Training

PILI `OHANA BACKGROUND OVERVIEW

The PILI ‘Ohana program represents a partnership between community-based organizations throughout the State of Hawai�i and a team of academic researchers from the Department of Native Hawaiian Health at the University of Hawai�i John A. Burns School of Medicine.

The aim of PILI ‘Ohana is to integrate community wisdom and expertise with scientific methods to conduct research on health disparities, with a specific emphasis on obesity, in Native Hawaiian and Pacific Peoples (including Filipinos, Chuukese, and other Pacific Islanders). The project is collectively owned amongst all research partners, both academic and community, on behalf of the Native Hawaiian and Pacific People communities served by the project. Community organizations serve as co-investigators with the academic researchers and play an active role in the planning, decision-making, and carrying out of research activities.

CBPR is a community-based participatory research partnership which has been defined as "a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings." Thus, the PILI ‘Ohana Program, a community-academic partnership, was formed to conduct CBPR activities aimed at eliminating health disparities and, in particular, obesity disparities in Native Hawaiian and Pacific Peoples.

PILI LIFESTYLE INTERVENTION PROGRAM (PLP)

The PILI program is a 9-month weight-loss and weight-loss maintenance program.  The weight-loss phase (8 lessons) is the first 3 months of the program, followed by the 6-month weight-loss maintenance phase (6 lessons). 

In addition, there are three assessment points: baseline assessment (prior to starting the 3-month weight-loss program); 3-month assessment (upon completion of the weight-loss phase, prior to the 6-month weight-loss maintenance phase); 9-month assessment (upon completion of the weight-loss maintenance phase). 

The PILI program and curriculum is based on weight control, behavior change, social systems, and lifestyle. 

• • Weight control, through healthy eating, physical activity, stress management, and supportive social network, can:
    • Reduce the risk for diabetes, heart disease, sleep apnea, and certain cancers.
    • Help better manage health problems.

• • Health behavior changes that are small, simple and realistic, are more likely to be maintained overtime.
    • Intense lifestyle interventions get big weight loss (for those who stay in) but for most are often not sustainable past 6 months to 1 year.

• • Social systems influence the adoption and maintenance of health behaviors
    • Family, friends, and co-workers influence an individual.
    • Most meals and activities are shared within a social context.

• Focus is on lifestyle and quality of life and not so much on weight.
  • Weight is simply a measure of how the lifestyle changes are going for those who are over weight.

Please see the Manual of Procedures for complete PLP program and assessment procedures.

Partners in Care is an educational program designed to meet the needs and interests of adults living with Type 2 Diabetes. The program is a culturally-adapted 3-month intervention to improve diabetes outcomes, focusing on ways to control blood sugar and live healthy with diabetes. 

The goal of PIC is to provide information about diabetes to give participants a better understanding of why it is important to get their glucose in balance and how to stay healthy with diabetes. Program materials provide basic information about diabetes self-care, encourage participants to work with their diabetes team, and emphasize the American Diabetes Association clinical guideline goals for blood glucose, A1c, blood pressure, and lipids. 

The PIC program involves hands-on activities, educational materials, and group support all geared toward improving and sustaining diabetes self-care. 

Participation in PIC entails:

• Attending all 12 one-hour weekly meetings.
• Completing a questionnaire.
• Checking your hemoglobin A1c and cholesterol levels during regular visits with your doctor.

All PIC lessons adhere to the American Diabetes Association 2010 Clinical Guidelines and the National Diabetes Education Program and can be delivered by community health workers and peer educators. Program topics include a variety of subjects ranging from what types of food to eat to how to talk with your health care provider. 

PIC participants will learn:

• How food and regular physical activity affect your blood sugar.
• How to monitor and regularly keep track of your blood sugar.
• HoImprove your mental health and mood
• How to avoid diabetes complicaitons.
• How to stay in balance during work, school, travel, and special events.
• How to get support from friends and family for your diabetes.
• How to talk with your health care provider and ask questions.

