Gender Differences in Preferred Drug Resistance Strategies of Rural Native Hawaiian Youths

Dimensions of Indigenous- and Gender-Specific Substance Use

While some studies on gender differences in the rates of substance use among indigenous youths have reported mixed findings (Hawkins et al., 2008), others have indicated significantly higher rates of substance use for indigenous girls than for indigenous boys (Schinke, Tepavac, & Cole, 2000; Wallace et al., 2003). For example, using a large, nationally represented sample across 420 different schools, Wallace et al. examined ethnic and gender differences in illicit substance use for 8th-, 10th-, and 12th-grade students. They found that across all ethnic groups, substance use was the highest among American Indian girls, with approximately 70% of these girls (compared with 54% of American Indian boys) having tried marijuana or hashish, 87% (compared with 81%) having tried alcohol, and 80% (compared with 69%) having tried cigarettes by the 12th grade. Epidemiological studies on Alaska Native and Native Hawaiian girls have similarly found gender disparities in rates of substance use, with these girls indicating a higher use of tobacco (Angstman et al., 2007; Glanz, Maskarinec, & Carlin, 2005; Glanz, Mau, Steffan, Maskarinec, & Arriola, 2007) and alcohol and marijuana (Mayeda, Hishinuma, Nishimura, Garcia-Santiago, & Mark, 2006) than their male counterparts.

Research has also identified gender-specific ecological risk factors for substance abuse for populations of indigenous youths. These studies have examined gender differences in the exposure to offers to use substances for American Indian (Dixon Rayle et al., 2006; Kulis, Okamoto, Dixon Rayle, & Sen, 2006) and Native Hawaiian (Okamoto, Kulis, Helm, Edwards, & Giroux, 2010, in press) youths. These studies also examined the perceived difficulty that these youths have experienced in dealing with these situations. In particular, Dixon Rayle et al. (2006) and Okamoto, Kulis, Helm, Edwards, and Giroux (2010) found that, compared with their male counterparts, American Indian and Native Hawaiian girls were exposed significantly more often to drug offers by peers and family members and found it significantly more difficult to resist these offers. Gender-specific research on indigenous youths has provided limited insights to account for these quantitative findings. Okamoto, Kulis, et al. (2010) indicated several reasons that may have accounted for Hawaiian girls’ higher exposure to offers to use substances (e.g., earlier initiation into substance use than boys). However, the study was limited in elucidating the reasons related to the perceived difficulty that these girls had experienced in dealing with drug offers.

Relational-Cultural Theory (RCT)

RCT evolved from clinical practice in the 1970s, when it was characterized by the centrality of relationships in women’s lives (Comstock et al., 2008). A central tenet of the theory is that women grow “through and toward” connection with others and that significant relationships are central to women’s sense of meaning and well-being (Jordan, 2001, 2008). West (2005) expanded on Jordan’s early theoretical principles by linking them directly to feminist theory building, while Comstock et al. elucidated the implications of RCT to counseling and direct practice. According to RCT, relational development occurs across the life span and is linked to individuals’ racial, cultural, and social identities (Comstock et al., 2008). In effect, psychological “disorders” become less about the individual and more about the relational and cultural context (Comstock et al., 2008; West, 2005). Disorders evolve more from culture-based relational disconnections between individuals than from problems or issues within the individual. West suggested that RCT had strong implications for the development of preventive interventions, including gender-specific interventions for youths in school settings.

To apply RCT to the lives of indigenous girls, it is important to understand their unique relational and cultural contexts. Some research has described these unique contexts for American Indian and Native Hawaiian youths and how these contexts may function to intensify both the risk of and protection from substance use for these youths (Hurdle, Okamoto, & Miles, 2003; Okamoto, Helm, Po‘a-Kekuawela, Chin, & Nebre 2009; Waller, Okamoto, Miles, & Hurdle, 2003). Specifically, these studies have described these youths’ close-knit networks of biological and ascribed family members within the home, school, and community and how these networks functioned as strong influences for or against the use of illicit substances. In other words, research has emphasized that indigenous youths live within a cultural context that both values and is characterized by close, interconnected relational networks and that these networks function as both ecological risk and protection. For indigenous girls, RCT would suggest that the demand to stay relationally “connected” is particularly strong, in that both gender and culture intersect to provide these girls with a sense of meaning and well-being through their significant relationships.

