D.P.H. - Public Health

Permanent URI for this collectionhttps://hdl.handle.net/10125/2147

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MENTAL HEALTH SERVICE DELIVERY FOR AFGHAN REFUGEES IN THE U.S.
(University of Hawai'i at Manoa, 2024) Basij-Rasikh, Shugufa; Braun, Kathryn; Public Health
Refugees are exposed to many stress factors that negatively impact their well-being prior to, during, and after resettlement that contribute to depression, anxiety, and somatization disorders (Abou-Saleh & Christodoulou, 2016). Refugees from war-torn countries, including Afghanistan, experience war trauma, as well as marginalization and discrimination in a new country, increasing the risk of depression and anxiety in refugees. As of September 15, 2022, the total Afghan population in the U.S. was 189,493, with Afghan refugees arriving in four major waves--during the Soviet-Afghan War (1979–1989), during the Afghan Civil War (1990 to 1995), during the U.S./NATO intervention and fall of the Taliban (1996-2001), and during U.S./NATO withdrawal and resumption of power by Taliban forces in 2021 (Alemi, n.d.). Although research on 4th-wave refugees is limited, research on earlier waves found that the prevalence of mental health disorders among Afghan refugees was high (Alemi et al., 2016). Despite high prevalence, many refugees in the United States do not receive mental health care due to limited English-language skills, lack of awareness of services, reluctance to seek help due to cultural stigma around mental disorders, and negative attitudes towards and by providers (Satinsky et al., 2019). Research also suggests that education, income, and other factors influenced access to and utilization of mental health resources (Steele et al., 2007). Research suggests that mental health help-seeking among early-wave refugees is low (Abou-Saleh & Christodoulou, 2016). What is not known are the main barriers that prevent access to and utilization of mental health care in the most recent wave of Afghan refugees (Byrow et al., 2020). The objective of this dissertation is to better understand the need for, access to, and use of mental health services among Afghan refugees in the U.S. Through three studies, I: 1) conducted individual interviews with service providers to understand mental health needs of Afghan refugees in the U.S.; 2) conducted one-on-one interviews with Afghan refugees to determine the needs for mental health care and the barriers to accessing mental health services; and 3) administered a survey with Afghan refugees in two cities of Sacramento and Fremont in California to assess the influence of socioeconomic status (SES), sex, and years in the U.S. on mental health service use and knowledge. Due to my recent refugee status from Afghanistan, I was uniquely qualified to conduct this research. The lawyer helping me with my personal asylum application established my connection with her friend who is lawyer in San Francesco. She connected me with the service providers and as well as with members of the U.S. Afghan community that assisted me in recruiting my samples. The aim of my first study was to identify service providers’ perspectives on the mental health needs and service use of Afghan refugees in the U.S. by conducting interviews with service providers. I completed interviews with nine service providers in January 2024. These service providers highlighted a number of barriers Afghan refugees face in accessing mental health services, including language barriers, cultural stigma, and a lack of knowledge about available resources. Furthermore, they emphasized the importance of providing culturally sensitive care and developing community-based support networks. The aim of my second study was to identify refugee perceptions of supports and barriers to mental health in a sample of 20 adult Afghan refugees in two cities of California--Fremont and Sacramento. I found that language barriers, cultural stigmas surrounding mental health, financial constraints, and limited access to services all contributed to Afghan refugees’ mental health issues. Those arriving since 2021 had better access to supportive services than those who came to the U.S. in earlier waves. Participants who received services were very grateful for the assistance. They also recognized the importance of family, community, and faith-based coping mechanisms in addressing mental health issues. The aim of my third study was to identify how socioeconomic status, sex, and years living in the U.S. influence mental health service utilization for Afghan refugees through quantitative surveys. Surveys were completed by 189 adults. I found that socioeconomic factors, such as household income in the U.S., significantly affected Afghan refugee mental health service utilization. Additionally, prior knowledge of mental health services and feelings of safety within the community were significant predictors of service use. Unexpectedly, neither sex nor years living in the U.S. were significantly associated with service utilization. Taken together, the findings suggest that addressing the complex interplay of socioeconomic, cultural, and structural factors is essential in promoting mental health service utilization among Afghan refugees in the U.S. Based on these findings, recommendations for practice are outlined, including providing targeted support for refugees with limited financial resources, improving language-appropriate and culturally competent mental health services, and increasing awareness and outreach efforts within refugee communities. These findings also can be useful in shaping policy in the area of mental health services for refugees and helping design interventions that promote access to and utilization of mental health services for Afghan refugees in the U.S. Future researchers in this area should consider longitudinal studies, which would allow for follow-up of Afghan refugees who need mental health services, comparing outcomes among those that do and do not receive mental health services
