Association between acculturation modes and type 2 diabetes among Native Hawaiians

Acculturation and Health Status in the Children's Healthy Living Program in the Pacific Region

Acculturation/enculturation has been found to impact childhood health and obesity status. The objective of this study is to use cross-sectional data to examine the association between proxies of adult/caregiver acculturation/enculturation and child health status (Body Mass Index [BMI], waist circumference [WC], and acanthosis nigricans [AN]) in the U.S.-Affiliated Pacific Islands (USAPI), Alaska, and Hawai'i. Study participants were from the Children's Healthy Living (CHL) Program, an environmental intervention trial and obesity prevalence survey. Anthropometric data from 2-8 year olds and parent/caregiver questionnaires were used in this analysis. The results of this study (n = 4121) saw that those parents/caregivers who identified as traditional had children who were protected against overweight/obesity (OWOB) status and WC > 75th percentile (compared to the integrated culture identity) when adjusted for significant variables from the descriptive analysis. AN did not have a significant association with cultural classification. Future interventions in the USAPI, Alaska, and Hawai'i may want to focus efforts on parents/caregivers who associated with an integrated cultural group as an opportunity to improve health and reduce child OWOB prevalence.

Social determinants of health literacy among parents and caregivers in the US-Affiliated Pacific

Health literacy is understudied in the US-Affiliated Pacific (USAP), where local populations have historically experienced social marginalization and disproportionate health inequities caused by the social determinants of health (SDOH). This cross-sectional study analyzed several SDOH indicators-acculturation, use of food assistance programs and demographic characteristics (race and ethnicity, household income, primary language spoken at home and educational attainment)-and their relationship to health literacy among 1305 parents/caregivers of young children ages 2-8 years old who participated in the Children's Healthy Living (CHL) program in Alaska, American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, and Hawai'i. Significantly increased odds of low health literacy were found among parents/caregivers with households where a language other than English was the primary language compared to English-only households (OR = 1.86, 95% CI = 1.22, 2.82), household income of <$35 000 compared to ≥$35 000 (OR = 2.15, 95% CI = 1.13, 4.07), parents/caregivers of Asian children compared to parents/caregivers of White children (OR = 2.68, 95% CI = 1.05, 6.84), parent/caregivers with less than or some high school education compared to high school completion (1st- to 8th-grade OR = 4.46, 95% CI = 2.09, 9.52; 9th- to 11th-grade OR 1.87, 95% CI = 1.06, 3.30) and parent/caregivers with acculturation status defined as marginalized as compared to integrated (OR = 2.31, 95% CI = 1.09, 4.86). This study indicates that some USAP parents/caregivers may lack the capacity to acquire health information, utilize health resources, and navigate health decision making. Future efforts to understand and improve health literacy in the USAP should be population specific, thoroughly assess personal and organizational health literacy, and inventory community health care capacity.

Experiences of Discrimination Among Native Hawaiians and Pacific Islanders Living in the USA

Experiences of racism and discrimination are stressors that adversely affect the well-being of marginalized populations, including Native Hawaiians and Pacific Islanders (NHPI). However, commonly used data aggregation methods obscure information on NHPI communities and their lived experiences. The aim of our study is to understand the types and frequency of discrimination experienced by NHPI adults in the USA. The study utilized online survey data collected from 252 NHPI adults living in the USA between September and October 2021. Younger NHPI adults, those who report constantly thinking about their race/ethnicity, and those who are socially assigned a race/ethnicity that does not match their own report experiencing more types of discrimination. NHPI who constantly think about their race/ethnicity and those who are socially assigned a race/ethnicity that does not match their own report a greater frequency of discrimination. Findings indicate the need to understand the experiences of discrimination in this population.

Prevalence of cardiovascular disease among Asian, Pacific Islander and multi-race populations in Hawai'i and California

BACKGROUND

Cardiovascular disease (CVD) remains the leading cause of death in the US. CVD incidence is influenced by many demographic, clinical, cultural, and psychosocial factors, including race and ethnicity. Despite recent research, there remain limitations on understanding CVD health among Asians and Pacific Islanders (APIs), particularly some subgroups and multi-racial populations. Combining diverse API populations into one study group and difficulties in defining API subpopulations and multi-race individuals have hampered efforts to identify and address health disparities in these growing populations.

METHODS

The study cohort was comprised of all adult patients at Kaiser Permanente Hawai'i and Palo Alto Medical Foundation in California during 2014-2018 (n = 684,363). EHR-recorded ICD-9 and ICD-10 diagnosis codes were used to indicate coronary heart disease (CHD), stroke, peripheral vascular disease (PVD), and overall CVD. Self-reported race and ethnicity data were used to construct 12 mutually exclusive single and multi-race groups, and a Non-Hispanic White (NHW) comparison group. Logistic regression models were used to derive prevalence estimates, odds ratios, and confidence intervals for the 12 race/ethnicity groups.

RESULTS

The prevalence of CHD and PVD varied 4-fold and stroke and overall CVD prevalence varied 3-fold across API subpopulations. Among Asians, the Filipino subgroup had the highest prevalence of all three CVD conditions and overall CVD. Chinese people had the lowest prevalence of CHD, PVD and overall CVD. In comparison to Native Hawaiians, Other Pacific Islanders had significantly higher prevalence of CHD. For the multi-race groups that included Native Hawaiians and Other Pacific Islanders, the prevalence of overall CVD was significantly higher than that for either single-race Native Hawaiians or Other Pacific Islanders. The multi-race Asian + White group had significantly higher overall CVD prevalence than both the NHW group and the highest Asian subgroup (Filipinos).

CONCLUSIONS

Study findings revealed significant differences in overall CVD, CHD, stroke, and PVD among API subgroups. In addition to elevated risk among Filipino, Native Hawaiian, and Other Pacific Islander groups, the study identified particularly elevated risk among multi-race API groups. Differences in disease prevalence are likely mirrored in other cardiometabolic conditions, supporting the need to disaggregate API subgroups in health research.

