Exploring Native Hawaiian and Pacific Islander Youths' E-Cigarette Resistance Strategies: Implications for Tobacco Product Use Prevention.

This study examined the e-cigarette and vaping resistance strategies used by Native Hawaiian and Pacific Islander (NHPI) youths in rural Hawai'i. Focus groups (N = 17) were conducted in eight geographically dispersed elementary, middle/intermediate, and multilevel schools in low-income communities on Hawai'i Island. Sixty-nine youths (67% NHPI, Mage = 12.5 years) participated in this study. The resistance strategies discussed across the greatest number of groups were "refuse" (saying no), "explain" (providing reasons for vaping refusal), "avoid" (avoiding people or places where e-cigarettes were used), and "leave" (walking away from a situation where e-cigarettes were being used). Participants described the challenges in using these strategies within contexts characterized by widespread peer and family vaping and strong social demands to use e-cigarettes. The findings suggest the need for multi-level interventions based on youths' resistance strategies to meaningfully reduce youth vaping use in rural and/or NHPI communities.

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.

Experiences of Discrimination Among Native Hawaiians and Pacific Islanders Living in the USA.

Experiences of racism and discrimination are stressors that adversely affect the well-being of marginalized populations, including Native Hawaiians and Pacific Islanders (NHPI). However, commonly used data aggregation methods obscure information on NHPI communities and their lived experiences. The aim of our study is to understand the types and frequency of discrimination experienced by NHPI adults in the USA. The study utilized online survey data collected from 252 NHPI adults living in the USA between September and October 2021. Younger NHPI adults, those who report constantly thinking about their race/ethnicity, and those who are socially assigned a race/ethnicity that does not match their own report experiencing more types of discrimination. NHPI who constantly think about their race/ethnicity and those who are socially assigned a race/ethnicity that does not match their own report a greater frequency of discrimination. Findings indicate the need to understand the experiences of discrimination in this population.

Racial Misclassification, Discrimination, Consciousness, and Self-Rated Health Among Native Hawaiian and Pacific Islander Adults in the USA.

BACKGROUND: Medical researchers have historically utilized the variable of race uncritically, rarely defining race, rarely acknowledging it as a social construct, and often omitting information about how it was measured. In this study, we use the following definition of race: "a system of structuring opportunity and assigning value based on the social interpretation of how one looks." We examine the influence of racial misclassification, racial discrimination, and racial consciousness on the self-rated health of Native Hawaiian and Pacific Islanders (NHPI) living in the United States of America (USA). METHODS: Our analysis used online survey data from a subgroup of NHPI adults living in the USA (n = 252) who were oversampled as part of a larger study of US adults (N = 2022). Respondents were recruited between September 7, 2021 and October 3, 2021, from an online opt-in panel of individuals across the USA. Statistical analyses include weighted and unweighted descriptive statistics for the sample, as well as a weighted logistic regression for poor/fair self-rated health. RESULTS: Odds of poor/fair self-rated health were greater for women (OR = 2.72; 95% CI [1.19, 6.21]) and those who experienced racial misclassification (OR = 2.90; 95% CI [1.20, 7.05]). No other sociodemographic, healthcare, or race-related variables were significantly associated with self-rated health in the fully adjusted results. CONCLUSIONS: Findings suggest that racial misclassification may be an important correlate of self-rated health among NHPI adults in the US context.

No Kakou, Na Kakou - For Us, By Us: Native Hawaiians and Pacific Islanders Informing Race Data Collection Standards for Hawai'i.

