Native Hawaiians are the indigenous people of Hawaii, comprising 20% of the state's population. Other ethnic groups in the state include whites (25%), Japanese (25%), Filipinos (15%), Chinese (5%), and others (1). Compared with whites and Japanese (the state's healthiest and most longevous group), Hawaiians have the highest cancer mortality rates, in part because they often are diagnosed at a late stage after cancer has spread and treatment options are limited (2). For example, 35% of Hawaiian women with breast cancer are diagnosed at a late stage, compared with 29% of whites and 22% of Japanese. Among women with cervical cancer, 41% of Hawaiian women are diagnosed at a late stage, compared with 34% of whites and 30% of Japanese. Among both men and women, 57% of Native Hawaiians with colorectal cancer are diagnosed at a late stage, compared with 50% of whites and 53% of Japanese, as are 33% of Native Hawaiians with melanoma, compared with 9% of whites and 7% of Japanese (2).

Native Hawaiians also have lower rates of cancer screening than other groups. For example, in 2001, only 36% of Hawaiians aged 50 and older had ever had a fecal occult blood test (FOBT), compared with 55% of whites and 55% of Japanese, and only 34% ever had a sigmoidoscopy or colonoscopy, compared with 53% of whites and 56% of Japanese. Only 47% of Hawaiian men aged 40 years and older have ever had a prostate-specific antigen (PSA) test, compared with 56% of white men and 50% Japanese men. Among women, 89% of Hawaiians aged 40 and older have ever had a mammogram compared with 88% of whites and 95% of Japanese (2,3). Hawaiians living in rural areas, especially the islands of Molokai, Lanai, and Niihau, have limited access to cancer screening: none of these islands have capability to provide colonoscopy, and neither Lanai or Niihau have mammography facilities.

Given the low screening rates and late stage of diagnosis, it appears that mainstream cancer screening programs are unsuccessful at recruiting Hawaiians. Other investigators suggest this may be because of the cultural inappropriateness of these programs (4). In contrast, a study conducted in the 1990s found that peer-led outreach groups incorporating traditional Hawaiian values of kōkua (proactive helping), aloha (compassion), and pili (bonding as family) and traditional talk-story communications (which emphasize personal connections, respect, active listening, and empathy) increased breast and cervical cancer screening among Hawaiian women (5). The sidebar provides a glossary of Hawaiian terms. Other Hawaiian values relevant to community-based programs are `ohana (blood relation and extended family), kuleana (acceptance of responsibility and outcomes), and laulima (working together toward a common good) (6,7).

Culturally appealing health education materials contribute to successful community-based programs. Kreuter et al recommended five strategies for tailoring materials to minority groups, including the following: 1) peripheral strategies (making materials attractive by including pictures of healthy Hawaiians); 2) evidential strategies (presenting facts about cancer’s impact on Hawaiians); 3) linguistic strategies (using Hawaiian words and phrases); 4) constituent-involving strategies (drawing directly on the experience of Hawaiians affected by cancer), and 5) sociocultural strategies (recognizing and working from Hawaiian values, beliefs, behaviors, and context) (8).

In this project, we tested `Ohana (family) Day, a community approach to increase cancer screening, especially among the underserved, that incorporated Hawaiian cultural styles and values. Funding from the Oregon Health & Science University's Native Researchers' Cancer Control Training Program was awarded to a junior researcher of Native Hawaiian ancestry affiliated with `Imi Hale — Native Hawaiian Cancer Network, one of the 18 special population networks supported through the National Cancer Institute's (NCI's) Center to Reduce Cancer Health Disparities (9). This paper describes the program, evaluation methods, and lessons learned about the feasibility and effectiveness of this approach.

The first `Ohana Day was held on Molokai, a small island south of Oahu (where 72% of Hawaii's population of 1,200,000 resides). About 80% of Molokai's 7404 residents are Hawaiian. The small island has a relatively low socioeconomic status, with a 12% unemployment rate (compared with 3% to 6% on other islands) (1). During 2000 through 2002, 122 cancer cases were reported on Molokai (Kevin Cassel, Cancer Information Services [CIS], oral communication, January 2005), where each new diagnosis of cancer often has a widespread impact on the members of this close-knit community.

This community was selected because of Molokai's high proportion of medically underserved Hawaiians, the lack of medical resources on the island, and its request for help with cancer screening. Molokai General Hospital, the island's only hospital, is a 30-bed facility providing acute and long-term care and low-risk obstetrical inpatient services. Four family practitioners live on Molokai, an obstetrician–gynecologist is flown in monthly to supervise the midwives and treat patients with complex cases, and other physician specialists visit periodically. Mammography, sigmoidoscopy, and laboratory services are available on the island; colonoscopy is not available.

