The characteristics of behaviour change interventions used among Pacific people: a systematic search and narrative synthesis - BMC Public Health

Matenga-Ikihele et al. BMC Public Health   (2021) 21:435

 RESEARCH ARTICLE                                                                                                                                    Open Access

The characteristics of behaviour change
interventions used among Pacific people: a
systematic search and narrative synthesis
Amio Matenga-Ikihele1,2* , Judith McCool1, Rosie Dobson3, Fuafiva Fa’alau4 and Robyn Whittaker3

  Background: Pacific people living in New Zealand, Australia, United States, and the Pacific region continue to
  experience a disproportionately high burden of long-term conditions, making culturally contextualised behaviour
  change interventions a priority. The primary aim of this study was to describe the characteristics of behaviour
  change interventions designed to improve health and effect health behaviour change among Pacific people.
  Methods: Electronic searches were carried out on OVID Medline, PsycINFO, PubMed, Embase and SCOPUS
  databases (initial search January 2019 and updated in January 2020) for studies describing an intervention designed
  to change health behaviour(s) among Pacific people. Titles and abstracts of 5699 papers were screened; 201 papers
  were then independently assessed. A review of full text was carried out by three of the authors resulting in 208
  being included in the final review. Twenty-seven studies were included, published in six countries between 1996
  and 2020.
  Results: Important characteristics in the interventions included meaningful partnerships with Pacific communities
  using community-based participatory research and ensuring interventions were culturally anchored and centred on
  collectivism using family or social support. Most interventions used social cognitive theory, followed by popular
  behaviour change techniques instruction on how to perform a behaviour and social support (unspecified).
  Negotiating the spaces between Eurocentric behaviour change constructs and Pacific worldviews was simplified
  using Pacific facilitators and talanoa. This relational approach provided an essential link between academia and
  Pacific communities.
  Conclusions: This systematic search and narrative synthesis provides new and important insights into potential
  elements and components when designing behaviour change interventions for Pacific people. The paucity of
  literature available outside of the United States highlights further research is required to reflect Pacific communities
  living in New Zealand, Australia, and the Pacific region. Future research needs to invest in building research
  capacity within Pacific communities, centering self-determining research agendas and findings to be led and
  owned by Pacific communities.
  Keywords: Pacific health; health behaviour change, systematic review, talanoa

* Correspondence:
 Epidemiology and Biostatistics, School of Population Health, University of
Auckland, Private Bag 92019, Auckland 1142, New Zealand
 Moana Research, Nga Hau Māngere Birthing Centre, 14 Waddon Place,
Auckland, Māngere, New Zealand
Full list of author information is available at the end of the article

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Background                                                           ‘Pacific people’ is a broad, collective term used to
Pacific people experience a disproportionately high               describe the dynamic and diverse groups of people from
burden of long-term conditions and the associated risk            the sub-regions of Oceania: Polynesia, Melanesia, and
factors [1–3], despite being minority communities in              Micronesia. Distinct from a Western appreciation of
major countries such as the United States (USA),                  health, health and wellbeing for Pacific people is holistic
Australia, and New Zealand. Cardiovascular diseases,              and intrinsically related to identity, land, cultural values,
diabetes, cancer, and respiratory diseases represent a            roles and responsibilities [15–17]. Although there are
leading threat to human health and are the largest cause          similar values observed within each Pacific Island, such
of premature mortality in the Pacific [4]. The burden of          as reciprocity, respect, relationships and collectivism,
multi-morbidity is also more significant, with people             there are vast linguistic, cultural, geographical, migration
experiencing two or more conditions requiring complex             and political differences between different Pacific Islands
care and management [5]. These ongoing health inequities          [16–18]. This diversity is further enhanced with place of
have persisted for several decades [6, 7] irrespective of large   birth (island born vs diaspora), and intermarriage where
investments to improve Pacific health outcomes [3, 5].            Pacific people now identify with two or more ethnic
   There is a growing appreciation of how adopting life-          groups [14, 16, 17].
style changes, such as being smoke-free, a healthy diet,             The family unit is an important institution for Pacific
regular physical activity, and limiting alcohol consump-          people, which extends beyond the nuclear family and is
tion, can positively affect health outcomes [8]. Even             inclusive of village and church groups [19–22]. Aligning
small changes in these health behaviours are known to             with the holistic Pacific Fonofale model [23], family re-
have overall positive health gains [9]. The challenges            mains an important foundation for Pacific people, pro-
when undertaking initial health behaviour changes and             viding a stable system of support despite social and
eventually maintenance recognises that identifying key            economic changes, transnational migration, urbanisation
characteristics that influence positive health change             and modernisation [15, 24]. An individual’s motivation
among Pacific people is necessary.                                to change behaviour is strongly interwoven with the
   Behaviour change interventions often consist of mul-           socio-cultural roles and family responsibilities [20, 25–
tiple components designed to effect change in both an             27]. Several studies have highlighted Pacific people to
individual’s perceptions (cognitions) and behaviours              perceive health as being able to provide for their families
[10]. These interventions are often underpinned by the-           and the wellbeing of their family unit, rather than the
oretical frameworks and may incorporate Behaviour                 physical ailments of an individual [21, 28, 29]. Moreover,
change techniques (BCTs); methods identified as the ‘ac-          studies that have included family and social support have
tive ingredients’ of an intervention (e.g. goal setting)          shown to be more effective than those requiring individ-
[11]. Behaviour change interventions that are grounded            uals to undertake behaviour change on their own accord
in theory are generally accepted to be more effective             [30]. Understanding the determinants of behaviour
than those that lack a theoretical basis [10–12].                 change for Pacific people is a necessary step towards de-
   Health behaviour theories provide a framework for in-          signing interventions that are culturally relevant, salient
terventions designed to alter health-related cognitions           and sustainable [14].
