
tion seeking, and negotiation capabilities presented
obstacles to care of the ill member. For example, a
woman whose mother had cancer disclosed that
she did not know what questions to ask the physi-
cian about her mother’s treatment and, thus, felt at
a disadvantage in her care. We also were reminded
of the greater emphasis on family than individual
well-being in Hawaiian culture, with expectations
that individual family members may have to forgo
individual pursuits for the good of the group. For
10
example, a daughter related that her mother would
avoid or quit treatment if she felt that treatment
would interfere with her ability to complete tasks
associated with her roles (as wife and mother) within
the family. The daughter felt that `ohana members
could use help reassigning daily household chores
(for example, food shopping), so their mother would
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have the time to comply with recommendations for
treatment, follow-up, and recovery.
In light of these findings, we felt that a fam-
ily-oriented (rather than an individually oriented)
intervention that incorporates Hawaiian values may
be of benefit to Native Hawaiian women with cancer
and facilitate coping in the `ohana.This article reports
on a pilot study of the feasibility of providing and
measuring the impact of such an intervention. Al-
though focused on Native Hawaiians, who comprise
less than 1 percent of the U.S. population, our work
has relevance for other social workers who want to
design and test the feasibility of culturally appropriate
interventions for other minority groups.
Method
The study was approved by the institutional review
boards (IRBs) of both the University of Hawai`i and
the Native Hawaiian Health Care Systems.The latter
is a community-based IRB that reviews research in
Hawaiian communities; its reviewers consider the
cultural and social impact of studies in addition to
human protection concerns (Braun, Tsark, Santos,
Aitaoto, & Chong, 2006). Because our study was a
feasibility study, we were concerned with assessing
recruitment, retention, measures, and intervention
components, in addition to securing preliminary
data on the effectiveness of the intervention. Thus,
we conducted a small sample randomized trial, with
participants assigned to either the culturally tailored
intervention or to a less intensive control condition.
Because many Native Hawaiians have reported
negative experiences with research, which in the
past was conducted primarily by non-Hawaiians
who appeared more concerned with advancing in-
dividual and institutional priorities than in reducing
disparities (Braun et al., 2006), the construction of
a no-treatment control group (a hallmark of earlier
research) was not considered.
Intervention and Control Conditions
Intervention. The intervention was designed to
increase knowledge and behavioral capabilities of
the `ohana, thereby enhancing its ability to provide
Social Work Volume 53, Number 1 January 2008
informational, tangible, and emotional support to the
woman with cancer. Areas of knowledge included
cancer basics, such as understanding treatment op-
tions and associated side effects. Behavioral skills
training emphasized telephone and Internet infor-
mation seeking, communication with the physician
and other health care providers, and renegotiation
of household duties. In developing a culturally ap-
propriate intervention, key cultural characteristics
for Native Hawaiians were considered, including an
emphasis on spirituality and connections of Hawai-
ians to each other; a focus on the `ohana, rather than
the individual, and members’ kuleana (responsibility)
within the family; the incorporation of Hawaiian
values and `olelo no `eau (proverbs) in the interven-
tion materials and sessions; and the sharing of food
(mea`ai) (Handy & Pukui, 1977; Pukui, Haertig, &
Lee, 1972).
The intervention was provided to the cancer
survivor and one or two survivor-selected family
members together. Sessions always began with a
prayer (pule) in which both God and ancestral spirits
were invoked for guidance, and often these prayers
were said by a kupuna (elder) from the `ohana.
Participants and staff would then disclose their ge-
nealogies to affirm their spiritual origins, discover
familial connections, and foster trust. An example of
a proverb included in the materials was “e ola koa,”
