The Impact of a Community Health Worker-Led Lifestyle-Social Determinants Program on Pacific Islander Cardiometabolic Health

Abstract

Introduction:

Native Hawaiians/Pacific Islanders (NHPIs) face disproportionate burdens of diabetes and cardiometabolic disease. This study assessed the feasibility and effectiveness of the PILI Pasifika Program (PPP), a culturally grounded, community health worker (CHW)–led lifestyle intervention that targets social determinants of health (SDoH) to improve cardiometabolic risk factors among NHPI adults.

Study design:

A parallel-group randomized controlled trial with an education material-only waitlist control was conducted. Implementation feasibility was assessed through interviews with CHWs, and participant acceptability via survey.

Setting/participants:

Across four US states and two US-affiliated Pacific Islands, 24 CHWs recruited and delivered the PPP to 242 NHPI adults with ≥1 cardiometabolic risk factor (130 intervention, 112 control), and assessed cardiometabolic, behavioral, and SDoH outcomes.

Intervention:

PPP consisted of 12 weekly sessions, adapted from the Diabetes Prevention Program and augmented with SDoH-focused activities.

Main outcome measures:

Weight, HbA1c, blood pressure, HDL, LDL, and total cholesterol. Data collected from 2024 to 2025, analyzed in 2025.

Results:

PPP participants compared with controls showed significant reductions in weight (-2.8 vs +0.5 kg), HbA1c (-0.8% vs +0.1%), systolic (-5.7 vs +2.6 mmHg) and diastolic (-3.4 vs +1.3 mmHg) blood pressure, LDL (-4.7 vs +7.6 mg/dL), and total cholesterol (-9.7 vs +9.4 mg/dL). Intervention participants also showed significant improvements in fruit/vegetable intake, physical activity, food literacy, social support, housing stability, and overall well-being. CHWs and participants found the PPP highly feasible, culturally relevant, and adaptable.

Conclusions:

The PPP, delivered by culturally competent CHWs, improved cardiometabolic, behavioral, and SDoH outcomes among NHPI adults and shows promise for scalable, sustainable implementation across diverse NHPI communities.

Trial registration:

ClinicalTrials.gov (NCT06471595).

Introduction

Native Hawaiians and Pacific Islanders (NHPIs) in the United States (US) and US-affiliated Pacific Islands (USAPI) experience disproportionately high rates of cardiometabolic conditions, such as obesity, hypertension, type 2 diabetes, and cardiovascular disease (CVD), than other racial/ethnic groups and the general population.^1,2 NHPIs also have among the highest rates of CVD-related mortality, attributable to their high diabetes prevalence.^3,4 These inequities stem from social, cultural, and environmental disruptions associated with Westernization, resulting in socioeconomic disadvantages. The shift from traditional subsistence living to sedentary lifestyles and diets high in processed, calorie-dense foods has intensified their chronic disease risk.^1,5

The social determinants of health (SDoH) – non-medical factors influencing health outcomes – are associated with cardiometabolic health.⁶ They include food insecurity, barriers to healthcare, discrimination, acculturative stressors, and language and literacy barriers.⁶ SDoH can influence healthy behavior change at the individual level.⁷ Compared to non-Hispanic Whites, NHPIs are three times more likely to experience food insecurity,⁸ four times more likely to live in multigenerational households,⁹ twice as likely to live in poverty or to be underinsured,^10,11 and 41% less likely to have a regular healthcare provider.¹² Many of these SDoH factors are associated with obesity, type 2 diabetes, hypertension, and CVD risk in NHPIs.^13,14 Yet, there are no culturally tailored lifestyle interventions available for NHPIs that also address SDoH that impact their adoption of a healthier lifestyle.

Community health workers (CHWs), as trusted frontline public health workers, can help link individuals to healthcare and social services while providing in-language and other culturally relevant education and support. Studies demonstrate CHWs can effectively deliver lifestyle interventions to NHPIs, yielding modest improvements in weight, glycated hemoglobin (HbA1c), and blood pressure.^15–19 Augmenting these culturally tailored lifestyle interventions with explicit strategies to address SDoH may improve cardiometabolic health among NHPIs.

In response, the present study evaluated the implementation feasibility and effectiveness of an NHPI-adapted version of the Diabetes Prevention Program’s lifestyle intervention (DPP-LI),^17,20 augmented by SDoH activities and delivered by culturally competent CHWs, to improve cardiometabolic health among NHPIs in the US and USAPI. Called the PILI Pasifika Program (PPP), it was hypothesized to lead to significant improvements in weight, blood pressure, HbA1c, and lipids, as well as in fruit and vegetable consumption, physical activity, and SDoH, compared with an education material-only waitlist control group. It was also hypothesized that it would be feasible to implement across NHPI groups and community settings.

