Jane H Lassetter, Nursing

Abstract

In our recent study, 84.4% of Native Hawaiian and Pacific Islanders (NHPIs) in Hawaii and Utah were overweight or obese, which puts them at increased risk for obesity-related diseases, including cardiovascular disease, diabetes, and some cancers. Pre-colonization NHPI diets were rich in fresh fruits and vegetables and fish, but research indicates current NHPI diets consist largely of processed and fast foods. Along with this change in NHPI diet came a change in activity, from fishing and farming to more sedentary jobs. The changes in diet and activity likely contribute to high NHPI overweight and obesity prevalence. People can make wise choices about food and activity practices if they are adequately informed and learn how to achieve and sustain healthy choices, especially if they have family support. With this idea in mind, grass-root efforts are occurring within NHPI communities in an attempt to reverse the obesity trend. However, little research on these efforts has been done. Therefore, the purpose of this study is to assess the effect of a family-focused intervention to improve activity and nutrition and promote weight loss, as needed, in NHPI families. Results of this research will indicate which activities are helpful and which need further refinement to improve NHPI nutrition and activity.

Background and Importance of the Project

Native Hawaiian and other Pacific Islanders (NHPIs) face significant health disparities related to being overweight or obese. In Utah, one of seven states with a significant NHPI population (U.S. Department of Health & Human Services, Office of Minority Health, 2011), there is an overall obesity prevalence of 23.4% (Levi, Segal, St. Laurent, & Kohn, 2011); however, NHPI obesity prevalence in Utah is 49%, more than double the overall obesity prevalence (Utah Department of Health, 2009).

In our recent study, 84.4% of NHPI participants in Utah and Hawaii were overweight or obese; NHPIs in Utah had significantly larger BMIs than NHPIs in Hawaii (p=0.017, p<0.05; Duncan, Lassetter, et al., in review). In addition, 45% of participants had a possibility or high likelihood of limited health literacy according to their performance on a nutrition fact label tool (Morgan, Lassetter, et al., in review), and most were not feeding their families the recommended number of servings of fruits and vegetables each day (unpublished data). In our focused ethnography, parents of NHPI children faced pressure from extended family and others to overfeed their children to promote weight gain. Parents who wanted their children to be in normal weight ranges had difficulty responding to this pressure (Lassetter & Clark, 2012). These findings suggest a need for an intervention to help NHPIs apply information on nutrition fact labels to decisions about nutrition, increase daily servings of fruits and vegetables, and appropriately respond to and resist pressure from others to increase their children’s weight. Grass-root efforts to achieve better nutrition and activity are occurring already in Utah’s NHPI community. Specifically, BYU alumni Joyce and Sale AhYou established the Queen Center, a non-profit, community-based organization dedicated to improving NHPI health in Utah. Recently they developed the “MANA Challenge,” an activity and nutrition program. Mana is Hawaiian for strength but also serves as an acronym for Movement, Awareness, Nutrition, and Action. To date, four groups of adults have participated in the program, and their anecdotal responses are positive. However, the MANA Challenge’s effectiveness has not been studied. Therefore, our purpose is to include families in the MANA Challenge and assess its effect on NHPI activity, nutrition, and weight loss, as needed. Our aims are to (1) increase participants’ activity; (2) improve participants’ self-chosen dietary habits (e.g. increase consumption of fresh fruits and vegetables, changing from whole milk to 2% or skim milk, reducing sweets in daily diet); (3) maintain participants’ normal BMIs and reduce overweight or obese BMIs toward the normal range; (4) enhance teen and adult participants’ ability to interpret nutrition fact labels; (5) enhance participants’ self-efficacy regarding healthy activity and eating; and (6) begin behaviors that will decrease participants’ risk for type 2 diabetes. For this study, we will modify the MANA Challenge by including more nutrition education, self-efficacy discussion, and role play. We will require several members of the same family (n= 7 families) to participate together and include their children. We want to involve families because NHPIs are more likely to participate in nutrition and activity programs that include family members and emphasize cultural traditions and values (Fujita, Braun, & Hughes, 2004). This intervention will require one graduate and ten undergraduate College of Nursing research assistants to prepare for data collection and the activities/classes, teach the nutrition content, facilitate role-play, lead the exercise activities, and collect and analyze data. Helping with the intervention and collecting and analyzing data with the primary investigator will provide excellent mentoring experiences for the nursing students as they “go forth and serve” by helping to improve NHPI participants’ activity and nutrition and, thereby, potentially reduce their risk for obesity and related diseases.

