Kupuna "Older Adults" COVID-19 Vaccination Efforts in Hawai'i: Barriers and Successes.

Prior to the availability of vaccines, kupuna (older adults) accounted for the majority of COVID-19 hospitalizations and deaths. Hawaii's phased vaccine-release plan prioritized kupuna, but it did not include guidance or strategies for kupuna to get to mass vaccination sites, for those residing in care and foster homes, or for the homebound. This paper presents findings from statewide efforts to facilitate a quick uptake of vaccines among kupuna of all ability levels. Researchers interviewed 32 individuals involved in kupuna vaccination efforts from state and county government agencies, health care organizations, and non-profit organizations. Data on the percentage of kupuna that initiated and completed the vaccination series by age group and island were obtained from the Hawai'i State Department of Health COVID-19 Dashboard. Overall, kupuna vaccination efforts across the state were successful. By July 30, 2021, 94% of adults age 65+ were vaccinated, although prevalence varied by county-from 88% on Maui to 98% on Kaua'i. Key barriers included cumbersome online systems for scheduling vaccination appointments, difficulties for some elders in accessing mass vaccination sites, and the need for education and consent forms in multiple languages. Successful strategies included funding coalitions for effective partnerships, establishing county- and language-specific call centers, and supporting translation/interpretation services, mobile and pop-up clinics, and mechanisms for in-home vaccinations. Hawai'i worked hard to facilitate the quick uptake of COVID-19 vaccines among older adults. Funding for coalitions that could identify gaps, coordinate expertise across public and private sectors, and advocate for elders were crucial elements of the state's success.

Scoping Review of Interventional Studies in Chronic Disease for Native Hawaiian, Pacific Islander, and Filipino Populations in the United States.

Native Hawaiians (NHs), Pacific Islanders (PIs), and Filipinos experience health disparities in the United States (US) and need interventions that work for them. The purpose of this paper is to present a review of interventions designed to address chronic disease in Native Hawaiian, Pacific Islander, and Filipino populations in the US that were tested for clinical impact through a randomized controlled trial (RCT). Articles were identified through a search of 4 databases, citation chasing, and colleagues. The 23 included articles reported on 21 interventions addressing 4 chronic conditions-cancer, obesity, cardiovascular disease, and diabetes. All projects were guided by advisory groups, and all interventions were theory-based and tailored to the population, with culturally- and language-appropriate educational materials delivered by same-race individuals in familiar church, club, or home settings. About half were tested through cluster RCT. The majority of the interventions were successful, confirming the value of developing and delivering interventions in partnership with community. Given the growing numbers of NHs, PIs, and Filipinos in the US, more investigational studies are needed to develop and test culturally tailored and grounded interventions that meet the health needs of these populations.

Health Disparities Investigator Development through a Team-Science Pilot Projects Program.

Profound health disparities are widespread among Native Hawaiians, other Pacific Islanders, and Filipinos in Hawai'i. Efforts to reduce and eliminate health disparities are limited by a shortage of investigators trained in addressing the genetic, socio economic, and environmental factors that contribute to disparities. In this conference proceedings report from the 2022 RCMI Consortium National Conference, we describe our mentoring program, with an emphasis on community-engaged research. Elements include our encouragement of a team-science, customized Pilot Projects Program (PPP), a Mentoring Bootcamp, and a mentoring support network. During 2017-2022, we received 102 PPP preproposals. Of these, 45 (48%) were invited to submit full proposals, and 22 (19%) were awarded (8 basic biomedical, 7 clinical, 7 behavioral). Eighty-three percent of awards were made to early-career faculty (31% ethnic minority, 72% women). These 22 awards generated 77 related publications; 84 new grants were submitted, of which 31 were awarded with a resultant return on investment of 5.9. From 5 to 11 investigators were supported by PPP awards each year. A robust usage of core services was observed. Our descriptive report (as part of a scientific conference session on RCMI specialized centers) focuses on a mentoring vehicle and shows how it can support early-stage investigators in pursuing careers in health disparities research.

The Lives of Native Hawaiian Elders and Their Experiences With Healthcare: A Qualitative Analysis.

