Deep-Structure Adaptations and Culturally Grounded Prevention Interventions for Native Hawaiians: A Systematic Review of the Literature

Abstract

Research has shown that Native Hawaiians disproportionately suffer from behavioral disorders and chronic physical diseases, yet they have historically lacked effective and culturally relevant prevention interventions to address their pervasive health disparities. This article systematically reviewed the recent culturally relevant prevention intervention literature focused on Native Hawaiians. In this review, we assessed 14 peer-reviewed articles published between 2015 and 2020 that met inclusion and exclusion criteria pertaining to the development and/or evaluation of prevention interventions for Native Hawaiians. The reviewed studies evaluated 10 different interventions that were developed using deep-structure adaptation or culturally grounded procedures, and primarily focused on prevention of substance use, obesity/diabetes, and pregnancy/sexually transmitted infections (STIs). Compared with prior, related literature reviews, the present review suggests an overall advancement in prevention science for Native Hawaiians, evidenced by an increase in federal funding and randomized controlled clinical trials of prevention interventions for the population. This review provides an update to the state of the science for Native Hawaiian prevention interventions, and points to areas of future research and development.

Epidemiological health research has indicated that Native Hawaiians have disproportionately suffered from physical and mental health conditions, such as obesity [1], diabetes [2, 3], chronic kidney disease [4], suicidal behaviors [5, 6], and substance abuse [6–8]. However, research has historically lagged, in terms of developing effective, culturally relevant interventions to address pervasive health disparities of Native Hawaiians [9, 10]. The lack of empirically supported interventions in the scientific literature for Native Hawaiians has been recently addressed through specific requests for research proposals from the National Institutes of Health, such as administrative supplements focused on the inclusion of Native Hawaiians in minority health and health disparities research issued by the National Institute on Minority Health and Health Disparities (NOT-MD-19–023), and the RFA entitled “Intervention Research to Improve Native American Health” or IRINAH [11]. While the latter call for proposals broadly focused on Indigenous U.S. populations, only one of the 35 funded IRINAH projects to date is focused on Native Hawaiians. The dearth of Hawaiian-focused IRINAH projects may indicate that this funding opportunity, and similar large-scale efforts, may not be effective in increasing the amount of intervention research for this population.

In order to examine the impact of broader systemic efforts to expand and develop the intervention literature for Native Hawaiians, the present study systematically examines the culturally relevant prevention intervention literature focused on this population. Specifically, we identified and synthesized recent empirical studies of Hawaiian-focused prevention interventions that were developed using either deep-structure adaptations or culturally grounded methods [12]. Key emergent themes were compared and contrasted across studies, and areas for future prevention research for Native Hawaiians are discussed.

Literature Review

Native Hawaiians: A Brief Background

For this literature review, “Native Hawaiians” are defined as descendants of the original inhabitants of the Pacific Region of Polynesia (e.g., Hawaiʻi, Tonga, and Sāmoa). This population is distinct from the broader contextualized definitions of Hawaiians, which include citizens or residents of Hawaiʻi who are long-term residents or were born on the islands [13]. Numbering over a half-million in the most recent U.S. Census, they reside primarily within the State of Hawaiʻi and in the Western states of the Continental U.S. [14]. Similar to other Indigenous populations, Native Hawaiians have historically experienced colonization, with accompanying adverse effects. Specifically, Native Hawaiians came under U.S. occupation in 1893, when Queen Liliʻuokalani, the sovereign of the Kingdom of Hawaiʻi, was illegally deposed. Descendants of early missionaries in Hawaiʻi, who became wealthy businessmen and landowners, conspired to overthrow the Hawaiian monarchy [15]. This event was a primary source of significant cultural and political trauma for Hawaiians, impacting them spiritually, physically, economically, socio-politically, and psychologically [16]. The United States eventually annexed Hawaiʻi in 1898, and granted it statehood in 1959. However, by this time, significant adverse population effects were well underway. In terms of population health, early Western settlers in the 1800s brought an influx of diseases to the islands, including tuberculosis, measles, influenza, and syphilis, resulting in a 90 percent decrease of the Native Hawaiian population a century after the settlers’ arrival [13, 17].