Methods

This is an intervention study incorporating key findings from my own previous descriptive studies and pertinent literature. The conceptual model for this study is Golan and Weizman’s (2001) Familial Approach to the Treatment of Childhood Obesity. Based on Bandura’s (1989) Social Cognitive Theory and the Family Systems Theory, this model involves parents/caregivers’ modeling healthy lifestyle behaviors, promoting healthy behaviors in their children, and creating environmental change to promote good health within their families. In order for parents to model healthy lifestyles and change their nutritional environment, increased nutritional skills are often needed, including understanding nutrition fact labels to enable healthy choices and preparing food in healthy ways. Parents also serve as activity role models. When parents become physically active, they often involve their children or, at least, encourage their children to be active. The chance of sustainability is improved when several family members are involved in efforts to improve the nutrition and activity environment in the home and support one another’s efforts (Fujita et al., 2004).

Recruitment, Inclusion Criteria and Setting

Families will be recruited through the Queen Center and the Hawaiian Cultural Center in Midvale, Utah. Procedures for recruitment will include word of mouth and distribution of fliers containing a brief description of the study and the researcher’s contact information.

To be included in this study, recruits will (1) self-identify as NHPI, (2) be free of known heart disease, and (3) have NHPI family members, who are willing to participate, including at least one child (age 5-17 years of age). We anticipate recruiting 7 NHPI families with an average of 5 family members (or significant others perceived as “family”). We will accept qualifying families on a first-come, first-serve basis.

The intervention and data collection will take place at the Hawaiian Cultural Center on four consecutive weeks in January and February 2013 and a reunion event for final data collection in March. A follow-up reunion in one year is also planned.

Design and Explanation of Procedures

After explaining the intervention and the study’s purpose and answering questions, the researcher will ask adult participants (18 years of age and older) to sign a consent form for themselves and their children. Children (8 to 17 years of age) will be asked to sign an assent form.

We will collect baseline data from adult participants at the beginning of the first class/activity. In addition, each participant (child and adult) will be privately weighed and measured to allow for BMI calculations. Participants will respond weekly to checklists about their activity and efforts to eat healthy foods.

The intervention will be four weekly classes/activities, the duration the Queen Center determined most appropriate for NHPI family involvement. The first 45 minutes each week families will participate together in physical activity, such as Zumba, hot hula, relay races and other physical activity. The next 30 minutes, adults will discuss a nutrition or self-efficacy topic, such as interpreting nutrition fact labels, small steps toward a healthier life style (e.g. no meat Tuesdays, eliminating soda, or changing from whole to 2% milk), and how to respond to friends or family members who say a normal weight child is too small. During this time, children will participate in learning activities to help improve their nutrition and activity, such as drawing a picture of their favorite meal, followed by group discussion of the healthfulness of color variety in meals. At the end of each class/activity, participants with visit with each other and researchers and NHPI facilitators while eating healthy food.

At the end of the fourth session, participants will complete the survey and be privately weighed and measured. Four weeks later, we will hold a reunion and ask participants to complete the survey and be privately weighed and measured. A follow-up reunion in one year is also planned to assess sustainability of the intervention.

Measurement and Instrumentation

Data collected pre, post, and 4-weeks post intervention will include demographic questions, questions about self-efficacy and dietary and exercise behaviors, Pfizer’s Newest Vital Sign, and the American Diabetes Association’s Diabetes Risk Test. Dietary and exercise behaviors will be assessed with questions on family food serving practices and exercise promotion patterns. Food serving questions were derived from a number of sources, including food records as described by the Australasian Child and Adolescent Obesity Research Network (ACAORN; 2010), established to coordinate research among research groups studying child and adolescent obesity in Australia and New Zealand. According to ACAORN, a 3-day food record is long enough to gain insight into regular food intake without being too labor-intensive for participants. So, participants will be asked, “how many of the last three days did you eat five or more servings of fruits and vegetables?” Options range from “0 = no days” to “3 = 3 days.” We will also ask about family physical activity. For example, “how many of the last seven days did you participate with your child(ren) in physical activity for at least 30 minutes?” Options range from “0 = no days” to “7 = 7 days.”

