Neighborhood-Level Stressors and Individual-Level Cardiovascular Disease Risk in Native Hawaiians: a Cross-Sectional Study.

Introduction: Native Hawaiian people have higher rates of illness and death related to cardiovascular disease (CVD) than non-Hispanic White people. Research in other populations has shown that individual-level CVD risk factors (ie, high-fat diet, physical inactivity, obesity, and tobacco use) are associated with neighborhood characteristics (ie, social cohesion, walkability, availability of healthy food, and safety). This association has yet to be examined among Native Hawaiians. Methods: We conducted a cross-sectional survey of community-dwelling Native Hawaiian people in 2020. Three multiple regression models and 1 logistic regression model were assessed. Each model included individual-level CVD risk factors, age, sex, education, income, and neighborhood characteristics. Results: The regression models for body mass index (BMI) and physical activity showed significant results. The BMI model (R2 = 0.22, F = 4.81, P < .001) demonstrated that age, sex, education level, physical activity, and percentage of fat in the diet were significantly related to BMI. The availability of healthy foods had a significant, independent relationship with BMI (standardized ß = -1.47, SE = 0.53, P = .01). The physical activity model (R2 = 0.21, F = 4.46, P < .001) demonstrated that age, sex, education, and BMI were significantly related to physical activity. None of the neighborhood characteristics had significant, independent relationships to physical activity. Conclusions: We found that neighborhood-level factors improved the model's ability to explain variance in BMI. Efforts to decrease BMI would benefit from improving the availability of healthy foods in neighborhoods, a finding supported by research in other populations.

Food Insecurity and Blood Pressure in a Multiethnic Population.

Food insecurity is a social determinant of health and is increasingly recognized as a risk factor for hypertension. Native Hawaiians bear a disproportionate burden of hypertension and known risk factors. Despite this, the relative effects of food insecurity and financial instability on blood pressure have yet to be investigated in this population. This study examines the relative effects of food insecurity and financial instability on blood pressure, controlling for potential confounders in a multiethnic sample. Participants (n = 124) were recruited from a U.S. Department of Agriculture-funded study called the Children's Healthy Living Center of Excellence. Biometrics (i.e., blood pressure, weight, and height) were measured. Demographics, physical activity, diet, psychosocial variables, food insecurity, and financial instability were assessed via self-report questionnaires. Hierarchical linear regression models were conducted. Model 1, which included sociodemographic variables and known biological risk factors, explained a small but significant amount of variance in systolic blood pressure. Model 2 added physical activity and daily intake of fruit, fiber, and whole grains, significantly improving the model. Model 3 added financial instability and food insecurity, further improving the model (R2 = 0.37, F = 2.67, p = 0.031). Food insecurity, female sex, and BMI were significantly and independently associated with increased systolic blood pressure. These results suggest a direct relationship between food insecurity and systolic blood pressure, which persisted after controlling for physical activity, consumption of fruits, fiber, and whole grains, and BMI. Efforts to reduce food insecurity, particularly among Native Hawaiians, may help reduce hypertension in this high-risk population.

Neighborhood level facilitators and barriers to hypertension management: A Native Hawaiian perspective.

Native Hawaiians have a disproportionately high prevalence of hypertension, which is an important and modifiable risk factor for cardiovascular disease (CVD). To reduce CVD among Native Hawaiians, we must better understand facilitators and barriers to hypertension management (i.e., diet, physical activity, stress reduction) unique to Native Hawaiians. Despite evidence of neighborhood-level facilitators and barriers to hypertension management in other populations, there is limited research in Native Hawaiians. Participants from a randomized controlled trial (n = 40) were recruited for 5 focus groups. All participants were self-reported Native Hawaiians and had uncontrolled hypertension. Discussions elicited experiences and perceptions of neighborhood-level stressors as they relate to participants' hypertension management efforts. Audio recordings were transcribed and analyzed using ATLAS.ti for emergent themes. Five themes were identified: neighborhood description, community resources, neighborhood change, safety, and social connectedness. Novel barriers to hypertension control included loss of culture and loss of respect for elders, change in community feel, and over-development. Facilitators included social cohesion and collective power. These data provide a deeper understanding of how Native Hawaiians experience neighborhood factors and how those factors impact their efforts to improve their diets, physical activity, and stress management. The findings help to inform the development of multilevel CVD prevention programs. Further research is needed to explore the subtheme of social and emotional stress related to neighborhood change and CVD health risk due to cultural and historic trauma references.

Ethnic differences in fast-food advertising exposure and body mass index among Asian American/Pacific Islander and White young adults.

