Ph.D - Public Health

Permanent URI for this collectionhttps://hdl.handle.net/10125/61893

Browse

Now showing 1 - 20 of 20

Improving healthcare access in rural Hawaiʻi: A multi-method investigation to mitigate existing barriers
(University of Hawai'i at Manoa, 2025) Kawakami, Keilyn Leinaala; Sentell, Tetine; Public Health
Having adequate healthcare access includes having sufficient insurance coverage, and also the ability to receive timely and quality care from healthcare professions. Poor access to healthcare services can lead to negative health outcomes, unmanaged chronic diseases, and a shorter life expectancy. Many factors contribute to healthcare inaccessibility including insufficient insurance coverage, cultural competency issues, financial barriers, provider workforce shortage, and a lack of transportation. Transportation is an understudied barrier to healthcare though it is critical to timely access services. Residents living in Hawai‘i face unique transportation-related issues due to the non- contiguous nature of the state. Hawai‘i is a geographically isolated archipelago comprised of six inhabited islands, which are separated by mountains and open ocean. Many residents of neighbor island and rural communities travel long distances for healthcare services. Much of this travel requires flying to the island of Oʻahu as the neighbor islands of Kauaʻi, Maui, Molokaʻi, Lānaʻi, and Hawaiʻi island have a shortage of healthcare providers and offer extremely limited specialty care services due to the lack of advanced medical equipment available. In these flights, neighbor islands residents may experience airline delays or cancellations, therefore postponing necessary care. All of this can have a negative impact on their overall health. Given the importance of this understudied topic, this three-study dissertation focused on healthcare access and transportation in the state of Hawai‘i. Study 1 analyzed demographic and socioeconomic factors as predictors for healthcare accessibility in Hawaiʻi. A secondary analysis was conducted using five waves of data (2018- 2022) from the Behavioral Risk Factor Surveillance System (BRFSS) to determine whether the participants were able to see a doctor for a regular checkup within the past year. Adjusted results indicate potential risk factors for poor healthcare access: working-class age (18-64-year-olds), low-income, unmarried, uninsured, neighbor island residency, and self-employment. Study 2 explored transportation-related barriers that Molokaʻi and Lānaʻi residents face for healthcare services. Eight community members from the islands of Molokaʻi and Lānaʻi were identified through purposive sampling and participated in semi-structured individual interviews and sequential focus group sessions. Participants shared their frustration with limited transportation options, the lack of insurance benefits in covering transportation, and the expensive costs they pay out-of-pocket when traveling to see providers. Although participants preferred decreasing the need to travel altogether, they also shared other ideas for solutions to these challenges, including the benefits of having additional airlines service the islands, improving insurance coverage for transportation benefits, and funding more specialists to frequently visit to provide care on island. Study 3 conducted a systematic review to identify the current literature, strengths, and gaps surrounding existing transportation interventions created to improve healthcare access among rural communities in the United States. The six articles that met the inclusion criteria discussed that transportation interventions are successful when they are easy to use for the patient, low-cost for the healthcare facility and insurance provider, and extend to patients living in the most remote areas. However, there have been issues with patients not being picked up on time, recruiting and retaining drivers, and the overwhelming nature of having to manage the interventions. The studies demonstrate that it would be beneficial for either healthcare facilities or insurance providers to assign a single point of contact to arrange transportation for the patients. In addition, driver recruitment and reliability could be improved by increasing incentives and penalties. Taken together, these three studies identified (1) which populations are most impacted by healthcare inaccessibility in Hawaiʻi, (2) what specific challenges these populations face when accessing and utilizing healthcare services, and (3) potential evidence-based solutions that could be implemented to decrease these barriers. Future research should identify funding sources as well as assess viability and sustainability of these solutions. These three studies can inform future interventions to improve healthcare accessibility and long-term health outcomes for residents living in rural communities in Hawaiʻi.
EXPLORING PAIWAN ELDER VIEWS OF HEALTH, AGING, AND SERVICE PREFERENCES
(University of Hawai'i at Manoa, 2024) Huang, Yu-Chi; Braun, Kathryn; Public Health
The objective of this dissertation was to develop a cultural lens for the Paiwan tribe of Taiwan by exploring Indigenous definitions of health and healthy aging and preferences for eldercare. My interest in this topic stems from my membership in the Paiwan community and as a former employee and current volunteer with our local tribal elderly care center. I completed three studies for this dissertation.In Study 1, I explored definitions of elderhood among Indigenous Peoples through a systematic literature review. To do this, I reviewed studies in which elderhood was defined and perceived within Indigenous communities. I found that the definition of elders within Indigenous communities predominantly revolves around their portrayal as symbols of wisdom, custodians and transmitters of cultural knowledge, and their ability to guide the sustainable development of tribes. Within Indigenous communities, elders are not only witnesses to history but also guardians of cultural values and traditional knowledge. This perspective of elderhood is critical for understanding healthy aging in Indigenous communities. In study 2, I established a “conceptualization of healthy aging” among Indigenous Paiwan elders. To do this, I conducted a focus group with Indigenous elders on their perspectives and thoughts regarding Paiwan health and healthy aging. I found that healthy aging encompasses more than just physical well-being. It includes the following aspects: establishing connections and interactions with others, communities, and traditional cultures; engaging in lifelong learning; contributing to one's tribe and family; and generating additional value in traditional domains. Furthermore, this study discovered that among the Paiwan elders, the definition of elderhood is not solely based on chronological age but rather on personal achievements and contributions to the tribe. This definition differs from that of elderhood in mainstream Taiwanese society. Additionally, the establishment of cultural health stations was found in this study to be beneficial for elder health. However, elders wanted the stations to increase land-based activities and substantively involve the tribe in the operation of stations. In Study 3, I identified the reasons that Paiwan elders participate and do not participate in the currently operating day care stations established by the Taiwan government. To do this, I administered a quantitative survey with the elders in daycare stations and elders not in the daycare stations to assess their reasons for participating or not and how services can be improved. I found that the elders, whether were or not they participated in the daycare stations, agreed that the current daycare stations were supportive and beneficial to their later lives. However, gender, age, living with others, personal economic status, and acceptance of the activities currently offered at the stations influenced their participation of daycare stations. The findings from this dissertation will assist Indigenous Paiwan elders to improve the structure and cultural relevance of services and policy around long-term care for their communities.
