D.P.H – Public Health
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Item Building Evidence To Reduce Childhood Asthma Health Disparities In Hawai‘i(University of Hawaii at Manoa, 2021) Uchima, Olivia; Sentell, Tetine; Public HealthAsthma, 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.Item 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 HealthApproximately 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.Item 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 HealthThis 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.Item 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 HealthTo 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.Item Addressing Filipino American Cardiovascular Health Disparities in Hawai‘i(University of Hawaii at Manoa, 2017-05) Domingo, Jermy-Leigh B.; Public HealthCardiovascular 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.Item Yoga for Veterans with Post-Traumatic Stress Disorder(University of Hawaii at Manoa, 2017-05) Cushing, Robin E.; Public HealthStudies 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.Item An Exploration Of Resilience Among Native Hawaiians(University of Hawaii at Manoa, 2017-05) Antonio, Mapuana; Doctor of Public HealthNative 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.Item Examining Eye Care in the South Pacific through a Health Systems Strengthening Lens(University of Hawaii at Manoa, 2016-08) Pearce, MatthewThere 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.Item Understanding Multilevel Factors in Prevention of Cavities among Japanese Children(University of Hawaii at Manoa, 2016-05) Yasuda, SakikoThe 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.Item Racial Discrimination, Health, and Healthcare in Hawaii's Chuukese Community(University of Hawaii at Manoa, 2016-05) Hagiwara, MeganPurpose: 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.