This article describes recommendations for standardized race data collection developed by the Hawai'i Native Hawaiian and Pacific Islander COVID-19 Response, Recovery, and Resilience Team (NHPI 3R Team). These recommendations attempt to address the expressed desires of Native Hawaiians and the diverse Pacific Islander communities in Hawai'i who seek greater visibility in data and research. The Native Hawaiian and Pacific Islander (NHPI) racial category is 1 of the 5 racial categories listed in the 1997 Statistical Policy Directive #15 issued by the Office of Management and Budget (OMB). The OMB directive sets the minimum standard for collection of race data in federal surveys, administrative forms, records, and other data collection. The NHPI 3R Team's recommendation provides a standard for detailed data collection that could improve smaller communities' ability to identify, advocate for, and address their own needs. The article also describes lessons learned through the collaborative and iterative process that was led by members and leaders of NHPI communities impacted by data driven decisions and policies. The NHPI 3R Team focused on expanding and standardizing race data collection as part of their COVID-19 response efforts, but implementation of the recommendations could produce benefits well beyond the pandemic.

The Hawai'i NHPI Data Disaggregation Imperative: Preventing Data Genocide Through Statewide Race and Ethnicity Standards.

Federal race and ethnicity data standards are commonly applied within the state of Hawai'i. When a multiracial category is used, Native Hawaiians are disproportionately affected since they are more likely than any other group to identify with an additional race or ethnicity group. These data conventions contribute to a phenomenon known as data genocide - the systematic erasure of Indigenous and marginalized peoples from population data. While data aggregation may be unintentional or due to real or perceived barriers, the obstacles to disaggregating data must be overcome to advance health equity. In this call for greater attention to relevant social determinants of health through disaggregation of race and ethnicity data, the history of data standards is reviewed, the implications of aggregation are discussed, and recommended disaggregation strategies are provided.

Ethnic differences in respiratory disease for Native Hawaiians and Pacific Islanders: Analysis of mediation processes in two community samples.

OBJECTIVE: The prevalence of asthma and chronic obstructive pulmonary disorder (COPD) is elevated for Native Hawaiians but the basis for this differential is not well understood. We analyze data on asthma and COPD in two samples including Native Hawaiians Pacific Islanders, and Filipinos to determine how ethnicity is related to respiratory disease outcomes. METHODS: We analyzed the 2016 and 2018 Behavioral Risk Factor Surveillance Survey (BRFSS), a telephone survey of participants ages 18 and over in the State of Hawaii. Criterion variables were a diagnosis of asthma or COPD by a health professional. Structural equation modeling tested how five hypothesized risk factors (cigarette smoking, e-cigarette use, second-hand smoke exposure, obesity, and financial stress) mediated the ethnic differential in the likelihood of disease. Age, sex, and education were included as covariates. RESULTS: Structural modeling with 2016 data showed that Native Hawaiian ethnicity was related to higher levels of the five risk factors and each risk factor was related to a higher likelihood of respiratory disease. Indirect effects were statistically significant in almost all cases, with direct effects to asthma and COPD also observed. Mediation effects through comparable pathways were also noted for Pacific Islanders and Filipinos. These findings were replicated with data from the 2018 survey. CONCLUSIONS: Native Hawaiian and Pacific Islander ethnicity is associated with greater exposure to five risk factors and this accounts in part for the ethnic differential in respiratory disease outcomes. The results support a social-ecological model of health disparities in this population. Implications of the findings for preventive interventions are discussed.

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.

Ethnicity, Coronavirus Disease-Related Stress, and E-cigarette Use and Cigarette Smoking Among Young Adults: A Longitudinal Study.

