Knowledge Gaps, Challenges, and Opportunities in Health and Prevention Research for Asian Americans, Native Hawaiians, and Pacific Islanders: A Report From the 2021 National Institutes of Health Workshop.

Asian Americans (AsA), Native Hawaiians, and Pacific Islanders (NHPI) comprise 7.7% of the U.S. population, and AsA have had the fastest growth rate since 2010. Yet the National Institutes of Health (NIH) has invested only 0.17% of its budget on AsA and NHPI research between 1992 and 2018. More than 40 ethnic subgroups are included within AsA and NHPI (with no majority subpopulation), which are highly diverse culturally, demographically, linguistically, and socioeconomically. However, data for these groups are often aggregated, masking critical health disparities and their drivers. To address these issues, in March 2021, the National Heart, Lung, and Blood Institute, in partnership with 8 other NIH institutes, convened a multidisciplinary workshop to review current research, knowledge gaps, opportunities, barriers, and approaches for prevention research for AsA and NHPI populations. The workshop covered 5 domains: 1) sociocultural, environmental, psychological health, and lifestyle dimensions; 2) metabolic disorders; 3) cardiovascular and lung diseases; 4) cancer; and 5) cognitive function and healthy aging. Two recurring themes emerged: Very limited data on the epidemiology, risk factors, and outcomes for most conditions are available, and most existing data are not disaggregated by subgroup, masking variation in risk factors, disease occurrence, and trajectories. Leveraging the vast phenotypic differences among AsA and NHPI groups was identified as a key opportunity to yield novel clues into etiologic and prognostic factors to inform prevention efforts and intervention strategies. Promising approaches for future research include developing collaborations with community partners, investing in infrastructure support for cohort studies, enhancing existing data sources to enable data disaggregation, and incorporating novel technology for objective measurement. Research on AsA and NHPI subgroups is urgently needed to eliminate disparities and promote health equity in these populations.

Diabetes Prevention for Pacific People in the United States: A Mixed-Methods Feasibility Study to Adapt the Diabetes Prevention Program With Samoan/Tongan Church Communities.

OBJECTIVE: To determine baseline characteristics of a group of Samoans/Tongans in Southern California at risk for type 2 diabetes mellitus and identify barriers, cultural factors, and readiness and capacity to implement a culturally tailored Diabetes Prevention Program (DPP) in a faith-based setting. DESIGN: A mixed-methods pilot that included piloting modified DPP sessions, conducting a survey, and focus groups (N = 4). SETTING: Samoan/Tongan faith-based organizations. PARTICIPANTS: Samoan/Tongan church members in Southern California who were interested in lifestyle behavior change. MAIN OUTCOME MEASURES: Surveys assessing sociodemographic, acculturation, health status, food insecurity, and psychosocial factors. Focus groups focusing on attitudes toward the curriculum, opportunities for tailoring, and specific barriers/facilitators for healthy weight, nutrition, and physical activity. RESULTS: Participants (N = 47) were on average 42 years old, female (57%), and identified as Pacific Islander (35% Samoan, 30% American Samoan, and 35% Tongan). Ninety-eight percent of respondents were overweight/obese, and 45% of households were food insecure. Less than half of respondents were born in the United States, and 28% reported "poor" or "fair" English proficiency. Those with higher body mass indexes were more likely to score lower on internal locus of control and self-efficacy for healthy eating and were motivated to lose weight to feel in control of their health. Focus group results revealed that members of the Samoan/Tongan communities are "underserved" and experience a lack of culturally relevant programs to address obesity and chronic disease. Several barriers to healthier lifestyles were identified including adaptation of traditional recipes made in the United States (ie, to be less healthy), role of stress, cultural values (eg, preference for larger body size), and lack of awareness about healthy lifestyles. The church was identified as a resource that could be leveraged further to positively impact health outcomes. CONCLUSIONS: Results demonstrate possible ways to tailor the DPP for US-based Samoan/Tongan populations by harnessing cultural traditions and addressing existing barriers and psychosocial constructs.

