Introduction

The COVID-19 pandemic, which began in 2019 and continues today, has left virtually no population in the world untouched. Yet, like other public health emergencies, the pandemic has had a disproportionate effect on vulnerable communities, including many ethnic minority communities in the USA, who have consistently experienced higher mortality and morbidity rates from COVID-19 [1]. Such is the case for Pacific Islander communities, who experienced some of the highest overall impacts from the pandemic. For the purposes of this paper, Pacific Islander is synonymous with the census racial category of “Native Hawaiians and Other Pacific Islanders.” Unfortunately, many data sources do not disaggregate PI health information from statistics on Asian communities, and others do not differentiate between subgroups of the PI population. Still, the data that is available shows widespread health disparities for PI communities with respect to COVID-19.

At the national level, most PI age groups had between 2.8 and 3.5 times the infection rate of Whites [2]. In states that reported PI data for COVID-19, PIs were overrepresented in COVID-19 infections in 91% of them and overrepresented in deaths in 61% of states [3, 4]. It is important to note, however, that within the Pacific Islander population, there was great variation in how communities were affected across ethnicities and between states. In Hawaiʻi for example, Native Hawaiians make up 21% of the population but only accounted for only 19% of the COVID-19 cases in the pre-vaccination period and 17% of COVID-19 deaths overall. In contrast, other Pacific Islanders, who make up only 4% of the population, comprised 25% of the COVID-19 cases in this same period and 14% of deaths overall [5]. Similarly, national research has shown that vaccine hesitance varies widely by ethnicity, from 56.3% among Tongans in the USA to 23.6% among Native Hawaiians [6].

The population of Pacific Islanders within the USA is incredibly diverse, made of individuals and their descendants from Hawaiʻi, Samoa, Tonga, Tahiti, Aotearoa, Tokelau, Guam, Mariana Islands, Saipan, Palau, Caroline Islands, Kosrae, Pohnpei, Chuuk, Yap, Marshall Islands, Kiribati, Fiji, Papua New Guinea, Vanuatu, and Solomon Islands [7]. It has only been since 1997, however, that the USA Office of Budget Management separated out the category of Native Hawaiians and other Pacific Islanders from the Asian racial category. This is despite the fact that the Pacific is one of the most ethnically and linguistically diverse areas of the world, with Pacific Islanders speaking approximately 25% of the world’s languages [8]. Although making up only .5% of the USA population, Pacific Islanders are the third fastest growing minority population in the USA [9, 10]. Despite century-long histories of colonization and imperialism from other nations, these communities are culturally and linguistically thriving today.

Pacific Islander diaspora also has different histories, relationships, and legal rights with the USA. For example, Hawaiʻi is considered by the USA to be a USA state, and thus, Native Hawaiians have the same citizen status as all others born within the USA; however, the status of Hawaiʻi as a state continues to be contested, given that the overthrow of the Hawaiian Kingdom in 1893 was in violation of international law, a fact acknowledged by the USA’s own investigation at the time [11]. Samoan islands were split into two sections in the early 1900s. The western islands currently known as Samoa gained their independence in 1962 from over 50 years of control and colonization by Germany and New Zealand [12]. The eastern island known as American Samoa (AS) is an unincorporated and unorganized territory of the USA since the division. As a USA territory, those born in AS are considered USA nationals. The Federated States of Micronesia and Republic of Marshall Islands have been part of a Compact of Free Association (COFA) since 1986, as has the Republic of Palau since 1994. These nations have experienced USA intervention since the end of World War II, when they were taken from Japanese control and placed in Trust Territory with the USA by the U.N. Security Council [13]. COFA citizens do not need visas to enter the USA but are considered non-immigrants and thus do not have the rights afforded to USA residents, nationals, or citizens.

Unfortunately, when reporting high rates among PI communities, news outlets and public health officials often fail to explain the sociohistorical context that might lead to such high rates, thus further stigmatizing Pacific Islander communities by suggesting that biological, cultural, or personal factors may be to blame for these high rates [14]. However, the COVID-19 pandemic has hit Pacific Islander communities particularly hard, in part due to economic disparities and health disparities [15]. Pacific Islanders face widespread challenges with respect to social determinants of health, such as employment, affordable housing, and education [1, 16,17,18]. Pacific Islanders also have higher rates of chronic health problems when compared to other groups in the USA, particularly with respect to diabetes and obesity [19] and certain types of cancer [16, 20]. Although specifics vary across PI communities, these chronic health problems can be linked historically to changes in diet due to colonization and USA intervention [20] and, in the case of individuals from the Marshall Islands, exposure to the fallout from nuclear testing [19,20,21]. Pacific Islanders also continue to experience racism, discrimination, marginalization, and challenges in accessing healthcare [16, 22].

