The Healthy Hawai'i Initiative: insights from two decades of building a culture of health in a multicultural state.

BACKGROUND: The Healthy Hawai'i Initiative was created in 2000 with tobacco settlement funds as a theory-based statewide effort to promote health-supporting environments through systems and policy change. Still active today, it is imbedded explicitly in a multi-sectoral, social ecological approach, effectively striving to build a culture of health before this was the name for such an ambitious effort. METHODS: From interviews with key informants, we analyze two decades of the Healthy Hawai'i Initiative (HHI) in the context of the Robert Wood Johnson Foundation (RWJF) Culture of Health Action Framework (CHAF). We list HHI accomplishments and examine how the Initiative achieved notable policy and environmental changes supportive of population health. RESULTS: The Healthy Hawai'i Initiative started with an elaborate concept-mapping process that resulted in a common vision about making "the healthy choice the easiest choice." Early on, the Initiative recognized that making health a shared value beyond the initial stakeholders required coalition and capacity building across a broad range of governmental and nonprofit actors. HHI coalitions were designed to promote grassroots mobilization and to link community leaders across sectors, and at their height, included over 500 members across all main islands of the state. Coalitions were particularly important for mobilizing rural communities. Additionally, the Initiative emphasized accessibility to public health data, published research, and evaluation reports, which strengthened the engagement to meet the shared vision and goals between diverse sector partners and HHI. Over the past two decades, HHI has capitalized on relationship building, data sharing, and storytelling to encourage a shared value of health among lawmakers, efforts which are believed to have led to the development of health policy champions. All of these factors combined, which centered on developing health as a shared value, have been fundamental to the success of the other three action areas of the CHAF over time. CONCLUSIONS: This evidence can provide critical insights for other communities at earlier stages of implementing broad, diverse, multifaceted system change and fills a key evidence gap around building a culture of health from a mature program in a notably multicultural state.

Influences on eating: a qualitative study of adolescents in a periurban area in Lima, Peru.

BACKGROUND: Peruvian adolescents are at high nutritional risk, facing issues such as overweight and obesity, anemia, and pregnancy during a period of development. Research seeking to understand contextual factors that influence eating habits to inform the development of public health interventions is lacking in this population. This study aimed to understand socio-cultural influences on eating among adolescents in periurban Lima, Peru using qualitative methods. METHODS: Semi-structured interviews and pile sort activities were conducted with 14 adolescents 15-17 years. The interview was designed to elicit information on influences on eating habits at four levels: individual (intrapersonal), social environmental (interpersonal), physical environmental (community settings), and macrosystem (societal). The pile sort activity required adolescents to place cards with food images into groups and then to describe the characteristics of the foods placed in each group. Content analysis was used to identify predominant themes of influencing factors in interviews. Multidimensional scaling and hierarchical clustering analysis was completed with pile sort data. RESULTS: Individual influences on behavior included lack of financial resources to purchase food and concerns about body image. Nutrition-related knowledge also played a role; participants noted the importance of foods such as beans for anemia prevention. At the social environmental level, parents promoted healthy eating by providing advice on food selection and home-cooked meals. The physical environment also influenced intake, with foods available in schools being predominantly low-nutrient energy-dense. Macrosystem influences were evident, as adolescents used the Internet for nutrition information, which they viewed as credible. CONCLUSIONS: To address nutrition-related issues such as obesity and iron-deficiency anemia in Peruvian adolescents, further research is warranted to elucidate the roles of certain factors shaping behavior, particularly that of family, cited numerous times as having a positive influence. Addressing nutrition-related issues such as obesity and iron-deficiency anemia in this population requires consideration of the effect of social and environmental factors in the context of adolescent lifestyles on behavior. Nutrition education messages for adolescents should consider the cultural perceptions and importance of particular foods, taking into account the diverse factors that influence eating behaviors.

A Systematic Review of Antimicrobial Resistance During the COVID-19 Pandemic.

Antimicrobial-resistant pathogens, or "superbugs," cause more than 35 000 deaths and more than 2.8 million antibiotic-resistant infections in the US each year. Worldwide, antimicrobial resistance (AMR) has claimed at least 700 000 lives per year, including 230 000 from multi-drug resistant (MDR) tuberculosis. AMR-related deaths are projected to increase to 10 million by the year 2050. The use of biocides, improper prescribing of antibiotics for viral infections, prolonged hospital stays, and other issues contribute to AMR. The purpose of this study was to determine whether the COVID-19 pandemic has had an impact on the rates of AMR globally. While it is still early for the results of research studies, 4 articles indicated an increase, 2 found a decrease, and 2 had mixed results. It is possible that this pandemic may be contributing to an increase of medication-resistant infections.