Association of cultural affinity and island food consumption in the Pacific Islander health study.

Objectives: The dietary patterns of Pacific Islander Americans are partially influenced by a rich cultural heritage. There is little known about how cultural affinity affects the dietary choices of this small, but quickly growing population. This analysis attempts to understand how the association of cultural affinity on island foods consumption (IFC) varies by key demographic characteristics.Design: A sample of 240 Samoan and Tongan adults in California from the Pacific Islander Health Study (PIHS) was used. Psychometric properties of a novel 11-item cultural affinity scale were assessed. Univariate and bivariate analyses of the cultural affinity scale were completed to understand the distribution of cultural affinity score. Separate multivariable Poisson regression was used to assess the effect of interactions between cultural affinity and five key demographic factors on IFC.Results: Psychometric analysis of the PIHS cultural affinity scale revealed two unique factors. Significant interactions were found between cultural affinity and ethnicity and birthplace: the association between cultural affinity and IFC was larger among Samoans compared to Tongans and Samoan or Tongan birthplace was found to have a weaker association between cultural affinity and IFC. Interactions between cultural affinity and age, financial insecurity, and educational attainment were not significant.Conclusion: Understanding how cultural affinity varies in its effect on IFC is a part of understanding overall dietary patterns in this population.

Incidence of ESKD Among Native Hawaiians and Pacific Islanders Living in the 50 US States and Pacific Island Territories.

RATIONALE & OBJECTIVE: Native Hawaiians and Pacific Islanders (NHPI) have been reported to have the highest rates of incident end-stage kidney disease (ESKD) compared with other races in the United States. However, these estimates were likely biased upward due to the exclusion of nearly half the NHPI population that reports multiple races in the US Census. We sought to estimate the incidence rate of ESKD, including individuals reporting multiple races, and describe the clinical characteristics of incident cases by race and location. STUDY DESIGN: Health care database study. SETTING & PARTICIPANTS: US residents of the 50 states and 3 Pacific Island territories of the United States whose ESKD was recorded in the US Renal Data System (USRDS) between 2007 and 2016, as well as US residents recorded in the 2010 Census. PREDICTORS: Age, sex, race, body mass index, primary cause of ESKD, comorbid conditions, estimated glomerular filtration rate, pre-ESKD nephrology care, and hemoglobin A1c level among ESKD cases. OUTCOME: Initiation of maintenance dialysis or transplantation for kidney failure. ANALYTICAL APPROACH: Crude ESKD incidence rates (cases/person-years) were estimated using both single- and multiple-race reporting. RESULTS: Even after inclusion of multirace reporting, NHPI had the highest ESKD incidence rate among all races in the 50 states (921 [95% CI, 904-938] per million population per year)-2.7 times greater than whites and 1.2 times greater than blacks. Also using multirace reporting, the NHPI ESKD incident rate in the US territories was 941 (95% CI, 895-987) per million population per year. Diabetes was listed as the primary cause of ESKD most frequently for NHPI and American Indians/Alaska Natives. Sensitivity analysis adjusting for age and sex demonstrated greater differences in rates between NHPI and other races. Diabetes was the primary cause of ESKD in 60% of incident NHPI cases. Patients with ESKD living in the territories had received less pre-ESKD nephrology care than had patients living in the 50 states. LIMITATIONS: Different methods of race classification in the USRDS versus the US Census. CONCLUSIONS: NHPI living in the 50 US states and Pacific territories had the highest rates of ESKD incidence compared with other races. Further research and efforts are required to understand the reasons for and define how best to address this racial disparity.

Sociodemographic factors influencing island foods consumption in the Pacific Islander Health Study.