Many of the island's preventive health services are offered through a partnership between Molokai General Hospital and Nā Pu`uwai, a federally funded Native Hawaiian Health Care System (NHHCS). Nā Pu`uwai is one of five NHHCSs in Hawaii that provide outreach, access, and primary and secondary prevention services in predominantly Hawaiian communities. About 2000 Molokai residents are registered with Nā Pu`uwai, which is staffed by a part-time physician, a registered nurse, four community health workers (CHWs), and a clinical psychologist who visits weekly from Oahu. It has been the practice of Nā Pu`uwai and Molokai General Hospital to offer an annual health fair and, at least annually, to have physician specialists from Honolulu fly in to spend a full day seeing patients. However, `Ohana Day was the first event to use a festival to draw whole families (rather than individuals only), to feature a large number of Native Hawaiian physicians, and to offer a comprehensive array of primary and secondary cancer screening services.

Because `Ohana Day was a research study, we also needed to consider the general distrust of research expressed by many Native Hawaiians following their experience with "hit-and-run" investigations; that is, projects in which researchers extracted data from the community but left no programs or solutions in place (10). Thus, all `Imi Hale projects employ community-based participatory research (CBPR) methods, which engage community members in planning, transfer skills, and result in tangible benefits for communities (9-11).

`Ohana Day, held in October 2003, included the following components: 1) a 1-day ho`olaule`a (community celebration and sharing) to which whole families were invited; 2) personalized recruitment by CHWs and the `Imi Hale researcher; 3) 30-minute, one-on-one, talk-story–style screening and education visits with a same-sex Hawaiian kauka (physician) (physician); 4) culturally relevant cancer education brochures; and 5) follow-up for abnormal findings. Principles of CBPR (10,11), Kreuter's strategies for targeting messages (8), and key Hawaiian cultural values guided the design of this event to address team-identified barriers (Table 1).

Following principles of CBPR, all aspects of `Ohana Day, from its development through implementation and dissemination of findings, were undertaken by the `Ohana Day team, which included the junior investigator from `Imi Hale and two Nā Pu`uwai CHWs, with assistance from the `Imi Hale program and research directors and several Hawaiian interns. Planning began 6 months before the event, and follow-up activities took an additional 6 months, making this a 1-year project. Decisions about `Ohana Day were made by the team at weekly meetings (either in person or by teleconference). These actions helped to ensure that Nā Pu`uwai felt ownership in the program and could institutionalize it (10,11). The transfer of skills was bidirectional: Nā Pu`uwai staff learned more about research and cancer resources that could be applied to Molokai, and `Imi Hale interns learned about community outreach and mobilization strategies from Nā Pu`uwai staff.

On the day of the event, 73 adults from 41 families were screened, including 63 Native Hawaiians, eight Filipinos, and two whites. The 73 participants included 42 who had preregistered. Of the 20 who preregistered but did not attend, we later learned that 11 attended funerals of two community members who had recently died and nine attended a community youth baseball game. Of the 31 who registered on event day, five were men who accompanied their wives to the event and were persuaded to participate while waiting for their wives, 14 attended with family members who had preregistered, and 12 had learned of the event through friends and neighbors.

Table 2 compares measures of health care status of participants before and after the event. Based on registration data for the 73 adult participants, 23 (32%) were not Nā Pu`uwai clients, 11 (15%) were uninsured, and five (7%) had not seen a physician in 5 or more years. One 55-year-old man reported never having had a physical examination. Only 39% of the men aged 50 and older were current with colorectal cancer screening (either FOBT, sigmoidoscopy, or colonoscopy), and 39% of men aged 40 and older were current with prostate cancer screening. For women, only 36% of those aged 50 and older were current with colorectal cancer screening. About one third of women aged 40 and older were not current with breast cancer screening, including 13 women who had never had a clinical breast examination or mammogram.

Significant improvements were found in screening compliance (whether received at the event or in the following 6 months) and insurance coverage 6 months after the event. For example, at 6-month follow up, 76% of female participants aged 50 years or older were current with colorectal cancer screening, 84% aged 40 years or older with mammogram, and 100% aged 40 years or older with clinical breast examination screening. For men, 97% aged 40 years or older were current with prostate cancer screening, and 75% aged 50 years or older were current with colorectal cancer screening. All 10 participants with abnormal findings (one colorectal, two breast, two prostate, and five skin) received follow-up screening, treatment, or both within 3 months of the event. All 23 participants who were not previous Nā Pu`uwai clients became clients, and all 11 without health insurance received assistance obtaining health insurance. Because insurance enrollment is a time-consuming process, free follow up was obtained for five uninsured participants who needed immediate attention for abnormal findings. Since the end of the project, 71 of 73 participants and their families have continued to seek assistance from Nā Pu`uwai with cancer screenings and other health issues, including hypertension and diabetes control (Valerie Starkey, unpublished data, November 2005).