Self-efficacy regarding healthy diet and exercise will be measured with two questions examining the relationship of social contextual factors and health behaviors. These questions were modified from other diet and exercise self-efficacy measures, including the Harvard Cancer Prevention Program Project (Emmons, Stoddard, Gutheil, Suarez, Lobb, & Fletcher, 2003; Franko et al., 2008; Resnik & Jenkins, 2000). We will ask, “How sure are you that you could (feed your family healthy meals) and (encourage your children to be physically active)? The five response options are: Not at all sure, Sure little of the time, Somewhat sure, Sure, and Very Sure.

Pfizer’s Newest Vital Sign (NVS) consists of six questions to assess the ability to read and understand a typical nutrition fact label. Scores range from 0-6 with 0 to 1 suggesting high likelihood of limited literacy, 2-3 suggesting a possibility of limited literacy, and 4-6 almost always indicating adequate literacy (Pfizer, 2012). NVS has been shown to have good internal consistency (Cronbach α = 0.76) and criterion validity (r = 0.59, P <.001; Weiss et al., 2005). In our recent study in Hawaii and Utah, NVS had good reliability (Cronbach α= 0.779). The American Diabetes Association’s Diabetes Risk Test is an eight-item questionnaire that assesses respondents’ risk for type 2 diabetes. Two questions are on modifiable risk factors, specifically weight and activity. Scores range from zero to ten, with scores greater than five indicating increased risk for type 2 diabetes. Although the tool may not be robust enough to show a change in four weeks, we anticipate an upward trend in participants’ responses to the activity question. Demographic questions will collect information on participant’s gender; year of birth; ethnicity; number of years lived in the U.S.; marital status; education and income levels; previous efforts to achieve weight loss, including surgical intervention; and number, gender and ages of adult participant’s children. In addition, each week families will complete a recall checklist about what they did the past week related to activity and nutrition. These checklists will include a 24-hour diet recall and questions, such as “what did your family do this week to improve their nutrition?” and “our family participated in at least 30 minutes of physical activity on ____ (number of days) this week.” Completed checklists will be included in data analysis.

Data Analysis

Data will be entered in SPSS and cleaned. Measures of central tendency (frequencies, means, and standard deviations) will be used to describe the demographic characteristics of the sample. Correlation coefficients will be used to calculate the relationships between study variables. ANOVA and t-tests will be conducted to examine differences between groups (e.g. pre, post, and 4-weeks post intervention). An expert nurse statistician will be consulted to assure accuracy and meaningfulness of data analysis.

Anticipated Outcomes Related to Mentoring

Expected Accomplishments

At least one graduate nursing student and ten undergraduate nursing students will work with me on this research. I have nearly ten years’ experience working with NHPIs and researching their health challenges. The graduate student has previous experience caring for NHPI populations because she went with me to Hawaii in 2005 when she was an undergraduate student for Nurs400 Global Health and Human Diversity. The students and I will work closely with NHPI leaders at the Queen Center to assure cultural appropriateness of the intervention overall as well as specific lessons and activities. Whenever possible, we will work with NHPI leaders in actually teaching and leading activities. Thus, the students and I will meet regularly alone and with NHPI leaders in planning, implementing, and evaluating the intervention.

The graduate student and I will explain to the undergraduate research assistants/students the IRB process, including review of the IRB documents and how we will protect our participants throughout the research process. In addition, they will complete BYU’s IRB tutorial to further familiarize them with the IRB and protection of human participants.

I will role model data collection for the graduate student, and together we will role model data collection for the undergraduate research assistants/students and serve as on-site resources for them. The students and I will travel together to and from the intervention activities and the reunion; this will provide excellent opportunities for continued mentoring and any last minute preparation and debriefing.