Methods

As part of the NIH Community Engagement Alliance Research Network,²¹ this study was conducted by Peau o le Vasa (“currents of the ocean”), a community-based participatory research (CBPR) partnership among the National Association for Pasifika Organizations (NAOPO), Papa Ola Lōkahi (POL), and the Department of Native Hawaiian Health (DNHH), University of Hawai’i at Mānoa. A multiple principal investigator (MPI) model was used: two community-based and one academic MPI, experienced in NHPI health. With input from NHPI leaders and CHWs, the MPIs co-developed the research aims and methods before securing funding. A steering committee of MPIs, coordinators, and CHW representatives guided all phases to ensure NHPI co-leadership and co-production.

Using this CBPR framework, a hybrid type 1 implementation–effectiveness trial was conducted. To test the effectiveness of the PPP on improving cardiometabolic risk factors (primary outcomes), lifestyle behaviors, and SDoH factors (secondary outcomes), a parallel-group, two-arm randomized controlled trial (RCT) with an education material-only waitlist control was employed. To evaluate feasibility, semi-structured interviews with CHWs were conducted to capture acceptability, adaptability, fidelity, compatibility, context, and CHW self-efficacy, and a brief participant survey was administered for acceptability.

The University of Hawai’i Institutional Review Board (IRB; protocol no. 2024–00113) approved the study. It was registered on June 17, 2024, on ClinicalTrials.gov with the study protocols and data analysis plan (https://clinicaltrials.gov/study/NCT06471595). Recruitment and implementation occurred between August 2024 and July 2025. Fig. 1 shows the CONSORT diagram for this RCT. Deidentified data can be available upon reasonable request, subject to approval by the study’s steering committee.

Figure 1.

CONSORT diagram of randomized controlled trial of the PILI Pasifika Program.

Population

NAOPO and POL, along with their network of NHPI CHWs, operated across three regions encompassing 15 sites: (1) the USAPI (two in Pohnpei, one in Yap), (2) the US Continent (one in Alaska, two in Arkansas, one in Oklahoma), and (3) Hawai’i (eight). NAOPO oversaw the USAPI and US Continental sites, while POL supervised the Hawai’i sites. NAOPO-affiliated sites were primarily community health centers, and POL-affiliated sites included Native Hawaiian Health Care Systems and other community-based organizations. This enabled assessment of feasibility and effectiveness across varied community contexts.

Eligibility criteria for participation in the trial were as follows: 1) self-identified NHPI ancestry, 2) age ≥18 years, 3) at least one self-reported cardiometabolic condition (i.e., pre-diabetes/type 2 diabetes, hypertension, dyslipidemia, or BMI ≥25), and 4) ability and willingness to engage in moderate physical activity (150 min/week) and adopt dietary changes. The cardiometabolic risk factor eligibility was ascertained by the question, “Have you been told by a doctor that you have any of the following medical conditions?” with the responses being high blood pressure, high cholesterol, diabetes or high blood sugar, high BMI, none, or don’t know. A CHW screened for eligibility.

Twenty-four CHWs from NAOPO and POL networks – ten from the USAPI, six from the US Continent, and eight from Hawai’i – completed 8–10 hours of training. Training covered cardiometabolic conditions (obesity, type 2 diabetes, hypertension, and hyperlipidemia), behavior change theory, chronic disease prevention, SDoH, SMART goal setting, motivational interviewing, group facilitation, and study protocols. Instruction included role-playing with feedback, standardized assessment procedures, accurate clinical measurements, and administration of self-report questionnaires, following previously developed protocols.^17,20 CHWs in the US Continent were trained via teleconference, while those in Hawai’i and the USAPI were trained primarily in person; clinical assessment training was conducted in person.

Trained CHWs recruited participants over 9 months using clinic and community registries, referrals, flyers, and community events. Each CHW recruited one cohort of 10–16 eligible NHPI participants, who were randomized to either the immediate PPP intervention or the control condition. Participants were screened using a standardized form, scheduled for baseline assessments if eligible, and provided informed consent before data collection in accordance with IRB-approved procedures.

Randomization was conducted in a 1:1 ratio within each participating site to ensure balanced allocation across locations. Household members were randomized together. Cohort-level randomization helped balance key participant characteristics across study arms, given site variability. Randomization was non-blinded because the behavioral nature of the intervention did not allow masking of participants or CHWs. The project biostatistician, independent from participant contact, conducted all randomizations.

Eligible, consented participants completed baseline clinical, behavioral, and SDoH assessments within two weeks before starting the PPP. After baseline data collection, they were informed of their randomized group assignment. The same measures were repeated at the 3-month follow-up, with the inclusion of an acceptability survey completed by the intervention participants at 3 months. CHWs conducted and recorded all assessments using standardized tools, with data managed in Research Electronic Data Capture (REDCap).

