D.P.H – Public Health

Permanent URI for this collectionhttps://hdl.handle.net/10125/24279

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Building Evidence To Reduce Childhood Asthma Health Disparities In Hawai‘i
(University of Hawaii at Manoa, 2021) Uchima, Olivia; Sentell, Tetine; Public Health
Asthma, a chronic lung disease that inflames and narrows the airways, affects about 6.2 million children in the United States (US). In 2013, childhood asthma was the leading cause of school absenteeism. Racial/ethnic disparities also exist, with Native Hawaiian children suffering from an extremely high prevalence of asthma. In Hawai‘i, important questions exist on this topic. The purpose of this dissertation was to shed light on childhood asthma disparities in Hawai‘i and provide evidence for developing asthma education programs to improve asthma-related health outcomes among children in Hawai‘i. This dissertation was comprised of three studies. Study 1 analyzed the Hawai‘i Health Information Corporation (HHIC) data (2015-2016) to establish the total direct cost of asthma-related emergency department (ED) visits among children with asthma in Hawai‘i. Findings showed Native Hawaiians had the largest proportion of all preventable ED visits compared to Asian Americans and Whites in Hawai‘i. Preventable ED visits also differed significantly by age, insurance provider, and island of residency. Study 2 was a systematic literature review assessing the effectiveness of school-based asthma education programs for children in the US in reducing acute health care services. The overall findings suggested school-based asthma education programs are associated with reductions in acute care services. Study 3 used qualitative methods through Photovoice to ascertain perceived factors that affect asthma management among children in Hawai‘i. Eight key themes (four supports and four barriers) were identified by students from the Wai‘anae Coast. The four supports were ‘āina (land), safe haven, alternative remedies, and communtiy support. The four barriers were various physical activity, food/edibile, environmental, and emotional triggers. Findings provided a better understanding on the role a student’s environment plays in asthma management. Overall, findings from this dissertation highlight the need for asthma education programs in Hawai‘i to reduce the financial burden on insurance payers, families, and health care systems from preventable acute asthma-related health care services, and provide evidence about the best ways to build such programs.
Program Evaluation Of Accessurf Hawai‘i, An Adaptive Surf, Swim And Canoe Program For People With Disablities
(University of Hawaii at Manoa, 2021) Schmid, Simone Maria; Braun, Kathryn L.; Public Health
Approximately 15% of the global population lives with disability (1). The proportion is even greater in the United States, where 1 in every 4 adults experienced disability in 2017 (2). People with disabilities have three times greater risk of developing non-communicable diseases than people without disabilities (3), in part because they are less active than their peers without disabilities (4). People with disabilities also are likely to experience social isolation and loneliness, which can lead to negative health consequences and even lower physcial activity levels (5–8). One approach to combating these health disparities is through community programming in adaptive sports. AccesSurf Hawai‘i provides people with disabilities the opportunity to participate in adaptive swimming, surfing, and canoeing. The purpose of my three-study dissertation was to evaluate AccesSurf’s impact on participants benefits, ability to assess community need during COVID-19, and program sustainability. Study 1 identified the benefits of aquatic physical activity and participation in AccesSurf programs for people with disabilities through a secondary data analysis of participant surveys (called “Fun Wall”) (n=442) and a Skills Tool (n=8). Results showed that participants improved in levels of aquatic physical activity, skills, independence, confidence, and community integration. Study 2 identified AccesSurf community’s need for programming during the COVID-19 pandemic through a mixed-method approach, first soliciting answers from open- ended questions (n=89), followed by a closed-ended questionnaire (n=149). There was high awareness and satisfaction across all programs, including the newly added virtual programs. The results provided insight into community needs, and showed differences between sub-groups, such as in feeling the effects of COVID-19 pandemic. Study 3 explored the contributing factors of AccesSurf’s sustainability, as well as opportunities for improvement, using a mixed-method approach. The closed-ended Program Sustainability Assessment Tool (PSAT) (n=15) was administered to governing members, followed by in-depth interviews (n=5). This study highlighted areas of strength, including AccesSurf’s adaptability, champions, and communications. Areas for improvement are strategic planning, stable funding, and partnerships with other community organizations and leaders. Taken together, findings confirm that the program was beneficial to participants, has high program satisfaction, and many characteristics supporting its sustainability, with some room for improvements, all of which benefits the AccesSurf community. Findings can inform similar organizations that are providing innovative, recreational physical activity options for people with disabilities and future research.