which means to “live a long time, like a koa tree
in the forest” and implies that every individual koa
tree needs to live long if the forest is to be healthy.
Other cultural values, such as kokua (cooperation),
kako`o (to support or uphold), and aloha (love), were
intrinsic to the intervention. Intervention materials
were illustrated with graphics that depicted Hawaiian
scenes of nature and people. All materials were pack-
aged in woven lauhala (plant fiber) bags, recogniz-
ing the importance of the lauhala tree in Hawaiian
rituals and symbolizing the interwoven bonds of
the `ohana. Finally, with the cultural emphasis on
“feeding the spirit within,” food was always shared
with the `ohana.
The intervention itself consisted of six sessions
over a three-month period (see Table 1). It was
provided by four MSWs, one of whom also was
a cancer information specialist, in teams of two.
Three staff members were Native Hawaiian, and the
cancer information specialist was a lifetime resident
of Hawai‘i intimately familiar with Hawaiian cul-
ture. In the first session, introductions were made,
the consent form and measures were administered,
Mokuau, Braun, Wong, Higuchi, and Gotay / A Family Intervention for Native Hawaiian Women with Cancer
educational materials were distributed, and supplies,
such as speakerphones (for accessing information
so that all `ohana members could hear) and bulletin
boards (for posting information such as medical
appointments and household chores) were pro-
vided. The educational materials and supplies were
provided in the lauhala basket, which participants
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then could keep.
In session two, participants learned how to use
the speakerphones to access cancer information
from the Cancer Information Service (CIS), the
National Cancer Institute’s information link to the
public. The third session taught families to access
information through the Internet, using either a
home computer or one at the local library. In session
four, ‘ohana was assisted with defining and renego-
tiating roles to facilitate the cancer survivor’s ability
to comply with treatment recommendations. Staff
members taught communication skills in session
five, and role-playing talk with physicians and other
providers took place. Interpersonal and emotional
issues around death, loss, and change most frequently
emerged in sessions four and five, as participants
discussed their personal roles and responsibilities in
supporting the cancer survivor and each other. In
the final session, the measures were readministered,
participants were thanked, and a final prayer was
offered for the `ohana.
In addition, sessions two through six included a
review of the previous session, both to confirm that
knowledge was retained over time and to address
new questions.The sites for the intervention varied
according to the interests of the `ohana and included
homes, business offices, and libraries.
Control. Women in the control group also invited
one to three family members to participate, but this
group received only two visits from the research
team over three months (see Table 1). Similarly
to the intervention group, two team members at-
tended these sessions, and the first session began
with a culturally competent introduction process,
the consent form was reviewed, and baseline data
were collected. Then, a packet of readily available
educational brochures was provided and reviewed,
and questions were answered. The second session
was devoted to answering additional questions,
gathering poststudy data, and closure. In addition
to being much less intensive, the control condition
was not culturally targeted outside of the introduc-
tion process, which was deemed necessary to retain
members of the control group in the study.
11
 Table 1: Outline of the Intervention and Control Conditions
Session Intervention Condition Control Condition
Baseline visit • Culturally competent introduction • Culturally competent
• Review of consent form introduction
• Collection of baseline data • Review of consent form
• Review of culturally tailored curriculum and readily available educational • Collection of baseline data
brochures in lauhala (plant fiber) basket • Review of readily available
• Provision of family bulletin board to be used to track patient medica- educational brochures