Social Ecological Framework

The social-ecological model is used to better understand health behaviors and the effect of potential prevention strategies. This model considers the complex interplay between individual, relationship, community, and societal factors. It allows us to address the factors that put people at risk for obesity.
Prevention strategies should include a continuum of activities that address multiple levels of the model. These activities should be developmentally appropriate and conducted across the lifespan.

• Individual:  The first level identifies biological and personal history factors that increase the likelihood of obesity.  Prevention strategies at this level are often designed to promote attitudes, beliefs, and behaviors that ultimately prevent obesity. Specific approaches may include education and self-monitoring techniques.
• Relationship:  The second level examines close relationships that may increase the risk of becoming overweight. A person's closest social circle-peers, partners and family members-influences their behavior and contributes to their range of experience.  Prevention strategies at this level may include having a support person in a weight-loss program.
• Community:  The third level explores the settings, such as schools, workplaces, and neighborhoods, in which social relationships occur and seeks to identify the characteristics of these settings that are associated with obesity.  Prevention strategies at this level are typically designed to impact the climate, processes, and policies in a given system. Social norm and social marketing campaigns are often used to foster community climates that promote healthy relationships.
• Societal:  The fourth level looks at the broad societal factors that help create a climate in which obesity occurs. These factors include social and cultural norms. Other large societal factors include the health, economic, educational and social policies that help to maintain economic or social inequalities between groups in society.

References
Centers for Disease Control and Prevention. (2009). The Social-Ecological Model: A Framework for Prevention. Retrieved from
http://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html

OBESITY OVERVIEW

Obesity presents an increasing national health problem.  The prevalence of overweight and obesity in the US general population has continued to increase at alarming rates despite wide spread public health campaigns to curb the growing epidemic. Currently, it is estimated that 27.8% of the US adult population has obesity (BMI≥30) and 35.7% are overweight (BMI≥25). However, there is considerable variability in obesity/overweight by region and race/ethnicity.  In Hawai’i, Native Hawaiians have the highest prevalence of overweight/obesity (76.3%) compared to 54.6% of Caucasians, 55.1% of Filipinos, and 46.2% of Japanese.

Not surprisingly, medical complications associated with overweight and obesity, such as diabetes, heart disease, and some forms of cancer, loom large as a major health problem that threatens to overwhelm US health care resources.  Overweight and or obese individuals, especially among minority and low socioeconomic sub-populations, are particularly at high-risk for developing associated medical complications and are more likely to develop them at a younger age.

Promising evidence-based interventions aimed at preventing the medical complications of excess weight strongly suggest that even modest weight loss can prevent or postpone the onset of medical complications such as Type 2 diabetes mellitus.

References
Centers for Disease Control and Prevention. (2012). Overweight and Obesity. Retrieved from http://www.cdc.gov/obesity/index.html

Hawai‘i State Department of Health. (2012). 2010 State of Hawai’i Behavioral Risk Factor Surveillance System. Retrieved from http://hawaii.gov/health/statistics/brfss/brfss2010/demo10.html

Diabetes Overview

Diabetes is a group of diseases characterized by high blood glucose levels that result from defects in the body's ability to produce and/or use insulin. There are 4 types of diabetes pre-diabetes, type 1 diabetes, type 2 diabetes, and gestational diabetes. Of these 4 types, the most common are pre-diabetes and type 2 diabetes. 

Before people develop type 2 diabetes, they almost always have "prediabetes" � blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes. Pre-diabetes; is also known as "borderline" diabetes, and doctors sometimes refer to pre-diabetes as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG), depending on what test was used when it was detected. This; condition puts you at a higher risk for developing type 2 diabetes and cardiovascular disease. 

Type 1 diabetes, previously known as juvenile diabetes, is usually diagnosed in children and young adults. In type 1 diabetes, the body does not produce insulin, and hyperglycemia is caused by insulin insufficiency. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. Only 5% of people with diabetes have this form of the disease. With the help of insulin therapy and other treatments, even young children with type 1 diabetes can learn to manage their diabetes. 

