Ke Ao Nōweo 'Ula (KANU): An emergent theory of wellbeing for Kānaka ʻŌiwi with behavioral health challenges

Qualitative study with community partner I Ola Lāhui which used the transformative paradigm and grounded theory. In utilizing decolonial and Indigenizing approaches, a new qualitative method was developed, hoʻomana i nā leo, empowering the voices and moʻolelo (stories) of potentially vulnerable Kānaka ʻŌiwi based on their intersectional identities. The resulting theory (version 1) contains detriments (72 processes across 6 process categories), supports and states (110 processes across 9 process), and outcomes (60 processes across 5 process categories). We elaborate on nine outstanding highlights: Moʻohihia: Cycles of Settler Colonial Stress Model version 1; ʻŌiwi critical consciousness and purpose; ʻĀina attachment; “Hawaiian enough”; Naʻauao as a central outcome; Emphasis on healing; Decolonial integrative holistic healthcare systems and mauli ola; Mauli ola’s relationship to resilience and survivance; Mauli ola’s relationship to historical or intergenerational trauma. The project also explores KANU as decolonial; whether or not axiological liminality is named as a detriment; to what extent the mind-body-spirit connection appears as a part of KANU; and to what extent an individual level is necessary for KANU. For methods, see below: 2. Goal 1 Methods Goal 1 used a community-based qualitative research design to explore an emergent theory of wellbeing (i.e., detriments, supports, states, and outcomes) for Kānaka ʻŌiwi who have experienced behavioral health challenges like depression. The name of the Goal 1 study was the Depression and Wellbeing in the Native Hawaiian Community Study (DAWN Study). The findings provide the foundations for an emergent theory of wellbeing which can then be iteratively re-constructed as more research is integrated in future efforts to understand its processes. The content of the subsequent sections are informed by the APA Publications and Communications Board Task Force Report on Journal Article Reporting Standards for Qualitative Research (Levitt et al., 2018). 2.1. Recruitment Participants were primarily recruited December 2020-July 2021 by community partner, I Ola Lāhui, a non-profit behavioral health organization that provides culturally-minded and evidence-based services to medically underserved, Kanaka ʻŌiwi, and rural communities. Given the aims of the present study, purposive sampling was the primary recruitment method utilized to ensure specific kinds of participants with varying, though related, views about depression in the Kanaka ʻŌiwi community were included (Robinson, 2014). Participants were recruited from three categories: Kānaka ʻŌiwi with a history of depressive symptoms, mental and behavioral health (MBH) providers who primarily serve Kānaka ʻŌiwi, and Kanaka ʻŌiwi cultural leaders. Additional inclusionary factors required that participants were 18 years of age or older, and an ability to communicate in English. We did not exclude clients who had comorbidities nor those who were on medications related to their depressive symptoms. Collaborating post-doctoral clinical psychologists from I Ola Lāhui recruited participants from within the center, as well as from their networks in the greater Kanaka ʻŌiwi community. The first author (JQ) also assisted with recruitment efforts through her own network and through one instance of snowball sampling within the MBH provider category (C. Parker et al., 2019). 2.2. Ethics All study procedures were reviewed and approved by the Institutional Review Board at the University of Hawai‘i at Mānoa. Participants completed an online informed consent form before participating in the study and were informed that their participation in the study was completely voluntary. Participants were told that, in the case that they may become stressed or uncomfortable answering any questions during the interview, they may skip a question, take a break, or withdraw from the study altogether. Importantly, participants who were recipients of services from I Ola Lāhui were informed that their decision to participate or to not participate in the study would not affect their relationship with I Ola Lāhui or the services they were receiving. 2.3. Participants The present study (N = 41) included Kānaka ʻŌiwi with a history of depressive symptoms (clients; n = 19, 46%), mental and behavioral health providers (MBH, n = 12, 29%), and Kanaka ʻŌiwi cultural leaders (CL, n = 10, 24%). Significant overlap across participant types was revealed in interviews as many cultural leaders had participated in MBH programming as facilitators or had graduate-level degrees related to MBH and many clients and MBH providers identified themselves as cultural practitioners. Many participants who were not categorized as clients also open discussed their own experiences in this domain. Kanaka ʻŌiwi client participants (M = 42.94, SD = 12.74; ages 22–72 years old) reported most recently seeking therapy for a range of