Table 4.

Intervention strategies informed by facilitators and barriers to nutrition components of a lifestyle intervention identified by breast cancer survivors in Guam and Hawai’i, organized by social ecological model (SEM) level.

SEM Level	Intervention Strategies for Nutrition Components	Perspectives and Illustrative Quotes
Individual	Guam Prepared foods for busy individuals Consider individual health issues (i.e., diabetes, hypertension, high cholesterol) Online resources available with in-person events Hawai’i Online or in-person in location that is culturally comfortable (e.g., individual in own home or group at hotel or lo’i (taro patch in Hawaiian))	“a nutrition class focusing on locally available foods....because if we say, oh, you need to eat this and it’s only available in the mainland or it costs $10 a pound... you can’t motivate people to eat that all if it’s going to cost that much. So locally available, hopefully not too costly”. —Guam Participant #3 “And they [University of Hawaiʻi] have the loʻi right?... But I think that would be a good place”. —Hawai’i Participant #10
Interpersonal	Guam Adapt local recipes, such as brown red rice, tofu kelaguen (animal protein in citrus marinade in CHamoru) Culturally appropriate nutrition content	“I so agree with the local foods, I think affordability and availability and freshness of it is very important to consider. And if there’s going to be a recipe for those locally available ingredients, I wish that it is available online so that for those who don’t have time--I mean, it is nice to make that resource very convenient for everyone”. —Guam Participant #4 “And even if you pick two things, things that you can actually grow here and then different ways that you can prepare it…finding alternate recipes [referring to cultural recipes]” —Guam Participant #16
Organizational	Guam Utilizing or partnering with existing community resources/programs (trusted source) for nutrition education, cooking classes, recipes, and gardening Topics: nutrition specific for cancer survivors and recipes that include healthy alternatives and local foods Pre-cooked meal options Hawai’i Healthier (local) alternatives and affordable menu/meal plans when eating out Pre-cooked meal options Nutrition education	“If there is a cooking class or someone’s house, if they’re comfortable or even in a restaurant… If there’s certain restaurants that maybe some of the survivors or patients like, and then they can get tips from those restaurants, they can sponsor the thing”. —Guam Participant #9 “So what made it easy for you, because we all work. You don’t have time, and I don’t have time, to cook. I really don’t. I work until late, that’s bad for me. They give you the food for you. [in reference to prepared foods in program]” —Guam Participant #13 “Yeah. I like that idea of integrating the food that we have here on the islands because it’s hard when you see all these different diets and you’re like, ‘Yeah, that’s cheap on the mainland, but here when we go to [wholesale store], it’s expensive. Everything is so expensive.’ So being able to integrate what we do have in terms of even the food that’s available here”. —Hawai’i Participant #1
Community	No data	No data
Policy	Guam Affordability and accessibility of healthy food Hawai’i High food cost	“I so agree with the local foods, I think affordability and availability and freshness of it is very important to consider”. —Guam Participant #4 “So even being aware of how expensive it is here and the food that we have that is available here all year round, not the ones that are shipped or the ones that go up and down with prices, but what is available, integrating that with menu and food preparation and all that, I think would help the local community here as well”. —Hawai’i Participant #1
Sociocultural (across all levels)	Guam Involve family in nutrition education due to food-centric culture Include fiestas (celebration gatherings in CHamoru) and fiesta food in education (e.g., healthy modifications to traditional foods and fiesta tables) Hawai’i Family-centered: family can be a support system for eating healthy together Sharing and exchanging stories with other survivors	“You remind me though, when you’re in Guam, you have to practically attend everything that happens, right?… So that is a stress factor, too, just being in here. Although family support is really good, it gets too much. So kind of learning to say, ‘No, I’m not coming’”. —Guam Participant #14 “For me, I would just have to do what I really... sometimes, no offense, I don’t want to do, but I got to do it if I want to live longer. If I want to be here to see the grandsons graduate”. —Hawai’i Participant #11