SAMOA Country Studies: A brief, comprehensive study of Samoa

The focus groups were conducted in Samoan by trained facilitators. We explored many of the same issues with all 13 health center clinicians in individual interviews, which were conducted in English. Group sessions and interviews were audiorecorded and transcribed, and Samoan comments were translated into English before analysis of themes, which was facilitated by use of NVivo software.

Linguistic translation of focus group transcripts provided another layer of analysis.

Behavioral and Perceived Stressor Effects on Urinary Catecholamine Excretion in Adult Samoans

It was necessary to recheck translations against the original language and to employ multiple translators to ensure that the correct meaning was transcribed. We selected measures for the 3 phases of evaluation, according to the Precede—Proceed Model: Because of the complexity of diabetes in behaviors and relevant disease outcomes, we had many relevant measures from which to choose. It was important to select measures previously used in lower-literacy populations and to limit the number of measures to reduce burden.

Our outcome selections also had to take into account the remoteness of the field site, with its lack of access to standardized research laboratories. Therefore, we chose to use a point-of-care assessment tool for hemoglobin A1c: Few intervention research measures had been used previously in American Samoa. When standardized measures from mainstream culture are used in other ethnic groups, they may lack cultural relevance, leading to measurement error or misinterpretation of findings.

Cultural translation focused on ensuring that the concepts we translated were as relevant as possible to Samoan life and culture. Cognitive interviews were an essential step in this process. The patients answered each question and then discussed their answers and their understanding of the translated items with a research interviewer. Through this process we were able to determine that many of our questions were appropriately translated, and we corrected or adapted others before administration to participants in the randomized controlled trial.

In adapting standardized measures, it is important to strike a balance between the emic perspective seeking equivalence within the culture and the etic perspective ensuring comparability across cultures. Although cognitive interviews are often used in item development, 71 , 72 our protocol used them to confirm the effectiveness and cultural salience of our translations.

After the qualitative studies were completed and themes were identified, we developed the intervention protocols and materials, drawing on PS2 interventions as a model. Unique considerations in the American Samoa population included higher blood glucose and blood pressure levels.

We adapted treatment algorithms to accommodate manageable staff workloads. We used somewhat higher cutpoints to define lower, medium, and higher risk; level of risk determined the frequency of visits for individuals. Because participants had limited access to professionally led diabetes education, we trained our community health workers to provide basic education during their home visits. To facilitate this, we developed flipcharts modeled on National Diabetes Education Program flipcharts for diabetes prevention by community health workers in other ethnic communities.

Diabetes self-care is more complicated than diabetes prevention, so we developed 8 flipcharts, 1 with basic diabetes information and 7 about diabetes-related behaviors monitoring, taking medication, healthy eating, being active, reducing risk, healthy coping, and problem solving. Further, the flipcharts were organized to include strategies in the Precede—Proceed Model: Linguistic translations of printed materials were requested by staff for themselves as well as for participants.

Although staff members were bilingual, their comfort with English varied.

Side-by-side translations facilitated shifting from one language to the other, reflecting the way people regularly speak. After drafts were developed for flipcharts and visit protocols, we reviewed them with local staff and practiced with role plays. Then we made further adaptations to better fit how the materials would be used. This process of collaboration, an integral part of community-based participatory research, 43 — 45 was invaluable; it revealed the need to scale back both the quantity and complexity of information, and it identified additional training needs for the staff.

Staff members also came up with novel interactive teaching tools, such as laminated photos of locally available foods that could be sorted into red, yellow, and green categories, according to the National Diabetes Education Program red light system for foods to eat more of, eat with caution, and avoid. Conducting a randomized trial in a setting where intervention research is unfamiliar required several cultural adaptations.

We provided education to all health center staff about research practices, including why we do research, why we randomize, what contamination across study groups is, and how it affects study goals. Health care personnel on the island have limited opportunities for continuing education, and few can afford to seek training elsewhere.

Therefore, health center clinicians specifically asked for more training on diabetes care as part of this project. This training was provided over a 4-day visit by author M. Our local project staff also received extensive training on diabetes management, assessment techniques, and study protocols, and all were certified on human participant protection.

WHEN IS CULTURAL ADAPTATION NECESSARY?

The community health worker training was geared to a lay audience with high school education. We used several hands-on learning techniques, such as role plays and daily quizzes, with prizes for correct answers or knowing where to find the correct information. Study protocols were approved by American Samoa and Brown University review boards. The randomized trial, which is under way, will test the effectiveness of an intervention coordinated by a nurse and community health worker team to provide outreach, education, and support to type 2 diabetes patients and their families.