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tions, appointments, family chores, and so forth • Questions and answers
• Questions and answers
2 • Review of previous session
• Installation of conference telephone
• Training in formulating questions
• Training in accessing the CIS, with return demonstration
• Questions and answers
3 • Review of previous session
• Training in accessing Web-based cancer sources (using family’s home
computer or holding session at public library), including return
demonstration
• Questions and answers
4 • Review of previous session
• Assistance defining and renegotiating roles to facilitate the cancer
survivor’s ability to comply with treatment recommendations
• Logs and task sheets completed
• Questions and answers
5 • Review of previous session
• Training in communications
• Assistance identifying communication challenges
• Role-playing conversations with health care providers
• Facilitation of intrafamily communication
• Questions and answers
Three-month • Review of previous session • Review of previous session
follow-up visit • Collection of three-month follow-up data • Collection of three-month fol-
low-up data
Note: CIS = Cancer Information Service, National Cancer Institute.

Sample Hawaiian women were assigned to the intervention

Several recruitment strategies were used, including
mailing study information to physicians and other
providers, promoting the study through print and
electronic media, and staffing a telephone hotline
where potential participants could get more infor-
mation. All inquiries were followed with face-to-
face contact. As part of our feasibility assessment,
we wanted to determine whether the intervention
worked with a variety of cancer types and ages, so
the only inclusion criteria were Native Hawaiian,
female, and diagnosed with cancer within the past
12 months.
Twelve women volunteered for the study. To
facilitate random assignment, 12 envelopes were
prepared and sealed by an independent statistician.
Each envelope included a paper with “intervention”
or “control” written on it. After a woman signed the
consent form, her name was written on the outside
of one of the envelopes, which was then opened to
determine her assignment. In this way, six Native
group and six were assigned to the control group.
However, two women assigned to the control group
withdrew from the study before the collection of
baseline data, leaving six in the intervention and four
in the control groups. As the women were blind
to which group they were randomized to, and the
control group was not a “no-treatment” control, we
assumed that the fact that both withdrawals were
from the control group was a matter of chance.
Comparing the groups demographically, the mean
age of women in the two groups was similar (about
55 years), and ages ranged from 25 years to 76 years
in the intervention group and 48 years to 84 years in
the control group.Women were three to 12 months
postdiagnosis (M = six months). Breast cancer was
the diagnosis for three women in the intervention
group and two women in the control group; other
women’s cancers were ovarian (control), throat (con-
trol), uterine (intervention), lung (intervention), and
lymphoma (intervention). Women in both groups

