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Oct 14, 2017 - Hawaiian diaspora . ... 1 Kupuna refers to an individual elder. ..... After introductions, we asked participants to define the term Bkupuna^ (elder).
J Cross Cult Gerontol (2017) 32:395–411 DOI 10.1007/s10823-017-9335-3 O R I G I N A L A RT I C L E

Away from the Islands: Diaspora’s Effects on Native Hawaiian Elders and Families in California Colette V. Browne 1 & Kathryn L. Braun 1

Published online: 14 October 2017 # Springer Science+Business Media, LLC 2017

Abstract Native Hawaiians, the indigenous people of Hawai‘i, were once a healthy and hardy people. But today they are affected by varying social and health disparities that have led to poor social and health outcomes. Most of the research on Hawaiians in general and Native Hawaiian elders in particular has been conducted in Hawai‘i, even though the Hawaiian Diaspora has resulted in 45% of this population residing in North America and Alaska. This qualitative study used key informant interviews and focus group methods to examine reasons for migration and perspectives on aging and caregiving in a sample of Native Hawaiian elders and family caregivers residing in Southern California. Findings identified three general themes: discrimination was a factor in their migration from Hawai‘i; similarly to non-Hawaiians, they are concerned about challenges associated with aging and caregiving; and Native Hawaiian cultural traditions and values continue to shape their caregiving and service preferences. Keywords Indigenous elders . Native Hawaiians . Hawaiian diaspora . Family caregiving . Cultural values

Introduction Native Hawaiians are the indigenous people of the Hawaiian archipelago. Similar to other indigenous peoples in the United States (U.S.)—American Indians and Alaska Natives— Native Hawaiians experience more health and social disparities compared to the dominant U.S. population (Braun and LaCounte 2015). In Hawai‘i, where Native Hawaiians comprise about

* Colette V. Browne [email protected] Kathryn L. Braun [email protected]

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Ha Kūpuna National Resource Center for Native Hawaiian Elders, Myron B. Thompson School of Social Work, University of Hawai‘i, Honolulu, HI, USA

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23% of the population, their life expectancy is significantly shorter and their prevalence of several chronic diseases significantly higher than Caucasians (about 21% of the population) and Japanese (about 22% of the population) (Wu et al. 2017). One result of this poor health profile is that Native Hawaiians have been underrepresented in the older age groups in the State of Hawai‘i (Ka’opua et al. 2011a). Census data document a growing Diaspora among Native Hawaiians; 45% of Native Hawaiians now reside in the continental U.S. and Alaska. Yet little is known about the social, emotional, and cultural well-being of Native Hawaiians outside of Hawai‘i, and even less is known about how the Native Hawaiian Diaspora affects nā kūpuna1 (elders) who face the additional challenges associated with advanced age (Kamehameha Schools 2014; Kana’iaupuni et al. 2005; Nakatsuka et al. 2013). In this study, we explore perspectives on aging, caregiving, and care preferences of community-dwelling nā kūpuna and ‘ohana (family) caregivers in two California communities to add to our knowledge of this population.

Background Native Hawaiians compose the largest subpopulation (46%) under the Native Hawaiian and Other Pacific Islanders (NHOPI) label (U.S. Census 2010). Included in the Other Pacific Islander category are Samoans, Chamorros, and Tongans. Census data identified 1.2 million NHOPI in 2010, with 540,103 as BNative Hawaiian alone^ and 681,182 as BNative Hawaiian in combination with one or more other races.^ More than 36,000 Native Hawaiians are over the age of 60, with two thirds residing in Hawai‘i, and one-third residing in the remaining 49 states but primarily in California, Washington, Nevada, Utah and Oregon (U.S. Census 2010). Data from the 2010 U.S. Census suggest that Native Hawaiians are less likely than all Americans to have college degrees (21% vs. 30.1%) or own their homes (42.4% vs. 63.1%). They have a lower per capita income ($21,973 vs. $28,889 for all Americans), and higher poverty rates among elders (12.1% of Native Hawaiian elders vs. 9.5% of all American elders) (American Fact Finder, 2016). Most research focusing on Native Hawaiian elders has been conducted in Hawai‘i (Alu Like 2005; Braun et al. 2014; Browne et al. 2014; Ka’opua et al. 2011a, b). These and other studies document higher mortality rates and lower life expectancy for Native Hawaiians compared to most other ethnic groups in the state (Ka’opua et al. 2011a, b). Among the five most prevalent race/ethnic groups in Hawai‘i, Native Hawaiians have the shortest longevity compared to Chinese, Japanese, Filipino Americans, and Caucasians (Wu et al. 2017). Generally, Native Hawaiians have higher mortality from heart disease and cancer than other ethnic groups, as well as greater prevalence of diabetes and obesity (Braun et al. 2014). Several studies have shown that being Native Hawaiian and having low socioeconomic status are associated with greater adverse childhood events, trauma over the life course, and greater mental health symptoms (Klest et al. 2013; Ye and ReyesSalvail 2014). Aczon-Armstrong et al. (2013) found that the prevalence of severe or moderately severe depression was nearly twice as high in Native Hawaiians as the state prevalence (4.8% vs. 2.7%). Dementia is an increasing concern for Native Hawaiians as well (Browne et al. 2016). Although the health profile of Native Hawaiians suggests a great need for health care services, several studies have found that Native Hawaiian underutilize preventive health, mental health, and long-term care services (Alu Like 1

Kupuna refers to an individual elder. Kūpuna refers to multiple elders. Nā kūpuna refers to the elders.