INTRODUCTION: Research has rarely examined ethnic differences in exposure to coronavirus disease (COVID)-related stress in relation to smoking and e-cigarette use. AIMS AND METHODS: Using pre- and post-COVID data from a sample of predominantly Asian American (AA) and Native Hawaiian and Pacific Islander (NHPI) young adults, this study aimed to test the effects of ethnicity on cigarette smoking and e-cigarette use through exposure to COVID-related stress. Young adults from Hawaii who provided pre-COVID data in or before January 2020 were followed up with in March-May 2021. N = 1907 (mean age = 24.9 [SD = 2.9], 56% women) provided complete data relevant to the current analysis at both waves of data collection. Structural equation modeling was used to test the effects of ethnicity (white, Asian [eg, Japanese, Chinese], Filipino, NHPI, and other) on pre- to post-COVID changes in cigarette and e-cigarette use via effects on COVID-related stress. RESULTS: Relative to Asian young adults, members of all other ethnic groups (NHPI, Filipino, white, and other) indicated greater exposure to COVID-related stress. Higher levels of COVID-related stress were associated with increased dual-use status and increased current e-cigarette and cigarette use frequencies. Higher COVID-related stress mediated the effects of NHPI, Filipino, and other ethnicity on increased dual-use status. CONCLUSIONS: The current data indicate that young adults of vulnerable ethnic groups who experience higher COVID-related stress are at increased risk for dual use of cigarettes and e-cigarettes. IMPLICATIONS: The findings imply that tobacco use prevention and treatment efforts may need to pay increased attention to racial or ethnic groups that have experienced greater adverse impact of the COVID-19 pandemic.

Prevalence of cardiovascular disease among Asian, Pacific Islander and multi-race populations in Hawai'i and California.

BACKGROUND: Cardiovascular disease (CVD) remains the leading cause of death in the US. CVD incidence is influenced by many demographic, clinical, cultural, and psychosocial factors, including race and ethnicity. Despite recent research, there remain limitations on understanding CVD health among Asians and Pacific Islanders (APIs), particularly some subgroups and multi-racial populations. Combining diverse API populations into one study group and difficulties in defining API subpopulations and multi-race individuals have hampered efforts to identify and address health disparities in these growing populations. METHODS: The study cohort was comprised of all adult patients at Kaiser Permanente Hawai'i and Palo Alto Medical Foundation in California during 2014-2018 (n = 684,363). EHR-recorded ICD-9 and ICD-10 diagnosis codes were used to indicate coronary heart disease (CHD), stroke, peripheral vascular disease (PVD), and overall CVD. Self-reported race and ethnicity data were used to construct 12 mutually exclusive single and multi-race groups, and a Non-Hispanic White (NHW) comparison group. Logistic regression models were used to derive prevalence estimates, odds ratios, and confidence intervals for the 12 race/ethnicity groups. RESULTS: The prevalence of CHD and PVD varied 4-fold and stroke and overall CVD prevalence varied 3-fold across API subpopulations. Among Asians, the Filipino subgroup had the highest prevalence of all three CVD conditions and overall CVD. Chinese people had the lowest prevalence of CHD, PVD and overall CVD. In comparison to Native Hawaiians, Other Pacific Islanders had significantly higher prevalence of CHD. For the multi-race groups that included Native Hawaiians and Other Pacific Islanders, the prevalence of overall CVD was significantly higher than that for either single-race Native Hawaiians or Other Pacific Islanders. The multi-race Asian + White group had significantly higher overall CVD prevalence than both the NHW group and the highest Asian subgroup (Filipinos). CONCLUSIONS: Study findings revealed significant differences in overall CVD, CHD, stroke, and PVD among API subgroups. In addition to elevated risk among Filipino, Native Hawaiian, and Other Pacific Islander groups, the study identified particularly elevated risk among multi-race API groups. Differences in disease prevalence are likely mirrored in other cardiometabolic conditions, supporting the need to disaggregate API subgroups in health research.

Developing culturally-responsive health promotion: insights from cultural experts.

Culturally-responsive health promotion initiatives are important to the creation of health equity for Indigenous and minority populations and these initiatives are complex and time-intensive to establish. The knowledge and resources of cultural experts are often pivotal in programs, yet there is minimal research on effective collaborations. The KaHOLO Project demonstrated strong success in the management of uncontrolled hypertension in the high-risk Indigenous population through a 6-month program based on the Hawaiian cultural dance of hula. This program was developed utilizing a community-based participatory research approach and implemented by cultural experts. To better understand the effectiveness of the research endeavor and program, six experienced hula experts and educators who delivered the community-based program were interviewed. As skilled and trusted cultural experts they set a safe supportive learning environment that promoted health and cultural goals. They articulated it was important that the program maintained cultural priorities and integrity. Through the methodical establishment of mutual respect, cooperation on research protocols and requirements was achieved. The development of cultural experts as health allies offers important inroads to the inclusion of minority and Indigenous cultures in health programming.