12 Social Work Volume 53, Number 1 January 2008

invited one to three family members to participate
in the study (M = two members). Family members
were primarily spouses and adult children.The mean
age of family members was about 54 years in both
groups, and about one-half of the family members
in each group were men.
Measures
In addition to a participant profile that solicited
information on sociodemographics, diagnosis, and
family composition, there were five measures to assess
intervention effects—a cancer knowledge inventory,
a self-efficacy scale, a coping scale, a psychological
distress inventory, and an adjustment scale.
To assess cancer knowledge, an inventory of 15
true–false items was constructed from materials in
the Cancer Survival Toolbox and other resources
(Morra & Potts, 1994; National Coalition for Cancer
Survivorship, 1998). Sample items included “cancer
is contagious,” “a Pap test detects ovarian cancer,”
and “CIS provides a nationwide toll-free telephone
service for people with cancer and their families.”
Correct answers were counted, for a possible range
of scores from 0 = no correct answers to 15 = all
correct answers. In pretesting, the scale’s internal
reliability and test–retest reliability were moderate
(α = .66 and r = .72, respectively).
A 12-item scale on self-efficacy also was con-
structed, asking participants to evaluate their con-
fidence in getting information on cancer, accessing
resources, discussing care with the physician, getting
help, and negotiating family tasks.These were scored
on a 10-point Likert-type scale. Possible scores
ranged from 12 = not confident with any item to
120 = very confident with every item. Based on
pretest data, the scale’s internal reliability was high (α
= .91), and the test–retest coefficient was moderate
(r = .68). A moderate correlation (.64) between this
scale and our measure of coping (described below)
supports its validity.
We used the Family Crisis-Oriented Personal
Evaluation Scale (F-COPES), a 30-item five-point
Likert-type scale (1 = strongly disagree to 5 =
strongly agree), to measure family coping behaviors
overall and on five subscales: (1) Social Support, (2)
Reframing, (3) Spiritual Support, (4) Mobilizing
Family to Accept Help, and (5) Passive Appraisal
(McCubbin, Larsen, & Olson, 1982). Total scores
ranged from 30 to 150, with a high score represent-
ing an increased number of coping strategies used.
For the total score, Cronbach’s alpha was .77, and
Mokuau, Braun, Wong, Higuchi, and Gotay / A Family Intervention for Native Hawaiian Women with Cancer
subscale reliability ranged from .62 to .83 (Fobair
& Zabora, 1995).
The 53-item Brief Symptom Inventory (BSI), a
shorter version of the Symptom Checklist-90 that
measures psychological distress, was included. The
Global Severity Index was constructed by adding
scores on each item (scored using a five-point Likert
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scale ranging from 0 = no experiencing of the symp-
tom to 4 = frequent experiencing of the symptom)
for a possible range of from 0 to 212; reliability for
the overall score was .80 (Derogatis, 1975a).
We proposed using the 46-item, four-point
Likert-type Psychosocial Adjustment to Illness
Scale–Self-Report (PAIS-SR) to assess illness adjust-
ment of patients (Derogatis, 1975b). However, family
members complained that the tool was inappropriate
for them, inasmuch as the questions focused on the
patient’s experiences. For example, questions focused
on patients’ experiences at home, work, and social
lives. Although the scale seemed appropriate for
patients, the patients complained that the battery
of tests was too long.Thus, we decided to drop this
measure from the study.
A feasibility study allowed program developers
and researchers to gather data about a new program
to refine it and the associated research measures and
protocol. Our feasibility evaluation was organized
around five areas: recruitment, retention, measures,
study protocol (for example, the number of sessions,
the sites for the intervention), and study materials
(bulletin boards and speakerphones). Each feasibility
item was discussed and data were documented at
monthly staff meetings, and minutes were kept of
these meetings. In addition, during the final data
collection session, participants were asked to com-
ment on their experience in the project, especially
their thoughts about the materials and services
received and the measures used. Responses were
recorded verbatim and later discussed and coded
by the research staff.
Data Analyses
Data were managed and analyzed using SPSS (1999).
We used t tests to examine differences between the
control and intervention groups on baseline knowl-
edge, self-efficacy, F-COPES, and BSI scores, with
a < .05 significance level. We used the Wilcoxin
signed-rank test to examine overtime change in
these measures, also with a < .05 significance level.
Although the small sample precluded correcting for
multiple comparisons, we felt that our confidence in
13
the worth of the intervention would be strengthened
if the intervention group showed greater improve-
ment on several outcomes. Feasibility data around the
five areas were collated from the minutes of monthly
staff meetings, data categories were confirmed, and
coded comments were counted.
in outcome variables than did the control group
(see Table 2).Women with cancer who received the
intervention showed significant improvement in the
F-COPES total score (p < .05) and on subscales
measuring spiritual support (p < .05) and mobilizing
the family to accept help (p < .05). These women
also reported a significant decrease in BSI score (p

Results
Intervention Effects
Baseline measures for patients were not significantly
different. For family members, those in the control
group had an unusually low mean baseline BSI score.
Looking at changes over the three-month follow-up,
the intervention group realized more improvements
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< .05).Their family members also reported benefits,
including significant increases in self-efficacy (p <
.05), four of the five F-COPES subscales (p < .05),
and the F-COPES total scores (p < .01).
Women with cancer in the control group did
not show significant change on any indicators.
Their family members showed significantly poorer