Research assistants/students will also help with data entry into SPSS. A professional statistician will consult with us to assure accuracy. Then research assistants/students and I will work together to determine the meaning and implications of the statistical results and determine how this information can be applied in enhancing future interventions for NHPI populations. The results will be shared with NHPI leaders who will help contextualize the findings to life within the NHPI culture and community in Utah. We will share results formally and informally within the NHPI community as they request.

The graduate student, select undergraduate student(s), and I will present the findings in 2013 at the BYU College of Nursing Research Conference and in 2014 at Western Institute of Nursing Conference, the Pacific Institute of Nursing Conference, and/or the Sigma Theta Tau International Research Congress. In addition, I plan to write a manuscript with the graduate student and select undergraduate student(s) to submit to a professional nursing journal for publication. I am considering The Journal of Transcultural Nursing and Journal of Nursing Scholarship as potential peer-reviewed nursing journals for our manuscript.

In summary, at the end of this mentoring experience, undergraduate students will be able to:

• Identify and adhere to the principles and process of protection of research subjects
• Assist in an intervention to help improve nutrition and activity for children and adults
• Be mindful of cultural nuances that can affect teaching methods
• Conduct survey research interviews with NHPIs
• Enter data in SPSS data entry program
• Clean and check data entry
• Interpret results of statistical analyses
• Evaluate effectiveness of an intervention based on statistical analysis
• Disseminate findings through podium presentations and manuscript submission

Mentoring Environment

In the proposed research, I will work closely with the graduate and undergraduate students. Every student involved will have opportunities to participate in planning and implementing the intervention, data collection, data entry into SPSS, data analysis, and dissemination of findings. I anticipate there will be a good deal of creative energy as we plan and implement the intervention as well as interest in understanding the data and what they mean. Participating in the research process will allow students to learn about the critical role of research in their nursing practice and understand the meaning and application of research in patient care.

Additionally, this research topic is closely linked to the Word of Wisdom; thus, there is a natural integration between what we will study and teach in the intervention and basic gospel principles. I will encourage students to discuss the relationship between our findings and the Word of Wisdom and the spiritual application to their own lives and practice. I will remind students of the importance of respecting cultural and religious beliefs different than our own and how we can and will work within the framework of others’ beliefs to teach the importance of good nutrition and exercise.

As data are collected, I will work with the research assistants/students on data entry into SPSS. This will help them understand the critical need for precision as they work together and verify each other’s data entry.

With the help of an expert statistician, the students and I will complete the statistical analyses. We will discuss the meaning of the statistical analysis, the successes and shortcomings of our intervention, and opportunities for improvement. Together we will develop abstract(s) for presentations at professional nursing conferences and manuscripts for professional nursing journals.

Influence of this Mentoring Environment Experience on Students’ Careers

Evidence-based practice through application of quality research is a cornerstone of nursing. When nurses understand and apply research to their patient care, patient outcomes improve. This translates into improved quality and length of life and better nurse-patient relationships. By providing students with a hands-on mentoring environment and opportunity to participate in the research process from intervention to data collection and analysis to dissemination of findings, they will have enhanced understanding of research and enthusiasm for applying it to improve their care. Through the process, research will come to life for them as they have opportunity to work with participants and see what a difference they can make in people’s lives through research. This will contribute to a desire for lifelong learning.

Many of our nursing students choose to further their education in graduate school. Working with the graduate nursing student will provide undergraduate students with an opportunity to become acquainted with a graduate student as she and I mentor them. They will have opportunities to visit and explore graduate school opportunities. In addition, familiarity with the research process and dissemination of findings will help the undergraduate students be successful in their graduate application process and completion of their graduate studies.

Qualifications, Experiences/Successes in Mentoring

The focus of my research trajectory is improving NHPI health and well-being. I completed my dissertation research, a qualitative descriptive study, with Native Hawaiians living in Las Vegas in 2008. My research mission statement is to determine ways to positively influence the proximal outcomes of healthy food choices and exercise promotion, which will in turn affect the more distal outcomes of reducing weight, body mass index (BMI), and associated risks due to overweight and obesity in NHPI families.

