Exploring the Dietary Experiences of Tongan Americans:
Barriers and Facilitators to Healthy Dietary Behaviors
DISSERTATION SUBMITTED TO THE GRADUATE DIVISION OF THE UNIVERSITY OF HAWAI'I AT MĀNOA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN
SOCIAL WELFARE
August 2020
Victor Kaufusi
University of Hawai'i at Mānoa
Dissertation Committee Members: Dr. Seunghye Hong (Chair) Dr. Jing Guo Dr. Peter Mataira Dr. Paula T. Araullo Tanemura Morelli Dr. Alan Titchenal (University Representative)
i
Abstract
Background and Significance: Over the past two decades, the quality of the Tongan-American diet has become of increasing concern to researchers, health professionals, and within the
Tongan American communities. Schmidt (2007) found the dietary behaviors among Tongan-
Americans consist of unhealthy foods including a high intake of sugar, salt, and fat. Yu et al.
(2016) argued that the adoption of healthy dietary behaviors can help to reduce the disproportionate rate of diseases. Obesity rates have increased among this population in the last
20 years (Flegal et al., 2010; Panapasa et al., 2012) and obesity is now considered to be an epidemic among Tongan-Americans (Panapasa et al., 2012). According to the World Health
Organization (2003), Tongans have the fifth-highest percentage of obese people in the world. In addition, the prevalence of diabetes among Tongan-American adults is also twice as high (21%) as compared to the U.S. population (10%) (Panapasa et al., 2012). These health disparities could be addressed by exploring the experiences with dietary behaviors among this population given the link between dietary behaviors and obesity and other chronic diseases such as diabetes.
Purpose of Study: The purpose of this study is to better understand the dietary experiences and attitudes of Tongan Americans that contribute to the disproportionate rates of obesity and other chronic diseases in an effort to inform culturally tailored health strategies to address the high incidences.
Methods: The study utilizes the principles of a grounded theoretical approach to understanding the lived experiences of Tongan American adults. The inductive nature of this exploratory qualitative study gives voice to participants' stories of how their behaviors around food and food preparation have evolved. The shift in dietary practices is among the underlying causes of the high rates of the chronic disease currently experienced by Tongan American adults. The
ii
methodology includes semi-structured interviews with 12 Tongan Americans (six men, six women).
Findings: The findings indicate that there are complex behaviors involved with dietary behaviors. Thus, there were various nuances between the Tongan American dietary behaviors and the facilitators and barriers to adopting healthy dietary behaviors among Tongan American adults, including variables at the individual, environmental, sectoral, and socio-cultural levels, as the framework. In this study, the findings show that the barriers to healthy dietary behaviors include (1) home and physical environment, (2) convenience, (3) time management, (4) stress,
(5) health literacy, and (6) the media; and the facilitators include (1) social support, (2) family meals, (3) meal planning and preparation, (4) individual health benefits, and (5) resiliency.
Further findings suggest the importance of considering social, structural, and cultural contexts when engaging Tongan American populations and formulating preventive strategies. Therefore, research efforts and intervention initiatives aimed at preventing health disparities among Tongan
Americans should be adaptable, innovative, multi-component, and multi-faceted, and should be culturally tailored to meet the needs of Tongan Americans.
