Culturally responsive approaches to health promotion

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May 29, 2018 - and NHPI cultural values/practices led to establishing sustainable and scalable interventions that signifi- cantly improved .... Overweight/Obesity Observational; CBPR 9-month PLP and SBG ..... Hawaiians, Samoans, Chuukese and Filipinos to elicit their ..... narrative structure in the stories we hear and tell.
Annals of Human Biology

ISSN: 0301-4460 (Print) 1464-5033 (Online) Journal homepage: http://www.tandfonline.com/loi/iahb20

Culturally responsive approaches to health promotion for Native Hawaiians and Pacific Islanders Joseph Keawe‘aimoku Kaholokula, Claire Townsend Ing, Mele A. Look, Rebecca Delafield & Ka‘imi Sinclair To cite this article: Joseph Keawe‘aimoku Kaholokula, Claire Townsend Ing, Mele A. Look, Rebecca Delafield & Ka‘imi Sinclair (2018): Culturally responsive approaches to health promotion for Native Hawaiians and Pacific Islanders, Annals of Human Biology, DOI: 10.1080/03014460.2018.1465593 To link to this article: https://doi.org/10.1080/03014460.2018.1465593

Published online: 29 May 2018.

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ANNALS OF HUMAN BIOLOGY https://doi.org/10.1080/03014460.2018.1465593

REVIEW ARTICLE

Culturally responsive approaches to health promotion for Native Hawaiians and Pacific Islanders Joseph Keawe‘aimoku Kaholokulaa, Claire Townsend Inga, Mele A. Looka, Rebecca Delafielda and Ka‘imi Sinclairb a Department of Native Hawaiian Health, John A. Burns School of Medicine, University of Hawai‘i at Manoa, Honolulu, HI, USA; bInitiative for Research and Education to Advance Community Health (IREACH), Washington State University, Seattle, WA, USA

ABSTRACT

ARTICLE HISTORY

Context: Obesity, diabetes and cardiovascular disease (CVD) have reached epidemic proportions among Native Hawaiians/Pacific Islanders (NHPI). Culturally responsive interventions that account for their interpersonal, sociocultural and socioeconomic realities are a public health priority. Objective: To describe cultural adaptation and culturally grounded approaches to developing health interventions for NHPI and to review the culturally responsive approaches used by, and outcomes from, two long-standing community-based participatory research projects (CBPR) in Hawai‘i: PILI ‘Ohana and KaHOLO Projects. Methods: A literature review of 14 studies from these two projects was done to exemplify the methods applied to culturally adapting existing evidence-based interventions and to developing novel interventions from the ‘ground up’ to address health disparities in NHPI. Of the 14 studies reviewed, 11 were studies of the clinical and behavioural outcomes of both types of interventions. Results: Both culturally adapted and culturally grounded approaches using community-based assets and NHPI cultural values/practices led to establishing sustainable and scalable interventions that significantly improved clinical measures of obesity, diabetes and hypertension. Conclusion: Several recommendations are provided based on the lessons learned from the PILI ‘Ohana and KaHOLO Projects. Multidisciplinary and transdisciplinary research using CBPR approaches are needed to elucidate how human biology is impacted by societal, environmental and psychological factors that increase the risk for cardiometabolic diseases among NHPI to develop more effective health promotion interventions and public health policies.

Received 20 October 2017 Revised 3 February 2018 Accepted 12 March 2018

Introduction Obesity, diabetes and cardiovascular disease (CVD) are interrelated cardiometabolic conditions that have reached epidemic proportions among Pacific Islander populations (Mau et al., 2009; Hawley and McGarvey, 2015), people with origins from the Pacific regions known as Melanesia (e.g. Fiji and Vanuatu), Polynesia (e.g. Hawai‘i, Samoa and Tonga), and Micronesia (e.g. Chuuk and Guam). The highest rates of obesity and diabetes in the world are found in the Pacific Region (e.g. Nauru, American Samoa and Vanuatu) (Chan et al., 2014). Once healthy and robust populations, their health has been negatively impacted by centuries of colonisation and exploitation by foreign powers, leading to cultural loss and economic deprivation (Spickard et al., 2002). Economic conditions, limited healthcare and educational opportunities and the effects of global warming in the Pacific have led to a diaspora of Pacific Islanders to countries such as New Zealand, Australia and the US, where they continue to face economic and acculturation-related challenges and discrimination that impact their physical and mental health status (Spickard et al., 2002; Ahlgren et al., 2014).