Traditional and new lifestyle interventions to prevent breast cancer recurrence (TANICA): a qualitative study

PURPOSE

Breast cancer is the second cause of death from cancer in Guam and Hawai'i and disproportionately impacts Native Hawaiian, CHamoru, and Filipino women. Although a few culturally informed interventions addressing breast cancer survivorship exist, none have been developed or tested for Native Hawaiian, CHamoru, and Filipino women. To address this, the TANICA study began with key informant interviews in 2021.

METHODS

Purposive sampling and grounded theory approaches were used to conduct semi-structured interviews with individuals experienced in providing healthcare or implementing community programs and/or research with ethnic groups of interest in Guam and Hawai'i. A literature review and expert consultation identified intervention components, engagement strategies, and settings. Interview questions aimed to understand the relevance of evidence-based interventions and explored socio-cultural factors. Participants completed demographics and cultural affiliation surveys. Interviews were independently analyzed by trained researchers. Themes were mutually agreed upon by reviewers and key themes were identified based on frequencies.

RESULTS

Nineteen interviews were conducted in Hawai'i (n=9) and Guam (n=10). Interviews confirmed the relevance of most of the previously identified evidence-based intervention components for Native Hawaiian, CHamoru, and Filipino breast cancer survivors. Ideas around culturally responsive intervention components and strategies emerged that were shared across and unique to each ethnic group and site.

CONCLUSION

Evidence-based intervention components appear relevant, yet cultural and place-based strategies are needed for Native Hawaiian, CHamoru, and Filipino women in Guam and Hawai'i. Future research should triangulate these findings with the lived experiences of Native Hawaiian, CHamoru, and Filipino breast cancer survivors to develop culturally informed interventions.

Increased social identification is linked with lower depressive and anxiety symptoms among ethnic minorities and migrants: A systematic review and meta-analysis

Evidence suggests that social identities, which provide purpose and a sense of belonging to the social world, promote resilience against psychological strain and protect well-being. This is especially important in ethnic minorities, who experience exclusion and discrimination from the majority group, and in migrant populations where adverse experiences, such as prejudice, disconnection from previous identities and issues of integration into the host country, negatively impact well-being. Drawing from the social identity theory, a meta-analysis was conducted examining the influence of group memberships and sense of belonging on ethnic minority and migrant mental health (depression and anxiety). The final search on three databases (i.e., PubMed, PsycINFO, Web of Science) was conducted on August 9th, 2022, identifying 3236 citations before removing any duplicates within and between databases. Across the 74 studies that met the inclusion criteria for the meta-analysis, increased social identification (ethnic, national and other types of identification) was associated with low psychological symptoms. We found that social identification is protective against common psychological disorders but with small effect sizes for depression (r = - 0.09, CI = [- 0.12; - 0.06]) and anxiety (r = - 0.08, CI [- 0.12; - 0.03]). Results are discussed with regard to the role that social context plays on ethnic minority and migrant mental health and the importance of facilitating migrant integration with the host society after displacement.

Awareness of and Support for HPV Vaccination Among Pacific Islander Women in Southern California

Pacific Islander (PI) women experience disproportionately high rates of cervical cancer and mortality and have lower rates of Pap testing. Since up to 70% of cervical cancers could be prevented by being vaccinated for human papilloma virus (HPV), this cross-sectional study explored the predictors of HPV and vaccine awareness, receipt of the vaccine, and attitudes toward vaccinating children among adult PI women in southern California, who historically have low rates of HPV vaccination and high rates of cervical cancer that could be prevented with HPV vaccination. Participants (n=148) consist a subsample of Chamorro, Samoan, and Tongan women, ages 21 to 65 years, who were in a larger randomized community study to promote Pap testing. Overall, younger age and higher American acculturation were significantly associated with ever hearing about HPV and the vaccine. However, American acculturation was also associated with negative attitudes toward vaccinating their children for HPV. This paper provides preliminary insights into barriers and facilitators to HPV vaccination among PIs in the USA and also informs the development of educational programs to reduce cervical cancer incidence and mortality in this underserved population.

Pacific Islands Cohort on Cardiometabolic Health Study: rationale and design

BACKGROUND

Pacific Islanders, including those residing in the US Affiliated Pacific Islands (USAPI), experience some of the highest mortality rates resulting from non-communicable diseases (NCDs) worldwide. The Pacific Island Health Officers' Association declared a Regional State of Health Emergency in 2010 due to the epidemic of NCDs in the USAPI. Obesity, a known risk factor for NCDs, has become an epidemic among both children and adults in Micronesia and other parts of the USAPI. There is some recent information about overweight and obesity (OWOB) among young children in the USAPI, but there is no data looking at the relationship between children and their biological parents. The Pacific Islands Cohort on Cardiometabolic Health (PICCAH) Study aims to collect data on NCD lifestyle factors from two generations of families (n = 600 child-parent dyads or 1,200 participants) living in Guam, Pohnpei, and Palau.

METHODS

The PICCAH Study is an epidemiological study using community-based convenience sampling to recruit participants in USAPI of Guam, Palau, and Pohnpei. The goal is to recruit participant dyads consisting of 1 child plus their biological parent in Guam (500 dyads or 1,000 participants), Pohnpei (50 dyads or 100 participants), and Palau (50 dyads or 100 participants). All participants are having the following information collected: demographic, health, and lifestyle information; anthropometry; diet; physical activity; sleep; acanthosis nigricans; blood pressure; and serum levels of fasting plasma glucose, fasting insulin, glycated hemoglobin, total cholesterol, triglycerides, LDL, and HDL.

DISCUSSION

The PICCAH Study is designed to establish the baseline of a generational epidemiologic cohort with an emphasis on cardiometabolic risk, and to better understand the extent of DM and CVD conditions and related risk factors of those living in the USAPI jurisdictions of Guam, Pohnpei, and Palau. This study also serves to further build research capacity in the underserved USAPI Region.