In evaluating `Ohana Day, 71 (93%) participants gave it the highest satisfaction rating on a 5-point scale. Best liked were education, including the brochures targeting Native Hawaiians (n = 26), everything (n = 17), one-on-one visits with the kauka (n = 16), and inclusion of family (n = 6). Participants were impressed with the helpfulness and caring of the kauka and the CHWs. One participant commented, "If they care about my health, I should too." When asked what should be changed, 25 participants said "nothing," and three said, "less waiting time to see the doctor." Participants wanted to learn more about such topics as diabetes, obesity, cardiovascular disease, psychology, and asthma.

As noted in previous studies, barriers to increasing cancer screening among racial and ethnic minority populations include limited cancer screening knowledge, limited accessibility of health services (especially culturally tailored services), and lack of clinician recommendations (4,5,11,16,17). `Ohana Day employed culture- and community-based strategies to address these barriers, and evaluation data suggest that `Ohana Day appealed to Hawaiians on Molokai and was effective at increasing cancer screening rates and bringing people without insurance, a medical point of contact, or both into the health care system.

A key element of success was `Ohana Day's fit with the community, which was ensured by joint planning and implementation by `Imi Hale and Nā Pu`uwai as equal partners, in contrast to many projects, which are designed by outsiders and modified through community involvement. Other elements of success were the time devoted to personalize recruitment, event day, and follow-up and the demonstration of caring by kauka and CHWs. These elements helped reduce the chance of participants dropping out during the year. The elements also helped establish and enhance relationships among community members and health providers, which proved necessary for changing health care use patterns among the underserved. The power of trust building also was reflected in the fact that 26 individuals registered for screening on event day, citing the recommendation of a family member or friend.

Also critical was the cultural targeting of Cancer 101 and brochures on cancer screening; `Imi Hale continues to develop and disseminate cancer-related brochures and curricula (9,13,14). Although not mentioned in the written evaluations by participants, both participants and providers expressed appreciation for brochures with Hawaiian faces. That 16 individuals indicated that they liked "everything" suggests that the relaxed, festival-like atmosphere was also important. Although each participant was allowed 30 minutes or more with a kauka and some participants had to wait to be seen, only three participants mentioned the waiting time as the thing they liked least.

We were gratified that the event attracted 23 more community members to avail themselves of Nā Pu`uwai services because our intent was to reach the medically underserved. Among the 50 participants who already were clients of Nā Pu`uwai, we were not surprised to find that many were not current with cancer screening recommendations, especially the men. Subsequent focus groups with Native Hawaiian men found that they avoid visiting physicians unless they are in pain (18). Men also communicated that health was traditionally the kuleana of women, and so they depended on wives and daughters to pressure them to seek health care when needed. This observation underscores the relevance of an `ohana-targeted event in Native Hawaiian communities; that is, increased awareness among women may help increase screening compliance for the entire family.

Despite intensive follow-up, one man did not have a PSA test within 6 months of the event, 6 women did not have mammograms, and 13 women did not have colorectal cancer screening. It was not surprising that postintervention colorectal cancer screening rates did not reach 100% because Molokai does not have colonoscopy capabilities and, in a separate study by `Imi Hale to increase colorectal cancer screening rates, we found that postintervention rates did not exceed 85% (13). Because all `Ohana Day participants are registered with Nā Pu`uwai, however, staff continue to remind them about their need for regular cancer screening.

`Ohana Day proved feasible on Molokai, and Nā Pu`uwai has incorporated `Ohana Day as an annual event. In 2004, the Nā Pu`uwai staff organized a similar cancer screening and education program on another small, medically underserved Hawaiian island (Lanai), with limited assistance from the `Imi Hale staff. These developments suggest that the Molokai staff has the experience and confidence to use the established protocol and to call on the services of the `Ahahui O Nā Kauka and others to continue the program on these two islands.

`Ohana Day's success and acceptance has led to several requests to offer it in other communities, but the question is whether it would be feasible. Certainly the time-intensive nature of `Ohana Day requires that it be prioritized for medically underserved communities with limited resources, rather than in communities with access to an array of cancer screening services.

Small sample size was a limitation to our study. Although many participants registered on-site, about 20 community members who had preregistered did not attend the event because of other obligations. Also, because a major goal was to test the feasibility of the event, we only recruited participants, and there was no control group against which to measure our effectiveness. Next steps include seeking funds for an experimental test of the program in other underserved Hawaiian communities, using a randomized controlled design, to examine its effectiveness with increasing cancer screening rates and bringing people without insurance, a medical point of contact, or both into the health care system. Given the participant appreciation of the educational aspects of the intervention, we recommend adding questionnaires to assess knowledge and attitudes to evaluations of future offerings. Future research also should be performed to identify barriers to cancer screening in Native Hawaiian communities.

Despite limitations, preliminary data suggest that interventions such as `Ohana Day that employ culture- and community-based strategies can increase compliance with cancer screening and follow-up recommendations in underserved Hawaiian communities.