RCT can be used to understand indigenous girls’ perceived difficulty in refusing offers to use illicit substances from peers and family members that has been found in recent empirical research (Dixon Rayle et al., 2006; Okamoto, Kulis, et al., 2010). The theory suggests that indigenous girls’ perceived difficulty in dealing with drug offers may be an outgrowth of balancing harmony within significant relationships and the goal of abstaining in the use of illicit substances. This difficulty may place these girls at an increased risk of substance use, particularly when the ability to effectively refuse substances threatens the harmony within a significant relationship. RCT suggests that indigenous girls may feel increased social pressure to accept drugs and/or alcohol to mitigate discord or conflict in the relationship with the drug offerer, particularly since relational disconnection is incongruent with their culture- and gender-based norms and values.

In the study presented here, qualitative methods were used to examine the gender-specific considerations and preferences in drug resistance strategies for rural Native Hawaiian youths. Research has indicated that rural youths have higher rates of alcohol use than their urban counterparts (Swaim & Stanley, 2011), with rural minority youths having particularly elevated risks of substance use (Curtis, Waters, & Brindis, 2010). The analysis in this study elucidated the ways in which Hawaiian girls balanced relational and health-related demands or expectations within various ecological settings (the home, school, or community). Using RCT as a framework for understanding the narratives of the participants, the findings also helped to elucidate the reasons behind indigenous girls’ perceived difficulty in refusing offers to use substances that were found in earlier studies (Dixon Rayle et al., 2006; Okamoto, Kulis, et al., 2010).

Method

Data from the study came from a multiyear pilot-feasibility study on drug prevention funded by the National Institute on Drug Abuse, in which youths were asked to adapt and/or validate narrative scripts to be used to create culturally grounded drug prevention videos. All research procedures were approved by the Institutional Review Boards at Hawai‘i Pacific University, the University of Hawai‘i at Mānoa, and the State of Hawai‘i Department of Education.

Procedures

Each youth participated in 1 of the 15 gender-specific focus groups (2–10 youths per group; M = 4.63, SD = 2.33), and the gender of the group facilitators matched that of the participants. The goal of these groups was to adapt and/or validate seven narrative scripts to be used to film culturally grounded drug prevention videos focused on rural Hawaiian youths. Each script outlined a brief vignette based on a drug-related problem situation that was developed and validated in prior research (Okamoto, Helm, Giroux, Edwards, & Kulis, 2010). Table 1 presents the names of the scripts, the associated drug-related problem situations, and the gender composition of the groups that adapted and/or validated each script. Following each situation, each script outlined three different types of responses for refusing drugs, such as avoiding the situation or saying no. The drug-refusal responses corresponding to each scripted situation also had been developed and validated in prior research (Okamoto, Helm, Giroux, & Kaliades, 2011; Okamoto, Helm, Giroux, Kaliades, et al., 2010). The semistructured interview schedule that was used for the focus groups is presented in Table 2. The participants were informed to keep all disclosures in the group setting confidential. Because we audiorecorded the interviews, the youths were asked to use preselected pseudonyms to refer to themselves and others who participated in the group discussions, as well as individuals in their stories.

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Table 1.

Titles of Narrative Scripts, Drug-Related Problem Situations, and Group Gender.

Title of script	Situation	Group gender
Bacardi Party	Your friends bring Bacardi to school and mix it with juice. They are drinking it on campus during recess. They offer you some	Female
Bully Boy	A big, bulky boy in school is known to be the leader of a group of “tough kids” who fight and do drugs. He approaches you one day at recess and asks you if you’d like to hang out with his group	Male
Kanikapila Invite	On the nights on which there is a full moon, lots of the older kids like to go out at night because they can Kanikapila and smoke marijuana and drink beer outside. Your older cousin invites you to come along	Male
Oh Brother	Your older brother enters your bedroom, closes the door, and asks you if you’d like to smoke some weed	Male
One Time	You are with a girl [or boy] you like and some other friends. They are all hiding in the bushes and smoking weed. They ask you if you want to try some. After you say no, they say, “Just try this once, it’s cool”	Female
Pā‘ina	You are at a family party where the adults have coolers full of beer. They are getting drunk, so you and your cousins can take a beer without the adults noticing. One of your cousins says to you, “Let’s grab one”	Female
Pulehu	Your dad, uncles, papa, and dad’s friends are making Pulehu in the yard, and you are with them. Your mom is inside the house. They are drinking a lot of beer, probably already drunk. Your dad offers you a beer	Male and Female

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Table 2.

