This research is supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number U54MD011240

Engaging NHPIs and Activating Communities to Take Steps (ENACTS)PI: Ka`imi A. Sinclair, PhD, MPH

Native-Controlling Hypertension And Risk Through Technology

(Native-Chart)

SIGNIFICANCEAND

BACKGROUND

Hawaiian Islands and the South Pacific

• 1.2 million (0.5%) of US population

• 43% Native Hawaiians, 15% Samoans, 9% Guamanians/Chamorros

• More than 2.6 million NHPI by 2050

Native Hawaiian and Pacific Islander Population

Skagit County471

Snohomish County6,481

King County23,664

Pierce County16,785

Thurston County3,467

Mason County471

Kitsap County4,265

Island County760

Seattle

Tacoma

Population of Native Hawaiians and Pacific Islanders by county in the Puget Sound region

Data from the U.S. Census Bureau, 2010 Census SF1, Table P6

Chronic disease result of: – Colonization– Cultural hegemony– Lack of access to healthy food sources

Significance

• Disproportionate burden of hypertension, diabetes, coronary heart disease (CHD), and stroke

• 3 to 4 times more likely to have CHD and stroke

• CHD and stroke 10 years earlier in life

• Mortality for CHD 68% higher and stroke 20% higher

• 30% less likely to have BP under control

• There are ways to control blood pressure and reduce risk for heart disease

SPECIFIC AIMS

1) At the individual level, to compare within-personchange in BP and secondary outcomes betweenthe intervention and control groups. We expectmore improvement in intervention participants.

2) At the family level, to evaluate ENACTS’ effects on BPand secondary outcomes as within-person change infamily members who provide primary support, and asmean change in other adult family members who arenot directly engaged in the intervention. We expectmore improvement associated with ENACTS.

3) At the policy level, to evaluate the intervention’s abilityto influence grocery store policy on using labels toclearly identify foods that are low in sodium or high inpotassium, some of which might not be easily identifiedwith existing labels (e.g., fresh produce). We expectENACTS to promote adoption of such policies.

• NHPI health expert – J. Keawe`aimoku Kaholokula, PhD• Bitesome App Creator – Edmund Seto, PhD• Research Coordinator – Katie Nelson, BS

J. Keawe`aimoku Kaholokula, PhD

Edmund Seto, PhD Katie Nelson, BS

Our Team

Recruiter/Assessor Nicole Lee Ellison, MPHPeer Educator Dan Pritchard, MEd

Research CoordinatorCasierra Cruz, MPH

Our Team

Asian Counseling and Referral Services

Recruitment Sites

Asia Pacific Cultural Center

Recruitment Sites

Recruitment Sites

APPROACH

Multi-level Theoretical Model

Indi

IndividualEducation

Family SupportText messaging

FamilyEducation

Text messaging

PolicyPhotovoice

(participatory photography)

Self-efficacyMotivation

Supportive EnvironmentHealthy Eating

Grocers label more low sodium, high potassium

foods

Blood Pressure Control

Overview

• Individual level - 8 weekly educational sessions on BP management and CVD prevention Healthy Hearts Among Pacific Islanders (HHAPI)

(Dietary Approaches to Stop Hypertension (DASH) diet) Other lifestyle changes to improve BP Text messages during 4-month maintenance phase

• Family level - family member is primary support person Training to provide autonomy support

• Policy level - enhances individual- and family-level impact Photovoice project to persuade grocery stores to

clearly identify pre-made foods and fresh produce that may help to lower blood pressure

Participant Eligibility Criteria

1. Self-reported physician-diagnosis of hypertension2. Self-reported NHPI3. Age 18 or older4. Systolic BP ≥ 130 mmHg5. Possession of a cellphone with a text messaging6. Not living in a household with someone who is

enrolled in the study as a participant7. Ability to understand written and spoken English8. Ability and willingness to follow all study protocols

