The ultimate goal of the Institutes is to strengthen curricula and to enhance the quality of teaching about the United States in academic institutions abroad. Institutes for Scholars will take place at various colleges, universities, and academic institutions throughout the United States over the course of six weeks beginning in or after June Each Institute includes a four-week academic residency component and up to two weeks of an integrated study tour.

Prospective applicants are encouraged to visit our website to obtain general information about the Institutes: The Institute on American Politics and Political Thought will provide a multinational group of 18 experienced foreign university faculty and practitioners insight into how intellectual and political movements have influenced modern American political institutions and a deeper understanding of major currents in U. Drawing upon the American Political Development approach, the Institute will provide a full and diverse understanding of U. The Institute will explore particular themes including self-rule and limited government, liberty and freedom, individualism and identity, equality and inequality, and the American Dream.

The Institute on Contemporary American Literature will provide a multinational group of up to 18 foreign university faculty and scholars with a deeper understanding of U. Its purpose is twofold: The program will explore the diversity of the American literary landscape, examining how major contemporary writers, schools, and movements reflect the traditions of the U.

At the same time, the program will expose participants to writers who represent a departure from that tradition, and who are establishing new directions for American literature. The Institute on Journalism and Media will provide a multinational group of 18 journalism instructors and other related specialists with a deeper understanding of the roles that journalism and the media play in U.

The Institute will examine the rights and responsibilities of the media in a democratic society, including editorial independence, journalistic ethics, legal constraints, international journalism, and media business models. The Institute will examine pedagogical strategies for teaching students of journalism the basics of the tradecraft: The program will also highlight the impact of technology on journalism, such as the influence of the Internet, the globalization of the news media, the growth of satellite television and radio networks, and other changes that are transforming the profession.

Employing a multi-disciplinary approach and drawing on fields such as history, political science, anthropology and sociology, law, and others, the program will explore both the historical and contemporary relationship between religion and state in the United States. Participants will examine the ways in which religious thought and practice have influenced, and been influenced by the development of American-style democracy.

Study will also include a survey of the diversity of contemporary religious beliefs in relation to the 1st amendment to the US constitution, elections, public policy, and the demography of the United States. Interfaith dialogue in the American context will be practiced in the context of the group itself as well as site visits to a diversity of religious communities. The Institute on U. Culture and Society will provide a multinational group of 18 experienced and highly-motivated foreign university faculty and other specialists with a deeper understanding of U.

The Institute will examine the ethnic, racial, social, economic, political, and religious contexts in which various cultures have manifested in U. The program will draw from a diverse disciplinary base, and will itself provide a model of how a foreign university might approach the study of U. Translating efficacious health treatments into routine clinical and public health practice to eliminate health disparities for communities at risk is an increasing public health priority.

Recent significant advances in diabetes care have the potential to prevent complications from diabetes and improve quality of life, yet these evidence-based practices are not being used in real-world settings. This is attributable to barriers to care, such as limited access, health worker shortages, underfinanced health systems, and cultural and language factors, among many challenges. One such framework is translation research: Several descriptive reports of observational diabetes interventions among other Pacific Islanders have been published, 11 — 13 as well as some comparison group studies among Samoans in New Zealand 14 , 15 and Pacific Islanders in the Torres Strait Islands near Australia.

The process of cultural adaptation brings yet another dimension to translation research, and this integrated process is termed cultural translation. We discuss our experience with cultural translation prior to and during our study, Diabetes Care in American Samoa — This intervention employs a primary care—based team comprising a nurse and 4 community health workers to support diabetes self-management.

We describe our process of choosing an intervention approach from evidence-based models, our community partnerships, and our use of formative research and applied adaptations to design a randomized trial to test the effectiveness of the intervention in the Samoan setting. We also discuss challenges to the translation and solutions we developed, which may inform adaptations of interventions in other settings. The health disparities and cross-cultural literature has emphasized the importance of culturally salient and competent interventions, with researchers documenting a variety of strategies to achieve this.

Lau also advocated a directed approach for treatment adaptation, which uses existing or original research to enhance engagement and contextualize the intervention content to the target community.

STUDY OF THE U.S. INSTITUTES

Whaley and Davis described different approaches to cultural adaptation that are commonly used: Deep structure reflects how cultural, psychological, social, political, environmental, and historical factors affect people differently across populations; these deeper factors should also be incorporated into interventions. Qualitative research, which incorporates such techniques as focus groups and in-depth interviews, is frequently used to gather information to learn about these key factors.