and behaviours [12, 13]. Most theoretical frameworks                 Acknowledging the cultural differences, values, beliefs,
used in public health and behaviour change interven-              structures, practices and worldviews of health and well-
tions are predicated on the individual changing their be-         being unique to Pacific people can provide the context-
haviours [10]. These models, developed within                     ual framework for developing health behaviour
Eurocentric perceptions of human behaviour, are built             interventions [25, 28]. Fundamental to the success of
on the assumption that behaviour is ultimately individ-           any programme centres around creating interventions
ual and rational. This position dismisses other drivers to        that are acceptable and accessible for Pacific people,
behaviour – namely, the spiritual, social, cultural, and          who have “the right to the highest attainable standard of
environmental (collective) variables [12–14]. Social and          health” in New Zealand [31]. Evidence suggests that
cultural dynamics are also often sidelined within main-           traditional or non-Pacific programmes have not been
stream health behaviour change models. Understanding              effective, despite considerable investments [22, 27, 32].
health behaviours and the context in which these occur            Furthermore, it is important to consider the role of inad-
is vital to designing effective interventions for minority        equate workforce capability in cultural diversity, institu-
and indigenous populations. Contemporary models of                tional racism, and unconscious bias have contributed to the
health behavior change are needed, which are inclusive            state of Pacific health in New Zealand [3, 15, 22, 27, 33].
inclusive, and reflect different culturally ascribed values,         Pacific led programmes reflect the importance of rela-
including wider spiritual, socio-cultural, and environ-           tional rather than individualistic relationships among
mental influences [13] for Pacific people.                        Pacific people. The significance of relationships can be
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understood using the Samoan concept of ‘teu le va’,          Eligibility criteria
which is premised heavily on the relational contexts be-     Studies were eligible to be included if they described an
tween people, things and the environment, as well as the     intervention designed to change health behaviour(s) in
nurturing and protection of mutually respectful relation-    Pacific people. Included studies were required to report
ships over individual agendas [15, 34, 35]. The culturally   a clinical or behaviour change outcome with or without
located concept of ‘va’ (relationships) cannot be mea-       randomised controlled conditions. Studies were also re-
sured and is not inherently visible within western frame-    quired to have at least 40% of participants identifying
works. When this ‘space’ is appropriately nurtured,          with a Pacific ethnicity and include participants aged
respect and trust ensue, translating into a higher ac-       over 16 years. Studies were excluded if they were not
ceptance of programme initiatives and health care            published in the English language or the full text was
[15]. It is also acknowledged in practical terms, such       not available. There was no time period restriction
as when health workers or providers are from the             applied to the search.
same ethnicity or cultural background, interactions
are reciprocated with respect, and better health out-
comes are achieved [14, 22, 27].                             Information sources
  Community inspired behaviour change requires the           The OVID Medline, PsycINFO, PubMed, Embase and
adoption of Community Based Participatory Research           SCOPUS databases were searched during January and
(CBPR) methods, a collaborative approach used in             February 2019, and again in January 2020 by the first
public health with minority communities [10, 36].            author (AI). Additional articles were identified from
True to the CBPR methodology, community mem-                 reference lists. A manual search of the New Zealand
bers, organisations, and researchers become equal            Medical Journal, Pacific Health Dialog, Pacific Health
partners in all aspects of the research process [36],        Review, Fiji Journal of Public Health and the Australian
addressing health from a holistic perspective. It            and New Zealand Journal of Public Health was also
builds trust among those who may have had negative           conducted during March 2019 and January 2020 for
experiences, and distrust researchers and the re-            further articles that may not have been included during
search process [10]. CBPR also aligns with several           the initial database searches.
core Pacific principles: reciprocity, nurturing rela-
tionships, respect, collectivism, and communitarian-         Search strategy
ism [16, 17]. Valuing the partnerships between               The search strategy used in Medline is provided in Table 1.
academia, health professionals and communities               The keywords, their synonyms and various spellings were
through CBPR has the potential to design and facili-         reviewed and agreed upon by three co-authors prior to
tate health behaviour change within the socio-               commencement. Terms used included 1) Pacific population
cultural context of communities [10]. Current Pacific        groups and phrases related to 2) health behaviour change.
health research guidelines [16] emphasise the need           Search terms were entered according to each database’s
for such approaches, which aligns with indigenous            requirements and using the Boolean operator of and/or to
guidelines developed for Māori in New Zealand [37],          combine terms. Database specific filters such as human
Aboriginal and Torres Strait Islanders in Australia          population, English language, and full-text articles were
[38] and First Nations communities in Canada [39].           applied where available.
  Improving the health and wellbeing for Pacific people
is an important equity issue [3, 15, 28]. Engaging mean-
ingfully and negotiating the spaces between Eurocentric      Study selection
theoretical frameworks and Pacific cultural constructs of    All articles were downloaded into RefWorks ProQuest
health and wellbeing [40] is needed if evidence-based        software, and duplicates were removed. Articles were
and culturally contextualised behaviour change interven-     screened for eligibility based on their title and abstracts
tions are to be adopted and sustained. The aim of this       by the first author (AI) and sorted accordingly. Full-text
systematic search and narrative synthesis is to describe     articles were then retrieved for the remaining papers and
the behaviour change components used in interventions        non-relevant studies excluded based on the inclusion
designed to improve health and effect health behaviour       criteria. The quality of studies were appraised using the
change among Pacific people.                                 Joanna Briggs Institute (JBI) Critical Appraisal Checklist
                                                             [42], a quality assessment tool to determine the meth-
Methods                                                      odological quality of quantitative studies. Studies were
The systematic review was informed by the Preferred          appraised by the first author (AI) and crosschecked by
Reporting Items for Systematic Reviews and Meta-             two co-authors (JM and RD) to determine the final deci-
Analyses (PRISMA) reporting guidelines [41].                 sion, and a consensus on inclusion or exclusion reached.