Intervention

The PPP was a combination of the 3-month NHPI-adapted DPP-LI, originally called the PILI Lifestyle Program (PLP),^17,20 with the SDoH components added for this study. The original PLP, developed through community engagement and assessments, addressed obesity in NHPI communities and was delivered by trained CHWs using workbooks, handouts, and homework. PLP has demonstrated effectiveness in improving weight, blood pressure, physical functioning, activity, and diet among NHPIs (details reported elsewhere).^17,20,22,23

NHPI CHWs and community leaders identified key SDoH challenges, including food and housing security, health literacy, discrimination, and health care access, informing the PPP’s SDoH component. CHWs developed activities tailored to local needs, providing resources and expert guidance on food access, employment, housing, and legal issues. SDoH discussions were integrated into PLP lessons, with CHWs helping participants create SDoH-focused SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) goals. Each 1.5-hour PPP session included both PLP and SDoH activities, with make-up sessions available (Appendix Table 1).

Participants randomized to the PPP arm received the intervention from a trained CHW within 2 weeks of completing their baseline assessments. Those randomized to the no-intervention, waitlist control received nothing from the study while the intervention arm was underway. The PPP was delivered mostly in Pohnpeian, Yapese, or Satawalese language at the USAPI sites and both English and Marshallese or Samoan for the other sites. All participants were asked to continue with their usual medical care and informed that participation in this study does not replace their routine health care or any other prescribed medical regimen. After study completion, wait-list participants received program materials (curriculum handouts) and access to a CHW to assist with the materials. This education material-only offering differed from the facilitated intervention and was provided for ethical reasons.

All CHWs completed CITI certification per IRB requirements. They received standardized training on study protocols, participant confidentiality, and intervention delivery, supplemented by a Manual of Procedures. Regular data checks ensured their accuracy, and check-ins and feedback from community partners, coordinators, and CHWs ensured ongoing updates, transparency, and accountability.

Throughout the intervention, adverse events (i.e., physical, emotional, or social difficulties) were monitored and, if any, documented by the CHWs using a standardized log, which was to be reviewed by the study’s MPIs. Events were to be classified by type, severity, and relatedness to the intervention. Serious adverse events (e.g., hospitalization, disability, or death) were to be reported immediately to the MPIs and the IRB.

Measures

Cardiometabolic measures (the primary outcomes) were collected using standardized protocols previously applied in other NHPI studies.^17,19,20,23 Finger-stick samples were analyzed for total cholesterol and HbA1c using the CardioChek^® Plus Analyzer and A1CNow+, respectively. Blood pressure was measured three times with an automatic device (Omron© HEM-907XL IntelliSense), and the average of the last two readings was used. Weight (kg) was measured with an electronic scale (Seca 876), height (cm) at baseline with a stadiometer (Seca 213), and BMI was calculated as weight (kg)/height (m²).

Fruit and vegetable intake was measured by 5 items and calculated by summing responses for fruit, leafy greens, and other vegetables, rated from 0 = never to 4 = >6 times/week and scored as 0, 1.5, 3.5, 5.5, and 6.5, respectively.²⁴ Physical activity was assessed using a 2-item questionnaire measuring weekly minutes of moderate-to-vigorous exercise, with a binary variable indicating whether participants met the 150 min/week recommendation.²⁵ Household food patterns were measured with three items on food preparation and shared meals in the past week, rated 0 = 0 days to 4 = 7 days and converted to midpoints (0, 1.5, 3.5, 5.5, 7; Cronbach’s α = 0.80).²⁶

Reducing or skipping meals was assessed by the question, “In the past month, how often did you cut the size of your meals or skip meals because there wasn’t enough money for food?,” rated on a 5-point scale (1 = never to 5 = always). Food literacy was assessed using 11 items on planning, managing, selecting, preparing, and eating healthy foods, averaged across 5-point Likert responses (0 = not at all/never to 4 = yes/always; Cronbach’s α = 0.94).²⁷ Food security was measured with the 10-item U.S. Household Food Security Survey, scored 0–10, with higher scores indicating greater food insecurity (Cronbach’s α = 0.89). Scores were classified as very low (0), low (1–2), marginal (3–5), and high (6–10) food insecurity.²⁸

Social and emotional support was assessed with the question, “How often do you get the social and emotional support you need?” rated on a 5-point scale (1 = never to 5 = always).²⁴ Well-being was measured using a 6-item, 11-point Likert-type questionnaire covering standard of living, health, relationships, achievement, safety, and community belonging, scored from 0 (not at all satisfied) to 10 (completely satisfied; Cronbach’s α = 0.91).²⁹ Concern about housing costs was measured with, “In the past month, how often have you been worried about not being able to pay your rent or mortgage?” rated on a 5-point scale (1 = never to 5 = always).²⁴ Regarding feasibility measure, semi-structured interviews with CHWs assessed five key feasibility domains: (1) acceptability of PPP components, including cultural relevance, content, materials, and delivery mode; (2) adaptability of implementation strategies while maintaining core components; (3) fidelity to prescribed content, frequency, and duration, as well as the nature and rationale for any adaptations; (4) alignment between implementation strategies and organizational priorities, including contextual influences on implementation; and (5) CHW self-efficacy, reflecting perceived capacity to implement the program.³⁰

Participant acceptability of the intervention was assessed at the 3-month follow-up using a brief survey developed for this study. Participants rated, on a 5-point scale (1 = not at all helpful/relevant to 5 = very helpful/relevant), the extent to which the intervention was relevant to their NHPI community, the usefulness of the lessons for improving health, and the helpfulness of the group delivery format. Additional items assessed the perceived helpfulness of lessons on healthy eating, physical activity, challenging social situations, communicating with healthcare providers, and the SDoH and homework activities.