Unveiling Ghost Provider Networks for Hawaiʻi Medicaid Members, 2023
(University of Hawai'i at Manoa, 2024) Holmes, Joshua Ryan; Wu, Yanyan; Public Health
Provider networks dictate which providers health plan members can see to receive health services. Given this importance, provider networks can act as both facilitators and barriers to members’ access to care. Ghost Networks refer to the portion of the provider network that may be unusable to some or all members. In Hawaiʻi, the extent to which the Medicaid provider network is available to members is unknown. All five health plan provider network files were combined to create a state-wide provider network. Overall, 94.1% of the provider network is open to accepting new members with variation depending on island-rurality location and provider specialty. A significantly smaller proportion of the provider network (75.3%) has actually seen a Medicaid member in the past 12 months. Various factors found to be positively associated with being active and accepting new members include providers offering telehealth to other island-ruralities and number of health plan contracts. Secret shopper calls for primary care and behavioral health providers identified pervasive provider directory inaccuracies and low appointment attainment (14.3%). Over half (55.9%) of provider directory listings may contain inaccuracies presenting another potential barrier to accessing care. These findings have important implications for addressing potential access to care issues for health plan members. Prevalent provider directory inaccuracies, changes in accepting new patients status, and widespread provider inactivity may limit the number of providers to which beneficiaries have access and ultimately impact health care utilization and outcomes.
UNDERSTANDING HOW TO BEST UTILIZE SOCIAL MEDIA TO ENCOURAGE PHYSICAL ACTIVITY AMONG ADOLESCENTS
(University of Hawai'i at Manoa, 2024) Santilena, Katharine; Keliʻikoa, L. Brooke; Public Health
In the state of Hawaiʻi, 15% of high school-aged students are considered to have obesity. The increase in sedentary lifestyles and lack of physical activity contributes to obesity prevalence among adolescents. Nationally, over three quarters of adolescents do not meet the federally recommended amount of an hour of moderate to vigorous physical activity each day. While not meeting recommendations for physical activity, adolescents in the US spend on average 3 hours on social media each day. In fact, 98% of adolescents in the US access social media on a smart device, making social media a ready avenue to promote physical activity. Social media is increasingly being used within health promotion marketing strategies to enhance community outreach and encourage healthy behaviors such as increasing physical activity. However, creating physical activity-focused social media content that resonates with adolescents and young adults remains a challenge. Despite the user-friendly components of social media, no widespread best practices have been created to advise health organization content creators who aim to target the adolescent and young adult population. The purpose of this dissertation is to examine how to best utilize social media to promote physical activity among young people. This dissertation research consisted of 3 studies, which were guided by McGuire’s Communication Persuasion Model. Study 1 was a systematic review of studies addressing adolescent and young adults' physical activity levels with a social media intervention. The analysis found that studies that used social media saw significant results when it came to participants’ physical activity levels in comparison to a control group or from baseline. Study 2 explored the social media content preferences of adolescents affiliated with the YMCA of Honolulu. The interviews found the following themes to make content more desirable for adolescents: 1) include more adolescents (13-17) within the visual of the post, 2) create comedic content intended to make the audience laugh, 3) use sports content displaying sports that adolescents also participate in such as basketball and volleyball, 4) prefer social media content that follows current trends, and 5) acknowledge that adolescents use social media as a means of information and staying connected with family and friends. Study 3 examined the relationship between the content themes from Study 2 with audience engagement of the YMCA of Honolulu’s Instagram within a four-year sample. ANOVA statistical analyses were run to examine if the themes contributed to the audience engagement (likes and comments) of the posts. The three themes that saw significant associations included adolescents within the visuals of the post, posting sports content, and creating content that reaches out to the community, suggesting if used within the Instagram posts there is a better chance of the audience engaging with the posts. As adolescent overweight and obesity continue to be a health issue within the Hawaiʻi adolescent population, it is important to explore innovative avenues of health promotion such as social media to promote and encourage physical activity. Findings suggest that these efforts must be done in collaboration with health organizations' target audiences and communities. However, continued work is needed to explore and identify resonating content that adolescents and other communities can relate to. By incorporating newer promotion materials such as social media, health organizations can continue to reach their audiences in more modern and effective ways.
Towards a Healthier Future in the Northern Mariana Islands: Understanding Influences of Diet and Physical Activity on Overweight and Obesity of Young Children
(University of Hawai'i at Manoa, 2024) Dela Cruz, Rica Ann; Novotny, Rachel; Public Health
Childhood overweight or obesity (OWOB) has many adverse health consequences throughout the life course. A group of islands where childhood OWOB is of great concern is the U.S. Commonwealth of the Northern Mariana Islands (CNMI), an archipelago located in the northwestern region of the Pacific. Various sociocultural and environmental influences have been found to affect childhood OWOB and related health behaviors, including diet and physical activity. Determinants of childhood OWOB found in the Pacific can be seen across the socioecological levels (i.e. individual, interpersonal, organizational, community, and policy). Very little research has been conducted to understand the sociocultural and environmental determinants of childhood OWOB specific to the CNMI. The objective of this dissertation is to fill this gap in the literature by describing the dietary patterns and physical activity behaviors of children in the CNMI and assess the sociocultural and environmental factors contributing to health behaviors, which ultimately determine weight status. Three study aims were examined to answer the central hypothesis developed from the Institute of Medicine’s framework on childhood obesity prevention – availability and/or quality of health-promoting foods and spaces for children’s activity in communities influences childhood diet and physical activity in remote Pacific islands such as the CNMI, which in turn determine childhood weight status. Aim 1 examined differences in dietary patterns and physical activity behaviors among CNMI children ages 2 to 8 years old of varying weight status and demographics using baseline data collected from the Children’s Healthy Living (CHL) program. Diet and physical activity data were assessed in terms of U.S. health indices using the 2005 Healthy Eating Index (HEI-2005), screen time, and metabolic equivalents (METs). Weight status was assessed using body mass index (BMI) category and BMI z score, with cut points as defined by the U.S. Centers for Disease Control and Prevention (CDC), removing underweight. This study found 1 in 3 CNMI children were OWOB, with the older age group of 6 to 8 years old having higher OWOB than 2- to 5-year-olds. Diet quality of CNMI children needs improvement, with