Objectives: Pacific Islander Americans are a small, but quickly growing population that experiences alarming disparities in obesity and obesity-related chronic illnesses influenced by dietary patterns. This population also has a unique culinary heritage including traditional foods and more contemporary imports such as tinned meats and refined carbohydrates. This analysis is a novel attempt to understand the sociodemographic factors influencing island foods consumption.Design: A sample of 240 Samoan and Tongan adults in California from the Pacific Islander Health Study was used. Following univariate and bivariate analyses, a series of four multivariable regression models were created to predict past week frequency of island foods consumption after sequential adjustment for demographic, socioeconomic, and cultural covariates.Results: Participants reported consuming island foods an average of 2.93 times in the previous week, with the largest proportion of participants (20.42%) reporting eating island foods 6 or more times. Age and Samoan ethnicity were initially significant, positive predictors of island foods consumption, but their effect was attenuated after addition of cultural covariates. With the third model that adjusted for birthplace, financial insecurity and Tongan birthplace were positive predictors. Both lost significance in the fourth and final model upon addition of cultural affinity, which was positively associated with island foods.Conclusion: Understanding how sociodemographic factors are associated with island foods consumption is a first step in understanding the broad way in which an ethnically specific dietary pattern may be associated with obesity-related chronic illness risk among Pacific Islander Americans.

Surveying Strategies for Hard-to-Survey Populations: Lessons From the Native Hawaiian and Pacific Islander National Health Interview Survey.

Calls for remedies for the persistent scarcity of accurate, reliable, national, disaggregated health statistics on hard-to-survey populations are common, but solutions are rare. Survey strategies used in community and clinical studies of hard-to-survey populations often cannot be, and generally are not, implemented at the national level.This essay presents a set of approaches, for use in combination with traditional survey methods in large-scale surveys of these populations, to overcome challenges in 2 domains: sampling and motivating respondents to participate. The first approach consists of using the American Community Survey as a frame, and the second consists of implementing a multifaceted community engagement effort.We offer lessons learned from implementing these strategies in a national survey, some of which are relevant to all survey planners. We then present evidence of the quality of the resulting data set. If these approaches were used more widely, hard-to-survey populations could become more visible and accurately represented to those responsible for setting national priorities for health research and services.

Impacts of Long-Term Obesity on the Health Status of Samoan and Tongan Men in the United States: Results from the Pacific Islander Health Study.

OBJECTIVE: To examine the impacts of long-standing obesity (BMIs ≥ 30.0 kg/m(2)) on health outcomes among Samoan and Tongan men (aged ≥ 18 years) in California using a life course perspective. DESIGN: Cross-sectional analysis of 103 males from the Pacific Islander Health Study (PIHS), a probability sample modeled after the National Health Interview Survey (NHIS). SETTING: Urban residential neighborhoods in San Mateo and Los Angeles counties using a multistage, cluster sample design. MAIN OUTCOME MEASURES: BMI, diabetes, hypertension, total cholesterol, smoking, drinking, arthritis, gout and migraines. RESULTS: Bivariate analysis shows high rates of poor health outcomes distributed throughout the obese and non-obese sample. Logistic analysis finds that being obese does not significantly increase observed negative health outcomes. After controlling for socio-demographic characteristics, the presence of obesity results in non-significant findings for hypertension (OR=1.02; CI: .21, 4.91), and high cholesterol (OR=.52; CI: .10, 2.73), while obesity significantly reduces the risk of diabetes by 60% (OR=.40; CI: .14, 1.17). When applying disease counts, obese men have a significantly lower risk of reporting multiple health conditions (OR=.72; CI: .52, 1.00). CONCLUSION: Overall, the health of Samoan and Tongan males in California is uniformly poor and obesity alone does not significantly increase risks of poor health outcomes. Using a life course perspective, the analysis offers new insights on the basic health of this understudied population.

Community-based participatory research approach to evidence-based research: lessons from the Pacific Islander American Health Study.

OBJECTIVES: Reports on the challenges and lessons learned from the Pacific Island American Health Study engagement with community-based organizations (CBOs) and faith-based organizations (FBOs) in Pacific Islander (PI) communities and mechanisms to facilitate the collection of robust data. METHODS: Academic-community partnership building was achieved with PI CBOs and FBOs. Focus group meetings were organized to plan various aspects of the study, develop questionnaire themes and protocols for survey, assist with the interviewer recruitment process, and strategize data dissemination plan. LESSONS LEARNED: The PIA-HS represents a model for overcoming challenges in data collection among small understudied populations. FBOs represent a valuable resource for community-based participatory research (CBPR) data collection and for effective interventions. CONCLUSION: The study methodology can be replicated for other racial/ethnic groups with high levels of religiosity combined with concentrated levels of residential clustering. Expansion of the Pacific Islander American Health Study (PIA-HS) to include other PI subgroups is encouraged.

