Island Nation, US Territory and Contested Space: Territorial Status As a Social Determinant of Indigenous Health in Guam.

The United Nations and International Federation of Social Work affirm the right of all people to determine their political status, preserve their environments and pursue endeavours for well-being. This article focuses on CHamoru, Guam's Indigenous people, and examines distal social determinants of health (SDOH) in the contested spaces of US territorial status and non-self-determining Indigenous nationhood. Published multi-disciplinary literature identified ways in which territorial status functions as an SDOH unique to non-self-determining Pacific Island nations. Indicated is the use of structural approaches that address mechanisms of US power and control, including economic policies that 'defacto' promote coca-colonisation and non-communicable diseases risk. Critical race theory centres race, colonisation and subversive narratives. In line with fourth-generation SDOH action-oriented research, we posit a CHamoru critical race theory model that weaves Indigenous, social work and public health perspectives. Lack of community input is a limitation of the current research. To assure relevance, the model will be vetted through community discussions. Our discussion guide may be tailored for other Indigenous communities. Social workers may play a meaningful role in promoting health equity through participatory action-oriented, cultural-political social work that upholds Indigenous self-determination and survivance in contested spaces.

Research Capacity Strengthening in American Samoa: Fa'avaeina le Fa'atelega o le Tomai Sa'ili'ili i Amerika Samoa.

Capacity-building partnerships are central to the sustainable development goals (SDGs), the UN's blueprint for achieving global health equity. The UN Permanent Forum on Indigenous Issues endorses the SDG and underscores the need for global partnerships that respect local leadership and culture. Innovations that weave or integrate Indigenous and Western knowledges are emphasised. These recommendations guided the INdigenous Samoan Partnership to Initiate Research Excellence (INSPIRE). INSPIRE is led by investigators from American Samoa and supported by US co-investigators. In project year one, INSPIRE queried: What weaving approaches are feasible for promoting community access to INSPIRE's research hub and for training Indigenous researchers? Weaving procedures involved interlacing Samoan and Western knowledges. Cultural tailoring strategies were used to customise communications. Formative evaluation suggests the feasibility of INSPIRE's efforts. Evidential tailoring provided information on American Samoa (A.S.) social determinants of health; trainees indicated increased research commitment. Linguistic and sociocultural relevance tailoring were positively received; trainees reported increased interest in research praxis and initiated an A.S. research capacity-strengthening model. Social work assured knowledge parity in development/delivery of the training curriculum and culturally safe discussions on social determinants of health, territorial status and Samoan survivance. Findings are context-specific yet offer considerations for capacity-strengthening partnerships seeking to advance health equity.

Addressing Risk and Reluctance at the Nexus of HIV and Anal Cancer Screening.

Anal cancer disproportionately burdens persons living with human immunodeficiency virus (PLHIV) regardless of natal sex, sexual orientation, gender expression, and ethnic identity. Culturally competent communications are recommended to address health disparities, with sociocultural relevance ensured through constituent dialogic processes. Results are presented from six provider focus groups conducted to inform the promotion/education component of a Hawai'i-based project on anal cancer screening tools. Krueger's focus group methodology guided discussion queries. Verbatim transcripts of digitally recorded discussions were analyzed using grounded theory and PEN-3 procedures. Adherence to an audit trail ensured analytic rigor. Grounded theory analysis detected the overall theme of risk and reluctance to anal cancer screening, characterized by anal cancer not being "on the radar" of PLHIV, conflicting attributions of the anus and anal sex, fear of sex-shaming/-blaming, and other interrelated conceptual categories. PEN-3 analysis revealed strategies for destigmatizing anal cancer, through "real talk" (proactive, candid, nonjudgmental discussion) nested in a framework of sexual health and overall well-being, with additional tailoring for relevance to Native Hawaiians/Pacific Islanders, transgender persons, and other marginalized groups. Application of strategies for health practice are specific to the Hawai'i context, yet may offer considerations for developing strengths-based, culturally relevant screening promotion/education with diverse PLHIV in other locales.

Is healthcare caring in Hawai'i? Preliminary results from a health assessment of lesbian, gay, bisexual, transgender, questioning, and intersex people in four counties.