Transcultural Lifestyle Medicine in Type 2 Diabetes Care: Narrative Review of the Literature

Disparities in type 2 diabetes (T2D) care is a global problem across diverse cultures. The Dysglycemia-Based Chronic Disease (DBCD) model promotes early and sustainable interventions along the insulin resistance (stage 1), prediabetes (stage 2), T2D (stage 3), and complications (stage 4) spectrum. In this model, lifestyle medicine is the cornerstone of preventive care to reduce DBCD progression and the socioeconomic/biological burden of disease. A comprehensive literature review, spanning 2000 to 2021, was performed and 55 studies were included examining the effects of lifestyle medicine and their cultural adaptions with different prevention modalities. In stage 1, primordial prevention targets modifiable primary drivers (behavior and environment), unhealthy lifestyles, abnormal adiposity, and insulin resistance with educational and motivational health promotion activities at individual, group, community, and population-based scales. Primary, secondary, and tertiary prevention targets individuals with mild hyperglycemia, severe hyperglycemia, and complications, respectively, using programs that incorporate structured lifestyle interventions. Culturally adapted lifestyle change in primary and secondary prevention improved quality of life and biomarkers, but with a limited impact of tertiary prevention on cardiovascular events. In conclusion, lifestyle medicine with cultural adaptations is an integral part of preventive care in patients with T2D. However, considerable research gaps exist, especially for tertiary prevention.

Associations between Cultural Identity, Household Membership and Diet Quality among Native Hawaiian, Pacific Islander, and Filipino Infants in Hawai'i

Public health efforts to reduce diet-related health disparities experienced by indigenous peoples could be enhanced by efforts to improve complementary infant feeding practices. The latter is possible through interventions informed by cultural determinants. This cross-sectional secondary analysis explored possible determinants of the complementary feeding practices of Native Hawaiian, Pacific Islander, and/or Filipino infants (NHPIF) in Hawai'i, ages 3-12 months. The objective was to determine the association between caregiver cultural identity and infant household membership with indicators of infant diet healthfulness. The cultural identities, infant household memberships, early infant feeding practices and additional demographic information (infant age and sex, household income) were assessed via an online questionnaire. Surrogate reporting of the infants' diets over four days was evaluated using an image-based mobile food record (mFR). Data collected by the mFR were evaluated to derive the World Health Organization's minimum dietary diversity (MDD) indicator and food group consumption. Data were summarized by descriptive statistics and analyzed using multivariate linear and logistic regressions. Seventy infant participants, ages 3-12 months, and their primary caregivers completed the study. Of these, there were 56 infant participants between the age of 6-12 months. Approximately 10% of infants, ages 6-12 months, met MDD for all four days. Meeting MDD and the number of food groups consumed were significantly associated with age. Caregiver cultural identity, infant household membership and infant sex had non-significant associations with indicators of infant diet quality. Findings inform the influences shaping dietary patterns of Native Hawaiian, Pacific Islander and Filipino infants in Hawai'i.

Association of cultural affinity and island food consumption in the Pacific Islander health study

Objectives: The dietary patterns of Pacific Islander Americans are partially influenced by a rich cultural heritage. There is little known about how cultural affinity affects the dietary choices of this small, but quickly growing population. This analysis attempts to understand how the association of cultural affinity on island foods consumption (IFC) varies by key demographic characteristics.Design: A sample of 240 Samoan and Tongan adults in California from the Pacific Islander Health Study (PIHS) was used. Psychometric properties of a novel 11-item cultural affinity scale were assessed. Univariate and bivariate analyses of the cultural affinity scale were completed to understand the distribution of cultural affinity score. Separate multivariable Poisson regression was used to assess the effect of interactions between cultural affinity and five key demographic factors on IFC.Results: Psychometric analysis of the PIHS cultural affinity scale revealed two unique factors. Significant interactions were found between cultural affinity and ethnicity and birthplace: the association between cultural affinity and IFC was larger among Samoans compared to Tongans and Samoan or Tongan birthplace was found to have a weaker association between cultural affinity and IFC. Interactions between cultural affinity and age, financial insecurity, and educational attainment were not significant.Conclusion: Understanding how cultural affinity varies in its effect on IFC is a part of understanding overall dietary patterns in this population.

Acculturation and Perceived Ethnic Discrimination Predict Elevated Blood Glucose Level in Sub-Saharan African Immigrants in Australia

Sub-Saharan African migrants experience significant sociocultural challenges, including those related to acculturation and perceived ethnic discrimination (PED), in addition to increased risk of non-communicable diseases, such as type 2 diabetes mellitus (T2DM). Although acculturation and PED are each established risk factors for elevated blood glucose level (EGBL) and T2DM, they have not been studied in relation to EBGL risk in a single model. This study aimed to investigate associations between acculturation, PED and EBGL in a sub-Saharan African migrant population in Australia. Face to face survey using a purposive sampling method was used to collect data from 170 adults, aged 18-72 years. A large proportion (41.8%) of the study group was in the integration mode of acculturation, which strongly correlated positively with EBGL/T2DM, although traditional mode correlated inversely with EBGL/T2DM. PED correlated positively with EBG/LT2DM. Immigrants manifesting the integration mode were 4.2 times more likely to have EBGL/T2DM than other acculturation modes. Multiple linear regression showed that the association between integration mode and EBGL/T2DM was mediated by PED. The apparent interaction between PED and acculturation in relation to EBGL/T2DM risk suggests that interventions to lower T2DM risk in this population may benefit from incorporating strategies to address these two important health determinants.

Ethnic and Gender Differences in 10-Year Coronary Heart Disease Risk: a Cross-Sectional Study in Hawai'i

Background

Cardiovascular disease (CVD) is the leading cause of death in the US. In Hawai‘i, Filipinos and Native Hawaiians have the highest rates of CVD-related risk factors. CVD risk across these ethnic groups has not been examined. This cross-sectional study examines 10-year CVD risk as determined by the Framingham Risk Score (FRS) across ethnic groups in Hawai‘i, controlling for clinical, demographic, and psychosocial factors.

Methods

This study includes secondary data analysis of the Kohala Health Research Project dataset. All non-pregnant adults (≥ 18 years of age) who resided in the community of interest during the study period were eligible to participate with 1462 participants completing the clinical examination and surveys. This analysis included clinical, demographic, and psychosocial variables. Ethnic differences were examined using the chi-squared test and one-way ANOVA. Multiple linear regression on FRS was conducted and least square means of FRS were calculated.