Type 2 diabetes, previously called adult onset diabetes, is the most common form of diabetes and 95% of diabetics have type 2 diabetes. In type 2 diabetes the body does not use insulin properly, which is called insulin resistance. The pancreas will initially make extra insulin to make up for the resistance, but over time it isn�t able to keep up and cannot make enough insulin to keep the body�s blood glucose at normal levels. Hyperglycemia is then caused by insulin inefficiency. Diabetes has been shown to be controlled and prevented through modifications in diet, physical activity and medication. 

Gestational diabetes develops during pregnancy. It is usually diagnosed between 24-28 weeks. Being diagnosed with gestational diabetes doesn�t mean that a woman had diabetes before she conceived, or that she will have diabetes after giving birth; however, women with gestational diabetes have an increased risk for type 2 diabetes. It is important that women follow medical advice regarding blood glucose levels during pregnancy so they and their baby both remain healthy. 

References

University of Hawai‘i John A. Burns School of Medicine, Department of Native Hawaiian Health, the Ulu Network. (2012). Diabetes 101. Honolulu: University of Hawai‘i. 

Weight Loss Maintenance

The success of behavioral weight loss interventions have been well documented with reported reductions of 5-10% in body weight, and these reductions are associated with significant clinical benefits. However, the maintenance of weight loss over time has proved difficult where a majority of participants in weight loss interventions return to their baseline weight within 1 year to 18 months of follow-up. Thus, investigators have turned their attention to the maintenance of weight loss.

Studies have identified social support and/or family involvement as a key factor in successful weight loss maintenance. Also, physical characteristics of the built environment, such as access to healthy food choices (e.g. distance to small grocery stores, presence of fast food restaurants) and physical activity/recreational facilities (e.g. playgrounds, parks, sidewalks), are correlated with weight loss maintenance. It is believed that long-term weight loss/maintenance relies on the extended social and physical environment to provide necessary social reinforcements (e.g., role-modeling, encouragements), resources (e.g., food options, physical activity facilities), and opportunities (e.g., incentives for healthy eating). Thus, obesity interventions that are likely to achieve long-term individual changes are those that target not only the immediate (e.g., family) but the extended social and physical environment as well.

Studies have shown that predictors of successful weight loss maintenance/prevention of weight gain include the use of behavioral strategies and psychological and social/environmental factors. Behaviors associated with weight loss maintenance include regular physical activity of 60 min/day, daily self-monitoring of weight, tracking of calorie and fat intake, eating breakfast, and a consistent dietary pattern across weekdays and weekends. Psychological predictors of success include self-efficacy, effective coping strategies, and ability to manage stress. Weight maintenance is also enhanced by the availability of social support and natural social reinforcements in the built environment.

References
Elfhag, K. & Rossner, S. 2005. Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain. Obesity Reviews, 6(1): 67-85.

Jeffery, R.W., Drewnowski, A., Epstein, L.H., Stunkard, A.J., Wilson, G.T., Wing, R.R., & Hill, D.R. (2000). Long-term maintenance of weight loss: current status. Health Psychology, 19(1 Suppl): 5-16.

Knowler, W.C., Fowler, S.E., Hamman, R.F., Christophi, C.A., Hoffman, H.J., Brenneman, A.T., et al. 2009. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet, 374 (9702):1677-1686.

Papas, M.A., Alberg, A.J., Ewing, R., Helzlsouer, K.J., Gary, T.L., & Klassen, A.C. (2007). The Built Environment and Obesity. Epidemiologic Reviews, 29(1): 129-143.

Wing, R.R., Tate, D.F., Gorin, A.A., Raynor, H.A., & Fava, J.L. (2006). A self-regulation program for maintenance of weight loss. New England Journal of Medicine, 355(15): 1563-1571.

