91038001130J Health Care Poor UnderservedJ Health Care Poor UnderservedJournal of health care for the poor and underserved1049-20891548-686925981093451108110.1353/hpu.2015.0063HHSPA707018ArticleImproving Access to Healthy Foods for Asian Americans, Native Hawaiians, and Pacific Islanders: Lessons Learned from the STRIVE ProgramKwonSimona C.DrPH, MPH1RideoutCatlinMPH1PatelShilpaMPH1AristaPedroMPH2TeppornEdward2LipmanJesse3KunkelSarahMA3LeDaniel Q.4ChinKathy KoMS2Trinh-ShevrinChauDrPH1NYU Center for the Study of Asian American HealthAsian & Pacific Islander American Health ForumKōkua Kalihi Valley Comprehensive Family ServicesBoat People SOS-AlabamaPlease send correspondence to Simona Kwon at simona.kwon@nyumc.org1572015520152272015262 0116136Summary

Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPIs) experience a large burden from certain chronic disease-related risk factors. The STRIVE Program funded four AANHPI community-based organizations (CBOs) to implement culturally adapted community gardens and farmers' markets to increase access to healthy foods. CBO key informant interviews were conducted to understand processes and lessons learned.

Asian AmericansNative Hawaiians and Pacific Islandershealth disparitiescommunity engagementchronic diseaseunderservedculture

Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPIs), the fastest-growing racial/ethnic population in the U.S.,1 experience a large burden from certain chronic diseases and their associated risk factors.2-15 AAs are three times less likely to be obese compared to Whites, however, the lack of disaggregated data masks significant subgroup differences. For example, Filipinos and NHPIs are more likely to be obese than the overall AA population (1.7 and 3.7 times, respectively).3,14,15 Immigrants from Central Asia are less likely to be overweight or obese (24.4%) than Southeast Asian immigrants (31.9%) or immigrants from the Indian subcontinent (40.1%).16 The combined prevalence of overweight and obesity is between 76% and 90% for NHPIs.17-20 One study of Native Hawaiians in Hawaii reported 49.1% were obese and 81.5% as overweight or obese.21 Despite low AA obesity rates, researchers have noted a trend of increasing obesity with later generations.8,10,13 In fact, both AAs and NHPIs appear to exhibit increased risk for obesity as a function of acculturation in the U.S.; NHPIs may be particularly vulnerable due to targeted calorie-dense fast food marketing and differing standards of body image.5 Despite the lower rates of obesity among AAs, higher rates of heart disease, diabetes and high blood pressure have been found across a range of BMIs thus suggesting BMI definitions for overweight/obesity in AAs should be lowered.12,22

Gaps in the literature and lack of disaggregated data on the nutrition patterns of AANHPIs exists; in general, however, Asian immigrants in the U.S. have been found to report less fruit and vegetable consumption compared to Asians in their native country.23 The extant literature indicates poor nutrition patterns for certain AANHPI subgroups.24,25 A community sample of NHPIs living in the US reported eating 1 mean daily serving of fruits and vegetables – well below the recommended minimum of 5 servings per day.24 In California, 57% of AAs consumed less than the recommended minimum of fruits and vegetables (Filipinos (62%), Chinese (58%), and Vietnamese (57%)) compared to the overall rate in California of 51%.25 Similarly, a community sample of Chamorros in CA reported 60% failed to consume the daily minimum.26 Potential contributors to poor nutrition among AANHPIs include the convenience and availability of fast foods,27 lack of access to traditional fruits and vegetables28 and increased consumption of calorie-dense, high fat foods, such as meats and sweets, due to the affordability and availability in the U.S. compared to native country. 29

Increasingly, the Centers for Disease Control and Prevention (CDC) has emphasized the dissemination of population-wide strategies using evidence-based, policy, systems, and environmental (EBPSE) approaches, including community gardens and farmers' markets, to mitigate these health disparities by increasing access to healthy foods. 28,30-32 Several studies indicate that increasing the number of community gardens is associated with an increase in availability and consumption of fruits and vegetables.33-37 Participation in community gardens has also been shown to be associated with lower body mass index38 and an increased willingness to eat healthy foods.39 A 2010 review of the literature on nutritional implications of farmers' markets and community gardens indicated that farmers' market programs were associated with greater intake of fruits and vegetables and more positive attitudes towards fruit and vegetables consumption.40 EBPSE strategies, however, are typically developed for mainstream populations with little consideration for English language proficiency or cultural appropriateness. A recognized gap in the literature exists regarding whether such strategies are also effective in reaching AANHPIs or other racial/ethnic minority populations.41-44 Adaptions or the process of alteration to “reduce mismatches” may increase the salience of the strategies thereby reducing inequities in reach and provision of services41,42,44,45 Thus, targeted and adapted community-level efforts are needed to supplement more broad-based approaches to achieve comparable results in AANHPIs.