Given the heavy impact of COVID-19 on Pacific Islander communities in the USA and ongoing challenges with health, social, and economic disparities, it is important to better understand the dynamics involved in PI communities’ responses to the COVID-19 pandemic, so as to improve responses to public health crises that may arrive in the future. The present review seeks to understand how PI communities in the continental USA and Hawaiʻi have responded to the COVID-19 pandemic at local levels, as well as to consolidate lessons learned and recommendations from researchers that work with PI communities within the USA context.

Method

This qualitative synthesis is part of a larger sco** review project designed to investigate available literature on Pacific Islander communities in the COVID-19 pandemic. A search was performed using the terms “Native Hawaiian and Pacific Islander,” “COVID 19,” “COVID,” and “Pacific Islander” in March 2022. This initial search returned 233 results. These articles were then screened based on title and abstract by the second and last author to identify (a) peer-reviewed articles or government documents (b) that focused on Pacific Islander populations within the USA and (c) that were about the COVID-19 pandemic.

Articles about Pacific Islander populations outside of the USA and articles that did not separate Native Hawaiian and Pacific Islanders from other ethnoracial groups (i.e., Asians) were excluded. This resulted in 41 articles that met these inclusion criteria. Next, the full texts of all articles were reviewed by the first and second author to see if they included accounts of PI community efforts to address COVID-19 and/or recommendations by the authors for how to work with PI communities during COVID-19. The decision to include government documents was based on the fact that many research results were released through this mechanism during the pandemic due to the necessity of timely reporting and response during the pandemic.

A total of 28 articles were included in the present study (see Table 1). Thematic analysis [23] was then used to extract and synthesize data based on the research questions. This flexible approach to qualitative coding has been endorsed as one of many appropriate methods for qualitative synthesis in health sciences [24]. A combination of deductive and inductive approaches was used; the first and second authors began by reading the included articles and extracting text segments related to (a) strategies used to address the COVID-19 pandemic and (b) lessons learned from responses to the COVID-19 pandemic in PI communities. Next, the second author reads through all coded segments in these two broad themes and generated and coded subthemes, which were discussed with the first author and then revised and double-checked.

Table 1 Themes discussed in articles included for qualitative synthesis
Full size table

Results

Strategies Used to Address the COVID-19 Pandemic in Pacific Islander Communities

In total, 14 articles detailed response strategies that were used to address the COVID-19 pandemic in Pacific Islander communities across the USA. These were further grouped into five subthemes: (a) community responses (six articles), (b) government responses (four articles), (c) collaboration among sectors (five articles), (d) research efforts (three articles), and (e) community outreach partnerships (three articles).

Community Responses

Grassroots Organizing and Community Leaders

In May 2020, the Pacific Leaders Assistance Network organized two virtual meetings of Micronesian community leaders across the USA to discuss service gaps and to address the disproportionate impact of COVID-19 on Micronesian populations. This led to the formation of the FSM (Federated States of Micronesia) COVID-19 Task Force USA [25]. The FSM Task Force is comprised of members representing all FSM states, living in 11 USA states and territories, and affiliated with dozens of community organizations, educational institutions, and government agencies [25]. This broad network served as a vehicle to facilitate communication and strengthen relationships across many geographic, cultural, and professional affiliations [25].

In Hawaiʻi, Micronesian communities took the lead on performing essential public health functions throughout the crisis: communicating culturally and linguistically appropriate health information; engaging in informal contact tracing; mobilizing communities and facilitating essential health services; distributing food and emergency resource kits; and redoubling long standing advocacy work, prior to formalized actions by government agencies [25]. In addition, their work was funded through grassroots efforts and resources of the Pacific Islander community leaders themselves [26].

Micronesian community leaders were proactive in protecting their communities from the economic and health impacts of COVID-19 [27]. Guided by strong cultural acknowledgement and resolute commitment to community care, members of the Pacific Islander community organized themselves into various task forces to meet the immediate needs of families who were most heavily impacted by the pandemic [28]. For example, the Marshallese Community Organization of Hawaiʻi (MCOH) organized food distribution and emergency support alongside community partners, acted as resource navigators for Marshallese community members, provided health messages in Marshallese and English via online social networks, and partnered with other organizations to extend reach and support capacity of initiatives directed at Pacific Islanders across the country [25].

Innocenta Sound-Kikku, a Kōkua Kalihi Valley Comprehensive Family Services staff member and respected “community aunty,” demonstrated how Micronesian communities respond and mobilize when reached through respectful and trusted relationships [25]. Following a long tradition of church leaders and community elders being situated at the core of community and mobilization efforts, she organized Micronesian church ministers into a Micronesian Ministers and Leaders Uut to address community concerns and disseminate critical public health information and advisories [25]. The term uut refers to the meeting houses found in many Micronesian societies where leaders meet for discussion of critical issues and decision-making on important matters [25]. In times of crises, Micronesian communities in Hawaiʻi and elsewhere rely on their elders and church leaders for guidance by forming uut abroad [25].