Matenga-Ikihele et al. BMC Public Health   (2021) 21:435   Page 4 of 15

Table 1 OVID Medline search strategy
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Data extraction                                              residing in the state of Hawai’i. Nine studies [43, 44, 46–
Using the PRISMA checklist [41], study information           48, 50–52, 64] used a multiethnic cohort comparing Pa-
including study characteristics, participant information,    cific (Native Hawaiians, Samoan, Tongan, Chuukese),
outcomes and behaviour change theoretical frameworks         Asian, Caucasian or other non-Pacific population
were extracted and included in a Microsoft Excel             groups. Seven studies focused on Pacific only cohorts,
spreadsheet. Study characteristics included authors, year    such as Native Hawaiian and other Pacific Islanders [45,
of publication, targeted health condition, the country in    53, 55, 56], Tongan and Samoan [62] and, Tongan, Niue
which the study was conducted, and sample sizes. Par-        and Cook Island [61] and Pacific Islanders (mixed) [67].
ticipant information included age, gender, and ethnicity.    Two studies compared Pacific and Indigenous Māori
   For each study BCTs were identified and coded using       [65, 66]. Nine studies were ethnic-specific focusing
the behaviour change taxonomy [11]. The 93 BCTs were         only on Native Hawaiians [49, 51], American Samoan
rated as either present (1) or absent (0). BCTs were         [58, 59], Marshallese [57, 60], and Samoan [63, 68,
coded when there was clear evidence of inclusion despite     69] populations. Studies were published between 1996
the wide-ranging terminology used. For instance, when        and 2020. Table 2 shows further details of the in-
the interventions mentioned education around “discuss-       cluded studies.
ing complications” or “reducing risk”, it was coded as         Among the twenty-seven studies included in the
information on health consequences (5.1). Social support     review, eleven were randomised controlled trials [44, 45,
(general) (3.1) was also coded as such, even when it was     48, 53, 55, 58, 59, 65, 66, 69] and thirteen were non ran-
not always explicitly mentioned. For example, if studies     domised studies [43, 46, 47, 49, 51, 52, 56, 57, 60, 62, 64,
required family members or a significant other to be         67, 68]. Other studies used a quasi-experimental design
part of the intervention, or the studies that delivered      [63], a prospective uncontrolled cohort study [61] and a
group sessions emphasised group support as an im-            descriptive intervention study [50]. The sample sizes
portant component for behaviour change. When                 ranged from 10 to 675 participants, with an age range
BCTs were not explicitly described as part of the            between 13 and 102 years. Across all twenty-seven stud-
intervention, codes were obtained from curriculum            ies, the samples included more than 60% female
lesson outlines where available.                             participants.
                                                               Interventions focused mainly on a single health con-
Results                                                      dition or specific behaviour. Ten studies increased
A total of 5941 records were identified using the            awareness and targeted health behaviour change in
search strategy described. An additional 30 articles         people with diabetes [45, 48, 50, 57–60, 62, 64, 68]
were identified by searching references. After remov-        and eight studies targeted weight loss [43, 44, 46, 47,
ing duplicates, 5699 articles were reviewed by title         51, 54, 63, 67]. Others targeted chronic disease self-
and abstract of which 5461 were excluded. The full           management [52], and health-related behaviour [66],
text of 208 articles were reviewed with articles ex-         hypertension [53, 65], smoking cessation [69], heart
cluded if they were not an intervention study (n =           failure [55], renal disease [61], physical activity [56],
132), studies focusing on participants aged under 16         and physical activity and nutrition combined [49].
years (n = 39), less than 40% of participants identi-        Overall, diabetes was the most common long term
fied as Pacific (n = 27) and full-text articles not          condition focused in the studies.
available (n = 10). Twenty-seven articles met the in-
clusion criteria and are included in this review. Fig-       Theoretical frameworks
ure 1 shows the study selection process. Five of the         Fifteen studies stated they used a theoretical behaviour
included studies reported on the same parent inter-          change framework in their intervention. Social cognitive
vention - the Pili Ohana Project (POP). These stud-          theory (SCT) was most frequently used (nine studies)
ies are included separately as they each provide             [43–47, 51, 53, 54, 67], with one study combining a
unique data and use different cohort samples and             range of theories such as participatory metatheory, the
intervention settings.                                       health belief model, SCT and the Pacific talanoa ap-
                                                             proach [67]. One study combined the theoretical do-
Study characteristics                                        mains framework with the Fonofale (Pacific) and Te
Fifteen studies were conducted in the USA - Hawai’i          Whare Tapa Whā (Māori) health models [66]. Other
[43–55], California [56] and Arkansas [57], as well as its   studies were informed by the trans-theoretical model
associated territories of American Samoa [58, 59] and        [49], social support model [48, 57], Precede-Proceed
the Marshall Islands [60]. Seven were based in New           model [58], and self-efficacy framework [52]. Various
Zealand [61–67] including one in Australia [68] and one      combinations of BCTs were incorporated across all 27
in Samoa [69]. Most studies involved Native Hawaiians        studies.
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 Fig. 1 PRISMA study selection process

Behaviour change techniques                                 solving / coping planning (n = 14), self-monitoring of
Using the behaviour change taxonomy [11], 27 different      outcome(s) of behaviour (n = 13), modelling of the be-
BCTs (from a total of 93) were identified and coded         haviour (n = 13), and goal setting (behaviour) (n = 11).
across all the interventions. Each study incorporated       Each study reported changes in clinical and behavioural
BCTs using different combinations, ranging from three       outcomes with the various BCTs used. Due to hetero-
to 18. The most common BCT was instruction on how           geneity of outcome measures, a meta-analysis was not
to perform a behaviour (n = 27), followed by social sup-    undertaken to determine the effectiveness of BCTs used
port (general) (n = 25) and behaviour rehearsal/practice    in each study.
(n = 21) as seen in Table 3. The two studies that did not
provide social support instead focused on behaviour         Intervention elements
change solely on the individual, despite other interven-    All but one study [65] culturally adapted or added cul-
tions delivered to individuals incorporating social sup-    tural elements to the design of their programme which
port from family and friends. Other commonly used           closely resonated with Pacific people. Examples included
BCTs included health consequences (n = 16), problem-        cooking with local or culturally appropriate food, using
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Table 2 Characteristics of included studies
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Table 2 Characteristics of included studies (Continued)
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hula (cultural dance) as a form of exercise, incorporating      always worked under the supervision of the research or
local language, and cultural customs during education           project lead, and alongside a multidisciplinary team
sessions, and using a minister or kupuna (elder) to lead        (nurses, physicians, nutritionists and pharmacists). A
and close education sessions. One study used co-design          multidisciplinary approach was used in eight studies
[66] with Pacific (including Māori) communities to              [43, 45–48, 51, 53, 65] where a CHW, PHE or HCA
design the behaviour change intervention. Another study         facilitated sessions or worked alongside health pro-
was informed by a Pacific nutrition train the trainer           fessionals (nurse specialist, physician, pharmacist,
workshop for Pacific people living in New Zealand [67].         nutritionist, physiotherapist) including a kumu hula
Thirteen studies were adapted for Native Hawaiian’s and         (hula expert). Three studies [58, 59, 65] used a
Pacific Islanders living in Hawai’i [43–55], four were          treatment protocol which determined the length and
adapted for Samoans residing in American Samoa [58, 59],        frequency of visits by a CHW, PHE or HCA. When
Australia [68] and Samoa [69], and two studies were             participants clinical observations were elevated (e.g.