STRIVE Program Description

To address this potential “mismatch” in strategy, the Asian & Pacific Islander American Health Forum (APIAHF) and the NYU Center for the Study of Asian American Health (CSAAH) co-led and developed the Strategies to Reach and Implement the Vision of Health Equity (STRIVE) Program funded by the CDC. Through a competitive request-for-proposal process, STRIVE distributed $3 million to 15 AANHPI community-based organizations (CBOs) across the U.S. and Guam to implement EBPSE strategies to increase healthy behaviors among AANHPI communities within a seven-month timeframe. Eligibility criteria included, understanding of community needs related to physical activity and nutrition, experience in multi-sector partnerships, and some demonstrated experience in implementing EBPSE strategies to address health disparities. All 15 CBOs were required to convene a multi-sector coalition, implement a needs and resource assessment using CDC's Community Health Assessment and Group Evaluation (CHANGE) tool,46 and to use the results to inform their strategy choice selected from the CDC identified 24 recommended strategies for environmental and policy changes to promote healthy eating and active living.32 CBOs selected strategies focused on increasing access to healthy foods: development of community gardens and farmers' markets, implementation of nutrition policies for congregant meals in faith-based settings; and on increasing opportunities for physical activities: implementation of worksite policies for physical activity breaks, school-based joint-use agreements, and promotion of walking trails. Further discussion of funding eligibility, the CHANGE tool, project deliverables and CBO strategies are discussed in Arista et al.47 This report is focused on the four CBOs (herein referred to as Partners) that implemented culturally-adapted community gardens and farmers' markets to highlight successful strategies to increase access to healthy foods for AANHPIs.

Interviews

The STRIVE Program used a mixed-methods evaluation to collect data on the process and project impact which was assessed as the estimated population reached by each Partner implemented strategy and measured using census and target population data. For the process evaluation, key informant interviews were conducted with lead project staff from all 15 funded Partners to understand the processes used to adapt strategies to the unique contextual factors of their communities. The interview guide (see Box 1) was informed by a review of the literature and guided by Resnicow's framework on cultural sensitivity, which identifies two dimensions to adaptation: 1) surface structure or matching to superficial (or, observable) characteristics (e.g., language, images); and 2) deep structure, which involves incorporating cultural, social, and historical influences on health behaviors of the target population.15 Using this framework, the interview guide focused on: 1) EBPSE strategy selection; 2) EBPSE strategy implementation; 3) facilitating factors of success; and 4) challenges. Two trained research interns conducted the interviews by telephone between January and February 2014. Using Atlas.ti, transcripts were independently reviewed and coded by two investigators using narrative analysis techniques48,49 and coding discrepancies were resolved within coders and a third investigator to achieve consensus.

What We Found

The interviews yielded a rich description of the processes Partners used to adapt strategies to the unique contextual factors of their communities. Themes highlighted the importance of the multi-sector coalition in strategy implementation, the recognition that EBSPE strategies are not “one-size-fits-all” but must be made relevant to the cultural and community context, and the need for a combination of surface- and deep-level adaptions at specific parts of implementation process. Themes and associated quotations are listed in Box 2. Two case examples chosen to highlight the range of the projects across AANHPI communities and to help illustrate the discussion are presented in Boxes 3-4.

EBPSE strategy selectionMulti-sector coalitions

Partners discussed the importance of community engagement and the role of multi-sector coalitions in identifying the appropriate EBPSE strategy. For many Partners, community members and coalitions provided direct input into strategy selection. Partners emphasized the importance of taking time in the beginning for listening sessions on food access, for example, using “talk story,” a Native Hawaiian cultural way of engaging in information sharing and discussions.50 These conversations helped build a foundation to support the selection of relevant and meaningful strategies to address community-defined needs (Box 2, Q1-Q2).

Environmental-level factors

Environmental factors such as regional geography, transportation-related issues, and as reported by all four Partners, a documented lack of access to fresh produce in the community were key considerations in strategy selection (Box 2, Q3-Q4).

Cultural factors

Partners incorporated cultural and traditional influences and norms around food to inform decision-making to implement farmers' markets and/or community gardens. For many AANHPI communities, growing one's own food is aligned with cultural traditions (Box 2, Q5).

EBPSE strategy implementation

Partners were asked to discuss the processes they used to implement their adapted strategies to reach their target community.

Multi-sector coalitions

A key theme was the importance of convening and the guidance provided by the multi-sector coalition in implementing the strategy. Continued and ongoing discussions with coalition members and adhering to an iterative process to ensure the strategy was being implemented in culturally- and linguistically-appropriate ways was also discussed (Box 2, Q7).

Cultural adaptations

All Partners targeted and adapted their EBPSE strategies using some combination of the two cultural dimensions, surface and deep structure. Partners noted surface structure adaptation in the form of translating materials into the community's language (Box 2, Q8). Partners also noted deep structure adaptations in the ways they adapted and implemented their strategies to reflect social, historical, and cultural aspects of the target community. These included promoting traditional foods and the importance of highlighting and sometimes re-introducing traditional herbs and vegetables back into the diet (Box 2, Q9). Religion and cultural concepts of sharing were also incorporated (Box 2, Q10-Q11). Partners also discussed the role of community leaders and hiring community members to carry out the project and to guide the adaptations (Box 2, Q12-Q14). Moreover, Partners emphasized the need to provide some type of cultural sensitivity training to consultants, volunteers, coalition members and to the project partner agencies (Box 2, Q15).

EBPSE strategies not one-size-fits-all

A key finding was the importance of allowing multi-sector coalitions the flexibility to adapt strategies to fit their local communities. This was accomplished, for example, by adaptions to not only the surface and deep structures, but also the community's socio-demographic characteristics and context, and to the multiple levels, including by individual implementation site. If multiple sites were being promoted, each site required site-specific modifications to the target AANHPI sub-group (e.g., if the population was made up of more recent immigrants, versus a more established community of the same sub-group) or to the venue (e.g., churches versus schools) (Box 2, Q16-Q18).