FORMATIVE RESEARCH FOR SNORKEL-RELATED DROWNING IN HAWAIʻI: A SOCIAL MARKETING APPROACH
(University of Hawai'i at Manoa, 2024) Kaumeheiwa, Bridget; Braun, Kathryn L.; Public Health
Abstract“Marketing has this sort of morbid power” (Lovato et al., 2007). Snorkelers, mostly visitors, fatally drown in Hawaiʻi several times per month (Galanis, 2019). Despite this sobering statistic, successful marketing of Hawaiʻi has effectuated not only an increasing number of visitors to the state but also an increase in snorkel-related drowning. While a thorough understanding of the causes of snorkel-related drowning is still evolving, residence status, advanced age, and pre-existing medical conditions are identified as predisposing factors. While these factors are not modifiable, behaviors that may modulate risk include snorkeling with a buddy, being efficient with equipment, learning to perceive and react in adverse conditions, selecting beaches with a lifeguard presence and access to emergency services, and conditioning oneself for the strenuous activity of snorkeling. Social marketing, which adopts commercial marketing practices to address public health or social justice issues, may be affectively applied to snorkel-related drowning prevention. Framing this marketing strategy with established behavior change models such as the Theory of Planned Behavior (TPB) can enhance desired behavior change. Formative research to understand and message the target audience is a required first step in social marketing and is a centerpiece of this paper. Study 1 derived and described snorkeling fatal, non-fatal, and pre-drowning incidents extracted from Hawaiʻi Emergency Medical System (EMS) patient care reports, including non-narrative (already coded) and narrative (post-coded) data. Of the 152 records reviewed, non-narrative data revealed that 77% of the snorkelers were visitors, 60% were male, mean age was 55.8 years old, and that 49% of the cases occurred in the county of Maui. Of the 27 deaths, 78% were male, 81% were visitors to Hawai‘i, and 96% received CPR by EMS responders. Although there were high proportions of missing data for some variables, non-narrative data showed the most frequent first intervenors for drowning snorkelers were bystanders/family members (61%), and the most common factor contributing to the drowning incident was exhaustion (44%), followed by issues with snorkeling equipment (22%). Study 2 surveyed Hawaiʻi visitors (n=483) for information on the product behavior of "snorkeling with a buddy". TPB constructs of intention, social norms, perceived behavioral control (PBC), and attitudes about drowning and snorkeling alone were studied. Most visitors both preferred (94%) and intended (88%) to not snorkel alone, and most (94%) perceived it was important to their peers/family that they snorkel with a buddy. The odds of intending to snorkel alone among those who felt it would be challenging to adjust their schedule to snorkel with a friend or family member was over ten times the odds of those who reported it would be easy to do so. The predictive model explained 33% of the variance in response to intention to snorkel alone (Nagelkerke R2, p <0.001) and correctly classified 91% of cases. Study 3 explored Maui County lifeguard observations, perceptions, and recommendations about snorkel-related drowning risk factors and prevention. Twelve lifeguards in three focus groups reported snorkelers were often ill-prepared for the hazards snorkeling presented, were often not open to lifeguard guidance, and that the visitor industry should clearly message the dangers of snorkeling to Hawaiʻi visitors. Together these studies indicate several possible strategies to address and prevent snorkel-related drowning. To the extent possible within resources constraints, EMS and other first responders should be encouraged to provide more information on the rescuee’s level of snorkeling and swimming experience and skill, contributing intrinsic and extrinsic factors, and equipment types and issues. Snorkeling equipment vendors, commercial tour operators, and others who deal directly with visitors should be encouraged to provide education on snorkeling in Hawai‘i and encourage visitors to swim with a buddy and/or with or near tour or hotel staff that have been trained in supervising snorkelers. Visitor industry investment in strategies that move beyond individual behavior messaging and take on the responsibility of changing visitor social norms and culture are needed. Research, likewise, must balance use of theory with empirical application and evaluation of current practices, including application of social marketing concepts beyond the formative research highlighted in these studies, to address the prevalence of snorkel-related drowning in Hawaiʻi.