Native Hawaiians are proud and resilient people who have endured significant impacts from colonization. Despite being in a time of vibrant cultural revitalization, Native Hawaiians have a shorter life expectancy than other racial and ethnic groups in Hawai'i. The primary aim of this paper was to share data from the first year of a 5-year study with Native Hawaiian kupuna (elders) on their experiences with healthcare, along with barriers to accessing healthcare. Ten kupuna living in rural areas of Hawai'i participated in three interviews each, which were held in an informal, talk-story style. The first interview focused on establishing rapport. The second interview focused on the kupuna's strengths, resiliencies, and what they would like to pass to the next generation. The third interview focused on the elders' experiences with healthcare, which is the focus of this paper. All ten kupuna reported growing up with limited access to Western healthcare; rather, their families successfully treated many illnesses and injuries with la'au lapa'au (Hawaiian herbal medicine) and other traditional healing practices, as they had done for generations. As Western medicine became more prevalent and accessible, they used both, but many preferred holistic treatments such as prayer, a return to the traditional diet, and la'au lapa'au. As a group, the kupuna rated their health as fair to good; two had diabetes, two had cardiovascular disease, four had neuropathies, and five were cancer survivors. The kupuna reported high turnover among providers in rural communities. Limited access to specialists often required them to travel to Honolulu for care, which was costly and especially difficult during coronavirus disease 2019 (COVID-19). Regardless of provider ethnicity, the kupuna appreciated those who took the time to get to know them as people and respected Hawaiian cultural practices. They advised that Western providers speak honestly and directly, have compassion, and build connections to patients and their communities.

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.

Neighborhood Social Cohesion and the Health of Native Hawaiian and Other Pacific Islander Older Adults.

Native Hawaiian and other Pacific Islander (NHPI) older adults experience various social and health challenges. There is a growing literature linking neighborhood conditions with health, yet few have focused on NHPI older adults. This study examines associations between neighborhood social cohesion and health outcomes (i.e., self-rated health, psychological distress, and memory) in this population. Data from the 2014 Native Hawaiian and Pacific Islander National Health Interview Survey (n=1,045 with respondents aged 50+) were analyzed with logistic regression models. The level of neighborhood social cohesion was determined by responses to items on perceptions of mutual help, dependability, trust, and close relationships within the neighborhood. Higher perceived neighborhood social cohesion was associated with lower odds of having serious psychological distress or memory problems. There was no statistical association of social cohesion with self-rated health. Socially cohesive neighborhoods are important to the health of NHPI. We discuss methods to improve neighborhood social cohesion as a way to promote health equity for NHPI older adults in the United States (U.S.).

Physical Activity and Health Among Native Hawaiian and other Pacific Islander Older Adults.

Objectives: Native Hawaiian and other Pacific Islander (NHPI) older adults often experience social disadvantages and poor health outcomes. Physical activity has been associated with better health in other racial groups, but limited studies have examined these associations in NHPI older adults. Methods: Using data from the 2014 Native Hawaiian and Pacific Islander National Health Interview Survey (n = 1,045), logistic regression models examined associations between physical activity and memory/psychological distress/self-rated health. Results: Sufficient levels of physical activity were associated with lower odds of memory problems, serious psychological distress, and poor/fair self-rated health. Unfortunately, only half of the sample reported sufficient physical activity and approximately 30% reported none. Also, 78% of the sample was estimated to be overweight/obese, and 29% had diabetes. Discussion: Culturally-appropriate interventions are recommended to increase physical activity in this population, which could also help reduce high rates of overweight/obesity and diabetes.

Developing a culturally responsive dementia storybook with Native Hawaiian youth.

Similar to the nation's majority and racial/ethnic minority populations, Native Hawaiian families provide the bulk of care to loved ones with dementia. Limited research has focused on youth caregivers, who are largely invisible to the eldercare service system. This knowledge gap is especially critical for Native Hawaiians who place a high value on eldercare, often provided in multigenerational homes. To address this gap, we describe the process by which a university-community center developed a culturally responsive storybook on dementia targeted to Native Hawaiian youth. The development process honored community-based participatory research principles grounded in the cultural values and practices of Native Hawaiians, active collaboration of an advisory council, and face-to-face engagement with Native Hawaiian youth. Future directions are shared about culture-based programming and evaluation in dementia care that may be useful in work with other racial/ethnic youth and families.