a HEI-2005 total score of 60.9 out of 100. Eighty percent of children exceeded the recommended amount of screen time, averaging about 5 hours of screen time per day. Almost 60% of children had the recommended amount of physical activity (1 hour or more of daily moderate to vigorous activity), averaging 1.3 hours of moderate activity per day, but only 0.07 hours of vigorous activity per day. Significant differences in HEI-2005, screen time, MET hours, and BMI weight status were found by age group (2-5 years old and 6-8 years old), race and ethnicity [Northern Marianas Descent (NMD), Other Pacific Islander, Filipino, and Other race and ethnicity], and CNMI village residence (Kagman, Koblerville/San Antonio, Oleai, and Tanapag/San Roque). Children who ate any fruits or vegetables classified as traditional in the CNMI also had higher HEI-2005 total scores than those who ate none. In statistical models, no association was found between HEI-2005 and MET hours with BMI z score or OWOB in the total sample of children. However, in subgroup analysis stratifying age groups, an inverse association was found between HEI-2005 and BMI z score among the 6- to 8-year-old children only, showing higher quality diet among 6- to 8-year-olds with lower BMI z score. Aim 2 assessed how the food and physical activity environments in CNMI communities affect diet, physical activity behaviors, and weight status of children using data collected from CHL’s Community Assessment Toolkit (CAT) surveys, which assessed food and physical activity environments using separate scoring systems. No significant associations were found between the food and physical activity environments and health behaviors (diet and physical activity) or weight status. Despite this, differences in environmental components were found by community, store type, and physical activity space facility setting, demonstrating how these environments can be improved. Aim 3 identified perceived facilitators and barriers that allow or inhibit parents/caregivers to promote healthy behaviors for children in the CNMI using a qualitative method and community-based participatory research approach called Photovoice. Parents/caregivers of children ages 2 to 8 years old were asked to take photos in their communities and homes of what they believed to be facilitators or barriers of healthy living for their children. Photos were discussed through focus groups that generated ideas for action to improve the food and physical activity environments in the CNMI. Seven (7) overarching themes of facilitators and barriers were found – Availability & Access to Food, Physical Activity Spaces, Activity Choices, Environmental Resources, Norms, Affordability of Food & Activities, and Family Influences. These results did not provide enough concrete evidence to support this dissertation’s central hypothesis that availability and quality of health-promoting foods and activity spaces in CNMI communities influence childhood diet and physical activity, which in turn would influence childhood weight status. Descriptive findings from Aims 1 and 2 and qualitative findings from Aim 3 suggest that there are some differences in the availability and quality of health-promoting foods and activity spaces in addition to differences in child dietary patterns and physical activity behaviors between CNMI communities. This dissertation also revealed the significant influence of individual level factors, such as age and race and ethnicity, on health behaviors and weight status. These findings suggest the need to expand data collection in the CNMI and for more robust methods to assess the association between environmental factors and individual level health behaviors and outcomes, particularly in smaller, more homogenous populations. From these findings, implications for public health practice include increasing interventions that focus on the transition into elementary school, supporting and expanding local sustainable agriculture, and creating policies and programs to improve food store outlets and physical activity spaces in the CNMI. Future research is needed to improve and expand methods for studying the food and physical activity environments, further examine traditional food intake of children, and continue surveillance on child diet, physical activity, and weight status.
How deep is your kaumaha? Unfolding the experiences of historical and intergenerational trauma among Wāhine
(University of Hawai'i at Manoa, 2022) Keaulana-Scott, Samantha; Chung-Do, Jane; Public Health
Historical trauma, the collective, intergenerational wounding from mass subjugation, has been theorized to unconsciously impact Indigenous peoples, including Kānaka Maoli (Native Hawaiians). Previous research has sought to measure historical trauma as a construct that determines the health of contemporary peoples and validate its use among Indigenous populations. However, only a couple of studies have empirically documented historical trauma among Kanaka Maoli and none among Wahine only. The aim of the present research was to contextualize and measure historical and intergenerational trauma among Wāhine in an effort to validate a historical trauma scale that reflects and measures their experiences. The central hypothesis for this dissertation was that historical trauma among Wāhine is unique, and as such, any scale to measure the construct among this group should be unique as well. A mixed-method design employed 1) a systematic literature review to determine existing psychometrically valid scales measuring historical trauma among Indigenous peoples, 2) a qualitative, phenomenological study to unpack the experiences of Wāhine with historical trauma through semi-structured interviews that began with moʻokūauʻhau (genealogy) and established pilina (relationships), and 3) a factor analysis to explore the psychometric properties of an adapted Historical Loss Scale (HLS) among an all-Wāhine sample. Considering all three studies, the results suggest the following: 1) measuring historical trauma has been achieved through several, psychometrically sound scales developed with or informed by Indigenous communities, 2) Wāhine face the brunt of multilevel violence from sexism, racism, and classism both historically and contemporarily that have been traumatic for their kūpuna Wāhine and themselves, and 3) Wāhine endorse an adapted, hierarchal, three-factor HLS model that measures the impact of historical traumatic events.
HEALTHY WRITING: INTEGRATING WRITING SKILL DEVELOPMENT INTO UNDERGRADUATE PUBLIC HEALTH CURRICULA
(University of Hawai'i at Manoa, 2023) Patil, Uday; Nelson-Hurwitz, Denise; Public Health
Undergraduate public health programs are booming. Public health graduates with strong writing skills are in high demand and are better prepared for a wider array of writing tasks in employment across the health sciences (Valladares et al., 2018). However, students are not writing well. While the theoretical benefits of writing instruction and practice in undergraduate public health coursework are transparent (August et al., 2019; Mackenzie, 2018; Valladares et al., 2018), implementing such ideas is still opaque. There are few established models or conceptual frameworks to guide the integration of public health topics to existing best practices in undergraduate writing pedagogy. This dissertation (a) qualitatively reviewed the program landscape of undergraduate writing in public health to create a framework of factors that support writing instruction and fitted this information into an intervention curriculum; (b) qualitatively evaluated the intervention; and (c) quantitatively evaluated the intervention. Findings show there are common instructional strategies practiced in undergraduate public health programs that result in better student writing outcomes. However, implementation of these practices into a writing-intensive public health course yielded limited and inconsistent results. More research is needed into public health-specific writing pedagogy to better prepare students for school and work.
