Culturally Relevant Physical Activity in the Behavioral Risk Factor Surveillance System in Hawai'i.

INTRODUCTION: Culturally relevant physical activity is a promising field for chronic disease prevention and management. Native Hawaiians and Other Pacific Islanders have higher rates of physical inactivity than other racial or ethnic groups and increased risk of chronic disease. The study objective was to provide population-level data from Hawai'i on lifetime experiences in the Native Hawaiian Indigenous practices of hula and outrigger canoe paddling across demographic and health factors to identify opportunities for public health intervention, engagement, and surveillance. METHODS: Questions about hula and paddling were added to the Hawai'i 2018 and 2019 Behavioral Risk Factor Surveillance System (N = 13,548). We considered level of engagement by demographic categories and health status indicators, accounting for the complex survey design. RESULTS: Overall, 24.5% of adults engaged in hula and 19.8% in paddling in their lifetime. Prevalence of engagement was higher among Native Hawaiians (48.8% hula, 41.5% paddling) and Other Pacific Islanders (35.3% hula, 31.1% paddling) than among other racial and ethnic groups. In adjusted rate ratios, experience in these activities was strong across age groups, education, sex, and income levels, particularly among Native Hawaiians and Other Pacific Islanders. CONCLUSION: Throughout Hawai'i, hula and outrigger canoe paddling are important and popular cultural practices with high physical activity demands. Participation was notably high for Native Hawaiians and Other Pacific Islanders. Surveillance information around culturally relevant physical activities can benefit public health programming and research from a strength-based community perspective.

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.

"Community 101 for researchers": an online training program to build capacity for ethical community-engaged research with Native Hawaiians and Pacific Islanders.

To address the history of unethical research and community distrust in research among Native Hawaiian and Pacific Islander communities, we developed the "Community 101 for Researchers" training program, which was launched in 2014 to enhance the capacity of researchers to engage in ethical community-engaged research. The purpose of this paper is to describe the development of this training program as well as its reach and feedback from participants. The Community 101 training program is a self-paced, 2-h online training program featuring community-engaged researchers from the University of Hawai'i and their longstanding community partners. Throughout the five modules, we highlight the historical context of Native Hawaiians and Pacific Islander populations in Hawai'i related to research ethics and use examples from the community as well as our own research projects that integrate community ethics, relevance, benefits, and input. To determine reach and gather participant feedback on the training, we extracted data from the user accounts. The training has been completed by 697 users to-date since its launch. Despite very little advertisement, an average of nearly 70 users have completed the Community 101 Program each year. The majority of the participants were located in Hawai'i though participants were also from other states and territories in the US, and international locations. The majority of participants were from universities in Hawai'i in 51 different departments demonstrating multidisciplinary relevance of the program's training. The general feedback from the 96 participants who completed an optional anonymous evaluation survey given at the end of the training was positive. The "Community 101 for Researchers" Training program is an accessible and relevant tool that can be used to advance ethical community engaged research, specifically with Native Hawaiian and Pacific Islander communities.

Cost Effectiveness of a Cultural Physical Activity Intervention to Reduce Blood Pressure Among Native Hawaiians with Hypertension.

OBJECTIVE: The aim of this study was to calculate the costs and assess whether a culturally grounded physical activity intervention offered through community-based organizations is cost effective in reducing blood pressure among Native Hawaiian adults with hypertension. METHODS: Six community-based organizations in Hawai'i completed a randomized controlled trial between 2015 and 2019. Overall, 263 Native Hawaiian adults with uncontrolled hypertension (≥ 140 mmHg systolic, ≥ 90 mmHg diastolic) were randomized to either a 12-month intervention group of hula (traditional Hawaiian dance) lessons and self-regulation classes, or to an education-only waitlist control group. The primary outcome was change in systolic blood pressure collected at baseline and 3, 6, and 12 months for the intervention compared with the control group. Incremental cost-effectiveness ratios (ICERs) were calculated for primary and secondary outcomes. Non-parametric bootstrapping and sensitivity analyses evaluated uncertainty in parameters and outcomes. RESULTS: The mean intervention cost was US$361/person, and the 6-month ICER was US$103/mmHg reduction in systolic blood pressure and US$95/mmHg in diastolic blood pressure. At 12 months, the intervention group maintained reductions in blood pressure, which exceeded reductions for usual care based on blood pressure outcomes. The change in blood pressure at 12 months resulted in ICERs of US$100/mmHg reduction in systolic blood pressure and US$93/mmHg in diastolic blood pressure. Sensitivity analyses suggested that at the estimated intervention cost, the probability that the program would lower systolic blood pressure by 5 mmHg was 67 and 2.5% at 6 and 12 months, respectively. CONCLUSION: The 6-month Ola Hou program may be cost effective for low-resource community-based organizations. Maintenance of blood pressure reductions at 6 and 12 months in the intervention group contributed to potential cost effectiveness. Future studies should further evaluate the cost effectiveness of indigenous physical activity programs in similar settings and by modeling lifetime costs and quality-adjusted life-years. TRIAL REGISTRATION NUMBER: NCT02620709.