CONTACT Joseph Keawe‘aimoku Kaholokula 96813, USA

[email protected]

ß 2018 Informa UK Limited, trading as Taylor & Francis Group

KEYWORDS

Native Hawaiians; Pacific Islanders; health promotion; intervention; obesity; diabetes; cardiovascular disease; cardiometabolic

In the US, Native Hawaiians (NH) and other Pacific Islanders (PI) face discrimination and experience socioeconomic circumstances that place them at risk for cardiometabolic related disorders (Kaholokula et al., 2009). The combined prevalence of overweight and obesity is 73.4% among NHPI (Native Hawaiians/Pacific Islanders), which is 20% greater than non-Hispanic Whites (Schiller et al., 2012). The prevalence of diabetes (Kirtland et al., 2015) and heart disease is 19% and 19.7%, respectively, among NHPI compared to 5% and 6.6% for non-Hispanic Whites (Grandinetti et al., 2007; CDC, 2014; Kirtland et al., 2015). NHPI also suffer a stroke an average of 10 years younger than non-Hispanic Whites, in part due to poorer hypertension management (Nakagawa et al., 2012). In Hawai‘i, the state with the largest NHPI population in the US, they are more likely to live in obesogenic environments (Mau et al., 2008) and experience a decade shorter lifespan than Japanese and Chinese, the longest living ethnic groups in Hawai‘i (Wu et al., 2017). Thus, reducing the risk of cardiometabolic disorders in NHPI through the development of health interventions and policies is a public health priority (Cook et al., 2010).

Department of Native Hawaiian Health; 677 Ala Moana Blvd., Suite 1016, Honolulu, HI

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The high prevalence of cardiometabolic disorders among NHPI has been attributed to genetic/biological dispositions (Minster et al., 2016), lifestyle behaviours (e.g. calorie-dense diet and physical inactivity) (Kolonel et al., 2000), socioeconomic deprivation (e.g. lower income and education levels), sociocultural challenges (e.g. colonisation and acculturation stressors) (Kaholokula et al., 2009), psychosocial stressors (e.g. discrimination) (Kaholokula et al., 2010), environmental conditions (Mau et al., 2008) and complex permutations of these variables (Kirtland et al., 2015). Health interventions targeting cardiometabolic disorders in NHPI communities need to be culturally responsive and account for their interpersonal, sociocultural and socioeconomic realities. In this article, an overview of culturally responsive approaches to health intervention development—cultural adaptation and cultural grounding—in the context of community-based participatory research (CBPR) is first provided. Following this is a literature review of studies from two longstanding CBPR projects in Hawai‘i, The PILI ‘Ohana Project1 HOLO Project2, that developed health interventions and the Ka for NHPI using cultural adaptation and culturally grounded approaches. The principles and steps involved in both approaches will be illustrated and the clinical, behavioural, and psychosocial outcomes resulting from these interventions will be discussed. Table 1 summarises the characteristics and findings of the intervention outcome studies from the two projects reviewed in this article.

Culturally responsive approaches to health intervention Health interventions that are not aligned with the cultural values, perspectives, and preferred modes of living of the target population are presumed to be less effective than culturally responsive interventions that account for these factors (Jumper-Reeves et al., 2014). Most evidence-based interventions (EBI) are developed using Western-centric theories of behaviour change and behavioural strategies tested in samples of predominately non-Hispanic Whites. For example, the Diabetes Prevention Program–Lifestyle Intervention (DPP-LI) is an EBI found effective in reducing a person’s risk for diabetes by addressing excess body weight (Hamman et al., 2006), which has been widely disseminated (Jiang et al., 2013; Dunkley et al., 2014; Hall et al., 2016). However, weight-loss outcomes between ethnic groups have been shown to differ given the same EBI targeting their lifestyle behaviours, with non-Hispanic Whites often having better outcomes (Kumanyika et al., 2002; West et al., 2008). These differences in outcomes may be due to cultural differences between ethnic groups not accounted for by an EBI developed and tested with a dissimilar cultural group (Kumanyika et al., 2002; Kumanyika, 2008). Although NHPI share many cultural similarities (e.g. deep ancestral origins, adaptation to island living, family/community orientation and cultural changes due to occupation by Western powers), especially when compared to European or Asian cultures, there are also many cultural dissimilarities (e.g. language, socio-political structures and aspirations) that