Results

Data from 1146 individuals were analyzed. Participants were 44.4% Native Hawaiian, 15.4% Filipino, 15.3% Japanese, and 25% non-Hispanic White; 55.4% were female and had a mean age of 48.8 years. For males, the unadjusted Japanese mean FRS was significantly higher compared with the other ethnic groups. For females, Filipino and Japanese mean FRS were significantly higher compared with Native Hawaiians and non-Hispanic Whites. In the fully adjusted model, there were no ethnic group differences in FRS among males and Filipinos had significantly higher FRS compared with non-Hispanic White among females.

Conclusions

This cross-sectional community-based epidemiological study examined ethnic differences in CVD risk after adjusting for age, depression, social support, and acculturation. The results suggest that some ethnic differences in CVD risk persist even after controlling for confounders but that recalibration of risk assessment is necessary.

A Resilience Model of Adult Native Hawaiian Health Utilizing a Newly Multi-Dimensional Scale

Resilience has conventionally focused on an individual's ability to overcome adversity. Recent research expands on this definition, making resilience a multi-dimensional construct. Native Hawaiians experience health disparities compared to the general population of Hawai'i. Despite the pressing need to address health disparities, minimal research examines resilience factors that serve as buffers for adverse experiences of Native Hawaiians. The purpose of this study was to estimate psychometric properties of scales that measured resilience-based factors through multiple levels using higher-order confirmatory factor analyses (CFA) and ascertain if this construct of resilience mediated or moderated adversity experienced by a sample of Native Hawaiians. Participants included 125 adults who participated in the Hawaiian Homestead Health Survey. Based on higher-order CFA, resilience comprised internal assets measured by hope, satisfaction with life, and environmental mastery, and external resources measured by social support and Native Hawaiian cultural identity. Results of the structural equation models were consistent with literature focusing on resiliency and health. Findings emphasized the importance of enhancing resilience by considering strengths and resources on the individual, interpersonal, and community levels. Findings also demonstrated the need to address adversity factors directly, with a specific need of addressing socio-economic status factors. According to structural equation models, resilience slightly mediated and moderated the effect of adversity related to socio-economic status. These findings have implications for future research exploring resilience as a mediator or moderator of adversity among Native Hawaiians and emphasize a multi-faceted construct of resilience to promote better health outcomes.

The Imperative for Research to Promote Health Equity in Indigenous Communities

Health disparities exact a devastating toll upon Indigenous people in the USA. However, there has been scant research investment to develop strategies to address these inequities in Indigenous health. We present a case for increased health promotion, prevention, and treatment research with Indigenous populations, providing context to the recent NIH investment in the Intervention Research to Improve Native American Health (IRINAH) network. We discuss the disproportionate costs and consequences of disparities borne by Indigenous groups, the limited evidence base on effective intervention for this population, how population uniqueness often makes transfer of existing intervention models difficult, and additional challenges in creating interventions for Indigenous settings. Given the history of colonial disruption that has included genocide, forced removal from lands, damaging federal, state and local policies and practices, environmental contamination, and most recently, climate change, we conclude research that moves beyond minor transformations of existing majority population focused interventions, but instead truly respects Indigenous wisdom, knowledge, traditions, and aspirations is needed, and that investment in intervention science to address Indigenous health disparities represent a moral imperative.

[Estimated prevalence of hypertension and associated factors in Krenak indigenous adults in the state of Minas Gerais, Brazil]

This cross-sectional study in 2016 aimed to describe the estimated prevalence of systemic arterial hypertension and associated factors in Krenak adults and elderly in an indigenous community located along the Rio Doce in eastern Minas Gerais state, Brazil. We measured weight, height, waist circumference, systolic blood pressure, diastolic blood pressure, and capillary blood glucose. Sociodemographic and lifestyle information was obtained from a face-to-face questionnaire. Poisson regression models were constructed to estimate independent associations between the target variables and hypertension. Prevalence of hypertension was 31.2% (95%CI: 24.4-37.9) in Krenak indigenous. The final model showed an independent association with increasing age, abdominal obesity, and hyperglycemia. The results highlight the need for effective measures in prevention, diagnosis, and follow-up of modifiable risk factors for hypertension, since high prevalence of this condition was observed in the Krenak indigenous community.

The moderating role of acculturation mode on the relationship between depressive symptoms and health-related quality of life among international students in Korea

We examined the moderating role of acculturation mode on the relationship between depressive symptoms and health-related quality of life (HRQoL) in international students. This cross-sectional study enrolled a convenience sample of 147 international students at a university in Korea. Participants' overall HRQoL was moderate (mean = 57.2 of 80). The main and interaction effects of depressive symptoms and selected acculturation modes explained 39.9% of the variance in HRQoL. For all acculturation modes except the integration mode, as depressive symptom scores increased, HRQoL decreased. Specifically, at high depressive symptoms levels, participants with the marginalization, separation, and assimilation modes had worse HRQoL than did the integration mode, while HRQoL was similar for all acculturation modes at low depressive symptom levels. These findings suggest that future prospective intervention strategies should be considered for not only depressive symptoms levels, but also for different acculturation modes to enhance HRQoL in this population.

Design and Outcomes of a Community Trial to Increase Pap Testing in Pacific Islander Women

BACKGROUND

Pap tests remain an essential cervical cancer detection method in the United States, yet they are underutilized among Pacific Islanders (PI) who experience elevated cervical cancer incidence and mortality. This study describes the design, methods, participants, and outcomes of a multiyear (2010-2016), community-based randomized intervention trial in southern California. Based upon strong collectivistic norms, the trial tested the efficacy of a unique social support intervention targeting Chamorro, Samoan, and Tongan women and their male husbands/partners.

METHODS

A single-session educational intervention was designed and tailored for ethnic- and gender-specific groups to increase men's social support for their female wives/partners to receive a Pap test, and for women to receive a Pap test. The comparison group received preexisting brochures on Pap testing (for women) or general men's health (for men). Pretest and 6-month follow-up data were analyzed.