Facilitating factors of success

Partners were asked to discuss what helped them to succeed based on their experience implementing adapted EBPSE strategies that could be shared with other individuals and organizations interested in increasing access to healthy foods for AANHPI communities.

Relationships with multi-sector stakeholders

A recurrent theme was the importance of strong relationships with their multi-sector coalition and the inclusion of key champions and decision-makers who could help provide resources, connections, and support (Box 2, Q19-Q20). Moreover, Partners emphasized the importance of the multi-sector aspect of their coalitions as a key factor to their success, for example, by engaging partners across businesses, schools, government, community, and health care agencies (Box 2, Q21).

Community trust in Partner organizations

Partners underscored that inherent community trust due to long-standing relationships and time-honored work as another key facilitator of success. This theme of community trust in Partners was identified as vital to Partners' ability to quickly mobilize coalition members and to implement their strategies within an accelerated timeline (Box 2, Q22).

STRIVE programmatic support and technical assistance

The training and provision of technical assistance provided by APIAHF and CSAAH was identified as a necessary facilitating factor (Box 2, Q23).

Modifications to EBPSE strategies

When asked if the strategies would have been successful without cultural adaptations, all four Partners agreed that modifications including translations, cultural adaptations, and targeting to the site or venue-level was critical to their success in reaching and serving their community (Box 2, Q24).

ChallengesCoalition- and consensus-building is time intensive

Many Partners discussed the challenges imposed by completing the project within the CDC required seven-month timeframe. As Partners were also required to work within a multi-sector coalition, Partners had to navigate between the tension of consensus-building and adhering to the fast-moving project timeline and deliverables (Box 1, Q25-26).

Lack of experience with PSE strategies

Some Partners spoke to the challenges of working with stakeholders and communities who may not have had prior experience in implementing a policy, systems, and environmental strategy. This resulted in Partners needing to spend additional time educating groups on the importance of population-wide approaches before they could secure commitment (Box 1, Q27).

Lessons Learned

Several lessons emerged from this study and are detailed below.

CBOs are trusted gatekeepers

CBOs can serve as successful lead organizations for implementing EBPSE strategies due to their established role as trusted community gatekeepers and inherent knowledge of the community. These qualities facilitated the accelerated implementation of relevant and sustainable strategies—maximizing limited resources and efforts.

Foster continued active community engagement

Despite the accelerated timeline of the project, all Partners emphasized the need to take time from the start to facilitate listening sessions, “talk story” or other culturally relevant information-sharing channels and to use an iterative process to build and maintain consensus to encourage engagement and ownership throughout the project.

Community members as strategy implementers

Partners consistently identified hiring of individuals from the community to implement the strategies as a successful practice. Community implementers share the characteristics of the community and can serve as successful bridges, guiding and informing the project to enhance relevancy of the strategies. For example, “Super Aunties”-- respected NHPI elder women -- provided cultural advising, community linkages, and translation expertise as described in Box 3.

Multi-sector coalitions enhance sustainability

All four Partners convened multi-sector coalitions to ensure diverse stakeholder input into the selection and implementation of their strategies. Key to the success of these coalitions was the inclusion of champions who also have decision-making roles within their sector and who could identify resources to ensure successful implementation and sustainability of the strategies. As illustrated in Box 3, the multi-sector coalitions created a web of connections that could enhance sustainability beyond the project period.

Cultural adaptation of EBPSE strategies increases salience

Attention to a combination of surface and deep structure is needed to guide the cultural modification to make the strategies meaningful and relevant to AANHPI communities. For example, Partners identified not only the translation of materials but also the need to build on cultural traditions and incorporate traditional vegetables and other values, as facilitators of success. In addition, an unexpected benefit of implementing the culturally adapted EBPSE strategies was the opportunity for bidirectional sharing and learning between the targeted community and the broader population (Box 2, Q6 and Box 4).

EBPSE strategies are not reaching AANHPIs and other under-served populations (one-size-does-not-fit-all)

Strategies that are EBPSE may not necessarily be generalizable to communities such as AANHPIs who are often missed by population-wide approaches. Evidence-based strategies are often derived from research conducted on mainstream populations – largely White, middle-class, and native English-speaking. Instead of a one-size-fits-all approach, a twin approach, which emphasizes integrating population-wide interventions with targeted interventions in communities that experience significant health disparities -- which is encouraged by the CDC's Division of Community Health in its approach to achieve health equity23 -- is warranted. 51,52

In sum, culturally adapted community gardens and farmers' markets are effective strategies to increase access to healthy foods for under-served AANHPI communities. The four Partners discussed in this report, reached a total of 212,391 community members through their strategies. As trusted community gatekeepers, AANHPI CBOs are well poised to implement meaningful adapted and sustainable EBPSE strategies to serve their communities.

This publication is supported by grants: U58 DP004685 and U58DP005621 from the Centers for Disease Control and Prevention, Racial and Ethnic Approaches to Community Health Cooperative Agreement; and P60MD000538 from the National Institutes of Health (NIH) National Institute on Minority Health and Health Disparities. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or the NIH. The authors would like to thank all of the STRIVE Partners as this program would not have been possible without their hard work and effort. These partners included Asian Pacific Community in Action (AZ), Asian Services in Action, Inc. (OH), Boat People SOS (AL), Boat People SOS (CA), Center for Pan Asian Community Services, Inc. (GA), Korean Community Services (NJ), Kokua Kalihi Valley Comprehensive Family Services (HI), New Mexico Asian Family Center (NM), National Tongan American Society (UT), Orange County Asian and Pacific Islander Community Alliance (CA), Operation Samahan (CA), Restaurant Opportunities Center of New Orleans (LA), Taulama for Tongans (CA), United Sikhs (NJ), University of Hawaii (Guam). We also acknowledge the contributions of Kirklyn Escondo (CSAAH) and Fran Linkin (CSAAH) for their assistance with data collection and analysis, and Marianne Chung (APIAHF) for her guidance and support on STRIVE.