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2005; Ka’opua et al. 2011a, b). Suggested reasons include lack of knowledge, mistrust of service providers, limited services in rural neighborhoods where many Native Hawaiians reside, experiences with culturally insensitive care, and high cost (Braun et al. 2014; Browne et al. 2014; Mokuau 2011). Positive trends in the Native Hawaiian population also have been documented. Native Hawaiians are increasing in numbers in Hawai‘i and, after years of population decline, now are approximating the population level reported at the time of initial Western contact (Kamehameha Schools 2014; U.S. Census 2010). A cultural renaissance that began in the late 1970s has grown, and there is increased attention and pride in Native Hawaiian language, cultural values, and traditions (Mokuau 2011). Nā kūpuna (Native Hawaiian elders) are recognized as major sources of knowledge and play a major role in caring for and raising grandchildren (Mokuau et al. 2015). Aging is viewed more optimistically within the Hawaiian culture than within Western culture, and the rate of suicide among Native Hawaiians aged 65+ is about half that of Caucasian elders in Hawai‘i (Else et al. 2007). Health and social service programs culturally tailored to meet the needs of Native Hawaiians are documenting a number of positive health outcomes, such as improvements in diabetes care and in family care cancer support services (Braun et al. 2015; Mau et al. 2010; Mokuau et al. 2012). Thus, although Native Hawaiian elders in Hawai‘i face a number of health issues, they also have cultural values and traditions that promote resiliency in later life (Braun et al. 2014; Mokuau 2011). To extend knowledge about Native Hawaiians living in the Continental U.S., we used qualitative methods to record key perceptions around aging and caregiving away from the Islands among nā kūpuna and ‘ohana (family) caregivers in two California locales. Our work was guided by minority stress (Meyer 2003; Sotero 2006) and resiliency perspectives and theories (Saleebey 1996). Briefly, minority stress theory builds on stress-process models that suggest that chronic stress generates psychological and physiological responses that accumulate over time to produce poor health outcomes. According to minority stress theory, racial/ethnic and minority populations in the U.S. are at greater risk due to stress from what is often a lifetime of discrimination, which increases risk for poor health outcomes (Meyer 2003; Pearlin et al. 2005). For indigenous peoples, minority stress is linked to historical trauma from colonization, forced loss of language and culture, systematic discrimination, and inter-generational marginalization (Braveheart and Debruyn 1998; Sotero 2006). Our second framework, resiliency theory, acknowledges and legitimizes trauma but speaks more to an increased attention to the inherent strengths in individuals and communities that can act as protective factors against stress (Saleebey 1996). Native Hawaiian scholars view cultural values as resiliency factors, providing refuge from the stress associated with poor Native Hawaiian status (Mau et al. 2010; Mokuau 2011). In Hawaiian culture, for example, individuals are placed within the context of the larger group (e.g., the family, neighborhood), the physical environment in which they live, and their spiritual beliefs (Braun et al. 2014). For many Native Hawaiians, good health is a reflection of one’s ability to balance responsibilities to the group, the land, and the spiritual world including ancestor and family gods (Braun et al. 2004). In sum, these two frameworks (minority stress and resilience) provided two perspectives from which to study Native Hawaiians on the U.S. Continent. These frameworks aided in the development of our study design, and provided a context from which to analyze findings and provide practice and policy recommendations.

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This qualitative study is part of a larger, six-year, mixed-method design study conducted by Hā Kūpuna National Resource Center for Native Hawaiian Elders in Honolulu, Hawai‘i. Established in September of 2006 with funding from the Administration on Community Living, U.S. Department of Health and Human Services, Hā Kūpuna is one of three congressionally mandated resource centers focusing on the health of native elders. Partner centers include the National Resource Center for Native American Aging and the National Resource Center for Alaska Native Elders (Browne et al. 2015). As with all three centers, the work of Hā Kūpuna is guided by principles of cultural competence with native communities and by a native advisory board (Mokuau et al. 2008).

Methods Design We used qualitative methods to listen for reasons for migration and perspectives on aging and caregiving away from the Islands. The Institutional Review Boards (IRB) of the University of Hawai‘i at Mānoa and Papa Ola Lōkahi (Native Hawaiian Board of Health) approved the study.

