Health
Blending cultural sensitivity with Western health care

By Beverly Creamer
Advertiser Staff Writer

Dr. William Ahuna chats with his patient, Shirl Torngren. Ahuna just completed a cultural sensitivity session aimed at understanding needs of Native Hawaiian women. Kyle Sackowski • The Honolulu Advertiser Information Medical centers who want to set up a free one-hour session of cultural sensitivity training, may call Claire Hughes at 586-4673 at the Health Department or Joyce Rowe at 595-7500 at the American Cancer Society.

One reason that researchers have identified is a reluctance on the part of this group to seek, or remain under, medical care, with the result that these women are consistently diagnosed when cancers are at later, harder-to-treat stages. One of the stumbling blocks has been that the women shy away from Western-style medical care, with its brisk, high-tech/low-touch way of dealing with patients.

Now a new program launched by the state Health Department, the American Cancer Society and Papa Ola Lokahi, the state's Native Hawaiian health care system, is aimed at improving understanding between health care providers and their Native Hawaiian breast cancer patients. The suggestions in the program are based on what researchers heard in focus groups of Native Hawaiian women aimed at exploring their concerns and experiences with the medical system.

Over the next few months, a group of 24 trainers will begin making contact with health providers throughout the Islands offering a free one-hour training session in cultural awareness designed to help make Native Hawaiian patients more comfortable in seeking medical care. While 20 percent of the state's population is of Native Hawaiian ancestry, only about 4 percent of Hawai'i's physicians are Native Hawaiian.

"We want to identify the bumps in the road and open rapport between health care providers and their patients," said Gayle Mackura, a trainer with Papa Ola Lokahi.

"We hope it will make women seek help earlier and stay with it, and even get others into it," said Claire Hughes, administrator of the Office of Health Equity for the Health Department.

"Many won't return if they think they've been treated with unkindness, indifference or disrespect," Mackura said. "It's seen as rude (in the Hawaiian culture) to ask a lot of questions. If she feels rushed or pressured, she may feel it's better not to say anything."

Penny Keli'i, a Department of Health employee on the Big Island, remembers how one of her best friends, who had breast cancer, was "turned off" after a visit to an insensitive doctor. "The doctor told her 'Don't be silly, don't be afraid of losing your hair with chemo,' and she left and never went back, saying she didn't want that. She died, with a full head of hair, and long before her time."

Keli'i, who will be doing cultural training for medical personnel on the Big Island, remembers going in for her first mammogram only because her physician made the appointment. "I know the importance of having a mammogram but I was scared," she admits.

"But when I did go, I had a Hawaiian technician and she was wonderful. She guided me through it. She knew this was not something I was used to. She said 'Now this will be uncomfortable, but it will not hurt. Any time it hurts, you tell me and we'll stop.' She had a lot of comforting phrases.

"I told her 'Next year when I come back I want to book your table.' "

One of the biggest stumbling blocks to care is the way that words are perceived: to speak of something is to empower it. "There is a belief in the Hawaiian community that if you talk about a disease it gives power to the disease so it's difficult for women to talk about breast cancer," Mackura said.

Though Dr. William Ahuna of the Kaiser Permanente clinic in Nanakuli and Wai'anae is part-Hawaiian and was raised in the culture, that concept came as a revelation. A few months ago, Ahuna was among 30 Kaiser personnel who participated in the first cultural awareness training.

"That was one of the ideas I wasn't familiar with," said Ahuna, who has since changed the way he approaches difficult subjects with patients. "Now I ask them how they feel about talking about it and try to sense what they're comfortable with and go with what they're ready to hear."

Ahuna also emphasizes to his patients that tests and procedures are a routine response to something suspicious, and that more than likely results will be negative. "I tell them we have to take it a step at a time, and not to be worried about anything until we know."

If there is bad news, "I'd say something to the effect 'I think the results are worse than we expected,' " he said. But he injects hope immediately, saying there are many steps (to be taken in treatment).

"I try to support them throughout and let them know I will be there for them," he said, "and let them know if they have any concerns they can always talk to me." He has taken several calls at home from patients needing more support.

Hughes, of Native Hawaiian ancestry also, emphasizes how the reaction of the primary physician is crucial in keeping those of Native Hawaiian ancestry coming back for care.

"In our focus group with key informants, women pointed out that if they liked the physician and they had made a connection, they were able to handle the worst of situations," she said. "If there was some bond, even a very new bond, if the news was really bad then it was much easier to handle. The physician was the key person to them."

And the support shown by him or her, along with a quiet, respectful manner, makes all the difference.

Mackura calls it "the grace and attitude of aloha."

As the training reaches deep into the cultural arena, it offers understanding of a whole range of subtleties. Those of Native Hawaiian ancestry exist as part of a community, an 'ohana, Mackura explained. The relationships are intertwined and interdependent. The way to appeal to a woman who needs care for cancer is not on the basis that she is important, but that she is important to her family.

The extended family also becomes important in something as seemingly simple as how a waiting room is laid out. A sense of ease for those of Native Hawaiian ancestry comes from waiting rooms with living plants (ti plants are considered healing), soft music playing (preferably Hawaiian), unconfining chairs without arms and spaces for children to play and be safe. A woman coming to a doctor's office often brings other family members for support, and they need to feel welcome, too. "If the receptionist says 'Keep the kids quiet,' " Hughes says, "you know the woman's never going back."

The patient might wish to have members of the family come into the consultation room. On the plus side for the medical system, a physician can enlist the help of these family members in whatever needs to be done at home to help the patient.

Hughes said the volunteer committee hopes to train every physician in the state, along with staff. A training video — prepared by the American Cancer Society's Native Hawaiian Cancer Subcommittee — will be supplied free along with the free training.