Abstract
Indigenous peoples, including Native Hawaiians and Pacific Islanders (NHPIs), experience significant cardiometabolic health disparities arising in large part from rapid changes to their diets and food systems. Innovative food sovereignty initiatives led by NHPIs are needed to address these disparities. This article describes a community-based participatory research study that incorporates social and biological measures to examine the impact of an Indigenous-led land-based food sovereignty youth leadership program on health disparities among NHPI youth in Hawai‘i. Grounded in the Indigenous knowledge that holistic health and well-being of people is inseparable from that of the environment and to counter rampant food insecurity in their community of Wai‘anae, O‘ahu, MA‘O Organic Farms developed a Youth Leadership Training (YLT) program that offers education, nutrition, physical activity, and access to health care. The program also engages YLT interns and their social networks in health education and research in the ongoing Mauli Ola study. Preliminary data from this study affirm the need to address the disproportionately high rates of obesity, type 2 diabetes mellitus (T2D), and poor mental health conditions among young NHPIs in the Wai‘anae community, and how the YLT program may provide an effective approach to address this need. Our unique academic-community partnership underscores the importance of social and biomedical research to understand health disparities in the NHPI population, which present novel avenues to enable disease prevention. The outcomes of the Mauli Ola study may serve as a valuable model for health disparities research while leveraging ongoing social programs that support Indigenous food sovereignty.
Keywords: Native Hawaiian, Pacific Islander, indigenous knowledge, social network, biomedical research, health disparities, community organization, partnerships, programs
INTRODUCTION: THE MA‘O ORGANIC FARMS FOOD SOVEREIGNTY INITIATIVE
Native Hawaiians and Pacific Islanders (NHPIs) have the highest prevalence of multiple cardiometabolic diseases of any population in Hawai‘i. Compared with Whites, they have 12% more cardiovascular disease (CVD), a four times higher prevalence of stroke and type 2 diabetes (T2D), a 30% higher prevalence of hypertension (HTN), and a 60% higher CVD mortality (Office of Minority Health, 2020). Changes to diet and traditional food sources are contributors to these disparities (Mau et al., 2008). Traditionally, NHPIs consumed an abundance of fresh fish, fruits, and vegetables, but colonization led to profound destruction of local food systems and disruption of traditional cultural connections, creating an environment in which only 15% of Hawai‘i’s food supply is grown locally (Hawaii State Department of Agriculture, 2016). These statistics underscore the need for community-based, NHPI-led programs to restore traditional food systems and population health.
MA‘O Organic Farms (MA‘O) is a Native Hawaiianled organization located in Wai‘anae, an area with the highest percentage of NHPIs in Hawai‘i, and rates of poverty, food insecurity, and T2D that are higher than any other region in the state (Look et al., 2013). Recognizing these disparities, MA‘O developed a farm-based food sovereignty initiative to create better access to local, healthy foods and support NHPI youth in reconnecting with the land. Since its inception in 2000, MA‘O has produced more than 1,600,000 lbs. of local organic produce, developed a community-supported agriculture program that provides healthy produce at reduced costs to Wai‘anae families, and launched the MA‘O Youth Leadership Training program (YLT), a 2-year internship for college students (17–25 years old) which restores and affirms the sacred and interdependent relationship between ‘āina (land; that which feeds) and ‘ōpio (youth).
The purpose of the YLT is to empower a community food system that promotes traditional and modern foodways, educational attainment for youth, health promotion, and socioeconomic opportunities. The YLT program interns work part-time on the farm while attending college. Interns receive college tuition, a monthly stipend, academic support, health insurance, and reallife work experiene in food sovereignty, nutrition, and Native Hawaiian culture. Between 2000 and 2020, the YLT provided internships and college scholarships to 426 college students and more than 600 high school students.
ASSESSING THE HEALTH IMPACT OF THE MA‘O FOOD SOVEREIGNTY INITIATIVE
In 2017, MA‘O partnered with Indigenous researchers from the University of Hawai‘i to develop the Mauli Ola (personal health/wellbeing) study. Guided by the principles of community-based participatory research (CBPR), the Mauli Ola study aims to better understand how the YLT program is modifying cardiometabolic risk factors among YLT participants and individuals within their social networks. Currently underway, this study is one of few to examine the impact of a community-wide food sovereignty initiative on health.