In Arkansas, the Marshallese COVID-19 task force, run by Marshallese leaders, brought together individuals and non-governmental organizations to help the increasing numbers of Marshall Islanders in need of economic and social support [29]. They assisted community members with applying for unemployment and housing relief, conducted outreach concerning prevention efforts, developed messaging relevant to the need for physical distancing and available resources, fundraised for personal protective equipment and funeral costs, and provided language assistance and translated materials to local organizations serving Pacific Islanders [28]. Community members also came together to hold poultry plants, like Tyson, accountable for the immense hardship workers endured as they contracted the virus in substantial numbers when governments and factories did little to help [29]. With a high proportion of poultry workers quarantined or on sick leave without pay, people across Northwest Arkansas contributed thousands of dollars to help Marshallese families avoid evictions, pay bills, cover funeral expenses, and put food on the table [29].

Among Pacific Islander communities in Salt Lake Valley and greater Utah, many leaders sought to acknowledge the significance of reciprocity in Pacific Islander culture through implementation of culturally responsive COVID-19 response strategies [30]. In Southern California, Pacific Islander community-based and faith-based organizations launched “Wellness Phone Banking” to check in with constituents and determine their needs [31].

Government Responses

Elevating Micronesian Leadership

By September 2020, state and county officials in Hawaiʻi had begun to engage Micronesian communities, including appointing Micronesian leaders to government positions. Tulpe Day, a Kosraean community leader who works for the County of Hawaii as an Immigration Information Specialist and serves on the Language Access Advisory Council [25], was asked by Hawaiʻi County Mayor Harry Kim to identify leaders for the County of Hawaiʻi COFA COVID-19 Task Force in response to a COVID-19 cluster in Kona. In Honolulu, attorney Shanty Sigrah Asher was hired as the first Pacific Islander Liaison Officer at the Office of Economic Revitalization for the City and County. Ms. Asher’s role is primarily to engage in outreach and to improve communication between government, community organizations, and community/church leaders and to provide up-to-date COVID-19 resources and information to the Pacific Islander community [25].

Emergency Funding

National funding initiatives, such as the National Institutes of Health Community Engagement Alliance and Rapid Acceleration of Diagnostics, promoted community engagement to reduce COVID-19 disparities by develo** and disseminating prevention strategies, including clinical trial participation and vaccine or therapeutic uptake [32]. In Arkansas, the COVID-19 strategy to reduce health disparities for the Pacific Islander and Latinx communities, led by the Federally Qualified Health Center (FQHC), employed resources from the University of Arkansas Medical Sciences, Arkansas Department of Health offices, and local healthcare providers for testing [33]. Financial support for this initiative was provided through the Arkansas Department of Health’s distribution of CARES act funding [33]. The “Share, Trust, Organize, Partner: the COVID-19 California Alliance” was another team that formed as part of a statewide coalition funded by the National Institutes of Health [31]. STOP COVID-19 CA comprises members from eleven academic sites and over seventy-five community partners across California [31].

Collaboration Among Sectors

COVID-19 Response Task Forces

In response to advocacy from NHPI leaders and in order to support the national COVID-19 strategy at the local level, the Hawai‘i Native Hawaiian and Pacific Islander COVID-19 Response, Recovery, and Resilience Team (NHPI 3R) was formed in early May 2020. The NHPI 3R Team comprised of more than 40 NHPI-serving organizations in Hawaiʻi, including community and grassroots organizations, nonprofits, churches, government, healthcare, industry, and academia [34]. Across the USA, Pacific Islander communities from Arkansas, California, Hawaiʻi, Oregon, Utah, Washington, and Washington DC banded together to create the National Pacific Islander COVID-19 Response Team [4]. Consisting of public health experts, physicians, community advocates, and more than three hundred volunteers from ten states, NPICRT formed to plan and implement infrastructure for informing and supporting Pacific Islander families and communities about COVID-19 [31]. The County of Hawaiʻi COFA COVID-19 Task Force included Marshallese, Kosraean, Pohnpeian, Chuukese, Yapese, and Palauan community leaders who volunteered their time to support the Department of Health, Civil Defense, and other government efforts [25]. Serving as a bridge between members of COFA communities, government agencies, and non-profit organizations, the County of Hawaiʻi COFA COVID-19 Task Force’s work included education and public health messaging, COVID-19 testing, on-site outreach and contact tracing, and post-testing wraparound services [25].