Sample We recruited participants with the assistance of Native Hawaiian Civic Clubs and other community-based programs in the Los Angeles (LA) and San Diego (SD) areas. These two communities were chosen because of the high proportion of Native Hawaiian residents compared to other locales (Kamehameha Schools 2014; U.S Census 2010). We started with a Native Hawaiian couple known for their engagement in Southern California-based civic and community services and asked them to serve as gatekeepers in the recruitment of key informants and focus groups participants. They identified key informants and helped us convene focus groups in LA in SD. Older adult participants (nā kūpuna) were Native Hawaiian, 55 years of age and older, and cognitively alert. ‘Ohana caregiver participants were Native Hawaiian and provided care to an older family member (60+), defined as any assistance to enable an elder to live independently, e.g., balancing a checkbook, providing transportation, cooking meals, and assisting with bathing. Key informants could be Native Hawaiians any age, but also knowledgeable about community services and/or were in community leadership positions. Thirty individuals participated: 10 Key Informants (5 in each site) and 20 kūpuna and ‘ohana caregivers (10 in each site).

Measures Our interview schedule was informed by our conceptual frameworks on minority stress theory and resilience. Interviews began with introductions and when and why each participant had moved from Hawai‘i to California. The discussion then turned to the

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definition of kupuna (elder), perceived health needs of nā kūpuna and ‘ohana caregivers, and supports and challenges to aging and caregiving away from the islands. The same questions were used with key informants and focus group participants. At the beginning of key informant interviews and both focus groups, the study’s voluntary nature and confidentiality safeguards were discussed, and participants signed consent forms. They completed a brief demographic questionnaire that asked questions about their age, gender, years away from Hawai‘i, and needs for assistance with care or caregiving. Two researchers (CB and KB) alternated research roles; KB led the interviews in LA, and CB led the interviews in SD. Participant responses were recorded verbatim and transcribed. Participants received an incentive, and food was provided as a culturally grounded practice of welcome and appreciation.

Data Analysis Our analysis was based on narrative data transcribed from our interviews and meetings recorded onto audiotapes and handwritten notes. Two researchers analyzed the data using the constant comparative method (Strauss and Corbin 1990). We coded and categorized the data using three basis types of coding: open, axial and selective (Strauss and Corbin 1990). We began with open coding, and independently read the transcripts to familiarize ourselves with the raw data. Patterns and themes began to emerge and this step allowed us to develop the common coding system. Transcripts were then coded based on the codebook. The researchers discussed how they coded passages in each transcript, and assigned codes were discussed until saturation and consensus were reached. This step ensured that all key issues were identified, captured, and recorded. Axial coding, our next step, occurred with open coding and related the categories identified in open coding to the subcategories (Strauss and Corbin 1999). In this step, we regrouped responses by each question, and broader themes and relationships among the categories, along with illustrative quotes, were identified (Curry et al. 2009). Finally, selective coding was used to think, refine, and integrate our final themes and subthemes into our Discussion section. An initial draft report was shared with California participants and Hā Kūpuna advisors. These informants guided us to clarify language and also provided cultural context for some of the themes.

Results Of the 30 participants, key informants tended to be older (mean age 71 in LA and 78 in SD) than focus group participants (mean age 62 in LA and 66 in SD). Years living on the U.S. Continent correlated with age. The majority of participants in both sites were welleducated and hard earned a college degree or had attended college. Among nā kūpuna in the focus groups, all also were caring (or had cared) for spouses, siblings, or parents. Nā kūpuna and ‘ohana caregivers reported providing (or having provided) 2 to 24 h of care per day. Most frequently, they helped (or had helped) the elder with shopping, going to the doctor, cooking, cleaning, bathing, medications, and paying bills. On average, they

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reported providing care for 10 years (range 5–33 years). Because comments across groups and communities were very similar, thematic data are presented for the 30 participants together, and results are organized around discussion questions.