The YLT interns are community co-researchers in the study and are consulted about study questions and perceived gaps in health knowledge within their community, informing not only the study measures but the development of a monthly health education session called “Ola Wednesday.” These interactive sessions include health education topics of greatest interest to the YLT interns such as health disparities, biological mechanisms underlying disease, social network interactions/behaviors, environment, and traditional foods. The sessions, taught by UH students and faculty, most of whom are NHPI, are open to the public and provide immediate benefit to the YLT interns and Wai‘anae community as well as assist in recruiting members of the YLT social networks to participate in the Mauli Ola study. Each year, approximately 25–50 YLT interns and 75–150 members of their social networks consent to participate in the study.
Using validated survey instruments, Mauli Ola study participants complete a questionnaire collecting background and demographic information, health behaviors (e.g., diet/nutrition, physical activity, medications), mental health data (e.g., self-esteem), and social network influences. Researchers also measure BMI and HbA1c as indicators of obesity and T2D, respectively, at an onsite exam. In addition, participant gut microbiome composition is assessed using a 16S rDNA metagenomics approach from self-collected stool samples. Blood samples are collected to measure various immunologic and metabolic biomarkers as well as for multi-omic analyses. To address specific research questions and hypotheses, researchers integrate and compare the data collected from YLT participants and their social networks longitudinally and compare data from participants in this program to that of the individuals recruited as part of other ongoing studies from the general NHPI population cross-sectionally. Data and samples collected are ethically managed in compliance with the University of Hawai‘i’s Institutional Review Board approved protocols. Results collected from the study are regularly shared with participants via NHPI community-informed data dashboards and academic venues including scientific journals, for example, Wells et al., 2022. Preliminary and statistical data summarizing salient YLT program facilitation and its impact on the local community are available online at www.maoorganicfarms.org.
FINDINGS
Data collection is underway; however, preliminary findings from the first cohort of Mauli Ola study participants are described in Table 1. Findings show several risk factors associated with chronic disease already apparent in youth (mean age of 19) residing in Wai‘anae. Of the 176 interns recruited in the study at baseline, most (65%) are of NHPI ancestry, a significant proportion are obese (34%) or overweight (18%) and include undiagnosed T2D (3%) and pre-diabetic (12%) individuals, and many (25%) reported low self-esteem (a risk factor of depression). We also found that YLT participants have complex social networks, with participants referring an average of four non-MA‘O affiliated individuals (friends and/or family members) into the study, exerting varying degrees of influence on health-related behaviors including diet/nutrition. These results substantiate the anecdotal evidence MA‘O has observed regarding the poor baseline health conditions among a significant proportion of NHPI youth at entry in the YLT program and provided data to inform activities that strengthened health promotion over the program duration.
TABLE 1.
Mauli Ola YLT Program Participant characteristics
| Participant characteristics at program entry | |
|
| |
| Total number (n) | 176 |
| Age | |
| Mean in years ± SE | 19.05 ± 0.16 |
| Sex | |
| Male | 73 (42%) |
| Female | 98 (57%) |
| Race/ethnicity | |
| NHPI | 108 (65%) |
| Asian | 28 (l7%) |
| White | 8 (5%) |
| Othera | 22 (l3%) |
| Unknown | l0 (5.6%) |
| Body mass index (BMI) | |
| Mean BMI ± SE | 28.00 ± 0.63 |
| BMI category | |
| Healthy (<25 BMI) | 73 (47%) |
| Overweight (25–29.9 BMI) | 32 (l8%) |
| Obese (≥25 BMI) | 60 (34%) |
| % Hemoglobin A1c (HbA1c) | |
| Mean % HbA1c ± SE | 5.30 ± 0.05 |
| T2DM category | |
| Normal (<5.7% HbA1c) | 148 (86%) |
| Prediabetic (5.7%–6.4% HbA1c) | 20 (l2%) |
| Diabetic (≥6.5% HbA1c) | 5 (3%) |
| Rosenberg Self-Esteem Scale | |
| Mean Self-Esteem Score ± SE | 17.36 ± 0.26 |
| Self-esteem category | |
| Low (<15 Score) | 40 (25%) |
| Normal (15–25 Score) | 116 (72%) |
| High (>25 Score) | 6 (4%) |
| Social network characteristics (M ± SE) | |
| Number of referrals | 4.07 ± 0.23 |
| Days/week of interaction | 5.64 ± 0.16 |
| Perceived social network influencesb (M ± SE) | |
| Eating (food choices, habits) | 3.48 ± 0.12 |
| Sugary drink intake | 2.42 ± 0.15 |
| Smoking | 1.13 ± 0.10 |
| Physical exercise | 2.71 ± 0.13 |
| Recreational activities | 2.95 ± 0.12 |
| Career advice | 3.54 ± 0.13 |
| Intake of vegetables and organic foods | |
| Mean VEG2 Scorec ± SE | 0.19 ± 0.01 |
| Organic food intake frequency | |
| Never | 17 (10%) |
| Sometimes | 93 (56%) |
| Often | 45 (27%) |
| Always | 11 (7%) |
Note. SE = standard error; NHPI = Native Hawaiians and Pacific Islander; BMI = body mass index.
