Let’s Move for Pacific Islander Communities: An Evidence-Based Intervention to Increase Physical Activity

Abstract

Pacific Islander (PI) populations of Southern California experience high obesity and low physical activity levels. Given PI’s rich cultural ties, efforts to increase physical activity using a community tailored strategy may motivate members in a more sustainable manner. In this paper, we: 1) detail the program adaptation methodology that was utilized to develop the Weaving an Islander Network for Cancer Awareness, Research and Training (WINCART) Center’s PI Let’s Move Program, a culturally-tailored program aimed to increase physical activity levels among members of PI organizations in Southern California, and 2) share the program’s pilot evaluation results on individual and organizational changes. The WINCART Center applied the National Cancer Institute’s program adaptation guidelines to tailor the evidence-based Instant Recess program to fit the needs of PIs. The end product, the PI Let’s Move Program, was piloted in 2012 with eight PI organizations, reaching 106 PI adults. At baseline, 52% of participants reported that they were not physically active, with the average number of days engaged in medium-intensity physical activity at 2.09 days/week. After the 2-month program, participants increased the number of days that they engaged in medium-intensity physical activity from 2.09 to 2.90 days/week. Post-pilot results found that 82% of participants reported intentions to engage in physical activity for at least the next six months. At baseline, only one organization was currently implementing a physical activity program, and none had implemented an evidence-based physical activity program tailored for PIs. After the 2-month timeframe, despite varying levels of capacity, all eight organizations were able to successfully implement the program. In conclusion, results from our program provide evidence that disparity populations, such as PIs, can be successfully reached through programs that are culturally tailored to both individuals and their community organizations.

Introduction

Compared to nearly all other ethnic groups, Pacific Islanders (PIs) suffer from significant cancer health disparities and barriers to care (Miller, Chu, Hankey, & Ries, 2008; Moy, Sallis, & David, 2010). Much of the disparity stems from lack of primary prevention, such as lack of physical activity (Ward et al., 2004). Obesity has been implicated as a causal factor in the onset of cancer, including breast, colon, endometrium, esophagus, and kidney cancers (Bianchini, Kaaks, & Vainio, 2002; Sharby, 2005; Vucenik & Stains, 2012) and rates of obesity are high in many ethnically diverse populations such as African Americans (36.1% obese) and Latinos (32.6% obese) (CHIS, 2012).

Particularly alarming are the high rates of obesity seen in PI populations. In 2011, national data showed that PIs are 30% more likely to be obese than non-Hispanic Whites, with 48.5% of PIs overweight (with a body mass index, BMI, between 25 to 29.9) and 34.7% obese (with a BMI equal to or greater than 30) (U.S. Department of Health and Human Services, 2012). In California, 2009 data revealed that 38% of adult Pacific Islanders (PIs) were overweight and 32% were obese, compared to only 33.9% and 21.1% of non-Hispanic Whites (CHIS, 2009). Exploratory research on PI youth and physical activity conducted by the Weaving an Islander Network for Cancer Awareness, Research and Training (WINCART) Center found that PI young adults (aged 15–25) had very low levels of moderate and vigorous physical activity. The bulk of daily activity was classified as light intensity (266.5 ± 71.0 min/day), time spent sedentary (508.1 ± 120.5 min/day), males had significantly higher levels (p<0.001) of moderate-intensity physical activity compared to females (45.4 ± 25.9 min/day vs. 24.7 ± 18.9 min/day), and total moderate and vigorous physical activity (47.6 ± 27.3 min/day vs. 27.0 ± 22.9 min/day) (Moy et al., 2010). Moderate and vigorous physical activity overall (38 min/day) was below national guidelines.

Increasing physical activity levels, even in short bouts, can yield significant health benefits specific to both prevention and survivorship of certain diseases. The benefits of engaging in 10-minutes of moderate to vigorous physical activity on a daily basis at work include increasing awareness of the importance of physical activity (Yancey et al., 2004), participation in vigorous physical activity (Yancey et al., 2006), and reduction in clinical disease risk indicators (Glazer et al., 2013). The relationship between physical activity and cancer outcomes has been extensively explored. For example, higher levels of recreational physical activity was associated with a 14% decreased risk of breast cancer of postmenopausal women (Bardia et al., 2006) and a 6% lower mortality risk for breast cancer (Holmes, Chen, Feskanich, Kroenke, & Colditz, 2005). In addition, physical activity has been significantly associated with a mortality risk reduction for colorectal cancer among women with stage I to III colorectal cancer (Meyerhardt, Giovannucci, et al., 2006), and has shown an overall reduction in both mortality rates and recurrence of colon cancer (Meyerhardt, Heseltine, et al., 2006).