Leaving Hawai‘i When introducing themselves, participants told us when and why they had moved from Hawai‘i. In general, nā kūpuna left Hawai‘i in their teens with their families or after high school or college to join the military, seek further education, follow siblings or spouses, and/or to find work. About half of nā kūpuna had married other Hawaiians, while the other half had married non-Hawaiians. Adult child caregivers in the focus groups were born on the U.S. Continent. Almost all (90%) of participants said they maintained ties with Hawai‘i through ongoing visits with Hawai‘i-based family. Stressors related to stigma, poverty, and discrimination experienced as Native Hawaiians in Hawai‘i in the 1940s and 1950s were common remembrances. An 84 year-old woman said: BYes, growing up in Hawai‘i, we felt discrimination and disrespect.^ Another elder shared: Once I was on the wards [as a nurse student in Hawai‘i], and there was a Hawaiian patient who said ‘What are you doing here?’ and I said I was a student nurse. And he said: ‘You should not be here—you should be on Hotel Street [with waitresses and prostitutes].’ I didn’t take it personally but I guess he’d never seen a Hawaiian nurse (age 81). This comment, shared by another focus group participant, also spoke to the discrimination she felt growing up in Hawai‘i due to her ethnicity: In school, I was discriminated against in Hawai‘i. We were getting ready to go to an assembly, and I was picked for the oratory contest. And the head teacher said: ‘Couldn’t you find someone else?’ So that hurt. But my teacher said: ‘She is the best in my class, and she is going to do it.’ Discrimination also happened on the job. I needed a letter of recommendation for college, and the boss said, ‘You are going to college? Hawaiians aren’t supposed to go to college.’ If I stayed in Hawai‘i, it would have festered (age 80). Another said, BMy sister was already in California, and she was making so much more money than we could in Hawai‘i. So I moved to join her and found a lot more opportunities, and I could send money home [to my family]^ (age 82). In contrast, a 79-year-old participant said that she had not experienced shame at being Native Hawaiian and perhaps she experienced and witnessed fewer acts of discrimination toward Native Hawaiians. She said: BI didn’t at all feel that way. It could be the home I was raised in. With my Hawaiian last name, my father instilled in us the importance of being proud of being Hawaiian. So I was proud.^ An interesting comment was voiced by another 67-year-old elder participant who shared that she thought Native Hawaiians living in Hawai‘i disregarded the BHawaiian-ness^ of Native Hawaiians who had migrated to the U.S. Continent. She noted how important Bbeing Hawaiian^ was to her regardless of where she lived: Most of our Hawaiians think that…[Native Hawaiians] are all in Hawai‘i. They forget when we all came here. We sometimes get the feeling that [other Hawaiians forget] that

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we flew over the ocean to come here to make a living because we couldn’t make it at home, not because we wanted our Hawaiian blood drained out of the plane. All believed that they had integrated well into California culture, and all reported success over the years in their work and careers, purchasing homes and raising families. A 67-year-old shared this statement: BI was making very good money [in California] compared to what I was making [at home]. I kept thinking ‘I want to go home.’ But then, I guess you get used to it. Now that I am making more money, I could send my mom money.^ A 78-year-old elder shared this comment: BIt’s less expensive to live here than in Hawai’i, mainly because of food.^ With all participants, love of Hawai’i persisted. A 56-year-old participant stated: BWe may leave the island but the island does not leave us^. Another elaborated: I always love going home. I try to go home maybe every year. Although I have lived here all these years and my children were born and raised here, they were raised the way I was raised. When you go home, I mean you are like, ‘oh my God, I’m home.’ They are so kind. So much aloha. You got in the store, and they go, ‘aunty this and that’ I have to go home and renew myself (age 72). Yet another elder participant commented: BWe don’t have other Native Hawaiians close to us like back home. We feel like we’re being assimilated in the society [but want to] keep our roots strong. How do we perpetuate our culture when we don’t have day-to-day contact like they do back home? It wears on you.^ Comments such as these spoke not only to the love of the physical space of Hawai‘i but to traditional Hawaiian cultural practices and values that are missed. We also heard concerns by some participants that their children were more BAmericanized,^ producing both positive and negative feelings. An 83-year-old participant saw her daughter as un-Hawaiian, saying: BHawaiians don’t ask [questions], but she is assertive in her approach to life.^ This characteristic is not always viewed affirmatively in Hawai‘i. But, the same participant noted that this trait was useful in California: BMy daughter will go find out…if there is something to be done she will go do it. .. no one will tell her she can’t get it done.^

Age and Aging After introductions, we asked participants to define the term Bkupuna^ (elder). Nā kūpuna and ‘ohana caregivers spoke positively about the concept of kupuna and the role of nā kūpuna in their families and in the Hawaiian culture. They spoke of the wisdom that comes with age and referred to the sharing of knowledge (e.g., Ba kupuna is one who teaches,^ Ba kupuna is a respected elder to learn from,^ and Bit’s not about age, but about knowledge and wisdom^). Participants suggested that the term kupuna was closely connected to intergenerational learning and caring for mo‘opuna (grandchildren). BYou learn from your grandparents and, if you’re lucky to be raised by grandparents, you’ll carry their generation forward,^ and BMy grandmother kept us in a Hawaiian bubble …we got information to pass along. It’s a natural process.^ Another said, B[Unlike] the way older people are looked at here, in Hawai‘i we are taught to respect our kūpuna and listen and learn.^ One caregiver was unfamiliar with the term, saying, BI was raised on the continent so I don’t know a lot of Hawaiian words. Kupuna was not a familiar word to me, but now [after this discussion] I consider myself a kupuna.^