Hawaii Cancer Facts & Figures 2003–20042004(Accessed atBarnesPMAdamsPFPowell-GrinerEHealth characteristics of the Asian adult population: United States 2004-2006Advance data200812218271366BittonAZaslavskyAMAyanianJZHealth risks, chronic diseases, and access to care among US Pacific IslandersJournal of general internal medicine2010254354020143177Centers for Disease Control and PreventionNational diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 20112011DavisJBuschJHammattZThe relationship between ethnicity and obesity in Asian and Pacific Islander populations: a literature reviewEthnicity & disease200414111815002930KandulaNRLauderdaleDSLeisure time, non-leisure time, and occupational physical activity in Asian AmericansAnnals of epidemiology2005152576515780772KlatskyALTekawaISArmstrongMACardiovascular risk factors among Asian AmericansPublic health reports (Washington, DC: 1974)1996111Suppl 2624LauderdaleDSRathouzPJBody mass index in a US national sample of Asian Americans: effects of nativity, years since immigration and socioeconomic statusInternational journal of obesity and related metabolic disorders: journal of the International Association for the Study of Obesity200024118894MaxwellAEBernaardsCAMcCarthyWJSmoking prevalence and correlates among Chinese- and Filipino-American adults: findings from the 2001 California Health Interview SurveyPreventive medicine200541693915917070NamSObesity and asian americans in the United States: systematic literature reviewOsong public health and research perspectives201341879324159554Office of Minority HealthHHS Fact Sheet: Minority health disparities at a glance2007PalaniappanLWangYFortmannSPCoronary heart disease mortality for six ethnic groups in California, 1990-2000Annals of epidemiology20041449950615310526Sanchez-VaznaughEVKawachiISubramanianSVSanchezBNAcevedo-GarciaDDifferential effect of birthplace and length of residence on body mass index (BMI) by education, gender and race/ethnicitySocial science & medicine (1982)20086713001018657344SchillerJSLucasJWWardBWPeregoyJASummary health statistics for U.S. adults: National Health Interview Survey, 2010Vital and health statistics Series 10, Data from the National Health Survey20121207US Department of Health and Human ServicesObesity and Asian Americanshttp://wwwomhrcgov/templates/contentaspx?ID=64582009Oza-FrankRAliMKVaccarinoVNarayanKMAsian Americans: diabetes prevalence across U.S. and World Health Organization weight classificationsDiabetes care2009321644619509010MauMKSinclairKSaitoEPBaumhoferKNKaholokulaJKCardiometabolic health disparities in native Hawaiians and other Pacific IslandersEpidemiol Rev2009311132919531765McEligotAJMcMullinJPangKDiet, psychosocial factors related to diet and exercise, and cardiometabolic conditions in Southern Californian Native HawaiiansHawaii medical journal201069162020544604SalvailFNguyenDLiangSState of Hawaii by demographic characteristics: Behavioral Risk Factor Surveillance SystemHonolulu, HIHawaii State Department of Health2008World Health OrganizationAmerican Samoa NCD Risk Factors STEPS Reporthttp://www.who.int/chp/steps/Printed_STEPS_Report_American_Samoa.pdfWorld Health Organization2007GrandinettiAChangHKChenRFujimotoWYRodriguezBLCurbJDPrevalence of overweight and central adiposity is associated with percentage of indigenous ancestry among native HawaiiansInternational journal of obesity and related metabolic disorders: journal of the International Association for the Study of Obesity1999237337YiSSKwonSCWyattLIslamNTrinhShevrinCWeighing in on the hidden Asian American obesity epidemicPreventive medicine201573C6925602909Health status of Cambodians and Vietnamese--selected communities, United States, 2001-2002MMWR Morbidity and mortality weekly report200453760515329651MoyKLSallisJFIceCLThompsonKMPhysical activity correlates for Native Hawaiians and Pacific Islanders in the mainland United StatesJ Health Care Poor Underserved20102112031421099072PonceNTsengWOngPShekYLOrtizSGatchellMThe State of Asian American, Native Hawaiian and Pacific Islander Health in California Report2009ChiemBNguyenVWuPLKoCMCruzLASadlerGRCardiovascular risk factors among ChamorrosBMC public health2006629817156462PanYLDixonZHimburgSHuffmanFAsian students change their eating patterns after living in the United StatesJournal of the American Dietetic Association1999995479917732CurtisMThe obesity epidemic in the Pacific IslandsJ Dev Social Transformation200413742AzarKMChenEHollandATPalaniappanLPFestival foods in the immigrant dietJournal of immigrant and minority health / Center for Minority Public Health2013159536022968231BrownsonRCFieldingJEMaylahnCMEvidence-based public health: a fundamental concept for public health practiceAnnual review of public health200930175201BrownsonRCHaireJoshuDLukeDAShaping the context of health: a review of environmental and policy approaches in the prevention of chronic diseasesAnnual review of public health20062734170KhanLKsobushKKeenerDRecommended community strategies and measurements to prevent obesity in the United StatesMMWR Recomm Rep20095812619629029AlaimoKPacknettEMilesRAKrugerDJFruit and vegetable intake among urban community gardenersJournal of nutrition education and behavior2008409410118314085BarnidgeEKHippPREstlundADugganKBarnhartKJBrownsonRCAssociation between community garden participation and fruit and vegetable consumption in rural MissouriThe international journal of behavioral nutrition and physical activity20131012824252563BlairDGieseckeCCShermanSA dietary, social and economic evaluation of the Philadelphia urban gardeningJournal of Nutrition Education1991231617CastroDCSamuelsMHarmanAEGrowing healthy kids: a community garden-based obesity prevention programAmerican journal of preventive medicine201344S193923415183LittJSSoobaderMJTurbinMSHaleJWBuchenauMMarshallJAThe influence of social involvement, neighborhood aesthetics, and community garden participation on fruit and vegetable consumptionAmerican journal of public health201110114667321680931ZickCDSmithKRKowaleskiJonesLUnoCMerrillBJHarvesting more than vegetables: the potential weight control benefits of community gardening Americanjournal of public health201310311105LautenschlagerLSmithCBeliefs, knowledge, and values held by inner-city youth about gardening, nutrition, and cookingAgric Human Values20072424558McCormackLALaskaMNLarsonNIStoryMReview of the nutritional implications of farmers' markets and community gardens: a call for evaluation and research effortsJournal of the American Dietetic Association201011039940820184990BarreraMJrCastroFGSteikerLKA critical analysis of approaches to the development of preventive interventions for subcultural groupsAmerican journal of community psychology2011484395421203823CardJJSolomonJCunninghamSDHow to adapt effective programs for use in new contextsHealth promotion practice201112253519858321DavidsonEMLiuJJBhopalRBehavior change interventions to improve the health of racial and ethnic minority populations: a tool kit of adaptation approachesThe Milbank quarterly2013918115124320170NierkensVHartmanMANicolaouMEffectiveness of cultural adaptations of interventions aimed at smoking cessation, diet, and/or physical activity in ethnic minorities. a systematic reviewPloS one20138e7337324116000ChenEKReidMCParkerSJPillemerKTailoring evidence-based interventions for new populations: a method for program adaptation through community engagementEvaluation & the health professions201336739222523308Community Health Assessment and Group Evaluation (CHANGE): Building a foundation of knowledge to prioritize community needs2010Accessed at http://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/change/pdf/changeactionguide.pdfAristaPTeppornEKwonSRecommendations for implementing policy, systems, and environmental improvements to address chronic diseases in Asian Americans, Native Hawaiians, and Pacific IslandersPreventing chronic disease201411E20225412025MishlerEResearch Interviewing: Context and NarrativeCambridge, MAHarvard University Press1986RiessmanCKNarrative Analysis Newbury ParkCASage1993KekaulikeSDHunterAMeyerAMNative Hawaiian education: Talking story with three Hawaiian educatorsJ Amer Indian Edu199939413AhernJJonesMRBakshisEGaleaSRevisiting rose: comparing the benefits and costs of population-wide and targeted interventionsThe Milbank quarterly20088658160019120981Diez RouxAVThe study of group-level factors in epidemiology: rethinking variables, study designs, and analytical approachesEpidemiologic Reviews2004261041115234951Key Informant Interview Topic Guide: Main Domains and Questions
Main DomainsQuestions
EBPSE Strategy Selection