This paper presents findings from a statewide needs assessment of lesbian, gay, bisexual, transgender, questioning, and intersex (LGBTQI) people in Hawai'i that relate to health status and health-related risk factors such as having health insurance coverage, having a regular doctor, experiencing sexual orientation (SO) or gender identity/expression (GI/E) discrimination in health/mental health care settings, and delaying care due to concerns about SO and GIE discrimination in Hawai'i, Honolulu, Kaua'i, and Maui counties. Results suggest that LGBTQI people in these counties generally rated their self-assessed health as "very good" or "excellent," but had slightly higher rates of smoking and less health insurance coverage than the general population of Hawai'i. Many respondents reported challenges to their health, and negative experiences with healthcare. Unlike prior studies that have shown no difference or a rural disadvantage in care, compared to urban locations, Hawai'i's counties did not have a clear rural disadvantage. Honolulu and Kaua'i Counties demonstrated better health indicators and lower percentages of people who had delayed care due to gender identity concerns. Findings suggest that health/mental health care providers should address potential bias in the workplace to be able to provide more culturally competent practice to LGBTQI people in Hawai'i.

Colorectal Cancer Screening at the Nexus of HIV, Minority Statuses, and Cultural Safety.

BACKGROUND: The incidence of non-AIDS-defining cancers has increased significantly among persons living with HIV (PLHIV). Screening education is recommended. PURPOSE: Social learning, minority stress, and cultural safety theories informed this pilot to assess the feasibility of a colorectal cancer screening intervention targeted to PLHIV, with additional tailoring for relevance to Native Hawaiians, a group with low participation in cancer screening. METHOD: The targeted education included behavioral modeling and barriers counseling in a culturally safe environment. Using a 2-group, pre/posttest design, AIDS service organizations were randomized to culturally responsive or standard education. AIDS service organizations consumers recruited through venue-based promotions were the unit of analysis. Knowledge-attitudes-practices, fecal occult blood test screening completion, and intervention feasibility were measured. RESULTS: Treatment arm participants, regardless of ethnicity, adhered to fecal occult blood test instructions and achieved increases in screening knowledge, attitudes, and practices. Relevance and acceptability of the educational intervention were endorsed. DISCUSSION: The culturally responsive intervention was successful in this group of PLHIV. Additional tailoring may be needed to reach PLHIV who do not participate in organizational activities. CONCLUSION/TRANSLATION TO HEALTH EDUCATION PRACTICE: This culturally responsive intervention shows promise for efficacy testing in a broader PLHIV population. Constituent-involving strategies were central to its development and delivery.

Testing the feasibility of a culturally tailored breast cancer screening intervention with Native Hawaiian women in rural churches.

The authors report on the feasibility of delivering a church-based breast cancer screening intervention tailored on the cultural strengths of rural-dwelling Hawaiians. Native Hawaiian women are burdened by disproportionately high mortality from breast cancer, which is attributed to low participation in routine mammography. Mammography is proven to be an effective means for detecting disease at its earliest stages, when treatments are most likely to be successful. Culturally tailored screening programs may increase participation. Hawaiian initiatives call for screening innovations that integrate Hawaiian cultural strengths, including those related to spirituality and the extended family system. Before full-scale testing of tailored interventions, it is important to conduct feasibility studies that gauge community receptiveness to the proposed intervention and research methods. Study results establish the attractiveness and potential effectiveness of the authors' screening intervention. Recruitment exceeded targets, and retention rates were comparable to those of other randomized behavioral trials, confirming the value of reaching rural Hawaiian women through churches. Women appreciated the integrative approach of Hawaiian and faith-based values, and positive outcomes are suggested.This article may be relevant to social workers interested in culturally responsive, community-based interventions and to researchers conducting pilot studies and controlled trials of interventions adapted from evidence-based programs.

Improving integration and coordination of funding, technical assistance, and reporting/data collection: recommendations from CDC and USAPI stakeholders.