Primary Support Person Eligibility Criteria

1. Age 18 or older

2. Possession of a cellphone with text messaging

3. Ability to understand written and spoken English

4. Ability and willingness to follow all study protocols

Study Flow DiagramScreen and Enroll 270 Participants & 270 Support Persons

Baseline Data Collection & Randomization

Intervention Group (n=135) Waitlist Group (n=135)

Education & order groceries Order groceries

8 week data collection 8 week data collection

6 month data collection

Maintenance Phase

3 weeks Photovoice; 16 weeks of text messages

6 month data collection

Education

Data Collection, Measures, and Outcomes

Baseline, 8 weeks, 6 months

Measures

• Sociodemographic

• Diet

• Physical Activity

• Height

• Weight

• Smoking status

• Alcohol consumption

• Comorbid conditions

Outcomes

• Blood Pressure* (Primary)

• Medications

• Dietary behaviors*

• Food purchasing

• CalFit* (energy expenditure)

• Autonomy support

• Knowledge

Process Evaluation

• Satisfaction

• Exposure

• Reasons for dropout* Indicates weekly measurement

Baseline Visit Data Collection

Participant

Baseline Visit 1:• Informed Consent• Study forms• Dietary History Questionnaire• 3 day food diary• 24 hour urine• Multiple blood pressure

measurements, height, weightBaseline Visit 2:• Study survey• ASA 24

Support Person

Baseline Visit 1:• Informed Consent• Study forms• Dietary History Questionnaire• 3 day food diary• Multiple blood pressure

measurements, height, weight• Study survey

Healthy Hearts Among Pacific Islanders (HHAPI)

Healthy Hearts Among Pacific Islanders (HHAPI)

• Increase knowledge and skills to manage blood pressure• Promote HHAPI eating plan (Dietary Approaches to Stop

Hypertension)

Includes whole grains, fish, poultry, beans, seeds, nuts, and healthy fats & oils

Limits sodium/salt, sweets, sugary drinks, and red meats

Encourages vegetables, fruits, and fat-free or low fat dairy products

Healthy Hearts Among Pacific Islanders (HHAPI)

• Participants encouraged to bring support person• American Heart Association guidelines• Social cognitive theory constructs combined with

cultural symbols and themes, cultural patterns and concepts, values, norms, and relationships to promote healthy eating, exercise, medication adherence, and stress reducing activities.

• Story begins each class – Uncle Fatu and Kimo

HHAPI Curriculum

Topics

Support Person Education

Autonomy support - when the support person respects the other person’s views or attitudes, offers choice(s), and encourages the person to make a decision. Your role as a partner in health Show empathy and concern Offer choices Problem solve & role play Encourage rather than criticize Set goals

Bitesome App – Edmund Seto, PhD

Policy Level Intervention

• Photovoice project – grassroots advocacy for grocery retail outlets to adopt policies that assist HTN management

• 3 weeks in duration (Weeks 9-11)

• 5 group sessions; 2 hours each

• $30 per session attended

• Education and activities: critical thinking, advocacy, photographs, group process

• Outcomes: Food labeling and store patronage

PY03 Accomplishments

• First cohort (n=16) at Asian Counseling Referral Services

• Existing weekly, retired Samoan group• Many couples – one eligible, one support

person• Enrolling new cohorts:

– Samoan groups, Chamorro, Marshallese & Micronesian groups

Duration of Engagement Per Cohort

Activity DurationRecruit NHPI community groups 1 – 3 months

Recruit individuals, complete 2 baseline data collection visits

1 month

Intervention classes 2 months

1st follow-up data collection 2 weeks

Maintenance phase 4 months

Final data collection 2 weeks

Wait list group receives classes 2 weeks~9.5 months/cohort

Lessons Learned

• No prior experience participating in research = significant time to recruit groups and explain study procedures

• Lengthy baseline data collection• Heterogeneity of Pacific Islander community =

potential language challenges if only in English• New recruitment sites – Vancouver/Portland,

Everett, Spokane• Capitalize on existing groups• New strategy for Bitesome App