adapted for Marshallese Islanders living in Arkansas [57]       high blood pressure), the CHW, PHE or HCA
and the Marshall Islands [60]. Ten studies [43, 44, 46, 47,     would communicate their results with their phys-
53, 54, 56, 57, 67, 68] stated they used a CBPR approach        ician for further clinical examination or treatment
where research leads partnered with Pacific communities         adjustments.
and organisations who informed the cultural and commu-            Eighteen studies delivered their intervention using
nity adaptation of programmes. While most interventions         group-based models [43–48, 51–57, 60, 62–64, 67, 68]
were delivered in English, seven studies offered a bilingual    and nine were delivered to individuals [49, 50, 55, 58, 59,
approach: one study offered English, Chuukese and Samoan        61, 65, 66, 69]. The intensity, duration, and time
[44], one offered English, Tongan and Samoan [62] and five      between intervention sessions varied. One study ran for
offered English and Samoan [58, 59, 63, 68, 69]. To ensure      a week [69], eight studies lasted twelve weeks [43, 45–
fidelity of the programme once culturally adapted, only         48, 51, 53, 66], with others lasting six-eight weeks [52,
three studies mentioned research leads observed their facili-   56, 57, 67], four months [60], six months [44, 64, 68],
tators [45, 50, 52].                                            nine months [54], twelve months [49, 50, 55, 58, 59, 63,
   Thirteen studies delivered their interventions alongside     65] and two years [61, 62]. Each session lasted between
community-based organisations [43–46, 48, 49, 51–53,            one to two and a half hours. Intervention follow-up
56, 59–61], three were based in churches [62, 63, 68],          ranged from three to 24 months. Six studies did not de-
three were delivered in participants workplaces [47, 54,        fine how many hours each visit or education session
64] and one in a community location [67]. Two studies           lasted [47, 49, 50, 58, 59, 68]. Three interventions used
visited participants in their homes [55, 65] and two used       multimedia with one utilising a diabetes educational
mobile phones with one using an app [66] and the other          video to compliment the physical activity sessions deliv-
delivering short message service (SMS) behaviour                ered [64], one used a DVD and workbook for partici-
change messages to participants [69]. Three studies en-         pants [54], while another intervention used video as the
abled participants to choose the location of their inter-       primary mechanism lasting 10 min [56]. Despite the lat-
vention, selecting either a church, community-based             ter study lasting two-months, and targeting church
organisation, workplace or home [50, 57, 58]. Only eight        groups and community organisations, it was unclear
studies encouraged participants to include family mem-          how many sessions participants viewed the video.
bers or a significant other to be involved with education
sessions [44, 48, 50, 55, 57, 58, 66, 68].                      Outcomes
   Eleven studies used peer health educators (PHE) [43–         Twenty-six studies reported positive outcomes and im-
47, 49, 51, 54, 60, 62, 63] to facilitate education sessions,   provements in intended behaviour change measures.
four studies used community health workers (CHW)                One study however found no significant difference be-
[50, 53, 57, 59], one used a health care assistant (HCA)        tween the intervention and control groups to health-
[65] while another study used the term community                related behaviours (physical activity, smoking behaviour,
coach facilitators (CCF) [68]. Of the three studies based       alcohol intake, fruit and vegetable intake) [66]. Five stud-
in churches, one used PHE [68] to deliver sessions to           ies reported improvements in nutritional intake [46, 47,
church members, while two [62, 63] set up health com-           49, 60, 67] and eight studies reported weight loss
mittees led by ministers wives and members within the           changes [43, 44, 46, 47, 51, 54, 60, 67]. Improvements in
church. These health committees then selected church            physical activity were reported in nine studies [46, 47,
members to become trained CHW. CHW and PHE were                 49, 52, 56, 62–64, 68]. In one study [64], physical activity
either trained by their research or project leads or            in the intervention group improved significantly com-
undertook formal education through a tertiary institu-          pared to the control group while in another study [63],
tion [50, 62–64, 68]. The PHE, CHW, HCA and CCF                 physical activity rates only improved in some
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Table 3 Frequency of behaviour change techniques used

participants, whereas those who reported they were sed-      Reported changes in Haemoglobin A1c (HbA1c) var-
entary at baseline remained unchanged post-                ied from baseline to follow up in six studies [45, 48, 50,
intervention. One study [62] which ran two intervention    57, 60, 68]. One study [50] reported a more significant
and control groups (one Samoan and one Tongan              reduction in HbA1c for the intervention group than the
church) reported weight, waist circumference and exer-     control group, and three studies [45, 57, 60] reported
cise improvements in only one of the intervention          positive changes post-intervention. Another study [48]
groups (Samoan), and not the second intervention group     however reported participant’s glycaemic control at six
(Tongan) or either control groups.                         months was not significantly different from those in the
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control group despite initial improvements after the first    participants to share and exchange their knowledge,
three months.                                                 emotions and experiences. Talanoa (conversation, a talk,
  Nine studies reported improvements in blood pres-           an exchange of ideas or thinking) provides a culturally
sure [46–48, 51, 53, 58, 60, 61, 65] and six studies          appropriate approach for ‘va’ (relationships) to be estab-
reported improvements in self-management and dia-             lished and nurtured between researchers, facilitators,
betes knowledge [45, 48, 60, 62, 64, 68]. Other reported      and participants. The nurturing of these relationships
improvements included self-reported health [52], self-        creates a space where talanoa or social conversations
efficacy [47, 52], smoking cessation [69], medication ad-     can take place, holistically intermingling the knowledge,
herence [60], improved cholesterol levels [51], and in-       experiences and emotions, shared between researchers
creased primary care physician visits compared to             and participants [72]. Talanoa constitutes a culturally
emergency department visits [59]. Satisfaction and            appropriate method which Pacific researchers have pri-
acceptability with the interventions were reported in         marily used to engage with Pacific communities [34, 16].