As a part of the post-colonial experience, Native Hawaiians have had to balance a transnational identity, navigating social networks and linkages between two communities with distinct worldviews [18]. Specifically, many Native Hawaiians experience stress in balancing conflicting Indigenous and Western norms within their homeland, which is an outgrowth of past colonization [17]. The emotional and physical stress of navigating conflicting, dual cultures can hinder the psychosocial adaptation of Native Hawaiians [19]. For example, the norms of interdependence and collectivism in Hawaiian culture conflict with individualism in Western culture. Collectivism in Hawaiian culture is particularly evident in the interpersonal influence of immediate, extended, and ascribed families within the context of Native Hawaiian communities [18, 20]. The familial relational context within Hawaiian communities profoundly impacts individuals’ social and behavioral norms, values, and worldviews, and intensifies both psychosocial risk of and protection against adverse health consequences [20]. For example, in the area of substance use, Goebert et al. [21] found that family emotional support functioned as a protective factor against Native Hawaiian youths’ substance use in a large (N = 4000) epidemiological study. Conversely, Okamoto et al. [7] found that offers to use drugs from family members were a risk factor for Native Hawaiian youths’ substance use, significantly predicting their use of alcohol, cigarettes, and marijuana in their study. These studies not only highlight the salience of family-based risk and protection for Native Hawaiians, but they also point to the need for culturally relevant substance use prevention programs and services to ameliorate Native Hawaiian health disparities.

Native Hawaiians and Prevention Interventions

To date, there have been two systematic literature reviews that have partially captured the nature and extent of prevention interventions for Native Hawaiians. Edwards et al. [10] examined the empirical literature from 1995 to 2009 focused on Native Hawaiian youth and drug use. They identified 32 articles focused on this topic, with the majority of them characterized as epidemiological studies. Only 4 of the articles in their review (13%) focused on empirical evaluations of programs. This subset of studies was comprised of evaluations of grassroots, community-based programs for Hawaiian youth, and as a result, lacked studies that used clinical trial procedures to establish program efficacy. The Edwards et al. study reflected the state of the science for Native Hawaiians and prevention in its early stage of development. The studies included in the review established community-based need for prevention through examining epidemiological rates, and examined community driven, grassroots efforts to combat a pervasive health disparity issue (substance misuse).

Lauricella, Valdez, Okamoto, Helm, and Zaremba [22] conducted a systematic review of empirical literature from 2003–2014 focused on culturally grounded prevention interventions for minority youth populations. They identified 31 empirical articles focused on this topic, with 4 articles (14%) focused on the early-stage development of a culturally grounded, school-based, drug prevention curriculum for rural Native Hawaiian youth (Hoʻouna Pono). The Hoʻouna Pono studies used a combination of qualitative and quantitative research methods to develop curriculum content on skills and strategies to resist drugs in difficult social situations with peers and family members. While the Lauricella et al. study was able to identify the emergence of empirically supported, culturally relevant prevention interventions for Native Hawaiians in the scientific literature, none of the Hawaiian-focused studies described in their review were at the phase to employ clinical trial procedures. Thus, while progress appeared to be emerging in the development of prevention interventions for Native Hawaiians since the Edwards et al. [10] study, the state of the science still appeared to reflect a relatively early stage of prevention intervention development for this population.

More recently, specific efforts to develop prevention interventions for Native Hawaiians have been described in the literature. For example, Kaholokula, Ing, Look, Delafield, and Sinclair [23] described the process of developing two culturally focused interventions—KāHOLO and PILI ‘Ohana—that target obesity, diabetes, and cardiovascular disease prevention. PILI ‘Ohana was created through a deep-structure adaptation of an evidence-based intervention (the Diabetes Prevention Program - Lifestyle Intervention) using community-based participatory research principles and practices. KāHOLO used culturally grounded methods to develop a cardiovascular disease prevention program that focused on the traditional cultural dance of Hawaiʻi (hula). These programs highlight the recent growth in the state of Native Hawaiian prevention science, and indicate the future direction of prevention science with the population.

Relevance of the Study

In order to examine the impact of recent Federal efforts to increase intervention research focused on Native Hawaiians, this study systematically examined the recent prevention intervention literature focused on the population. The present review also serves as an update to the prior systematic literature reviews [10, 22], which both suggested early stages of development for the prevention intervention literature for Native Hawaiians. Unlike the prior literature reviews, which focused on interventions for children and adolescents, the present review encompasses prevention literature for Native Hawaiians across the life span. This review also includes deep-structure cultural adaptations to interventions, as well as culturally grounded approaches, in order to address the prevention needs of Hawaiian communities dealing with a wide array of pervasive health disparities. The findings from this literature review have implications for the health promotion of Native Hawaiians, Pacific Islanders, and other Indigenous populations, especially those across the Pacific region.