I have mentored undergraduate and graduate students throughout my academic career. In total, I have mentored 6 ORCA students and 24 undergraduates through MEGs. Since receiving graduate faculty status in 2010, I have chaired two successful graduate theses and am currently chairing three graduate students, one on a scholarly paper and two on theses.

I last applied for and received a MEG in 2010. Through that grant I involved two alumni, two graduate students, and six undergraduate students from BYU and BYU-Hawaii. Additionally I involved faculty from Department of Nutrition, Dietetics, and Food Science at BYU, Biology at BYU-Hawaii, and the College of Nursing at the University of Utah. To date, that MEG has helped generate four presentations at local professional nursing conferences, three presentations at regional professional nursing conferences, and two presentations at an international conference. All presentations have been well received as determined by audience questions and follow-up from attendees after the conferences. Two of the regional presentations have published abstracts. In addition, two manuscripts are currently under review. Those involved are included in the author lists of the manuscripts and presentations. This research helped us understand the needs of NHPIs related to interpreting and applying information on nutrition fact labels and the prevalence of NHPI overweight and obesity in Utah and Hawaii.

In another recent study I involved two alumni and five undergraduate nursing students, including one who received an ORCA grant. As with the study discussed above, these students helped throughout the research process. This research has generated four presentations at local nursing conferences; three presentations at regional nursing conferences, one of which has a published abstract; and one presentation with a published abstract at an international nursing conference. A manuscript on this research is currently in progress with manuscript submission planned for November, 2012. All students involved in this research will be included in the author list. A second manuscript will be written and submitted for publication in 2013.

These research projects and other previous research have laid a firm foundation for the proposed research by helping us understand NHPIs’ strengths and needs. It is time to progress to an intervention. I enjoy mentoring students and look forward to opportunities to mentor a new group of students on this important project.

References

• American Diabetes Association. (2012). Diabetes risk test. Retrieved from http://www.diabetes. org/diabetes-basics/prevention/diabetes-risk-test/
• Australasian Child and Adolescent Obesity Research Network. (2010). Dietary intake assessment. Retrieved from, http://sydney.edu.au/medicine/acaorn/streams/nutrition/dietary-intake/ index.php
• Bandura, A. (1989). Social cognitive theory. In R. Vasta (Ed.), Annuals of child development, Vol. 6. Six theories of child development (pp.1-60). Greenwich, CT: JAI Press.
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• Emmons, K. M., Stoddard, A. M., Gutheil, C., Suarez, E. G., Lobb, R., & Fletcher, R. (2003). Cancer prevention for working class, multi-ethnic populations through health centers: The healthy directions study. Cancer Causes and Control, 14, 727-737.
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• Fujita, R., Braun, K. L., & Hughes, C. K. (2004). The traditional Hawaiian diet: A review of the literature. Pacific Health Dialog, 11(2), 250-259.
• Golan, M., & Weizman, A. (2001). Familial approach to the treatment of childhood obesity: A conceptual model. Society for Nutrition Education, 33(2), 102-107.
• Lassetter, J. H., & Clark, L. (2012). Pacific Islander parents’ perceptions of child body size and feeding practices. Sigma Theta Tau 23rd International Research Congress Proceedings: Focusing on Evidence Based Practice, available on line through the Virginia Henderson International Nursing Library.
• Levi, J., Segal, L. M., St. Laurent, R., & Kohn, D. (2011). F as in fat: How obesity threatens America’s future. Washington, D.C.: Robert Wood Johnson Foundation.
• Morgan, S., Lassetter, J. H., Brown, L. B., VanServellen, G., Clark, L., Alleger, B., Curtis, S., Muffler, A., Coleman, J., Miyamoto, S. Z., Mounga, V., Goodwill, R., Cummings, J., & Hanohano, B. (submitted August, 2012). Relationship between demographic characteristics and health literacy in Pacific Islanders. Journal of Nursing Scholarship.
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• U.S. Department of Agriculture. (2011). Choose my plate. Retrieved from, http://www. choosemyplate.gov/
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