Healthy Living in the Pacific Islands: Results of a Focus Group Process to Identify Perceptions of Health and Collaboration in the U.S-Affiliated Pacific Islands

Background

Pacific Island health systems must deal with health conditions typical of both developed and developing countries (Feasley, 1998). The U.S. affiliated Pacific islands are in transition from "developing" to "developed," having gone through dramatic socio-economic transformations since the end of World War II, and their peoples have begun to experience the major demographic and epidemiological transitions that accompany modern social change.

Even though life expectancies in the island jurisdictions remain below levels in developed nations, demographic transitions in the islands have decreased rates of infant mortality, and people are living longer today than in the past. As a consequence, population growth pressures are high, and communities are predominately composed of young people, with their own particular health needs.

Moreover, while disease levels are higher than U.S. indicators, epidemiological transitions in the islands reveal a shift of health problems away from common infectious diseases (influenza, tuberculosis, etc.) and toward chronic and non-communicable health problems (e.g., heart disease, diabetes, and cancer). The Islands suffer a disproportionate burden of ailments, including cancer, type 2 diabetes, cardiovascular disease, fetal and infant under nutrition, and adult obesity (Coyne, 2000). In addition to genetic predisposition, these diseases are greatly influenced by behavioral factors, many of which are life style habits that begin in peoples' early childhood and adolescence (Martorell, 2001; Barker, 2001)

Figure 1.
Map Showing the Pacific Region
(U.S. affiliated Pacific Islands highlighted)

SOURCE: Pacific health dialog: Pacific peoples of New Zealand. Journal of Health and Clinical Medicine for the Pacific 4(2). 1997.

Purpose and Objectives 

The Healthy Living in the Pacific Islands (HLPI) initiative was the culmination of a series of meetings involving the Cooperative Extension Directors of the land-grant institutions in the U.S. affiliated Pacific (American Samoa, Commonwealth of the Northern Marianas, Federated States of Micronesia, Guam, State of Hawai'i, Palau, and the Republic of the Marshall Islands). The Directors sought to address concerns about the health and quality of life among Pacific Islanders.

A Principal Investigator (Rachel Novotny) was identified and asked to develop a concept paper, which was reviewed and approved by directors at a meeting in July 2001. Following approval, the Principal Investigator then worked with the local land-grant colleges to identify Co-Principal Investigators (Co-PIs) at each site and brought them together in October 2001 for a further strategic planning session guided by an experienced facilitator.

The Co-PIs were concerned that any approach should involve community members from the respective communities and should verify local community visions of healthy living, document their listing of problems, and confirm their strategies to improve their communities, implementing a "bottom-up" process, or a participatory community-based approach (Malek, 2002; Nyden, 2003; RSC 2002). This was a formidable challenge because the target communities are spread across 4,000 miles of a geographic area larger than the continental United States (Figure 1).

As a group, the Co-PIs decided that a focus group methodology was an appropriate tool to identify local health concerns, possible community actions to improve health, and perceptions of collaboration within the diverse island communities. This information would then be used for program planning and design.

Although originally used as a market research tool to assess people's preferences and reactions to new products, the focus group process has become a key social science methodology for program planning and development (Krueger, 2000; Gamon, 1992). The interviewing process for collecting qualitative data was ideal for the HLPI planning group, where a single methodology, applied across the multi-lingual, multi-cultural populations was needed.

Focus groups are a frequently used need assessment methodology for planning of programs to ethnic minorities and diverse, multi-cultural communities (Duncan, 1999; Ewert, 1994; Hockenberry Meyer, 1999; Hobbs, 2001; Malek, 2002) and are suited to the group/community-focused cultures of the Pacific. The focus group tool then forms an integral part of community-based participatory research, which has been described by O'Toole, Aaron, Chin, Horowitz, and Tyson (2003) as being able to "make meaningful contributions to improving health and well-being of traditionally disenfranchised population groups and communities."

Methods

To standardize the methodology across the multi-site project, the University of Hawaii HLPI staff sent each island jurisdiction guidelines for conducting their focus groups. Focus groups were defined to the Co-PIs as: "a group of individuals selected and assembled by researchers to discuss and comment on, from personal experience, the topic that is the subject of the research."

It was suggested that one group of community leaders and one group of homemakers be selected. The recommended number of people per group was to be six to 10, with sessions to last from 1 to 2 hours. Neutral locations were advised for avoiding either negative or positive associations with a particular site or building.

The Co-PIs in each jurisdiction then applied the guidelines to their island situation and conducted one or more focus groups using a standardized set of four question themes agreed upon at the first strategic planning conference. These were:

Question 1. What is health to you?

Probes: How do you recognize it? What does it look like? How does it feel?

Question 2. What is collaboration to you?

Probes: How do you recognize it? What does it look like? How does it feel?

Question 3. What are the key health problems in our community?

Probes: What are the main reasons that we have this health problem?

Question 4. What would be effective community actions to improve health?

Probes: Who would have to do what to improve health in the community? How could these actions be accomplished?

Facilitators were warned against selecting groups that were either too homogeneous or heterogeneous, which might limit the expression of diverse opinions.