reasons related to their mental and behavioral health: COVID-related stress; negative family or self-issues; substance abuse; other types of stress; and grief of loss. The total time these issues were addressed in therapy ranged from 2 months to 51 years (M = 6 years) for a total of 71 years of therapy engagement across participants. MBH professionals (M = 4.33, SD = 7.13; ages 30–55 years old) were asked about their licensure type: Licensed Clinical Psychologist (n = 6), Licensed Marriage Family Therapist (n = 1), Licensed Mental Health Counselor (n = 1), and Licensed Clinical Social Worker (n = 1). Three MBH providers were awaiting licensure from psychology and social work programs. MBH providers brought a total number of 152 years of experience to the study, reporting a range of 4–27 years of experience providing MBH services (M = 13 years). Kanaka ʻŌiwi cultural leaders (M = 47.80, SD = 8.65; ages 36–67 years old,) reported being experts in nine practices: hula (spiritual dance), lei (sewing flower garlands), lomilomi (massage), hoʻoponopono (reconciliation), lāʻau lapaʻau (herbal medicine), oli (chanting), oihana ʻawa (ritual using kava), hale mua o kualiʻi (men’s eating house of Oʻahu), and lāʻau kāhea (calling medicine). Six cultural leaders reported having graduate degrees; two cultural leaders reported current employment related to mental health, six reported graduate degrees, and three of these degrees were related to mental or behavioral health (Table 1, DAWN Study Participant Demographics). 2.4. Procedures A total of thirty-nine 90-minute online video interviews were conducted and recorded via Zoom: 1 pilot focus group interview with three MBH providers, and 38 one-on-one interviews with the remaining 38 participants. The interview team consisted of the author and two post-doctoral fellows serving as therapists for I Ola Lāhui. Interview questions were determined over multiple meetings with I Ola Lāhui and qualitative methods expert and consultant to the study Jane Chung-Do, DrPH. Interviewers used a guide consisting of semi-structured questions which were created collaboratively between I Ola Lāhui and the university research team (Appendix B). Interviewers were encouraged to use a “talk-story” approach, keeping language casual and flexible to the participants’ communication styles; interviewers were also instructed to keep questions broad, giving participants an opportunity to describe their conception of wellbeing, and allowing for the interview to center participant voices. The first set of questions was given to all participants regardless of their participant type, and interviewers were encouraged to use wording most appropriate for the individual (e.g. for clients, “What does wellbeing look like for Kānaka Maoli, including yourself?”). A second set of optional cues for questions were offered to interviewers as possible follow-up questions, based on the participants’ initial responses (e.g., “How does ____ contribute to wellbeing for Native Hawaiians?” See Appendix C). The wording of these optional questions and cues depended upon the nature of the interview, and interviewers iteratively updated and noted these documents through memos and team meetings, identifying possible questions to edit for clarity and relevance, in alignment with the grounded theory approach to data collection (Charmaz, 2016). Wellbeing questions were asked first, followed by questions regarding depression and intervention preferences. All interviews were transcribed by five undergraduate research assistants who received in-depth training via didactics and homework assignments on transcription theories and procedures prior to the project. Each transcript was first transcribed, word-for-word, while watching the interview video. Then, a second research assistant watched the video and edited the transcript as needed for quality assurance. 2.4.1 Coding and Analysis Rationale Interviews were then coded using a computer-assisted qualitative data analysis software NVivo Version 12 (QSR International, 2019). Given the chosen approach of grounded theory and the complexity of the data gathered, a flexible three-cycle coding approach was utilized (Deterding & Waters, 2021), prioritizing an initial in vivo coding approach for cycle one, using exact words from interviews as codes (Saldaña, 2013). Six interviews, two from each of the three categories of participants (i.e., client, provider, and cultural leader), were randomly selected and coded by two team members individually (JQ and one research assistant) to create an initial codebook (see Appendix D for an excerpt, or view the GoogleSheet here). Raters met to discuss and resolve any discrepancies in coding to ensure interrater reliability. Once consensus was reached, the initial codebook contained 200 codes that emerged out of data from the first randomly selected six transcripts, as well as definitions and examples of each code. Then, a team of five (one post-doctoral community partner, two PhD students in clinical psychology