Method

Figure 1 illustrates a PRISMA flow diagram of the process of identifying articles for this review. In Step 1, the three primary authors conducted a computerized search of online databases, including PsycNET, PubMed, and EBSCO. To ensure mutual exclusivity with the Edwards et al. [10] and Lauricella et al. [22] literature reviews and to highlight the most recent empirical research, we focused on studies published between 2015 and 2020. In each database, the primary terms “health”, “Native Hawaiian”, and “prevention” were used. During these searches, we employed other relevant terms, such as “intervention”, “culturally grounded”, and “culturally relevant” to expand the search perimeter. The online database search yielded 483 different articles. We also conducted a focused search of 13 different journals that have a history of publishing research focused on Native Hawaiians (see Table 1). The focused journal search yielded 344 articles. After eliminating duplicate articles between the two search methods, there were 473 unique articles for potential inclusion in this review.

Figure 1.

PRISMA Flow Diagram for Literature Review. This figure illustrates our process for identifying and reducing the number of articles included this review, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement.

Table 1.

Focused Journal Searches: Empirical Prevention Articles on Native Hawaiians: 2015–2020^*

Journal	Number of Articles
American Journal of Community Psychology	40
Children & Schools	3
Health & Social Work	10
Health Education & Behavior	31
Health Promotion Practice	33
Journal of Community Psychology	55
Journal of Health Care for the Poor & Underserved	25
Journal of Primary Prevention	13
Journal of Racial and Ethnic Health Disparities	66
Prevention Science	41
Progress in Community Health Partnerships	9
Social Work	6
Social Work Research	12
Total	344

^*Search Term: Hawaiian

In Step 2, the three primary authors read and evaluated all abstracts based on the inclusion and exclusion criteria for the study. Articles were included in this study if they (1) focused on Native Hawaiians, either exclusively or in combination with related populations (e.g., Pacific Islanders, other Indigenous groups); (2) focused on the development and/or evaluation of culturally adapted¹ or culturally grounded programs; (3) described an empirically driven approach to the development and/or evaluation of the programs; and (4) were published between 2015 and 2020. Articles were excluded in this study if they (1) focused on populations other than Native Hawaiians. These included articles that may have sampled Native Hawaiians, but the focus was on the broader ethnic categorization (e.g., Asian/Pacific Islanders); (2) focused on culturally generic or surface-structure adaptations of interventions; (3) were non-empirical in nature (e.g., descriptive or theoretical articles); (4) were not peer reviewed; and (5) were published prior to 2015. Based on our initial assessment of articles, we reduced the number of articles to 34.

In Step 3, the research team screened the full text of the 34 remaining articles using the inclusion and exclusion criteria. During this step, the full-text analysis of articles revealed that several of them were primarily etiological or correlational in nature, or described research initiatives, such as community/university collaborations, rather than prevention programs for Native Hawaiians. These articles were eliminated from inclusion in the study. One particular article was a protocol paper that described a prospective randomized controlled trial of the KāHOLO program [24]. Because this paper did not report on outcome findings from the program, we deemed it non-empirical in nature and eliminated it from the pool of articles. The full text analysis of articles in Step 3 reduced the number of articles to 14.

Results

The 14 peer-reviewed articles which met inclusion and exclusion criteria for this study are outlined in Table 2. The majority of studies in this review focused on substance use prevention (33%), followed by obesity/diabetes (20%) and pregnancy/STI (20%) prevention. The development and/or evaluation of 10 different prevention interventions were described across the reviewed articles. All but one study (Patel et al. [25]) took place exclusively in the State of Hawaiʻi. Of the Hawaiʻi-based studies, 31% took place on multiple islands across the State, 31% took place on the Island of Oʻahu, 31% took place on Hawaiʻi Island, and 7% (1 article) did not disclose its study’s location.

Table 2.