A Cultural Dance Program Improves Hypertension Control and Cardiovascular Disease Risk in Native Hawaiians: A Randomized Controlled Trial.

BACKGROUND: Native Hawaiians have higher hypertension (HTN) and cardiovascular disease (CVD) rates than non-Hispanic whites, calling for culturally responsive interventions to close this gap. PURPOSE: We tested the effects of a 6-month behavioral intervention, a cultural dance program based on hula (the customary dance of Hawai'i), for improving blood pressure (BP) and CVD risk among Native Hawaiians with uncontrolled HTN. METHODS: In a randomized controlled trial, we tested the effects of the hula-based intervention among 263 Native Hawaiians with uncontrolled HTN (systolic ≥ 140 or ≥ 130 mmHg if diabetes) and no CVD at enrollment. All participants received a brief culturally tailored heart health education before random assignment to the hula-based intervention (n = 131) or the education-only waitlist control (n = 132). Intervention received hula lessons and group-based activities for 6 months. Control received only 1-week education through 6 months. RESULTS: Intervention yielded greater reductions in systolic (-15.3 mmHg) and diastolic (-6.4 mmHg) BP than control (-11.8 and -2.6 mmHg, respectively) from baseline to 6 months (p < .05). At 6 months, 43% of intervention participants compared to 21% of controls achieved a HTN stage <130/80 mmHg (p < .001). The 10-year CVD risk reduction was two times greater for the intervention group than the control group based on the Framingham Risk Score calculator. All improvements for intervention participants were maintained at 12 months. CONCLUSIONS: This trial represents one of the few rigorously conducted examinations of an Indigenous practice leveraged for health promotion, with implications for other ethnic populations.

Growing from Our Roots: Strategies for Developing Culturally Grounded Health Promotion Interventions in American Indian, Alaska Native, and Native Hawaiian Communities.

Given the paucity of empirically based health promotion interventions designed by and for American Indian, Alaska Native, and Native Hawaiian (i.e., Native) communities, researchers and partnering communities have had to rely on the adaptation of evidence-based interventions (EBIs) designed for non-Native populations, a decidedly sub-optimal approach. Native communities have called for development of Indigenous health promotion programs in which their cultural worldviews and protocols are prioritized in the design, development, testing, and implementation. There is limited information regarding how Native communities and scholars have successfully collaborated to design and implement culturally based prevention efforts "from the ground up." Drawing on five diverse community-based Native health intervention studies, we describe strategies for designing and implementing culturally grounded models of health promotion developed in partnership with Native communities. Additionally, we highlight indigenist worldviews and protocols that undergird Native health interventions with an emphasis on the incorporation of (1) original instructions, (2) relational restoration, (3) narrative-[em]bodied transformation, and (4) indigenist community-based participatory research (ICBPR) processes. Finally, we demonstrate how culturally grounded interventions can improve population health when they prioritize local Indigenous knowledge and health-positive messages for individual to multi-level community interventions.

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.

2016 Writing Contest graduate Winner: Cardiovascular Disease Training for Community Health Workers Serving Native Hawaiians and Other Pacific Peoples.

To help community health workers (CHW) meet increased demand for their services, it is essential to have data supported strategies for approaches to their training and capacity development. The objective of this paper is to report on the development, implementation, and evaluation of "Heart 101," a cardiovascular disease (CVD) training program, conducted among CHW in Hawai'i who serve Native Hawaiians and other Pacific Peoples (NHPP). Principles from Community-Based Participatory Research provided a framework to develop and implement the 5-hour training curriculum. Developers incorporated teaching strategies shown to be effective among learners that represent the majority of CHW, and included principles of adult learning theory and culture-based education. Training participants completed pre-, post-, and 6-months post-training knowledge tests, as well as demographic and participant satisfaction surveys. Data analysis based on pre- and post-training knowledge tests (n=30) indicated that Heart 101 significantly increased CVD knowledge by 32% (P < .001, t test). Long-term CVD competency measured at six-months post-training (n = 20) was also shown to be significant (P < .001, t test). Analysis of knowledge by subtopic suggested CHW strengths in clinical aspects of CVD and weaknesses in medical terminology and basic science aspects. These results, along with positive participant satisfaction, suggest that a culturally relevant and interactive course is a strong approach for CVD information dissemination to CHW serving NHPP communities, and provides insight on potential areas for special focus in their training. The demonstrated success of Heart 101 has positive implications for the standardization of CHW education and for their professional development.