Includes Black, Hispanic, and other race/ethnic groups <10% of the state population based on US Census 2022.
Perceived influences of participants by their social networks on indicated health-related behaviors as measured by a Likert-type scale with a range of 0–5, with no (0) to very highly influential (5).
Normalized composite vegetable intake score (Wells et al., 2022).
LESSONS LEARNED AND FUTURE RESEARCH
This study is one of few that is assessing the impact of a food sovereignty initiative on youth participants and their social networks. Community-based organizations like MA‘O that engage Indigenous youth in ‘āina-based food sovereignty and social justice programs can play a critical role in shaping health trajectories among 1090 HEALTH PROMOTION PRACTICE / November 2023 Indigenous youth. The active participation of the youth in collecting health-relevant data as part of social and biomedical research studies offers education and training benefits beyond the research findings, including (1) increasing youth awareness of health disparities in the NHPI population; (2) youth empowerment over their own personal health; and (3) enhanced programming that integrates Indigenous knowledge in ‘āina-based practices for health and wellbeing.
Subsequent activities of the Mauli Ola study will center on assessing the YLT program as a food sovereignty and youth leadership intervention aimed at promoting and sustaining behaviors that support healthy living, including social network influences on diet and nutrition, which potentially mitigate the risk of obesity, diabetes, and mental health conditions among NHPIs. The Mauli Ola study may provide a novel Indigenous-led model applicable to a wide range of programs that target education, economic development, environmental protection/sustainability, food sovereignty, and cultural restoration, all of which have indirect impacts on health but are not necessarily designed to intentionally capture nor address health disparities.
Acknowledgments
The authors would like to acknowledge and thank all of the participants of the Mauli Ola study who made this work possible and we are especially grateful for the many researchers and community facilitators from UHERO and the Maunakea Lab at the University of Hawai‘i at Mānoa including Rafael PeresDavid, Krit Phankitnirundorn, Lining Han, Braden P. Kunihiro, Brennan Y. Yamamoto, Lesley Umeda, Ming-Hao Lee, Nina P Allan, Noelle C. Rubas, Riley K. Wells, Rosa H. Lee, Tony Head, Christian K. Dye, Chandler K.L. Nunokawa, Kim Dong-Yoon, Micah Char, Naurú I. Vargas-Maya, Trevor McCracken, and Anthony Sigmund, and from the Wai‘anae Community Redevelopment Corporation and MA‘O Organic Farms including Claire Sullivan, Tori-lyn Smith, Kiana Tector, and Tiare Toetu‘u-Aipa. A special mahalo to Dr. Valarie Bluebird Jernigan for insightful suggestions to this manuscript and advocacy of this work. Additionally, we are grateful to our state and national funders for their support of this study including Hawai‘i Community Foundation (grant no. 16ADVC-78884), Hawai‘i Medical Service Association (HMSA) Corporate and HMSA Foundation (grant no. NH-021701), Kamehameha Schools (grant no. 010399–02), the National Institutes of Health (NIH) National Institute of General Medical Sciences (grant no. P20GM139753), and the NIH National Institute on Minority Health and Health Disparities (grant nos. R01MD017210 and R56MD014630). This manuscript and its contents are solely the responsibility of the authors and do not represent the official view of its supporters. This work was supported by the Office of Minority Health Grant # 1 CPIMP211317–02-00, Hawai‘i Community Foundation (grant no. 16ADVC-78884), Hawai‘i Medical Service Association (HMSA) Corporate and HMSA Foundation (grant no. NH-021701), Kamehameha Schools (grant no. 010399–02), the National Institutes of Health (NIH) National Institute of General Medical Sciences (grant no. P20GM139753), and the NIH National Institute on Minority Health and Health Disparities (grant nos. R01MD017210 and R56MD014630).
Footnotes
Supplement Note: This article is part of the Health Promotion Practice focus issue titled, “Indigenous Food Sovereignty as a Path to Health Equity.” The issue presents community-academic partnerships that advance health guided by a decolonizing and Indigenous framework. We are grateful to the Center for Indigenous Innovation and Health Equity, funded through the Office of Minority Health (CPIMP211317), for providing support for the issue. The entire issue is available open access at: https://journals.sagepub.com/toc/hppa/24/6.
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