Our approach to cultural translation relied on the following steps: We drew many of these steps from previous research, particularly the Precede—Proceed Model for health program planning, 23 which we applied in our study; however, here we emphasized steps that are involved in cultural translation of an intervention.

An important starting point, as indicated in the Precede phase of the Precede—Proceed Model, 23 is to learn about the target population, including its social and political history, its health problems, and how these problems relate to the culture and health behaviors. We started by reading the available literature. For centuries these islands remained in relative isolation, allowing them to maintain traditional lifestyles.

However, colonization and subsequent modernization greatly affected the lifestyle and health of Samoans. Anthropological and epidemiological studies on the health of Samoans have been conducted by author S.


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Samoans residing in California, Hawaii, American Samoa, and Samoa suffer increasingly high levels of overweight, obesity, and the associated chronic noncommunicable conditions, including hypertension, type 2 diabetes, and high-risk lipid profiles. The increasing prevalence of obesity and diabetes among Samoans at the population level results from the general influences of socioeconomic modernization and specifically from the shift away from agrarian work to more sedentary jobs and an increased reliance on imported foods of low nutritional quality.

Imported meats of low nutritional quality, such as turkey tails and mutton flaps, and animal protein offered by an increasing number of US-based fast food restaurants, have replaced seafood as sources of protein and fat. Certain cultural beliefs have complicated the changes brought on by modernization.

The traditional respect for and acceptance of large body size is gradually changing, as idealization of thinner bodies spreads among Samoans; however, many individuals with large sizes still do not view themselves as overweight. Traditionally, Samoan culture is both hierarchical and collectivist; therefore, the extended family is responsible for the support of its members, but a matai or other elder may be designated to make major health care decisions.

The effects of chronic illness on the island led local health care providers and public health officials in American Samoa to approach author S. They specifically asked for an intervention to be used in their new community health center. Before we met with local stakeholders about formulating a research proposal, we reviewed the literature for effective diabetes interventions in primary care settings, diabetes interventions among Pacific Islanders and other ethnic minority populations, and cultural adaptation procedures.

From this review, we identified a menu of ideas to present in American Samoa. The movement for translation of evidence-based interventions calls for adaptations of specific approaches to new settings to reach populations in need. The parallel movement for community-based participatory research reflects a demand for greater sensitivity to local perceptions, needs, and circumstances and for inclusion of local stakeholders in formulating research questions, selecting methods, and interpreting results.

Still, it is important that the adaptation be community guided. Our academic research team contributed research expertise in American Samoa and in diabetes interventions. American Samoa is designated as a medically underserved area and health professional shortage area. One certified nurse diabetes educator and 1 registered dietician work at the hospital. All stakeholders recognized the need for serious attention to diabetes care.

We discussed several intervention ideas, drawn from evidence-based models in primary care and other minority settings, including the use of case management, group-cluster visits, family group visits, peer outreach workers, self-management support, and peer-led support groups. Health center staff suggested using a peer outreach worker to assist clinical staff with care coordination and to reach family members who influence self-care behaviors in Samoan culture.

This approach would extend healthy lifestyle messages to the whole family, which is likely to include other people at risk for diabetes. The research team advocated for the scientific strength of a randomized controlled trial, but local partners did not want to withhold care from a control group. This conflict has been common in community-based research, and alternative designs may serve both interests.

Local partners also appreciated outcome data provided by this design, so that if the intervention proved successful, a case could be made for extending it to other areas of the island. Area health professionals and health center staff welcomed the opportunity for training that our project might facilitate. Although some community members had participated in the Centers for Disease Control and Prevention Diabetes Today focus groups and coalition training, 8 — 10 our project would specifically target a health care setting.

Patient focus groups and provider interviews were important elements for our partners, to ensure that the community health worker intervention would be effectively tailored to local culture and practices.

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

We also educated our partners about the process and time line for seeking funding and the need to collect preliminary data. Sharing research funds by way of local subcontracts was a concrete recognition of our partnership. The study design is shown in Figure 1. Drawing from Lau's framework, 21 we concluded that the American Samoan cultural context required cultural adaptation of the intervention. The epidemiological studies we consulted suggested differences in risk between Samoans and other ethnic groups in the United States. Many cultural practices contributed to these risks and needed to be taken into account.