Ka-HOLO Project: a protocol for a randomized controlled trial of a native cultural dance program for cardiovascular disease prevention in Native Hawaiians.

BACKGROUND: As a major risk factor for cardiovascular and cerebrovascular disease (CVD), hypertension affects 33% of U.S. adults. Relative to other US races and ethnicities, Native Hawaiians have a high prevalence of hypertension and are 3 to 4 times more likely to have CVD. Effective, culturally-relevant interventions are needed to address CVD risk in this population. Investigators of the Ka-HOLO Project developed a study design to test the efficacy of an intervention that uses hula, a traditional Hawaiian dance, to increase physical activity and reduce CVD risk. METHODS: A 2-arm randomized controlled trial with a wait-list control design will be implemented to test a 6-month intervention based on hula to manage blood pressure and reduce CVD risk in 250 adult Native Hawaiians with diagnosed hypertension. Half of the sample will be randomized to each arm, stratified across multiple study sites. Primary outcomes are reduction in systolic blood pressure and improvement in CVD risk as measured by the Framingham Risk Score. Other psychosocial and sociocultural measures will be included to determine mediators of intervention effects on primary outcomes. Assessments will be conducted at baseline, 3 months, and 6 months for all participants, and at 12 months for intervention participants only. DISCUSSION: This trial will elucidate the efficacy of a novel hypertension management program designed to reduce CVD risk in an indigenous population by using a cultural dance form as its physical activity component. The results of this culturally-based intervention will have implications for other indigenous populations globally and will offer a sustainable, culturally-relevant means of addressing CVD disparities. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02620709 , registration date November 23, 2015.

Cultural Dance Program Improves Hypertension Management for Native Hawaiians and Pacific Islanders: a Pilot Randomized Trial.

OBJECTIVE: Native Hawaiians and Pacific Islanders (NHPI) bear an unequal burden of hypertension and cardiovascular disease. Hula, the traditional dance of Hawaii, has shown to be a culturally meaningful form of moderate-vigorous physical activity for NHPI. A pilot study was done in Honolulu, Hawaii, to test a 12-week hula-based intervention, coupled with self-care education, on blood pressure management in NHPI with hypertension in 2013. METHOD: NHPI with a systolic blood pressure (SBP) ≥140 mmHg were randomized to the intervention (n = 27) or a wait-list control (n = 28). Blood pressure, physical functioning, and eight aspects of health-related quality of life (HRQL) were assessed. RESULTS: The intervention resulted in a reduction in SBP compared to control (-18.3 vs. -7.6 mmHg, respectively, p ≤ 0.05) from baseline to 3-month post-intervention. Improvements in HRQL measures of bodily pain and social functioning were significantly associated with SBP improvements in both groups. CONCLUSION: Using hula as the physical activity component of a hypertension intervention can serve as a culturally congruent strategy to blood pressure management in NHPI with hypertension. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01995812.

Engaging Pacific Islanders in Research: Community Recommendations.

BACKGROUND: Health disparities continue to persist among Native Hawaiian and Pacific Islander (NHPI) communities. OBJECTIVES: This study sought to understand the perspectives of community organizations in the Ulu Network on how researchers can collaborate with communities to promote community wellness. METHODS: Key informant interviews and small group interviews were conducted with the leadership in the Ulu Network. RESULTS: Five themes were identified that highlight the importance of investing time and commitment to build authentic relationships, understanding the diversity and unique differences across Pacific communities, ensuring that communities receive direct and meaningful benefits, understanding the organizational capacity, and initiating the dialog early to ensure that community perspectives are integrated in every stage of research. CONCLUSIONS: Increasing capacity of researchers, as well as community organizations, can help build toward a more equitable and meaningful partnership to enhance community wellness.

Patient perspectives on the Hula Empowering Lifestyle Adaptation Study: benefits of dancing hula for cardiac rehabilitation.

BACKGROUND: The Hula Empowering Lifestyle Adaption Study, funded by the National Institute on Minority Health and Health Disparities, was a 5-year research trial evaluating the impact of the traditional Native Hawaiian dance form, hula, as an exercise modality for cardiac rehabilitation, compared with usual care, on individuals recently hospitalized for a cardiac event or who had recently undergone coronary artery bypass surgery. METHOD AND RESULTS: Seeking to learn what physical, mental, spiritual, and social effects the intervention may have had for participants, we interviewed 20 of a total of 35 patients who were enrolled in the dance arm of the study. Classical thematic triangulation analysis was used. Participants recognized that hula's coordination of body, mind, and spirit as a group activity deepened their appreciation of and connections to Hawaiian culture. This was true for those who were Native Hawaiian, connecting to their own cultural heritage, as well as for non-Native Hawaiians, who found that it improved their appreciation of the surrounding cultural traditions of the host culture where they now live. CONCLUSIONS: Not only was hula a safe activity that improved functional capacity, participants also regarded its significant sociocultural aspects-even for participants who are not Native Hawaiian -as enhancing its value and meaningfulness. Learning the words of well-known Hawaiian songs provided additional long-term cues that encouraged "ownership" of the therapy and acted as practical reminders of the importance of exercise and lifestyle moderation while also offering new spiritual connections to the surrounding social environment.