Is PrEP for me? Knowledge, Attitudes, Behaviors, and Perspectives about PrEP among Black Women Living in the South
(University of Hawaii at Manoa, 2022) Sophus, Amber; Braun, Kathryn L.; Public Health
Significant racial and regional disparities are associated with HIV incidence rates among Black women in the United States, particularly of those who live in the South. While strides to improve HIV prevention efforts with Black, heterosexual women have occurred, more is needed. Pre-exposure prophylaxis (PrEP) is a woman-controlled HIV prevention strategy that can combat high rates of HIV and be used without the need to negotiate with a sexual partner. Although Black women are at the highest risk for HIV acquisition, they have the lowest rates of PrEP uptake in the U.S. The purpose of this dissertation was to expand public health understanding of the current status of HIV and AIDS prevention interventions for Black women in the U.S., highlight key aspects of recruitment ads that appeal to Black women to improve recruitment efforts for this population, and expand PrEP-related research on population characteristics and health behaviors associated with PrEP use among Black women who live in the South. This dissertation reports on findings from three studies. Study 1 was a systematic review that provided an examination of the status of HIV/AIDS prevention interventions for Black, heterosexual women in the U.S. from 2012-2019. Findings highlight gaps in HIV/AIDS prevention interventions for Black women in the U.S., specifies sub-populations of Black women that may need more attention in terms of HIV/AIDS services and programs, and provides recommendations for current and future HIV/AIDS prevention interventions that are specified for Black women. Study 2 used formative qualitative research to examine Black women’s general likes and dislikes about women-focused ads, and their preferences for ad content and ad locations in order to gain the interest of Black women to participate in health-related research. Findings not only extend the existing literature by describing aspects of online and physical ads that may appeal to Black women but highlight a specific area of featuring Black health providers as well as patients within ads that has not yet been identified in the current literature. Study 3 used quantitative methods through the use of an online survey to identify population characteristics and health behaviors associated with general likelihood to use PrEP and whether an individual planned to start PrEP soon (i.e., in the next 3 months) among a sample of at-risk HIV-negative cisgender Black women. Findings extend current PrEP-related literature about PrEP uptake among Black women by providing insight into additional factors associated with likelihood to use PrEP and future plan to use PrEP within this population. Findings also indicate a need to further examine how PrEP stigma may affect PrEP use among Black women.Overall, findings from this dissertation highlight the need for additional programs and resources that improve HIV prevention strategies for Black women and help promote PrEP uptake within this vulnerable population.
Program Evaluation Of The Kūpuna Food Security Coalition In Honolulu County: Effectiveness Of Community-based Intervention To Address Food Insecurity Among Older Adults
(University of Hawaii at Manoa, 2022) LEE, JIN YOUNG; Braun, Kathryn L.; Public Health
According to the U.S. Census, about 5.3 million older adults in the U.S. are food insecure despite the availability of multiple federally supported supplemental food programs. The reality is that this number likely underestimates the number of food-insecure older adults due to inadequate measurement methods. Food insecurity for older adults is a highly complex issue that goes beyond the financial resource constraints captured in the census to include factors at all levels of the Social-Ecological Model. COVID-19 made the problem even worse due to increased demand and reduced accessibility for older adults. Public/non-profit partnerships are a proven way to address this kind of complex social issue. However, there are no published studies that systematically investigated the success of this type of coalition approach in addressing older adult food insecurity. The Kūpuna Food Security Coalition (Coalition) is a community partnership formed in 2020 to address the complex issue of food insecurity among older adults in Honolulu County. This dissertation evaluated the Coalition's approach to addressing food insecurity for older adults and assessed whether their work could be replicated in other communities and whether the approach was scalable to meet demand across broad, diverse geographies. Study 1 evaluated the operating model of the Coalition, which was based on Collective Impact framework. Looking at the successes and lesson learned in the Coalition's strategy and structure, the study found that their approach worked well in addressing food insecurity among older adults in the short term and that this framework could be replicated by other public/non-profit partnerships. Study 2 developed a model, called the Older Adult Food Insecurity Index, to predict the number of food-insecure older adults at a local and national level, addressing a significant gap in available tools. Multiple factors associated with food insecurity for older adults across all levels of the Social-Ecological Model were identified, weighted by relative impact, and combined with publicly available data at a local level to create the predictive model. Using this model to predict the number of older adults in Honolulu County, which was the geographic focus of the Coalition, resulted in the likely number of food insecure older adults being 2.5 times higher than identified in the most recent census. Study 3 leveraged an adequacy performance evaluation approach to assess the scalability of the Coalition's approach, incorporating both cross-sectional and longitudinal assessments relative to the number of food insecure older adults identified in Study 2. This study found that there were no barriers to the scalability of the Coalition's approach to address food insecurity for older adults across geographies, demographics, or changes in market demand. This multi-faceted assessment of the Coalition’s approach, while identifying several opportunities, confirmed that the model was replicable and scalable for other communities and coalitions that want to address the issue of food insecurity for older adults.