The Prevalence, Economic, And Social Cost Of Methamphetamine Use; And The Effects Of Economic Recessions, Unemployment Rates, And Methamphetamine Arrests On Child Abuse In Hawai`i
(University of Hawaii at Manoa, 2020) Linn, Nancy S. C.; Hurwitz, Eric; Public Health
This is the first study in Hawai`i to estimate the prevalence and cost of methamphetamine (meth) use and the first investigation of the association of the impact of the periodicity of economic recessions, unemployment rates, and meth arrests on child abuse for the years 2007 to 2017, based on free, open source, and unrestricted data gathered for other purposes. The Hawai`i age-adjusted meth use prevalence was above the national estimates and ranged from 5,050 per 100,000 in 2007 to 3,387 per 100,000 in 2017, with a range from 3,114 to 5,219 per 100,000. The economic and social cost estimates were found to average between 41 to 68 billion dollars (range 15 to 105 billion dollars) when the lost potential from meth use and meth-related impacts were included. The quality-adjusted life-years approach, the Department of Transportation (DOT) Maximum Abbreviated Injury Scale (range 1-6, 6=death), and the DOT Value of a Statistical Life were included in the computation of lost potential of meth users and abused children using the RAND and state of Montana approach. When lost potential was not included, the cost of meth use was found to average between 120 to 173 million dollars per year (range 49 to 269 million dollars). The five factors for the cost estimates included: 1) treatment costs, 2) health burden, 3) child endangerment, 4) criminal justice costs, and 5) lost productivity attributable to meth. Meth arrests were found to lag unemployment rates by one year while child abuse lagged about four years behind unemployment and meth arrests, although the Granger causalities were not significant.
The Effects of Early Life Factors on Elder Physical Activity Disparities in High and Middle Income Countries
(University of Hawaii at Manoa, 2017-05) Hwang, Phoebe W.-N.; Public Health
To delay chronic disease and promote general health among older adults, physical activity (PA) is often recommended and promoted in a public health setting. Unfortunately, there are a number multi-level factors associated with low PA that occur prior to old age, known as early life adversities. It is well established across the globe that social and economic adversity are associated with poor health outcomes and behaviors. This dissertation presents findings from two quantitative studies with a global sample and one qualitative study with a local sample to examine the effect of life course factors and older adult physical performance and PA behavior disparities. The first two studies utilized global health data from the International Mobility in Aging Study (IMIAS), and found that site location, gender, income, and sex were associated to PA. In addition, economic adversity transition is associated to physical performance. The third study found that neighborhood type (urban vs. rural) played a role in Native Hawaiian older adult PA type and physical performance. This relationship could possibly be mediated by how discrimination and poverty are perceived, as they were perceived differently by older adults from the two different neighborhoods. Results from this dissertation support targeting childhood and life course environmental and socio-demographic factors as effective ways to improve older adult PA and physical performance. Future PA promoting interventions should be tailored to their target population based on region, and not just ethnicity. To build on findings from this dissertation, future research is needed to further examine how childhood adversity and perceived discrimination plays a role in older adult physical performance and PA behaviors.
Addressing Filipino American Cardiovascular Health Disparities in Hawai‘i
(University of Hawaii at Manoa, 2017-05) Domingo, Jermy-Leigh B.; Public Health
Cardiovascular Disease (CVD) is the leading cause of death in the United States (U.S.). Among Filipino Americans (FAs), CVD is the leading cause of death among males and second among females. Research indicates a high prevalence of hypertension and behavioral risk factors associated with CVD. Culturally relevant health interventions targeted for FAs can increase their participation in healthy behaviors, leading to an improvement in their overall health. The purpose of this dissertation was to advise the development of culturally targeted health interventions. Shedding light on FA CVD-related disparities allows for effective programming in Hawai‘i’s Federally Qualified Health Centers (FQHCs). This dissertation was comprised of three studies. Study 1 analyzed four years of Hawai‘i’s Behavioral Risk Factor Surveillance System (BRFSS) data (2011 to 2014). Findings confirmed that FAs in Hawai‘i were less physically active, smoked more, and were more obese than other Asian subgroups. Contrary to the national literature, FAs in Hawai‘i reported the lowest CVD prevalence of the five ethnic groups in the sample, after controlling for sociodemographic and health care access variables. Study 2 was a systematic literature review of CVD-related programs tailored to FAs. Few articles were found, confirming need for more published research on improving CVD health of FAs. Described interventions found success by attending to FA cultural values, food, social relationships, and family. Analysis of the articles also suggested that interventions should employ word of mouth recruitment strategies to successfully reach FA communities. Study 3 used qualitative methods to explore essential strategies to successfully attract FAs to CVD prevention programs in Hawai‘i’s Federally Qualified Health Centers (FQHCs). Three key themes emerged. First, FQHCs should understand FA issues, context, and culture. Next, multiple levels of buy-in are necessary when creating health programs and interventions. Last, FQHCs should follow specific tips for successful health interventions (e.g., employing FA staff, flexible scheduling). Taken together, findings confirm the need for culturally tailored programs to support FA populations. Further, FAs experience a high prevalence of disease-related (e.g., hypertension, diabetes) and behavioral risk factors associated with CVD. Hawai‘i’s FQHCs, are well positioned to implement CVD prevention interventions tailored to the FA community.