Community and Government

In Hawaiʻi, Pacific Islander community leaders adapted and built on existing partnerships with government and new agencies to collaboratively respond to challenges that would increase the impact and effectiveness of their COVID-19 response [25]. Community leaders also engaged in dialogue with government leaders and agencies, better positioning themselves to provide feedback on present and future initiatives to address COVID-19 response and recovery for Pacific Islanders [25]. Many community leaders continued their pre-pandemic efforts to advocate for the reinstatement of Medicaid access at the federal and state levels for Pacific Islanders [25]. Together, Pacific Islander community leaders and government agencies identified new avenues of establishing, supporting and prioritizing strong relationships between community and government as vital to successfully addressing disparities in COVID-19 and other existing inequities [25]. The increase in collaboration between the government and Pacific Islander communities enhanced the impact of these efforts and amplified the voices of the community [25].

Community and Academia

The University of Arkansas for Medical Sciences (UAMS) has engaged in community-based participatory research (CBPR) with the Marshallese community since 2013 to address health disparities [35]. CBPR shares power and builds trust between academic researchers and community partners by honoring their unique contributions in order to integrate contextually and culturally situated knowledge, practices, and resources [35]. In March 2020, UAMS leveraged existing relationships with key community partners to address COVID-19 in the Marshallese community, resulting in the collaborative development of a COVID-19 Comprehensive Response Plan for the Marshallese Community in Northwest Arkansas [35].

Research Efforts

Data Collection, Disaggregation, and Reporting

The National Pacific Islander COVID-19 Response Team mobilized its regional task forces in California, Washington, Arkansas, Oregon, Utah, and Hawaiʻi to query their county and state health departments to report disaggregated rates of COVID-19 in Pacific Islander populations [20]. Disproportionately high rates of COVID-19 cases in Pacific Islander communities began to emerge as more counties reported disaggregated data [20]. The successful collaboration between NPICRT regional task forces and county health departments sparked the conceptualization and application of a new health information cycle for Pacific Islander communities, and the NHPI COVID-19 Data Policy Lab was formed as a result [20]. In September 2020, the NHPI COVID-19 Data Policy Lab launched a real-time dashboard of COVID-19 rates in Pacific Islander populations throughout the country [20]. In addition to NHPI-specific national COVID-19 data, the dashboard features state-level summaries, a USA heat map, and line graphs of NHPI cases and deaths over time [36]. At least ten regional National Pacific Islander COVID-19 Response Teams and the National Pacific Islander COVID-19 Response Team rely on the NHPI COVID-19 Data Policy Lab dashboard.

As requested by NPICRT, the NHPI COVID-19 Data Policy Lab methodology consisted of faculty and community researchers manually scra** case and death data from 11 online state and county COVID-19 dashboards [36]. By June 2020, NPICRT expanded data requests to 32 states and counties [36]. To increase efficiency, in August 2020, the NHPI COVID-19 Data Policy Lab shifted to the COVID Racial Data Tracker Dashboard as a primary source of state-level data to calculate case and death rates, with population denominators aligned to each state’s race/ethnicity tabulations of cases and deaths [36].

In Hawaiʻi, the Department of Health COVID-19 case report form was revised to collect disaggregated data after a recommendation was made by local Native Hawaiian and Pacific Islander communities and grassroots groups early in the pandemic [37]. During periods of higher incidence, HDOH continued to prioritize obtaining important demographic information, including race, even when conducting abbreviated case interviews [37]. Efforts were designed to achieve a balance between highlighting the concerns of specific populations given high incident rates and inadvertently contributing to the stigmatization of groups who have been marginalized and who experience racism [37].

Advocacy

The NHPI COVID-19 Data Policy Lab dashboard data was used in various communities to increase awareness of COVID-19 impacts on NHPIs and urge decision makers to support community-driven efforts [36]. In September 2020, the NPICRT presented the NHPI COVID-19 Data Policy Lab’s research at the state level to advocate for equitable COVID-19 action during a meeting with the director of the California Department of Public Health. The meeting resulted in the California Department of Public Health’s commitment to prioritize NHPIs in California’s COVID-19 efforts [36]. That same month, the NHPI COVID-19 Data Policy Lab supported a national campaign demanding that the National Academies of Sciences, Engineering, and Medicine include NHPIs in their plan for equitable allocation of the COVID-19 vaccine by sending in advocacy letters and providing public comments. These efforts advised the National Academies of Sciences, Engineering, and Medicine’s final vaccine plan, which recognized NHPIs as a priority population [36]. Additionally, the Inland Empire Pacific Islander COVID-19 Response Team used data from the NHPI COVID-19 Data Policy Lab to advocate for disaggregated NHPI data in Riverside County, California. This motivated the health department to support the Inland Empire Pacific Islander COVID-19 Response Team with more than $60,000 to combat COVID-19 among NHPIs through interventions [36].