Statistical Analysis

Based on the assumption of an intra-cluster correlation coefficient of 0.2, a total sample size of 144 provided 80% power to detect a 0.55 standard deviation difference between groups (two-tailed α = 0.05) based on multilevel modeling. This effect size calculation was based on prior intervention trials on changes in HbA1c, diabetes care profile, self-care, and problem areas.¹⁹ Allowing for a 10% attrition rate, it was determined that a minimum of 160 participants (80 per arm) was needed to detect any statistically significant differences.

Baseline characteristics were summarized using means ± standard deviations (SD) for continuous variables and frequencies (%) for categorical variables. Group differences were assessed with χ², Fisher’s exact, or two-sample t tests. Changes in primary and secondary outcomes from baseline to 3-month follow-up were evaluated using multivariable linear regression adjusted for baseline values and region; logistic regression was used for the binary physical activity variable. All analyses followed an intention-to-treat approach, with missing 3-month data imputed using last observation carried forward. Cohen’s d, computed from the regression models, was used to quantify the magnitude of intervention effects, providing a standardized measure of change that facilitates interpretation of clinical and practical significance.³¹ Regarding clinical significance, Cohen’s d calculates the size of the difference between groups in standard deviation units, which allows for the interpretation of whether an observed change is not only statistically significant but also clinically meaningful. Larger d values indicate changes that are more likely to be noticeable and impactful in real-world settings. Statistical significance was set at p < 0.05, and analyses were done in R v4.5.2.

Interim analyses were not planned, given the short 9-month accrual period. Participant safety and study conduct were overseen by the MPIs and the IRB through ongoing monitoring and the reporting of adverse events.

Interviews with CHWs were conducted via Zoom, transcribed, and summarized for the program manager during implementation to support timely adjustments (e.g., clarifying confusing data collection questions). Analysis involved an iterative, domain-based synthesis of responses as interviews progressed, enabling cross-site comparison and identification of emerging themes and implementation challenges. For this report, summaries were jointly reviewed to generate domain-specific observations and recommendations. This approach supported assessment of program feasibility and acceptability while informing refinement for larger-scale implementation.

Results

Table 1 summarizes the demographic, clinical, behavioral, and SDoH characteristics of the 242 participants (130 randomly assigned to intervention and 112 to control) who were enrolled. A balance between study arms at baseline was achieved across all measured variables. A majority were female, but evenly distributed across study arms.

Table 1.

Summary of Participants’ Baseline Demographic, Clinical, Behavioral, and Social Determinants of Health Characteristics by Total and Study Arm