Addressing the Needs of Food Insecure Children
(University of Hawaii at Manoa, 2020) Monlux, Amalie; Braun, Kathryn L.; Public Health
Food insecurity affects 50 million Americans, which is about 14% of the population (Gundersen & Zilliak, 2015). Seventeen percent of households with children are food insecure (Hunt et al., 2018). A recent study reported that 15% of children ages 2-5 living in a food-insecure household are obese, compared to 11% of children in food-secure homes (Kaur, Lamb & Ogden, 2015). Children who are food insecure are more likely to present with poor nutritional outcomes (Hunt et al., 2018). There exist few studies on household food insecurity in sub-populations, so this dissertation focused on several understudied sub-populations. The purpose of this dissertation was to determine the needs of children in food insecure households in specific populations. This dissertation included three studies, and was guided by the Social Ecological Model framework. The first study was a secondary analysis of data from Hawaiʻi-based children in the Children’s Healthy Living (CHL) Program to determine differing characteristics of food-secure and food-insecure children. I found that food-insecure children were more likely to be living with overweight or obesity, and their caregivers were more likely to not have a college education and not be employed. The second study was a systematic literature review on the effects of school-based food pantries on children’s diets. The articles included in this review reported that children who participate in school-based food pantries increased their consumption of fruits and vegetables and decreased their consumption of unhealthy food intake. For the third study, I completed a series of one-on-one interviews with food-insecure parents who are college students. This study found that college students who are parents utilize a variety of strategies to increase their household food-security status, including focusing on price versus nutritional quality of food, reaching out to family and friends, attending food banks or food pantries, and prioritizing their children before themselves. Taken together, the findings show four things. First, financial resources are a strong predictor of household food insecurity. They are also a determining factor in food purchasing decisions. Households with limited financial resources are more likely to be food insecure. They are also more likely to purchase food based on price, not on nutritional quality. Secondly, children who are food insecure are more likely to be overweight or obese (OWOB). Third, food assistance programs are helpful, but do not prevent food insecurity. Lastly, food security status does not seem to influence the amount of fruits and vegetables in a child’s diet. The quantitative study using CHL data showed no significant difference in fruit and vegetable consumption in children who were food secure or food insecure. The studies included in the literature review reported that children ate more fruits and vegetables when offered, with no mention of food security status. The parents who were interviewed for the qualitative study discussed that they are more worried about price of a food than nutritional value, which limited the amount of fresh food they would buy. This study offers several recommendations. First, food distribution programs such as school pantries and food banks, should increase their focus on supplying fruits and vegetables. Second, increasing minimum wage and providing affordable housing would help families have more disposable income for healthy foods. Third, the income criterion for eligibility for federal food assistance should be increased so that more families qualify.
Inflammation, Type 2 Diabetes, and Cancer: Identifying Biomarkers Associated with Colorectal Cancer and Type 2 Diabetes, and the Use of microRNA Molecules as a Therapeutic Use for Cancer Treatment
(University of Hawaii at Manoa, 2020) Guillen, Jenni Kimiko; Grandinetti, Andrew; Public Health
ABSTRACT Chronic disease has been a growing epidemic for the past few decades. Approximately 70% of the world’s population dies from a noncommunicable disease every year. This accounts for over 38 million annual deaths worldwide. Cardiovascular disease, cancer and diabetes account for a large proportion of chronic death cases. The methods for controlling and reducing cases of chronic disease have been focused on the reduction of lifestyle risk factors, such as poor nutrition and a lack of physical activity, and increasing screening, surveillance and treatment. These preventive measures and early surveillance tools are considered more effective at reducing loss and less costly than treating those with later stages of chronic disease. Diagnostic, prognostic, and treatment methods come in a variety of forms. One of the more recent methods is the screening of molecular biomarkers. The field of molecular biomarkers has recently exploded. In 2016, it was reported that over 768,000 papers were directly linked with biomarkers, and that the number of publications have exponentially grown within the last few years. With the overwhelming amount of publications, it has become necessary to systematically review the information so that health care providers, policy makers, researchers and other key public health members can access these novel markers readily. The aim of this dissertation was to focus on early screening for prevention and early detection of colorectal cancer (CRC) and on novel treatment techniques for patients with CRC. Through the implementation of systematic review and meta-analysis approaches, this dissertation had 3 main study objectives: 1) to identify and quantify acylcarnitine and carnitine biomarkers that are upregulated or downregulated in three diabetic conditions (type 1, type 2, and gestational diabetes) and in prediabetes, 2) to explore 5 key microRNA molecules upregulated in CRC patients that have been found to have high sensitivity and specificity percentages (>60%), and 3) to identify microRNA molecules that act as tumor suppressors in patients with CRC and their target gene(s) or gene product(s) whose expression is affected by tumor-suppressing miRNAs. In the first study, the systematic review and meta-analysis of the acylcarnitine and carnitine biomarkers in the prediabetic and diabetic conditions revealed that these biomarkers are, for the most part, upregulated in those with diabetes when compared to non-glycemic participants. An upregulation of acylcarnitine, a short-chain fatty acid, was found in participants diagnosed with gestational diabetes, prediabetes, and type 2 diabetes, but not in type 1 diabetes, an autoimmune disease. In addition, the systematic review found 30 more acylcarnitine/ carnitine molecules were upregulated and 3 were downregulated in patients with type 2 diabetes. The meta-analysis of type 2 diabetes confirmed the findings of the systematic review for 4 acylcarnitine derivates: an upregulation of acylcarnitine, propionylcarnitine, isovalerylcarnitine, and palmitoylcarnitine. However, in contrast to the other diabetic conditions, type 1 diabetes was found to have a downregulation of free carnitine with no other biomarkers clearly upregulated. In the second study, the systematic review of miRNA-1246, miRNA-202, miRNA-532, miRNA- 1229, and miRNA-21 found that all 5 key microRNAs were significantly upregulated (p<0.05) in those with CRC and additionally in patients with colorectal adenoma (CRA), which can develop into colorectal cancer. All of the studies for miRNA-1246, miRNA-202, miRNA-532, miRNA- 1229 and most of the studies for miRNA-21 also reported high sensitivity and specificity percentages (>60%). The meta-analyses of miR-21 supported the systematic review and was found to have significant overall pooled estimate effects for both the odds ratio (OR = 7.37 [2.25, 24.14] with outlier and 4.14 [1.91, 8.98] without outlier) and the overall survival hazard ratio (OS HR = 2.97 [1.73, 5.09] with outlier and 2.13 [1.67, 2.72] without outlier). However the overall pooled disease free survival HR was not significantly different between CRC patients and non-CRC participants, HR = 2.12 (0.94, 4.79), which could be due to the number of included studies (n=3). In the third study, a systematic review of the tumor-suppressing microRNAs that regulate target genes and gene products known to directly affect the development of CRC was conducted. These tumor-suppressing miRNA molecules are irregularly expressed and their downregulation can lead to the overexpression of oncogenic genes. Therefore, recovery or reintroduction of these tumor suppressing miRNAs could be a potential treatment for individuals diagnosed with cancer. The analysis of this study identified 93 microRNAs and 61 target genes. Of the microRNAs and gene targets found, only 5 miRNAs (miR-22, miR-23a, miR-137, miR-375, miR-425-5p) and 4 genes (ZEB2, LGR5, BCL2, CCND1) were reported in more than one study. With the lack of published results on the same miRNAs and target genes, it is difficult to assess whether these biomarkers can be used in a clinical setting. More research needs to be conducted on tumor-suppressing miRNAs and their target genes in order to accurately assess the value of using miRNAs as a treatment for CRC. The development of using biomarkers for diagnostic, prognostic, and therapeutic purposes requires the continuous identification and quantification of these molecules in patients with chronic diseases at various stages. The body’s processes are complex and sometimes not well understood, but with continued research, a better understanding of how these mechanisms work will lead to better prevention, control, and treatment.