Yoga for Veterans with Post-Traumatic Stress Disorder
(University of Hawaii at Manoa, 2017-05) Cushing, Robin E.; Public Health
Studies have determined that approximately 15% to 20% of military service members are returning from deployment with Post-Traumatic Stress Disorder (PTSD) symptoms. The Department of Defense (DoD) and the Veterans Health Administration (VHA) have spent billions on post-9/11 veterans. However, many service members and veterans do not seek treatment due to the stigma of seeking care, side effects of treatment, or fear that a record of treatment will harm their professional military careers. These same individuals look for alternative options, such as mind-body therapies, to help in treating their PTSD symptoms. This dissertation research was comprised of three studies (papers) to address several research questions exploring the usefulness of the mind-body therapies on reducing PTSD symptoms in the military. The first study was a systematic literature review looking at the effect of mind-body therapies on combat veterans and service members suffering from PTSD (Study 1). The major finding of the systematic review was that mind-body therapies are promising therapies for reducing PTSD symptoms in veterans and service members. The second study was single-group pre-posttest study testing a military-tailored, trauma-sensitive yoga intervention with veterans suffering from PTSD (Study 2). I recruited 18 veterans with PTSD symptoms to participate in a 6-week intervention of 60-minute, weekly yoga classes. I compared their baseline and post-intervention responses on scales measuring PTSD symptoms as a primary measure and depression, anxiety, insomnia, and mindfulness as secondary measures. The participants demonstrated significant reductions in PTSD symptoms and all of the secondary measures. For Study 3, I conducted interviews with 9 veterans to explore their perceptions of the benefits and barriers to practicing a trauma-sensitive yoga. While Study 2 demonstrated that yoga can yield statistically significant improvements in wellbeing, study 3 provided me a deeper understanding of individual's perspectives of why veterans continue to practice or not practice yoga.
An Exploration Of Resilience Among Native Hawaiians
(University of Hawaii at Manoa, 2017-05) Antonio, Mapuana; Doctor of Public Health
Native Hawaiians are represented in the literature as experiencing poor health when compared to other major ethnic groups and the general population of Hawai‘i. Despite the pressing need to address health disparities experienced by Native Hawaiians, minimal research takes a strengths-based approach or examines resilience factors that serve as buffers for adverse experiences of Native Hawaiians. Strengths-based approaches to health may specifically foster resilience, a concept referring to an individual’s ability to overcome adversity through protective factors, which in turn leads to better health outcomes. The overall purpose of this dissertation was to examine factors that foster resilience and increase the overall health and wellbeing of Native Hawaiians. The conceptual model of this dissertation was based on an integration of the concept of Lōkahi—balance with the ‘āina (land or environment), kānaka (the community), and akua (God or the spiritual realm)—and the Socio-Ecological Model, which considers prevention on multiple levels including the individual, interpersonal, and community level. Studies 1 and 2 were based on data collected from the Hawaiian Homestead Survey. In study 1, psychometric properties of scales that measured resilience factors through internal assets and coping resources available to an individual on multiple levels were determined through higher order confirmatory factor analyses (CFA). In study 2, structural equations models were developed to determine whether resilience (based on the construct developed in study 1) served as a mediator or moderator of adversity (measured through SES and perceived racism) on health. In study 3, a total of 12 key informant interviews were conducted to explore the concept of resilience specific to health through the perspective of Native Hawaiians currently residing on Hawaiian Homestead Lands. Together, the results from this dissertation suggest that: 1) health may be perceived through a holistic perspective; 2) resilience may be considered as a multi-dimensional construct, consistent with recent research focusing on resilience; and 3) socio-economic burdens and competing demands may be considered as substantial adversities for Native Hawaiians residing on Hawaiian Homestead Lands. The final chapter of this dissertation provides implications for practice, policy, and future research.