Kumu hula perspectives on health.

To prepare for research studies that would evaluate the impact of hula as part of a clinical intervention, including cardiovascular disease (CVD) prevention and management programs, kumu hula defined as "culturally recognized hula educators and experts," were interviewed. Investigators sought to elicit their views regarding hula's traditional and contemporary connections to health and well-being, assess the cultural appropriateness of such projects, and suggest ways to maintain hula's cultural integrity throughout clinical intervention programs. Six prominent kumu hula from five different Hawaiian Islands participated in semi-structured key informant interviews lasting between 60 and 90 minutes. Each was asked open-ended questions regarding their attitudes, beliefs, and experiences regarding the connections of hula to health as well as their recommendations on maintaining the integrity of the dance's cultural traditions when developing and implementing a hula-based CVD program. All kumu hula endorsed the use of hula in a CVD intervention program and articulated the strong, significant, and enduring connections of hula to health and well-being. Each kumu hula also recognized that health is the full integration of physical, mental, emotional, and spiritual well-being. When care is taken to preserve its cultural integrity, hula may be an effective integrated modality for interventions designed to improve health and wellness.

Developing a culturally based cardiac rehabilitation program: the HELA study.

BACKGROUND: Heart disease disproportionately affects Native Hawaiians and other Pacific people. In response, researchers proposed and communities endorsed, developing a cardiac rehabilitation (CR) program based on the hula, a Native Hawaiian dance form. The utilization of cultural practices in health interventions can improve outcomes and increase enrollment and retention, but requires sensitivity and understanding. OBJECTIVE: This paper provides the conceptual framework and methods used for integration of multiple communities' perspectives to inform the design of a hula-based CR intervention. METHODS: Specific strategies and processes were established to ensure the equity of scientific-clinical and patient- cultural knowledge and perspectives. Multiple methods were used and a flow diagram defined steps for the intervention development. RESULTS: Patient and cultural consultations provided information about the multidimensional benefits of hula and its use in a CR intervention. Clinical and scientific consultations provided specific guidelines for exercise prescription and patient monitoring. Integrating findings from all consultations identified important direction and requirements. CONCLUSIONS: Community-based participatory research (CBPR) principles guided a complex collaboration of multiple communities; although time consuming, inclusive consultations provided valuable information and relationships.

Diabetes training of community health workers serving native Hawaiians and Pacific people.

PURPOSE: Training of community health workers (CHWs) serving Native Hawaiian and Pacific People about diabetes prevention, control, and management was identified as a priority in a needs assessment of health agencies in Hawaii. METHODS: Principles from Community-Based Participatory Research provided a framework to develop and implement a 4-hour training curriculum. The curriculum developers incorporated teaching strategies shown to be effective with this population and included culturally relevant material. Nineteen health organizations participated in the training that reached 111 CHWs over a 3-year period. RESULTS: Based on comparison of pre- and post-diabetes knowledge test results, the training participants showed significant gain in diabetes knowledge. CONCLUSIONS: A culturally tailored diabetes education gives CHWs the relevant knowledge and tools to participate in the delivery of diabetes education to a minority group experiencing disparate health outcomes. A community-based method facilitated development of seminar content and delivery strategies.

Type 2 diabetes in native Hawaiians and Pacific Islanders in Hawaii.

There is significant disparity between the prevalence of diabetes in Native Hawaiians and Pacific People (includes Pacific Islanders and Filipinos) in comparison with other ethnic groups in Hawaii. In this article, prevalence, risk factors, complications and intervention studies are reviewed. Native Hawaiians and Pacific People have significantly higher prevalence rates of diabetes in comparison to other ethnic groups in Hawaii. They also have higher prevalence rates for the risk factors and complications associated with diabetes, such as obesity and end stage renal disease, respectively. Although the reasons for these disparities are complex and not clearly understood, literature suggests that genetics, acculturation, lifestyle, and cultural beliefs may be related. There is also a lack of specific research on diabetes in Native Hawaiians and Pacific people. Future research needs to include the collection of more comprehensive data on age, ethnic group and socioeconomic status.