Talking Story : Using Culture to Educate Pacific Islander Men about Health and Aging

Relatively little attention has been paid in the literature to strategies promoting the health of Native Hawaiian and other Pacific Islander (NHPI) men. To fill this void, a Native Hawaiian cancer survivor and a Marshallese minister in Orange County, California, founded the Kane Group to promote men’s health information and support. This group is comprised of 10 to 15 NHPI men, ages 35 to 83, with a diverse background of experiences in the U.S. healthcare system and health conditions, including multiple site cancer survivors and/or co-morbidity and chronic condition, like high blood pressure, diabetes. The Kane Group provides social support and engages in discussions, using the island tradition of “talk story”, to relate a variety of men’s health issues from prostate cancer to physical fitness to end-of-life decision making in a supportive and safe environment. The group weaves Pacific Islander culture and values into the process and conduct of the support groups. This community commentary describes the innovative strategies, successes, and challenges that emerged with the development of the group that were designed to celebrate Pacific Islander men’s health, provide information, fellowship, and support for the many who are facing health crises. © 2010 Californian Journal of Health Promotion. All rights reserved.

Many successful efforts have been dedicated to addressing Native Hawaiian and Pacific Islander (NHPI) women's health issues, like breast and cervical cancer, in a culturally appropriate manner (Aitaoto et al., 2009;Banner et al., 1995;Mokuau & Braun, 2007;Mokuau et al., 2008); however, less attention has been placed on their male counterparts.In response to this void, a Native Hawaiian cancer survivor and a Marshallese minister formed a Pacific Islanders men's health information and support group, the Kane Group (kane, the Hawaiian term for men).The Kane Group converges facets of gender and culture within the Pacific Islander community to address gaps in the health knowledge of Pacific Islander men.It is a semi-formal group consisting of 10 to 15 NHPI men, ages 35 to 83, who meet every three to four months in varying locations (e.g., restaurants, senior centers, NHPI serving community-based organization) to engage in discussions related to a variety of men's health issues from prostate cancer to physical fitness to end-of-life decision making.This narrative presents the innovative strategies, successes, and challenges that emerged with the development of a group designed to celebrate Pacific Islander men's health, and to provide information, fellowship and support for the many who are facing health crises.

Kane Group Members
Members represent islands from all over the Pacific Oceania including Hawai`i, Guam, the Marshall Islands, Fiji and Samoa, now residing in Southern California.The men were recruited for membership in the Kane Group through their association with group founders and their affiliation with Pacific Islander clubs, NHPIserving community-based organizations, and faith organizations.These men possess a diverse background of experiences with the U.S. healthcare system and health conditions.Some of the participants have health insurance and use formal healthcare services regularly, while others are uninsured and their only experience with the healthcare system is through the emergency room.Many of the men are multiple site cancer survivors and/or have a chronic condition, like high blood pressure, diabetes.
Although the Kane Group founders do not have backgrounds in social work, or have much familiarity with the literature on health education, they do have a firm grasp of their Pacific Islander culture and draw strength from that cultural knowledge to motivate Kane Group members to participate in primary and secondary prevention activities like regular exercise and cancer screening.As these Pacific Islander men share experiences with one another in the island tradition of "talk story" (Affonso et al., 2007;Ishida et al., 2001), they discover that their experiences with aging, health, and healthcare use may not be idiosyncratic, they learn more about men's health, discern between normal and pathological aging processes (Hayflick, 1998), like loss of skin elasticity versus melanoma, become more empowered in their health decisions, and realize that they are making a difference for their family and their island community-at-large.

Talk story
The Kane Group was created to address gender and cultural factors that may inhibit Pacific Islander men from participating in preventive health behavior.For instance, men and women gather socially for different reasons and for different functions (Walker, 1994).Men tend to gather around activities, like playing golf, paddling canoe, or attending sports events; whereas, women tend to gather to socialize and provide social support for one another.Men do not usually discuss their last prostate exam or scheduling their next colonoscopy over a round of golf.In response, the Kane Group was established to add a social support component to men's social gatherings by providing a venue for Pacific Islander men to come together in the sake of discussing men's health issues in a supportive and safe environment.A tool of the Kane Group that is used for breaching sensitive discussion topics, like cancer and mortality, is its "talk story" format.Talk story has been described as a conversation pattern that integrates narration and joking in a contrapuntal style (Watson, 1975).To illustrate, participants often use humor when they are volunteering sensitive health information about themselves.In addition, many of the Kane Group members do not have health insurance or a usual place they go to when they are sick or need healthcare; therefore, they do not usually have the opportunity to discuss or learn about their own health issues and consequently are less likely to participate in preventive health care services (DeVoe et al., 2003).In those instances, the men's group serves a surrogate source of health information.