Table 2: Outcome Variables at Baseline and Three-Month Follow-up

Cancer Patients Family Members
(n = 10) (n = 18)
Intervention Control Intervention Control
Variable (n = 6) (n = 4) (n = 10) (n = 8)
Knowledge
Baseline 12.00 12.00 12.20 11.25
Three-month follow-up 13.00 11.25 13.00 12.50
Self-efficacy
Baseline 107.33 90.50 88.20 101.63
Three-month follow-up 113.67 105.00 109.20* 98.38
F-COPES
Social Support subscale
   Baseline 33.33 29.25 30.10 26.50
   Three-month follow-up 36.50 33.00 35.40* 26.63
Reframing subscale
   Baseline 34.50 34.75 31.80 32.77
   Three-month follow-up 35.17 36.75 34.70* 30.13
Spiritual Support subscale
   Baseline 19.50 19.50 19.50 15.38
   Three-month follow-up 22.67* 20.00 21.60* 14.75
Mobilizing Family to Accept Help subscale
   Baseline 13.67 16.25 14.10 16.13
   3-month follow-up 18.00* 16.25 17.30* 13.13*
Passive Appraisal subscale (reverse scored)
   Baseline 13.67 12.75 14.50 15.63
   Three-month follow-up 12.67 11.75 12.40 15.25
Total
   Baseline 114.17 110.00 109.70 106.88
   Three-month follow-up 125.17* 113.75 121.40** 99.50*
BSI
Baseline 26.67 36.75 32.00 7.50
Three-month follow-up 17.00* 36.25 39.00 28.25
Note: F-COPES = Family Crisis-Oriented Personal Evaluation Scale; BSI = Brief Symptom Inventory. Numbers in bold type indicate an improved score. The Wilcoxin signed-rank test
was used.
*p < .05. **p < .01.

14 Social Work Volume 53, Number 1 January 2008

scores on the F-COPES total score (p < .05) and
the subscore measuring ability to mobilize family
to accept help (p < .05). The mean BSI scores for
family members in the control group was higher
(worse) at three months, but this difference was
not significant.
10 women for the study. Several factors interfered
with recruitment, including potential participants
“not feeling well enough to participate” and be-
ing “too busy.” Most significantly, recruitment is
constrained by the fact that Hawaii does not have a
comprehensive cancer center that provides one-stop
access to cancer care. Instead, cancer care is offered

Feasibility Evaluation
Qualitative findings from staff and participants
were useful in helping to evaluate the feasibility
of this intervention for future research and its ac-
ceptability to this population. In terms of feasibility,
this pilot study revealed recruitment to be a major
constraint for future research with Native Hawai-
ian cancer patients, as it took 18 months to accrue
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in multiple facilities, requiring researchers to recruit
patients through individual physicians or through
public media venues. Although several recruitment
strategies were used to alert physicians and the
public about the study, the majority (70 percent)
of participants came to the study because “they
knew someone who knew someone” involved in
the research (see Table 3).

Table 3: Feasibility Evaluation

Factor Condition
Intervention and Control Conditionsa
Recruitment and attrition • 70% of patients came to the study through word of mouth and physician referral, and none
responded to media announcements or brochures.
• Once enrolled, no one dropped out.
Measures • 60% of patients and 50% of family members complained about number of tools.
• No difficulties were reported for completing the knowledge, self-efficacy, and F-COPES
measures.
• High mean baseline and follow-up scores on the knowledge test suggest this tool needs to be
refined.
• PAIS-SR measure dropped after first four families complained of its inappropriateness for fam-
ily members and burden on patients.
• BSI: 62% of family members in the control group reported no or few symptoms at baseline but
many symptoms at follow-up.

Intervention Condition Onlyb

Cultural relevance • 100% of patients and family members appreciated attention to Hawaiian values and practices
throughout the intervention/
• 100% of patients and family members appreciated the starting of each session with prayer.
• 67% of patients and 60% of family members valued the close connections and personal rela-
tionships developed with the research team.
• 67% of patients and 80% of family members appreciated the cultural tailoring of the
curriculum.
Study protocol and materials • 100% of patients and 80% of family members felt that learning to access CIS and Web-based
cancer sources was helpful.
• 83% of patients and 90% of family members felt the session on communication skills was
helpful.
• 83% of patients and 80% of family members felt the session on renegotiating roles was helpful.
• 83% of patients and 70% of family members felt sessions 2 and 3 could be combined.
• 83% of patients and 70% of family members appreciated receiving the speakerphone and bul-
letin board.
• 67% of patients and 60% of family members appreciated the flexibility in accommodating fam-
ily schedules.
Note: F-COPES = Family Crisis-Oriented Personal Evaluation Scale; PAIS-SR = Psychosocial Adjustment to Illness Scale–Self-Report; BSI = Brief Symptom Inventory; CIS = Cancer
Information Service, National Cancer Institute.
a
Cancer patients: n = 10; family members: n = 18.
b
Cancer patients: n = 6; family members: n = 10.