RESULTS

Intervention and comparison groups were mostly equivalent on pretest demographics and outcome variables. Intervention women who were not compliant with Pap screening recommendations at pretest were significantly more likely to have scheduled and received a Pap test at 6-month follow-up. However, 6-month follow-up results indicated no intervention effect on changes in women's Pap testing knowledge, fatalistic attitudes, or perceived social support from their male partner.

CONCLUSIONS

Ethnic- and gender-tailored community interventions can successfully increase Pap test behaviors for PI women, although more research is needed on the specific pathways leading to behavior change.

IMPACT

Collaborative community-based interventions lead to increases in women's cancer prevention and early detection for Pacific Islander and other collectivistic communities.

Investigating differences in dietary patterns among a small cross-sectional study of young and old Pacific peoples in NZ using exploratory factor analysis: a feasibility study

OBJECTIVES

Obesity among Pasifika people living in New Zealand is a serious health problem with prevalence rates more than twice those of the general population (67% vs 33%, respectively). Due to the high risk of developing obesity for this population, we investigated diet quality of Pacific youth and their parents and grandparents. Therefore, we examined the dietary diversity of 30 youth and their parents and grandparents (n=34) to identify whether there are generational differences in dietary patterns and investigate the relationship between acculturation and dietary patterns.

METHODS

The study design of the overarching study was cross-sectional. Face-to-face interviews were conducted with Pasifika youth, parents and grandparents to investigate dietary diversity, that included both nutritious and discretionary food items and food groups over a 7 day period. Study setting was located in 2 large urban cities, New Zealand. Exploratory factor analyses were used to calculate food scores (means) from individual food items based on proportions consumed over the week, and weights were applied to calculate a standardised food score. The relationship between the level of acculturation and deprivation with dietary patterns was also assessed.

RESULTS

Three distinctive dietary patterns across all participants were identified from our analyses. Healthy diet, processed diet and mixed diet. Mean food scores indicated statistically significant differences between the dietary patterns for older and younger generations. Older generations showed greater diversity in food items consumed, as well as eating primarily a 'healthy diet'. The younger generation was more likely to consume a 'processed diet'. There was significant association between acculturation and deprivation with the distinctive dietary patterns.

CONCLUSION

Our investigation highlighted generational differences in consuming a limited range of food items. Identified dietary components may, in part, be explained by specific acculturation modes (assimilation and marginalised) and high socioeconomic deprivation among this particular study population.

An Examination of the Relationship between Discrimination, Depression, and Hypertension in Native Hawaiians

Native Hawaiians bear a disproportionate burden of hypertension. Discrimination and depression are potential hypertension risk factors. Although the relationship between discrimination and depression is well established, how these factors affect hypertension risk in indigenous populations remains unknown. We examined the relationship between discrimination, depression, and hypertension in adult Native Hawaiians. We hypothesized that greater frequency of perceived discrimination and greater frequency of depressive symptoms would independently increase the likelihood of having hypertension. Surveys were mailed to 540 adult Native Hawaiians residing on five Hawaiian Homesteads. The surveys measured: hypertension status, sociodemographic factors (age, gender, income, employment status), body mass index (BMI), physical activity frequency, smoking, Hawaiian cultural affiliation, American cultural affiliation, perceived discrimination, and depressive symptoms. Respondents (n=171) were mostly female (71%), a mean age of 57yrs, and 54% reported having hypertension. The logistic regression model included perceived discrimination, depression, BMI, frequency of vigorous physical activity, and Hawaiian cultural affiliation, and sociodemographic variables. The model showed that Hawaiian cultural affiliation and discrimination were significantly related to hypertension status. Depression was not related to hypertension status. Interaction analysis found that for individuals with lower Hawaiian cultural affiliation, frequent perceived discrimination was significantly associated with lower odds of having hypertension. The negative association between perceived discrimination and hypertension status was opposite from hypothesized. However, the interaction suggests this relationship holds only for less culturally affiliated individuals. These results underscore the varied nature of hypertension determinants and may have clinical implications for the treatment of hypertension in Native Hawaiians.

A Co-Designed, Culturally-Tailored mHealth Tool to Support Healthy Lifestyles in Māori and Pasifika Communities in New Zealand: Protocol for a Cluster Randomized Controlled Trial

Background

New Zealand urgently requires scalable, effective, behavior change programs to support healthy lifestyles that are tailored to the needs and lived contexts of Māori and Pasifika communities.

Objective

The primary objective of this study is to determine the effects of a co-designed, culturally tailored, lifestyle support mHealth tool (the OL@-OR@ mobile phone app and website) on key risk factors and behaviors associated with an increased risk of noncommunicable disease (diet, physical activity, smoking, and alcohol consumption) compared with a control condition.

Methods

A 12-week, community-based, two-arm, cluster-randomized controlled trial will be conducted across New Zealand from January to December 2018. Participants (target N=1280; 64 clusters: 32 Māori, 32 Pasifika; 32 clusters per arm; 20 participants per cluster) will be individuals aged ≥18 years who identify with either Māori or Pasifika ethnicity, live in New Zealand, are interested in improving their health and wellbeing or making lifestyle changes, and have regular access to a mobile phone, tablet, laptop, or computer and to the internet. Clusters will be identified by community coordinators and randomly assigned (1:1 ratio) to either the full OL@-OR@ tool or a control version of the app (data collection only plus a weekly notification), stratified by geographic location (Auckland or Waikato) for Pasifika clusters and by region (rural, urban, or provincial) for Māori clusters. All participants will provide self-reported data at baseline and at 4- and 12-weeks postrandomization. The primary outcome is adherence to healthy lifestyle behaviors measured using a self-reported composite health behavior score at 12 weeks that assesses smoking behavior, fruit and vegetable intake, alcohol intake, and physical activity. Secondary outcomes include self-reported body weight, holistic health and wellbeing status, medication use, and recorded engagement with the OL@-OR@ tool.

Results

Trial recruitment opened in January 2018 and will close in July 2018. Trial findings are expected to be available early in 2019.