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Nā kūpuna and ‘ohana caregivers commented on the challenges of growing old and the chronic diseases that are common among elders. Participants emphasized the importance of exercise, good nutrition, and health education programs to encourage healthy living. They also noted increased need for services for older adults, especially health care, caregiver education, and transportation services to prevent elder isolation. Services were welcomed by families, as this ‘ohana caregiver stated with pride: When my mother came [to live with us] she had diabetes and high blood pressure. We went to a nutritionist, and I was taught how to make her meals properly and healthy. My mother is no longer on medication for diabetes, no meds whatsoever (age 71). Participants often voiced their comments through a Native Hawaiian cultural lens. For example, for some it was important to receive care from Native Hawaiian care providers (BThey understand cultural things^). Others agreed, but acknowledged that this kind of help was hard to find (BHawaiians have pursued so many different careers, so it’s hard for us to find Hawaiian doctors.^). The Native Hawaiian Civic Clubs were important to Bhelp keep us attuned to what is happening back home^ and Bto help us remember our family members and traditions.^ Others had connected with other Pacific Islander groups in California, including Samoans, Tongans, and Chamorros, to sponsor health and cultural programs. Some also preferred to go to health clinics that served large Pacific Islander populations. A key informant working in the Native Hawaiian community talked positively about a program her club was engaged in: We have Pacific Island Navigators, women from the various Pacific Islander communities that speak their native language to educate and train their communities on the prevalent disparities among the various Pacific Islanders (Hawaiians, Tongans, and Samoans). Additionally, they are able to provide them resources for childcare, food stamps, or access to medical services. [After training] the navigators take their knowledge back into their communities [age 80). However, two participants stated that it was sometimes difficult to discuss health and care issues with other Native Hawaiians. As one shared: As a civic club, we have kūpuna lunches, we socialize and talk story, and I try to do a bit of health education and brochures. I offered to talk about stroke, diabetes, and heart disease, but they said they didn’t want that as a program^ (age 84). Another participant who also works with elders said this: BKūpuna are sensitive and we must be careful asking questions, especially personal questions, so we have to ask in roundabout way. They don’t want to get too personal^. Others commented in a similar way, e.g., Bkupuna never like to ask for help, it’s not the Hawaiian way^ and Bgrowing up, be seen and not heard^.

Family Caregiving Like caregivers everywhere, participants commented on the challenges of caregiving. For example, a 67-year-old ‘ohana caregiver said: BIt was a new experience because I was an only child and the roles were reversed. It was a learning experience. I had to take care of her personal needs, and it was harder for her than me.^

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However, a difference between Hawai‘i and California was noted in how elders were considered by family. Most caregivers reported that Hawaiian culture emphasized care of nā kūpuna, whereas the mainstream U.S. culture did not. Many nodded to these comments: Bas Hawaiians, when you grow up, you take care of kūpuna^ and BIt’s our kuleana (responsibility); we have to do it.^ A participant went on to explain: I helped care for my blind mother-in-law during her last 5 years because my husband and sister-in-law didn’t get along with her. She lived 45 minutes away in an assisted living facility. My personal experience is that kūpuna are looked upon differently up here than in Hawai‘i. They are seen as a burden. It really upset me that they felt she was a burden. How can you consider this a burden? They took care of you during your growing years, and now they need extra help. That really bothers me (age 70). Said another 67-year-old participant, BWe were all raised Hawaiian. Our thinking is basically like the islanders…respect and taking care of the kūpuna.^ Other aspects of being Hawaiian also were important, including traditional connections to land, food, family, and spirit. An 83-year-old participant commented: How do I think like a Hawaiian? I see the people I work with and I think I’m more patient than they are—we are a more giving people, more family oriented. Our children and family are most important… To us the land—we are in tune with sky and land. More with nature I think. Another kupuna who teaches other older adults in adult education classes said: They [kūpuna) are our blessings. Everyone in my class cares about each other, it’s a family. Some people don’t like it when you mention God’s name. He is a big part of who we are. So, I just say what comes to my heart and I think the students feel it as well. Eating healthy and incorporating Hawaiian food was mentioned as an important for nā kūpuna and ‘ohana caregivers. However, concerns were raised about cost of Hawaiian foods. A 78-year-old participant explained: BThose of us who grew up in Hawai‘i have a keen palate for different kinds of food, which are all rich and ono [tasty]. We need local but healthier recipes. We pay $26 for a 3 pound bag of poi.^.2 Another key theme was affordability of eldercare, e.g., BNot everyone can afford assisted living…it can get very expensive^ and Bfinances are a huge barrier [to accessing and receiving care]^ A key informant shared: BWe took care of my mother…she ended up with Alzheimer’s at 65 and died at 72. It was a financial burden.^ Another said: BFinancially many of our families are struggling just to make a living. A lot don’t have insurance.^ A kupuna noted about her ‘ohana: They are all financially struggling. It’s the fees for their meds [and fees] to have someone step in and take care of them when family has to go to work. We do not have those finances. The kūpuna are home sitting by themselves. I don’t think the majority of them mix well to send them to the facilities outside, even if the families can afford it. They tend to want to be with their own kind.

2 1 Poi is a highly nutritious starch, somewhat similar to a potato, made by mashing the kalo (taro) plant’s corm, or root. Among Native Hawaiians, it is considered a highly important and sacred part of Hawaiian life.