Culturally-responsive health promotion initiatives are important to the creation of health equity for Indigenous and minority populations and these initiatives are complex and time-intensive to establish. The knowledge and resources of cultural experts are often pivotal in programs, yet there is minimal research on effective collaborations. The KaHOLO Project demonstrated strong success in the management of uncontrolled hypertension in the high-risk Indigenous population through a 6-month program based on the Hawaiian cultural dance of hula. This program was developed utilizing a community-based participatory research approach and implemented by cultural experts. To better understand the effectiveness of the research endeavor and program, six experienced hula experts and educators who delivered the community-based program were interviewed. As skilled and trusted cultural experts they set a safe supportive learning environment that promoted health and cultural goals. They articulated it was important the program maintained cultural priorities and integrity. Through the methodical establishment of mutual respect, cooperation on research protocols and requirements was achieved. The development of cultural experts as health allies offers important inroads to the inclusion of minority and Indigenous cultures in health programming.

Traditional and new lifestyle interventions to prevent breast cancer recurrence (TANICA): a qualitative study.

PURPOSE: Breast cancer is the second cause of death from cancer in Guam and Hawai'i and disproportionately impacts Native Hawaiian, CHamoru, and Filipino women. Although a few culturally informed interventions addressing breast cancer survivorship exist, none have been developed or tested for Native Hawaiian, CHamoru, and Filipino women. To address this, the TANICA study began with key informant interviews in 2021. METHODS: Purposive sampling and grounded theory approaches were used to conduct semi-structured interviews with individuals experienced in providing healthcare or implementing community programs and/or research with ethnic groups of interest in Guam and Hawai'i. A literature review and expert consultation identified intervention components, engagement strategies, and settings. Interview questions aimed to understand the relevance of evidence-based interventions and explored socio-cultural factors. Participants completed demographics and cultural affiliation surveys. Interviews were independently analyzed by trained researchers. Themes were mutually agreed upon by reviewers and key themes were identified based on frequencies. RESULTS: Nineteen interviews were conducted in Hawai'i (n=9) and Guam (n=10). Interviews confirmed the relevance of most of the previously identified evidence-based intervention components for Native Hawaiian, CHamoru, and Filipino breast cancer survivors. Ideas around culturally responsive intervention components and strategies emerged that were shared across and unique to each ethnic group and site. CONCLUSION: Evidence-based intervention components appear relevant, yet cultural and place-based strategies are needed for Native Hawaiian, CHamoru, and Filipino women in Guam and Hawai'i. Future research should triangulate these findings with the lived experiences of Native Hawaiian, CHamoru, and Filipino breast cancer survivors to develop culturally informed interventions.

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.

A Cluster Randomized Controlled Trial Comparing Diabetes Prevention Program Interventions for Overweight/Obese Marshallese Adults.

This study compared the effectiveness of two Diabetes Prevention Program (DPP) interventions on weight loss among overweight and obese Marshallese adults. The study was a two-arm cluster randomized controlled trial conducted in 30 churches in Arkansas and Oklahoma. Marshallese adults with a body mass index ≥25 kg/m2 were eligible for the study. The study sample included 380 participants. Participants received either a faith-based adaptation of the DPP or a family-focused adaptation of the DPP, each delivered over 24 weeks. The primary outcome was weight change from baseline. Secondary outcomes included changes in Hemoglobin A1c, blood pressure, dietary intake, family support for healthy behaviors, and physical activity. Outcomes were examined longitudinally using general linear mixed effects regression models, adjusting for baseline outcomes, sociodemographic covariates, and clustering of participants within churches. Reductions in weight were small for both groups. Overall, only 7.1% of all participants lost 5% or more of their baseline body weight. There were no significant differences in weight loss between the 2 arms at 6 months (P = .3599) or at 12 months (P = .3207). Significant differences in systolic and diastolic blood pressure were found between the 2 arms at 6 months (P = .0293; P = .0068, respectively). Significant within-arm changes were found for sugar-sweetened beverage consumption and family support for both arms at both follow-ups. Both interventions achieved a modest weight loss. While even modest weight loss can be clinically significant, future research is needed to identify chronic disease prevention interventions that can successfully reduce weight for this at-risk population.