Conclusions

Currently, there are no scalable, evidence-based tools to support Māori or Pasifika individuals who want to improve their eating habits, lose weight, or be more active. This wait-list controlled, cluster-randomized trial will assess the effectiveness of a co-designed, culturally tailored mHealth tool in supporting healthy lifestyles.

Trial Registration

Australia New Zealand Clinical Trials Register ACTRN12617001484336; http://www.ANZCTR.org.au/ACTRN12617001484336.aspx (Archived by WebCite at http://www.webcitation.org/71DX9BsJb)

Registered Report Identifier

RR1-10.2196/10789

Distinguishing between primary and secondary racial identification in analyses of health disparities of a multiracial population in Hawaii

OBJECTIVE

To examine the importance of distinguishing between primary and secondary racial identification in analyzing health disparities in a multiracial population.

METHODS

A cross-sectional analysis of 2012 Hawaii Behavioral Risk Factor Surveillance System (H-BRFSS). As part of the survey, respondents were asked to identify all their races, and then which race they considered to be their primary race. We introduce two analytic approaches to investigate the association between multiracial status and general health: (1) including two separate dichotomous variables for each racial group (primary and secondary race; for example, 'primary Native Hawaiian' and, separately, 'secondary Native Hawaiian'), and (2) including one combined variable for anyone choosing a particular racial group, whether as primary or secondary race ('combined race'; e.g. Native Hawaiian). Linear regression then compares the multiracial health disparities identified by the two approaches, adjusted for age and gender.

RESULTS

The 2012 H-BRFSS had 7582 respondents. The four most common self-identified primary racial/ethnic groups were White, Japanese, Filipino, and Native Hawaiian. Native Hawaiians were the largest multiracial group with over 80% self-identifying as multiracial. Health disparities for Native Hawaiians, Portuguese and Puerto Ricans were attenuated by 10% after accounting for multiracial status. Populations that self-identified secondarily as Japanese, Puerto Rican, Mexican, and other PI had significantly poorer self-reported health.

CONCLUSION

The analysis illustrates the importance of accounting for multiracial populations in health disparities research and demonstrates the ability of two approaches to identify multiracial health disparities in data sets with limited sample sizes. The 'primary and secondary race' approach might work particularly well for a multicultural population like Hawaii.

Thirty-Day Inpatient Readmissions for Asian American and Pacific Islander Subgroups Compared With Whites

Asian and Pacific Islander (API) 30-day potentially preventable readmissions (PPRs) are understudied. Hawaii Health Information Corporation data from 2007-2012 statewide adult hospitalizations ( N = 495,910) were used to compare API subgroup and White PPRs. Eight percent of hospitalizations were PPRs. Seventy-two percent of other Pacific Islanders, 60% of Native Hawaiians, and 52% of Whites with a PPR were 18 to 64 years, compared with 22% of Chinese and 21% of Japanese. In multivariable models including payer, hospital, discharge year, residence location, and comorbidity, PPR disparities existed for some API subpopulations 65+ years, including Native Hawaiian men (odds ratio [OR] = 1.14; 95% confidence interval [CI] = 1.04-1.24), Filipino men (OR = 1.19; 95% CI = 1.04-1.38), and other Pacific Islander men (OR = 1.30; 95% CI = 1.19-1.43) and women (OR = 1.23; 95% CI = 1.02-1.51) compared with Whites, while many API groups 18 to 64 years had significantly lower PPR odds. Distinct PPR characteristics across API subpopulations and age groups can inform policy and practice. Further research should determine why elderly API have higher PPR rates, while nonelderly rates are lower.

Bi-cultural dynamics for risk and protective factors for cardiometabolic health in an Alaska Native (Yup'ik) population

Alaska Native people experience disparities in mortality from heart disease and stroke. This work attempts to better understand the relationships between socioeconomic, behavioral, and cardiometabolic risk factors among Yup'ik people of southwestern Alaska, with a focus on the role of the socioeconomic, and cultural components. Using a cross-sectional sample of 486 Yup'ik adults, we fitted a Partial Least Squares Path Model (PLS-PM) to assess the associations between components, including demographic factors [age and gender], socioeconomic factors [education, economic status, Yup'ik culture, and Western culture], behavioral factors [diet, cigarette smoking and smokeless tobacco use, and physical activity], and cardiometabolic risk factors [adiposity, triglyceride-HDL and LDL lipids, glycemia, and blood pressure]. We found relatively mild associations of education and economic status with cardiometabolic risk factors, in contrast with studies in other populations. The socioeconomic factor and participation in Yup'ik culture had potentially protective associations with adiposity, triglyceride-HDL lipids, and blood pressure, whereas participation in Western culture had a protective association with blood pressure. We also found a moderating effect of participation in Western culture on the relationships between Yup'ik culture participation and both blood pressure and LDL lipids, indicating a potentially beneficial additional effect of bi-culturalism. Our results suggest that reinforcing protective effects of both Yup'ik and Western cultures could be useful for interventions aimed at reducing cardiometabolic health disparities.

Considering the Role of Stress in Populations of High-Risk, Underserved Community Networks Program Centers

BACKGROUND

Cancer disparities are associated with a broad range of sociocultural determinants of health that operate in community contexts. High-risk populations may be more vulnerable to social and environmental factors that lead to chronic stress. Theoretical and empirical research indicates that exposure to contextual and sociocultural stress alters biological systems, thereby influencing cancer risk, progression, and, ultimately, mortality.

OBJECTIVE

We sought to describe contextual pathways through which stress likely increases cancer risk in high-risk, underserved populations.

METHODS

This review presents a description of the link between contextual stressors and disease risk disparities within underserved communities, with a focus on 1) stress as a proximal link between biological processes, such as cytokine responses, inflammation, and cancer and 2) stress as a distal link to cancer through biobehavioral risk factors such as poor diet, physical inactivity, circadian rhythm or sleep disruption, and substance abuse. These concepts are illustrated through application to populations served by three National Cancer Institute-funded Community Networks Program Centers (CNPCs): African Americans in the Deep South (the South Carolina Cancer Disparities Community Network [SCCDCN]), Native Hawaiians ('Imi Hale-Native Hawaiian Cancer Network), and Latinos in the Lower Yakima Valley of Washington State (The Center for Hispanic Health Promotion: Reducing Cancer Disparities).