We randomized villages instead of patients because of extensive familial and local community ties. Villages are matched by size and location in the health center catchment's area, and villages in the pairs are randomly assigned to intervention or control group. Control participants receive their usual care at the health center for 1 year, after which they will receive the intervention. Eligibility for this sample is broad, because this translational research is intended to test real-world effectiveness: Characteristics of the total population of health center diabetes patients will be used to assess the sample's representativeness and external validity and to ensure that this research is relevant to practicing clinicians and policymakers.

Some challenges during implementation of the trial have required other adaptations. Because research funding is temporary, local staff were hired on 1-year contracts, as required by American Samoa government policy. Delays in contract approvals caused a 6-month wait before staff could start working.

Further, contract renewals required special extensions by the governor because government policy allowed only 1-year nonrenewable contracts. Therefore, renewals also involved delays. These delays led to significant gaps in staff coverage, which caused us to fall behind on our time line. Although the original research job descriptions differentiated between research assistants who were to do assessment interviews and data entry and community health workers responsible for patient education and support , we decided to cross-train staff on all tasks. We found this to be more effective in building a consistent team that is able to manage all necessary tasks, especially when gaps in staff coverage occur.

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These accommodations have required more training, closer supervision, and additional quality control mechanisms. We could not do this work without a full-time field director, who supervises the research in American Samoa, bridging the requirements of research and local authority and policy. Another key adaptation involves working with the limited access to medical supplies that is common in low-income communities and island economies.

Blood glucose—testing equipment and supplies are too costly for most island residents, and they do not have individual medical insurance to cover these costs; therefore, most patients only have access to blood sugar testing at the medical clinic. It is also common for the medical clinic to be without these crucial supplies for varying periods because of funding shortages. Our study was not funded to provide blood-testing supplies for individuals.

We therefore had to redefine the role of blood glucose monitoring to include problem solving within families to increase access to meters and supplies. Community health workers also provide regular testing during their visits. We plan to do additional qualitative studies with participants in the intervention group and with study staff and clinicians at the health center, after the posttreatment assessments at the 1-year follow-up.

These qualitative studies will examine the salient features of the intervention in the view of participants and providers, such as perceived efficacy, burden, facilitators and barriers, and potential for sustainability and wider spread. For example, we will ask about the extent to which community health workers were fully integrated into the health care system, how confident patients became in self-care, and how both of these factors could be improved.

These data will be used to complement quantitative data outcomes and provide a qualitative thick description of the experiences participants and staff had with the intervention. Posttreatment qualitative data are especially important in this first intervention study in American Samoa because they will provide in-depth feedback on the intervention and research procedures to guide future research.

We are deliberately collecting qualitative data from the perspective of both participants and the staff who delivered the intervention, to determine whether future adaptations are needed to meet either group's needs. Participation of community partners in interpreting results is encouraged in all community-based research. Our multidisciplinary research team, consisting of anthropologists, health psychologists, a physician, and a nurse diabetes educator, have also provided different perspectives that have been valuable throughout the process.

When posttreatment data are available, we will seek these partners' input as well to help interpret our findings. Also at that juncture, our community partners will help us consider next steps if community health worker services prove to be valuable to find ways to sustain and further disseminate community health worker services for diabetes care. Although many efficacious interventions exist to improve diabetes care, including examples in ethnic minority populations, 49 , 50 , 61 , 62 evidence-based treatments are needed by many underserved ethnic groups and communities to further reduce health disparities in diabetes.

Our approach to cultural translation drew from the emerging science of translation research and cultural adaptation to bring strong scientific methods to American Samoa. Cultural adaptation was necessary in this context because diabetes risk on the island is much higher than in the general US population, and cultural practices contribute to this risk.

Our community partners selected an approach coordinated by community health workers and primary care providers. Previous adaptations of community health worker interventions in other ethnic groups have improved cultural competency, reach, and participation rates, but few of these trials used randomized designs, and sample sizes were often small, yielding few clear differences in outcomes.

Previous studies on diabetes interventions in Pacific Island populations also lacked randomized designs and produced little data specific to American Samoans. We chose to adapt the community health worker—nurse team intervention from PS2, 59 , 60 which was conducted in an African American population, because it was evidence based, had proved successful in a randomized controlled trial, and incorporated features found in other successful diabetes interventions.

The PS2 interventions were integrated with primary care, providing a good model for the primary care context in American Samoa. We have found many of our practical and cultural adaptations to be beneficial. Conducting qualitative research was important to our community partners to ensure cultural competency of the community health worker approach in the local primary care setting. The patient focus groups and provider interviews offered practical advice about community health worker roles and job duties, such as ways of showing respect while visiting patients' homes and discussing sensitive medical topics.