Total Glucose Intolerance, Hypertension, and Metabolic Syndrome in a Multi-Ethnic Community in Rural Hawai‘i: The Kōhala Health Research Project
(University of Hawaii at Manoa, 2020) CUNANAN, VANESSA LLENARIZAS; Grandinetti, Andrew; Public Health
Using cross-sectional data from the Kōhala Health Research Project, this dissertation examined the prevalence of, and risk factors for, chronic diseases and conditions that may disproportionately affect underserved and understudied ethnic groups. Studies 1 and 2 analyzed prevalence differences and prevalence ratios for total glucose intolerance (TGI) and hypertension among Filipino Americans (FAs) in the study. TGI includes type 2 diabetes and its precursor states of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) (1, 2). Study 3 utilized confirmatory factor analysis (CFA) and multi-group CFA to determine the best fitting metabolic syndrome (MetS) model structure for the study sample; configural invariance across different ethnic groups in the study; and, how the measured risk variables manifested or clustered according to ethnic group. Findings demonstrated disproportionately high prevalence of TGI and hypertension in the FA group. The CFA revealed an acceptable fit for a 4-factor model possibly underlying the MetS structure. High factor loadings for the obesity and hypertension factors emphasized the importance of preventing and/or mitigating the effects of these MetS components across all ethnic groups. Configural invariance from the multi-group CFA indicated acceptable fit, suggesting that the pattern of fixed and free parameters in the 4-factor model was equivalent or stable across all five ethnic groups. By analyzing TGI and hypertension prevalence with ethnicity, place of birth, and acculturation mode in addition to CFA and multi-group CFA, the overarching objective of this dissertation was to add to existing knowledge on prevention, screening, and intervention practices for chronic diseases and conditions with enormous impact on vulnerable populations – all crucial, timely, and fair given public health’s mandate and mission of optimal and equitable health for all.
Evaluation Of A Post-baccalaureate Medical Education Program For Disadvantaged Students To Diversify The Healthcare Workforce In Hawaiʻi (1996 – 2016)
(University of Hawaii at Manoa, 2019) Purdy, Chanley Malia; Braun, Kathryn L.; Public Health
In Hawai‘i, Native Hawaiians and other Pacific Islanders (NHOPI) comprise 26.2% of the population, but make up only 3.7% of the physician workforce. The Association of American Medical Colleges (AAMC), the American Medical Association (AMA), and the Institute of Medicine (IOM) have stated that a health care workforce reflective of the population it serves will help reduce health disparities and increase equity. This is, in part, because physicians from underrepresented minority groups tend to be more likely to serve patient populations that are underrepresented, underserved, and in rural areas, and because many underrepresented patients prefer race- and language-concordant providers. On average, less than 20% of John A. Burns School of Medicine graduates are of an underrepresented minority (JABSOM OSA, 2016). The Department of Native Hawaiian Health (DNHH) medical education division was created to increase diversity in the medical profession in Hawai‘i. The ‘Imi Hoʻōla Post-Baccalaureate Program (IH), although longstanding, has not been formally evaluated to determine whether they are meeting the mission of increasing diversity of the health care workforce. This dissertation included three studies. For the first, a secondary data analysis was conducted to determine profile differences between students who successfully completed the IH program, and those who did not. A high science grade point average (GPA) and attitude towards academic success are important predictors for IH program completion. Through a series of focus groups with program participants, the second study identified the key components of the IH program that led to successful matriculation and academic achievement in medical school. These included financial support, social support, and mentorship. The third study assessed the practice outcomes of IH graduates through a secondary data analysis and found that 58% of IH graduates practice primary care, 39% practice in Hawaiʻi or the Pacific Basin, and 44% practice in an underserved and/or rural area. The findings of this research suggest that IH admits students who are committed to its mission of producing physicians that practice primary care in medically underserved areas in Hawaiʻi and the Pacific Basin, and that pipeline and pathway programs such as IH are a successful way to increase diversity in the healthcare workforce. Taken together, recommendations for programming and policy include setting science GPA minimums for admission and increasing financial support and mentorship for participants of IH. Recommendations for future research include gathering better data on IH non-completers, and interviewing IH graduates to identify factors and barriers affecting their commitment to IH’s mission.
The Association between Dietary Folate and Vitamin B12 Intake and Genital Human Papillomavirus (HPV) Infection in Men
(University of Hawaii at Manoa, 2019) Santibenchakul, Somsook; Katz, Alan R.; Public Health
Human papillomavirus (HPV) infection, which is an established cause of venereal warts and anogenital carcinoma, is one of the most prevalent sexually transmitted infections worldwide. Most HPV infections are asymptomatic, suggesting that other co-factors might play a role in the progression from infections to HPV-related diseases. Nutritional status is known to influence the immune system and alter host defense mechanisms, so it may be a determinant factor of the body’s cellular and biological response toward HPV infection. This dissertation presents an analysis which aims to understand the role of dietary intake – as a proxy of nutritional status – and the natural history of HPV infection in men. The first research question focuses on the association between dietary folate and vitamin B12 intake and persistent genotype specific HPV infections. The acquisition and clearance of genotype specific HPV infections and dietary folate and vitamin B12 intake are investigated in the second and third research question. All the analyses accounted for potential confounders such as energy intake, age, and risky sexual behaviors. This dissertation utilized data from the Hawaiʻi HPV male longitudinal study, which followed 445 adult men between 2004-2006. Compared to those with the highest intake level, our analyses did not yield strong evidence to support our hypothesis that men who consumed less dietary folate and vitamin B12 were at a higher risk of genotype specific HPV infections. However, we did find that men whose dietary folate and vitamin B12 intake were in the lowest and middle tertiles had higher odds of persistent genotype specific HPVs. Men whose dietary vitamin B12 intake was in the middle tertile had a higher risk of acquiring genotype specific HPVs. During the persistent stage of infection (> 130 days), men whose dietary folate intake was in the lowest tertile had a lower rate of any risk and oncogenic HPV clearance. Men whose dietary vitamin B12 intake was in the middle tertile had a lower rate of oncogenic HPV clearance.