Community Outreach Partnerships

Because federal guidance for COVID-19 quarantine were not developed with an understanding of the unique cultural and economic situations of NHPI communities, community organizations took it upon themselves to develop effective strategies and culturally appropriate messaging [28]. Pacific Islander community organizations extended existing outreach and education efforts to include information about COVID-19 and provided culturally appropriate messaging via outlets and platforms preferred by community members [25]. For example, strategic communication to Pacific Islander communities regarding COVID-19 prevention, quarantine, vaccine distribution, and availability of relief programs was found to be most effective with the use of trusted messengers [28]. As such, Pacific Islander elders, church leaders, and other community leaders relayed and reinforced evidenced-based public health messages from the Centers for Disease Control and Prevention, the State of Hawaiʻi, and the local government offices to their community networks [25].

The Micronesian Ministers and Leaders Uut utilized technology to mobilize community through an approach rooted in cultural traditions and values. During their weekly meetings, the uut invited representatives from legal, educational, medical, and social services to disseminate information and address questions and concerns from attendees [25]. Their guests and community partners included the Hawaii Department of Education superintendent, administrators, and teachers; medical providers; American Civil Liberties Union; Medical-Legal Partnership for Children in Hawaiʻi; Office of the Public Defenders; FSM government and FSM Consulate Office officials; Hawaiʻi legislators; Hawaiʻi Department of Health staff; and other service providers [25].

In Northwest Arkansas, UAMS co-developed COVID-19 communications with Marshallese community members as part of their COVID-19 Comprehensive Response Plan to increase prevention, testing, quarantine, and follow-up care among the Marshallese community. [35]. The CBPR partnership also launched eleven Facebook live sessions from March to July 2020, garnering approximately 25,000 views per session [35]. In addition, UAMS and community partners created eighteen YouTube videos that covered topics such as proper mask use, social distancing, and quarantine and isolation guidance [35].

Lessons Learned from Pacific Islander Responses to the COVID-19 Pandemic

Authors from 23 articles provided lessons learned and recommendations for work by and with Pacific Islander communities to address COVID-19. These were grouped into five subthemes: (a) cultural and linguistically responsive outreach and messaging (14 articles); (b) partnership, engagement, and capacity building (12 articles); (c) trauma-informed and strength-based approaches (10 articles); (d) research, data collection, and dissemination (11 articles); (e) policy changes and health equity (9 articles).

Cultural and Linguistically Responsive Outreach and Messaging

Information and outreach are part of any public health campaign. In the publications included in this review, researchers concluded that PI individuals, families, and communities need access to information about when and how to seek emergency care, risk and protective factors for COVID-19, virus prevention and detection, and quarantine and isolation [3, 32]. Studies concluded that outreach to ensure equitable access to protective equipment, cleaning supplies, isolation space, thermometers, and medications is also essential [26].

Authors highlighted that COVID-19 response efforts must be both culturally and linguistically responsive to the diverse needs of Pacific Islander communities in order to have the greatest possible impact, which will require early planning by health officials [26]. Public education materials about COVID-19 and vaccinations should be made available in the languages spoken by local communities, and community health workers as well as individuals staffing information lines should be fluent in the languages spoken by target communities [2, 26,27,28, 31, 31, 32, 38, 39]. Such inclusion of PI languages in outreach efforts also supports language revitalization [31]. In addition to the language that information is provided in, the way in which information is communicated also affects its impact. Simplified, consumer-friendly communication products such as radio, hotlines, social media, news media, websites, videos, testimonials, toolkits/resource kits, 211 assistance, telephone communication, mailers, community spaces, and small guides or infographics are appropriate mediums for sharing information with PI communities [21, 26, 31, 32, 40]. At the same time, internet access needs to be accessible to community members for such campaigns to be effective [26].

Cultural considerations about preferred ways of communicating and receiving information will also help to increase the impact of the information provided. Authors emphasized the importance of information coming from people with whom they have trusted relationships (referred to as “trusted messengers”) that are not simply transactional [21, 25, 32]. Strategies for culturally appropriate communication include communication from trusted community leaders, such as faith leaders [14, 17], health professionals [41] such as physicians [32], and health workers that are from the community [14, 17], engaging entire families and emphasizing multigenerational communication [17, 32, 39] and engaging existing groups, networks, and communities [17, 25, 26, 32, 42].

Scholars reflected that messaging should also reflect established cultural values that are held dear in different cultural groups, for example, by emphasizing altruism and the importance of protecting friends, family, and community [32] or focusing on caring, compassion, and unity [27]. It is important to pay attention and tailor approaches to the specific social context of each community and culture [21, 36], as well as to pay attention to within-group differences, such as those due to gender, subculture, level of health-literacy, religion, and experiences of discrimination [17]. Health promotion and communication must also recognize issues of social justice [28] and social determinants of health [26]. For example, there is a need to recognize and support communities to engage in cultural practices in a socially distanced way [27] and understand that families that live in multi-generational homes have need for affordable and accessible housing or may need additional support services for self-quarantine [33].