Characteristics	Total (N = 242)	Intervention (N = 130)	Control (N = 112)	P-Value a
Age (years)	43.3 ± 13.9	43.4 ± 14.5	43.2 ± 13.3	0.900
Regionb				0.179
US Continent	68 (28.1%)	43 (33.1%)	25 (22.3%)
Alaska	20 (8.3%)	11 (8.5%)	9 (8.0%)
Arkansas	32 (13.2%)	16 (12.3%)	16 (14.3%)
Oklahoma	16 (6.6%)	16 (12.3%)	0 (0.0%)
Hawaii	114 (47.1%)	57 (43.8%)	57 (50.9%)
USAPI	60 (24.8%)	30 (23.1%)	30 (26.8%)
Yap	20 (8.3%)	10 (7.7%)	10 (8.9%)
Pohnpei	40 (16.5%)	20 (15.4%)	20 (17.9%)
Sex				0.667
Male	83 (34.3%)	43 (33.1%)	40 (35.7%)
Female	159 (65.7%)	87 (66.9%)	72 (64.3%)
Pacific Islander ethnicity				0.489
Marshallese	56 (23.8%)	33 (26.8%)	23 (20.5%)
Native Hawaiian	47 (20.0%)	20 (16.3%)	27 (24.1%)
Pohnpeian	39 (16.6%)	20 (16.3%)	19 (17.0%)
Samoan	33 (14.0%)	21 (17.1%)	12 (10.7%)
Tongan	34 (14.5%)	17 (13.8%)	17 (15.2%)
Yapese	20 (8.5%)	10 (8.1%)	10 (8.9%)
Other Pacific Islander	6 (2.6%)	2 (1.6%)	4 (3.6%)
Educational attainment				0.503
Less than high school	19 (8.1%)	8 (6.5%)	11 (9.9%)
High school/GED	111 (47.4%)	55 (44.7%)	56 (50.5%)
Some college	81 (34.6%)	47 (38.2%)	34 (30.6%)
College graduate or more	23 (9.8%)	13 (10.6%)	10 (9.0%)
Marital status				0.800
Never married	62 (26.4%)	33 (26.8%)	29 (25.9%)
Married/Partnered	137 (58.3%)	73 (59.3%)	64 (57.1%)
Disrupted marital status	36 (15.3%)	17 (13.8%)	19 (17.0%)
Employment				0.827
Full-time paid work	106 (45.3%)	51 (41.5%)	55 (49.5%)
Part-time paid work	35 (15.0%)	22 (17.9%)	13 (11.7%)
Unemployed	37 (15.8%)	20 (16.3%)	17 (15.3%)
Retired	12 (5.1%)	7 (5.7%)	5 (4.5%)
Disabled	13 (5.6%)	7 (5.7%)	6 (5.4%)
Keeping house	17 (7.3%)	8 (6.5%)	9 (8.1%)
Student	14 (6.0%)	8 (6.5%)	6 (5.4%)
Household income				0.399
Less than $25,000	126 (52.1%)	68 (52.3%)	58 (51.8%)
$25,000–$49,999	44 (18.2%)	19 (14.6%)	25 (22.3%)
$50,000–$74,999	23 (9.5%)	14 (10.8%)	9 (8.0%)
$75,000–$99,999	19 (7.9%)	10 (7.7%)	9 (8.0%)
$100,000 and above	20 (8.3%)	11 (8.5%)	9 (8.0%)
Not provided	10 (4.1%)	8 (6.2%)	2 (1.8%)
Qualifying conditions
Overweight/obesity	226 (93.4%)	122 (93.8%)	104 (92.9%)	0.758
Pre-Diabetes/Diabetes	155 (64.0%)	87 (66.9%)	68 (60.7%)	0.316
Hypertension	233 (96.3%)	124 (95.4%)	109 (97.3%)	0.511
Dyslipidemia	200 (82.6%)	110 (84.6%)	90 (80.4%)	0.383
Weight (kg)	99.8 ± 27.9	101.7 ± 28.9	97.7 ± 26.9	0.274
Body-mass-index	37.5 ± 9.7	37.7 ± 8.6	37.2 ± 10.9	0.705
Systolic blood pressure (mmHg)	128.5 ± 21.2	129.0 ± 21.5	127.8 ± 21.0	0.666
Diastolic blood pressure (mmHg)	82.5 ± 15.3	82.9 ± 15.7	82.0 ± 14.9	0.684
Total cholesterol (mg/dL)	164.4 ± 52.4	160.4 ± 49.4	168.7 ± 55.3	0.225
Hemoglobin A1c (%)	6.9 ± 2.1	7.0 ± 2.1	6.8 ± 2.1	0.499
High-density lipoprotein (mg/dL)	43.9 ± 10.6	43.5 ± 11.8	44.2 ± 9.0	0.638
Low-density lipoprotein (mg/dL)	88.7 ± 42.1	85.6 ± 42.8	92.2 ± 41.2	0.233
Fruit/vegetable consumption score	8.3 ± 4.9	8.4 ± 4.9	8.1 ± 4.9	0.729
Physical activity (>=150 min/week)	25 (11.2%)	12 (10.3%)	13 (12.0%)	0.688
Skipping/reducing meals	2.1 ± 1.1	2.1 ± 1.1	2.1 ± 1.1	0.718
Worry about paying rent/mortgage	2.3 ± 1.4	2.4 ± 1.3	2.3 ± 1.4	0.429
Social/emotional support	3.2 ± 1.2	3.0 ± 1.2	3.3 ± 1.3	0.180
Household food pattern	3.8 ± 2.3	4.0 ± 2.3	3.7 ± 2.3	0.375
Food literacy	2.6 ± 1.1	2.6 ± 1.0	2.5 ± 1.1	0.654
Food insecurity	3.0 ± 3.0	3.2 ± 3.1	2.8 ± 3.0	0.267
Wellbeing	7.2 ± 2.3	7.1 ± 2.3	7.3 ± 2.2	0.534

Note: Data shown as mean (M) ± standard deviation (SD) or group size and percentage.

^aP values based on the Welch Two-Sample t-test, Pearson’s Chi-squared test, or Fisher’s exact test.

^bData for the specific states or jurisdictions within the US Continent and USAPI regions are included, but analyses are at the region level.

Nineteen participants dropped out of the study (Fig. 1). Retention at 3 months was 88.5% (n = 115) for intervention and 96.4% (n = 108) for control. No adverse events were reported. At one site, staff inadvertently delivered the intervention to all participants, including those randomized to the control arm. Of the 16 participants at this site, eight were assigned to the control arm. The error was identified three weeks into the 12-week program and reported to the IRB. The site was allowed to continue with all participants in the intervention, which accounts for the higher number in the intervention group. The CHWs at these sites received booster training on the protocols, and protocol adherence monitoring was heightened going forward.