What process did your coalition use to select your EBPSE strategy?

How were the coalition members involved in the process of choosing your EBPSE strategy?

EBPSE Strategy Implementation

What were key differences between your local community and the broader population that led you to adapt your EBPSE strategy?

Were there any environmental factors that influenced how you adapted your EBPSE strategy? If yes, please describe.

Were there any cultural and/or social factors that influenced how you adapted your EBPSE strategy? If yes, please describe.

Were there other changes that you made to your EBPSE strategy to make it more relevant to your local community? If yes, please describe.

Who was involved in making these decisions about adapting your EBPSE strategy?

Did you implement your EBPSE strategy at multiple sites? If yes, please describe.

Did you implement your EBPSE strategy among multiple ethnicities? If yes, please describe.

Facilitating Factors of Success

What were the key elements that contributed to your success in adapting and/or implementing your EBPSE strategy for your community?

Do you think your EBPSE strategy would have been as successful without cultural adaptations? Why or why not?

Challenges

What were the most significant challenges you experienced in adapting and/or implementing your EBPSE strategy? How did you overcome them?

Select Domains, Key Themes and Sample Quotes Related to Culturally oAdapted Strategy Selection and Implementation
Domains and Key ThemesSample Quotes
Domain 1: EBPSE Strategy Selection
Multi-sector coalitionsQ1 “Because originally, off the bat really, we went and talked to the community. We went and talked to community leaders, we talked to a lot of clients when they walked in our office, and just seeing what was the need especially when it comes to nutrition in our community.” (STRIVE Partner 1)
Q2 “I think the other thing that we did to take a more culturally based approach was just slow down a little bit in the early stages of the grant and do more what we call ‘Talk Story'with people…to have those conversations in a context where the people from the community were speaking and given the opportunity to give some direction to the conversations.” (STRIVE Partner 3)
Environmental-level factors, e.g. Lack of fresh produceQ3 “…our markets here only have fresh produce once a week, so we wanted to expand that access.” (STRIVE Partner 1)
Environmental-level factors, e.g. Transportation and geographical constraintsQ4 “… we live in a driving city, there's not really too much that is walk-able in [name of area]… transportation is a challenge, particularly for low-income community members…So we wanted to [implement community gardens in] parks mainly because it's a public space but we also wanted to [implement community gardens in] apartment communities to address the transportation issue.” (STRIVE Partner 2)
Cultural factors, e.g. Norms and values around food and food productionQ5 “Because the work was already culturally rooted for behalf of the gardens, that's generational, for [region] for making a garden and living off of the land. So we did not have to make a case for that, we simply reminded them of the benefits of the gardens and that was the buy-in and thus the participation” (STRIVE Partner 4)
Q6 “And that's where we wanted to have that intercommunity kind of exchange where we had [ethnic sub-group] community members and non-[ethnic sub-group] community members working together in these gardens and sharing growing tips and things like that, but also just encouraging to grow and eat these nutritious foods instead of going to the local market who sell sub-par produce…” (STRIVE Partner 1)
Domain 2: EBPSE Strategy Implementation
Multi-sector coalitionsQ7 “I think coalition members were a key element, tapping into existing relationships were a key element, and kind of just doing constant reassessment; going back to the community and constantly getting feedback as to how we're moving forward and how we should continue to move forward” (STRIVE partner 2)
Cultural adaptations -Surface structure, e.g. Language concordanceQ8 “We actually did translate our material in multiple different languages…we did translate most of our brochures to meet the community needs because that's what we base our organization off basically, because we have the capacity to serve sixteen different languages.” (STRIVE Partner 2)
Cultural adaptations -Deep structure, e.g. Incorporate traditional foodQ9 “We had a couple of presentations around what items community members may like to garden. And there were giveaways and those giveaways included culturally specific herbs such as Thai basil or cumin. And we talked about the health benefits of traditional herbs and things that people have stopped using as frequently since they've moved to the United States and maybe they want to re-incorporate in their diet..” (STRIVE Partner 2)
Cultural adaptations -Deep structure, e.g. Incorporate cultural or social characteristics of local communityQ10 “…we're in a community where there's a lot of communal activity and that space is often a communal space, so doing things where our organizational strategy was not so much top-down or delegated work but people working together, meeting people in kind of an open way, beginning activities with a circle… And tied into that, prayer and religion is an important way that the community comes together…we really wanted to honor the religious place where people were coming from. So working with churches, allowing prayer to be part of different activities, and giving people that place where that cultural expression sometimes comes through religious terms is welcome.” (STRIVE Partner 3)
Q11 “Those were definitely cultural considerations; the community project poster is an image of [jurisdiction]. And all of our partners. Just on the basis of participation, the inclusiveness, spirit of sharing, the island style of getting information, inviting them to the [consortium] meetings…those are all cultural elements of what we had here. It's not just language, it's not just about cultural sensitivity, it's about understanding the limitation and the potential of what the [jurisdiction] offers (STRIVE Partner 4)