CONCLUSIONS

Stress experienced by the underserved communities represented in the CNPCs is marked by social, biological, and behavioral pathways that increase cancer risk. A case is presented to increase research on sociocultural determinants of health, stress, and cancer risk among racial/ethnic minorities in underserved communities.

CBPR-Informed Recruitment and Retention Adaptations in a Randomized Study of Pap Testing Among Pacific Islanders in Southern California

BACKGROUND

Pacific Islanders (PIs) experience high cervical cancer rates in the United States. Stage of diagnosis is also later for PIs than non-Hispanic Whites. The Pap test is severely underutilized among PIs: only 71% of Asian American and Pacific Islander women age 25 years or older received a Pap test within the last 3 years (U.S. average, 82%). Community-based participatory research (CBPR) is increasingly seen as an essential approach in designing and conducting culturally relevant and appropriate studies that reduce cancer incidence and other health disparities among minority and other medically underserved populations.

PURPOSE

The purpose of this article is to describe the lessons learned thus far regarding the identification, recruitment, and retention of PI community organizations and members into a CBPR-informed, randomized, community trial promoting Pap testing.

METHODS

This 5-year study used CBPR to develop and test the efficacy of a social support intervention for Chamorro, Samoan, and Tongan women to increase Pap testing in southern California. Eligible women were between the ages of 21 and 65, and married or in a long-term relationship with a man for at least 5 years. Women and their husbands or significant others received a 2-hour, culturally tailored workshop that include a group activity, information on Pap testing, a video, and corresponding materials. Comparison participants received a brochure about Pap testing. Three waves of data are collected from all participants: pretest (before workshop or brochure), posttest 1 (immediately after workshop or brochure), and posttest 2 (6 months follow-up).

RESULTS

Of the 76 organizations approached to participate in the study, 67 (88.2%) eventually agreed to participate. Thus far, 473 women and 419 men completed the study pretest, post-test, education, and 6-month follow-up. Only 242 women and 204 men of the eligible participants have completed the follow-up survey (63.5% of women and 60.5% of men retained after 6 months).

LESSONS LEARNED

The main strategy to overcome initial recruitment challenges was study staff persistence, because they averaged five contacts with each church or clan leader before receiving confirmation that an educational session can be scheduled. Personal connections provided an introduction to the most appropriate church or clan leader. Other efforts for retention include creation of an online version of the survey, re-attending church services, and creating special events organized around clan activities.

CONCLUSIONS

Although CBPR improves the cultural competence and relevance of study activities for ethnically diverse populations, selected past research shows that it does not ensure that such designs overcome all of the unique challenges in ethnically diverse communities. PI-specific organizational recruitment and individual retention is influenced by study issues and cultural factors in each community.

Immigrant generation and diabetes risk among Mexican Americans: the Sacramento area Latino study on aging

OBJECTIVES

We examined whether acculturation and immigrant generation, a marker for assimilation, are associated with diabetes risk in an aging Mexican-origin population.

METHODS

We analyzed data on 1789 adults aged 60 to 101 years from the Sacramento Area Latino Study on Aging. We ascertained type 2 diabetes on the basis of diabetic medication use, self-report of physician diagnosis, or a fasting glucose of 126 milligrams/deciliter or greater. Logistic regression modeled prevalent diabetes.

RESULTS

Adjusting for age and gender, we observed significant but divergent associations between immigrant generation, acculturation, and diabetes risk. Relative to first-generation adults, second-generation adults had an odds ratio (OR) of 1.8 (95% confidence interval [CI] = 1.4, 2.4) and third-generation adults had an OR of 2.1 (95% CI = 1.4, 3.1) of having diabetes. Greater US acculturation, however, was associated with a slightly decreased diabetes rate. In the full model adjusting for socioeconomic and lifestyle factors, the association between generation (but not acculturation) and diabetes remained significant.

CONCLUSIONS

Our study lends support to the previously contested notion that assimilation is associated with an increased diabetes risk in Mexican immigrants. Researchers should examine the presence of a causal link between assimilation and health more closely.

Las generaciones de inmigrantes y sus descendientes y el riesgo de diabetes en la población de los Estados Unidos de origen o ascendencia mexicana: el Estudio sobre Envejecimiento en Latinos del Área de Sacramento (estudio SALSA)

Objetivo. Se investigó si la aculturación de los inmigrantes y sus descendientes y la generación a la que pertenecen, un marcador de la asimilación, se relacionan con el riesgo de diabetes en una población de adultos mayores de ascendencia u origen mexicano.

Métodos. Se analizaron los datos sobre 1 789 adultos de 60 a 101 años de edad del Estudio sobre Envejecimiento en Latinos del Área de Sacramento (estudio SALSA). Se determinó la presencia de diabetes tipo 2 con base en el uso de medicamentos antidiabéticos, la mención por el paciente del diagnóstico de un médico, o una glucosa en ayunas de 126 mg/dL o mayor. Se aplicó un modelo de regresión logística para la prevalencia de diabetes.

Resultados. Tras ajustar por edad y sexo, se observaron asociaciones significativas pero divergentes entre las generaciones de inmigrantes y sus descendientes, la aculturación y el riesgo de diabetes. En relación con los adultos de la primera generación, los de la segunda tuvieron una razón de posibilidades (odds ratio, OR) de padecer diabetes de 1,8 (intervalo de confianza [IC] de 95% = 1,4, 2,4) y los adultos de la tercera generación tuvieron una OR de 2,1 (IC de 95% = 1,4, 3,1). Sin embargo, una mayor aculturación a los Estados Unidos se relacionó con una tasa ligeramente menor de diabetes. En el modelo completo, tras la incorporación de ajustes para tener en cuenta los factores socioeconómicos y del modo de vida, la relación entre la generación y la diabetes seguía siendo significativa, no así la relación de esta última con la aculturación.