iii
Table of Contents
Chapter 1 ...... 1 Introduction ...... 1 Chapter 2 ...... 5 Literature review ...... 5 First-Generation Tongans ...... 5 Traditional Tongan Health ...... 5 Traditional Tongan Dietary Behaviors ...... 6 Policy Change and Chain Migration ...... 7 Tongan Americans and Native Hawaiian and Other Pacific Islanders ...... 7 Hidden Population ...... 8 Cultural Tailoring ...... 9 Tongan American Dietary Behaviors ...... 10 Health Disparities and Dietary Behaviors ...... 10 Obesity and Dietary Behaviors ...... 10 Diabetes and Dietary Behaviors ...... 11 Healthy and Unhealthy Dietary Behaviors ...... 12 Healthy Dietary Behaviors ...... 12 Unhealthy Dietary Behaviors ...... 13 Factors Associated with Dietary Behaviors ...... 14 Theoretical Framework ...... 15 Social Ecological Model ...... 15 Individual Level Factors ...... 18 Gender ...... 18 Stress ...... 19 Perceptions ...... 19 Socioeconomic Status ...... 20 Health Literacy ...... 22 Environmental Settings ...... 23 Home Environment ...... 23 Physical Environment ...... 24 Sectors of Influence ...... 25
iv
Governmental Policies ...... 25 Food Advertisement Regulation ...... 26 Social and Cultural Norms ...... 27 Traditional Preparation of the Food ...... 27 Cultural Meaning of Food ...... 28 Impact of Colonization on Traditional Food Practices ...... 28 Using the SEM to Explore the Dietary Experiences of Tongan Americans ...... 30 Chapter 3 ...... 31 Statement of problem ...... 31 Purpose of Study ...... 31 Study Goals and Research Question ...... 32 Study Goals ...... 32 Overall Proposed Research Questions ...... 32 Chapter 4 ...... 33 Methodology ...... 33 Methods ...... 33 Selection of Appropriate Methodology ...... 33 Study Participants ...... 34 Sampling ...... 34 Demographic Survey ...... 36 Semi-Structured Interviews...... 36 Interview Procedures...... 37 Transcription ...... 38 Data Analysis ...... 38 Open Coding ...... 39 Axial Coding ...... 39 Selective Coding ...... 40 Narrative Analysis ...... 41 Chapter 5 ...... 43 Findings ...... 43 Barriers to Adopting Healthy Dietary Behavior ...... 43 Home Environment ...... 43 Physical Environment ...... 44 Convenience ...... 46 Time Management ...... 48
v
Stress ...... 49 Health Literacy ...... 51 Media ...... 52 Facilitators to Adopting Healthy Dietary Behavior ...... 53 Social Support ...... 53 Family Meals ...... 55 Meal Planning and Preparation ...... 56 Health Benefits ...... 57 Resilience ...... 58 Core Category ...... 60 Summary Analysis of the Narratives ...... 60 Preparation of the food in a Tongan-American Home ...... 69 Healthy Diet and Mental Well-Being ...... 70 Conceptual Map of Findings ...... 71 Summary of Findings ...... 72 Individual Level ...... 73 Physical Environment ...... 76 Home Environment ...... 76 Sectors of Influence ...... 78 Cultural and Social Norms ...... 78 Chapter 6 ...... 80 Discussion ...... 80 Study Limitations ...... 80 Implications for Social Work Policy, Research, and Practice ...... 81 References ...... 84 Appendices ...... 116 Appendix A ...... 116 Appendix B ...... 119 Appendix C ...... 120 Appendix D ...... 121 Appendix E ...... 122 Appendix F...... 123 Appendix G ...... 126
vi
Chapter 1
Introduction
The dietary shift among Tongan American adults from their traditional diet consisting of foods from the land, such as taro, ufi, fruits, and vegetables, to a Western diet, which consists of processed foods high in sodium and saturated fats and high in cholesterol, has contributed to the current high incidence of chronic disease among the population (Panapasa et al., 2012). The history of the Tongan American people shows that their dietary behaviors were healthy before the migration of the first generation of Tongans to the United States (Veatupu et al., 2019).
Then, a significant change in U.S. immigration policy in 1965 opened the door for large groups of Tongans to migrate to the United States (Keely, 1971). One of the unintended consequences of the policy change was the collapse of Tongan political systems and rule and protocols surrounding social behaviors. Tongans left an island environment that was conducive and conditioned to their social, cultural, and dietary needs and entered an unknown Western society with limited resources and skills. The acculturation to life in the United States has thus influenced a shift from their traditional diet to a Western diet (Vakalahi, 2011). For example,
Schmidt (2007) conducted a study of Tongan Americans and found that their diet included increased consumption of foods high in sugar, salt, and fat which has ultimately led to high rates of obesity, diabetes, and coronary disease.
Consequently, this change in dietary behaviors has come at a cost. The research shows that the health of Tongan Americans has dramatically declined since their first wave of arrivals in the United States. According to Lipski (2010), once indigenous people have become exposed to the Western diet and lifestyle, they are in danger of rapidly developing chronic illnesses. As evidence, current health data shows that Tongan Americans are suffering from health disparities.
1
For instance, according to the World Health Organization (2003), the Tongan population includes the fifth-highest percentage of obese people in the world. Tongan American adults are experiencing significant rates of obesity, with 67% of Tongan Americans reported as being overweight compared with the average 40%–50% of the total U.S. population (Panapasa et al.,
2012). The prevalence of diabetes among Tongan American adults is also twice as high (21%) as that of the overall U.S. population (10%) (Panapasa et al., 2012).
