Using Talanoa, a Pan Pacific Indigenous Approach, To Identify Solutions to Public Health Issues

The COVID-19 pandemic was a public health emergency that required various public health policies and programs at the state and federal level to be established to protect the health and safety of the nation. These mainstream policies and programs proved to be inadequate in addressing the specific needs of Native Hawaiian and Pacific Islander (NHPI) communities as evidenced by the high case counts and low vaccination rates in these communities. In an effort to better understand and address the high case counts and low vaccination rates, a partnership was developed between the Hawai'i State Department of Health (HDOH), medical providers, and a network of NHPI-serving organizations. After the failure of Western approaches for data gathering, leaders of the partnership used an Indigenous qualitative interview method called Talanoa situated within a cultural safety framework to learn reasons for low vaccine uptake and identify NHPI-specific solutions. Findings suggest that the use of Talanoa and its ingrained cultural safety framework allowed us to gather richer data, identified solutions grounded in community, and assisted with building sustainable trusting partnerships.

Developing culturally-responsive health promotion: insights from cultural experts

Culturally-responsive health promotion initiatives are important to the creation of health equity for Indigenous and minority populations and these initiatives are complex and time-intensive to establish. The knowledge and resources of cultural experts are often pivotal in programs, yet there is minimal research on effective collaborations. The KāHOLO Project demonstrated strong success in the management of uncontrolled hypertension in the high-risk Indigenous population through a 6-month program based on the Hawaiian cultural dance of hula. This program was developed utilizing a community-based participatory research approach and implemented by cultural experts. To better understand the effectiveness of the research endeavor and program, six experienced hula experts and educators who delivered the community-based program were interviewed. As skilled and trusted cultural experts they set a safe supportive learning environment that promoted health and cultural goals. They articulated it was important that the program maintained cultural priorities and integrity. Through the methodical establishment of mutual respect, cooperation on research protocols and requirements was achieved. The development of cultural experts as health allies offers important inroads to the inclusion of minority and Indigenous cultures in health programming.

Building a Culturally Aware Native Hawaiian Health Professions Workforce

The Native Hawaiian Health Scholarship Program (NHHSP) strives to build a culturally aware Native Hawaiian health professional workforce through coaching, mentoring, and networking, who are committed to serving the unique health needs of Native Hawaiians throughout the State of Hawai'i. As of October 2020, 302 scholarships have been awarded to 277 recipients across 12 health disciplines with 90% remaining in Hawai'i. In 2019, NHHSP began re-imagining how to build a vibrant, culturally aware workforce, committed to service, leadership, and improvement of Native Hawaiian health through program expansion. This article describes the transformation of NHHSP to Mauli Ola Mālamalama (MOM), a success-oriented strategy-based Native Hawaiian Health Workforce Development Center of Papa Ola Lōkahi. Researchers conducted a qualitative assessment using surveys and interviews among alumni of the program to understand their experience of being a recipient and its meaning to them. Questions included work experience, challenges, solutions, impact of working in rural communities, mentorship, and legacy. The 5 themes identified by alumni were awareness, passion, inherent culture, reciprocity, and legacy. The overarching theme of the assessment, aloha, is embedded in the passion and desire to serve Native Hawaiian communities. Re-imagining the program from NHHSP to MOM began with examining the core values of suitability, commitment, and leadership. These values were then embedded in all aspects of the program and supports provided to recipients. MOM strives to ensure that recipients are culturally aware as they enter the workforce. This broader vision will help increase the number of Native Hawaiians in health care roles.

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare of the Native Hawaiian Population in Hawai'i

Native Hawaiians (NHs) are among the most vulnerable groups at greater risk for coronavirus disease 2019 (COVID-19). To understand the impact of COVID-19 on the state's population, a 35-question cross-sectional survey was administered across the state of Hawai'i. NH data from the larger report are provided here. The findings indicate that the impact of COVID-19 is disproportionately affecting NH households in areas of income and housing stability, chronic disease prevalence, emotional wellness, and COVID-19 prevention. Short-, medium-, and long-term recommendations are presented as next steps to addressing the health inequities among NHs.