Age-Friendly Health Systems and cultural relevancy: Exploring the application of the geriatrics 4Ms model with Native Hawaiian elders
(University of Hawai'i at Manoa, 2023) Ibrao, Miquela; Braun, Kathryn L.; Public Health
The US Health Resources and Services Administration has made educating providers, families, and caregivers on the 4Ms framework a requirement of federally funded programs like the Geriatrics Workforce Enhancement Program (GWEPs). The 4Ms – Mobility, What Matters, Medication, and Mentation –were originally developed as a medical framework intended for use with healthcare practitioners. The prioritization of the framework by the Health Resources and Services Administration has resulted in its adaptation for use with patients, families, and caregivers. As GWEPs works to move the 4Ms model from hospital-based care to community care, it is important that the model be translated from clinical use to a model that can be used effectively with communities. The purpose of this dissertation was to assess 3 of the 4Ms of geriatrics – Mobility, What Matters, and Medications – to support Native Hawaiian kūpuna aging preferences. Study 1 explored differences in mobility limitation between race/ethnic groups of community dwelling older adults age 55+ in Hawai‘i using the Hawai‘i Behavioral Risk Factor Surveillance System (BRFSS). Analyses found that Native Hawaiians have a higher prevalence ratio and odds ratio of mobility limitations at younger ages when compared to other race/ethnicities included in the study. SDOH independent variables suggested that social interventions may be effective in promoting mobility with the population. Study 2 explored What Matters in healthcare through a qualitative analysis of 20 Native Hawaiian kūpuna interviews. Themes identified included the routine incorporation of traditional healing, a strong sense of family as part of their decision-making processes, varied preference for home-based care at the end-of-life, and the importance of healthcare practitioners taking the time to “talk story” and building relationships with the communities they serve. Study 3 conducted a systematic review on existing programs that integrate Traditional Medicine into Western healthcare settings and their effectiveness with Indigenous populations in the US. A majority of the models described with American Indian and Alaskan Native populations were on the topic of behavioral health, particularly substance abuse and mental health, while with Native Hawaiians they were on general health with primary care clinics. Findings on effectiveness showed positive impacts on experience of care and population health suggesting the model holds promise. Three conclusions from overall findings of the study were: Native Hawaiian kūpuna need mobility intervention at younger ages than the retirement age of 65; What Matters in health for kūpuna vary and it is important that providers “talk story”; and Traditional Medicine is a valued and effective model of care. Although the 4Ms are packaged as distinct entities they often overlap, resulting in findings from multiple studies supporting recommendations for Mobility, What Matters and Medication. A recommended 5th M – multicultural – could promote culturally relevant care in Western healthcare systems.
Mana Health: Understanding the Role of Mana Exchange in Optimizing Native Hawaiian Health
(University of Hawaii at Manoa, 2023) Makahi, Emily K.; Braun, Kathryn L.; Public Health
Mauli Ola, or Native Hawaiian wellness, is a holistic view of health that includes physical, mental, emotional well-being, and spirituality (Wegner & University of Hawaii at Manoa: Department of Sociology, 1989). However, Mauli Ola was impacted by several historical moments that led to changes in the cultural, political, and national sovereignty of Hawaiian civilization. The introduction of colonial control affected the health status of the indigenous people, who now have a health status far below that of dominant White United States population groups (McCubbin & Marsella, 2009). Despite the importance of spirituality among Native Hawaiians and the potential of mana-filled interventions to improve well-being, no studies have been done to assess how Mana is defined and experienced on the individual level and best integrated into healthcare programs and systems and evaluation methods. This dissertation was comprised of three studies. Study 1 collected data using phenomenology methods to understand how Native Hawaiians experience Mana and with whom/what they interact with to acquire positive Mana. Findings helped to define Mana Exchange and identify six factors of Mana Exchange. The Mana Exchange Survey (MES), used as an instrument to measure frequency of Mana Exchange behaviors, was created and the following studies were used to test validity of MES instrument. Study 2 conducted cognitive interviews to test the face validity of the MES instrument and test its acceptability among Native Hawaiian adults. Interviews informed new versions of the MES by informing the researchers to add, revise, and retain items. The findings of this study led to a final MES instrument that is novel to Native Hawaiian spirituality evaluation that measures Mana Exchange as a quantitative behavior of Mana. Study 3 used psychometric testing of the MES to continue to test the instrument’s validity. Statistical analysis showed that the MES measured three factors of Mana Exchange, titled Ao, Pō, and Akua. Individuals can acquire positive Mana through Ao, the living, through Pō, the spiritual realm of deceased individuals, and through Akua, things and people regarded in high spiritual beings. Findings also suggest that the MES is a reliable and valid instrument worthy of further exploration and study. Overall, findings from this dissertation highlight the ability for Native Hawaiian health-related constructs to be captured through instrument development that is accepted by the community and statistically significant. This dissertation has added to the scholarship of Mana and continue highlight need to increase best practices to evaluating Native Hawaiian health.
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.

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