Prevalence of Dementia in American Indians and Alaska Natives Compared to White, Black, and Hispanic Medicare Beneficiaries: Findings from the National Health and Aging Trends Study.

OBJECTIVE: To estimate the prevalence of dementia among American Indian and Alaska Native (AIAN) Medicare beneficiaries and compare the prevalence of dementia in AIANs and other racial and ethnic minority groups-non-Hispanic Blacks (NHBs) and Hispanics-with non-Hispanic Whites (NHWs) Medicare beneficiaries. METHODS: We used survey data from Round 5 of the National Health and Aging Trends Study (NHATS, 2015) (N = 7,449), a nationally representative study of Medicare beneficiaries ages 65 years and older. We used logistic regression to estimate the age- and sex-adjusted prevalence of dementia with 95% confidence intervals by race/ethnicity as well as prevalence differences between groups. RESULTS: The majority of participants were between 65 and 74 years old. Approximately half of them were female. NHWs had a prevalence of 5% for dementia, and AIAIs had a prevalence of 9%, four percentage points higher than NHWs (95%CI 1%, 11%). We estimated a similar difference in the prevalence of dementia in AIAN Medicare beneficiaries compared to NHBs. CONCLUSION: While previous research has reported that AIANs share a similar or lower prevalence of dementia than NHWs, our findings suggest a potentially higher prevalence of dementia among AIAN Medicare beneficiaries. A relatively small number of AIAN resulted in wide confidence intervals for many of our associations. Future research should focus on recruiting a larger sample and on dementia prevalence and unique risk factors within and among AIAN tribes.

Unified in Our Diversity to Address Health Disparities Among Asian Americans, Native Hawaiians, and Pacific Islanders.

The COVID-19 pandemic disproportionately impacted Asian Americans, Native Hawaiians, and Pacific Islanders (AA/NHPIs) in the United States. AA/NHPIs have historically been subjected to discrimination, which was exacerbated by the pandemic. To bring attention to their unique concerns, an AA/NHPI Interest Group of the National Institutes of Health Community Engagement Alliance Against COVID-19 Disparities (CEAL) was formed. This article highlights major concerns raised by the Interest Group: The pervasive and arbitrary practice of data aggregation by public health agencies and health-related researchers, the lack of culturally responsive services in the context of cultural safety, and leadership underrepresentation.

Identifying the Physical and Emotional Needs of Health Care Workers in Hawai`i During the COVID-19 Pandemic.

A mixed-methods study was performed to identify the physical and emotional needs of Hawai`i health care workers during the COVID-19 pandemic, and the degree to which these needs are being met by their clinic or hospital. Qualitative interviews and demographic surveys were conducted with two cohorts of health care workers. Cohort 1 (N=15) was interviewed between July 20 - August 7, 2020, and Cohort 2 (N=16) between September 28 - October 9, 2020. A thematic analysis of the interview data was then performed. Participants' primary concern was contracting the illness at work and transmitting it to their families. Solo practitioners working in outpatient clinics reported more financial challenges and greater difficulty obtaining PPE than those employed by hospitals or group practices. While telehealth visits increased for both inpatient and out-patient settings, the new visit type introduced new barriers to entry for patients. The study findings may serve to better understand the effect of COVID-19 on health care workers and support the development of hospital and clinic procedures. Further research into the impacts of COVID-19 on nurses in Hawai`i is recommended.