Examining Eye Care in the South Pacific through a Health Systems Strengthening Lens
(University of Hawaii at Manoa, 2016-08) Pearce, Matthew
There is great potential to reduce the incidence and prevalence of visual impairment if concentrated effort is made through interventions that follow the health systems-strengthening framework. This dissertation uses three studies to examine eye care in Pacific Islands Countries and Territories (PICTs) through a health systems-strengthening lens. The first study used qualitative methods to analyze key informant interviews. The key informants represented six nongovernmental organizations (NGOs) active in eye and vision care in PICTs. A grounded-theory approach was used to create a theoretical frame work which was compared to the health systems-strengthening framework. NGOs are active in five of the six health system building blocks, but function in a limited area of those building blocks. The second study used qualitative methods to analyze PICT community expectations of the non-health enhancing aspects of the health system. Eight focus groups were held in two countries: Fiji, and Western Samoa. The focus groups were generally satisfied with the eye care component of the health system. The seven elements of responsiveness were important and applicable in PICT settings although some elements (prompt attention, dignity) were more important than others. The third study used quantitative methods to investigate the level of professional motivation PICT eye care providers have, as well as to determine what, if any, aspects of the health system can predict motivation level, and lastly to determine how NGOs influence professional motivation. PICT eye care providers were highly motivated, but that motivation seems to be intrinsic. PICTs have a highly motivated eye care workforce, despite a perception of a lack of support from Ministries of Health. Communities appreciate having eye care services available, but have concerns with wait times and not always being treated with dignity. Half of respondent NGOs primarily provide clinical services, which is what is least desired by eye care providers. Efforts to strengthen the health system will require, in part, the identification, and support of leaders and a shift of vision NGOs from concentrating on eye care to concentrating on the broader health system. The involvement of community in the planning and decision making process is encouraged.
Understanding Multilevel Factors in Prevention of Cavities among Japanese Children
(University of Hawaii at Manoa, 2016-05) Yasuda, Sakiko
The objective of this dissertation is to understand multilevel factors in prevention of cavities among Japanese children. Oral health is important to general health and quality of life, and cavities cause irreversible negative damage over the life course. This dissertation consists of three studies. The first study is a systematic review to examine school-based interventions to prevent cavities for elementary school age children in Japan. Of the 13 included studies, 12 tested fluoride mouth-rinsing (FMR) programs. FMR programs appear to be very effective in preventing childhood cavities in Japan, which does not have systemic water fluoridation. The second study was used quantitative methods to examine factors to explain disparities in cavities among 12-year-old children across Japan’s 47 prefectures. Data by prefecture were culled from public databases and analyzed using SPSS. Three factors--average income per person in the prefecture, percentage of schools in the prefecture with school-based FMR interventions, and average numbers of convenience stores per 100,000 persons—explained almost 50% of national variance in cavities of 12-year-old children in Japan. The third study was used qualitative methods to examine barriers and facilitating factors for Japanese parents living in Hawai‘i to prevent cavities for their children. Uninsured status, slow adaptation to the U.S. oral health system by Japanese mothers, and Japanese hesitancy to ask questions were found to be the main barriers. Insured status, high cost for insurance and treatment, and the U.S. check-up appointment system were found to be the main facilitating factors. In conclusion, this dissertation found strong evidence that FMR should be introduced at all schools in Japan as a culturally competent approach to reducing cavities in children. Findings also suggest that municipalities in Hawai‘i need to be aware that short-term residents from Japan have limited knowledge of the U.S. oral health care system. They also have passive attitudes about prevention of cavities in their children due to Japanese policies that provide free annual check-up at schools and low or free treatment. Therefore, policy makers in Japan also need to support programs that teach parents to take more responsibility for preventing cavities in their children.
Racial Discrimination, Health, and Healthcare in Hawaii's Chuukese Community
(University of Hawaii at Manoa, 2016-05) Hagiwara, Megan
Purpose: The purpose of this dissertation was to assess the relationship between racial discrimination and health in Hawai‘i’s Chuukese community. Increased experiences with racial discrimination has been found to negatively affect health in other communities. Experts in this field have highlight the importance of tailoring you tool you specific study population. Anecdotal evidence of racial discrimination towards Chuukese has been documented, however no formal research has been published. This dissertation looks to fill that gap. Methods: Based off of findings from a review of the peer-reviewed literature (study 1) and interviews with community members (study 2) a culturally appropriate measurement tool was created. Using this tool face-to-face interviews with Chuukese community members were conducted (study 3). Bivariate relationships between racial discrimination and health were explored. Multivariate logistic regression was conducted to test if these relationships were still significant after controlling for demographic characteristics, access to appropriate healthcare, and tobacco use. Results: Major findings from study 1 include: 1) the majority of studies done with other indigenous and Asian Pacific Islander groups only measured individual rather than collective racial discrimination; and 2) tools created specifically for these study populations included unique examples of racial discrimination for their particular group. In study 2 examples of racial discrimination experienced by the Chuukese community were identified, along with methods and words to help facilitate Chuukese individuals disclosing experiences with racial discrimination in future quantitative research. Lastly in study 3, 72 face-to-face interviews were conducted with Chuukese community members. Analysis revealed that: 1) Chuukese in Hawai‘i experienced high levels of both collective and individual racial discrimination; 2) Increased experiences with any type of racial discrimination was significantly associated with bad self-report health outcomes, often times even after controlling for our other variables; and 3) for the Chuukese community collective experiences with racial discrimination may have a stronger impact on their health outcomes compared to individual experiences. Conclusion: When addressing health inequities in Hawai‘i’s Chuukese community it is important to consider their experiences with racial discrimination. In particular collective racial discrimination may be particularly important when considering health inequities of this group.