There was variation across the six sites in implementing the guidelines because each community had unique inter-agency and community networks. The only achievable standardization was in the methodology and questions discussed. Focus groups were conducted in the local language and recorded on audiotape for subsequent transcription and translation.

The outcome was that the HLPI Co-PIs conducted a total of 13 focus group sessions (Table 1) involving 127 Pacific Islander or mixed Pacific Islander/Asians from six Pacific Island jurisdictions.

Table 1.
Characteristics of Focus Groups in Each of the Six U.S. affiliated Pacific Islands, 2002

Site	Focus Group Location	Type of Participants	Number of Participants
American Samoa	School, staff room	High school students	12
	Village, home	Homemakers	5
	Office of Samoan Affairs	Community leaders	8
Commonwealth of the Northern Marianas: Saipan	Office of Aging	Inter-agency stakeholders	9
Federated States of Micronesia: Chuuk	Moen	Leaders of government agencies	10
Guam	Community Center	Elderly housing residents, community resident association leaders	12
	Community Center	Homemakers, family members, community resident association leaders	11
	Community Center	Homemakers, family members, community resident association leaders	10
	Community Center	Homemakers, family members, leaders of village municipal planning council	8
Hawai'i: O'ahu	Village library	Community leaders	23
	Village library	Homemakers	8
Republic of the Marshall Islands: Majuro	College of the Marshall Islands	Homemakers	6
	Ministry of Health	Church leaders	5
* A focus group was also held in Palau, but due to staff turnover the data were lost.

Each Co-PI processed, transcribed and translated the recordings of their respective focus group sessions. For each question, in each focus group session, co-investigators identified one or more topics or "Themes" which generalized key points that were verbalized by the participants in their discussions. For each theme, they then identified one or more "quotes" representative for that key point and topic.

Results

At a strategic planning meeting involving all the Co-PIs and facilitated by a trained group facilitator, the community focus group data and analyses of themes were shared by each Co-PI in oral presentations with summary handouts. The discussion and development of a common understanding of insights gained from the focus group process was integrated directly into the strategic planning process being guided by the facilitator. The sharing of the focus group experiences, and the substance of the resultant findings played a key role in how Co-PIs designed the final program framework.

Table 2.
Selected Quotes from Focus Group Meetings in Six U.S. Affiliated Pacific Islands, 2002

Site	What Is Health?	What Is Collaboration?	What Are the Key Health Problems in Our Community?	What Would Be Effective Community Actions to Improve Health?
American Samoa	Being strong and well Living long, happy life, no illness Feeling physically and emotionally good	Building trust and friendship Working together as a community	Obesity, diabetes, high blood pressure, heart disease Arthritis, gout Drugs, alcohol and tobacco	Health education messages by peers Community clean up and mass exercising Enforce law Leadership from top
Chuuk - FSM	Physically, mentally  and spiritually fit Being well "feels complete 'Well built' not emaciated or weak	Sharing and maximizing resources Quality service, holistic approach 'fengen', Chuukese word for collaboration	Lack of exercise Poor diet Fat is beautiful Poor sanitation No access to health programs	Community  organization and  mobilization Capacity building - education, scholarships Improve recreational facilities
Saipan - Northern Marianas	Balancing your physical needs Life and clean  environment	Working together for a common goal	Poor family planning Overeating Lack of personal responsibility for own health	Support from  government and private sector for community  programs Combat  misinformation
Guam	Healing practices Prevention and education Support and  assistance Environmental stewardship	Communication Planning and  organizing Leadership skills	Unhealthy lifestyles Lack of access to affordable health care Environment	Education and skill building Address health  issues in public  forums
O'ahu - Hawai'i	Balance between physical, mental health and exercise Economics and community Diet and genetics	Discovering and developing assets Focus Partnership and  opportunity	Mental health Substance abuse Environmental  pollution McDonald's is cheap but healthy food is expensive	Start small, pilot programs Role modeling
Marshall Islands	Happiness, peace and no problems Health is life Able to move, work, have good thoughts	A united community Willing to listen Accomplishment Get together  developing goals	Selling local food to buy imported Lack of knowledge and understanding importance of local foods	Family planning programs Do more physical activity Clean the environment

Discussion

A comparison of the results to the question "What is health?" (Table 2) across the range of the six sites identified several common themes. These included not only the concept of physical health, but also mental and spiritual health, the idea of working with others to maintain and prevent ill health, and also environmental health. The environment and ecological system were conceptualized by the Pacific Islanders as a part of how they define "health." The idea of "economic health" articulated by the Hawaii focus groups also conceptualizes the overall social and economic health of the community as part of a holistic view of personal "health."

A comparison of the responses to the third question across the range of the six sites listed such things as "specific chronic diseases," "drug use" (including alcohol and tobacco), "diabetes," and "high blood pressure"--all health consequences aggravated by, if not resulting from, life style habits. Interestingly, the list includes life style habits both integral within some of the cultures (see themes for Chuuk- FSM: "fat is beautiful," Saipan-CNMI: "overeating," and Guam), as well as life style habits acquired from the external world (see themes for the Marshall Islands: "selling local food to buy imported" and Hawaii: "McDonald's is cheap but healthy food is expensive").