Results from Literature Review

Study	Program Name	Issue	N Size	Study Type	Age Range	Clinical/ Translational Level	Study Design	Major Finding(s)	Funding
Abe et al. [33]	Pono Choices	Pregnancy and STIs	2,203	CG	Pre-Adolescent	T2	RCT	Significant increases in sexual health knowledge; non-significant changes in risky sexual behaviors, attitudes, skills, or intentions 12-months after baseline	OAH
Cassel et al. [29]	SunSafe Adaptation	Skin Cancer	50 (Focus Groups); 250 (Surveys)	DSA	Adolescent	T2	MIX	Significant increase in knowledge, attitudes and sun protection behaviors, from pre- to post-test	CDC
Helm et al. [34]	Puni Ke Ola Photovoice Project	Substance Use	10	CG	Adolescent	Tl	QUAL	An emerging framework for a community-based, Native Hawaiian model of drug prevention	NIMHD, SCRA, Queens
Ing, Miyamoto, etal. [35]	PILI@Work	Obesity	217	DSA	Adult	T2	RCT	Significant improvements in weight loss and systolic and diastolic blood pressure from baseline to 3-month post-intervention	NCI, NIMHD, Queens
Ing, Zhang, et al. [36]	Partners in Care Adaptation	Type 2 Diabetes	47	DSA	Adult	T2	RCT	Significant improvements in HbAlc, diabetes-related self-management knowledge, and behaviors from baseline to 3-month assessment	NIMHD, Queens
Ing et al. [37]	PILI@Work	Obesity	217	DSA	Adult	T2	RCT	Participants receiving a face-to-face intervention internalized their locus of weight control and perceived more family support for weight loss from 3-month to 12-month follow up	NCI, NIMHD, Queens
Kaholokula et al. [26]	Ola Hou i ka Hula	Hypertension	55	CG	Adult	T2	RCT	Significant reduction in systolic blood pressure in intervention group, compared to control group	NIMHD, NIGMS, Queens
Kaʻopua et al. [38]	N/A	HIV and Anal Cancer	28	DSA	Adult	Tl	QUAL	Identified risk and reluctance to anal cancer screening, and strategies for destigmatizing anal cancer	NIMHD
Okamoto et al. [39]	Hoʻouna Pono	Substance Use	213	CG	Pre-Adolescent	T2	RCT	Significant increases in non-confrontational drug resistance strategies in intervention group; significant increases in fighting in control group	NIDA
Okamoto et al. [40]	Hoʻouna Pono	Substance Use	8	CG	Adult	Tl	QUAL	Stakeholders validated the cultural validity and educational utility of the curriculum	NIDA
Okamoto et al. [41]	Hoʻouna Pono	Substance Use	486	CG	Pre-Adolescent	T2	RCT	Small, significant changes in the intended direction for cigarette/e-cigarette and hard drug use	NIDA
Okamoto et al. [30]	Hoʻouna Pono	Substance Use	24	CG	Adult	T3	QUAL	Implementation strategies included cultural validation of the curriculum, and creating flexibility in the curriculum for diverse educational settings	NIDA
Patel et al. [25]	STRIVE Project	Health Disparities	1.4 mil	DSA	Adult	T2	MIX	Described culturally adapted, community-based approaches to increase healthy food intake and physical activity	CDC,NIMHD
Takishima-Lacasa and Kameoka [27]	Girl Power Hawaiʻi	STI	13	DSA	Adolescent	Tl	QUAL	Described deep-structure cultural and content validation of the adapted curriculum using a phased model	N/A

NOTE. Issue: STI = Sexually Transmitted Infection, HIV = Human Immunodeficiency Virus. Study Type: CG = Culturally Grounded; DSA = Deep Structure Adaptation. Clinical/Translational Level: T1 = Program Development; T2 = Efficacy/Effectiveness Trials; T3 = Implementation and Dissemination. Study Design: MIX = Mixed Methods; RCT = Randomized Controlled Trial; QUAL = Qualitative. Funding: CDC = Centers for Disease Control and Prevention; OAH = Office of Adolescent Health, U.S. Department of Health and Human Services; NIMHD = National Institute on Minority Health and Health Disparities, National Institutes of Health; NIDA = National Institute on Drug Abuse, National Institutes of Health; NCI = National Cancer Institute, National Institutes of Health; NIGMS = National Institute on General Medical Sciences, National Institutes of Health; SCRA = Society of Community Research and Action; Queens = Queen’s Health Systems.