Mokuau, Braun, Wong, Higuchi, and Gotay / A Family Intervention for Native Hawaiian Women with Cancer 15
 With regard to the measures, the majority of pa-
tients (60 percent) and family members (50 percent)
indicated that there were too many to complete, even
after we dropped the PAIS-SR from the test battery.
The knowledge and self-efficacy tools developed for
the project had high-moderate to high reliability;
however, high mean baseline and follow-up scores
on the knowledge test suggest that this tool needs
to be refined. The F-COPES measure was accept-
able to participants, and its use helped show change
among participants in the expected direction. The
BSI measure produced some unusually low baseline
findings (0 at baseline and 25–60 at follow-up) for
four family members in two different families, and
highlighted the limitations of a small sample. In
future research, a larger randomized sample would
correct for this type of statistical fluke.
In terms of acceptability, participants who received
the intervention provided concrete information with
regard to what they felt were its strengths and what
they found helpful. All intervention participants
appreciated cultural tailoring of the curriculum
and sessions (for example, the attention to family
and intrafamily kuleana, the inclusion of Hawaiian
graphics and proverbs in educational materials,
the sharing of food, and the honoring of pule and
ancestors as sources of spiritual support). Patients
(67 percent) and `ohana (60 percent) felt they had
developed close connections and personal relation-
ships with the research team.They disclosed that the
incorporation of “Hawaiian ways” increased their
level of comfort with the study and was a major
reason why they referred (or would refer) others
to join the study.
Participants in the intervention group over-
whelmingly indicated (80 percent to 100 percent)
that family support was enhanced by training that
taught them how to access information, commu-
nicate with health care providers, and renegotiate
household duties. However, patients (83 percent) and
`ohana (70 percent) felt that there were too many
sessions, and that training in telephone and Internet
access could be achieved in one session rather than
two. In line with the number of sessions and the
difficulties in getting family members together to
attend all sessions, patients (67 percent) and `ohana
(60 percent) were grateful for the research team’s
flexibility in scheduling sessions on weekends and in
the evenings. The majority of patients (83 percent)
and `ohana (70 percent) in the intervention group
also appreciated receiving materials that supported
16
the care of the cancer patient (for example, speak-
erphones and bulletin boards).
Discussion
The growing body of literature on cancer survivor-
ship recognizes that many patients confront their
disease within the context of their families (Baider
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et al., 2000;Veach et al., 2002). The apex of the lit-
erature on family support indicates that when family
members can successfully cope with the disease, the
likelihood is the cancer patient will be reinforced
in efforts to stay healthy (Blanchard, Ruckdeschel,
& Albrecht, 1996; Bloom, 2000; Keller et al., 1996;
Northouse, 1995).
Although the family may be the major resource
for the cancer patient, it is evident that family
members are in need of support as well. Many of
the concerns of family members reflect the need
for information about the disease and its treatment,
for assistance in learning ways to provide tangible
assistance to the cancer survivor, and for learning
how to deal with the emotional concerns around
the loss of life. For a special population, such as Na-
tive Hawaiians, these needs are accentuated because
of their rates of high mortality and low survival.
Furthermore, the cultural emphasis on the `ohana
suggests that a family-oriented intervention would
best serve this population. In this pilot study, we de-
veloped and established the feasibility and potential
effectiveness of a culturally tailored intervention
designed to enhance family support for Native
Hawaiian women with cancer.
It was gratifying that cancer patients and their
family members in the intervention group showed
improvement on more outcome variables than did
patients and families in the control group, despite the
fact that this pilot study was constrained by a small
sample and the different amounts of time required
for the control and intervention groups. Advances
for the intervention group were noted especially
in self-efficacy and coping. Improved self-efficacy
likely reflected the heavy emphasis in the training
on skills development in the areas of information
seeking and communication. For example, the
research staff spent time explaining how new skills
are performed, coaching families while they tried
out these skills in role-play situations, and in later
sessions asking participants to give examples of how
they used new skills.
The intervention group realized increased coping
skills, especially in the areas of spiritual support and
Social Work Volume 53, Number 1 January 2008
mobilizing the family to accept help. Whereas the
importance of spiritual support for cancer patients
in general has been documented (Carr & Morris,
1996; Jenkins & Pargament, 1995), its centrality for
Native Hawaiian cancer patients is newly emerg-
ing (Braun et al., 2002). For many Native Hawaiian
cancer patients and their `ohana, spiritual beliefs and
practices provide the strength to confront the disease.
Recognizing the important role of spirituality as a
cultural characteristic for Native Hawaiians, efforts
were made to tailor the intervention to include
spiritual practices, such as prayers, introductions
using genealogy, and invocation of ancestors for
strength. Inherent in the Native Hawaiian view of
spirituality is the affirmation of the role and re-
sponsibility of the `ohana in providing assistance to
`ohana members when confronting problems such as
cancer.Thus, the cultural reliance on family support
may precipitate its “mobilization” when confront-
ing issues, and it is plausible that Native Hawaiians
may use resources such as the `ohana and spirituality
before external resources such as those sponsored
by hospitals and other health care organizations