Partnership, Engagement, and Capacity Building

Conclusions from the included articles emphasize that engagement of PI community groups is an essential part of the public health response. Engagement of community groups allows for the identification and use of trusted messengers [32] to create more effective interventions for PI Communities [14] and also helps to amplify community voices [25]. This is particularly important, considering that there is often a lack of support and advocacy for PI communities in legislative arenas [26]. Culturally congruent pandemic response also requires that organizations engage with and support mobilization of PI communities [17, 27, 28, 31, 35], and that non-NHPI individuals and organizations practice cultural humility [28, 32]. Institutions and organizations should engage PI community leaders and representatives as well as local organizations that already have trusted relationships with PI communities, in order to develop and implement successful research and community interventions [3, 14, 26,27,28, 32, 38]. Strengthening and harnessing the power of community networks are also crucial in effectively reaching members of the PI community to address potential concerns about vaccination [42], as is inclusion of community members in the vaccine development process [32].

Authors highlighted that partnership and engagement are also important for coordination of culturally and linguistically appropriate care provisions. Support is needed specifically to provide wraparound support for families with COVID-19 positive members vaccine access [28]; address structural barriers to health system access by providing navigational support [26, 32]; and provide support for self-quarantine, including food, medication, worksite support, and behavioral health [33]. Case management programs, community health navigators, and government organizations should be staffed by individuals from the community that speak the language of the people they serve [3, 17, 28].

Efforts are also needed to increase PI representation in sectors that hold power within the realm of public health, specifically in government, research, and the health workforce. There is a need for all levels of government to work to build long-term, trusting relationships with PI communities [20, 33], as well as for efforts to support PI leadership roles within government [25]. Partnerships between communities, government, and academic institutions can increase community capacity and resilience [36]; facilitate data sharing to develop needed services [38]; and conduct health research that is more representative of PI communities and understands the impact of racial bias on PI communities [43]. Similarly, funders and academic institutions should also prioritize investment in building research capacity and supporting PI individuals in becoming research and data scientists [43]. Finally, there is a greater need for more PI representation in the health workforce [38], and organizations should hire and engage with PI community health workers and navigators [17, 26, 40].

Trauma-Informed and Strength-Based Approaches

Trauma-informed and strength-based approaches are also essential components to achieve health equity in the PI community. That is, organizations working with PI communities must understand the diverse, challenging histories that many PI communities have faced, while at the same time focusing on the strengths of PI communities, rather than the deficit-based approach that is often used when discussing health inequities. Authors noted that providers and organizations must be aware of histories of colonization and historical trauma that PI communities have experienced, as well as contemporary experiences of marginalization, discrimination, and structural racism [14, 17, 27, 32]. At the same time, providers and organizations must recognize and center interventions around the strengths of PI families, communities, and cultures; such strength-based approaches also improve engagement and help to build trust [17, 27].

Additionally, scholars highlighted the need to understand current health inequities, while simultaneously working to achieve health equity. First, organizations would be better equipped to work with PI communities if they had foundational knowledge about the unique social context and barriers that different PI communities face [42], including the special citizenship status of some PI communities [28]. Structural barriers to vaccine access can and should be reduced through activities such as mobile clinics, home visits, and community vaccination sites, all while prioritizing at-risk groups and addressing the barriers that are unique to each PI community [32, 39, 41, 42]. Inequities in social determinants of health must similarly be addressed, such as those related to access to education, housing, personal protective equipment, and communication technology such as phone and broadband internet access [17, 26].

More specifically, government and medical organizations should work to develop long-term relationships and build trust with PI communities. This is especially crucial given the historical and contemporary harms many PI communities have experienced, facts that need to be understood and taken into account when considering issues such as vaccine hesitancy [14, 32, 41]. Medical professionals’ vaccine messaging campaigns should be empathetic and understanding, validating concerns acknowledging how the medical field has contributed to systemic racism. Venues such as community workshops, town halls, or hotlines should be developed to provide safe spaces to discuss concerns about vaccines with trusted medical professionals. [32]. There is also a need for advocacy to challenge structural racism that is evident in health strategies designed by and for the majority [26].

Research, Data Collection, and Dissemination

Researchers emphasized the need for data disaggregation, transparency, timeliness, and equity. The importance of disaggregating data from PI communities cannot be understated, as data is needed to understand how pandemics affect specific populations and to inform the public health response in an equitable way. Data disaggregation is particularly important given the diverse languages, cultures, and histories represented in the Pacific and the diverse ways in which communities may be affected by and need to respond to pandemics [17, 27, 37, 43]. PI communities have unique cultures and histories and have been impacted by historical inequity and injustice in diverse ways [43]. At the very least, researchers suggested that NHPI’s should be separated from Asian Americans and other racial categories, and that all levels of government, as well as community and research organizations, should at a minimum adhere to OMB 15 guidelines in order to have consistent, standardized disaggregation for populations. Beyond this, however, standardized means of reporting PI racial and ethnic subdivisions should be the norm [43], as the federal government currently aggregates diverse PI populations into one statistical group [27].