However, despite the high incidence, the health literature shows that to mitigate this increasing health concern, the adoption of healthy dietary behaviors which is vital to reducing the disproportionate rates of chronic disease. Caperon et al. (2019) referred to healthy dietary behaviors as not only the consumption of, but the preparation or acquisition of healthy foods which affects the ability to eat healthily. According to Makris and Foster (2011), the adoption of a healthy diet reduces chronic diseases. For example, the Dietary Guidelines for Americans are based on evidence that eating a healthy diet can reduce the risk of chronic disease. As such, the guidelines include recommendations for “foods to reduce” (i.e., saturated and trans-fat, cholesterol, sodium, added sugar, refined grains, alcohol) and “foods to increase” (i.e., fruits, vegetables, whole grains, low-fat dairy and protein foods, oils) in order to maximize the nutrient content and health-promoting potential of the diet (Makris & Foster, 2011). Given the known health benefits, nothing has been done to explore the reasons for lack of adherence to the dietary guidelines, which would potentially inform culturally tailored strategies to address the high rates of chronic diseases among Tongan American adults.
The choice to change one’s diet to adopt healthy dietary behaviors can be challenging because of the multiple factors involved (Kelly & Barker, 2016). Health researchers stressed that changing a diet can be especially challenging because choosing highly processed foods that
2
contain unhealthy chemicals and additives are so readily available (Abdulmumeen, Risikat, &
Sururah, 2012; Kelly & Barker, 2016). Likewise, the relatively low cost, accessibility, convenience, and in most cases, the combination of multiple factors can also make it difficult to change a diet (Kelly & Barker, 2016). The literature notes that other factors also make it difficult to change one’s diet. For example, Norman et al. (2015) found that stresses from both works and within the home environment made it difficult to adopt healthy dietary behaviors. On the other hand, in another study, Shepherd et al. (2005) found that support from family, full availability of healthy foods, and self-image all facilitated the adoption of healthy dietary behaviors. Notwithstanding, the literature does indicate that multiple factors are associated with a potential dietary change (Liao, Siegel, White, Dulin, & Taylor, 2016; Norman et al., 2015;
Popovic-Lipovac & Strasser, 2015).
There are studies that capture the participants’ stories about their behaviors around food can be an effective method for addressing the gap in the literature (Liao et al., 2016; Norman et al., 2015; Popovic-Lipovac & Strasser, 2015). For example, Norman et al. (2015) found that stresses from work and within the home environment made it difficult to adopt healthy dietary behaviors. Nevanperä et al. (2012) investigated associations between chronic stress, eating behavior, and weight among working women and found that high levels of chronic stress from occupational burnout at work were associated with unhealthy dietary behaviors. Webb et al.
(2018) also explored the association between stress in the home and dietary behaviors and concluded that higher levels of family stress were predictive of lower diet quality (i.e., lower fruit and vegetable intake in the home.) Conversely, Shepherd et al. (2005) found that support from family, full availability of healthy foods, and self-image all facilitated the adoption of healthy dietary behaviors. In another study of 12,851 French adults, Méjean et al. (2018), found
3
that frequency and time for meal preparation, cooking skills, preparation from scratch, was prospectively associated with healthy dietary behaviors and decreased risk of obesity. This is confirmed by previous researchers in the field that concluded that multiple factors are associated with a change in dietary behaviors (Norman et al., 2015; Popovic-Lipovac & Strasser, 2015).
However, due to the lack of research on Tongan American health disparities, the incidence of chronic disease will continue to increase among Tongan Americans (Panapasa et al., 2012) unless research is done to promote culturally tailored strategies to the high incidence of chronic disease.
There is a knowledge gap in the literature in regard to the shift from the traditional healthy to the current unhealthy dietary behaviors that occurred over the last 70 years. We can conclude that there are multiple factors possibly contributed to the shift in their dietary behaviors. However, little has been done to explore these factors. For this reason, a qualitative study will employ the Social Ecological Model to explore the factors associated with the dietary behaviors of Tongan-Americans. The Social-Ecological Model (SEM; see Figure 1) offers insight into how multiple elements at the individual, environment, influential, and social and norms levels intersect to shape a person’s dietary behavior and, afterward, his or her health outcomes (Bronfenbrenner, 1979; McLeroy, Bibeau, Steckler, & Glanz, 1988).
This study will therefore explore the dietary experiences and attitudes of Tongan
Americans that contribute to the disproportionate rates of obesity and other chronic diseases among Tongan American adults.