(Gotay & Lau, 2003).
The improvement in BSI scores for Native Hawai-
ian cancer patients suggests the intervention helped
patients manage their stress and reduce their distress
levels. In contrast, BSI scores did not change for fam-
ily members in the intervention group and appeared
higher for family members in the control group at
the three-month follow-up.This may reflect family
members’ perceptions of increased responsibility in
helping their loved ones deal with the disease. Lit-
erature indicates that for some caregivers the added
demands of the illness create psychological distress
levels that are often as high as, and on some occa-
sions higher than, the patients’ (Northouse, 1995).
Although this interpretation is feasible for the in-
tervention group, unusually low BSI baseline scores
for two control families highlight the limitations of
a small sample and suggest that future research in
which there is a larger randomized sample is needed
to minimize statistical anomalies.
Future examination of this intervention’s ef-
fectiveness will require a larger sample. Recruiting
Native Hawaiians to research, especially in the
absence of a centralized cancer care program in
the state, presents a challenge to investigators in
Hawai`i. In this pilot study, conventional recruit-
ment strategies, such as printed advertisements and
telephone hotlines, were not very helpful, and only
Mokuau, Braun, Wong, Higuchi, and Gotay / A Family Intervention for Native Hawaiian Women with Cancer
when personal contacts were made (for example,
through providers and face-to-face contact) were
we able to recruit participants. Gotay et al. (2000)
suggested that using existing social networks and
family constellations to promote cancer interven-
tions can be a powerful tool for an ethnic minority
population such as Native Hawaiians. Due to the
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centrality of social networks in Native Hawai-
ian culture (Pukui et al., 1972), it is probable that
information relayed by this venue may be more
persuasive than that presented in more impersonal
brochures and newspaper advertisements (Gellert,
Braun, Morris, & Starkey, 2006). Furthermore, the
historical lack of culturally tailored interventions for
this population suggests they are not yet familiar or
fully aware of the benefits of participation (Gotay,
2000) and would be disinclined to participate unless
encouraged by someone they knew and trusted. In
future studies, we will continue to rely on multiple
recruitment strategies but will emphasize the social
network approach.
Data collected through this pilot study suggest
ways in which the research tools and the inter-
vention can be refined. For example, we saw very
little change in knowledge among participants,
due in part to high baseline knowledge scores. In
refining the knowledge measure, items should be
modified to relate directly to curricular content
rather than to general cancer knowledge. In terms
of the intervention, we learned that it easily could
be streamlined from six sessions by merging the
sessions on telephone and Internet access. Future
research may focus on four to five sessions, thereby
addressing participants’ concerns about too many
sessions and also serving to decrease the differences
in the amounts of time for the control and inter-
vention groups.
The findings of this study should be interpreted
with caution in light of the limitations inherent in
a feasibility study such as this one—small sample
size, nonequivalent intervention and control condi-
tions, and lack of a no-treatment control—thereby
limiting the conclusions one can reach. Neverthe-
less, the findings suggest that culturally tailoring
interventions to reflect Hawaiian values, protocols,
and visuals may serve to increase their acceptability
and perhaps their effectiveness. There is growing
support for the development of culturally tailored
interventions for different ethnic populations (Gotay
& Lau, 2003: Kreuter, Lukwago, Bucholtz, Clark, &
Sanders-Thompson, 2003), and this was reported
17
by intervention participants as a major reason to
recommend participation to others.
Implications for Social Work
We believe the use of professional social workers
in the design and delivery of the intervention was
essential to its success. Social workers have a long
history in working with families and are competent
in conducting assessments of existing problems,
implementing family support interventions, and
evaluating the effectiveness of intervention mod-
els. The training provided in `ohana intervention
is anchored in family practice models used by
social workers that emphasize family strengths and
resources, improve the capacity of families to cope
with stress, and incorporate cognitive–behavioral
paradigms for new learning. Furthermore, social
workers in the health field are knowledgeable about
social services in hospitals and clinics and can serve
key roles in educating families about how to access
health information, enhance familial relationships,
and improve communication with physicians and
other health care providers.
Social work is a profession dedicated to eliminat-
ing inequities that plague ethnic minority groups
such as Native Hawaiians. In working with Native
Hawaiian women who confront high cancer mor-
tality, social workers must be cognizant of cultural
factors that will enhance the delivery of services
and reduce health disparities. Using a culturally
tailored intervention that includes cultural values
and practices may give greater meaning to the word
survivorship for Native Hawaiian women and their
`ohana. Social workers also can play a role in de-
signing and testing culturally tailored interventions
when they are lacking. Also, attention to culture is
critical in the conduct of research, as we learned
that the bulk of Native Hawaiian participants in
our research were recruited through social networks
(rather than media announcements and physician
referral). In both cases, our findings confirm the
importance of NASW’s Code of Ethics (2000), which
espouses the ideal that “social workers should have
a knowledge base of their clients’ cultures and be
able to demonstrate competence in the provision
of services” (p. 9).
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Noreen Mokuau, DSW, is professor of social work, School

