The purpose of this study was to document the health care experiences of Korean immigrant older adults, 65 years of age or older, living in Los Angeles County, who have health care access through Medicare and/or Medi-Cal, access to a large Korean ethnic enclave, and a diverse social support network. Twelve Korean immigrant older adults were recruited through word-of-mouth via community contacts. Semi-structured qualitative interviews were conducted with individual seniors, with the help of a bilingual, bicultural interpreter. Translated transcripts of the interviews were coded, and domains were identified via a "grounded theory" approach. The themes that emerged were: 1) ambivalence toward Korean primary care doctors, 2) limited health care choices, 3) dependence on a diverse social support network, 4) personal responsibility for one's health, and 5) the idea of enduring difficulties in life and expected health challenges "old age." Implications of the findings are discussed for service and policy, with attention to the importance of language and culture for this population.

The purpose of this study was to explore the cultural knowledge and health perspectives of second-generation Hmong, who have an increased risk of overweight, obesity, and chronic illnesses associated with being overweight and obese. In examining health perspectives that guide their actual health behaviors, I sought to examine if and how the second-generation live and reconcile their two worlds socially and emotionally. A total of 17 interviews were conducted with 11 second-generation students from Southern California institutions, 7 first-generation parents (two sets of parents), and 1 aunt who is considered the 1.5 generation. First and second generations are active players in syncretizing opposing cultural elements with mundane concerns of day to day life. Second-generation participants gather what they know to be traditional and modern, but most of their belief systems are grounded through a Eurocentric stance in which Eastern is the alternative to what they consider normal. However, Hmong traditions and Eastern models of understanding health are conceivable because of their direct experiences and relationships with their family and friends who share similar backgrounds, which then allow them to accept or at least consider a multicultural approach to health. This process is constant for the second generation where each individual adopts some components of each approach, as to why many participants stated, “we do whatever works.”

Southeast Asian women, including Cambodians and Thais, experience higher rates of breast and cervical cancer incidence than any other racial/ethnic group in the U.S. Incidence of cervical cancer among Cambodian and Thai women is among the highest in the U.S. and incidence rate of breast cancer for these two groups is rapidly increasing, while rates are decreasing for other racial/ethnic groups. Cambodians and Thai women also experience higher rates of late-stage breast cancer than non-Hispanic White women, resulting in increased morbidity and mortality from the disease. Despite these staggering statistics, little is known about barriers and facilitators of screening for Cambodian and Thai women, particularly women in Southern California, which is home to the largest population of both groups.

This dissertation sought to better understand breast and cervical cancer screening behavior among Cambodian and Thai women in California. Using a mixed methods approach, this study has the following aims: 1) identify individual and environmental level predictors of breast and cervical cancer screening among Cambodian and Thai women in Northern and Southern California, 2) examine the association between behavioral intention and mammogram adherence among Cambodian and Thai women in Southern California, 3) explore ethnic-specific, culturally-based norms and systems-related factors that influence the decision-making process for Cambodian and Thai women in Southern California, and 4) examine the role of community health navigators in assisting Cambodian and Thai women to overcome individual and environmental barriers to mammogram screening in Southern California.

Results from this study contribute to breast and cervical cancer literature and expands the existing literature on Cambodian and Thai women. By stratifying data analysis, the quantitative portion of this study identified community-specific individual, social, and environmental level predictors of breast and cervical cancer screening. Additionally, the qualitative portion of this study found that while self-efficacy and health-care seeking behavior differ between Cambodian and Thai women in Southern California, these two groups are influenced by similar factors in the decision-making process. Lastly, using a mixed methods approach, this study found that Cambodian and Thai women are not able to act on their intentions to get screened without assistance from a Community Health Navigator. This finding supports previous research that found behavioral intention to be a poor indicator of actual behavior in more disadvantaged communities.

The overall findings of this dissertation research have significant implications for how health disparities are conceptualized and addressed in diverse communities. This research recognizes that health behavior is a function of individual, social, and environmental factors and as such, a mixed methods approach is need to better contextualize and interpret breast and cervical cancer screening practices for Cambodian and Thai women in Southern California. This dissertation research underscores the need to move beyond the traditional research paradigm of using quantitative methods alone and reinforces the value of using mixed paradigms and methods to better understand health behavior in order to design more effective interventions to eliminate health disparities.

ABSTRACT OF THE DISSERTATION

How do Native Hawaiian Concepts of Well-being Inform

the Meaning And Social Function of Food?