An Investigation of Pregnancy Intention Disparities, Measurement, and Meanings in Hawaii and Among Native Hawaiians
(University of Hawaii at Manoa, 2015-08) Elia, Jennifer
About half of all pregnancies in the United States are unintended (mistimed or unwanted), and this figure has held steady for decades despite recognition as a public health priority and efforts to reduce it. Unintended pregnancy has been associated with negative health and social outcomes for mother and child. Hawai‘i has the second highest unintended pregnancy rate in the U.S., and Native Hawaiians appear to have the highest rates of unintended pregnancy among the state’s major ethnic groups. The purpose of this dissertation was to examine unintended pregnancy in Hawai‘i, with a particular focus on Native Hawaiians, in terms of how different groups are affected (disparities), how it is assessed (measurement), and how it is conceptualized (meanings). The first of three studies used data from the Hawai‘i Pregnancy Risk Assessment Monitoring System to examine disparities by race/ethnicity and other maternal characteristics in: pregnancy intention; trying to get pregnant; discordant responses for intention and trying; contraceptive use before pregnancy; and “didn’t mind” pregnancy as a reason for contraceptive non-use. The second study examined three measures of pregnancy intention – the London Measure of Unplanned Pregnancy (LMUP), National Survey of Family Growth (NSFG) intention categories, and “trying” to get pregnant – in relation to demographic characteristics and pregnancy outcome (prenatal care vs. abortion) through a survey of pregnant women in Honolulu. With eight focus groups of Native Hawaiian women and men, the third study qualitatively described factors related to pregnancy planning and decision-making within this community. Findings from these three studies speak to the complexity of pregnancy intention and its importance to public health. Many women in Hawai‘i became pregnant when they were not intending, trying, and/or wanting to get pregnant. Furthermore, a substantial proportion of women reported ambivalence towards their pregnancies and did not use contraception despite being “at risk” for unintended pregnancy. Disparities by race/ethnicity and other demographic characteristics were significant in bivariate and multivariate analyses. Cultural factors and social norms may influence the perception and impact of unintended pregnancy among Native Hawaiians. Suggestions for further quantitative and qualitative research and other implications are described.
An Investigation of Hula as a Culturally Appropriate Physical Activity for Health Promotion
(University of Hawaii at Manoa, 2015-05) Mabellos, Tricia
Physical activity (PA) both prevents and treats many established cardiovascular disease (CVD) risk factors, including hypertension and obesity. CVD continues to be the leading cause of death in the United States (US), making it a major public health concern. Native Hawaiians and Pacific Islanders (NHPI) share an unequal burden of CVD compared to the general population. According to the Office of Minority Health, NHPI in Hawai‘i are 3 times more likely to have CVD and are 1.7 times more likely to die of heart disease than their White counterparts. This dissertation explored hula, the indigenous dance of Native Hawaiians, as a physical activity (PA) in health interventions. This three-part dissertation aimed to: 1) evaluate physiological variables of hula to establish the dance as a moderate and/or vigorous physical activity, 2) ask NHPI that participated in a hula-based intervention for hypertension about their thoughts about the use of hula, and 3) determine if changes in blood pressure could predict changes in health-related quality of life after participation in a hula-based intervention for hypertension. The study in Chapter two demonstrated that physiological variables of low and high intensity hula were able to reach moderate and vigorous intensity PA, respectively. The qualitative study in Chapter three asked participants of a hula-based, hypertension management intervention about their thoughts on the use of hula for a health intervention. Participants all agreed that hula appeared to be a suitable alternative PA for a health intervention. The study in Chapter four conducted a multiple regression to determine if change in systolic and diastolic blood pressure could predict changes in health-related quality of life (HRQOL). Only one subscale from the SF-12, Social Functioning, was shown to be significant. This study showed that improvement in hypertension does not appear to have an impact on HRQOL for NHPI that participated in a hula-based study. Overall, this dissertation demonstrated that hula can be implemented as a valid alternative to traditional PA for health interventions as shown both quantitatively from several indicators and qualitatively from program participants.