of Social Work, University of Hawai `i, 1800 East–West
Road, Honolulu, Hawai`i 96822; e-mail: noreen@hawaii.
edu. Kathryn L. Braun, DPH, is professor of public health
and social work, University of Hawai`i, and research director,
`Imi Hale Native Hawaiian Cancer Network. Linda K.
Wong, MSW, is a social work fellow, Ke Ola Mamo, Native
Hawaiian Health Care System. Paula Higuchi, MSW, is
a partnership program manager, National Cancer Institute’s
Cancer Information Service, Cancer Research Center of Hawai`i,
University of Hawai`i. Carolyn C. Gotay, PhD, is a professor,
Cancer Research Center of Hawai`i, University of Hawai`i.This
study was performed under the `Imi Hale Native Hawaiian
Cancer Network, funded by the National Cancer Institute
(U01-CA86105-03). The authors would like to acknowledge
Joelene Lono, Noelani Napalapalai, Julie Oliveira, and Nalani
Reid. Thanks also to Dr. Lynne Wilcox for assistance with the
authors’ randomization procedure and to Dr. Peter Holck for
assistance with data analysis.
Original manuscript received May 16, 2005
Final revision received March 30, 2006
Accepted May 3, 2006

Mokuau, Braun, Wong, Higuchi, and Gotay / A Family Intervention for Native Hawaiian Women with Cancer 19