Cultural adaptations -Deep structure, e.g. Hire staff from local communityQ12 “…our coalition members consisted mostly of leaders from the community, so what we did was…we used that to our advantage and…we worked with our coalition members to conduct these outreaches as well so they were able to reach out within their own language or they know their own community members.” (STRIVE Partner 2)
Q13 “We did hire staff largely from the local community; we hired several consultants from the local community… We hired one staff from outside the local community that didn't work out as well and replaced that person with somebody that was more familiar with the cultural issues…which was a benefit to the project… we kind of learned from that situation that we needed a little bit more cultural connection…” (STRIVE Partner 3)
Q14 “…we are working with leaders within the community… So whether that's the cultural norms or the religious norms, we accounted for all that just naturally without I guess trying to develop it; we already had it in house, especially through our coalition members..” (STRIVE Partner 2)
Cultural adaptations -Deep structure, e.g. Cultural sensitivity trainingQ15 “Training, we had a cultural sensitivity training that we did with our staff in the earlier part of the project and we had some community leaders that discussed some of the cultural perspectives to consider with that and we did fairly involved processes with that to train staff.” (STRIVE Partner 3)
EBPSE strategies not one-size-fits-allQ16 “Some of the sites had an easier institutional framework to work with than others; schools for instance …Other sites are a little more diffuse. So definitely institutions like churches you need to tailor that approach to be more personable, much more Talk Story, a lot more relationship building…” (STRIVE Partner 3)
Q17 “…we worked in two counties and in [name of county]-one of the two counties that we worked on; there were more new immigrants and refugee groups and in the second county there were more longer present immigrants. And so we addressed both of those counties a little bit differently.” (STRIVE Partner 2)
Q18 “With the community gardens, what we…the tweaking that we had to do we increased for example some of the support and resources for folks that needed them without necessarily, without making it across the board for example. ……So, yeah we've had to tailor it also to people who've been in condominiums and apartments so we have earth blankets, we've had to introduce new ways so people can grow fruits and vegetables without having a garden and a yard.” (STRIVE Partner 4)
Domain 3: Facilitating Factors of Success
Relationships with multi-sector stakeholdersQ19 “I think key lessons would be to begin projects like this by inventorying who the resources are already existing in the community; working off the relationships that you have with those key community stakeholders. Enabling our work to support the work of others who have already been doing it and in turn we get support from them..” (STRIVE Partner 3)
Q20 “Yeah, pretty much if you're somebody in the city we cornered you somewhere at McDonalds, or City Hall, or at the gas station. We followed you, we stopped you, we made sure that you know there's a farmers market coming… I think we spoke to almost everybody in town…And the state too…” (STRIVE Partner 1)
Q21 “… so we have a lot of our not-for-profits, we have private, and we have [government]…if you don't have that infrastructure of all these different sectors of the community…you're just gonna have the regular buy in from the regular sources of people…when you expand that into the private sector, into the not-for-profit sector, you really change the dynamic of the program… So when you bring all three of those to a group together you really have a powerful organization that can get things moving.” (STRIVE Partner 4)
Community trust in Partner organizationsQ22 “… [Partner name] is an organization that already has a great deal of respect within the community; it's been around since the 1970's. And so I think that that, [Partner name] as an organization has already set us up to do what we're doing in such a short period of time and besuccessful doing it..” (STRIVE Partner 3)
STRIVE programmatic support and technical assistanceQ23 “… I think knowing very clearly the relationship we had with [name of partner] with the STRIVE team with [CSAAH and APIAHF Project Officers] and the entire team there, that helped. The early on reporting, the progress reports, the conference calls; that helped.” (STRIVE Partner 4)
Modifications to EBBPSE strategiesQ24 “I think this is true for most people, but especially when you're thinking of low income immigrant groups, they spend a significant amount of their time working and just worrying about work and not necessarily worrying about themselves or extracurricular type of things. And although this ends up being a long-term benefit in the immediate it can seem frivolous when you first start. So if we weren't able to tailor that in such a way that it was more palatable, it seems more appropriate, it seems more in-line with who they are and what they can do given their current situation, it would not have been successful at all.” (STRIVE Partner 2)
Domain 4: Challenges
Coalition- and consensus-building is time intensiveQ25 “…as we're working with institutions there's a lot of people that need to be in on decision making processes or meeting or planning and so it can be complicated to get all of the necessary people together to make decisions and proceed. That is a bit of a challenge, and additionally you don't wanna be so pushy that you become alienating, so we always made it a point to remember to move at the pace of the community or at the pace of the institution we were working with to make sure the project still seemed, could be successful, but also seemed welcoming.” (STRIVE Partner 3)
Q26 “… if you're going to do a public strategy and you're going to incorporate anything that has to do with county level or city level government then you definitely need to allot the appropriate time for that to take place.” (STRIVE Partner 2)
Lack of experience with PSE strategiesQ27 “…significant challenge was: on the private side the apartment communities were notnecessarily…some of them seemed very receptive to having community gardens, what they were not as receptive to was implementing policies around that.” (STRIVE Partner 2)
Case Study: Kōkua Kalihi Valley Comprehensive Family ServicesOrganization