Focus group participants also reported that images from materials produced for other Pacific Islands were not acceptable because they wanted to see their own people, their own foods, and local examples of physical activities. The adapted flipcharts included these local images for teaching diabetes self-management; these flipcharts continue to be a valued resource for both community health workers and patients in our ongoing trial. Other adaptations included higher cutpoints on treatment algorithms to accommodate the higher-risk population in American Samoa and flexible teaching on glucose monitoring to accommodate patients' limited access to meters.

These adaptations appear to be feasible for this setting. The more challenging situations have involved delays in hiring staff and renewing contracts through the local government and delays in purchasing and shipping supplies. These issues have been further complicated by tight research timelines and limited funds. Yet such challenges are common in real-world settings, and practical interventions must be flexible enough to accommodate them.

It is helpful to be mindful of multiple layers of cultural translation, bridging not only ethnic cultures but also research and medical cultures, and to be respectful of each. We have tried to find solutions at each juncture that are guided by the values inherent in local cultural practices, best medical practices, and sound principles of research methods and human participant protection. When these different values have not appeared to be compatible, we have tried to find common ground and to retain the most salient features of each value system.

Although cultural translation is necessary to ensure cultural competency and practical implementation in real-world settings, each adaptation risks diminishing the validity of the evidence-based treatment on which it is modeled.

STUDY OF THE U.S. INSTITUTES

Translation research brings new questions to be considered by researchers and in future analyses. How far can we adapt an intervention before it becomes a different intervention altogether and we have lost fidelity with the original treatment? We have used core components identified as successful in systematic reviews and meta-analyses—treatment algorithms, community outreach, one-on-one interventions, and multiple contacts over time. Can we retain the salient components? It is helpful if we consider and document our challenges and lessons learned as key findings of this work rather than as mere disruptions of the randomized trial's implementation.

Effective interventions should be developed that go beyond a static view of cultural competence and have a chance of being sustained and further improved by local health care and public health organizations. Cultural competency is also best viewed as a lifelong process and not an end result. So too is research and intervention science, because we are constantly seeking to improve on our experience in these ever-changing systems. We also appreciate the contributions of our collaborators Ray Niaura and Samuel Holzman, Brown University, to the early phases of this work.

• Mariages du père Olifus, Les (French Edition)?
• Threatening Development (A Little BirdN B&B Adventure Book 2).
• About Cook Islands, Niue, Samoa and Tokelau;
• Kerrigan in Copenhagen.
• New Age Thought (A Variety of Passion);
• Bill Bailey!

All study protocols for the qualitative phases and intervention trial were approved by the American Samoan and Brown University institutional review boards. National Center for Biotechnology Information , U. Am J Public Health. Goldstein , MD, and Stephen T. Author information Article notes Copyright and License information Disclaimer.

Introduction

At the time of the study, Judith D. Meaghan House and Stephen T. Reprints can be ordered at http: Accepted February 18, This article has been cited by other articles in PMC. Abstract Translation of research advances into clinical practice for at-risk communities is important to eliminate disease disparities. Open in a separate window. Diabetes Care in American Samoa, — INSIGHTS Although many efficacious interventions exist to improve diabetes care, including examples in ethnic minority populations, 49 , 50 , 61 , 62 evidence-based treatments are needed by many underserved ethnic groups and communities to further reduce health disparities in diabetes.

Human Participant Protection All study protocols for the qualitative phases and intervention trial were approved by the American Samoan and Brown University institutional review boards. Translation research for chronic disease: Considerations for diabetes translational research in real-world settings.

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A pilot urban church-based programme to reduce risk factors for diabetes among Western Samoans in New Zealand. Improving diabetes care in the primary healthcare setting: Sustaining better diabetes care in remote indigenous Australian communities. Reaching underserved populations and cultural competence in diabetes education. Cultural competence and evidence-based practice in mental health services: Results of the Healthy Body Healthy Spirit trial. Making the case for selective and directed cultural adaptations of evidence-based treatments: Clin Psychol Sci Pract.

An Educational and Ecological Approach.

Youth blood pressure levels in Samoa in and — Am J Human Biol. Farming and adiposity in Samoan adults. Nutrition and health in modernizing Samoans: Ohtsuka R, Ulijaszek SJ, editors. Cambridge University Press; Obesity in Samoans and a perspective on its etiology in Polynesians. Am J Clin Nutr. Interdisciplinary translational research in anthropology, nutrition, and public health. Institutes for Scholars SUSIs are intensive post-graduate level academic programs with integrated study tours whose purpose is to provide foreign university faculty and other scholars the opportunity to deepen their understanding of U.

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