The importance of culturally tailoring health programs and interventions to meet the cultural and linguistic needs of diverse communities has been widely recognized and practiced. Disparity populations, such as PIs, are better reached and programs are more effective when they are culturally tailored to the target population (Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2003; Noar, Benac, & Harris, 2007). However, while there have been numerous collaborative efforts to culturally tailor health programs and materials for Asian American, Latino, and African American communities, there are no known reports on physical activity programs designs specifically for PIs. With more than 1.2 million Native Hawaiians and Pacific Islanders (NHPIs) in the U.S. and 286,145 NHPIs in California, this population is one of the fastest growing racial groups in the U.S. with a 40% growth rate between 2000–2010 (Census, 2010). The local PI population of Southern California experiences high obesity and low physical activity levels, both of which underscore them as an at-risk, underserved population with cancer disparities that may be mediated by a comprehensive community-based program that is both culturally and linguistically appropriate.

Community-based participatory research (CBPR), defined as “a partnership approach to research that equitably involves community members, organization representatives, and researchers in all aspects of the research process” (Israel, Eng, Schulz, & Parker, 2005), is increasingly being used in the public health arena to address health disparities and improve health outcomes in underserved communities. This approach to research has shown great promise in better understanding health prevention and promotion strategies, determining barriers and assets to care and self-management, and developing culturally appropriate programs that are sustainable in communities. The WINCART Center is a unique CBPR effort to reduce cancer health disparities in Southern California’s PI communities. WINCART is funded by the National Cancer Institute (NCI) Center to Reduce Cancer Health Disparities as one of 25 Community Network Programs (CNPs), to utilize CBPR to reduce the unequal burden of cancer in disparity communities across the U.S. (Braun et al., 2012). The WINCART Center Steering Committee (CSC) manages the operations of the overall center and includes one representative from each of three academic and six community partner organization, six WINCART staff, one Community Health Educator (CHE), and the NCI Program Officer (Tanjasiri & Tran, 2008), examined health data on PI health and physical activity data. After extensive reviews and discussions held over the course of six months, the WINCART CSC adopted physical activity promotion as a major community education campaign to address the high rates of overweight and obesity in the Chamorro, Marshallese, Native Hawaiian, Samoan and Tongan populations of Southern California.

As a way to address obesity, cancer health disparities, and lack of physical activity among Southern California’s PI communities, the WINCART Center culturally adapted the evidence-based Instant Recess Program to create the WINCART PI Let’s Move Program. The PI Let’s Move Program is intended for use by PI community- and faith-based organizations and groups, with the objective of increasing the frequency of moderate and vigorous physical activity among PI adults in community settings. The purpose of this paper is to describe the culturally tailored program adaptation approach and short-term impacts on PI individuals and organizations.

Materials & Methods

The Instant Recess Program

An Instant Recess break is defined as a short (10 minutes), low impact, and structured physical activity routine for adults or children that is done in settings where people gather (i.e. work, school, meetings, churches, sports venues) (Yancey, 2010). Recess breaks restructure the environment to make the healthy choices easier and the unhealthy choices more challenging, therefore encouraging or pushing people toward a socially desirable behavior (Yancey, 2010). For example, when Instant Recess was implemented in a school-setting, it was found that physical activity increased from baseline to follow-up and was maintained in the following semester, and light (51% increase) and moderate (16% increase) increases were seen among participants (Whitt-Glover, Ham, & Yancey, 2011).

National Cancer Institute Program Adaptation

This program was supported by the WINCART Center funded by grant number 1U54CA153458 from the National Institutes of Health, National Cancer Institute, Center to Reduce Cancer Health Disparities. All program protocols and evaluation tools were approved by the California State University, Fullerton Institutional Review Board.

The WINCART Center utilized the nine recommended program adaptation guidelines set forth by the National Cancer Institute (NCI) to adapt Instant Recess to the WINCART PI Let’s Move Program (see Table 1). First, a needs assessment was undertaken to review California Health Interview Survey data on obesity and physical activity. Next, the Instant Recess program was selected and shared with the WINCART CSC. Third, the CSC worked to adapt the program by identifying PI-specific activities and leaders. Fourth, a draft of the activity demonstration was filmed and supplemental materials were developed. In steps 5 and 6, the materials were shown to the entire WINCART Center staff and volunteers, and consumer tested with 30 people at six PI organizations. Seventh, feedback was used to modify the materials.