Kōkua Kalihi Valley Comprehensive Family Services (KKV) was formed as a non-profit corporation in 1972, in response to the absence of accessible and culturally appropriate health care services for the valley's low-income, Asian and Pacific Island immigrant population. Today, KKV employs 180 staff who are fluent in 20 Asian and Pacific Island languages and dialects, and work out of nine locations throughout the valley including a federally qualified health center. Our mission is to work together toward healing, reconciliation and the alleviation of suffering in Kalihi Valley, by serving communities, families and individuals through strong relationships that honor culture and foster health and harmony.

Targeted jurisdiction

Kalihi Valley is a distinct geographic jurisdiction within Honolulu County (Census Tracts 61-65).

Demographic profile of target community

For many Kalihi Valley residents, the long distance to the nearest supermarket, limited car ownership, and high food prices restrict access to fresh fruits and vegetables, particularly to culturally important foods such as taro, breadfruit, tapioca and fish.1 Low-income residents instead turn to fast food outlets and processed goods to feed their families, further exacerbating health problems.2 More specifically, Kalihi Valley residents face numerous structural, economic and social barriers to good health, resulting in significant health disparities. Among patients seen at KKV, 19% have a diagnosis of diabetes; and 40% of elderly patients are affected by cardiovascular disease. A 2001 Department of Health study of hunger and food insecurity in Hawaii found that Kalihi was the third worst community on the island of O'ahu, with 28% of Kalihi residents living in food insecure households.3 Across the state, food insecurity was significantly more likely among single adult households—which comprise 47% of families in one public housing community.4

STRIVE project

Our strategy was to initiate systemic change that would build on the work that we were doing to improve local food systems. We approached this work grounded in a process of understanding the ways people connect to food, land, and culture, and how the strength of these connections impacts their overall health. Our STRIVE project allowed us to leverage existing relationships with community members, schools, community centers, and churches to build stronger networks, ultimately creating a web of connections that would go well beyond the program period. In order to accomplish this, we aimed to increase the number of AANHPIs in Kalihi Valley with improved access to environments with healthy food and beverage options. More specifically, we worked closely with community members to develop culturally tailored EBPSE strategies that included farmers' markets and community gardens with a complementary gardening network. For example, we partnered closely with Kuhio Park Terrace and another community spaces to initiate farmers' markets with the capacity to accept Supplemental Nutrition Assistance Program (SNAP) benefits. Building on our experience working with the community to grow fruits and vegetables, we also partnered with schools and churches to initiate and establish community gardens with culturally appropriate foods. Lastly, to create a web of connections sustained by the community's resilience, we established the foundations of a gardening network comprised of schools, churches, senior centers, and other community centers.

