October 2004 // Volume 42 // Number 5 // Research in Brief // 5RIB4

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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

A focus group process was used to gather data on perceptions of health and community collaboration within 6 U.S. affiliated Pacific Islands as part of a process to encourage a community-based participatory approach to addressing community health issues and planning. The focus groups revealed Pacific Islanders' perceptions of health and key local health issues and elements of collaboration. The results were applied to a community-oriented planning process, resulting in the creation of a broad planning framework within which islands could implement their own activities. This approach shows potential for initiating future activities in which communities collaborate in the planning process.

Nicky Davison
Project Administrator, Healthy Living in the Pacific Islands
University of Hawai'i - Manoa,
Honolulu, Hawai'i

Randall Workman
Advancing a Research Agenda for Tobacco Prevention and Control
Office of Sponsored Programs and Research
University of Guam
Mangilao, Guam

Yihe Goh Daida
Program Administrator
Department of Human Nutrition Food and Animal Sciences
University of Hawai'i - Manoa
Honolulu, Hawai'i

Rachel Novotny
Professor and Department Chair
Department of Human Nutrition Food and Animal Sciences
University of Hawai'i - Manoa
Honolulu, Hawai'i

Donna Ching
Extension Specialist in Agricultural Leadership
Department of Family and Consumer Sciences
University of Hawai'i - Manoa
Honolulu, Hawai'i


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."


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


Focus Group Location

Type of Participants

Number of Participants

American Samoa

School, staff room

High school students


Village, home



Office of Samoan Affairs

Community leaders


Commonwealth of the Northern Marianas: Saipan

Office of Aging

Inter-agency stakeholders


Federated States of Micronesia: Chuuk


Leaders of government agencies



Community Center

Elderly housing residents, community resident association leaders


Community Center

Homemakers, family members, community resident association leaders


Community Center

Homemakers, family members, community resident association leaders


Community Center

Homemakers, family members, leaders of village municipal planning council


Hawai'i: O'ahu

Village library

Community leaders


Village library



Republic of the Marshall Islands: Majuro

College of the Marshall Islands



Ministry of Health

Church leaders


* 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.


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


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


Lack of personal responsibility for own health

Support from  government and private sector for community  programs

Combat  misinformation


Healing practices

Prevention and education

Support and  assistance

Environmental stewardship


Planning and  organizing

Leadership skills

Unhealthy lifestyles

Lack of access to affordable health care


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


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


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


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."


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.


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