Table 1.

NCI’s Program Adaptation Guidelines and WINCART Center Activities

National Cancer Institute Program Adaptation Guidelines	WINCART Center Activities
1) Determine the needs of your audience and whether this program addresses those needs.	Focused on need to address obesity prevention and physical activity promotion in community-based settings Identified Instant Recess as targeting individuals and organizations
2) Review the program and its materials with your intended audience for feedback on its appropriateness.	Endeavored to create a low-medium impact physical activity video for PI adults that incorporates movements, people, and music from the Islands Showed Instant Recess to WINCART CSC, who discussed relevance and acceptance to PIs
3) Define the extent of adaptation needed and potential ways to implement the new program.	Shifted focus away from worksites (focus of Instant Recess) to PI social, cultural and faith-based organizations (focus of PI Let’s Move!) Identified PI physical activity leaders (to choreograph and demonstrate the physical activity routine Collaboration with PI filmmaker to incorporate other PI cultural elements into the Let’s Move video
4) Develop “mock-up” versions of the adapted products.	Drafted Let’s Move video and Created supportive materials (poster and brochure) to distribute to interested PI organizations and individuals NCI’s 8 Ways to Prevent Cancer posters translated to be in-language
5) Work with expert advisors to ensure that the adapted products maintain the accuracy of the originals.	Showed draft video and materials to the WINCART CSC for comment and refinement
6) Pilot test the adaptation with representatives from your audience.	Consumer-tested the first draft of the video within six PI organizations Feedback: choreography was too advanced/complicated for sedentary adults
7) Modify or revise the adapted program and products based on pilot test feedback.	Revised video choreography to include more fluid motions and less advanced footwork
8) Implement the program	Identified potential PI organizations and groups in Southern California WINCART Community Health Educator recruited and provided technical assistance and evaluation support to all participating organizations and groups
9) Evaluate the effectiveness of your adapted program and products	Conducted Pre and Post Organizational Assessment to explore capacity to implement physical activity programs Conducted Post Individual Assessment to assess behavior change, attitude towards physical activity, and future intentions to continue with physical activity

In step 8, the PI Let’s Move Pilot Program was finalized to contain four key program components – 1) identify a Program Champion, a leader within the organization or group who can motivate their membership to engage in physical activity; 2) establish a verbal policy among the organization or group to participate in 10-minutes of physical activity at every organizational or group meeting; 3) create an environment that is conducive to physical activity by displaying in the PI languages the 8 Ways to Prevent Cancer posters (Chamorro, Marshallese, Native Hawaiian, Samoan, and Tongan) and providing adequate space to participate in physical activity as a group; and 4) participate in the PI Let’s Move 10-minute physical activity break video at every organization or group meeting.

Evaluating the Let’s Move Pilot Program

In step 9, evaluation of the PI Let’s Move Pilot Program consisted of a pre- and post-organizational assessment and a post-test only individual assessment. The organizational pre-assessment was conducted by the WINCART Community Health Educator with each participating organization or group’s Program Champion just prior to implementing the PI Let’s Move Pilot Program. The organizational pre-assessment was comprised of – 1) Agency Background, which included services that organization or group provides, population(s) served, geographic area served, and language(s) are services offered in; and 2) Agency Capacity, which asked Program Champions to report on their level of preparedness to implement a physical activity program specific to organizational support, staffing, partnerships, community needs, community education, and evaluation by rating their level of preparedness on a scale of 1–5, with 1=no plan and 5=well prepared.. In addition, open-ended questions were asked about the organization or group’s priorities, barriers, and training needs.

The organizational post-assessment was completed by the Program Champion at each organization or group at the end of the 2-month pilot timeframe. This post-assessment contained three parts – 1) Implementation of the PI Let’s Move Program, which gave Program Champions the opportunity to report if they implemented all four “waves” of the pilot program and any implementation challenges that they encountered; 2) A RE-AIM Evaluation, which covered reach, effectiveness, adoption, implementation, and maintenance; and 3) Organizational or Group Capacity, which asked about the organization or group’s priorities, barriers, and training needs. Upon completion of the Organizational Post-Assessment, participating organizations and groups of the PI Let’s Move Pilot Program were given a Certificate of Completion and a gift card valued at either $100 (for organizations with 10–19 participants) or $200 (for organizations with membership of 20 or more participants).