Data are shown in Table 2 for the primary and secondary outcomes. Participants of the intervention arm significantly improved on six of the seven measured clinical outcomes at three months compared to those in the control arm, which included significant differences in weight, systolic and diastolic blood pressure, HbA1c, LDL, and total cholesterol, but no significant difference in HDL. The intervention arm also showed significant improvements in fruit and vegetable consumption, physical activity, food literacy, social and emotional support, financial stress related to rent or mortgage, and overall well-being compared to controls, with no significant differences between study arms in food insecurity, social cohesion, household food pattern, and skipping or reducing meals due to financial constraints, although the latter approached significance in favor of the intervention arm (p = .063).

Table 2.

Summary of Intent-to-treat Analysis of Primary and Secondary Outcomes from Baseline to 3-month Follow-up

Outcome Variables	Baseline		3-month Follow-up		Changea		Effect Size	P-Value
	M	SD	M	SD	M	SD	Cohen’s d (95% CI)
Weight (kg)							−0.48 (−0.74, −0.23)	<0.001
PILI Pasifika	101.7	28.9	98.9	29.7	−2.8	4.8
Control	97.7	26.9	98.3	27.4	0.5	8.3
Systolic Blood Pressure (mmHg)							−0.43 (−0.68, −0.17)	0.001
PILI Pasifika	129.0	21.5	123.3	21.2	−5.7	18.9
Control	127.8	21.0	130.4	22.3	2.6	20.7
Diastolic Blood Pressure (mmHg)							−0.30 (−0.55, −0.04)	0.024
PILI Pasifika	82.9	15.7	79.4	13.3	−3.4	15.0
Control	82.0	14.9	83.4	17.8	1.3	16.8
Hemoglobin A1c (%)							−0.76 (−1.01, −0.50)	<0.001
PILI Pasifika	7.0	2.1	6.2	1.7	−0.8	1.5
Control	6.8	2.1	6.9	2.2	0.1	1.0
Total Cholesterol (mg/dL)							−0.65 (−0.90, −0.39)	<0.001
PILI Pasifika	160.4	49.4	150.7	45.2	−9.7	42.5
Control	168.7	55.3	178.2	53.4	9.4	35.1
High-density Lipoprotein (mg/dL)							−0.05 (-0.31, 0.21)	0.692
PILI Pasifika	43.5	11.8	43.4	12.7	−0.1	9.6
Control	44.2	9.0	44.4	11.7	0.3	9.8
Low-density Lipoprotein (mg/dL)							−0.50 (−0.76, −0.25)	<0.001
PILI Pasifika	85.6	42.8	80.6	41.5	−4.7	39.2
Control	92.2	41.2	99.8	39.7	7.6	33.1
Fruit/Vegetable Consumption (#/week)							0.54 (0.27, 0.81)	<0.001
PILI Pasifika	8.4	4.9	11.4	5.2	3.2	6.0
Control	8.1	4.9	8.8	4.9	0.8	4.9
Physical Activity (>=150 min/week)b							0.37 (0.10, 0.63)	0.007
PILI Pasifika	0.1	0.3	0.2	0.4	0.1	0.4
Control	0.1	0.3	0.1	0.3	0.0	0.3
Worries about paying rent/mortgage							0.31 (0.06, 0.57)	0.018
PILI Pasifika	2.4	1.3	2.2	1.3	−0.1	1.2
Control	2.3	1.4	1.9	1.1	−0.4	1.0
Skipping/Reducing Meals							0.25 (-0.01, 0.50)	0.063
PILI Pasifika	2.1	1.1	2.0	1.2	−0.1	1.1
Control	2.1	1.1	1.8	0.9	−0.4	1.1
Social/emotional support							0.44 (0.18, 0.70)	0.001
PILI Pasifika	3.0	1.2	3.5	1.1	0.5	1.5
Control	3.3	1.3	3.1	1.3	−0.2	1.4
Household Food Pattern							−0.18 (-0.44, 0.08)	0.171
PILI Pasifika	4.0	2.3	3.8	2.1	−0.2	2.1
Control	3.7	2.3	4.0	2.4	0.3	2.2
Food Literacy							1.03 (0.77, 1.29)	<0.001
PILI Pasifika	2.6	1.0	3.5	0.7	0.9	1.1
Control	2.5	1.1	2.6	1.1	0.1	1.0
Food Insecurity							−0.17 (-0.43, 0.08)	0.187
PILI Pasifika	3.2	3.1	2.3	3.0	−1.0	3.1
Control	2.8	3.0	2.6	3.2	−0.2	3.2
Wellbeing							0.50 (0.24, 0.76)	<0.001
PILI Pasifika	7.1	2.3	8.1	1.7	1.1	2.3
Control	7.3	2.2	7.3	2.4	0.0	2.1

Note. Boldface indicates statistical significance (p<0.05). M = mean, SD = standard deviation; Cohen’s d = effect size for the standardized difference between the two means; CI = confidence interval; P = probability value, CI = confidence interval.

