Thursday, June 13, 2013
Obesity predisposes individuals to an increased risk for morbidity, disabilities, mortality and a tremendous healthcare burden (Brown, Gotshalk, Katzmarzyk, & Allen, 2011). In the Native Hawaiian population, the rapid increase in rates of obesity suggest rather than biological or genetic changes, this increase can be attributed to changes in health behaviors (Hill & Peters, 1998). Health behaviors are changeable, although the complexity of overweight and obesity should not be understated. Obesity and obesity-related diseases and conditions are prevalent in the Native Hawaiian population, partly because of behavioral components, but also because of a genetic predisposition to overweight and obesity (Brown et al., 2011). Although Hawaii as a whole, does not have higher rates of overweight and obesity and related disorders than the American population, Native Hawaiians (who make up only 10-11% of the Hawaiian population) are at a higher risk of chronic and other conditions related to obesity (Brown et al., 2011). The goal of this proposal is to create a culturally sensitive weight management program for Native Hawaiian women that considers their biological, psychological, and social aspects of being overweight or obese. The Transtheoretical Model (TTM) is utilized as a parameter for this program. Further, the anticipated challenges to the program are discussed.
The target population for this program is Native Hawaiian women. Although the problem with overweight and obesity in Native Hawaiians is not exclusive to women or adults, this program is designed specifically for adult Native Hawaiian women. More than 62% of Native Hawaiian women are overweight, 34% of whom are severely overweight (Aluli, 1991; Mau et al., 1997). Hawaiian women have experienced an increase in insulin resistance (Mau, Grandinetti, Arakaki, & Chang, 1997), an increase in kidney disease (Mau, West, Shara, Efird, Alimineti, Saito, & ... Ng, 2007), and a significant increase in overweight and obesity (Brown et al., 2011). Further, this population has seen an escalation in many chronic diseases as well as a risk for breast cancer (Maskarinec, Zhang, Takata, Pagano, Shumay, Goodman, ... and Kolonel, 2006). Overweight, obesity, alcohol consumption, and nulliparity have risen alongside this increase in breast cancer (Maskarinec et al., 2006). Although all of these factors represent changeable health behaviors that deserve attention, this proposal focuses on overweight and obesity in Native Hawaiian women.
Addressing a Need
Obesity continues to increase in the Native Hawaiian population. Hawaiians are at a greater risk of dying earlier than White Americans because of chronic conditions such as diabetes and obesity. Mental illness and substance abuse in youth contribute to their early demise as well (Park, 2010). Native Hawaiians are almost twice as likely as Whites to die from heart disease, and three times more likely to receive a diagnosis of chronic heart disease (U.S. Department of Health and Human Services (USDHHS), 2010). Further, the frequency of high blood pressure is 70 percent higher in Native Hawaiians than in Whites (State of Hawaii, 2010; USDHHS, 2010). At this time, no culturally sensitive weight management programs designed for Native Hawaiian women exist in the Hawaiian archipelagos.
In exploring the cognitive and behavioral components of overweight and obesity in this population, research suggests stressors (specifically, discrimination) for this indigenous population may contribute to negative health behaviors that provoke weight gain (Agosto, 2011; McCubbin & Antonio, 2012). Of all ethnicities living in Hawaii, Hawaiians have the lowest incomes, the least education, and the highest level of social problems and health issues (Mokuau & Matsuoka, 1995). Although a paucity of research exists regarding these issues, McCubbin and Antonio (2010) found a connection between overt discrimination and body mass index scores for a sample of Native Hawaiians. This research suggests that an effective weight management program for Native Hawaiian women must also include teaching coping mechanisms to relieve the psychosocial stress of discrimination and cognitive strategies to increase self-esteem and reduce other psychological aspects of overweight and obesity (Agosto, 2011).
The program is a culture-oriented weight awareness and management program, sensitive to the needs of Native Hawaiian women. Utilizing the parameter of the transtheoretical model of health behavior change, this program aims to create an awareness of cultural tendencies for food consumption and its effects on the Hawaiian population. Additionally, the program will address and treat the effects of overt discrimination on weight gain in this population, and teach effective coping strategies to manage this stressor unique to the indigenous Hawaiian population (McCubbin & Antonio, 2010). Furthermore, it will incorporate strategies that aim to change self-esteem, body image, and attitudes toward food that have been previously successful in establishing weight loss in Native Hawaiian women (Agosto, 2012).