four studies [52, 56, 62, 64].                                   One study [58] used co-design with Pacific and Māori
                                                              communities, complimenting CBPR. Co-design em-
Discussion                                                    powers users to tailor interventions according to their
The aim of this review was to describe behaviour change       cultural needs and context from design inception [64].
components used in interventions to improve health and        As such, participants in this study aligned their well-
effect health behaviour change among Pacific people. To       being priorities with ethnic-specific models of health and
our knowledge, it is the first study to highlight and de-     wellbeing, namely Fonofale [23] (Pacific) and Te Whare
scribe the theoretical underpinnings and BCTs used in         Tapa Whā (Māori) [73]. Despite co-designing a cultur-
interventions designed to improve health among Pacific        ally tailored, lifestyle support intervention, the authors
people. Twenty-seven studies met the inclusion criteria       noted participation in the control and intervention
for the review. Most studies focused on diabetes and          groups did not affect adherence to health-related behav-
weight loss, followed by hypertension, physical activity,     iour guidelines. Perhaps considerations regarding digital
and smoking cessation.                                        inclusion and the digital health literacy skills required
  An important feature to highlight was the collabora-        for this intervention were overlooked, which are known
tive CBPR approach used to culturally adapt interven-         equity issues for Pacific people in New Zealand [74, 75].
tions. When CBPR was not used, studies partnered                 All studies in this review incorporated cultural adapta-
with church-based organisations, workplaces, or local         tions and elements, and utilised BCTs of some sort.
communities, evident from 1996 until 2020. An elem-           Using Michie’s behaviour change taxonomy [11], 27
ent that could strengthen partnerships and provide            BCTs (out of a possible 93) were identified and used in
self-determination with future research agendas is the        different combinations across all studies. The minimum
need to continue building research capacity and cap-          number of BCTs used in a study was three, the majority
ability among Pacific communities. This ensures               being 18 techniques. Specific behaviours targeted in-
future research builds on existing capacity within            cluded combinations of physical activity, healthy eating,
Pacific communities rather than duplicating efforts           self-management, medication adherence, problem-
with external research agencies. To do this, meaning-         solving, coping, and increasing knowledge of health con-
ful partnerships with Pacific communities using CBPR          ditions. The most popular BCT was instruction on how
must be established, which demonstrates cultural in-          to perform a behaviour (4.1), used to demonstrate cul-
tegrity, rigour and acknowledgement of Pacific world-         turally appropriate meals, facilitate exercise classes and
views and values. Moreover, Pacific communities self-         provide educational sessions around the targeted health
determination for Pacific research is necessary to            conditions and behaviours; followed by social support
improve health equity [14, 36] and culturally safe            (unspecified) (3.1). Providing social support resonates
research practices [16, 70, 71].                              with Pacific values, drawing strength from socio-cultural
  Despite evidence of the impact on behaviour change,         relationships within their collective contexts, such as
most interventions were short-term with varying study         extended family, community, and church networks
designs and little regard to sustainability. Only two stud-   [17, 22, 28].
ies followed up on weight maintenance after completing           Most studies in this review were based in the USA or
a three-month weight loss programme [44, 54]. Most in-        its affiliate countries (American Samoa and the Marshall
terventions were also centred on Eurocentric theoretical      Islands). Only seven were from New Zealand and one
frameworks, namely SCT. While studies are considered          from Australia and Samoa. All but two of the studies
more effective when incorporating such theoretical com-       were representative of Pacific countries from Polynesia,
ponents [10–12], only one study [67] included the             with another from Micronesia (Marshall Islands).
Pacific talanoa approach as a means of allowing               Importantly, there were no studies from Melanesian
Matenga-Ikihele et al. BMC Public Health   (2021) 21:435                                                     Page 12 of 15

countries that met our search criteria, despite evidence         Although most interventions were delivered alongside
showing they too experience high rates of long-term            community-based organisations, alternative sites such as
conditions [76]. Pacific people throughout the diaspora        workplaces, churches, homes, and the use of multimedia
are diverse with different contexts and cultural               and mobile phones offer non-traditional approaches that
constructs, language, migration histories, constitutional      are also acceptable for Pacific communities. Incorporat-
ties and health needs [16, 17]. Even though Pacific            ing traditional cultural art forms such as hula also draw
people share many commonalities, they are not a                on the cultural nuances that have resonated with Pacific
homogenous group.                                              communities for centuries. The wide age range of 13
   A key component for more than half the studies,             and 102 years was only evident in the group delivered
which needs to be acknowledged, was the utilisation of         interventions based in churches. Though not the focus
Pacific health workers (CHW, PHE, HCA) from partici-           of this review, including young people in interventions
pants own communities. Even if they were not leading           alongside their parents and grandparents, enables an
intervention components, they worked within a multidis-        intergenerational approach to improving health and
ciplinary team who provided supervision and support. In        wellbeing within Pacific families [77]. Furthermore, evi-
one study [53], PHE worked alongside a kumu hula               dence suggests that exercise among older people is pro-
(hula expert), who delivered hula lessons while PHE fo-        tective against fall-related fractures [78]. More studies
cused on the education modules. Another study [62]             reporting on the long-term effects of BCTs would be
found church members were more connected to the fa-            beneficial to determine factors supporting sustained
cilitators from their church than those who were not,          behaviour change among Pacific populations.
which is essential to consider. Few differences were
found between the different roles (CHW, PHE, HCA) as           Limitations
all were required to undertake training before working         A key limitation of this review is due to heterogeneity of
with participants. Studies that used Pacific health            participants, types of interventions and outcomes, a
workers provided an important link between academia            meta-analysis was not completed. Therefore, conclusions
and the community, assisting with the cultural adapta-         cannot be drawn on the effectiveness of behaviour
tion of programmes and supporting participants through         change interventions among Pacific people. All eligible
behaviour change. Bilingual programmes may be more             studies focused on Pacific populations from Polynesia
effective by overcoming language barriers, especially          living in the USA, American Samoa, and New Zealand.
when interventions are delivered predominately in Eng-         One study focused on the Marshall Islands, Australia,
lish. Pacific health workers’ added value was their ability    and Samoa, which limits the generalisability of findings.