^aComparisons based on a multivariable linear model with the change in value (follow-up value minus baseline value) as the dependent variable, adjusting for the baseline value and region.

^bBinary coding used for categorizing those who met or did not meet the recommended physical activity level (≥150 min/week); the percentage meeting recommendations at baseline and at 3-months were 10.3% and 19.3% for the intervention arm and 12% and 7.3% for the control arm, respectively.

As summarized in Table 3, CHWs reported high satisfaction with the PPP, noting strong cultural fit, flexibility in lesson timing, and that it was favored over other lifestyle interventions. The PPP demonstrated strong adaptability, with CHWs making context-specific modifications such as extending session durations, incorporating local foods (e.g., breadfruit, taro, seafood), tailoring grocery lessons to regional availability, and using social media to enhance engagement. Despite these adaptations, fidelity to the intended lesson sequence was maintained. CHWs affirmed the PPP’s alignment with organizational missions, identifying community leader support, food provision, and social media engagement as key facilitators. All CHWs expressed confidence in delivering the PPP and achieving program goals.

Table 3.

Key Findings Regarding the Feasibility of Implementing the PPP

Domain	Findings/Lessons Learned
Acceptability: Satisfaction with the PPP.	All 24 CHWs reported overall satisfaction with the lessons, including the SDOH content. CHWs in Alaska and Hawai’i (n = 5) compared PPP favorably to other lifestyle interventions, noting more time for lessons, better cultural fit, and the addition of SDOH activities
Adaptability: Ability to adapt the PPP to local needs.	CHWs suggested several adaptations: All 24 CHWs recommended allowing more time for each lesson to improve engagement, foster culturally appropriate discussion, and strengthen participant relationships (e.g., through shared meals); CHWs in Alaska and the USAPI (n = 14) suggested adapting the food label lesson to include unlabeled local foods (e.g., breadfruit, taro, locally caught seafood); CHWs in the USAPI (n = 10) recommended adjusting grocery shopping lessons to reflect regional food availability and insecurity; All CHWs endorsed translation into Pacific languages, using real-time interpretation, group chat, and social media; CHWs in Hawai’i and Alaska (n = 12) recommended incorporating role-play into the “asking your doctor questions” lesson, to account for cultural norms around authority.
Fidelity: Ability to implement the PPP as intended.	All CHWs reported successful implementation of the program, even with adaptations. No issues were identified that interfered with the lesson sequence or fidelity to the curriculum’s intent.
Compatibility: Fit with the organization’s mission.	CHWs and institutional leads agreed that PPP aligned well with their organizations’ missions and priorities.
Context: Political, economic, or social influences on implementation.	CHWs navigated various contextual influences, especially in recruitment and engagement: 10 CHWs emphasized the value of gaining support from community leaders (e.g., pastors), especially in communities without a longstanding CHW presence; 20 CHWs provided food to enhance attendance, engagement, and relationship building; all 24 CHWs used social media between lessons—for translation support, transportation coordination, and fostering engagement (e.g., sharing steps walked).
Self-efficacy: Ability to execute the goals of PPP.	All 24 CHWs expressed confidence in their ability to deliver the PPP and achieve its goals.

Of the intervention participants, 101 completed the acceptability survey at three months. On a 5-point scale, participants rated the PPP as highly relevant to NHPI communities (4.7 ± 0.5) and its lessons as ‘extremely helpful’ for improving health (4.9 ± 0.3). The group delivery format was also highly endorsed (4.9 ± 0.4). Eating lessons were rated ‘very helpful’ (4.6 ± 1.6), while lessons on challenging social situations (3.4 ± 1.5), communicating with doctors (3.5 ± 1.3), SDOH activities (3.5 ± 1.8), and exercise lessons (3.9 ± 1.5) were ‘moderately helpful.’ Homework activities were rated ‘least helpful’ (2.1 ± 1.4).

Discussion

This study evaluated the feasibility and effectiveness of the PPP – a CHW-delivered, culturally adapted DPP-LI incorporating a focus on SDoH – to advance health equity among NHPIs. Consistent with the stated hypotheses, the PPP was both feasible in its implementation and effective in improving cardiometabolic health among at-risk NHPIs. By addressing lifestyle behaviors within the context of SDoH challenges, the CHWs effectively translated the PPP into meaningful behavior change and clinical outcomes for participants, showing it can be feasibly implemented across different contexts, demonstrating its scalability and sustainability.