Semistructured Interview Schedule.

1.	What did you think about the situation described in this script?
	• Are youths in this community exposed to these types of situations?
2.	Describe in as much detail as possible the setting in which you see this situation occurring.
	• Where would this situation occur in your community?
	• Who do you see as being present in the situation? Who is involved in the discussion and who is in the background?
	• When do you see this situation occurring in your community?
3.	What do you think about the dialogue described in the script?
	• How would you change the language to fit in with the way kids in this community talk?
	• Are there things that were not included in the script that, if included, would make the dialogue more consistent with the way kids in this community talk or act (e.g., additional language, nonverbal reactions, and so forth)?
4.	On the basis of responses to Questions 1–3, facilitators will make some on-the-spot revisions to the narrative script. After they have done so, select the same group participants to read the parts of the revised script.
	• What do you think about the changes that were made to the script?
	• Are there any other changes that should be made to make the script more consistent with the way kids talk and act in this community?
5	How do you think kids in this community would react to a video vignette using this script, if it was presented as part of a drug prevention program in your school?

Results

Across all the focus groups, 54% of the narrative content came from the boys’ groups, and 46% came from the girls’ groups. The primary gender differences for the participants were evident in the discussion and/or modification of proposed responses to drug offers described in each script. The boys were more inclined to endorse and/or describe responses that “disconnected” the protagonist in the script from the drug offerer more abruptly (e.g., “[S]he would leave the situation”), while the girls were more inclined to endorse and/or describe methods to stay relationally “connected” in the situation, despite the drug offer (e.g., “Next time,” “not now, maybe later”). As an example of a disconnected response to a drug offer, several boys described how the female youth protagonist in “Pulehu” should react to her father’s offer to drink beer with him. In this script, a 13-year-old girl (Ku‘u) is offered a beer by her father in front of several uncles and a grandfather. The boys compared her actions with how they would behave in this type of situation. Facilitator:

So how would you feel [if your father offered you beer]?

In contrast to the refusal strategy endorsed by the boys, the girls who validated “Pulehu” felt differently about how Ku‘u should respond to her father’s offer of alcohol. Their suggested responses illustrated concern for the father’s well-being and an attempt to stay relationally connected with him. Facilitator:

OK, so it sounds like all of you guys would be [feeling] some level of discomfort [and] fear [if your father offered you a beer], or I think you said feel[ing] scared, confused, [and] pressured.

The theme of relational connectedness was also evident in other scripts validated by the girls’ focus groups. For example, in “Pā‘ina,” several girls discussed the merits of two different responses to a drug offer from a cousin—diverting the topic away from drug use by suggesting to the offerer that they go play a game with other cousins (Response 2) or leaving the situation and going inside to watch television (Response 3). “Candy” described how Response 2 would allow her to help her cousin who is offering her alcohol, supporting the importance of staying relationally connected with him as a potential intervention strategy. Facilitator:

So what’s the difference between the second response and the third response?

The importance for girls of staying relationally connected in drug resistance also extended to scripts with peers as drug offerers. In “One Time,” a group of older adolescents described how the female youth protagonist (Kiana) should refuse a marijuana offer from a boy whom she just had met and shared a mutual attraction (Eric). The group participants debated whether Kiana should refuse the offer by saying “no thanks, I’m cool.” They debated various responses that conveyed refusal, but also suggested the potential for drug use in the future, so as not to “cut off” the relationship. Sherrie:

I like the “No thanks, I’m cool.” Like, she’s trying to flirt with him at the same time ‘cause she does like him, you know. Like, or “no thanks,” not “I’m cool” but something else. Not “No thanks.”

The data further suggested that the female participants were more aware of and/or concerned about the long-term ramifications of their interactions to their relational networks when they refused drugs. This concern was exemplified by “Pearl’s” statement that Kiana in “One Time” should choose a refusal strategy that would minimize Eric’s friends from pressuring him away from dating her in the future (i.e., “Brah, drop her, man.”). Also demonstrating insight related to the long-term relational impact of drug refusal strategies, the female participants who validated “Bacardi Party” described how responses to drug offers that involved telling an adult authority figure at school about the offer might be construed as “tattletailing” and could eventually lead to a fight among peers. Overall, the girls expressed insights into the impact that specific drug resistance strategies could have on their relationship with the drug offerer, as well as with their relationships with individuals who are in the offerer’s social network.