Cultural traditions
As mentioned earlier, the Kane Group draws upon culture as a source of strength.The group weaves Pacific Islander culture and values into the process and conduct of the support groups.The use of cultural rituals gives added meaning to the men's gathering beyond the health education agenda and the sharing of personal experiences.All of the group meetings begin and end with prayer.Although not all of the participants are religious, spiritualism is fundamental to Pacific Island culture.These prayers are normally lead by an elder or a faith leader and underscore the importance of the gatherings.Next, food is provided.Central to most Pacific Islander cultures is eating food at social gatherings.As many of the men in the group say, "it is important to nourish the body as it is to nourish the mind."The foods that are served are chosen purposefully.According to Pacific Islanders, there is a wealth of symbolism in food.For instance, for our Kanaka Maoli (Native Hawaiian) participants, taro, poi (a product of pounded taro root), and breadfruit derive from the ancient Gods and embody nourishment and healing properties (Hughes, 1949).
To transition from the meal to the group discussion, participants introduce themselves in the island way by providing their name, what island they are from, and specific region of their island.Pacific Islanders come from a tradition of oral history.Historically, names indicated lineage and status in the social hierarchy (Milner, 1961).Furthermore, knowing which island and island region a person is from helps to establish connections, confer similar worldviews and facilitates the openness in group discussion.
The Kane Group discussions usually start with a presentation by the facilitator, a Pacific Islander PhD student with formal training in conducting focus groups, certification in gerontology, and a background in cancer prevention and control research.The facilitator functions on a voluntary basis and was solicited by one of the founders of the group.Having a Pacific Islander facilitator is significant to the men.Since many cultural values are shared across Pacific Islander groups, like cooperation and being responsible for another person (in Hawaiian these values are referred to as laulima and kuleana, respectively) (Affonso et al., 2007), participants are likely to assume that the facilitator shares similar worldviews and values, and are more apt to letting their guards down when sharing sensitive personal experiences.
The facilitator and the Kane Group members work in a symbiotic manner.For example, the facilitator would bring up potential benefits of colorectal cancer screening and early cancer detection in his presentation, and then men who have had a colonoscopy would volunteer their experiences to the rest of the group.Having participants share their experiences, especially those who are cancer survivors, demystifies certain health care procedures and establishes a more compelling argument for preventive health care.
There are many success stories that have come out of the Kane Group.One story is of a participant who, after attending a meeting on primary, secondary and tertiary health prevention (Geiss et al., 1993), voiced that he felt more empowered to advocate for himself in the medical setting and planned to be proactive about his health care.This same person also shared that he had a history of cancer in his family and did not know that he was at a higher risk for certain cancers.He now felt comfortable in not waiting for a doctor to recommend a cancer screening procedure and asking for cancer screenings before the recommended age guideline (which is contrary to Pacific Islander cultural socialization).Another success story from the Kane Group is the development of an offshoot men's group, a Marshallese bicycling group.After a Kane Group discussion on obesity and lifestyle behaviors, a few men took the initiative to create a bicycling group.This group also collects bicycles left out with the trash and refurbishes them for group members who do not have a bike or the resources to attain one.

Successes and challenges
The successes of the Kane Group are not without some challenges.One of the largest hurdles of the group is language.For some participants, English is a second language.This is especially difficult for the facilitator when he has to talk about technical medical issues.Although pictures and diagrams can help convey health messages, it is difficult to gauge how much those participants understand.Languages can also serve as a barrier for participants when asking questions and/or voicing concerns about health issues.Language, however, is just a symptom of a much larger problem.For some of our Pacific Islander communities, there is a lack of their representation in the health field.Many of these community members feel that they do not have the health resources available, nor same-ethnicity providers to go to when they have questions about their health.Although the challenges of language and lack of ethnic congruent health providers is not unique to Pacific Islanders, NHPI groups are often left out of programs and interventions that address these matters due to their numerically small numbers, making them a particularly underserved and vulnerable community.
In summary, the Kane Group is a creative example of how to be resourceful and strategic in promoting men's health and preventive health behavior.The Kane group draws from the strengths of culture to cultivate a safe environment for men to share experiences and establish interdependence.Through the process of sharing and willingness to be vulnerable, these Pacific Islander men learn more about their health and what to expect as part of the aging process.Knowledge gained from the Kane Groups, coupled with the social support provided by other participants, facilitates the men to be more comfortable and in control of their health care.