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However, caregivers noted that sometimes an elder could not be cared for at home. A 67year old kupuna said: BMy cousin had to go into a home, the government pays half and he pays half, but he had to sell his home.^ Another participant elaborated: Finances are a huge barrier [to accessing and receiving care]. Kūpuna stay with their children because they cannot afford better care. Everyone pools their resources to try to make it work. When my mother-in-law went into care, we sold her home, but that money would only last 10 years, so this is a concern. Many Hawaiian families don’t have those resources (age 78).

Care Preferences We looked at care preferences because differing health profiles and cultural values have been found to affect the type of care preferred and used (Andrulis and Brach 2007; Shaw et al. 2009). Elders and families enthusiastically shared opinions about the care they and their elder received from programs. Foremost, they enjoyed the Native Hawaiian Civic Clubs, where they could Bget together for hula and comradery, maybe a dozen of us are from the islands and the rest are all mixed.^ Participants knew about Medicare, but few were familiar with other programs and services for older adults. Only one person was aware of services offered through their area agency on aging (AAA), programs supported through the Administration on Community Living. Nā kūpuna and ‘ohana caregivers alike made references to positive experiences with care services. For example, a caregiver appreciated services from the local Alzheimer’s Association, saying: BWe learned more about how to take care of him and they put us in touch with other agencies. They came out to make our house safer.^ But we also heard multiple reasons why nā kūpuna and caregivers do not use publically available services even when eligible, available, and accessible. The two main themes were that family members do provide care, saying BIt is a family kuleana (responsibility)^ and that families need help to pay for care. Also, participants expressed concern about a lack of Native Hawaiian care providers, saying: BAre there some Hawaiian social workers who could come speak?, and BI retired in health care and we have lots of doctors but only a few Hawaiians.^ Another elder participant explained: BNative Hawaiian health professionals understand cultural things, our diet, [someone] we can relate to.^ Participants fondly remembered when Native Hawaiian faculty from the University of Hawai‘i visited to train nā kūpuna and their caregivers on the importance of Native Hawaiian and Pacific Islander health. ‘Ohana and nā kūpuna participants noted difficulties accessing service. One elder participant said: BThere are a lot of people who can help, but not knowing where to go or how to go about getting the information is difficult.^ Another said that accessing services was made easier when agency personnel were knowledgeable about working with culturally different elders. One 83-year-old shared: BStaff needs to be trained to work with kūpuna. Kūpuna cannot verbalize quickly, and service providers get impatient. They may not answer right away—staff walk away. They need [to show] respect.^ Participants provided their own suggestions as to how to inform nā kūpuna and caregivers of services in their community, e.g., through civic clubs, clinics, and Pacific Islander health navigators. A participant who had worked with the local Area Agency on Aging (AAA) said

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that more native people should give feedback to the local AAA, Alzheimer’s Association, or AARP chapter on how to work with Native Hawaiians.

Discussion Knowledge about aging and elder caregiving in the Native Hawaiian population is increasing, although knowledge on nā kūpuna who reside away from the islands is limited (Braun et al. 2014; Browne et al. 2009). We interviewed 30 Native Hawaiian key informants, kūpuna, and ‘ohana caregivers in LA and SD to hear their thoughts about aging and caregiving away from the Islands. Findings identified three general themes: discrimination was a factor in their migration and Diaspora from Hawai‘i; similarly to non-Hawaiians, they were concerned about challenges associated with aging and caregiving; and Native Hawaiian cultural traditions and values continued to shape their lives and those of their families.

Discrimination and the Hawaiian Diaspora The first theme identified was around the topic of discrimination. Similar to other migrants, Native Hawaiians in our sample had experienced discrimination in their birthplace (Massey et al. 1993). Although none said directly that this was the cause of their migration, they noted that relocating to California greatly expanded their opportunities and earning power, and this is consistent with other migrants (Aitaoto et al. 2012; Nakatsuka et al. 2013). Overall, our participants believed their move was positive. For those who left the islands as teens and young adults, they talked about the financial benefits that allowed them and their families to earn a living, own a home, and raise a family. Although racial prejudice is deeply ingrained in U.S. culture (Jones et al. 2008), participants’ discussions suggested that they did not experience discriminatory practices and behaviors after moving to California. It may be that we were unable to retrieve this information, or it could be that California was less discriminatory against Native Hawaiians in the 1960s and 1970s than was Hawai‘i. We also did not hear any comments about present-day real and/or perceived discriminatory behaviors, and this is contrary to research conducted on Native Hawaiians and Native Hawaiian elders in Hawai‘i (Browne et al. 2014; Kaholokula et al. 2012). Research has linked poor health outcomes among indigenous Americans with a history of colonization, devaluation of cultural values, and institutionalized discrimination (Braveheart and Debruyn 1998; Kaholokula et al. 2012; Mokuau 2011). Specifically, colonized people always lose life, land, language, culture, and power in their homelands post-colonization (Sotero 2006). A topic for future study is an examination of why Native Hawaiians did not report feelings of discrimination in California at that time and how this might connect to their health status compared to their peers who remained in Hawai’i. More data are needed on service use among Native Hawaiian elders. Thus, an additional topic for further study should investigate service patterns among a broader sample of Native Hawaiian elders and whether public care utilization is a result of insensitive care and discrimination, a preference for family care, or a combination of the two. Earlier research conducted on Native Hawaiians in Hawai’i, for example, identified stressors related to stigma, prejudice and discrimination as one reasons for why Native Hawaiian elders limited their public service use (Browne et al. 2014).