Assessing Multiracial Ethnic Identity Status and Mental Health in Hawaiʻi
(University of Hawaii at Manoa, 2019) Stupplebeen, David A.; Goebert, Deborah; Public Health
The multiracial population, or people who identify as two or more races, is one of the fastest growing segments of the population nationally, and about one-quarter of people in Hawai‘i are multi-racial. How multiracial people identify racially or ethnically has been explored by researchers for nearly 100 years. Many theories developed during this time suggest that multiracial people develop an identity in a linear fashion, though others contend that ethnic and racial identity is situational and in reaction to a number different factors, ranging from individual-level factors like skin color to policy-level factors related to data collection. In addition, ethnic and racial identity have a demonstrated relationship with self-esteem and mental health outcomes. However, much of this research has been conducted on the continental United States. The purpose of this dissertation was to examine the relationship between ethnic and racial identity and mental health across the lifespan in Hawaiʻi. Study 1: In the first study, the psychometric properties of the Multiracial-Heritage Awareness and Personal Affiliation scale (M-HAPA), which measures identity status, was tested with a cohort of multiracial Hawaiʻi-based adolescents. After iterative exploratory factor analyses and confirmatory factor analysis, this study found that the cohort endorsed five different identity statuses. Study 2: The second study examined the relationship between identity status, self-esteem, and depression via structural equation modeling. This study found a highly significant relationship between identity status, self-esteem and depression, and that identity status and self-esteem mediated one another. Study 3: A qualitative study that employed a timeline method examined the relationship between ecological factors that affect identity status and mental health across time in a sample of multi-racial adults in Hawai‘i. Thematic results from this study reflected the racism and health model and common factors across the lifespan that affect identity and mental health. Taken together, these three studies demonstrate the relationship between ethnic identity and mental health for multiracial individuals across the life course in Hawaiʻi. Implications for public health practice, educators, and mental health practitioners include considerations for multiracial identity status in culturally grounded interventions, shifting practice to include cultural humility, and supporting multiracial individuals in their identity development through increased practitioner awareness of multiracial identity issues.
Asthma Prevalence Disparities Among Native Hawaiian/other Pacific Islander, Asian, And White Adults In The United States – Social Epidemiologic Findings From The Behavioral Risk Factor Surveillance System (brfss), 2001–2010
(University of Hawaii at Manoa, 2018-12) Jessop, Holly; Katz, Alan R.; Public Health
Objectives: Despite relatively high asthma prevalence, little is known about the epidemiology of asthma among Native Hawaiian/Other Pacific Islanders (NHOPI), or the roles of socioeconomic factors in asthma disparities among NHOPI. Methods: Multivariable logistic regression using 2001-2010 Behavioral Risk Factor Surveillance System data was conducted to provide adjusted lifetime and current asthma prevalence estimates and ratios, within groupings by sex and self-identified census categories of race for the overall US population, as well as separately for the US state of Hawai‘i. Asthma prevalence disparities by race were also investigated within groupings by sex and indicators of socioeconomic status (SES). The comparative abilities of risk factors to predict asthma within strata by race or SES were investigated using dominance analysis. Results: Asthma prevalence markedly differed between groupings by sex and race, with those self-identifying as NHOPI frequently having the highest point estimates of ever-diagnoses and current asthma. There was evidence of excess asthma in Hawai‘i compared to other US regions, especially among White women and Asians. Sociodemographic factors predictive of adult asthma prevalence varied by both sex and race. Women often had higher asthma prevalence than males of the same race, but the degree to which sex modified asthma prevalence differed by race, sociodemographic characteristic, and/or socioeconomic status. There were consistent dose-response declines in asthma prevalence with increasing SES only among Whites and women of race other than NHOPI, White, or Asian. Asthma was most frequent among NHOPI within some lower and upper levels of SES. Asthma disparities by race were modified by sex and SES; stratification by SES attenuated associations between asthma and race. However, some asthma disparities by race persisted after controlling for SES, including for NHOPI and in comparison with Asians. The dominant factors predictive of adult asthma prevalence depended on sex and race, as well as education attainment. Conclusions: The distribution of asthma in the US is not socially equitable and instead depends on race and/or SES. The findings of this work call for greater considerations in asthma studies regarding interactions between race and social factors and provide a baseline with which to plan and compare other prevention programs, epidemiological investigations, and surveillance for asthma.
Social and Behavioral Domains in Acute Care Electronic Health Records: Barriers, Facilitators, Relevance, and Value
(University of Hawaii at Manoa, 2018-08) LaWall, Emiline G.; Public Health
Social and Behavioral Determinants (SBD) are defined as environmental, financial, or psychosocial factors that impact the health of individuals and communities. There is increasing awareness that SBD affects health in a more profound way than access to (and quality of) medical services (Gold et al, 2017; Nguyen et al, 2015). Understanding and applying SBD data can mitigate health iniquities and reduce the burden of chronic disease (Roux et al, 2015). Despite this, SBD measures are infrequently and inconsistently documented by healthcare providers (Hripcsak, Forrest, Brennan and Stead, 2015). To address this concern, the Institutes of Medicine (IOM) established a set of 12 SBD data for standardization within Electronic Health Records (EHR; IOM, 2014). The objective of this dissertation was to provide new evidence about the barriers, facilitators, relevance and value of adding SBD to the EHR in acute care settings. The conceptual model of this dissertation integrates the IOM’s 12 recommended SBD in to the commonly-recognized Anderson Model of Healthcare Utilization, which relates the use of health care services to several population characteristics and environmental factors. In the first study, focus groups were conducted to ascertain hospital employees’ perceptions of current and future use of SBD in the EHR. In the second and third studies, two years of de-identified EHR data was collected from two hospital sites on Oahu, Hawai‘i to assess whether the previously-deployed SBD measures of “Physical Activity” and “Social Connection and Social Isolation” could inform the common acute care process measures (length-of-stay and potentially preventable readmissions, respectively). For the study of “Physical Activity” in predicting length-of-stay, a piecewise regression with a breakpoint for time was used. Multiple-logistic regression was used to examine “Social Connection and Isolation” in predicting potentially preventable readmissions. The results from this dissertation demonstrate that SBD can be incorporated in to acute care quality efforts and social service referrals, subsequently providing improvement to patients’ immediate course of care. However, we must continue to conduct feasibility of implementing these measures within the nuances of various acute care workflows. Identifying creative ways to capture SBD, such as patient self-report or natural language processing, may be more optimal mechanisms to obtain trended SBD data, with minimal disruptions to clinical workflows.