should be considered during intervention development. Okamoto et al. (2014) describe a continuum of approaches in developing culturally responsive health interventions, anchored on one end by cultural adaptation and the other by culturally grounded approaches. Culture, as defined by Haynes et al. (in press) is ‘the shared patterns of behaviours and interactions, cognitive constructs, and affects that are learned through a process of socialisation and that distinguish members of a group from members of another group’. Cultural adaptation is the most common approach to adapting an EBI for a new population; that is, modifying an intervention found efficacious through rigorous scientific study in another population with different cultural characteristics to fit the cultural characteristics of a new population. Essentially, the goal of cultural adaptation is to preserve the core elements of the original intervention while incorporating culturally relevant elements. Adaptations can take the form of surface structure modifications, such as changing the programme’s name, terms used and food/eating examples to be culturally specific (e.g. using the native language and metaphors) and geographically local (Castro et al., 2004). Adaptations can also take the form of deep-structure changes in which substantial changes are made to the EBI, such as incorporating the new cultural group’s perspectives (e.g. worldviews and values) and practices into the core elements (Resnicow et al., 1999). Culturally grounded approaches are those in which the sociocultural context is at the core of the intervention and elements of the programme are based on the worldviews, beliefs and customs of the target population (PalmerWackerly et al., 2014; Lauricella et al., 2016). These types of interventions are referred to as originating from the ‘groundup’ because they emerge from the cultural group’s own worldviews and preferred practices rather than relying solely on Western notions of health promotion (Walters et al. in press). Okamoto et al. (2014) recommended culturally grounded approaches for populations where there is a high need for intervention, the science to inform adaptation is lacking and there is a high scientific and health impact that could result from the development of ‘ground up’ interventions. Ironically, many of the culturally grounded approaches proposed are actually a return to traditional worldviews and practices that were part of everyday life for indigenous communities and a source of their wellbeing prior to Western intrusion. In Pacific cultures, such culturally grounded approaches have involved the use of traditional dances to reduce CVD risk (Look et al., 2012) and dietary patterns for obesity treatment (Shintani et al., 1999) and connecting health to spirituality for improving cancer awareness and screening (Aitaoto et al., 2007).

Community-based participatory research approaches in health interventions CBPR is an approach to research that equitably and meaningfully involves relevant stakeholders of a specified community, such as its members, leaders and community-based organisations (e.g. churches, community health centres and cultural

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Table 1. Characteristics of the intervention outcomes studies from the PILI ‘Ohana and KaHOLO projects reviewed. Source

Target condition

Design

Mau et al. (2010)

169 NHOPI adults with BMI  25  NH 52%  Chuukese 27%  Samoan 12%  Filipino 5%  OPI 1%  Non-OPI 2%

Participants

Overweight/Obesity

Pre–post evaluation; CBPR

PLP’s 3-month culturally adapted DPP-LI phase

Kaholokula, Mau, et al. (2012)

144 NHOPI adults with BMI  25  NH 52%  Chuukese 26%  Samoan 11%  Filipino 7%  OPI 3%  Non-OPI 3%

Overweight/Obesity

RCT; CBPR

PLP’s 6-month family and community focused WLM phase (n ¼ 72) vs standard behavioural follow-up group (SBG; n ¼ 72)

Sinclair et al. (2013)

82 NHOPI adults with type 2 diabetes and A1c  7%

Diabetes

RCT; CBPR

3-month culturally adapted PIC programme (n ¼ 48) vs waitlist control (n ¼ 34)

Kaholokula et al. (2013)

100 NHOPI adults with BMI  25  NH 71%  Chuukese 22%  OPI 22%

Overweight/Obesity Observational; CBPR 9-month PLP and SBG

Kaholokula, Wilson, et al. (2014)