to connect all the elements within each study (i.e. lan-       This review was also limited to studies with more than
guage, ethnicity, BCT, facilitating education sessions) ef-    40% of the study population identified as Pacific. This
fectively enhancing social support and promoting               would have excluded other studies that included a
positive behaviour change outcomes. Building capacity          smaller sample of Pacific people.
among Pacific communities to self-determine their re-
search aspirations is essential for community-led and          Conclusion
owned research [34, 70, 71].                                   This review provides new and important insights into
   A positive outcome, not well represented in the litera-     potential elements and components when designing be-
ture, was the minister’s wives role as facilitators within a   haviour change interventions for Pacific people. It also
church setting. Minister’s wives were key to establishing      highlights the paucity of literature available for Pacific
health committees and facilitating nutrition and exercise      communities living outside of the USA.
programmes. Policy change was also possible within the           Future behaviour change research with Pacific com-
church context. One church [62] created policies to in-        munities should be community created and owned, cul-
corporate nutritional guidelines for the congregation and      turally anchored, and centred on a collective approach.
another [63] invested in five members to become key fa-        Culturally relevant interventions are essential for uptake
cilitators for the nutrition and physical activity compo-      and maintenance of behaviour change programmes.
nents. Churches can establish themselves in a way where        CBPR provides a useful framework to ensure interven-
health interventions could be mobilised with the right         tions are culturally grounded, which is vital for the up-
support structures in place. Churches have long been           take and maintenance of behaviour change when
viewed as an extension of the family, preserving tradi-        programmes initially intended for non-Pacific popula-
tions and cultures, and mediating between the commu-           tions are adapted. Framing behaviour change from the
nity and broader society [22]. As such, it is not              context of Pacific cultural values becomes an integral
surprising positive behaviour change outcomes were             part of this process. Moreover, negotiating these spaces
reported within this faith-based setting.                      through talanoa and understanding how the physical,
Matenga-Ikihele et al. BMC Public Health           (2021) 21:435                                                                                   Page 13 of 15

social, and spiritual elements are intrinsically linked to                        Received: 6 August 2020 Accepted: 10 February 2021
the sustenance of Pacific people’s health and wellbeing is
critical [28]. While interventions can include common
cultural elements; approaches need to be contextualised                           References
to each Pacific Island community.                                                 1. Hunter DJ, Reddy KS. Noncommunicable diseases. N Engl J Med. 2013;
  Community centred aspirations determined by Pacific                                 36914:1336–43.
                                                                                  2. Tolley H, Snowdon W, Wate J, Durand AM, Vivili P, McCool J, et al.
communities is fundamental to ensuring the health out-                                Monitoring and accountability for the Pacific response to the non-
comes measured by interventions, are elements that are                                communicable diseases crisis. BMC Public Health. 2016;161:958–12. https://
relevant and applicable to their lived realities and world-                 
                                                                                  3. Pacific Perspectives Limited. Tofa Saili: A review of evidence about health
views. Future research needs to invest in building                                    equity for Pacific Peoples in New Zealand. Wellington: Pacific Perspectives;
research capacity within Pacific communities, centering                               2019.
self-determining research agendas, and findings to be led                         4. World Health Organisation. Addressing noncommunicable diseases in the
                                                                                      Pacific islands,
and owned by communities. This recognises Pacific                                     ncds-in-the-pacific (2020).
communities are more than programme facilitators.                                 5. Ministry of Health. Health and Independence Report 2018. Wellington:
                                                                                      Ministry of Health; 2020.
                                                                                  6. Ministry of Health. Tupu Ola Moui: Pacific health chart book 2012.
Supplementary Information                                                             Wellington: Ministry of Health; 2012.
The online version contains supplementary material available at https://doi.      7. Ministry of Health and Ministry of Pacific Island Affairs. Tupu Ola Moui:
org/10.1186/s12889-021-10420-9.                                                       Pacific health chart book 2004. Wellington: Ministry of Health and Ministry
                                                                                      of Pacific Island Affairs; 2004.
 Additional file 1. PRISMA study selection process                                8. Ministry of Health. Annual data explorer 2017/18. New Zealand: Health
                                                                                      Survey; 2019.
Abbreviations                                                                     9. Hills AP, Byrne NM, Lindstrom R, Hill JO. Small changes' to diet and physical
BCT: Behavior change techniques; CBPR: Community based participatory                  activity behaviors for weight management. Obes Facts. 2013;63:228–38.
research; CCF: Community coach facilitators; CHW: Community health          
workers; HbA1c: Haemoglobin A1c; HCA: Health care assistant; PHE: Peer            10. Riekert K, Ockene J, Pbert L. The handbook of health behaviour change. 4th
health educators; POP: Pili Ohana Project; PRISMA: Preferred Reporting Items          ed. New York: Springer Publishing Company; 2014.
for Systematic Reviews and Meta-Analyses; SCT: Social cognitive theory;           11. Michie S, Johnson M. Behaviour change techniques. In: Gellman MD, Rick
USA: United States of America                                                         Turner J, editors. Encyclopaedia of Behavioral medicine. New York: Springer;
                                                                                      2013. p. 182.
Acknowledgements                                                                  12. Glanz K, Bishop DB. The role of behavioral science theory in development
Not applicable                                                                        and implementation of public health interventions. Annu Rev Public
                                                                                      Health. 2010;311:399–418.
Authors’ contributions                                                                809.103604.
AI designed the search strategy, reviewed by JM and RD. AI conducted the          13. Davis R, Campbell R, Hildon Z, Hobbs L, Michie S. Theories of behaviour and
search, screening, data-extraction, and analysis. JM and RD assisted with data        behaviour change across the social and behavioural sciences: a scoping
interpretation. AI drafted the manuscript and all authors contributed to revi-        review. Health Psychol Rev. 2015;93:323–44.
sions, critically reviewing manuscript drafts, reading, and approving the final       99.2014.941722.
manuscript.                                                                       14. Tukuitonga C. Impact of culture on health. Pacific Health Dialog. 2018;211:
Funding                                                                           15. Tiatia-Seath J. The importance of Pacific cultural competency in healthcare.
This research was funded by the Health Research Council of New Zealand                Pacific Health Dialog. 2018;211:8–9.