Nutrition Overview

It is well evident that good nutrition plays an essential role in maintaining health.  By having a healthy diet, some diseases or other health conditions can be prevented or lessened.  To have and maintain good health, it is important to have a diet filled with nutrients from various food sources.  Foods that share similar nutritional properties are grouped together.  There are five food groups:

• Vegetables:  These can be fresh, frozen, canned or dried.  Dark green, red and orange vegetables have a lot of nutrients, so try to eat a lot of these.  100% vegetable juice even counts in this group!
• Fruits:  These can be fresh, canned, frozen or dried.  100% fruit juice also counts in this group.
• Grains:  There are whole grains and refined grains.  Whole grains have more nutrients so at least half the grains you eat should be whole grains (e.g., whole-wheat bread, whole-grain cereals, oatmeal, brown rice).  Refined grains include white rice, white bread, enriched pasta, flour tortillas. 
• Dairy:  All milks and calcium-containing milk-products (i.e., cheese, yogurt) count in this category; however, foods that don’t have a lot of calcium are not included (i.e., butter, cream, sour cream, cream cheese).  Try to have most of your choices in this category be fat-free (skim) or low-fat dairy products.   
• Protein Foods:  This group includes lean meats, poultry, seafood, beans and peas, eggs, processed soy products, unsalted nuts, and seeds. By selecting lean meats; trimming away visible fats; broiling, roasting, or poaching (as opposed to frying); removing skin from poultry, you can lower the fat content while still getting the nutrients.        

For each food group, the recommended amount of food you need to eat depends on your age, sex, and level of physical activity. For more information about recommended daily food amounts, check out - http://www.choosemyplate.gov/myplate/index.aspx

References
Centers for Disease Control and Prevention. (2012). Nutrition for Everyone. Retrieved from http://www.cdc.gov/nutrition/everyone/basics/foodgroups.html

Behavior Change Principles

Behavior change is an opportunity to make new goals and positive changes.  For health behaviors, it can lead to lifestyle changes that can enhance an individual’s overall quality of life.  In changing a behavior, making an action plan is an important step in getting started.  An action plan sets the stage for achieving goals; it gives you a timetable of necessary steps to reach your goal.  There are four strategies in behavior change that can help an individual achieve their goal.

1 – Specific, short-term
The first step in making an action plan is setting a specific, short-term goal. The goal should be measurable (e.g., “I will walk 20 minutes every day” as opposed to “I will try my best to walk more”).  It is recommended that the timeframe for achieving the goal be between one and two weeks.  The goals should be specific, such as the number of minutes to walk.
Specific, short-term goals help individuals build self-confidence about their ability to start a new behavior or change an existing behavior (i.e., walking more; being less sedentary). Even if it is not a very challenging goal, achieving the goal builds self-confidence and encourages continued effort to try more challenging goals.

2 - Actionable
An actionable goal is one targeted to a behavior that an individual has direct control over (e.g., reducing the amount of fat in one’s diet).  Non-actionable goals include those related to body weight, blood pressure or other physiological measures.
Weight loss is best viewed as the result of specific, direct actions. Setting a specific goal that is not actionable creates an opening for failure and loss of self-confidence. Failing to achieve a non-actionable goal does not provide an individual with feedback as to what caused them to not achieve their goal. If an individual makes a non-actionable goal (i.e., body weight target), it should be paired with related, actionable goals (i.e., increasing minutes of exercise or decreasing daily calorie intake). The status of the non-actionable goal (i.e., body weight) can then be used as a reference for whether achieving the actionable goals (i.e., exercise, diet) is having the intended effect.

3 – Confidence
An individual should only set goals that they are confident in achieving. Achieving such a goal raises the individual’s self-confidence about their ability to successfully perform the behaviors needed for that goal. 
To rate a participant’s confidence in achieving a goal, they can rate their confidence in achieving a goal on a scale of 0 to 10. If their confidence in achieving a goal is below 7, the goal should be revised so that the individual feel stronger in achieving the goal.

4 - Cues-to-action
Cues-to-action can be thought of as an event or stimulus that triggers an individual to do a specific behavior.  Cues can be from others (i.e., receiving a reminder to go walking) or internally from oneself (i.e., elevated blood glucose).  By receiving cues, an individual can be triggered to perform behaviors necessary to achieve their goal.

Manual of Procedures

The Manuals of Procedures outline the components, structure and administration of the PILI ‘Ohana Interventions. They serve as guides to implementing the programs.