Understanding Native Hawaiian Caregivers' Beliefs About Pediatric Asthma Management

Native Hawaiian health beliefs and cultural practices may influence how Native Hawaiian caregivers manage their children's asthma. Understanding the use of cultural practices as an asthma management strategy among Native Hawaiian caregivers who have a child with mild persistent, moderate persistent, or severe persistent asthma may inform the development of effective culturally-based asthma management interventions. A qualitative descriptive methodology with medical anthropology framework was used to describe pediatric asthma management strategies, define cultural asthma management practices, and identify cultural practices caregivers were aware of but did not use. Eighteen face-to-face interviews with self-identified Native Hawaiian caregivers of school-aged children between 5 and 12 years with asthma were interviewed. The study found that Native Hawaiian caregivers across all asthma severity types believed that the perceived cause of asthma was hereditary and environmental exposure. Also, standard asthma management strategies were used by caregivers with an emphasis on preventing exposure to known asthma triggers. If asthma symptoms presented themselves, Native Hawaiian caregivers often managed them with alternative practices before using the prescribed medication. Alternative practices included the use of massage and exposure to salt air. Native Hawaiian caregivers readily discussed awareness of cultural practices. However, cultural practices such as lā'au lapa'au (herbal medicine) and lomilomi (massage) were seldom, if ever, used. The study provides healthcare providers with knowledge regarding Native Hawaiian caregivers and their beliefs about the perceived cause of asthma and strategies for managing asthma, including use and awareness of cultural practices.

Abstract P3054: A Cultural Dance Program Proves Efficacious for Hypertension Control: A Randomized Controlled Trial

Minority populations are at high risk for hypertension (HTN) and its sequellae. Native Hawaiians (NH) are 70% more likely to have HTN; 4 times more likely to have coronary heart disease (CHD) or stroke than Whites. Hula, the traditional dance of NH, offers the promise of a culturally responsive strategy to improve HTN control.

We conducted a randomized clinical trial (RCT) with a waitlist control to test the impact of a hula-based intervention on systolic blood pressure (SBP) in 263 NH with uncontrolled HTN (SBP ≥ 140 mmHg or ≥ 130 mmHg if diabetes) but no prior CHD or stroke. All participants received HTN education (e.g., diet, exercise, medication) during 3 1-hr sessions over 2 weeks, and were then randomly assigned to hula-based intervention (HI; n = 131) or waitlist control ( n = 132). The HI received 6 months of hula (2 1hr sessions/week x 3 months, then 1 lesson/month x 3 months with self-directed practice), with group activities to reinforce HTN education and healthy behaviors. Waitlist control received the initial HTN education and then offered hula after the study. Assessments were done at 0-, 3- and 6-month, with 12-month for HI only. We used standard approaches to assess clinical and other measures.

Baseline characteristics were balanced between the groups, except for weight. Adjusting for weight and baseline SBP in intent-to-treat analysis, HI achieved significant reductions ( p < .05) in SBP (-15.3 mmHg; SE = 1.6) and DBP (-6.4 mmHg; SE = 1.0) compared to controls (-11.8 mmHg, SE = 1.7; -2.6 mmHg, SE = 1.0, respectively). From 6 to 12 months, HI maintained their SBP (mean change: 1.47 mmHg, SE = 1.26; p = .16) and DBP (mean change: 0.82 mmHg, SE = 0.81; p = .63) improvements at 12 months. HI were more likely to achieve SBP reduction ≥ 10 mmHg than control, 60% vs 48% ( p = .03), respectively. Retention was similar for both groups at 6 (83%; 218 of 263) and 12 (77%; 101 of 131) month follow-up.

A hula-based intervention improved HTN control in NH with elevated SBP. Notably, our study demonstrates the feasibility of recruiting and retaining a high-risk minority population for a RCT. With strong implications for other indigenous populations, to our knowledge, these findings represent one of the few rigorously performed examinations of an indigenous practice leveraged for health promotion.

A Community-Based Participatory Research Guided Model for the Dissemination of Evidence-Based Interventions

BACKGROUND

Dissemination is a principle within community-based participatory research (CBPR); however, published research focuses on the dissemination of findings from CBPR projects but less on dissemination of interventions developed through CBPR approaches. To disseminate an evidence-based lifestyle intervention tailored for Native Hawaiians and other Pacific Islanders, the PILI 'Ohana Project (POP), an 11-year CBPR initiative, developed an innovative dissemination model.

OBJECTIVES

The community-to-community mentoring (CCM) model described in this paper extends the application of CBPR values and principles used in intervention development to intervention dissemination.

METHODS

The CCM model combines a CBPR orientation with the diffusion of innovation theory, the social cognitive theory, and key concepts from community organizing and community building to address the multilevel factors that influence uptake of an evidence-based intervention (EBI). Grounding the model in CBPR principles provides benefits for intervention dissemination and integrates a focus on community benefits and capacity building.