BACKGROUND: Current US Federal funding mechanisms may foster program silos that disable sharing of resources and information across programs within a larger system of public health services. Such silos present challenges to USAPI communities where human resources, health infrastructure, and health financing are limited. Integrative and coordinated approaches have been recommended. The CDC Pacific Islands Integration and Coordination project was initiated by the CDC Division of Cancer Prevention and Control (DCPC). The project aim was to identify ways for the CDC to collaborate with the USAPI in improving CDC activities and processes related to chronic disease. This article focuses on recommendations for improving coordination and integration in three core areas of health services programming: funding, program reporting/data collection and analysis, and technical assistance. METHOD: Preliminary information on challenges and issues relevant to the core areas was gathered through site visits, focus groups, key informant interviews, and other sources. This information was used by stakeholder groups from the CDC and the USAPI to develop recommendations in the core programming areas. Recommendations generated at the CDC and USAPI stakeholder meetings were prepared into a single set of recommendations and stakeholders reviewed the document for accuracy prior to its dissemination to CDC's National Center for Chronic Disease Prevention and Health Promotion programs management and staff. RESULTS: Key recommendations, include: (1) consideration of resources and other challenges unique to the USAPI when reviewing funding applications, (2) consideration of ways to increase flexibility in USAPI use of program funds, (3) dedication of funding and human resources for technical assistance, (4) provision of opportunities for capacity-building across programs and jurisdictions, (5) consideration of ways to more directly link program reporting with technical assistance. CONCLUSIONS: This project provided a unique opportunity for CDC and USAPI stakeholders to share diverse perspectives on challenges to public health programs in the USAPI. Despite diverse experiences, the final set of recommendations reflected a high level of concordance between USAPI and CDC stakeholders. Recommendations have informed or reinforced actions initiated by the DCPC, including the dedication of funds for leadership institutes aimed at enhancing USAPI capacity for sustainable, integrated regional and jurisdictional cancer control infrastructure. Such efforts are an important beginning, but more remains to be done. Indicated is the need for continuous dialogue and collaboration. While this project focused on the USAPI, our results may be relevant to those interested in inter-organizational collaborations, medically underserved areas, public health services programs, and community-based participatory approaches.

Cancer disparities in the Federated States of Micronesia: funding challenges of a developing nation in epidemiological transition.

This article describes funding and other challenges to cancer control in the Federated States of Micronesia (FSM) and examines funding opportunity announcements (FOAs) as a critical facet in implementation of the U.S. Compact of Free Association (COFA). As a health-relevant policy, COFA commits the United States to improve the health of FSM citizens and, specifically, allows the FSM to apply for U.S. federal health FOAs. Emerging research suggests discrepancies in the intent and implementation of COFA and indicates that the capacity of the FSM to secure U.S. health funding may be at least partially hindered by the ways in which FOAs are structured. Current cancer-related FOAs were identified to evaluate their relevance to the FSM. Eligibility requirements of all FOAs were systematically reviewed and compared with FSM infrastructural and human resources. Findings indicate that most FOAs have requirements more likely to be met in fully developed health service entities. Such requirements disadvantage the FSM when competed with the relatively more resource-rich U.S. states and health services systems. This situation predisposes the FSM to increased risk of disparate cancer outcomes. Highlighted is the need for distributive justice and specific efforts that enhance the health services infrastructure in the FSM and increase opportunities for resource-appropriate interventions. Findings provide considerations for those in international social welfare, public health, and other disciplines interested in the advancement of global health partnerships to eliminate cancer disparities in underresourced nations.

Improving integration and coordination of funding, technical assistance, and reporting/data collection: recommendations from CDC and USAPI stakeholders.