Community Engagement Practices at Research Centers in U.S. Minority Institutions: Priority Populations and Innovative Approaches to Advancing Health Disparities Research.

This paper details U.S. Research Centers in Minority Institutions (RCMI) Community Engagement Cores (CECs): (1) unique and cross-cutting components, focus areas, specific aims, and target populations; and (2) approaches utilized to build or sustain trust towards community participation in research. A mixed-method data collection approach was employed for this cross-sectional study of current or previously funded RCMIs. A total of 18 of the 25 institutions spanning 13 U.S. states and territories participated. CEC specific aims were to support community engaged research (94%); to translate and disseminate research findings (88%); to develop partnerships (82%); and to build capacity around community research (71%). Four open-ended questions, qualitative analysis, and comparison of the categories led to the emergence of two supporting themes: (1) establishing trust between the community-academic collaborators and within the community and (2) building collaborative relationships. An overarching theme, building community together through trust and meaningful collaborations, emerged from the supporting themes and subthemes. The RCMI institutions and their CECs serve as models to circumvent the historical and current challenges to research in communities disproportionately affected by health disparities. Lessons learned from these cores may help other institutions who want to build community trust in and capacities for research that addresses community-related health concerns.

Effectiveness of mHealth Interventions for Improving Contraceptive Use in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: mHealth interventions are being tested to improve contraceptive uptake in low- and middle-income countries (LMICs); however, the effectiveness of these interventions has not been systematically reviewed. OBJECTIVES: The primary objective of this systematic review was to assess the effectiveness of mHealth interventions to improve contraceptive uptake and adherence in LMICs. A second objective was to identify mHealth features and behavior change communication components used in these mHealth interventions. METHODS: A systematic search was conducted of online databases for peer-reviewed articles that reported on intervention studies with men and women from LMICs and measured mHealth intervention impact on contraceptive uptake and/or adherence. Key search terms included "mHealth" or "mobile health," "contraception" or "family planning," and "low- and middle-income countries." PRISMA guidelines were followed for reporting review methods and findings. The Cochrane risk-of-bias 2 tool for randomized trials was used to assess the risk of bias of the included studies. The GRADE approach was used to determine the quality of evidence. RESULTS: Eight randomized controlled trial studies met the inclusion criteria. Four studies experienced implementation challenges (e.g., intervention components were not utilized fully by participants, intervention participants did not receive the full intervention content, contamination, low response rate, and/or missing data). Only 3 interventions were found to be effective, and these included a "push" approach, interactive communication, information tailored to participants, motivational messaging, and male partner involvement. CONCLUSION: To date, the delivery of mHealth interventions for improving family planning in LMICs has met with implementation challenges that have reduced the researcher's ability to test intervention effectiveness. Although 3 of 8 studies found improved contraceptive use in the intervention group, the review cannot draw concrete conclusions on the overall effectiveness of mHealth interventions to increase contraceptive use in LMICs. Further research with robust program fidelity is recommended.

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.

Insights in Public Health: Outpatient Care Gaps for Patients Hospitalized with Ambulatory Care Sensitive Conditions in Hawai'i: Beyond Access and Continuity of Care.

Ambulatory care sensitive conditions (ACSCs) are conditions that can generally be managed in community-based healthcare settings, and, if managed well, should not require hospital admission. A 5-year, mixed methods study was recently concluded that (1) documented disparities in hospitalizations for ACSCs in Hawai'i through quantitative analysis of state-wide hospital discharge data; and (2) identified contributing factors for these hospitalizations through patient interviews. This Public Health Insights article provides deeper context for, and consideration of, a striking study finding: the differences between typical measures of access to care and the quality of patient/provider interactions as reported by study participants. The themes that emerged from the patients' stories of their own potentially preventable hospital admissions shed light on the importance of being heard, trust, communication, and health knowledge in their relationships with their providers. We conclude that improving the quality of the relationship and level of engagement between the patient and community/outpatient providers may help reduce hospitalizations for ACSCs in Hawai'i and beyond. These interpersonal-level goals should be supported by systems-level efforts to improve health care delivery and address health disparities.