The focus group discussions on "what is collaboration?" and " what actions would improve health?" both generated the identification of similar program approaches, which can be noted in several of the sites. Across the six sites, the themes speak of collaboration as "building trust and friendship," "sharing and maximizing resources," "listening and sharing ideas to make progress," "working together for a common goal," and "discovering and developing assets." It is interesting, too, that many of the cultures have a vernacular word for collaboration within the community, e.g., "fengen" in Chuuk.

In the strategic planning discussions following presentations, various co-investigators commented on how the focus group findings "confirmed" and provided examples for the project mission statement and "validated" the groups' listing of underlying values.

The analysis of questions about collaboration and community actions guided the decisions made in structuring the program framework, with optional program strategies for achieving each objective. The focus groups spoke of education, of working together as a community, of community based activities. These then became the strategies to be used in the project planning process: a) health education communications/media, b) community-based interventions, c) institutional capacity building, and d) training and policy development. These project action strategies were made a part of the program-planning framework to provide alternative approaches for specific, annual project plans.

Conclusions and Future Directions

The focus group methodology approach worked well in allowing these diverse communities to articulate their own perceptions of health and collaboration while being able to retain the central common themes necessary for program planning. The focus group approach can be used to guide the planning and project implementation process by allowing the communities to communicate their specific needs and concerns across a wider range of health, social, and economic issues.

Despite the many differences in the communities across this vast geographic region, there is a large degree of commonality in the way the cultures perceive "health" and in ways of working together ("to collaborate") to overcome some of the existing health disparities.

Empowered by the focus group findings, the co-investigators were able to develop an "umbrella" program framework, within which each individual site could design specific programs, that responded to the specific needs of the individual communities while retaining the common program goal of: "reducing disparities in the prevalence of chronic diseases among Pacific Islander peoples by addressing the multiplicity of influential factors and respecting cultural values, using community-based, holistic, collaborative and sustainable approaches in our Pacific Island communities."

Acknowledgements

The authors would like to acknowledge the other Co-Principal Investigators on the HLPI Project, without whose work article paper would not have been possible: Julia Alfred (COM/Marshall Islands Ministry of Health), Eric Enos (UH/Wai'anae Community), Floria James (NMC), and Ansina Kony (COM-Chuuk).

Funding for this project was provided by USDA-CREES Grant Number 00-38826-9180 (Amendment #2) through the Agricultural Development in the American Pacific (ADAP) Project.

References

Barker, D. (2001). The malnourished baby and infant. Br Med Bull. 2001: 60:69-88.

Coyne, T. (2000). Lifestyle diseases in Pacific communities. Technical paper no. 219. Secretariat of the Pacific Community, Noumea, New Caledonia.

Duncan, S. F., & Marotz-Baden, R. (1999). Using focus groups to identify rural participant needs in balancing work and family education. Journal of Extension [On-line], 37(1). Available at: http://www.joe.org/joe/1999february/rb1.html

Ewert, M. D., & King Rice, J. A. (1994). Managing diversity within Cooperative Extension. Journal of Extension [On-line], 32(2). Available at: http://www.joe.org/joe/1994august/a1.html

Feasley, J. C., & Lawrence, R. S. (eds) (1998). Pacific partnerships for health: Charting a course for the 21st century. National Academy Press, Washington, DC

Gamon, J. A. (1992). Focus groups--A needs assessment tool. Journal of Extension [On-line], 30(1). Available at: http://www.joe.org/joe/1992spring/tt2.html

Hobbs, B. B. (2001). Diversifying the volunteer base: Latinos and volunteerism. Journal of Extension [On-line], 39(4). Available at: http://www.joe.org/joe/2001august/a1.html

Hockenberry Meyer, M. (1999). Native Americans' interest in horticulture. Journal of Extension [On-line], 37(1). Available at: http://www.joe.org/joe/1999february/a4.html

Krueger, R. A., & Casey, M. A. (2000). Focus groups: A practical guide for applied research. Sage Publications, Beverly Hills, California.

Malek, F. (2002). Using the focus group process to assess needs of a growing Latino population. Journal of Extension [On-line], 40(1). Available at: http://www.joe.org/joe/2002february/tt2.html

Martorell, R., Stein, A., & Scroeder, D. (2001). Early nutrition and later adiposity. J Nutr. 13: 874S-880S.

Nyden, P. (2003). Academic incentives for faculty participation in community- based participatory research. Journal of General Internal Medicine Vol. 18 (7) 576-585.

O'Toole, T., Aaron, K., Chin, M., Horowitz, C., & Tyson, F. (2003). Community based participatory research: Opportunities, challenges, and the need for a common language. Journal of General Internal Medicine Vol. 18 (7) 592-594.

RSC. Royal Society of Canada (2002). Guidelines for participatory research in health promotion. Retrieved March 14, 2002 from: http://www.ihpr.ubc.ca/guidelines.html