Using Deliberative Pedagogy as a Tool for Critical Thinking and Career Preparation Among Undergraduate Public Health Students.

Engagement of undergraduate public health students in active learning pedagogy has been identified as critical for recruitment, retention, and career preparation efforts. One such tool for engagement that has proven successful in STEM programs is deliberative pedagogy, where it is used to stimulate student interest in research and policy applications of technical course content. Broadly applied, deliberative pedagogy is a consensus model of decision-making, applied as an in-class exercise, where students work in small groups and model a community task force with assigned group roles. In these groups, students collect evidence from literature and media sources, and prepare a consensus response to an assigned question. Here we present an adaptation of this pedagogy to provide undergraduates with the tools needed to actively engage in public health policy and planning work groups. This adaptation is first applied during an introductory public health course, where it is used as a tool for engagement and excitement, and as a critical thinking exercise. It additionally serves as an opportunity for students to apply information literacy skills and engage with research and policy initiatives discussed in class. The same tool is reintroduced prior to graduation in a capstone course, where the emphasis shifts to application of research skills and analytical concepts. The activity is also an opportunity for students to apply professional skills needed for engagement in program development, program evaluation, institutional policy, and legislative advocacy. Through application of this pedagogical tool at two critical time points in an undergraduate curriculum, students develop skills necessary for early career professionals and are better prepared to actively engage in policy and planning as it relates to critical public health initiatives, both locally and globally.

Identifying perceived barriers and enablers of healthy eating in college students in Hawai'i: a qualitative study using focus groups.

BACKGROUND: To design effective nutrition education interventions for college students, research is needed to determine the factors influencing food choices. The purpose of this study was to identify perceived barriers and enablers of healthy eating in college students ages 18-24 at the University of Hawai'i at Manoa. METHODS: Prior to conducting focus groups, an interview guide was developed based on a literature review of relevant studies. The interview guide was successfully tested in the first focus group and used in the rest of the focus groups. Eleven focus groups with group sizes of two to six were conducted (n = 44). Focus groups were audio-recorded and transcribed. Transcripts were coded in NVIVO11 using content analysis, and additional codes were added to the codebook based on emergent ideas from the transcripts. After completion of the final codebook, transcripts were recoded with the new codebook. Final code counts were used to identify overarching ideas based on the socio-ecological model of health, consisting of four levels of influence: individual (intrapersonal), social environmental (interpersonal), physical environmental (community settings), and macrosystem (societal). RESULTS: The largest barriers according to level of influence in the socio-ecological model were nutrition knowledge deficit (individual), peer pressure (social environmental), unsupportive institutional environment (physical environmental), and cost (macrosystem). The largest enablers were nutrition knowledge (individual), parental influence (social environmental), an institutional environment with consistent healthy offerings (physical environmental), and social media (macrosystem). Some factors served as barriers for some participants and enablers for others, such as parental influence. CONCLUSION: Factors such as individual knowledge and parental support were cited as having a positive influence in promoting healthy eating, while factors such as the cost of living and food availability at college serve as barriers even for motivated students. Results from this study identify potential areas of intervention, such as improving nutrition knowledge (individual), offering more healthy options (physical environmental), or reducing cost of food (macrosystem). However, more research is needed to identify which level of intervention may be most effective in changing food habits, and which barriers or enablers are deciding factors in determining this population's food choices.

Health Literacy in a Social Context: Review of Quantitative Evidence.

BACKGROUND: Conceptual literature has consistently noted that health literacy exists within a social context. This review examined how the intersection of social context and health literacy has been operationalized in quantitative, empirical research. METHODS: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched seven databases, including PubMed and CINAHL (The Cumulative Index to Nursing and Allied Health Literature), using a range of potentially relevant keywords, and we hand-searched bibliographies. Inclusion criteria were quantitative studies of any design in which measurement of health literacy and measurement of social context intersected. We identified 1,052 unduplicated articles; 34 met inclusion criteria. KEY RESULTS: We found three distinct perspectives on the intersection between health literacy and social context. Most common (n = 23) were studies measuring an association between individual health literacy and individual social capital, social support, or social engagement, particularly whether social support varied by health literacy and/or if this relationship mediated health outcomes. Another group of studies (n = 6) took the perspective that being health literate by definition included social context, including access to and/or use of social support as a domain in individual health literacy assessment. Five studies considered the social context of health literacy as an independent property measured beyond the individual level; two measured community-level health literacy and three measured health literacy capacity/concordance in caregiving dyads. The studies showed significant definitional and measurement complexity and overlap. In the most dramatic example, a similar question was used across various studies to measure (1) health literacy, (2) a social support domain in health literacy, (3) social support, and (4) a study outcome distinct from, but associated with, health literacy. Potential useful methods, such as social network analyses, were missing from the literature. DISCUSSION: Existing quantitative research on health literacy in a social context supports more attention to this topic. This review quantified evidence, revealed gaps, noted limitations, and identified important questions for future research. [Health Literacy Research and Practice . 2017;1(2):e41-e70.]. PLAIN LANGUAGE SUMMARY: This study systemically compiles existing quantitative empirical research (34 articles) focusing on the intersection of health literacy in the social context. We find considerable measurement complexity in the current body of work on this topic and identify three distinct perspectives that researchers have taken while considering this topic. This information will be useful for future development of this important research area.

