J Immigrant Minority Health (2012) 14:475–480
DOI 10.1007/s10903-011-9487-0
ORIGINAL PAPER
Health is Wealth: Methods to Improve Attendance in a Lifestyle
Intervention for a Largely Immigrant Filipino-American Sample
Anne R. Leake • Venus C. Bermudo •
Jose Jacob • Marianela R. Jacob • Jillian Inouye
Published online: 7 June 2011
Ó Springer Science+Business Media, LLC 2011
Abstract Diabetes prevention requires lifestyle changes,
and traditional educational programs for lifestyle changes
have had low attendance rates in ethnic populations. This
article describes the development and implementation of an
educational program, emphasizing retention strategies,
cultural tailoring and community participation. Commu-
nity-based participatory research approaches were used to
adapt and test the feasibility of a culturally tailored lifestyle
intervention (named Health is Wealth) for Filipino-Amer-
ican adults at risk for diabetes (n = 40) in order to increase
program attendance. A unique feature of this program was
the flexibility of scheduling the eight classes, and inclusion
of activities, foods and proverbs consistent with Filipino
culture. We found that with this approach, overall program
attendance for the experimental and wait-listed control
groups was 88% and participant satisfaction was high with
93% very satisfied. Flexible scheduling, a bilingual facili-
tator for the classes, and the community-academic part-
nership contributed to the high attendance for this lifestyle
intervention.
Keywords Diabetes prevention
Lifestyle intervention

Attendance
Filipino-American
A. R. Leake (&)
J. Inouye
Department of Nursing, University of Hawaii Manoa,
2528 McCarthy Mall Webster 436, Honolulu, HI 96822, USA
e-mail: aleake@hawaii.edu
V. C. Bermudo
Health Education, Lanai Community Health Center,
Lanai City, HI, USA
J. Jacob
M. R. Jacob
Philippine Nurses Association of Hawaii, Pearl City, HI, USA
Background
Lifestyle intervention educational programs tend to have
low attendance and completion rates [1, 2]. Mau et al. [3]
reported a retention rate of just over 50% in a culturally
tailored lifestyle intervention education program for over-
weight and obese Asians and Pacific Islanders in Hawaii.
The efficacy of lifestyle changes to prevent type 2 diabetes
(T2D) has been demonstrated in both national and inter-
national studies [4–6].
Filipinos are the second largest group of immigrants to the
US after Mexicans [7, 8]. In 2007, there were about 3 million
Filipino immigrants in the US with California having the
largest number (about 750,000 people, or 46% of the US
total) [8]. Hawai’i was the state with the second largest
number of Filipino immigrants (about 99,000 people, or 6%
of the US total) with 47% of all Filipinos in Hawaii foreign-
born [9]. Filipino-Americans (FAs) are at risk for developing
T2D even in the absence of obesity. The Filipina Women’s
Health Study measured the rates of diabetes, heart disease,
hypertension and osteoporosis among 454 female FAs age 50
and older in San Diego County, and found that one in three
had diabetes compared to one in 11 Caucasian women [10].
Of those female FAs with diabetes, 90% were not obese, and
60% did not know they had diabetes. FAs in Hawaii have a
prevalence of diabetes of 10%, surpassed only by native
Hawaiians at 13% [11]. A survey study of a multiethnic
population from Hawaii showed that FAs also had the
highest rate of metabolic syndrome (MetS) occurring at
lower BMIs compared to other Asian and Pacific Islander
ethnic groups [12]. In that study FAs had the highest adjusted
odds for prevalence of MetS (prevalence OR = 4.2; 95%
CI = 2.4–7.3). Impaired fasting glucose is one of the five
diagnostic criteria for MetS and can herald the development
of T2D [13]. FAs are clearly a group at high risk for T2D.