Pacific PhD Scholarship. The funder had no role in designing the study,           16. Health Research Council of New Zealand. Pacific Health Research
collecting, analysing, or interpreting data, or in writing the manuscript.            Guidelines. Auckland: Health Research Council of New Zealand; 2014.
                                                                                  17. Ministry for Pacific Peoples. Yavu: Foundations of Pacific development.
Availability of data and materials                                                    Wellington: Ministry for Pacific Peoples; 2018.
The datasets used and analysed in the current study are available from the        18. Grey A. The definition and measurement of ethnicity: a Pacific perspective.
corresponding author on reasonable request.                                           Wellington: Gray Matter Research Ltd; 2001.
                                                                                  19. Ministry of Health. Making a Pacific difference: Strategic initiatives for
                                                                                      the health of Pacific people in New Zealand. Wellington: Ministry of
Ethics approval and consent to participate
                                                                                      Health; 1997.
Not applicable.
                                                                                  20. Fa'alau F, Jenson V. Samoan youth and family relationships in Aotearoa New
                                                                                      Zealand. Pacific Public Health. 2006;132:17–24.
Consent for publication
                                                                                  21. Norris P, Fa'alau F, Va'ai C, Churchward M, Arroll B. Navigating between
Not applicable.
                                                                                      illness paradigms: Treatment seeking by Samoan people in Samoa and New
                                                                                      Zealand. Qual Health Res. 2009;1910:1466–75.
Competing interests                                                                   9732309348364.
The authors declare that they have no competing interests.                        22. Ministry of Health. Improving quality of care for Pacific peoples. Wellington:
                                                                                      Ministry of Health; 2008.
Author details                                                                    23. Pulotu-Endemann FK. Fonofale model of health. Paper presented at the
 Epidemiology and Biostatistics, School of Population Health, University of           paper presented at the Pacific models for health promotion workshop,
Auckland, Private Bag 92019, Auckland 1142, New Zealand. 2Moana Research,             Massey University. Wellington, New Zealand.
Nga Hau Māngere Birthing Centre, 14 Waddon Place, Auckland, Māngere,                  nz/wp-content/uploads/formidable/Fonofalemodelexplanation1-Copy.pdf.
New Zealand. 3National Institute for Health Innovation, University of             24. Lee H, Francis ST. Migration and transnationalism: Pacific perspectives:
Auckland, Auckland, New Zealand. 4Pacific Health Section, School of                   Australian National University Press; 2009. p. 7.
Population Health, University of Auckland, Auckland, New Zealand.
Matenga-Ikihele et al. BMC Public Health             (2021) 21:435                                                                                        Page 14 of 15

25. Mavoa HM, McCabe M. Sociocultural factors relating to Tongans' and                      Native Hawaiian-serving worksites in Hawai'i. Transl Behav Med. 2016;62:
    indigenous Fijians' patterns of eating, physical activity and body size. Asia           190–201.
    Pac J Clin Nutr. 2008;173:375.                                                    48.   Ing CT, Zhang G, Dillard A, Yoshimura SR, Hughes C, Palakiko DM, et al.
26. Sheridan N, Kenealy T, Salmon E, Rea H, Raphael D, Schmidt-Busby J.                     Social support groups in the maintenance of glycemic control after
    Helplessness, self-blame and faith may impact on self-management in                     community-based intervention. J Diabetes Res. 2016;2016:7913258. https://
    COPD: a qualitative study. Prim Care Respir J. 2011;203:307–14. https://doi.  
    org/10.4104/pcrj.2011.00035.                                                      49.   Mau MK, Glanz K, Severino R, Grove JS, Johnson B, Curb JD. Mediators of
27. Ryan D, Southwick M, Teevale T, et al. Primary care for Pacific people.                 lifestyle behavior change in native Hawaiians: initial findings from the native
    Wellington: Pacific Perspectives; 2011.                                                 Hawaiian diabetes intervention program. Diabetes Care. 2001;2410:1770–5.
28. Firestone R, Funaki T, Dalhousie S, Henry A, Vano M, Grey J, et al. Identifying
    and overcoming barriers to healthier lives. Pacific Health Dialog. 2018;212:      50.   Beckham S, Bradley S, Washburn A, Taumua T. Diabetes management:
    54–66.                                           utilizing community health workers in a Hawaiian/Samoan population. J
29. Sa'uLilo L, Tautolo E, Egli V, Smith M. Health literacy of Pacific mothers in           Health Care Poor Underserved. 2008;192:416–27.
    New Zealand is associated with sociodemographic and non-communicable                    hpu.0.0012.
    disease risk factors: surveys, focus groups and interviews. Pacific Health        51.   Gellert KS, Aubert RE, Mikami JS, Ola K'A. Moloka'i's community-based
    Dialog. 2018;212:65–70.                          healthy lifestyle modification program. Am J Public Health. 2010;1005:779–
30. Baig AA, Benitez A, Quinn MT, Burnet DL. Family interventions to improve                83.
    diabetes outcomes for adults. Ann N Y Acad Sci. 2015;13531:89–112. https://       52.   Tomioka M, Braun KL, Compton M, Tanoue L. Adapting Stanford's chronic                                                             disease self-management program to Hawaii's multicultural population.
31. Human Rights Commission. Human Rights in New Zealand. Auckland:                         Gerontologist. 2012;521:121–32.
    Human Rights Commission; 2010.                                                    53.   Kaholokula J, Look M, Mabellos T, Zhang G, de Silva M, Yoshimura S, et al.
32. Paddison CAM. Exploring physical and psychological wellbeing among                      Cultural dance program improves hypertension management for native
    adults with type 2 diabetes in New Zealand: identifying a need to improve               Hawaiians and Pacific islanders: a pilot randomized trial. J Racial Ethn Health
    the experiences of Pacific peoples. N Z Med J. 2010;1231310:30.                         Disparities. 2017;41:35–46.