BACKGROUND: Fast-food advertising (FFA) is a potential contributor to obesity. Few studies have examined the relationship between FFA exposure and body mass index (BMI) among young adults. Furthermore, these studies have rarely examined ethnic differences in the relationship between FFA exposure and BMI, specifically across Asian American/Pacific Islander (AAPI) subgroups. OBJECTIVE: This study aimed to investigate ethnic differences in the association between FFA exposure and BMI in a sample of predominantly AAPI young adults. METHODS: Cross-sectional data were collected in 2018 from 2622 young adult college students (ages 18-25 years; 54% women) on O'ahu, Hawai'i. FFA exposure was assessed using a cued-recall measure. Multiple regression and analysis of covariance were used to analyze the data. RESULTS: A significant association was found between higher FFA exposure and higher BMI (p < 0.05; 2-tailed) in the entire sample, adjusting for ethnicity, other demographic variables, and levels of physical activity. However, when examined by ethnic group, the association between FFA exposure and BMI was not statistically significant. A statistically significant main effect of ethnicity on BMI was found. Native Hawaiian/other Pacific Islanders (NHPI) reported the highest mean BMI [27.07 (SD ± 7.74) kg/m2] compared with the other four ethnic groups (p < 0.001). The effect of ethnicity on FFA exposure was not found to be statistically significant. CONCLUSION: FFA exposure appears to adversely influence BMI in a population of predominantly AAPI young adults. Although we did not find ethnic differences in FFA exposure or in the association between FFA exposure and BMI, the current data make a case for similar future investigation with larger subgroup sample sizes. Regulations that curtail FFA exposure among young adults may be needed.

Ethnic and Gender Differences in 10-Year Coronary Heart Disease Risk: a Cross-Sectional Study in Hawai'i.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in the US. In Hawai'i, Filipinos and Native Hawaiians have the highest rates of CVD-related risk factors. CVD risk across these ethnic groups has not been examined. This cross-sectional study examines 10-year CVD risk as determined by the Framingham Risk Score (FRS) across ethnic groups in Hawai'i, controlling for clinical, demographic, and psychosocial factors. METHODS: This study includes secondary data analysis of the Kohala Health Research Project dataset. All non-pregnant adults (≥ 18 years of age) who resided in the community of interest during the study period were eligible to participate with 1462 participants completing the clinical examination and surveys. This analysis included clinical, demographic, and psychosocial variables. Ethnic differences were examined using the chi-squared test and one-way ANOVA. Multiple linear regression on FRS was conducted and least square means of FRS were calculated. RESULTS: Data from 1146 individuals were analyzed. Participants were 44.4% Native Hawaiian, 15.4% Filipino, 15.3% Japanese, and 25% non-Hispanic White; 55.4% were female and had a mean age of 48.8 years. For males, the unadjusted Japanese mean FRS was significantly higher compared with the other ethnic groups. For females, Filipino and Japanese mean FRS were significantly higher compared with Native Hawaiians and non-Hispanic Whites. In the fully adjusted model, there were no ethnic group differences in FRS among males and Filipinos had significantly higher FRS compared with non-Hispanic White among females. CONCLUSIONS: This cross-sectional community-based epidemiological study examined ethnic differences in CVD risk after adjusting for age, depression, social support, and acculturation. The results suggest that some ethnic differences in CVD risk persist even after controlling for confounders but that recalibration of risk assessment is necessary.

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.

Advancing Community-Based Participatory Research to Address Health Disparities in Hawai'i: Perspectives from Academic Researchers.

Community-based participatory research (CBPR) continues to be recognized as an effective research approach in which academic researchers work in partnership with communities to address health disparities. Although the literature suggests benefits associated with CBPR, more needs to be done to advance CBPR to ultimately reduce health disparities. Hawai'i presents a research-rich opportunity for CBPR because of its ethnic diversity and geographic location, resulting in close-knit communities with unique experiences and concerns. This study aims to better understand the experiences of academic researchers who are conducting CBPR in Hawai'i and their perceptions of its benefits and challenges as well as recommendations to advance the field. Twelve academic researchers with Hawai'i-based CBPR experience were interviewed. Four major themes emerged from their responses: the importance of prioritizing relationship-building; reciprocal learning and other benefits of CBPR; navigating the tensions between CBPR and funding priorities; and building an academic setting that supports CBPR. Increasing awareness of CBPR and its benefits, as well as transforming the culture in all spaces where CBPR occurs may maximize its potential to ultimately promote health equity.

An Examination of the Relationship between Discrimination, Depression, and Hypertension in Native Hawaiians.