Understanding How Parents Decide on Vaccinating Their Child with the Human Papillomavirus (HPV) Vaccine
(University of Hawaii at Manoa, 2015-05) Dela Cruz, May Rose
The human papillomavirus (HPV) is the most prevalent sexually transmitted infection and causes certain cancers in females and males. HPV causes 70% of all cervical cancers in women and 90% of all genital warts in women and men. There is currently an HPV vaccine recommended by the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) to be administered to girls and boys between the ages of 11 and 12 years. Unfortunately, the uptake for the HPV vaccine remains low for girls and boys nationally and in Hawai‘i due to factors associated with parental decisions to vaccinate their children. This dissertation addresses gaps related to HPV vaccine uptake in Hawaiʻi through three studies which: 1) examines barriers and motivators to HPV vaccine uptake among Hawai‘i parents of teenage children through interviews, 2) determines the prevalence of HPV vaccination uptake by four ethnicities (Native Hawaiian, Filipino, Japanese, and Caucasian) through a population-based survey in Hawai‘i, and 3) evaluates a health education brochure developed and culturally tailored for parents residing in Hawai‘i. There are many factors that contributed to a parent’s decision to vaccinate their child with the HPV vaccine. The parents’ interview reinforced the importance of a physician recommendation and confirmed that health education materials would be helpful to parents, with parents preferring receipt of brochures from their physician. Data from 799 parents through the population-based telephone survey in Hawai‘i found that 55% of parents with daughters had vaccinated their daughter with one or more shots, compared to only 41% of parents with sons. After adjusting for important demographic variables, Caucasian parents of both boys and girls, individuals who have not heard of the HPV vaccine, and parents of young teens regardless of ethnicity, were least likely to vaccinate them with the HPV vaccine. In this survey, the main motivator to vaccinate was a physician recommendation, and the main barrier was the lack of awareness of the HPV vaccine. A four- step protocol was useful in developing an HPV vaccine brochure and testing its attractiveness, acceptability, messenger effectiveness, personal relevancy, and readability with providers and parents in Hawai‘i. The developed HPV vaccine brochure could be disseminated to parents in Hawai‘i to increase HPV vaccination. This dissertation research yielded findings about HPV vaccine uptake in Hawai‘i and produced a health education brochure to assist in increasing uptake by addressing parent-identified barriers and motivators to uptake. The research provides insights into a number of factors that affect parental decisions to vaccinate their 11-to-12-year-old children in Hawai‘i, which will be useful for interventions to improve vaccination rates.
Community Interventions to Promote Physical Activity
(University of Hawaii at Manoa, 2015-05) Choy, Lehua
Physical activity (PA) is an essential health-promoting behavior. Unfortunately, the majority of U.S. adults are not sufficiently active, and certain groups are even less likely to engage in regular PA. To increase population-levels of PA and resolve PA disparities, community interventions are needed to address multiple levels of a social ecological framework. The purpose of this dissertation research was to contribute to the knowledge about effective community interventions for PA, with a particular focus on the process of engaging community members to participate in the design and implementation of community interventions. The dissertation research was comprised of three studies. The first study was a systematic literature review of community-based participatory research interventions for PA. The major finding of the systematic review was that community participation was integrated rather inconsistently in the intervention process, but nearly all interventions were able to impact multiple levels of a social ecological framework. In the second study, a grounded theory approach was used to develop a theory of change for how a community coalition, Get Fit Kaua‘i, was able to create policy and environmental changes. This qualitative study was comprised of semi-structured interviews with a purposeful sample of 25 coalition stakeholders. The theory resulting from the interviews highlighted the importance of capacity building, the influence of community context, and the complementary programmatic activities that enabled built environment policy changes. In the third study, a secondary data analysis employed structural equation modeling to assess the cross-sectional association between perceived social and built environment factors with PA levels in a sample of 3,626 Hawai‘i adults. The resulting model confirmed that community interventions must address intrapersonal factors, along with modifiable factors in the built and social environments. Together, the dissertation studies contribute to the evidence supporting the utility of community interventions to promote PA. The studies reflect the challenges facing community interventions that seek to address the upper levels of policy and environmental change in the social ecological model. Based on the dissertation findings and study limitations, the final chapter provides practice implications and directions for future research.
Translating research to practice: aligning the "three streams" of policymaking to address bullying and youth violence among youth in Hawaiʻi
(University of Hawaii at Manoa, 2013-05) Sugimoto-Matsuda, Jeanelle June
Youth violence remains a major public health issue in the United States. Bullying is one form of youth violence, and one that can result in physical injury, social and emotional distress, and even death. Research has supported the use of a social ecological approach to address the complex and multi-faceted nature of youth violence and bullying. This includes policies at the legislative, regulatory, and organizational levels. Unfortunately, a gap still remains between the data emerging from scientific and empirical studies and the policymaking process. This three-part dissertation aims to examine how research and evidence can be better connected to practice, specifically policy. Kingdon's "three streams" concept, and landmark work on agenda setting and policy formation, serves as the foundation for the conceptual framework of this dissertation. The first study employed quantitative methods to determine the scope and risk-protective factors of bullying and youth violence among high school youth in Hawaiʻi, by analyzing Youth Risk Behavior Survey data. The second study summarized and synthesized recommendations from empirical evaluations of bullying and youth violence policies, using the scientific literature. The third study used a qualitative methodology (key informant interviews) to examine factors that influence the process of translating public health evidence to policymaking, and contrasted the perspectives of organizational professionals with legislators in Hawaiʻi. Ultimately, this dissertation research hopes to provide a deeper understanding of the issue of youth violence and bullying, and how that information can be used to strengthen prevention policies.