BACKGROUND: Current US Federal funding mechanisms may foster program silos that disable sharing of resources and information across programs within a larger system of public health services. Such silos present challenges to USAPI communities where human resources, health infrastructure, and health financing are limited. Integrative and coordinated approaches have been recommended. The CDC Pacific Islands Integration and Coordination project was initiated by the Division of Cancer Prevention and Control (DCPC). Its project aim was to identify ways for the CDC to collaborate with the USAPI in improving CDC activities and processes related to chronic disease. This article focuses on recommendations for improving coordination and integration in three core areas of health services programming: funding, program reporting/data collection and analysis, and technical assistance. METHOD: Preliminary information on challenges and issues relevant to the core areas was gathered through site visits, focus groups, key informant interviews, and other sources. This information was used by stakeholder groups from the CDC and the USAPI to develop recommendations in the core programming areas. Recommendations generated at the CDC and USAPI stakeholder meetings were prepared into a single set of recommendations and stakeholders reviewed the document for accuracy prior to its dissemination to CDC's National Center for Chronic Disease Prevention and Health Promotion programs management and staff. RESULTS: Key recommendations, include: (1) consideration of resource s and other challenges unique to the USAPI when reviewing funding applications, (2) consideration of ways to increase flexibility in USAPI use of program funds, (3) dedicate funding and human resources for technical assistance, (4) provide opportunities for capacity-building across programs and jurisdictions, (5) consider ways to more directly link program reporting with technical assistance. CONCLUSIONS: This project provided a unique opportunity for CDC and USAPI stakeholders to share diverse perspectives on challenges to public health programs in the USAPI. Despite diverse experiences, the final set of recommendations reflected a high level of concordance between USAPI and CDC stakeholders on ways to improve coordination and integration of CDC processes and activities in the three core areas. Recommendations have informed some actions already initiated by the DCPC, including the dedication of funds for leadership institutes aimed at enhancing USAPI capacity for sustainable, integrated regional and jurisdictional cancer control infrastructure. Such efforts are an important beginning, but more remains to be done. Indicated is the need for continuous dialogue and collaboration. While this project focused on the USAPI, our results may be relevant to those interested in inter-organizational collaborations, medically underserved areas, public health services programs, and community-based participatory approaches.

Coping With Breast Cancer at the Nexus of Religiosity and Hawaiian Culture: Perspectives of Native Hawaiian Survivors and Family Members.

This article describes research to develop a breast health intervention for women in Hawaiian churches. Native Hawaiian women are disproportionately burdened by breast disease and tend to be diagnosed at advanced stages when treatment options are more limited. Research suggests that cultural conflict may be a factor in Hawaiian women's underutilization of conventional health services. Phenomenological approaches guided data collection and analysis to explore the influence of religiosity and ethnocultural tradition in coping with breast cancer. The overarching theme was kakou (we or us), which emphasized ways of coping oriented to the family collective and focused on family well-being. Findings offer a portal for understanding the lived experience of survivors and families in Hawaiian churches. Considerations are suggested for those practitioners assisting clients from collectivist-oriented cultures.

Adaptation to long-term prostate cancer survival: the perspective of elderly Asian/Pacific Islander wives.

Increasingly evident is the important role of partners in patients' adaptation to diagnosis, treatment, and recovery. Yet, little is known about partners' adaptation when patients reach the benchmark known as long-term survival. This study describes elderly wives of prostate cancer survivors' perspectives of adaptation to the enduring challenges of prostate cancer survival and considers their experience in the context of ethnicity. Content analysis and grounded theory methods guided data collection and analysis of two waves of in-depth interviews with 26 elderly Asian/Pacific Islanders (Chinese, Filipino, Japanese, Native Hawaiian) living in Hawai'i. Continuous learning was the most common phenomenon as reflected in four types of adaptive work: involvement in husband's health, affirmation of the marital bond, normalization of adversity, and participation in personally meaningful acts. Issues are highlighted for consideration in developing culturally relevant, age-appropriate, and strengths-based interventions.

Training community practitioners in a research intervention: practice examples at the intersection of cancer, Western science, and native Hawaiian healing.

This practice paper describes the preintervention training component of a feasibility study exploring the use of ho'oponopono, an indigenous Hawaiian healing practice, for enhancing psychosocial adaptation to breast cancer among Native Hawaiian women. Practitioners' adherence to research protocols and competence in intervention delivery are both regarded as essential to obtaining valid results in tests of intervention feasibility and efficacy; thus, training in this study dually focused on fortification of adherence and enhancing competence among those recruited to deliver the ho'oponopono intervention. A manual-based training, using adult pedagogical strategies infused with Native Hawaiian cultural practices, was delivered to community practitioners. Effects of the training on practitioners' knowledge and skills were evaluated through multiple methods. Knowledge significantly increased between pre- and post-intervention assessment. However, knowledge application for some practitioners was hindered by skill deficits, stylistic differences, and cultural conflict. Ongoing attention to competence and adherence is indicated. In-service training may bolster competence; however, practitioners may have difficulty in adhering to protocols for different reasons, and individualized clinical supervision and cultural consultation may be helpful in some situations.