Physical Activity and the Built Environment Among Adults on O‘ahu
(University of Hawaii at Manoa, 2018-08) Hafoka, Siosaia F.; Public Health
The benefits of physical activity have been well documented. It has shown to decrease risks of non-communicable diseases (NCDs) including diabetes, hypertension, and obesity. Native Hawaiians and other Pacific Islanders (NHPI) are among the populations most affected by non-communicable diseases (NCDs). Population studies have also reported that very few NHPIs meet physical activity recommendations of at least 150 minutes of physical activity per week. This dissertation explored the physical activity status of NHPI in a rural community. By using a social ecological approach, this dissertation aimed to: 1) identify the physical activity status of NHPI and their perceptions of the active living environment, 2) assess physical features and amenities, community programs, and policies that promote physical activity, and 3) have community members identify perceptions of the built environment that influence physical activity behaviors. The study in Chapter Two used the International Physical Activity Questionnaire and the Rural Active Living Perceived Environment Support Scale (RALPESS) to capture physical activity and community perceptions. Chapter Three objectively assessed the environment and examined amenities and facilities by performing an audit on 60 street segments. This study showed that Laʻie had the most sidewalks, crosswalks and bike lanes/path segments. The qualitative study in Chapter Four revealed community-specific barriers and facilitators to being physically active. The data from this dissertation reported that a high proportion of NHPI meet physical activity recommendations and that future research should more closely examine the social environment of NHPI communities.
Community Health Worker Certificate Program Evaluation
(University of Hawaii at Manoa, 2018-05) Schlather, Charlie; Public Health
Racial and ethnic minorities in the United States and in Hawaiʻi experience greater mortality and morbidity than non-minorities from many chronic conditions, including heart disease, cancer, and diabetes (Centers for Disease Control and Prevention, 2011; Centers for Disease Control Division for Heart Disease and Stroke Prevention, 2015; Pobutsky, Bradbury, & Wong Tomiyasu, 2011). One approach to combating health disparities involves the use of Community Health Workers (CHWs). Valued for their strong connection to the communities they serve, CHWs effectively bridge the gap between providers and patients of differing ethnic and cultural backgrounds to improve access to and quality of health care, especially for underserved minorities. To build CHW training capacity for the State of Hawaiʻi, the University of Hawaiʻi Maui College (UHMC) developed the CHW Certificate Program (UHMC-CHW), and a comprehensive evaluation was completed to determine its effectiveness in providing core competency training for CHWs. This disseration was comprised of three studies. Study 1 measured the effectiveness of the UHMC-CHW courses to teach students the CHW core competencies and improve student confidence in applying these competencies in the field. Overall, students gained knowledge and confidence in CHW core competencies and were satisfied with the courses in meeting their training needs. Study 2 used qualitative methods to collect CHW employer perspectives on the effectiveness of the UHMC-CHW in preparing new and incumbent CHWs for the workforce in Hawaiʻi. Employers reported student participation in the program improved self-confidence and performance in the field. Study 3 administered a survey to measure the impact of the UHMC-CHW on the careers of certificate completers. Graduates reported employment and wage gains, improvements in the core CHW skills, satisfaction in the program, and a desire to continue their education. Taken together, findings confirm the program was successful in teaching students the core CHW skills, building confidence in applying those skills, and ultimately improving performance in the field. The program positively impacted the careers of graduates. Results provide validation for the effectiveness of for the UHMC-CHW to provide core competency training for Hawai‘i’s CHWs.
Informing the Process of the Collective-Efficacy-Mechanism-to-Action Model through Analysis of a Multilevel, Multisite Intervention: The Children's Healthy Living Program
(University of Hawaii at Manoa, 2018-05) Butel, Jean A.; Public Health
Interventions to reduce health disparities should target organizations, communities, and policy, plus individuals and families. Community collective efficacy (CE), defined as social cohesion combined with willingness to act/intervene, has potential to affect health outcomes. Place-based relationships are central to CE, as social cohesion is built through social bonding, social bridging, and social leveraging. CE involves citizen empowerment and civic engagement, preparing citizens to act to address organizational, community, and policy issues. However, there is a lack of pathway clarity by which CE is strengthened in community interventions aiming for multilevel change. In this dissertation, the Collective Efficacy Mechanism to Action Model (CE MAM) is proposed to fill this gap. The model is tested using Children’s Healthy Living (CHL) program data, which aimed to prevent young child obesity through 19 activities in four areas: (1) assessing/strengthening school wellness policies and the community’s physical environment; (2) partnering/advocating for environmental change; (3) promoting CHL messages; and (4) building capacity to promote six CHL behavioral objectives (increasing children’s physical activity, fruit/vegetable consumption, water consumption, and sleep, and decreasing sugar-sweetened beverage consumption and recreational screen time). Intervention effect was tested through a cluster randomized controlled trial in Alaska, American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, and Hawai’i, where nine communities received the intervention, and nine matched communities served as controls. Chapters one, two, and three provide background. Chapter four presents results on CE intervention dose obtained across the nine communities, suggesting a critical CE dose for affecting community outcomes. Chapter five presents results from social network analyses in each intervention community, suggesting strong linkages between community groups, local schools, and large organizations are needed to affect change in children’s behaviors. Chapter six explored strategies and barriers in intervention implementation across the nine communities, finding that multiple CE building blocks need to be strengthened simultaneously to affect change, and that time for tailoring the intervention to local conditions was a barrier. Multilevel community interventions could use the CE MAM to develop, implement, and track interventions. The actualization of the CE MAM may prove beneficial in reducing health inequality and improving community outcomes.

Browse

Recent Submissions