Disaggregation can help to identify specific risk and protective factors, understand the impact of COVID-19 on Pacific Islander communities, create causal models, and choose intervention and policies for pandemic response [17, 28]. Even if numbers may be small, disaggregated data is needed to quickly inform responses for PI populations [36]. To address the issue of small sample sizes, NHIS should collect a second round of specifically NHPI data to create larger sample sizes at the national level [43]. Government and academic institutions can also partner with PI organizations that do their own data collection to assist in identifying community needs [38]. Disaggregation is also needed for categories other than race and ethnicity. For example, vaccine trial outcomes should also be disaggregated by age, chronic disease, and disability status [32].

Researchers also suggested specific research methodologies. For example, longitudinal studies of vaccine intent could show flexibility or stability of these attitudes over time and help to understand why perceptions on vaccination shifted in PI communities [42]. Authors also emphasized the importance of researchers’ understanding of how racial and ethnic inequity affects risk and protective factors [44]. Specifically, machine learning algorithms that create public health models should be created by researchers to understand racial equity, so as not to perpetuate racial inequities through the use of machine learning [43].

Finally, researchers identified the need for timely, transparent, and accurate data reporting. This includes data on COVID-19 infection rates, death rates, vaccination rates, and clinical trial participation and outcomes [27, 32, 38]. Accurate data dissemination is important in hel** to combat misinformation [32] as well as to create informed responses to the pandemic [27]. Data reporting should also be transparent [32]. Data on gaps in terms of resources, policy changes, and disparities should be shared along with successes, and it should be acknowledged when specific information is not available. It is also important that research information is disseminated in a way that is accessible for individuals of any educational background or linguistic community [32, 43]. Especially when looking at data on COVID-19 predictors, historical context should be included as to why rates may be higher, so as not to further stigmatize PI communities [14]. As previously mentioned, strong, egalitarian partnerships are needed to ensure that research findings are presented through the community in ways that are culturally congruent, and trustworthy. In this approach, community voices and perspectives are included in an equitable manner when collecting and interpreting data and that data collected will be useful to the community [32, 38, 43].

Policy Changes and Health Equity

Several authors emphasized a need for macro-level advocacy intervention, particularly looking toward the possibility of future pandemics. Specifically, it must be recognized that there are structural barriers to accessing many of the resources needed for adequate prevention and treatment of disease, and these structural inequalities must be addressed. For example, PI households need access to both knowledge and supplies needed for prevention, detection, and treatment, such as personal protective equipment, thermometers, medication, and space for isolation [26]. Access to information about sites for vaccination, as well as prioritization of vaccines for high-risk groups, is also necessary, both for initial and booster vaccines [42, 45]. Policies that allow for adequate paid sick leave for testing, isolation, and quarantine are also needed [21, 29], as well as free testing, equipment, and hazard pay for essential workers [27].

Community health workers and others fluent in PI languages should be employed to help PI communities navigate healthcare systems and provide linguistically appropriate support [17, 26]. Specific attention was given to the status of COFA migrants [28, 29] such as the need for access to Medicaid and Medicare and, more generally, increased funding and services, all of which could be negotiated into the COFA agreements. In addition, long-term policy changes are needed that will address structural racism and broader racial and ethnic disparities in social determinants of health that affect NHPI communities, such as equity in education, employment, healthcare, housing, criminal justice, leadership, and food insecurity [21, 42, 46]. Resources must also be increased for local NHPI communities [46], and federal grants to state governments should be flexible enough to allow these organizations to address NHPI community needs [28].

Discussion

This paper sought to synthesize the available literature on Pacific Islander responses to and lessons learned from the COVID-19 pandemic, within a USA context. There have been several examples of responses to the pandemic in PI communities, including grassroots community response, state and federal government responses, inter-sector collaboration, research efforts, and community outreach. In addition, authors of research on the COVID-19 pandemic have provided consistent lessons learned and recommendations for working with PI communities during public health crises. These include the importance of cultural and linguistically appropriate outreach and messaging; use of trauma-informed and strengths-based approaches; data disaggregation, transparency, timeliness, and equity in research; and policy changes for health equity. These examples, suggestions, and lessons learned provide key strategies for supporting existing strengths and promoting resiliency among PI communities in future pandemics or other public health emergencies.