Mapping the Possibilities: Using Network Analysis to Identify Opportunities for Building Nutrition Partnerships Within Diverse Low-Income Communities.

OBJECTIVE: To identify communication and collaboration patterns among organizations involved in nutrition education within an ethnically diverse low-income community. DESIGN: A snowball sample methodology was used to identify 27 organizations involved in nutrition activities in the community. The researchers conducted an online survey and network analysis to identify communication and collaboration patterns among these organizations. SETTING: An urban neighborhood in Honolulu, HI. PARTICIPANTS: Individuals responsible for nutrition activities at state, county, and nonprofit organizations. MAIN OUTCOME MEASURES: Network structure, betweenness, and centralization. ANALYSIS: Communication was uncentralized and collaboration was limited. Collaboration was affected by differences in mission, location, and population served. Child care/youth development organizations and community health centers provided links across the community. Agencies serving different ethnic populations were poorly linked and located on the periphery of the network. Ethnic-specific churches expressed strong interest in nutrition partnership but were not identified as potential partners by other agencies in the network. CONCLUSIONS AND IMPLICATIONS: Limited communication between agencies serving different populations in the same community may result in missed opportunities for collaboration. Network analysis is an effective tool for identifying these gaps and helps build community capacity for improving nutrition outcomes.

Assessing Face Validity of a Food Behavior Checklist for Limited-resource Filipinos.

Diet-related chronic health conditions are prevalent in the Filipino American community; however, there is a lack of rigorously validated nutrition education evaluation tools in Tagalog for use in this population. This study aimed to develop and evaluate the face validity of a Tagalog-language food behavior checklist (FBC). A multi-step method was used, involving translation of questionnaire text from English to Tagalog by a team of professionals, creation of accompanying color photographs, cognitive testing with the target population, final review by the team of professionals, and assessment of readability. Subjects for cognitive testing were men (n=6) and women (n=14) 18 years or older in Hawai'i who received or were eligible to receive Supplemental Nutrition Assistance Program (SNAP) benefits, self-identified as Filipino, and preferred Tagalog rather than English. Participants were recruited from churches, the Filipino Center, and other community sites. Cognitive interviews revealed several issues with text and photographs, such as preferences for specific terms, and images that did not adequately illustrate the text. Image changes were made to reflect items most commonly consumed. The team of professionals agreed with participant suggestions. Assessment of readability revealed a reading level appropriate for a low-literacy population of grade 5.9. The multi-step process, which allowed members of the target audience to reveal the appropriateness of the questionnaire, yielded a Tagalog-language FBC found to have adequate face validity. After further evaluation of validity and reliability, this tool may be used to evaluate behavior change resulting from the United States Department of Agriculture's (USDA) nutrition education programs.

Assessing state-level active living promotion using network analysis.

BACKGROUND: Physical inactivity is a growing problem in the United States, one that is being addressed through the development of active living communities. However, active living promotion requires collaboration among organizations that may not have previously shared goals. METHODS: A network analysis was conducted to assess Hawaii's active living promotion network. Twenty-six organizations playing a significant role in promoting active living in Hawaii were identified and surveyed about their frequency of contact, level of collaboration, and funding flow with other agencies. RESULTS: A communication network was identified linking all agencies. This network had many long pathways, impeding information flow. The Department of Health (DOH) and the State Nutrition and Physical Activity Coalition (NPAC) were central nodes, but DOH connected state agencies while NPAC linked county and voluntary organizations. Within the network, information sharing was common, but collaboration and formal partnership were low. Linkages between county and state agencies, between counties, and between state agencies with different core agendas were particularly low. CONCLUSIONS: Results suggest that in the early stages of development, active living networks may be divided by geography and core missions, requiring work to bridge these divides. Network mapping appears helpful in identifying areas for network development.