We found little evidence of differences in attrition or compliance because no comparative studies between Samoans and other ethnic groups have been conducted. We chose a directed approach to adaptation, drawing on evidence-based treatments of type 2 diabetes in other ethnic minority groups to identify an outreach worker design that fit our local partners' wishes.

Community health worker interventions have been used for decades in ethnic minority communities. Many communities have used these workers in group-based approaches to diabetes self-management education, 50 , 53 — 57 and community health workers clearly have enhanced the cultural competency of the interventions and improved reach and participation rates. However, individuals in groups had lower participation rates than did individuals participating in home visits provided by community health workers. Some primary care interventions successfully used community health workers in care-management approaches.

A cluster-randomized trial in 21 health centers in Pacific Torres Strait Islands compared having visiting diabetes specialists available for referral in all sites with a proactive community health worker reminder system in 8 sites. In one of the few well-designed randomized controlled trials with a community health worker model, Project Sugar compared 4 types of care delivery among African Americans with diabetes in a Baltimore, Maryland, managed-care setting: A second study, Project Sugar 2 PS2 , more intensively and successfully compared the nurse—community health worker team with usual care.

The available research indicated that the nurse—community health worker team model best fit the American Samoa context. Community health workers integrated within the medical team would help support self-management and extend the reach, quantity, and quality of interventions among diabetes patients. PS2 used the Precede—Proceed Model as a theoretical framework, which appears suitable for a collectivist culture and has been extensively applied around the world in many cultures.

Outreach workers had been used in American Samoa for maternal and child health initiatives, but there had been no such interventions for diabetes care. PS2 also used many of the best-practice components that were identified in reviews, such as treatment algorithms, community outreach, one-on-one interventions, and multiple contacts over time. Original qualitative research, with its well-established methodology, is a common approach to formative work to identify what cultural adaptations are needed for intervention development.

We conducted focus groups with diabetes patients and in-depth interviews with health center providers. In 6 focus groups, with a total of 39 persons with diabetes, we explored barriers to and facilitators of diabetes self-care in American Samoa, attitudes about stress and depression, and feedback on proposed community health worker roles and home visits. We also sought feedback on sample images and messages, drawing from standard diet and exercise messages used by the National Diabetes Education Program 65 and other Pacific health care materials 66 to see whether further adaptation was needed for project-specific tools.

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

Linguistic translation of focus group transcripts provided another layer of analysis. It was necessary to recheck translations against the original language and to employ multiple translators to ensure that the correct meaning was transcribed. We selected measures for the 3 phases of evaluation, according to the Precede—Proceed Model: Because of the complexity of diabetes in behaviors and relevant disease outcomes, we had many relevant measures from which to choose.

It was important to select measures previously used in lower-literacy populations and to limit the number of measures to reduce burden. Our outcome selections also had to take into account the remoteness of the field site, with its lack of access to standardized research laboratories.

Therefore, we chose to use a point-of-care assessment tool for hemoglobin A1c: Few intervention research measures had been used previously in American Samoa. When standardized measures from mainstream culture are used in other ethnic groups, they may lack cultural relevance, leading to measurement error or misinterpretation of findings. Cultural translation focused on ensuring that the concepts we translated were as relevant as possible to Samoan life and culture.

Cognitive interviews were an essential step in this process. The patients answered each question and then discussed their answers and their understanding of the translated items with a research interviewer. Through this process we were able to determine that many of our questions were appropriately translated, and we corrected or adapted others before administration to participants in the randomized controlled trial. In adapting standardized measures, it is important to strike a balance between the emic perspective seeking equivalence within the culture and the etic perspective ensuring comparability across cultures.

Although cognitive interviews are often used in item development, 71 , 72 our protocol used them to confirm the effectiveness and cultural salience of our translations. After the qualitative studies were completed and themes were identified, we developed the intervention protocols and materials, drawing on PS2 interventions as a model. Unique considerations in the American Samoa population included higher blood glucose and blood pressure levels.


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

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

    Although staff members were bilingual, their comfort with English varied. Side-by-side translations facilitated shifting from one language to the other, reflecting the way people regularly speak. After drafts were developed for flipcharts and visit protocols, we reviewed them with local staff and practiced with role plays. Then we made further adaptations to better fit how the materials would be used.