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Kalusugan ay kayamanan (Health is Wealth in the
Philippines’ national language) was a cultural belief of the
sakadas (original Filipino immigrants who came to Hawaii
beginning in 1886 as plantation workers). The Philippine
Nurses Association of Hawaii (PNAH), a community
partner for this project, chose this name for the project to
bridge the cultural values of the importance of good health,
the value of working hard, and that the dreams of sakadas
followed them to America so they would have a better life
for their families. Using a community-based participatory
research (CBPR) approach, a partnership was developed
between the academic nursing investigator and the PNAH
in 2004. This partnership conducted a preliminary study
that found prevention of T2D in adults to be a priority for
the FA community for diabetes research [14]. The PNAH
guided the implementation of the project as a full partici-
pant in the dissemination of results to both the Filipino
community and the scientific community. Three PNAH
Board members served as the advisory committee during
the curriculum design and participated in recruitment and
baseline measurement of study participants.
The social and economic circumstances of Filipinos in
Hawaii can be barriers to a healthy lifestyle. The Hawaii
Department of Health’s Healthy People 2010 Report
showed that 13.7% of Filipinos hold more than one job,
more than double the national average of 5.4% and higher
than the state average of 12.6% [15]. Having two jobs often
means that Filipinos have little leisure time and emphasizes
the need for flexibility in the time and location of a lifestyle
intervention in order to enhance access.
In summary, the FA community in Hawaii is at high risk
for T2D, and although there is evidence that lifestyle inter-
ventions can lower risk, a lack of awareness of perceived risk
and lack of time are potential barriers to participation in
educational programs for this disease. The purposes of this
study were twofold: to culturally adapt a widely used dia-
betes prevention lifestyle intervention education program for
FAs, and to test the feasibility of this adapted program by
measuring attendance and participant satisfaction.
Conceptual Framework
Social learning theory was the theoretical framework guid-
ing the development and implementation of the intervention
[16]. The intervention was intended to increase self-efficacy
for lifestyle improvement in the areas of diet and exercise for
the prevention of T2D. The intervention was designed for
small groups to optimize the elements of social learning (i.e.,
role modeling, vicarious learning, verbal persuasion and
graduated mastery experiences). In social learning theory,
personal or social impediments can interfere with attendance
in a lifestyle education program [17].
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Methodology
Design
This feasibility study was a randomized trial design with a
wait-listed control group. Forty participants were randomly
assigned to one of two groups, experimental and control.
The experimental group (n = 21) received the intervention
first, and the control group (n = 19) received the inter-
vention 6 months after the experimental group. Participants
were randomized by drawing a numbered poker chip from
a bag. While the sample size was too small to detect dif-
ferences in outcomes between the groups, the feasibility
study design was selected to answer methodological
questions about flexible scheduling.
Participants
Community health nursing students conducted five half-
day community screenings at the public park that would be
the site of the intervention. The community screening fliers
emphasized avoiding diabetes, heart attack and stroke
rather than weight loss because being overweight is not
considered to be a problem by most FAs [18]. The fliers
were green with a $20 bill depicted on one side as an eye-
catching way to emphasize the project name. PNAH
members also recruited adults from churches with large FA
congregations.
Inclusion criteria were FA adults age 18 and above who
scored nine points and above on the American Diabetes
Association survey tool ‘‘Are You at Risk for Diabetes?’’.
Exclusion criteria were participants with a diagnosis of
diabetes, or uncompensated cardiac disease, respiratory
disease or musculoskeletal disease that would prevent
exercising. During the first 6 months of the study, com-
munity presentations and diabetes screenings were held
with FA community groups in collaboration with the
PNAH. Of the 176 adults screened, 150 were found to be
eligible, and 42 agreed to enroll in the study with two of
those found ineligible due to fasting blood glucose
[125 mg% at baseline. This 72% refusal rate is similar to
the 84% refusal rate in a community-based study targeting
individuals at high risk for diabetes in Sweden [19]. The
control group received the intervention immediately after
the conclusion of the intervention group.