33. Southwick M, Kenealy T, Ryan D. Primary care for Pacific people: a Pacific        54.   Ing CT, Miyamoto RES, Fang R, Antonio M, Paloma D, Braun KL, et al.
    and health systems approach. Wellington: Pacific Perspectives; 2012.                    Comparing weight loss–maintenance outcomes of a worksite-based lifestyle
34. Tualaulelei E, McFall-McCaffery J. The Pacific research paradigm :                      program delivered via DVD and face-to-face: a randomized trial. Health
    opportunities and challenges. MAI J (Online). 2019;82:188–204. https://doi.             Educ Behav. 2018;454:569–80.
    org/10.20507/MAIJournal.2019.8.2.7.                                               55.   Mau MKLM, Lim E, Kaholokula JK, TMU L, Cheng Y, Seto TB. A randomized
35. Anae M. Teu Le Va: Samoan relational ethics. Knowl Cult. 2016;43:117–30.                controlled trial to improve heart failure disparities: The Mālama Pu‘uwai
36. Yang K, Chung-Do JJ, Fujitani L, Foster A, Mark S, Okada Y, et al. Advancing            (caring for heart) Study. Open Access J Clin Trials. 2017;9:65–74. https://doi.
    community-based participatory research to address health disparities in                 org/10.2147/OAJCT.S136066.
    Hawaii: Perspectives from academic researchers. Hawai‘i J Med Public              56.   LaBreche M, Cheri A, Custodio H, Fex CC, Foo MA, Lepule JT, et al. Let's
    Health. 2019;783:83–7.                                                                  move for Pacific Islander communities: an evidence-based intervention to
37. Hudson M, Milne M, Reynolds P, et al. Te Ara Tika guidelines for Māori                  increase physical activity. J Cancer Educ. 2016;312:261–7.
    research ethics: a framework for researchers and ethics committee                       007/s13187-015-0875-3.
    members the Pūtaiora writing group. Auckland: Health Research Council of          57.   McElfish PA, Bridges MD, Hudson JS, Purvis RS, Bursac Z, Kohler PO, et al.
    New Zealand; 2010.                                                                      Family model of diabetes education with a Pacific Islander community.
38. Australian Institute of Aboriginal and Torres Strait Islander Studies. AIATSIS          Diabetes Educ. 2015;416:706–15.
    code of ethics for Aboriginal and Torres Strait Islander research.                58.   DePue JD, Dunsiger S, Seiden AD, Blume J, Rosen RK, Goldstein MG, et al.
    Canberra. Australian Institute of Aboriginal and Torres Strait Islander                 Nurse-community health worker team improves diabetes care in American
    Studies (AIATSIS). 2020.                                                                Samoa: results of a randomized controlled trial. Diabetes Care. 2013;367:
39. Assembly of First Nations. Ethics in First Nations research. Canada:                    1947–53.
    Environment Stewardship Unit; 2009.                                               59.   Hamid S, Dunsiger S, Seiden A, Nu'Usolia O, Tuitele J, DePue JD, et al.
40. Mila-Schaaf K, Hudson M. The interface between cultural understandings:                 Impact of a diabetes control and management intervention on health care
    negotiating new spaces for Pacific mental health. Pacific Health Dialog.                utilization in American Samoa. Chronic Illness. 2014;102:122–34. https://doi.
    2009;151:113.                                                                           org/10.1177/1742395313502367.
41. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for         60.   Reddy R, Trinidad R, Seremai J, Nasa J. Marshallese diabetic health
    systematic reviews and meta-analyses: the PRISMA statement. PLoS Med.                   improvement pilot project in Ebeye. Californian J Health Promot. 2009;7:
    2009;67:e1000097.                         125–30.
42. Joanna Briggs Institute. The Joanna Briggs Institute Critical Appraisal tools     61.   Tan J, McCready F, Noovao N, Tepueluelu O, Collins J, Cundy T.
    for use in JBI systematic Reviews: Checklist for Randomized Controlled Trials;          Intensification of blood pressure treatment in Pasifika people with type 2
    2017.                                diabetes and renal disease: a cohort study in primary care. N Z Med J. 2014;
43. Mau MK, Kaholokula JK, West MR, Leake A, Efird JT, Rose C, et al. Translating           1271404:17–26.
    diabetes prevention into native Hawaiian and Pacific Islander communities:        62.   Simmons D, Voyle JA, Fou F, Feo S, Leakehe L. Tale of two churches:
    the PILI 'Ohana Pilot project. Prog Community Health Partnersh. 2010;41:7–              differential impact of a church-based diabetes control programme among
    16.                                                 Pacific Islands people in New Zealand. Diabet Med. 2004;212:122–8. https://
44. Kaholokula JK, Mau MK, Efird JT, Leake A, West M, Palakiko DM, et al. A       
    family and community focused lifestyle program prevents weight regain in          63.   Bell AC, Swinburn BA, Amosa H, Scragg RK. A nutrition and exercise
    Pacific Islanders: a pilot randomized controlled trial. Health Educ Behav.              intervention program for controlling weight in Samoan communities in
    2012;394:386–95.                              New Zealand. Int J Obes Relat Metab Disord. 2001;256:920.
45. Sinclair KA, Makahi EK, Shea-Solatorio C, Yoshimura SR, Townsend CK,                    0.1038/sj.ijo.0801619.
    Kaholokula JK. Outcomes from a diabetes self-management intervention for          64.   Simmons D, Fleming C, Cameron M, Leakehe L. A pilot diabetes awareness
    Native Hawaiians and Pacific People: Partners in Care. Ann Behav Med.                   and exercise programme in a multiethnic workforce. N Z Med J. 1996;
    2013;451:24–32.                              1091031:373–5.
46. Kaholokula J, Kaholokula J, Wilson R, Wilson R, Townsend C, Townsend C,           65.   Hotu C, Bagg W, Collins J, Harwood L, Whalley G, Doughty R, et al. A
    et al. Translating the diabetes prevention program in native Hawaiian and               community-based model of care improves blood pressure control and
    Pacific islander communities: the PILI ‘Ohana project. Transl Behav Med.                delays progression of proteinuria, left ventricular hypertrophy and diastolic
    2014;42:149–59.                              dysfunction in Maori and Pacific patients with type 2 diabetes and chronic
47. Ing CK, Miyamoto RE, Antonio M, Zhang G, Paloma D, Basques D, et al. The                kidney disease: a randomized controlled trial. Nephrol Dial Transplant. 2010;
    PILI@Work Program: a translation of the diabetes prevention program to                  2510:3260–6.
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