Examining Long-Term Service and Support Needs and Preferences of Native Hawaiian Elders: A Mixed-Method Approach.

Objective: The Native Hawaiian population experiences numerous disparities in health and income. Using a mixed-method research (MMR) design, we summarize findings from three phases of an MMR approach used to uncover kupuna (elder) long-term service and support (LTSS) needs and care preferences. Methods: Key informants in Hawaiian health were interviewed, secondary analyses of large state data sets were conducted, and kupuna and "ohana (family) caregivers were engaged in listening sessions. Results: Quantitative data confirmed numerous health disparities experienced by older Native Hawaiians, whereas qualitative data exposed their limited knowledge of this poor health profile and revealed their historical and contemporary experiences with discrimination in education, employment, and health care. Hawaiian culture was identified as a continued source of resilience in support of elders and family caregiving regardless of geographic setting. Discussion: We suggest three practice, policy, and research directions that offer the potential to respond to and improve kupuna health and service use.

Estimating intervention dose of the multilevel multisite children's healthy living program intervention.

Increased community collective efficacy (CE), defined as social cohesion among neighbors and their willingness to intervene for common good, is associated with improved community health outcomes. However, processes to increase CE and estimate its dose within an intervention are not well understood. The 2 year Children's Healthy Living (CHL) intervention aimed to improve child behaviors known to affect obesity. We used data from CHL to estimate CE dose and examine its association with a successful outcome from CHL-reduction in children's recreational screen time. Monthly reports from nine intervention communities were quantified, and CE dose was calculated for each community overall, at 4 time intervals (6, 12, 18, and 24 months), and for each CE building block-social bonding, social bridging, social leveraging, empowerment, and civic engagement. CE dose at each time interval and change in screen time was correlated using Spearman's rho. Next, communities were categorized as having a high CE dose or a low CE dose, and differences between four high-dose and five low-dose communities were compared using a two-tailed t-test. The correlation between change in screen time and CE dose was significant (rs = 0.83, p = .003). Significantly more activities facilitating empowerment and civic engagement were conducted in high-dose communities, which were more likely to show improvements in screen time, than in low-dose communities. This method of estimating an intervention's CE dose and examining change over time and effect of CE and its building blocks on intervention outcomes shows promise.

HPV vaccination prevalence, parental barriers and motivators to vaccinating children in Hawai'i.

Objective: To determine the prevalence and barriers to human papillomavirus (HPV) vaccine uptake among 11-18 year olds in the Hawai'i's four major ethnic groups-Native Hawaiians, Filipinos, Japanese, and Caucasians. Study design: A telephone survey assessed parents' knowledge of HPV and the HPV vaccine, status of their child's HPV vaccine uptake, variables operationalizing the Health Belief Model, and barriers and motivators to uptake. Results: Across the groups, 799 parents completed the survey. About 35% of daughters and 19% of sons had received all three shots. Although ethnic differences in vaccine uptake were seen in bivariate analysis (with significantly lower uptake in Filipino youth), in multivariable logistic regression analysis, only Caucasian parents were significantly less likely to start their sons on the HPV vaccine series compared with Japanese parents (reference group). Having heard about the vaccine, believing in its effectiveness, and older age of the child were also associated with vaccine uptake. Motivators for HPV vaccination were physician's recommendation and wanting to protect one's child. The primary barrier to uptake was lack of knowledge about the vaccine. Conclusions: Findings reinforce the fact that a physician's recommendation and receipt of information about the vaccine are strong motivators for parents to vaccinate their children, regardless of ethnicity.

Correction to: Native Hawaiian Views on Biobanking.

The original version of this article unfortunately contained a mistake. The name of "Maile Taualii" is now corrected in the author group of this article.