CONCLUSIONS

By establishing co-equal, mutually beneficial relationships at the core of the CCM model, opportunities are created for building critical consciousness, community capacity, and social capital. More research is needed to determine the effectiveness of this model of intervention dissemination which may enhance diffusion of CBPR interventions and empower communities in the process.

Social Support Groups in the Maintenance of Glycemic Control after Community-Based Intervention

Native Hawaiians and other Pacific Islanders (NH/PI; e.g., Samoan and Chuukese) have higher type 2 diabetes prevalence compared to other groups in Hawai'i. Partners in Care (PIC), a culturally tailored, community-based, diabetes self-management education intervention (DSME), is effective at improving participants' glycemic control and self-care behaviors. Maintenance of improvements is challenging. Diabetes-related social support groups (SSG) are a promising maintenance component for DSME. This study examined the effects of a diabetes-specific SSG component relative to a control group, after the receipt of the 3-month PIC intervention, which was delivered to 47 adult NH/PI with type 2 diabetes. Participants were then randomized to either a 3-month, 6-session SSG or a control group. Hemoglobin A1c (HbA1c), blood pressure, triglycerides, cholesterol, and diabetes self-management knowledge and behaviors were assessed at baseline, 3 months, and 6 months. Results indicated significant improvements in HbA1c, diabetes-related self-management knowledge, and behaviors from baseline to 3-month assessment. However, no differences between the SSG and control group from 3-month to 6-month assessment suggest that all participants were able to maintain initial improvements. The SSG group had a significant decrease in systolic blood pressure from 3-month to 6-month assessment while the control group did not. Study limitations and future directions are discussed.

Facilitating Community Participants' Research Engagement: Community Members' Perceptions of Community-based Research

Objectives

To describe the perspectives of community participants about engaging in community-based participatory research, and then to use the information to develop a model to depict the community participants’ perceptions of interfacing with academic researchers.

Method

A diverse group of Native Hawaiian community-dwelling participants engaged in open-ended and semi-structured focus group interviews, addressing community members’ perceptions of community-based participatory research.

Results

Three key areas were identified: (1) reciprocal trustable is needed; (2) perceptions about the purpose, research intent and expectations; (3) expectations of roles and responsibilities of the researcher(s). A model showing the reciprocity between the academic partner and the community partner is needed to establish the full CBPR process is proposed.

Conclusion

The three themes implied the community participants’ expectations of reciprocal relationships. The dimensions influencing community members’ perceptions of community-based research need to be taken into account when academic researchers interface with community participants. Successful community-based participatory research approaches for addressing the challenges of translating research findings into community actions is enhanced when the expectations of community members are taken into account.

The PILI 'Ohana Project: a community-academic partnership to achieve metabolic health equity in Hawai'i

Native Hawaiians and Pacific Islanders (NHPI) have higher rates of excess body weight and related medical disorders, such as diabetes and cardiovascular disease, compared to other ethnic groups in Hawai'i. To address this metabolic health inequity, the Partnership for Improving Lifestyle Intervention (PILI) 'Ohana Project, a community-academic partnership, was formed over eight years ago and developed two community-placed health promotion programs: the PILI Lifestyle Program (PLP) to address overweight/obesity and the Partners in Care (PIC) to address diabetes self-care. This article describes and reviews the innovations, scientific discoveries, and community capacity built over the last eight years by the PILI 'Ohana Project's (POP) partnership in working toward metabolic health equity. It also briefly describes the plans to disseminate and implement the PLP and PIC in other NHPI communities. Highlighted in this article is how scientific discoveries can have a real-world impact on health disparate populations by integrating community wisdom and academic expertise to achieve social and health equity through research.

Translating the Diabetes Prevention Program in Native Hawaiian and Pacific Islander communities: the PILI 'Ohana Project

Native Hawaiians/Pacific Islanders experience a high prevalence of overweight/obesity. The Diabetes Prevention Program Lifestyle Intervention (DPP-LI) was translated into a 3-month community-based intervention to benefit these populations. The weight loss and other clinical and behavioral outcomes of the translated DPP-LI and the socio-demographic, behavioral, and biological factors associated with the weight loss were examined. A total of 239 Native Hawaiian/Pacific Islander adults completed the translated DPP-LI through four community-based organizations (CBOs). Changes from pre- to post-intervention assessments in weight, blood pressure, physical functioning, exercise frequency, and fat in diet were measured. Significant improvements on all variables were found, with differences observed across the four CBOs. CBOs with predominately Native Hawaiian and ethnically homogenous intervention groups had greater weight loss. General linear modeling indicated that larger baseline weight and CBO predicted weight loss. The translated DPP-LI can be effective for Native Hawaiians/Pacific Islanders, especially when socio-cultural, socio-economic, and CBO-related contextual factors are taken into account.