The individual post-test gathered demographic data, retrospective questions regarding participants’ physical activity levels prior to the PI Let’s Move Pilot Program, a series of before/after questions specific to medium-intensity activities, intent to be physically active in the future, and open-ended questions for participants to share what they liked/disliked about the program. To further promote physical activity, individual participants were given a water bottle, pedometer, and drawstring backpack valued at $5.

All individual and organizational data were entered into SPSS with a descriptive analysis conducted for each of the three assessments (organizational pre, organizational post, and individual post).

Each of the six WINCART community partners were encouraged to provide contact information for at least 1–2 PI organizations and groups who might be interested in implementing the PI Let’s Move Pilot Program. Of the eight participating PI organizations, three were faith-based groups and five were community groups or organizations. All participating organizations were located in Los Angeles, Orange or San Diego County and offer services and programs in variety of PI languages, including Chamorro, English, Fijian, Marshallese, Samoan, and Tongan.

Results

Organizational Pre- and Post-Assessment

The organizational pre- and post-assessment of the eight participating WINCART PI Let’s Move Pilot Program sites revealed that at pre-assessment, organizations and groups with varying levels of capacity and experience in implementing physical activity programs were able to successfully implement the program components. Prior to implementing the PI Let’s Move Pilot Program, only one organization was currently implementing a physical activity program, and none had implemented an evidence-based physical activity program tailored for PIs. On average, participating PI Let’s Move Pilot Program sites were especially inexperienced in the areas of staffing a physical activity program, conducting a community needs assessment, and evaluating a program. Overall, participating sites felt prepared in having the organizational support necessary to implement a physical activity program. See Table 3 for complete organizational pre-assessment findings.

Table 3.

Organizational pre-assessment results of participating organizations and groups (N=8)

	Mean (S.D)
Infrastructure Components* (1=no plan, 5=well prepared)
Organizational Support (overall) – advocate/champion for the program at your site, verbal support from agency leaders, adequate resources, and procedures/protocols in place to facilitate the program	3.88 (0.99)
Staffing (overall) – identified staff/volunteers to work on program, staff have adequate time for program, and trained staff to carry out follow-up/evaluation for program	2.63 (0.92)
Partnerships (overall) – formed coalition, advisory committee, and/or partnership, help meetings/discussions, and conducted community activities together	3.25 (1.04)
Program Components*
Community Needs Assessment (overall) – defined/identified a specific community, continually communicating with community, and shared needs assessment/research results with community	2.63 (1.41)
Community Education (overall) – identified strategies/activities to reach community, developed plan of activities for reaching the community, established means of getting feedback on program, and mechanisms in place for sustaining program	2.88 (1.46)
Community Partnerships and Provider Networks (overall) – developed plan for educating community partners on physical activity, relevant support systems in place to facilitate physical activity recommendations, tracking the number of participants, tracking how many sustained physical activity levels, and ongoing communication between agency and partners	2.75 (1.58)
Evaluation (overall) – identified questions you want evaluation to answer, trained staff to conduct evaluation, shared evaluation findings with community, and refined program based on evaluation	1.88 (0.99)

^*Program Champions rated their organization on a scale of 1–5, 1=no plan, 5=well prepared

Organizational post-assessment data showed that of the eight participating organizations and groups, seven successfully implemented all four of the program components and one successfully implemented two of the four program components. Program Champions reported that recruiting participants into the program was relatively easy since they incorporated the program with a pre-existing organization or group. All of the participating organizations and groups reported that they did not change the PI Let’s Move Pilot Program in any way, and that it did not cost them anything to implement the program. Program Champions expressed their appreciation for having a program to share with their community that represents PI culture. Some of the barriers that participating organizations and groups faced with regards to meeting the healthy lifestyle needs of their community included the belief among organizational leaders that PI culture placed higher importance on family versus healthy lifestyle, difficulty of adult and elderly populations to adapt to change, the need for consistent messaging around healthy eating and physical activity, and having someone in a high status position (i.e. Pastor) to motivate their membership to have a healthy lifestyle.

Individual Post-Assessment

PI Let’s Move Pilot Program participants (n=106) were mainly PI (over 95%), female (67%) and between the ages of 20–40. The individual post-assessment of the PI Let’s Move Pilot Program participants showed that more than half of participants (52%) were not engaged in regular physical activity prior to program participation. However, at the end of the 2-month pilot program, self-reported responses of participants showed an increase from 2.14 to 2.98 days per week engaged in medium-intensity physical. In addition, more than 82% of participants indicated that they intended to continue to engage in physical activity for at least the next six months. Answers to open-ended questions on the individual post-assessment indicated that participants liked the fun and upbeat movements in the video, the program is both simple and fun and gets them moving, and the program does a nice job at representing PI culture. Other participants reported that the video was too short, too slow, and too feminine.