Some of the more serious and insightful responses in relation to this theme came from the female participants who validated “Pulehu.” These participants expressed an overall concern with how adult family members might perceive Ku‘u’s refusal to drink alcohol with her father. Boo Boo:

I would feel pressured because that’s your family, and you don’t want to like [does not finish statement], and it’s with your uncle guys and stuff. [Repeats a little bit louder] I would feel pressured because it’s your dad and your uncle guys.

Later in the group discussion, these participants expressed concern specifically about the impact of one of Ku‘u’s responses to her father’s alcohol offer, in which she yelled to her mother “Look what dad gave me!” The girls in this focus group described how this response might affect her father’s relationship with her mother and subsequently her relationship with her father (Kana). Facilitator:

[Reading the script] So Kana hands her the beer he just cracked open. Ku‘u looks down hesitantly at the beer in her hand, then she looks back toward the house and yells out.

Conversely, several of the boys who validated “Pulehu” did not seem to express as much concern about Ku‘u’s response to her father’s alcohol offer. On the surface, they seemed to minimize the impact or extent of the problems that this response might have caused Ku‘u’s family. Facilitator:

OK, so in Response 2, Kana says, “E Ku‘u, relax and have a beer with us.” And then, Kana hands her the beer he just cracked open. Ku‘u looks down hesitantly at the beer in her hand, then she looks back toward the house and yells out, “Mom, look what dad gave me!” Ku‘u holds up the beer. Her Mom steps out the door with her hands on her hips. What do you think about that response?

Discussion

To elucidate recent findings related to the ecological risk of drug use for indigenous girls (Dixon Rayle et al., 2006; Okamoto, Kulis, et al., 2010), this article examined gender differences in preferred drug resistance strategies for rural Hawaiian youths who participated in a culturally grounded drug prevention pilot-feasibility study. An analysis of the modifications to the narrative scripts described by the participants indicated distinct gender differences and supported the theoretical principles of RCT. Compared with the female participants, the male participants were more likely to endorse drug resistance strategies that relationally disconnected the youth protagonist from the drug offerer in the script. These strategies allowed the protagonist to eliminate the personal risk of substance use in the short term, but eventually might result in adverse relational consequences. Conversely, the female participants appeared to favor resistance strategies that maintained a connection to the drug offerer. They considered the long-term relational consequences of their actions and behaviors and appeared to balance the need to maintain relational and social harmony with the goal of abstinence from drugs.

Although the need for Hawaiian girls to stay relationally connected in the midst of drug-related problem situations is consistent with RCT, it also may account for the perceived difficulty that indigenous girls have expressed in dealing with these situations found in prior research (Dixon Rayle et al., 2006; Okamoto, Kulis, et al., 2010). Developmentally, indigenous preadolescent girls may be more aware of the social and relational consequences of different drug refusal strategies than their male counterparts. Because of this awareness, these girls may not see relational disconnection as an option in drug-related problem situations, since they may perceive it as culturally disrespectful or as leading to problems within their close-knit social network. In some cases, the female participants described how relational connectedness in drug resistance with family members could even function as an intervention strategy, emphasizing the social responsibility that some of these girls felt in preventing the substance use of family members. In any case, the qualitative findings strongly suggested that indigenous girls are compelled to engage in interactions with significant individuals who are offering them drugs, while simultaneously meeting the conflicting goals of maintaining social and relational harmony with these individuals and personally abstaining from drugs. Balancing all these considerations represented an enormous challenge for these girls.

Conclusion

Despite these limitations, the study built on prior gender-specific theory and practice by examining the preferred ways in which Hawaiian girls manage offers to use substances by peers and family members. Coupled with the framework of RCT, the findings suggest that drug prevention interventions for Hawaiian youths should target the relational and cultural context (rather than the individual) as a primary focus of the intervention (West, 2005). Future research should examine the relational connectedness of Native Hawaiian girls in drug-related problem situations more closely, including subthemes that may provide more insights into the aspects or nature of relational connectedness with these youths. The findings from this study may have implications for the development of gender-specific drug prevention programs for other populations of indigenous youths, particularly those in rural or reservation communities.