An examination of influential factors in diabetes prevention efforts
(University of Hawaii at Manoa, 2013-05) Hsu, Laura Jy
Type 2 Diabetes Mellitus (hereafter referred to as "diabetes") is a growing public health concern in the United States (U.S.), making prevention a priority. An estimated 79 million U.S. adults (35% of adults) have pre-diabetes, a health condition that denotes a high risk for diabetes, surpassing the number of adults who have diabetes. Clinical trials have shown that diabetes can be prevented in individuals with pre-diabetes through lifestyle health behaviors including weight loss, physical activity, and diet/nutrition. Understanding the factors that influence diabetes prevention is important in efforts to improve the health of at-risk individuals. This three-part dissertation aimed to better understand the influential factors in diabetes prevention efforts and the implications for chronic disease prevention. Through a secondary data analysis of the National Health and Nutrition Examination Survey (NHANES), the first study quantitatively examined the impact of risk awareness on physical activity and diet in pre-diabetic individuals. The second study used survival/time-to-event analysis and data from the epidemiological Kohala Health Study to investigate the predictive ability of the metabolic syndrome in Native Hawaiians at risk for diabetes. The third study used qualitative methods to identify the salient factors that influence the perceptions of potential adopters on lifestyle interventions, and how the identified issues affect the implementation of lifestyle interventions. Together, these three studies suggest that in order to decrease diabetes incidence, prevention efforts will need to extend beyond the education and awareness efforts at the individual-interpersonal level (i.e. prevention programs), and address the broader environmental context (i.e. public policies, community norms, organizational values). Individual-level prevention programs will need to be complemented by population-based strategies that seek to minimize the underlying causes of diabetes.
A community-based participatory research approach to assist vulnerable communities in developing a disaster preparedness plan to lessen the impact of natural disasters
(University of Hawaii at Manoa, 2013-05) Crabtree, Christopher A.
Background: In 2010, more than 200,000,000 people were negatively affected by natural disasters (CRED, 2009). That number is increasing as population densities continue to grow in coastal and other vulnerable areas (Hays et al., 2001). The top-down approach typically employs external evaluation and assessment teams and applies a universal preparedness plan and externally produced, high-value technology, which fails to take into consideration the specific needs, resources, and capacities of vulnerable communities (Wisner, 2004; Mercer, 2008; Burton, 1993). This dissertation study will examine the utilization of Community-based Participatory Research (CBPR) in interventions aimed at helping communities plan for and minimize the impact of natural disasters on their communities. Method: This dissertation study employed three different methods. A systematic literature review was conducted employing the PRISMA protocol. PhotoVoice, a qualitative research method, was utilized with a community in Hawaii to complete the vulnerability, capability, and gap analysis and to develop disaster reduction strategies. A one-group, pre-post-survey design was used to assess changes in participants self-rated perceptions following the development and implementation of the community disaster training and exercise program. Results: The literature review identified 14 CBPR interventional studies related to natural disasters that operationalized all nine CBPR principles to a degree. The principle of sustainability was least operationalized. Through PhotoVoice, the community identified 42 vulnerabilities and 50 capabilities, sorted into 17 themes. Thirteen gaps were then identified, which yielded 16 feasible strategies to reduce the community's vulnerabilities. The community helped develop and lead a training and exercise related to tsunami preparedness, as well as evaluation tools. A bootstrap pair sample analysis on the pre and post-survey demonstrated significant increases in the mean in all skill areas (p<.05). The majority of participants agreed that CBPR principles were reflected in the training and exercise program. In addition, the community was successful in developing a contextually appropriate tsunami evacuation plan. Conclusion: Applying CBPR principles to disaster preparedness research was effective at increasing community capacity, system development, and commitment to sustainability.
Assessing how to increase smokers' motivation to quit
(University of Hawaii at Manoa, 2011-05) Williams, Rebecca Joy
This three-part dissertation study aims to explore how to increase motivation to quit in current smokers with low motivation. Recognizing what motivates smokers to quit and how to increase motivation are key elements to tailoring successful smoking cessation strategies, especially for those with low motivation to quit. Chapter One reviews the literature on motivation and smoking in the US, and how these two are related. Chapter Two tested the Health Action Process Approach using data from a cross-sectional survey of current smokers and multiple measures of motivation to quit and risk perceptions. Results supported the model, indicating that non-intenders had lower risk perceptions compared to intenders. Chapter Three examined the differences in perceptions of how those with high, medium, and low motivation to quit smoking perceive smoke-free laws and the extent to which a physician was involved in motivating them to quit. Using cross-sectional data of current smokers, chi-square tests and ordinal logistic regression compared smokers by their level of motivation to quit. Some areas of smoke-free law perceptions and physician involvement differed across levels of motivation to quit smoking. Chapter Four identified factors that influence cessation, investigated quit attempts, and explored methods for staying quit using focus groups with adult ex-smokers. Several key themes relating to motivation to quit smoking were identified that may have implications for the design of smoking cessation programs for adults. Chapter Five will summarize the main findings and discuss implications of results. To decrease morbidity and mortality associated with tobacco use, researchers need to identify factors that lead to increased motivation to quit and develop interventions based on these findings to be able to assist smokers in quitting. The concept of motivation is important because smoking cessation interventions will not be successful for smokers that are unmotivated to quit.