Discussion

Disparity populations, such as PIs, can be effectively reached through culturally tailored programs that are hosted in community-based locations where people naturally gather on a regular basis. In designing a program that recognized the unique cultural elements of the PI communities, positive outcomes included changes in behavior and attitude towards physical activity. Prior to the PI Let’s Move Program, there were no evidence-based physical activity programs that were culturally tailored to meet and address the unique needs and issues of PI communities in the U.S. The bulk of the positive dialogue around the PI Let’s Move Program was centered on the communities’ appreciation for a program that has been culturally adapted for them. Although culturally adapting a program can take additional time and resources, the evaluation findings of the PI Let’s Move Program show that there is increased value in a program that is culturally tailored versus one that is not.

Community organizations and groups with minimal or no experience in implementing a physical activity program were able to successfully implement all four components of the PI Let’s Move Program. Evaluation findings demonstrate the feasibility and short-term impacts from a program that promotes short bouts of physical activity. Many physical activity programs for underserved and sedentary adults are complicated interventions that are especially challenging for adult populations that are overweight or obese (Brawley, Rejeski, & King, 2003). These types of programs make uptake, maintenance, and sustainability of the program nearly impossible. The PI Let’s Move Program is a short (10 minute exercise break) and group-based, which results in a more practical and enjoyable intervention that can help PI adults to jumpstart their physical activity levels.

It is important to note that recall bias is a limitation because participants were asked to retroactively report on their physical activity level in the individual post-assessment. To avoid this bias, future studies should make a strong attempt to administer both individual pre- and individual post-assessments as part of the program evaluation plan.

Future efforts to build on the success of the PI Let’s Move Program include a broader dissemination and program evaluation across the U.S., with a particular focus on cities with high populations of PIs. Through the WINCART Center’s vast network of PI-serving organizations, faith-based groups, and projects, plans have already been made to focus dissemination efforts in Salt Lake City, UT; Hawaii; Northern California, Seattle, WA; and Washington, DC. In addition, the WINCART Center is open to the possibility of utilizing the PI Let’s Move Program in a future randomized control trial on physical activity and obesity in PI populations. The WINCART PI Let’s Move Program Toolkit is available to view and download on the CES4Health website. And lastly, WINCART hopes that other collaborative efforts, regardless of the communities they serve and the health promotion issues they address, are inspired to culturally adapt their programs to meet the specific needs and integrate the important cultural aspects of their target audience.

Table 2.

Characteristics of Participating Organizations and Groups (N=8)

Name of Organization or Group	Healthy Lifestyles Services Offered in Past	Populations or Communities Served	Geographic Area Served	Languages Services Provided In
Assembly of God Marshallese Christian Center	Physical activity opportunities* Healthy eating education Healthy eating options	Marshallese community	Located in Costa Mesa, CA; serves Orange County, CA	English Marshallese
Faith Advisory Board of TCSC & APIOPA	Physical activity education Opportunities for physical activity Healthy eating education Policies and environmental changes to promote physical activity and health eating	Tongan and other Pacific Islander communities	Located in Hawthorne, CA, serves South Los Angeles, Beach Cities, and South Bay Areas	English Tongan
Famili Pe Taha	Physical activity education Opportunities for physical activity	Tongan community	Located in Santa Ana, CA, serves Orange County, CA	English Tongan
Pacific Islander Cancer Survivors Network	Physical activity education Opportunities for physical activity Healthy eating education	Chamorro community	Located in Long Beach, CA, serves Los Angeles and Orange Counties, CA	Chamorro English
Pacific Islander Neighborhood Action Council	N/A	Pacific Islander families	Located in Hawthorne, CA, serves South Los Angeles, CA	English Fijian Tongan
Samoan Community Council of San Diego	N/A	Samoan community	Located in San Diego, CA, serves San Diego County, CA	English Samoan
Tongan Neighborhood Action Council	N/A	Pacific Islander families	Located in Hawthorne, CA, serves South Los Angeles, CA	English Tongan
United Samoan Church Youth	Physical activity education Healthy eating education Healthy eating options Environmental changes to promote physical activity and health eating	Pacific Islander community, mainly Samoan	Located in Carson, CA, serves Los Angeles and Orange Counties, CA	English Samoan

^*Assembly of God Marshallese Christian Center was the only organization at the time that the pre-organizational assessment was administered that currently offered a physical activity program (a walking club).