Site
The site for the classes was an outdoor neighborhood park
with ample parking frequented by FA families and located
near two churches with large FA congregations. Classes
were conducted under a canopy to provide shade and cover
from rain. Two 90 min sessions were scheduled on each
J Immigrant Minority Health (2012) 14:475–480 477

Sunday afternoon, one at noon and one at 2 pm. Six Sundays Lessons, and role-playing with Lola’s family members who
that included or followed a holiday were excluded from the are trying to adopt healthier lifestyles. Six of the 10 HHHF
schedule. At enrollment participants could select their own sessions were incorporated into the Health is Wealth class
class times tailored to their needs and their family schedules. curriculum, with two sessions about diet, two about phys-
Most participants scheduled all of their 8 sessions at the time ical activity, and two about self-management skill building.
of enrollment. Two additional sessions on stress management were also
developed using features from HHHF (Filipino proverbs,
Cultural Tailoring of the Intervention role playing, and Lola’s Life Lessons).
To increase self-efficacy, each session ended with
The project’s Health is Wealth curriculum was developed writing a ‘‘Pledge to Myself’’ with a behaviorally specific
through cultural adaptation of the curriculum used for the objective to work on until the next scheduled session. The
national Diabetes Prevention Program (DPP) study [4]. participants were asked to take home the pledge and keep it
First, priority elements for the FA population were iden- in a visible place as a reminder. Each session began with a
tified in the 16 DPP sessions and modified to create the discussion of how the participants did with their pledges.
eight sessions of the Health is Wealth curriculum. The The curriculum was then reviewed by a focus group
correspondence between the DPP and Health is Wealth consisting of seven FA women and one man who were on
sessions is shown in Table 1. The eight sessions were then the staff at a community health center. The first author led
culturally tailored based on the cardiovascular disease the focus group with the second author serving as recorder.
prevention curriculum developed at the National Institute Based on the focus group results, the curriculum was
of Health, National Heart Lung and Blood Institute (NIH/ revised to increase emphasis on relaxation exercises to
NHLBI) called Healthy Heart, Healthy Family (HHHF), manage stress as an important component of a healthy
which targets the FA population [20]. HHHF tells the story lifestyle, and a tool to track the number of steps walked
of the dela Cruz family from the perspective of Lola (the was revised.
grandmother) featuring Filipino proverbs, Lola’s Life
Implementation of the Intervention
Table 1 Kalusugan ay Kayamanan (KAK) curriculum lessons, with
corresponding lessons from the Diabetes Prevention Program (DPP) The park tables were colorfully arranged to create a
Session KAK lesson DPP lesson relaxing and festive atmosphere to engage participants.
Exercise equipment and a digital scale were available as
1 Prevent diabetes: get active Getting started being active options to use before or after the sessions. The Filipino lay
Goal setting and action leader, a recent immigrant herself, presented the curricu-
plans
lum in Tag-lish (English interspersed with Pilipino, the
2 Aim for a healthy weight: Four keys to healthy eating
start small out
Tagalog-based national language of the Philippines) and
served as a role model of healthful eating. At each session,
Take charge of what’s
around you the lay facilitator established a personal connection to gain
Tip the calorie balance acceptance by participants.
3 Keep your cool: stay You can manage stress Because Filipinos value amor propio (self-esteem),
focused phone calls to reschedule missed sessions were conducted
4 Stay on track: be prepared Move those muscles to prevent participants feeling that their absence was a
Being active: a way of shortcoming. Emphasizing that absence was not a problem
family life to the program was also a way to acknowledge that
Problem solving important or unforeseen events might interfere with atten-
5 Keep going: find time The slippery slope of dance. Flexible rescheduling and makeup classes gave due
lifestyle change importance to participants’ other obligations and concerns
Jump start your activity plan regarding family, social ties, and jobs.
6 Find the fat: trim down Healthy eating Each of the eight sessions was offered four times over a
Be a fat detective six-month period. The information presented in each ses-
Three ways to eat less fat sion stood alone to allow participants maximum flexibility
7 Time out: breathe easy Worries to attend all eight sessions without having to attend them in
Talk back to negative a particular order. The leader of the small groups was a FA
thoughts lay leader with training and experience facilitating self-
8 Don’t give up: remember Ways to stay motivated management education groups. The first author monitored
your pledge
the quality and fidelity of the curriculum.