Sociodemographic, behavioral, and biological variables related to weight loss in native Hawaiians and other Pacific Islanders

OBJECTIVE

Native Hawaiians and other Pacific Islanders (NHs/PIs) have a high obesity prevalence compared to other ethnic groups. We examined socio-demographic, behavioral, and biological factors related to ≥3% weight loss in 100 overweight/obese NHs/PIs who completed a lifestyle intervention.

DESIGN AND METHODS

Data were from 56 Native Hawaiians, 22 Chuukese, and 22 Other Pacific Islanders who participated in a randomized controlled trial of the Partnership for Improving Lifestyle Intervention (PILI) 'Ohana Project. All completed a 3-month weight loss program (WLP) to initiate weight loss and were then randomized into either a 6-month family/community focused WLP called the PILI Lifestyle Program (PLP; n = 49) or a standard behavior WLP (SBP; n = 51). We collected baseline, 3- and 9-month follow-up data on socio-demographics, weight (kg), a 6-min. walk test, dietary fat, exercise frequency, and blood pressure.

RESULTS AND CONCLUSION

Based on ANCOVA or logistic fit, ethnicity, sex, initial weight loss, fat in diet at baseline, change in systolic blood pressure, and intervention type were significantly associated (P ≤ .05) with ≥3% weight loss at 9-month follow-up. A logistic regression model indicated that Chuukese (OR = 6.04; CI = 1.14-32.17) and participants who had more weight loss in the first 3-months (OR = 1.47; CI = 1.22-1.86) and who were in the PLP (OR = 4.50; CI = 1.50-15.14) were more likely to achieve ≥3% weight loss [model; χ(2) (7, N = 100) = 45.50, P < .0001]. The same lifestyle intervention does not benefit all NHs/PIs equally, possibly due to differences in acculturation status and social support. The findings also point to the importance of initial weight loss to sustain motivation toward long-term weight loss maintenance.

A family and community focused lifestyle program prevents weight regain in Pacific Islanders: a pilot randomized controlled trial

Preventing weight regain after the loss of excess weight is challenging for people, especially for ethnic minorities in the United States. A 6-month weight loss maintenance intervention designed for Pacific Islanders, called the PILI Lifestyle Program (PLP), was compared with a 6-month standard behavioral weight loss maintenance program (SBP) in a pilot randomized controlled trial using a community-based participatory research approach. Adult Pacific Islanders (N = 144) were randomly assigned to either PLP (n = 72) or SBP (n = 72) after completing a 3-month weight loss program. Successful weight maintenance was defined as participants' postintervention weight change remaining ≤ 3% of their preintervention mean weight. Both PLP and SBP participants achieved significant weight loss maintenance (p ≤ .05). Among participants who completed at least half of the prescribed sessions, PLP participants were 5.1-fold (95% confidence interval = 1.06, 24; p = .02) more likely to have maintained their initial weight loss than SBP participants. The pilot PLP shows promise as a lifestyle intervention to address the obesity disparities of Pacific Islanders and thus warrants further investigation.

Translating diabetes prevention into native Hawaiian and Pacific Islander communities: the PILI 'Ohana Pilot project

BACKGROUND

Native Hawaiians (NH) and Other Pacific Islanders (OPI) bear an excess burden of diabetes health disparities. Translation of empirically tested interventions such as the Diabetes Prevention Program Lifestyle Intervention (DPP-LI) offers the potential for reversing these trends. Yet, little is known about how best to translate efficacious interventions into public health practice, particularly among racial/ethnic minority populations. Community-based participatory research (CBPR) is an approach that engages the community in the research process and has recently been proposed as a means to improve the translation of research into community practice.

OBJECTIVES

To address diabetes health disparities in NHOPIs, CBPR approaches were used to: (1) culturally adapt the DPP-LI for NHOPI communities; and (2) implement and examine the effectiveness of the culturally-adapted program to promote weight loss in 5 NHOPI communities.

METHODS

Informant interviews (n=15) and focus groups (n=15, with 112 NHOPI participants) were completed to inform the cultural adaptation of the DPP-LI program. A team of 5 community investigators and 1 academic research team collaboratively developed and implemented the 12-week pilot study to assess the effectiveness of the culturally adapted program.