    This process of collaboration, an integral part of community-based participatory research, 43 — 45 was invaluable; it revealed the need to scale back both the quantity and complexity of information, and it identified additional training needs for the staff. Staff members also came up with novel interactive teaching tools, such as laminated photos of locally available foods that could be sorted into red, yellow, and green categories, according to the National Diabetes Education Program red light system for foods to eat more of, eat with caution, and avoid.

    Conducting a randomized trial in a setting where intervention research is unfamiliar required several cultural adaptations. We provided education to all health center staff about research practices, including why we do research, why we randomize, what contamination across study groups is, and how it affects study goals.

    American Samoa (America's Forgotten Colonies, Part 1/3)

    Health care personnel on the island have limited opportunities for continuing education, and few can afford to seek training elsewhere. Therefore, health center clinicians specifically asked for more training on diabetes care as part of this project. This training was provided over a 4-day visit by author M. Our local project staff also received extensive training on diabetes management, assessment techniques, and study protocols, and all were certified on human participant protection.

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

    We randomized villages instead of patients because of extensive familial and local community ties. Villages are matched by size and location in the health center catchment's area, and villages in the pairs are randomly assigned to intervention or control group. Control participants receive their usual care at the health center for 1 year, after which they will receive the intervention.

    Eligibility for this sample is broad, because this translational research is intended to test real-world effectiveness: Characteristics of the total population of health center diabetes patients will be used to assess the sample's representativeness and external validity and to ensure that this research is relevant to practicing clinicians and policymakers.

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

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

    These accommodations have required more training, closer supervision, and additional quality control mechanisms. We could not do this work without a full-time field director, who supervises the research in American Samoa, bridging the requirements of research and local authority and policy.

    Another key adaptation involves working with the limited access to medical supplies that is common in low-income communities and island economies. Blood glucose—testing equipment and supplies are too costly for most island residents, and they do not have individual medical insurance to cover these costs; therefore, most patients only have access to blood sugar testing at the medical clinic. It is also common for the medical clinic to be without these crucial supplies for varying periods because of funding shortages.

    Our study was not funded to provide blood-testing supplies for individuals. We therefore had to redefine the role of blood glucose monitoring to include problem solving within families to increase access to meters and supplies. Community health workers also provide regular testing during their visits.

    We plan to do additional qualitative studies with participants in the intervention group and with study staff and clinicians at the health center, after the posttreatment assessments at the 1-year follow-up. These qualitative studies will examine the salient features of the intervention in the view of participants and providers, such as perceived efficacy, burden, facilitators and barriers, and potential for sustainability and wider spread.


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      7. For example, we will ask about the extent to which community health workers were fully integrated into the health care system, how confident patients became in self-care, and how both of these factors could be improved. These data will be used to complement quantitative data outcomes and provide a qualitative thick description of the experiences participants and staff had with the intervention. Posttreatment qualitative data are especially important in this first intervention study in American Samoa because they will provide in-depth feedback on the intervention and research procedures to guide future research.

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

      Also at that juncture, our community partners will help us consider next steps if community health worker services prove to be valuable to find ways to sustain and further disseminate community health worker services for diabetes care. Although many efficacious interventions exist to improve diabetes care, including examples in ethnic minority populations, 49 , 50 , 61 , 62 evidence-based treatments are needed by many underserved ethnic groups and communities to further reduce health disparities in diabetes. Our approach to cultural translation drew from the emerging science of translation research and cultural adaptation to bring strong scientific methods to American Samoa.

      Cultural adaptation was necessary in this context because diabetes risk on the island is much higher than in the general US population, and cultural practices contribute to this risk. Our community partners selected an approach coordinated by community health workers and primary care providers.

      Introduction

      Previous adaptations of community health worker interventions in other ethnic groups have improved cultural competency, reach, and participation rates, but few of these trials used randomized designs, and sample sizes were often small, yielding few clear differences in outcomes. Previous studies on diabetes interventions in Pacific Island populations also lacked randomized designs and produced little data specific to American Samoans. We chose to adapt the community health worker—nurse team intervention from PS2, 59 , 60 which was conducted in an African American population, because it was evidence based, had proved successful in a randomized controlled trial, and incorporated features found in other successful diabetes interventions.

      The PS2 interventions were integrated with primary care, providing a good model for the primary care context in American Samoa.