Breastfeeding and the male partner: association between male attitudes and breastfeeding outcomes
(University of Hawaii at Manoa, 2011-12) Mitchell, Kristen Marie
The purpose of this three-part dissertation is to understand the importance of informal social support, specifically of the male partner, on breastfeeding intentions and behaviors. It explores the impact male partner perceptions and attitudes may have on breastfeeding and implications for improving breastfeeding outcomes with intervention strategies focusing on male partners. Chapter 1 outlines the benefits of breastfeeding, summarizes data on breastfeeding rates in Hawaiʻi and the US, describes the influence that informal support can have on a woman's breastfeeding behaviors, and presents the purpose and conceptual framework of the dissertation research. Chapter 2 reports the results of a systematic literature review on fathers' influence on and perceptions of breastfeeding and father-focused interventions to increase breastfeeding and discusses implications for future intervention development. Chapter 3 presents findings from a qualitative study in which male partners of pregnant women and new moms were interviewed regarding their attitudes, knowledge, and feelings about breastfeeding. Chapter 4 investigates the infant-feeding attitudes of WIC mom and partner pairs using a quantitative approach to explore associations between mom and partner attitudes and infant feeding intentions and whether the partner's infant feeding attitudes influence infant feeding intentions over and above the mom's attitude. Participants for Chapters 3 and 4 were recruited within the Hawaiʻi US Department of Agriculture's Women, Infants, and Children (WIC) program. Chapter 5 presents the main conclusions of the dissertation research, implications for practice and policy, future research directions, and contributions the research makes to literature. Consistent with recent national and international research, results suggest that the male partners of the Hawaiʻi WIC population are an important source of support and influence in the initiation and continuation of breastfeeding. Male partners want to be more involved in the infant feeding process, but do not feel they have the tools and knowledge to support a breastfeeding mom. To increase breastfeeding rates and change cultural norms related to breastfeeding, it is important to improve male partners' attitudes toward and perceptions of breastfeeding. Findings suggest that an intervention based in Social Cognitive Theory may have the best chance of improving the male partner's knowledge and attitudes about breastfeeding.
Chronic disease risk factors among multiethnic blue- and white-collar workers in Hawaii
(University of Hawaii at Manoa, 2011-12) Leslie, Jodi H.
Blue-collar workers (BCW) are reported to have a higher prevalence of obesity and hypertension, compared to white-collar workers (WCW). Learning factors related to high prevalence of diseases among BCW is needed to effectively address them in worksite health promotion efforts. The purpose of this three-paper dissertation is to identify factors related to the high prevalence of obesity and hypertension among BCW. Chapter one provides an overview on literature reporting sociodemographic, behavioral, health, and job characteristics of BCW. Chapter two presents findings from the first study, reporting on associations between occupational types and obesity among subscribers of a health plan in Hawaiʻi who completed the Succeed questionnaire. The association between being a BCW and obesity was attenuated by ethnicity, with an inverse association seen after controlling for education. Ethnic minorities and those with low education levels should be targeted in obesity reduction efforts. Chapter three presents findings from the second study, which estimated associations between occupational types and hypertension, among Kohala Health Research Project participants. Being a BCW was not associated with hypertension, after controlling for obesity and ethnicity. Efforts to decrease hypertension among workers should focus on reducing obesity and should target ethnic groups at higher risk. Chapter four reports on the final study, which identified supports and barriers to healthy eating and physical activity among workers of a health care organization in Hawaiʻi. WCW cited onsite availability of health and fitness opportunities as supportive, while lack of the same and job demands were barriers to healthy behaviors. BCW saw their ability to bring home lunch and their jobs as supportive of healthy behaviors, and that not having enough time to eat and illness/injury were barriers. Differing influences to health, among BCW and WCW, should be considered when developing a worksite wellness program. Taken together, the three studies suggest that high prevalence of obesity and hypertension among BCW may be associated with their ethnic minority status and lower educational levels, rather than their blue-collar jobs per se. Findings from these studies can help inform development of worksite health promotion programs relevant to both WCW and BCW.

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