RESULTS

A total of 127 NHOPIs participated in focus groups and informant interviews that resulted in the creation of a significantly modified version of the DPP-LI, entitled the PILI 'Ohana Lifestyle Intervention (POLI). In the pilot study, 239 NHOPIs were enrolled and after 12 weeks (post-program), mean weight loss was -1.5 kg (95%CI -2.0, -1.0) with 26% of participants losing > or = 3% of their baseline weight. Mean weight loss among participants who completed all 8 lessons at 12 weeks was significantly higher (-1.8 kg, 95%CI -2.3, -1.3) than participants who completed less than 8 lessons (-0.70 kg, 95%CI -1.1, -0.29).

CONCLUSION

A fully engaged CBPR approach was successful in translating an evidence based diabetes prevention program into a culturally relevant intervention for NHOPI communities. This pilot study demonstrates that weight loss in high risk minority populations can be achieved over a short period of time using CBPR approaches.

Partnerships to address obesity disparities in Hawai'i: the PILI 'Ohana Project

Community-based participatory research (CBPR) is an approach to scientific research that is gaining broader application to address persistent problems in health care disparities and other hypothesis-driven research. However, information on how to form CBPR community-academic partnerships and how to best involve community partners in scientific research is not well-defined. The purpose of this paper is to share the experience of the Partnership for Improving Lifestyle Interventions (PILl) 'Ohana Project in forming a co-equal CBPR community-academic partnership that involved 5 different community partners in a scientific research study to address obesity disparities in Native Hawaiians and other Pacific Peoples (i.e., Samoans, Chuukese, and Filipinos). Specifically, the paper discusses (1) the formation of our community-academic partnership including identification of the research topic; (2) the development of the CBPR infrastructure to foster a sustainable co-equal research environment; and (3) the collaboration in designing a community-based and community-led intervention. The paper concludes with a brief summary of the authors' thoughts about CBPR partnerships from both the academic and community perspectives.

Cancer assessment methodology in a native Hawaiian community

BACKGROUND

Limited data have been collected on cancer in Native Hawaiian communities, although Native Hawaiians tend to have higher cancer mortality rates than other ethnic groups in Hawaii.

OBJECTIVES

We sought to describe the community-based participatory research (CBPR) process used to deliver a culturally tailored protocol, combining traditional Native Hawaiian practices and random sampling methods, to determine cancer screening practices and program preferences of residents of a Hawaiian Homes (HH) community.

METHODS

Following a culturally tailored protocol, we attempted to survey half of the 644 households in the Waimanalo Hawaiian Homes Community (WHHC). Pairs of Native Hawaiian college students performed the majority of data collection; a community member joined them if available. Visits to the selected homes were tracked and participation rates estimated. Additional information on this methodology emerged from discussions between researchers and community members.

RESULTS

Of the 449 households accessed, 187 (42%) completed the survey, with an average of two visits per household. Individuals at 63 (14%) households refused outright. The remaining 199 (44%) homes were visited up to five times, but produced no response. Although some homes were vacant, often it appeared that residents were home but unresponsive. Our sampling procedure (targeting every other house and requiring accrual of 75 individuals in each of four age-gender groups) reduced participation.

CONCLUSIONS

The use of CBPR built capacity for all partners by engaging them in all levels of research. The results, however, suggest the need for a more inclusive sampling strategy and the continued use of CBPR.

Contrast of pediatric asthma management approaches in a multicultural and collectivistic population

BACKGROUND

Although asthma is the most prevalent chronic illness in childhood and affects approximately 9 million children, the management approaches used by practitioners may not be efficient from the perspective of families. Clinicians often maintain their usual customs of practice, and the context of the clinical encounter is defined in terms of an individual illness management. In collectivistic and multiethnic settings, the extended kin group or extended family shares responsibility for illness management. The goal of this study is to describe health care providers' strategies to manage children with asthma in a multicultural and collectivistic cultural context.

METHODS

Data were obtained through semistructured in-depth practitioner interviews. Western-trained and traditional practitioners participated.

RESULTS

Narrative analysis strategies produced two major themes: 1) fix the asthma and 2) making connections. Practitioners who perceived their responsibility to fix the asthma (make things physiologically normal) often ran into constraints with dealing with the extended family group. Other practitioners who used strategies of making connections often capitalized on the assistance of others to problem-solve the asthma management.

CONCLUSION

In terms of asthma management, the barriers most frequently reported by practitioners were related to the sociocultural and physical environment. There may be vast differences in asthma management approaches for populations from collectivistic cultural orientation.