Native Hawaiians bear a disproportionate burden of hypertension. Discrimination and depression are potential hypertension risk factors. Although the relationship between discrimination and depression is well established, how these factors affect hypertension risk in indigenous populations remains unknown. We examined the relationship between discrimination, depression, and hypertension in adult Native Hawaiians. We hypothesized that greater frequency of perceived discrimination and greater frequency of depressive symptoms would independently increase the likelihood of having hypertension. Surveys were mailed to 540 adult Native Hawaiians residing on five Hawaiian Homesteads. The surveys measured: hypertension status, sociodemographic factors (age, gender, income, employment status), body mass index (BMI), physical activity frequency, smoking, Hawaiian cultural affiliation, American cultural affiliation, perceived discrimination, and depressive symptoms. Respondents (n=171) were mostly female (71%), a mean age of 57yrs, and 54% reported having hypertension. The logistic regression model included perceived discrimination, depression, BMI, frequency of vigorous physical activity, and Hawaiian cultural affiliation, and sociodemographic variables. The model showed that Hawaiian cultural affiliation and discrimination were significantly related to hypertension status. Depression was not related to hypertension status. Interaction analysis found that for individuals with lower Hawaiian cultural affiliation, frequent perceived discrimination was significantly associated with lower odds of having hypertension. The negative association between perceived discrimination and hypertension status was opposite from hypothesized. However, the interaction suggests this relationship holds only for less culturally affiliated individuals. These results underscore the varied nature of hypertension determinants and may have clinical implications for the treatment of hypertension in Native Hawaiians.

Culturally responsive approaches to health promotion for Native Hawaiians and Pacific Islanders.

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.

Comparing Weight Loss-Maintenance Outcomes of a Worksite-Based Lifestyle Program Delivered via DVD and Face-to-Face: A Randomized Trial.

BACKGROUND: Native Hawaiians and other Pacific Islanders have high rates of overweight and obesity compared with other ethnic groups in Hawai'i. Effective weight loss and weight loss-maintenance programs are needed to address obesity and obesity-related health inequities for this group. AIMS: Compare the effectiveness of a 9-month, worksite-based, weight loss-maintenance intervention delivered via DVD versus face-to-face in continued weight reduction and weight loss maintenance beyond the initial weight loss phase. METHOD: We tested DVD versus face-to-face delivery of the PILI@Work Program's 9-month, weight loss-maintenance phase in Native Hawaiian-serving organizations. After completing the 3-month weight loss phase, participants ( n = 217) were randomized to receive the weight loss-maintenance phase delivered via trained peer facilitators or DVDs. Participant assessments at randomization and postintervention included weight, height, blood pressure, physical functioning, exercise frequency, and fat intake. RESULTS: Eighty-three face-to-face participants were retained at 12 months (74.1%) compared with 73 DVD participants (69.5%). There was no significant difference between groups in weight loss or weight loss maintenance. The number of lessons attended in Phase 1 of the intervention (ß = 0.358, p = .022) and baseline systolic blood pressure (ß = -0.038, p = .048) predicted percent weight loss at 12 months. DISCUSSION AND CONCLUSION: Weight loss maintenance was similar across groups. This suggests that low-cost delivery methods for worksite-based interventions targeting at-risk populations can help address obesity and obesity-related disparities. Additionally, attendance during the weight loss phase and lower baseline systolic blood pressure predicted greater percent weight loss during the weight loss-maintenance phase, suggesting that early engagement and initial physical functioning improve long-term weight loss outcomes.

Self-Reported Experiences of Discrimination and Depression in Native Hawaiians.

Discrimination is an acute and chronic stressor that negatively impacts the health of many ethnic groups in the United States. Individuals who perceive increased levels of discrimination are at risk of experiencing psychological distress and symptoms of depression. No study to date has examined the relationship between perceived discrimination and mental health in Native Hawaiians. The purpose of this study is to explore the relationship between perceived discrimination and depression based on the Homestead Health Survey mailed to Native Hawaiian residents of Hawaiian Home Lands. This study also explores the role of cultural identity and how it may impact experiences of discrimination and symptoms of depression. Based on cross-sectional data obtained from 104 Native Hawaiian residents, a significant positive correlation was found between perceived discrimination and symptoms of depression (r= 0.32, P<.001). Cultural identity did not significantly correlate with discrimination or depression. Multiple linear regression analyses indicate that the relationship between depression and discrimination remained statistically significant (coefficient estimate of 0.18; P<.01), after accounting for differences in socio-demographics and degree of identification with the Native Hawaiian and American cultures. These findings are consistent with other studies that have focused on the effects of discrimination on psychological wellbeing for other ethnic minority populations.

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.

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.