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Data Collection
To facilitate enrollment, baseline assessments were held
four times in the park on Sunday afternoons, and once on
Sunday morning at one of the churches. Volunteer graduate
students and PNAH members who completed NIH training
on protection of human subjects participated in the baseline
assessments. Four stations were used for informed consent,
written surveys, physical measurement and randomization
with scheduling of sessions for the experimental group.
Measures
The primary outcome was attendance at sessions over
6 months. We hypothesized that attendance could be
increased to 75% with cultural tailoring for a family-focus
and flexibility in scheduling. Participant satisfaction was
measured by an anonymous written survey asking partici-
pants to rate the importance of features of the intervention
and satisfaction with the learning activities. This survey
was administered to all participants at the time of their
post-test measurement session. All participants were mea-
sured pre-intervention.
Analysis
Class attendance as the primary outcome was determined
by having the facilitator record attendance at each session.
Attendance data was later entered by date on an Excel
spreadsheet. Attendance for each participant and class size
for each session was analyzed from the spreadsheet. Par-
ticipant satisfaction as the secondary outcome was tallied
and analyzed on an Excel spreadsheet.
Protection of Human Subjects
The Committee on Human Studies at the University of
Hawaii, Manoa reviewed and approved the study protocol.
Results
Demographics of Participants
Participants included 32 females and 8 males (n = 40)
with a mean age of 57 years (SD = 13.5) and a range of
21–75 years. Forty-five percent of participants speak
English at home, 17.5% speak a combination of English
and a Filipino dialect, and 37.5% speak only a Filipino
dialect at home. Most of the participants (85%) were
recruited from churches rather than community events.
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Attendance
Of the 40 enrolled participants, 35 completed all 8 sessions
of the intervention for a completion rate of 88%. For the
five enrolled who did not complete all 8 sessions, two
attended no sessions, two attended 1 session, and one
attended 2 sessions. Of the 5 non-attenders, 3 were in the
wait-listed control group and one of those started a new job
requiring work on Sundays during the waiting period. The
two non-attenders attending no sessions were a couple with
young children who became the only two study dropouts
for a drop out rate of 5%. Both dropouts had BMIs that
were at the high end of the range for the group.
Class Size
To assess the variation in class size for both control and
experimental groups, attendance at each of the 68 sessions
conducted was tallied. The class size ranged from one to 10
participants, with a mean and a median of four participants
per session. These results are displayed in Fig. 1. Only
15% of the sessions had more than 6 participants.
Program Evaluation by Participants
Written program evaluations to measure participant satis-
faction were submitted anonymously by 32 of the 35 par-
ticipants attending post-test measurement assessment. At the
end of the intervention phase there were no significant dif-
ferences between the wait-listed control group and the
intervention group that received the intervention first. Par-
ticipants rated their overall satisfaction as either very satis-
fied (93%) or satisfied (7%). The four content areas of diet,
exercise, self-management and stress management were
equally rated as ‘very important’ by 100% of respondents.
Most participants ranked seven of 10 features as very
important in their decision to participate in the intervention,
13
12
11
# of Occurrences
10
9
8
7
6
5
4
3
2
1
1 2 3 4 5 6 7 8 9 10
# Attending Class
Fig. 1 Variation in class size (e.g., a class size of 3 people occurred 9
times)
J Immigrant Minority Health (2012) 14:475–480
with the percentage choosing this response in parentheses:
the time of day (78%), day of the week (80%), ability to
reschedule sessions (80%), number of lessons (74%), out-
door setting (83%), location close to home (77%), and the
lesson materials including binder, DVD, CD, book and
handouts (77%). The remaining three features were rated as
very important less often: participating with people I already
know (44%), having a Filipino teacher (57%), and the $10
gift card for measurement sessions (47%).