239 NHOPI adults with BMI  25  NH 52%  Chuukese 9%  Samoan7%  Filipino 5%  OPI 1%  Non-OPI 7%

Overweight/Obesity

Pre–post evaluation; CBPR

Intervention

PLP’s 3-month culturallyadapted DPP-LI phase

Key findings Mean weight loss was –1.5 kg (95% CI ¼ –2.0, –1.0) at 3-months, with 26% losing >3% of their baseline weight. Mean weight loss among those who completed all eight lessons was significantly higher (–1.8 kg, 95% CI ¼ –2.3, –1.3) than those who completed less than eight lessons (–0.70 kg, 95% CI ¼ –1.1, –0.29). Participants of both groups achieved significant weight loss maintenance (p  0.05) after completing the 3month CA DPP-LI. PLP participants who completed at least half of the prescribed sessions were 5.1-fold (95% CI ¼ 1.06–24; p ¼ 0.02) more likely to have maintained their initial weight loss than SBG participants. Significant baseline adjusted differences found at 3 months between PIC and waitlist control group in intent-to-treat (–1.6 vs –0.3; p < 0.001) and complete case analyses (–1.1 vs –0.3; p < 0.0001) for A1c and in diabetes understanding and in performing diabetes self-management. Ethnicity, sex, initial weight loss, fat in diet at baseline, change in SBP, and intervention type were associated (p  0.05) with 3% weight loss at 9 months. Adjusted for other variables, Chuukese (OR ¼ 6.04; CI ¼ 1.14–32.17), participants with greater weight loss in the 1st 3-months (OR ¼ 1.47; CI ¼ 1.22–1.86), and those who were in the PLP (OR ¼ 4.50; CI ¼ 1.50–15.14) were more likely to achieve 3% weight loss at 9 months. Significant improvements in weight (–1.7 kg ±3.5), SBP (–3.3 mmHg ±18.6), DBP (–3.4 mmHg ±12.5), physical functioning measured by 6 minute walk test (106.6 ft ±238.4), exercise (continued)

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Table 1. Continued Source

Participants

Target condition

Design

Intervention

Townsend et al. (2014)

112 employees of 10 NH Overweight/Obesity Preliminary pre–post PLP’s 12-month culturallyserving organisations evaluation; CBPR adapted DPP-LI and with BMI  25 family and community  NHOPI 60% WLM (work Other 40% place version)

Townsend et al. (2016)

217 employees of 15 NH Overweight/Obesity serving organisations with BMI  25  NH 38%  OPI 21%  Asian 21%  Caucasian 14%  Other 2%

Ing et al. (2016)

47 NHOPI adults with type 2 diabetes and A1c 7%  NH 57%  Micronesian 34%  Filipino 4%  Other 4%

Delafield et al. (2016a)

343 NHOPI adults with BMI  25

Pre–post evaluation; CBPR

PLP’s 3-month culturallyadapted DPP-LI phase (workplace version)

Diabetes

RCT; CBPR

3-month culturally adapted PIC programme and randomisation to either SSG (n ¼ 25) or control (n ¼ 22)

Overweight/Obesity

Pre–post evaluation; CBPR

PLP’s 3-month culturally adapted DPP-LI phase

Key findings frequency and fat in diet were found. Larger baseline weight (p ¼ 0.002) and type of CBO (p ¼ 0.007) delivering the intervention predicted weight loss. CBO with predominately NH and ethnically homogenous intervention groups had greater weight loss. Significant improvements in weight (–1.86 kg ±4.16), physical functioning measured by 6 minute walk test (93.37 ft ± 145.47), exercise frequency, fat in diet, weight locus of control, eating self-efficacy and family support were found at 12month follow-up. Eating self-efficacy at baseline was associated with weight change at 12-month from baseline (p < 0.01). Significant improvements in mean weight loss (–1.2 kg ± 2.63), BMI (–0.45 ± 0.97), SBP (–2.8 ± 12.5), DBP (–2.01 ± 8.05), physical functioning 6 minute walk test (74.65 ± 154.71), fat in diet scores, physical activity level, family support and eating self-efficacy were achieved at 3-month follow-up. Baseline weight and change in DBP, physical activity level, community support and locus of weight control were independently and significantly associated with 3-month weight loss. Significant improvements in HbA1c (0.76 ± 1.86), diabetes-related self-management knowledge (0.73 ± 0.97) and selfmanagement behaviours (11.1 ± 21.87). While the SSG group had a significant decrease in systolic blood pressure from 3to 6-month assessment and the control group did not, there were no significant differences across the groups. Significant overall (n ¼ 343) improvements in mean weight loss (–1.4 kg ±3.41), BMI (continued)

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Table 1. Continued Source

Participants

Target condition

Design

Intervention

Key findings

(–0.51 ± 1.23), SBP (–3.89 ± 17.19), DBP (–2.36 ± 11.38), physical functioning 6 minute walk test (111.54 ± 277.99), fat in diet scores and physical activity level were achieved at 3-month follow-up. Kaholokula et al. (2016) 240 NHOPI adults Overweight/Obesity RCT; CBPR Participants of both PLP with BMI  25 groups who lost 3% at start of WLM efforts were significantly (p < 0.05) more likely to lose 5% at 12(44% for GS; 56% for DVD) and 18-month follow-up (57% for GS; 43% for DVD) than those who started at