Neel (1962) suggested that Native Hawaiians developed a culturally specific, highly efficient metabolism because of their geographically isolated location that may have predisposed them to limited resources and the need for biological efficiency. This theory was partly based on research that determined an association between an increased tendency toward obesity and a higher percentage of Hawaiian ancestry (Grandinetti, Chang, Chen, Fujimoto, Rodriguez, & Curb, 1999; Neil, 1962). The program described herein will utilize research guidelines that suggested when Hawaiians returned to their pre-Western contact diet, they lost weight and were healthier, with lower serum cholesterol and blood pressure (Shintani, Hughes, Beckam & O'Connor, 1991). The proposed weight management program is holistic because it addresses biological, psychological, and social aspects of weight loss in Native Hawaiian women, and culturally sensitive because it increases awareness of factors exclusive to weight gain in this diverse population. It combines a culture-appropriate diet and seeks to resolve culture-specific psychological issues.
The Transtheoretical Model
The Transtheoretical Model (TTM) of behavior change provides a parameter for understanding the process of change that will occur over the course of the biopsychosocial weight management program for Native Hawaiian women. The TTM emphasizes the behavioral processes aligned with attitude and awareness change and readiness to change (Glanz, Rimer, & Viswanath, 2008). Central to the TTM is the belief that emotional attitudes and beliefs change with increased awareness and understanding, and this process is the antecedent to change. Further, it explains that individuals cannot make durable behavior changes, until they are cognitively ready to change (Glanz et al., 2008; Rossi, 2004). An important consideration in utilizing the TTM in relation to the biopsychosocial weight management program for Native Hawaiian women is the exclusively cultural factors associated with weight gain in this population. Without embracing all of these factors, and creating awareness in each individual, weight management may not be effective or successful for these women. The TTM accounts for individual variation of cultural embeddedness as well as other contextual circumstances such as an increased awareness of discrimination, and stress related to cultural issues as explained above. Brug (2004) found tailored interventions, such as those accommodated by the TTM, are more effective and promote a higher rate of durable change. The TTM takes into account individuals' readiness to understand, prior to engaging in their education. It theorizes that individuals cannot take action until they are cognitively ready to understand what is involved in making change (Glanz et al., 2008).
Although this program is designed to affect the various and complex issues of weight management effectively, challenges should be anticipated. One of the primary issues is the sizeable task of increasing self-esteem. Because this issue is inherent in obese and overweight Native Hawaiian women, it must be addressed and at least, partly mitigated, with the hope of continuing to resolve this issue longitudinally. Self-esteem issues do not develop in a vacuum, and it is understandable and expected that resolving such powerful and wholly pervasive psychological issues are far more difficult to resolve in an environment in which personal variables cannot be controlled.
In the action stage of the TTM, the women would have decided to take action against their food consumption habits and their self-perceptions. However, although individuals may be vigilant, they may revert to past behaviors, attitudes, and beliefs (Glanz et al., 2008). Similarly, in the maintenance stage, the women must continue to maintain vigilance against cultural and contextual tendencies, although at this stage their resolve has been strengthened and new and healthier patterns continue to be implemented (Glanz et al., 2008). Psychological cues, such as overt discrimination and the Hawaiian cultural tendency to use food as a social communication, will continue to plague these women, and they should be advised that their changes in health behaviors, beliefs, and attitudes are an ongoing journey.
Another challenge to this program is in its culturally sensitive delivery. Because Hawaiians continue to experience low socioeconomic status, far less education, and a higher level of social and psychological issues than other ethnicities in Hawaii, the experience of discrimination is common, and many harbor anger toward other ethnicities, but especially the White citizens of Hawaii. It will be important to engage Native Hawaiian women as facilitators, speakers, and teachers in the program. For program facilitators not of Hawaiian descent, cultural competency training will be critical to the facilitator's success as well as the success of the program (Kamaka, Paloma, & Maskarinec, (2011).
Although overweight and obesity is a complex issue for any population or individual, Native Hawaiian women face biological, psychological, and social factors idiosyncratic to their indigenous culture. The program described herein aims to guide Native Hawaiian women toward an appropriate weight management plan that accommodates the biological, psychological, and social implications of being a Native Hawaiian woman. The program relates to the stages of change described in the TTM and utilizes awareness as a key factor in implementing durable change in food consumption as well as other aspects of this program's weight management. The most significant aspects of this program is that it is culturally sensitive toward Hawaiian women and considers individuals' readiness for change.
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