Conclusiones. El presente estudio respalda la idea, anteriormente cuestionada, de que la asimilación se relaciona con un mayor riesgo de diabetes entre los inmigrantes de origen mexicano. Los investigadores deben analizar más detalladamente la presencia de una relación causal entre la asimilación y la salud.

Children's Healthy Living (CHL) Program for remote underserved minority populations in the Pacific region: rationale and design of a community randomized trial to prevent early childhood obesity

BACKGROUND

Although surveillance data are limited in the US Affiliated Pacific, Alaska, and Hawaii, existing data suggest that the prevalence of childhood obesity is similar to or in excess of other minority groups in the contiguous US. Strategies for addressing the childhood obesity epidemic in the region support the use of community-based, environmentally targeted interventions. The Children's Healthy Living Program is a partnership formed across institutions in the US Affiliated Pacific, Alaska, and Hawaii to design a community randomized environmental intervention trial and a prevalence survey to address childhood obesity in the region through affecting the food and physical activity environment.

METHODS/DESIGN

The Children's Healthy Living Program community randomized trial is an environmental intervention trial in four matched-pair communities in American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, and Hawaii and two matched-pair communities in Alaska. A cross-sectional sample of children (goal n = 180) in each of the intervention trial communities is being assessed for outcomes at baseline and at 24 months (18 months post-intervention). In addition to the collection of the participant-based measures of anthropometry, diet, physical activity, sleep and acanthosis nigricans, community assessments are also being conducted in intervention trial communities. The Freely Associated States of Micronesia (Federated States of Micronesia, and Republics of Marshall Islands and Palau) is only conducting elements of the Children's Healthy Living Program sampling framework and similar measurements to provide prevalence data. In addition, anthropometry information will be collected for two additional communities in each of the 5 intervention jurisdictions to be included in the prevalence survey. The effectiveness of the environmental intervention trial is being assessed based on the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework.

DISCUSSION

The Children's Healthy Living Program environmental trial is designed to focus on capacity building and to maximize the likelihood of sustainable impact on childhood obesity-related behaviors and outcomes. The multiple measures at the individual, community, and environment levels are designed to maximize the likelihood of detecting change. This approach enhances the likelihood for identifying and promoting the best methods to promote health and well-being of the children in the underserved US Affiliated Pacific Region.

TRIAL REGISTRATION

NIH clinical trial # NCT01881373.

Immigrant generation and diabetes risk among Mexican Americans: the Sacramento Area Latino Study on Aging

OBJECTIVES

We examined whether acculturation and immigrant generation, a marker for assimilation, are associated with diabetes risk in an aging Mexican-origin population.

METHODS

We analyzed data on 1789 adults aged 60 to 101 years from the Sacramento Area Latino Study on Aging. We ascertained type 2 diabetes on the basis of diabetic medication use, self-report of physician diagnosis, or a fasting glucose of 126 milligrams/deciliter or greater. Logistic regression modeled prevalent diabetes.

RESULTS

Adjusting for age and gender, we observed significant but divergent associations between immigrant generation, acculturation, and diabetes risk. Relative to first-generation adults, second-generation adults had an odds ratio (OR) of 1.8 (95% confidence interval [CI] = 1.4, 2.4) and third-generation adults had an OR of 2.1 (95% CI = 1.4, 3.1) of having diabetes. Greater US acculturation, however, was associated with a slightly decreased diabetes rate. In the full model adjusting for socioeconomic and lifestyle factors, the association between generation (but not acculturation) and diabetes remained significant.

CONCLUSIONS

Our study lends support to the previously contested notion that assimilation is associated with an increased diabetes risk in Mexican immigrants. Researchers should examine the presence of a causal link between assimilation and health more closely.

Association between perceived racism and physiological stress indices in Native Hawaiians

The association between racism and the physical health of native U.S. populations has yet to be examined despite their high risk for stress-related disorders and a history of discrimination toward them. We examined the correlation between perceived racism and the two physiological stress indices of cortisol level and blood pressure in 146 adult Native Hawaiians. Attributed and felt racism were assessed with a 10-item shortened version of the Oppression Questionnaire. Height, weight, blood pressure, and salivary cortisol samples (AM and PM) were collected and analyzed along with information on Hawaiian ancestry, BMI, age, sex, marital status, education level, general psychological stress, and ethnic identity. The results indicated that Native Hawaiians reporting more attributed racism had significantly (P < .05) lower average cortisol levels than those reporting less attributed racism, after adjusting for socio-demographic, biological, and psychosocial confounders. Native Hawaiians reporting more felt racism had a significantly higher systolic blood pressure than those reporting less, but this association was not significant after adjusting for the aforementioned confounders. Racism appears to be a chronic stressor that can "get under the skin" of Native Hawaiians by affecting their physical health and risk for stress-related diseases, possibly, through mechanisms of cortisol dysregulation.

Cardiometabolic health disparities in native Hawaiians and other Pacific Islanders

Elimination of health disparities in the United States is a national health priority. Cardiovascular disease, diabetes, and obesity are key features of what is now referred to as the "cardiometabolic syndrome," which disproportionately affects racial/ethnic minority populations, including Native Hawaiians and other Pacific Islanders (NHOPI). Few studies have adequately characterized the cardiometabolic syndrome in high-risk populations such as NHOPI. The authors systematically assessed the existing literature on cardiometabolic disorders among NHOPI to understand the best approaches to eliminating cardiometabolic health disparities in this population. Articles were identified from database searches performed in PubMed and MEDLINE from January 1998 to December 2008; 43 studies were included in the review. There is growing confirmatory evidence that NHOPI are one of the highest-risk populations for cardiometabolic diseases in the United States. Most studies found increased prevalences of diabetes, obesity, and cardiovascular risk factors among NHOPI. The few experimental intervention studies found positive results. Methodological issues included small sample sizes, sample bias, inappropriate racial/ethnic aggregation of NHOPI with Asians, and a limited number of intervention studies. Significant gaps remain in the understanding of cardiometabolic health disparities among NHOPI in the United States. More experimental intervention studies are needed to examine promising approaches to reversing the rising tide of cardiometabolic health disparities in NHOPI.