By

Darrah Leigh Goo Kuratani

Doctor of Philosophy in Public Health

University of California, Los Angeles, 2015

Professor Marjorie Kagawa Singer, Chair

It is well known that indigenous communities are vulnerable to the plight of the social gradient of health and are overly burdened by chronic diseases. One common risk factor for the major chronic illnesses among indigenous communities, such as heart disease, metabolic syndrome, diabetes, and cancer is obesity. The indigenous people of Ka Pae Aina (the Hawaiian Islands), the Kanaka Maoli (Native Hawaiians), reside as minorities in their native land, and have the poorest health outcomes. They also have one of the highest rates of obesity in the world. Even though obesity rates have risen for all groups nationally, Native Hawaiians are almost twice as likely to be obese. In Hawaii, Native Hawaiians have the highest obesity rate (47%) when compared to other ethnic and racial groups, including Non-Hispanic Whites (NHW) (21%), Japanese (16%), and Filipinos (21%) (HHDW, 2013). The epidemiology clearly shows that the problem exists, but current research does not explain why the obesity rate for Native Hawaiians is so incredibly high. Such reasons remain poorly explored, and this lack of knowledge undermines efforts to effectively reduce the rates of obesity.

The U.S. colonized native Hawaiians in 1898, and colonial culture and laws have worked to marginalize, stigmatize and alienate Native Hawaiian people from the larger society. The overarching impact of imposed and embedded colonial denigration of the Native Hawaiian people has been reported to be the perpetuation of negative self-image and their social position has been restricted to the bottom of the political hierarchy. The consequences of both these forces generally has been to limit their lifestyle choices and options about their own health and well-being. Yet these factors are rarely included as active factors in the theoretical frameworks used to address the health status of this population.

Rather, studies that address Native Hawaiians and other indigenous peoples, often intimate that their culture is a large part of the problem. However, interventions designed to improve the negative health status of native peoples and Native Hawaiians, in particular, do not seem to identify what it is about culture, and in particular, whose culture, may actually be influencing the behaviors that lead to overweight and obesity. Previous interventions that have integrated cultural values and practices in weight loss programs with Native Hawaiians have shown initial benefit, but were unable to sustain long term results. This is likely because the focus was on individual level beliefs and practices. The larger social and political forces that address daily realities of work and low incomes, and institutionalized discrimination towards Native Hawaiians were not addressed. Individual level strategies are necessary, but not sufficient to sustain healthier choices if these contextual forces are not addressed.

In the 1970s, the Hawaiian Renaissance was founded and became an emotional and political turning point for Native Hawaiians. Its goal was to reinvigorate cultural pride and interest in the values and wisdom of Native Hawaiian culture in contrast to the 120 years of explicit denigration of Native Hawaiian culture, and explicit pressure to assimilate into white European Christian culture. The spirit of the Hawaiian renaissance has given rise to a counter consciousness and spurred an ongoing struggle to recognize and reconcile the two competing sets of cultural messages for the native peoples and, primarily, the political power and social structure of Hawaiian society today.

This study applied a socio-ecologic conceptual cultural lens to understand the concepts of well-being among Native Hawaiians to investigate if and how social, political, and historical contextual forces may still affect Native Hawaiians’ sense of self, and if and how these forces may impact their conceptualizations of and decisions regarding health. The intent was to investigate how a multi-level, multidimensional concept of culture might better elucidate how we understand the relationships of these contextual forces on the meaning of well-being and food, the use of food in social relationships, and, ultimately, its potential relationship to rates of obesity.

This ethnographic study was conducted on the island of Oahu with participant, observational, archival investigations and one-on-one inductive qualitative, interviews with twenty-nine Native Hawaiian participants. Interviews were audio-recorded, transcribed, and analyzed. The conceptual frameworks that guided this study included, the Cultural Framework for Health (CFH), and the philosophical and theoretical concept of empathy. The CFH recognizes and incorporates an explicit definition of culture as a scientifically grounded, multidimensional, and multi-level construct, inclusive of biopsychosocial and ecological frameworks and recognizes and incorporates geographical, historical, social and political realities of diverse communities.

The findings show that Native Hawaiians’ conceptualizations of well-being are based on five core Native Hawaiian cultural values: 1) ohana (family), 2) aloha (love, care, and compassion), 3) kokua (to help without being asked), 4) lokahi (harmony), and 5) mana (life force, energy, power). One of the key ways these values are expressed and manifested interpersonally is symbolically through the meaning and use of food. Food was found to be a key component in how Native Hawaiian identity is conceptualized and as a way to express and access love, compassion, and comfort. Notably, the findings showed that the conceptualizations of well-being extend beyond the individual and include family, community, social, political and historical issues and structures that have the potential to provide a sense of worth and empowerment.

This study suggests that the use of food may also be a coping mechanism for Native Hawaiians to seek comfort from the feelings of powerlessness and denigration by the overarching social structure that has relegated them to being “the forgotten people.” Health interventions would likely be more effective and long lasting if this more comprehensive and scientifically grounded cultural analysis informed the design and implementation of such efforts.