Satisfaction with the learning activities was also very
high, with 25 of 32 respondents (78%) rating all activities
as satisfied or very satisfied. Seven respondents rated their
satisfaction with a few learning activities as neutral, e.g.
three out of five on a Likert scale: for the Filipino proverbs,
role playing the dela Cruz family, Lola’s life lessons (five
respondents) and for the exercise equipment and the
relaxation CD (one respondent for each, with one writing
she did not have a CD player).
Discussion
Cultural Tailoring
Flexible scheduling allowed more options for participants
with little leisure time and many social and family events
and obligations. Flexible scheduling helped to achieve a
high program completion rate of 88%, and the median class
size of four participants provided ample opportunity for
group discussion and mutual support. In hindsight,
repeating each session three times instead of four times,
and over four months instead of six months, could have
sufficed to achieve 80% attendance. Holding two different
lessons per afternoon may be a cost-effective approach for
an outdoor intervention requiring equipment and supplies.
The low drop out rate (5%) may be related to high BMI at
baseline or assignment to the control group.
The sessions provided many opportunities for the
facilitator and the participants to discuss common feelings,
concerns and practices in trying to practice a healthy life-
style. The facilitator herself is a recent immigrant to the
U.S. Her open and honest discussion of her own health
practices prior to learning about a healthy lifestyle changed
the teacher-student relationship to a peer relationship. With
this type of relationship, the information in the intervention
was more readily accepted and participants were able to
support each other in their efforts to prevent diabetes. In
social learning theory, these elements that increase self-
efficacy are vicarious learning and role modeling.
Social ties are a cultural value for Filipinos. A certain
level of interpersonal connection must be attained for
participants to continue. Anecdotally participants shared
with the facilitator that the class experience was almost like
479
a revisit to the Philippines. This connection to home was
further strengthened by being able to share the same val-
ues, sentiments, and traditions as they emerged in class
discussions of Lola’s Life Lessons and during conversa-
tions before and after classes. The participants always
lingered after class to talk with each other and the pre-
senters, reflecting the development of interpersonal ties.
Participant Sample
The sample of participants recruited primarily from chur-
ches (n = 40) was a good reflection of the adult Filipino
population in Hawaii with 22 speaking a Filipino dialect at
home (55%), similar to the findings of a large (n = 1307)
strata-cluster survey study of FAs in Hawaii [21]. The
sample was primarily recruited from churches with only
three (7%) recruited from community at large. Many Fili-
pino-Americans attend church regularly, and recruiting
from two large churches may have provided additional
social support to some participants outside the sessions.
The sample is largely middle aged and older, with 85%
between the ages of 43 and 69 years old, the group most at
risk for diabetes.
Although retention for this study was good, recruitment
to lifestyle interventions remains challenging. Even with
community-based recruitment, this study had to identify 3.5
people at risk for diabetes to recruit one person. A multi-
strategy recruitment approach using social marketing,
referrals and outreach phone calls post-screening may have
increased the recruitment yield [22, 23]. Word-of-mouth
testimony based on participant satisfaction and success
could be incorporated into future social marketing efforts.
Contributions to Science
There is a paucity of literature on intervention research
with FAs. A single group educational session done in Los
Angeles on breast and cervical cancer screening for FA
women achieved 80% attendance [24]. Flexible scheduling
with several offerings of each session for a healthy lifestyle
intervention is a feasible approach to increase attendance
for FAs and possibly other ethnic minorities. The rela-
tionship between the facilitator and participants was also
found to be important by Maxwell et al. [24].
The ongoing academic-community partnership between
the first author and a community organization of Filipino
nurses was a co-learning experience. Both partners were
fully involved in all stages of the research. This long-
standing relationship between a Caucasian PI and a
minority nurses group is another unique contribution to the
literature.
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Acknowledgement Funded by NIH/NINR #5P20NR010671 Center
for Ohana Self-management of Chronic Illness.
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