Improving Asian American, Native Hawaiian, and Pacific Islander health: national organizations leading community research initiatives.

BACKGROUND: Functionally, many CBPR projects operate through a model of academic partners providing research expertise and community partners playing a supporting role. OBJECTIVES: To demonstrate how national umbrella organizations deeply rooted in communities, cognizant of community needs, and drawing on the insights and assets of community partners, can lead efforts to address health disparities affecting their constituents through research. METHODS: Case studies of two Asian American, Native Hawaiian, and Pacific Islander national organizations. RESULTS: Strategically engaging a diverse range of partners and securing flexible funding mechanisms that support research were important facilitators. Main challenges included limited interest of local community organizations whose primary missions as service or health care providers may deprioritize research. CONCLUSIONS: Efforts to make research relevant to the work of community partners and to instill the value of research in community partners, as well as flexible funding mechanisms, may help to promote community-driven research.

Efficacy of Federal Data: Revised Office of Management and Budget Standard for Native Hawaiian and Other Pacific Islanders Examined.

This policy brief examines the status of federal data since the implementation of the 1997 Revised OMB 15 standards for the collection of race and ethnic data, identifies ongoing data limitations, and present recommendations to improve policy and interventions for Native Hawaiians and other Pacific Islanders (NHPI). While most federal agencies are taking appropriate steps to comply with the revised OMB standards, many are having less success reporting disaggregated information on NHPIs. This suggests that increased efforts to obtain robust samples of NHPIs warrants immediate attention in order for federal agencies to fully comply with the revised OMB standards.

Mortality patterns of Native Hawaiians across their lifespan: 1990-2000.

OBJECTIVES: We examined mortality patterns across the lifespan of Native Hawaiians and compared mortality disparities across races. METHODS: We determined the age-specific and age-adjusted mortality rates of Native Hawaiians from 1990 to 2000 by using national census and vital registration data. RESULTS: Among Native Hawaiians aged younger than 1 year, expected deaths were 15% lower than for Blacks and 50% higher than for Whites. Among older adults, Native Hawaiians had higher rates of mortality compared with the general population, particularly in 1990 and 1995. Crude death rates for Native Hawaiians were similar to those for Blacks in 1990 and 1995 but were 20% lower than those for Blacks by 2000. Crude death rates for Native Hawaiians were 30% higher than for Whites in 1990 and 1995 and more than 40% higher than for Whites in 2000. CONCLUSIONS: Compared with Whites, Native Hawaiians and Blacks face similar challenges regarding infant and early-life mortality and increasing risks of mortality in mid-life and early old age. Our analyses document a need for renewed efforts to identify the determinants of ill health and commitment to address them.

Oral health status of older adults in Fiji: 1985-1999.

This paper examines the oral health status of older adults in Fiji to determine the risks of dental disabilities. Using cross-sectional data collected in 1985 and 1999, logistic regression models are used to measure the effect of select demographic, socioeconomic and health variables on difficulty with chewing. While the general picture for the older persons is quite positive, the largest concern is the striking increase in poverty as a predictor for our dependent variable.

Disability among older women and men in Fiji: concerns for the future.

This study examines the composition of elderly population at risk of disability and speculates the impact of disability on the quality of their lives and their longevity. Using census and survey data collected in Fiji, life table estimates of unimpaired life expectancy across time are presented for older people and the potential costs of disability, in terms of productive years of life lost. From a planning perspective, the study discusses medical and support services that may be needed to support older individuals in Fiji. The study also describes policy implications of the findings, focusing on the older women, and considers the implications for older women of other developing countries.