Success

We launched the project in the summer of 2013, which included culturally adpated EBPSE strategies such as farmers' markets and community gardens within a gardening network. Initially we proposed to reach nearly 19,000; however, given the enthusiasm and commitment from the community, we ultimately reached over 25,000 AANHPIs. The following are factors that led to our success:

An ongoing partnership between the Hawaii Department of Health;

Cultural advising and language skills provided by Super Aunties who have existing ties in the community. Super Aunties' status as elders was critical in outreach efforts;

Strong relationships with Kuhio Park Terrace housing complex residents and management;

An emphasis on building and strengthening relationships through working and eating together.

1 Lucas K, Yamamura T. USDA Grant Final Report [unpublished]. Kōkua Kalihi Valley Comprehensive Family Services, August 2013.

2 Lucas K, Yamamura T. USDA Grant Final Report [unpublished]. Kōkua Kalihi Valley Comprehensive Family Services, August 2013

3 Onaka, Alvin T. Hunger and Food Insecurity in Hawaii: Baseline Estimates. Hawaii Health Survey, 1999-2000. Hawaii Dept. of Health, Office of Health Status Monitoring, October 2001.

4 Farrington Complex Community Assessment of Young Children and Their Families. Buckley Consulting, March 2009.

Case Study: Boat People SOS - AlabamaOrganization

Opened in the aftermath of Hurricane Katrina in early 2006, Boat People SOS-Bayou La Batre is the Alabama branch of Boat People SOS (BPSOS), a national Vietnamese-American nonprofit community-based organization with a 32-year track record of service. Our mission is to empower, organize, and equip Vietnamese individuals and communities in their pursuit of liberty and dignity. While we focus on the disproportionately underserved population of Southeast Asians (which includes Vietnamese, Cambodians, and Laotians) in the greater Bayou La Batre area, we make our services available to all community members in surrounding cities and in South Mobile County regardless of ethnic background.

Targeted jurisdiction

Bayou La Batre, Alabama, and surrounding towns of St. Elmo, Irvington, Coden, and Grand Bay; South Mobile County.

Demographic profile of target community

The Southeast Asian community in Alabama are a largely immigrant community. Southeast Asians experience a large burden from certain chronic disease-related risk factors, such as diabetes, high blood pressure, and low consumption of fresh fruits and vegetables.1, 2 Factors related to these health disparities include low English language proficiency, low socio-economic status, low rates of health insurance and social isolation.3 Many Southeast Asian community members have experienced war-related trauma and post-war persecution, torture and even imprisonment. Community members suffered losses of homes and loved ones during their escape and long-term internment in refugee camps. Their refugee resettlement experience was no less traumatizing. Within the local area, many Southeast Asian community members were still struggling to recover from Hurricane Katrina in 2005 when they were hit by the economic downturn and the 2010 Deepwater Horizon Oil Spill. This environmental disaster disrupted members'livelihood and exacerbated their poverty, isolation and health risks. There are approximately 1,013 Southeast Asians residing in the greater Bayou La Batre area, comprising more than 1/3 of the city's total population.

STRIVE project

The greater Bayou La Batre area presents residents with environmental barriers to healthy eating, including a lack of availability of fresh produce, and few public transportation options. To address these barriers, our organization implemented a two-pronged strategy focused on increasing access to environments with healthy food options for the community at large, with additional targeting to the Southeast Asian and elderly community through implementation of a new farmers' market and increased access to an existing community garden. Our two-pronged strategy was bi-directional in nature, with the community garden intended to supply regional and ethnic-specific produce to the farmers' market. The community garden was also targeted to community members without access to independent gardens, such as low-income apartment dwellers. In addition, several of our farmers' market vendors adopted the Senior Farmers' Market Nutrition Program, thereby increasing access to healthy foods for our low-income seniors.

Success

Launched in the summer of 2013, our farmers' market was attended by 96 community members on its opening day, successfully providing the greater Bayou La Batre area with increased access to nutritious produce. A key goal met was to foster a culture of healthy eating and living among the Bayou La Batre population. On the opening day of our farmers' market, we were also excited to see an additional objective met: for the first time, members from all of the different communities in Bayou La Batre came together to participate in the event. For example, politicians who only saw each other at debates had an opportunity to talk with community members and each other. The farmers' market also presented opportunities for bidirectional cultural learning. Asian American community members were shopping for both traditional Asian produce as well as unfamiliar produce while non-Asian community members were exposed to and showed interest in the Asian ethnic produce. As a result, our EBPSE strategy was able to reach 12,000 community members, providing increased access to healthy food options to our community at large, and importantly, reaching our Southeast Asian and elderly community through targeted approaches. In the end, the farmers' market offers our local residents an opportunity to purchase fresh fruits and produce, which will not only improve their health and quality of life, but also keeps the money spent in the community, helping growers, consumers and the local economy.

1 Yu Xu, M, Ross C, Ryan R, et al. Cancer Risk Factors of Vietnamese Americans in Rural South Alabama. Journal of Nursing Scholarship 2005;37(3):237-244.

2 UCLA Health Center for Policy Research, 2011-2012 Health Profiles, Vietnamese Ethnic Group. (Accessed at: http://healthpolicy.ucla.edu/health-profiles/race_ethnicity/Documents/AsianGroups/Vietnamese.pdf)

3 Niedzwiecki M, Duong TC. Southeast Asian American Statistical Profile. Washington, DC: Southeast Asia Resource Action Center (SEARAC); 2004. (Accessed at: http://www.seasite.niu.edu/lao/seastatprofilemay04.pdf)