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Returning to minority stress theory, one potential question that we cannot answer is whether or not the participants’ socioeconomic status (SES) could have led to their feelings around the absence of discrimination in their lives in California. Studies with other ethnic groups have produced mixed results about the association between real and perceived discrimination and SES. A review of the role of discrimination in racial differences in health articulates the challenges as well as the need for more research in this area (Williams and Mohammed 2009). Was our sample healthier because of their better SES compared to Native Hawaiians in Hawai‘i, and therefore more resilient? We did not solicit information about participants’ financial status; however, all spoke to leading successful lives and being homeowners in California. It could be that Native Hawaiians residing in California are not confronted on a daily basis with the evidence of historical trauma, and their Diaspora has provided some physical and emotional distance from it. Another potential explanation may be that the move to the Continent came many years ago, and the Hawai‘i that they remember has changed in a positive way. There is evidence that the Native Hawaiian cultural renaissance that began in the late 1970s contributed to a return to respect and honoring of Hawaiian culture. The participants were contrasting their California experiences to a Hawai‘i that existed years ago. In other words, it could well be that today’s sociohistorical times are more respectful compared to when the majority of our participants were born. Browne et al. (2009) provide a historical timeline that identifies key cultural and historical markers in the lives of nā Kūpuna and link this timeline to social and health care strategies. In doing so, the authors offer a rationale for the development and implementation of culturally based solutions. Participants admitted mixed feelings about seeing their own children acclimate to BAmerican^ culture. Participants were concerned that positive regard for nā kūpuna may be lost as children adopt American values favoring individualism over collectivism (Braun et al. 2014; Mokuau 2011). On the other hand, others admired those qualities in their children who were more comfortable asking for help than their parents, linking them to needed resources and education.

Challenges Associated with Aging and Caregiving Our second finding, similar to the findings from other national studies, identified the emotional and financial challenges of growing old and caregiving (National Alliance for Caregiving and AARP 2015; Pearlin et al. 2005). All of our participants were concerned by the high costs of medication and home and institutional services for older adults, and these are national concerns as well (AARP 2011). Like other Americans, Native Hawaiians in California preferred family and home care but lacked knowledge of services and where to find help with eldercare (AARP 2011). Many also said they would prefer to receive help from other Native Hawaiians, but that few providers were Hawaiian. These feelings, experiences, and preferences are not unique to Hawaiians, but are reflective of the ways in which many U.S. elders and families feel about the desire to be respected for who they are (Vieder et al. 2002). Nonetheless, providers who want to work effectively with Native Hawaiian elders should learn more about a population whose cultural values remain strong despite their Diaspora. It is helpful to establish trust and personal and respectful connections with the elder and his/her family, to ask about preferred services, and to ask permission before asking intrusive questions and conducting physical exams (Braun et al. 2014). Native Hawaiians may prefer educational and health services that are

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provided through social gatherings and that reinforce practices important to Hawaiian cultural values (Ka’opua et al. 2011a, b).

Diaspora and the Primacy of Native Hawaiian Cultural Values We also found that, even after many years away from the islands, Native Hawaiian cultural values persist in those we interviewed. Participants believed that they had acclimated to their new locale but missed Native Hawaiian culture. Although participants in general stated that aging was a universal experience, they also spoke positively of Native Hawaiian cultural values around caring for kūpuna, which is seen as a family responsibility, and the role of elders in intergenerational learning and cultural preservation (Mokuau 2011). Participants maintained a Hawaiian view of health, which included well-balanced relationships with family, land, and spirit. These findings provide insight into the primacy of Native Hawaiian culture even with the Diaspora. Those living on the continent expressed the importance of coming together through Hawaiian civic groups and other culturally sponsored events. Such events provide a cultural connection to other Native islanders outside of Hawai’i that feel isolated in relation to their geography and ‘ohana. Another interesting finding is the connection in California across Pacific Islander groups, which generally does not occur in Hawai‘i. Returning to resiliency theory, this may illustrate the ways in which Native Hawaiian cultural values and traditions are in fact examples of their resiliency in California in the ways they create new communities of support around Pacific Islander values and culture. The social coherence within these communities—a common feature of Diaspora—can be viewed from a strengths and resiliency perspective discussed earlier in this paper. Meyer’s (2003) stress model may also be helpful here, as it offers a unique perspective to this study that incorporates discussions on stressors such as stigma and discrimination but that also pays attention to the strengths in the community and within the individual and his/her culture.