Link

PILI Lifestyle Intervention Program (PLP) Assessment Manual of Procedures

PILI Lifestyle Intervention Program (PLP) Assessment Manual of Procedures outlines the components, structure and administration of the PILI assessments. It serves as a guide to implementing PILI assessments at baseline, 3-months and 12-months.

PILI Lifestyle Intervention Program (PLP) Implementation Manual of Procedures

The PLP Implementation Manual of Procedures outlines the components, structure and administration of the PLP Intervention. It serves as a guide to implementing the PLP curriculum.

Partners In Care (PIC) Manual of Procedures

The PIC Manual of Procedures outlines the components, structure and administration of the entire PIC program. It serves as a guide to implementing the PIC curriculum.

Link

Facilitator Teaching Strategies

The Facilitator Teaching Strategies section includes general teaching skills, learning styles and strategies.

Teaching Skills
1 - Create a Comfortable Learning Environment
Be approachable and have an open atmosphere where participants feel comfortable asking you questions.  Be aware of diverse backgrounds.   By making everyone in the class feel included, they will ask more questions & learn more. 
2 - Delivery of Material
Deliver lesson content at an appropriate level.  Show excitement about material; participants will be more engaged if they see you engaged and enthusiastic about material. By making things interesting, you will more likely keep their attention.  Be aware of different learning styles.   Use visuals and/or hands-on activities that get participants engaged. 
3 - Preparation & Organization
Practice your lessons and demonstrations prior to teaching the lesson.  Manage your time so you allow yourself enough time to cover the entire lesson and allow participants time to ask questions.  Use the logical flow of material, but don’t lose sight of the big picture. 
4 - Understanding the Needs of Participants
Your participants may be at different levels about lesson content.  Know when to explain more or less based on their understanding of material.  Be able to simplify a difficult concept.  Have patience and be respectful of all participants. 
5 - Setting Goals & Expectations
Set your own realistic goals for what you want participants to get out of each lesson.  Communicate your expectations to participants and have them also set their own goals. 

Learning Styles and Strategies
A good thing to remember in being a facilitator is that you are also a teacher.  As a teacher you have the amazing opportunity to teach people new concepts and skills!  Even greater is that in being a PILI Facilitator, you have the opportunity to teach participants about having a healthy lifestyle!  In being a teacher it is helpful to remember that different people have different ways of learning.  For example, whereas one PILI participant may learn well be just listening to information, another PILI participant may learn better by being shown visuals.  There are different learning styles that individuals approach learning.  Many people use a combination of learning styles to learn material.  By including different learning styles in your PILI lessons, you will be more effective and have more engaged participants in your group.   Below are different learning styles:

• Active and Reflective
  • Active Learners – prefer doing something with information received (i.e., discussing, explaining or testing)
  • Reflective Learners – prefer reflective observation of material
• Sensing and Intuitive
  • Sensor Learners – prefer to learn through facts & data
  • Intuitor Learners – prefer principles & theories
• Visual and Verbal
  • Visual Learners – prefer that information be presented visually (pictures, diagrams, charts, plots, animations, etc.)
  • Verbal Learners – prefer spoken or written explanations
• Sequential and Global
  • Sequential Learners – prefer material to be presented in a logically ordered progression
  • Global Learners – learn best by being given the big picture or goal of a lesson before being presented with steps, and by having the freedom to devise their own methods for solving problems

References
Felder, R.M. & Silverman, L.K. (1988). Learning and Teaching Styles in Engineering Education. Engineering Education, 78(7): 674–681.

Saphier, J., Haley-Speca, M.A., & Gower, R. (2008). The Skillful Teacher: Building Your Teaching Skills. Acton, MA: Research for Better Teaching.

PILI ‘Ohana Lifestyle Intervention Program (PLP)

In this section you will find:

• The PLP Intervention Manual of Procedures.
• The PLP Assessment Manual of Procedures.
• The PLP Facilitator Guides for the entire 9 month program(both weight loss and weight loss maintenance phases).

Partners In Care (PIC)

In this section you will find:

• The Partners In Care (PIC) Manual of Procedures.
• The Partners In Care (PIC) Facilitator Guides/Mentor Notes.