The ability of communities to respond to and address large-scale interruptions, such as pandemics or disasters, has been attributed in the literature to the concept of community resilience. Some authors describe a resilient community as one that is able to promote wellbeing among its members in an equitable way [47] or to adapt to disruption in a way that promotes communal goals [48]. Resiliency during public health disasters like COVID-19 has been shown to come from multi-level interventions that focus on the inherent resilience that already exists within the community and bolster efforts and adaptations that focus on specific community needs [49,50,51]. While the COVID-19 pandemic will continue beyond the 2 years we have experienced, the initial response efforts have highlighted the importance of swift action taken by communities to minimize some negative impacts [51]. Previous research from earlier epidemics and other public health disasters have suggested that a focus on community-led efforts, rather than initiatives forced onto communities, will result in higher rates of recovery from the disaster across different measures [52]. The findings from the present study, which emphasize building on PI community strengths at multiple levels, align with existing models of community resilience for public health disasters. At the same time, the articles reviewed in this study emphasize another layer that goes beyond simply looking at “local” solutions: the importance of cultural resources and protective factors.

Although little published material uses the term “community resilience” with respect to PI communities, Pacific Islanders have had their own ways of co** with disasters since before colonization. These often rely on the use of traditional knowledge systems and systems of relations, religion and spirituality, traditional governance systems, strong family ties, and community support [53]. Indeed, a large body of literature suggests that general resilience and protective factors for Pacific Islander peoples are related to family, community, and cultural factors such as collective-oriented values, close-knit families and family support, strong cultural identity, connectedness to land and understanding of natural resources, indigenous knowledge and wisdom, and faith and spirituality [17, 21, 27, 29, 54, 55]. Multiple studies have also demonstrated the importance of religious support, traditional knowledge, and both formal and informal health workforce development for post-disaster mental health in Pacific Island nations [56].

The results from the present study also highlight the importance of Pacific Islander cultural approaches to cope with disasters in the context of COVID-19; examples are the use of traditional and religious leadership structures [14, 17, 25], collectively-oriented cultural values [27, 32], mobilization of resources and information through families and communities [17, 32, 39], and development of a Pacific Islander health workforce that is able to provide culturally and linguistically appropriate services [17, 26, 38, 40]. The ability of communities to take culturally appropriate actions to maintain the health of community members is part of the concept of health sovereignty. Health sovereignty refers to autonomy in making decisions regarding healthcare needs and practices in the best interest of the community members being served [57] and includes the ability of leadership to make culturally appropriate public health decisions, as well as the inclusion of culturally relevant medicinal practices, ceremonies, and alternative medicines [58]. In the recent pandemic, Pacific Islander countries such as Samoa and Tonga that had significant autonomy over their own health decisions were able to achieve substantially lower rates of COVID-19 infection than that of the western world [59]. This is a stark contrast to PI communities’ significantly higher rates of infection outside of these countries, where health sovereignty is not present.

The use of cultural approaches in the future crises is likely to result in improved responses, but this will only be possible if Pacific Islander communities have increased autonomy to make healthcare decisions for themselves. This means that those in positions of power must understand the importance of these cultural approaches and provide support to Pacific Islander communities in implementing them. This requires long term advocacy, trust building, education, and capacity building. However, one needs only look to current collaborative efforts in Pacific Islander communities for examples of how this can be done. In Hawaiʻi, for example, community navigators, social justice advocates, cultural practitioners, university faculty, state employees, and other community partners created the Ulu State Disaster Response Cultural Training series. This six-part webinar program, designed to educate providers and community about Hawaiian and Chuukese cultural understandings of disasters and disaster response, was funded through a state mechanism under the federal Substance Abuse and Mental Health Services Administration [24]. Other successful examples include the community-based participatory research partnerships and cross-sector task forces discussed in this review [25, 27, 35].

This current review has several limitations. First, it was limited to peer reviewed and government documents, which likely excluded the efforts of several local PI community organizations that may not have access to academic and government research apparatuses. Future studies may consider analyzing additional gray literature such as community organization reports and news articles. Second, despite the insistence by authors of the importance of understanding the context of specific PI communities, the articles reviewed largely focused on PI populations in general across the USA. Only the Marshallese ethnic group was the focus of several papers, which suggests the need for more research on COVID-19 with specific PI subpopulations. Similarly, the papers that were dedicated to a particular geographic area focused on Hawaiʻi, California, Arkansas, and Utah. Given that these states have some of the largest PI populations, it is not surprising that this is where there would be more examples of documented PI community efforts to address COVID-19. However, there may be differing challenges as well as community strengths in geographies where the PI population is less concentrated.

PI communities have many strengths and existing cultural practices that can effectively help to address public health challenges but need better access to resources, including being in positions of decision-making power. Whether in states with a high concentration of PI diaspora or not, organizations and institutions, from local to federal government, should work immediately to build and strengthen trusting partnerships and provide support for Pacific Islanders in the political, research, and health workforces. Future public health crises such as COVID-19 are inevitable; however, their disparate impacts on PI and other ethnic minority communities are preventable if local communities have the autonomy to implement the culturally and linguistically responsive solutions that they know will work best within their own communities.