Half of the studies used culturally grounded methodologies to develop programs or curricula. These methods entailed processes or procedures to develop interventions from the values, beliefs, and worldviews of Native Hawaiian communities. For example, Kaholokula et al. [26] described the social, educational, and cultural components of Ola Hou i ka Hula. A precursor to the KāHOLO program, Ola Hou i ka Hula integrated the traditional dance of Native Hawaiians (hula) as an integral physical activity component of a community-based hypertension prevention program. Researchers employing deep-structure adaptations of evidence-based curricula typically utilized focus groups to meaningfully infuse cultural content and context into their interventions. Takishima-Lacasa and Kameoka [27], for example, described a phased model for their deep-structure adaptation of Girl Power, which included the selection of an evidence-based intervention from the scientific literature, development of an adaptation guide in collaboration with community stakeholders based on the selected intervention, and focus groups with NHPI girls to inform the adaptation of intervention content.

Fishbein, Ridenour, Stahl, and Sussman [28] described a translational spectrum of prevention science, which classifies studies as T0 (basic discoveries), T1 (program development), T2 (efficacy/effectiveness trials), and T3 (implementation and dissemination). Approximately a third of the studies (29%) in this review were classified as T1 studies. They described qualitative methods used to adapt and/or validate prevention programs for Native Hawaiians, thus reflecting the early stages of culturally relevant program development. Nearly two-thirds of the studies in this review (64%) were classified as T2 studies. The majority of T2 studies in this review (78%) used randomized controlled trial designs to evaluate program efficacy and/or effectiveness. Most of these studies reported relatively small sample sizes and/or modest positive program effects. Two T2 studies used a combination of both qualitative and quantitative methods to evaluate program effects. For example, Cassel et al. [29] described their use of focus groups to adapt the SunSafe skin cancer prevention curriculum for NHPI youth, and described the evaluation of their adapted curriculum using randomized controlled trial procedures. Finally, one study in this review was classified as a T3 study. This study focused on the program implementation of a culturally grounded, substance use prevention curriculum for Native Hawaiian youth [30].

Notably, 93% of the studies in this review received some form of federal funding to support the development and/or evaluation of a culturally relevant program for Native Hawaiians. The most commonly cited federal funding source was the National Institutes of Health (NIH; 79%). Within NIH, the most commonly cited institutes funding studies in this review were the National Institute on Minority Health and Health Disparities (41%), followed by the National Institute on Drug Abuse (23%). Almost half of the studies (46%) received funding from multiple sources (i.e., federal- and state-level funding sources).

Discussion

This study systematically examined the recent empirical prevention literature focused on Native Hawaiians. Despite its compressed time frame (2015–2020), this review identified 14 articles meeting relatively restrictive inclusion and exclusion criteria. This is contrasted with only four intervention articles focused on Native Hawaiian youth and drug use over a 15-year time span (1995–2004) identified by Edwards et al. [10], and four Hawaiian-focused prevention articles over a 12-year time span (2003–2014) identified by Lauricella et al. [22]. While Edwards et al. and Lauricella et al. were more limited in their scope compared to the present study, comparing those findings to the present findings suggest that there has been more intervention research for Native Hawaiians that has been generated in recent years.

In terms of the types of studies, the present review also demonstrates an increase in the number of efficacy and effectiveness trials focused on Native Hawaiians, compared to prior systematic reviews. Specifically, Edwards et al. [10] found that the majority of studies focused on Native Hawaiian youth in their review were epidemiological in nature, suggesting that prevention science for Native Hawaiians was primarily within the T0 (basic discovery) phase in the late 1900s and early 2000s. Further, Edwards et al. indicated that the few intervention studies included in their review were predominantly community grassroots programs that added an a posteriori evaluation component. This is contrasted to the planned, purposeful, T2 clinical trials that were identified and included in the present literature review. The present review even included a recent T3 study on prevention implementation science for Native Hawaiians. Overall, these findings suggest that the state of the science of Native Hawaiian prevention research has been advancing through the translational spectrum of prevention science described by Fishbein et al. [28] over the past decade.