The homeless population in the United States (US) is diverse and consists of men, women, families, youth and veterans dealing with a range of issues related to domestic violence, post-traumatic stress disorder, mental illness, substance abuse, and poor physical health. Homeless populations are especially vulnerable to chronic diseases including lung and colorectal cancer, asthma, heart disease, chronic obstructive pulmonary disease, and stroke, all of which are exacerbated by their poor housing conditions and lifestyle behaviors. Tobacco use is highly prevalent and an understudied health issue in homeless populations. Up to 80% of those who are homeless are using tobacco. Homeless individuals recognize the negative consequences of smoking, including the dangers to their health, to their appearance, and the high cost of smoking. Notably, evidence suggests that 37%-76% of homeless adult smokers would like to quit their smoking habit.

Yet, remarkably few studies on tobacco use and cessation among homeless populations have been conducted, despite their known vulnerability to tobacco use. This dissertation addresses a unique set of gaps in the literature that focus on the possible influences of the built environment and local or city/county-level tobacco use policies on tobacco use prevalence among homeless adults living in transitional shelters in Los Angeles County. The findings from this research can inform the efforts of policy makers, shelter staff, and homeless services providers to create more relevant and effective programs for addressing tobacco use in this vulnerable population.

There are several important findings from this dissertation. First, rates of smoking are high among those living in transitional homeless shelters in Los Angeles County, with 63% of participants reporting being a current smoker. Second, we did not find the expected individual-level demographic differences, with the exception of Latinos, who reported less smoking than other race/ethnicity subgroups. Third, there were few differences at the shelter level in regards to residents' smoking status, contrary to what was expected considering the variations in populations served at the various shelters. Fourth, qualitative data analyses indicated findings showed a need for tobacco use reduction/cessation efforts at the shelter-level, and identified suggestions for improving the effectiveness of smoking reduction interventions with this population. Finally, to our knowledge, this research constitutes the first study to assess tobacco use behaviors in conjunction with conventional measures of the built and policy environments surrounding transitional shelters. The new as well as the unexpected findings for transitional shelters for the homeless support the need to expand on current measures of the social, built, and policy environment to include attention to more informal sources of tobacco and better measures to capture the cultural rules operating for this unique population.

Asian American is predicted to be the largest immigrant group by the year 2055. Breast cancer is the primary cancer diagnosis and the second-leading cause of death among Asian-American women. Despite the lengthy presence of Asian immigrants in the US and the recent predictions of increasing breast cancer incidence in this population, the unique cultural needs and psychological responses to cancer survivorship remain relatively unknown. In order to expand the understanding in Asian American breast cancer survivorship, this dissertation applied the Transactional Model of Stress and Coping to examine how stressors experienced by the Asian American breast cancer survivors and their coping use influenced their psychological well-being. Secondary data analysis was conducted on 233 participants (Chinese = 44%, Japanese = 37%, and Vietnamese = 19%) who completed qualitative questionnaires that assessed their physical, emotional, social, and financial stress. Participants also completed standardized measures on their coping strategies used and psychological well-being. The analysis on the relationship between stress and psychological well-being indicated that higher levels of stress (in all four types of stressors) were associated with poor psychological well-being. Moderation of ethnicity on the relationship between stress and psychological well-being was unable to be tested due to low sample size. The analysis of the relationship between coping and psychological well-being revealed ethnic differences in the following coping strategies: expressive suppression, active coping, denial, use of emotional support, use of instrumental support, positive reframing, acceptance, and self-blame. The increased use of all emotion-focused coping strategies of positive valence and problem-focused coping strategies was associated with good psychological well-being (except the relationship between cognitive reappraisal and self-stigma). Furthermore, the increased use of all emotion-focused coping strategies of negative valence was associated with poor psychological well-being. Moderation of ethnicity on the relationship between coping and psychological well-being could not be tested due to low sample size. Mediation of coping on the relationship between stress and psychological well-being could not be tested either, due to low sample size. The findings from this dissertation could advance public health theories and improve doctor-patient communication with Asian American breast cancer survivors.  

Pilipino Americans comprise the second largest Asian American subgroup in the United States and experience the highest rates of breast cancer compared to any other Asian American subgroup for which data is available. However, literature specific to the social support experience of Pilipino American breast cancer survivors is minimal. Utilizing a qualitative research approach, this thesis investigated three areas of the social support experience among Pilipino American breast cancer survivors: (1) How social support is perceived and received; (2) Role of support groups; and (3) Role of religion. One semi-structured focus group interview was conducted with eight participants from the greater Los Angeles area. Emergent themes included sources of support, survivorship, relationships and ways of coping. Participants' discussion surrounding these topics was contextualized by cultural values specific to the Pilipino American population. Thesis findings can inform future projects that build the social support literature on breast cancer survivorship.