Practice and Policy Recommendations Strategies to support Native Hawaiian elders and their ‘ohana caregivers in California may include attending to the financial needs and costs of growing old and providing care, tailoring programs to Native Hawaiian groups to make them more attractive, and improving the cultural sensitivity of providers (Braun et al. 2014). There are numerous federal, state, and private sector organizations and services working to provide elder and family support services to promote independence, support family in caregiving tasks, and potentially delay institutionalization. Nonetheless, our study participants seemed unfamiliar with aging programs and services. This is also not unusual for elders and families of any ethnic group, and more needs to be done to educate families about aging and about long-term care services and supports. More also needs to be done to support families in providing long-term care by making support services more accessible and affordable. In the absence of a universal and affordable long-term care funding mechanism, programs funded through Title VI of the Older Americans Act are in alignment with national directions to help elders age in place (Browne et al. 2015). Programs that have been tailored to Native Hawaiian populations have been successful in improving their health care utilization in Hawai‘i, and should be piloted in other sites.

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Especially useful are interventions that reflect Native Hawaiian resiliencies around values related to family, community, and church. Research in Hawai‘i has shown cancer screening and treatment completion among Native Hawaiian can be improved through family-day events (Gellert et al. 2006), through church-based programs (Ka’opua et al. 2011a, b), through familyfocused interventions (Mokuau et al. 2012), and through lay navigator programs (Braun et al. 2015). Policymakers and providers must advocate for strategies that reduce the financial stressors related to age and care and that promote care that is responsive to the preferences of this and other populations facing Diaspora from their birthplace (Browne et al. 2009). Returning to the theoretical work discussed earlier, those in this sample spoke of stigma and discriminatory practices when living in Hawai‘i, but similar comments about California went missing. Further research together with a stronger articulation and merging of these frameworks may help professionals enhance their understanding of Native Hawaiian aging issues and caregiving concerns, as well as the effects of migration—both positive and negative—on elder well-being. Research suggests that health and care-oriented interventions can be more acceptable and successful when cultural values are viewed as strengths and are built into programs and approaches (Andrulis and Brach 2007; Kamehameha Schools 2014; Mokuau et al. 2012; Singleton and Krausse 2009). Practices that are both culturally and historically informed acknowledge the resiliency that exists in these communities, and promote respectful and responsive care. Professionals who reflect and recognize the resiliencies in this population will aim to partner with community cultural guides, leaders, and groups who ultimately are the most knowledgeable about improving well-being and care to Native Hawaiians living away from the Islands. Results from this and other studies also suggest that any useful practice or policy framework should be grounded in the theoretical work around minority stress and the role of social stigma and discrimination in order to better understand how individuals seek and secure care and assistance (Mokuau 2011; Williams and Mohammed 2009). One resource to consider is provided by revisions to the National Standard for Cultural and Linguistic Appropriate Services (CLAS), developed by the Department of Health and Human Services Office of Minority Health (U.S. Office of Minority Health 2013). Another is legal action against discrimination in employment, health care, and service delivery.

Limitations The major limitation of the study was small sample and its focus on two California communities. Similarly, to other cross-sectional datasets, our sample of kūpuna, and ‘ohana caregivers included mostly women (National Alliance for Caregiving and AARP 2015; AARP 2011) who were relatively well-educated and physically independent. As we did not solicit questions about their financial status, we can make no statement here other than noting that participants felt they Bdid well^ in California, but expressed financial concerns related to aging and caregiving. We also had difficulty distinguishing between nā kūpuna and caregivers in our sample. We had initially thought that we could clearly delineate these groups, but most of nā kūpuna were or had also been caregivers, and they had much to share on the topic of eldercare. Also, the fact that interviews took place at a community center meant that participants were relatively high functioning. Because participants were recruited through agencies and Native Hawaiian Civic Clubs, familiarity with some services may have influenced their answers. Whether or not those who

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participate in Native Hawaiian Civic Clubs are more committed to their culture is unknown, but this certainly may have been the case. Despite these limitations, we feel that this work contributes to our knowledge of aging-related needs and preferences of Native Hawaiians outside of Hawai‘i. Still, research should be done with Native Hawaiians living in other states to see if their experiences are similar to those of our California participants.

Conclusions Native Hawaiians living in Southern California noted benefits (including a higher standard of living and fewer experiences of discrimination) of relocating from Hawai‘i, were challenged (especially financially) by aging and caregiving, and noted strong connection to Native Hawaiian cultural values even after 35–65 years away from the Islands. The persistence of Native Hawaiian cultural values and practices suggested continued preference for culturally based services and culturally sensitive service providers. To better serve Native Hawaiians and develop relevant policies and programs for them, significantly more research on Native elders is needed on those living in North America, as well as those living in their traditional homelands. Funding This study was funded in part by the Administration on Community Living, DHHS, Washington, DC, by grant number #90O10007–01-00. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings andf conclusions. Points of view or opinions do not, therefore, necessarily represent official governmern policy.

Compliance with Ethical Standards Conflict of Interest The authors declare that they have no conflict of interest.

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