The majority of the studies included in this review were supported by federal funding, and several of them were supported by multiple federal sources (e.g., NIMHD, NIGMS, and NIDA). The majority of the calls for research proposals from these federal sources are topical in nature (e.g., suicide, substance use, prevention), and those that are population based, such as IRINAH [11], have been more broadly focused on Indigenous groups in general, including American Indians, Alaska Natives, and Native Hawaiians. This demonstrates that most of the studies in this review were funded by federal mechanisms that did not specifically target the Native Hawaiian population. The number of extramurally funded prevention studies focused on Native Hawaiians in this review is in stark contrast with anecdotal and empirical accounts from 10 years ago that indicated a scientific bias against research focused on the population [31, 32]. Okamoto [31], for example, described common critiques against research focused on Native Hawaiians. Studies with the population were described as “non-generalizable” or “limited” in their reach, suggesting they had a low scientific impact because they did not serve to inform the larger ethnic rubric (i.e., Asian/Pacific Islanders). We would argue that the emerging prevalence of funded prevention studies in recent years focused on Native Hawaiians represents a paradigmatic shift over the past decade. It suggests that the scientific community increasingly recognizes the importance of culturally relevant prevention research for Native Hawaiians, and the implications of this research for Indigenous and Pacific Islander health.

Recent advances in Native Hawaiian prevention science can largely be attributed to the earlier contributions of Native Hawaiian researchers, such as Marjorie Mau and Keawe Kaholokula, who have advocated over the years to fund more research focused on Native Hawaiian health from federal funding agencies and to recognize Native Hawaiians as Indigenous people. However, despite these scientific advances, this review points to areas of future prevention research that are needed for Native Hawaiians. While studies in this review addressed health disparity issues relevant to Native Hawaiians (e.g., youth substance misuse, obesity, diabetes, and STIs), there were a lack of culturally relevant prevention studies related to mental health (e.g., suicidality), and some chronic physical conditions (e.g., kidney disease). Further, the majority of the studies in this review took place in the State of Hawaiʻi. As a result, much is still not known about the prevention intervention needs of Native Hawaiians living in the Continental U.S., where nearly 50% of all Native Hawaiians reside. Future research should address these gaps in the science.

Finally, it is worth noting that, of the 14 studies included in this review, only two were written by self-identified Native Hawaiian researchers as lead authors. This highlights the fact that the scientific workforce lacks Native Hawaiian prevention researchers to contribute to culturally relevant prevention development and evaluation [15]. Future federal efforts should work toward advancing both Native Hawaiian prevention science and the Native Hawaiian scientific workforce, in order to address the specific needs of Hawaiian communities and to continue to move the field forward.

Limitations of the Study

There were several limitations to this study. First, this review focused on a narrow (5 year) time period. This decision was made to avoid overlap with related systematic literature reviews [10, 22], thereby reducing redundancies in the included studies with prior reviews, as well as focusing the review on the most up-to-date published prevention research on Native Hawaiians. However, this decision left out several adult-focused prevention studies published prior to 2015 in our review. Second, because this review focused on the published, peer-reviewed literature, culturally relevant prevention programs for Native Hawaiians that were in the early (pre-publication) stages of development or were unpublished were not included in this review. Future literature reviews could incorporate the “grey” literature to identify unpublished interventions for Native Hawaiians, although these types of articles are often difficult to find.

Conclusions

Despite its limitations, this study identified recent advances in the prevention intervention literature focused on Native Hawaiians. The findings suggest that recent federal efforts to expand and develop prevention interventions for Native Hawaiians have resulted in advancing the translational spectrum of prevention science for the population. Although progress has been made, there still exists an overall lack of research in the recent prevention literature focused on Native Hawaiians. As a result, there are several health disparity areas for the population that need future research. More T3 studies focused on the dissemination and implementation of efficacious prevention programs for Native Hawaiians need to be conducted. This could be achieved through federal investments in funding opportunities intended to move the translational spectrum of prevention science for Native Hawaiians into the realm of T3 studies, and a focused effort in training new and/or early-stage investigators in conducting T3 studies with Native Hawaiian communities. Finally, more studies are needed that are led by an expanded cadre of Native Hawaiian prevention researchers. Future related systematic literature reviews might focus on culturally relevant prevention interventions for other Pacific Islanders, such as Samoans, Tongans, and Marshallese, in order to establish the need for research with these related, yet distinct, populations. These groups collectively comprise the majority of the Native Hawaiian/Pacific Islander categorization, yet have received less federal health research funding than Native Hawaiians. By continuing to advance the field of prevention for Native Hawaiians and other Pacific Islanders, pervasive health disparities will be addressed and alleviated for these populations.