PPP participants achieved significant three-month improvements over waitlist controls in weight (-2.8 kg), systolic (-5.7 mmHg) and diastolic (-3.4 mmHg) blood pressure, HbA1c (−0.8%, or −1.68 mmol/mol), and LDL (−4.7 mg/dL) and total cholesterol (−9.7 mg/dL). These short-term outcomes are comparable to, or exceed, results from longer-term (≥ 9 months) DPP-LIs. Meta-analyses of DPP programs report mean changes of −3.2 kg in weight, −4.3 mmHg in SBP, −2.6 mmHg in DBP, and −5.3 mg/dL in total cholesterol; the original DPP reported a −0.7 mg/dL reduction in LDL.^32,33 Although no significant effect on HDL was found, other studies of DPP-adapted interventions indicate a significant effect on HDL (+0.85 mg/dL).³³ HbA1c effects across studies are mixed, but found to have a greater effect on non-Hispanic Whites (−0.59%) and Asian Americans (−0.48%) than other groups.^34,35

The PPP, compared to the results from prior studies of its parent intervention, the culturally-adapted DPP-LI from which the PPP was adapted, produced greater 3-month improvements in weight (−2.8 vs. −1.5 kg), SBP (−5.7 vs. −4.0 mmHg), and DBP (−3.4 vs. −2.7 mmHg).^2,17,20,36 Earlier PLP evaluations did not assess HbA1c or lipids and included less representative NHPI samples. Nevertheless, the added SDoH component likely provided additional benefits above and beyond the adapted DPP-LI component only.

The findings also suggest the PPP yields clinically meaningful benefits. A 1 kg weight loss is associated with a 16% reduction in diabetes incidence over 3 years in high-risk adults³⁷ and a 2–5% reduction in excess body weight is linked to improvements in SBP (by 24%), HbA1c (by 80%), and triglycerides (by 46%).³⁸ These effects likely work synergistically and are estimated to reduce future CVD risk by 30–50%, exceeding the benefit of improving any single risk factor alone.³⁹ Notably, the PPP effects on these cardiometabolic outcomes, measured by Cohen’s d, were in the strong range (d = ~0.50) with narrow 95% confidence intervals, reflecting high precision and consistent effect direction.

Comparisons between CHW-led and health professional-led DPP-LIs show no differences in cardiometabolic outcomes,³³ indicating that effectiveness can be maintained while reducing delivery costs. CHW-delivered interventions can lower staffing and training costs, leverage community infrastructure, and support group-based delivery, enhancing cost-effectiveness and scalability.⁴⁰ Accordingly, the CHW-led PPP could be sustained through mechanisms such as Medicaid reimbursement for CHW services, value-based payment models, public health contracts, and partnerships with health systems and community organizations. The PPP’s modular design and community-informed SDoH components also facilitate adaptation across NHPI subgroups and regions while preserving core intervention elements, supporting its potential as a sustainable, equity-focused model for improving cardiometabolic health.

Beyond clinical outcomes, the PPP improved multiple behavioral and SDoH factors. PPP participants showed higher fruit and vegetable intake and physical activity compared to control participants. The PPP also produced significant improvements in food literacy, perceived social and emotional support, worries about housing costs, and overall well-being, as well as potentially reducing the likelihood of meal skipping due to financial stress. Although between-group differences in food insecurity were not significant – likely reflecting low baseline levels across both arms – findings underscore that integrating behavioral and SDoH components can enhance both health behaviors and upstream determinants.

Finally, the PPP demonstrated a high level of feasibility across domains of acceptability, adaptability, fidelity, compatibility, context, and CHW self-efficacy. CHWs recommended adding dietary and physical activity materials tailored to specific NHPI subgroups to address cultural and regional diversity, which could be achieved through a PPP toolkit with subgroup- or region-specific supplements to the core curriculum. Such toolkits, which include educational materials and implementation guides, have been shown to enhance the cultural relevance and real-world applicability of evidence-based interventions.⁴¹ Participant acceptability ratings mirrored those of CHWs, reinforcing the PPP’s scalability for effective implementation and sustainability across diverse NHPI and community settings.

Limitations

The limitations of this study include potential cross-contamination within close-knit NHPI communities, protocol deviations across sites, the use of SDoH measures not yet validated for NHPIs, and a short follow-up period. Any cross-contamination was likely minimal, as statistically significant group differences with moderate to large effect sizes were observed. A protocol violation at one site introduced minor group imbalance; however, this was addressed analytically, and the small number of misassignments is unlikely to have materially affected outcomes. Although NHPI-specific validity data for the SDoH measures are lacking, internal consistency was very good to excellent (Cronbach’s α = .80–.94), and measures detected change in expected directions. The short three-month follow-up period makes it unclear whether the observed effects can be sustained over a longer time period. Notwithstanding, key strengths include the broad representation of diverse NHPI populations across the US and USAPI, recruitment from real-world settings with varied cardiometabolic risk profiles, and the use of CHWs across regions, which support the PPP’s generalizability, scalability, and sustainability.

Conclusions

The PPP was found to be feasible for implementation by CHWs across diverse settings and contexts, acceptable to participants, and effective in improving weight, blood pressure, blood glucose, and cholesterol levels. It also demonstrated effectiveness in improving key lifestyle behaviors, including diet and physical activity, as well as addressing SDoH, particularly food literacy, social and emotional support, and financial-related stress. Collectively, these findings suggest that the PPP is a promising, scalable, and sustainable chronic disease prevention program that addresses the SDoH influencing behavior change for NHPIs.