4
Chapter 2 Literature Review
First-Generation Tongans
Tongans are a small population from a remote island in the Pacific Ocean. The
Polynesian kingdom of Tonga consists of 170 islands islets in the South Pacific and located between the latitudes 15°35’S and 22°20’S and longitudes 173°38’W (Randall et al., 2004). The islands are separated into three major groups: Tongatapu; Ha’apai; and Vava’u (Randall et al.,
2004). The first generation of Tongan immigrants arrived in the United States as young and healthy labor missionaries for the Church of Jesus Christ of Latter-Day Saints (LDS) (Morris,
2014). Pottie et al. (2015) defined a first-generation immigrant as someone foreign-born. In the late 1950s, first-generation Tongans arrived at the North Shore town of La'ie, Hawai'i, to help construct the infrastructure for the LDS (Ka'ili, 2008). According to Ka'ili (2008), the LDS played a prominent role in the migration of first-generation Tongans. For instance, it created overseas networks for Tongans by providing visas, employment, scholarships, and, most importantly, the opportunity to migrate to the United States. Since then, the Tongan population has steadily grown. In 2000, nearly 88% of Tongans lived in five states: California (15,252),
Utah (8,655), Hawai'i (5,988), Texas (1,371), and Washington (1,029), with a total Tongan population of approximately 33,000 (Hixson et al., 2012). Then, in 2010, the U.S. Census reported that the total population of Tongan Americans had increased to about 60,000 (Hixson et al., 2012).
Traditional Tongan Health
Although literature on the subject is scant, what can be deduced is that first-generation
Tongans were typically healthy before migrating to the United States. Rubalcava et al. (2008) found that first-generation immigrants often arrived as healthy individuals. For instance,
5
research has shown that these immigrants had better health outcomes and behaviors than the second generation (born in the United States to immigrant parents; Teruya & Bazargan-Hejazi,
2013). Given, no other health data is available to verify those studies’ reported health outcomes for traditional Tongans we can only assume they were fit, strong and healthy based on their traditional diet and physiques. Historical accounts from European maritime records provided added insight into the health of the traditional Tongans. For example, records from early
Europeans to the Tongan islands described how they marveled at the physical stature and health of traditional Tongans (Cook et al., 1999; Kaeppler, 1971; Lee, 2003; Morton, 1998).
Nevertheless, the literature does show that traditional healthy dietary behaviors contributed to the robust health outcomes among Tongans before their migration to the United States.
Traditional Tongan Dietary Behaviors
Research shows that the traditional Tongan dietary behaviors were associated with improved diet quality (Evans et al., 2003). The literature on the traditional Tongan diet shows that before migrating to the United States, Tongans ate a diet consisting of crops such as fruits and vegetables, an abundance of fish, and little meat, which contributed to their superior health outcomes (Englberger et al., 1999; Evans et al., 2003). Healthy dietary behaviors include the preparation and low consumption of sugar, salt, and saturated fat contribute to more robust health outcomes (Green, 1984). According to Slavin and Lloyd (2012), diets with a high intake of fruits and vegetables promote healthier results. Current scientific evidence suggests that the consumption of fruits and vegetables is vital in the prevention of coronary heart disease, and evidence is accumulating for a protective role in stroke (Rodriguez-Casado, 2016; Van Duyn &
Pivonka, 2000). In addition, evidence also shows that fruits and vegetables have a protective
6
role in the prevention of cataract formation, chronic obstructive pulmonary disease, diverticulosis, and possibly, hypertension (Alissa & Ferns, 2017; Van Duyn & Pivonka, 2000).
Policy Change and Chain Migration
As part of the post-World War II modernization effort, a change in U.S. policy opened the door for chain migration, which promoted the movement of more Tongans into the country
(Keely, 1971). On October 3, 1965, President Lyndon B. Johnson signed the Immigration and
Naturalization Act of 1965, also known as the Hart-Celler Act, into law (Keely, 1971; Kennedy,
1966). The passage of the bill abolished an earlier quota system based on national origin and established a new immigration policy that focused on reuniting immigrant families (Keely, 1971;
Kennedy, 1966). As a result, a large population of immigrants began migrating to the United
States through a chain migration process. Chain migration refers to the process that allows immigrants to the United States to sponsor other family members for admission, such as parents, children, and siblings, who can then sponsor other immigrants themselves (Ka'ili, 2008). The policy benefited Tongans because family relations are integral to their cultural values.
Therefore, the majority of the second wave of Tongan immigrants came as a result of a family connection to the early Tongan immigrants who first arrived as LDS labor missionaries in Laie,
Hawai'i, in the late 1950s (Ka'ili, 2008).
Tongan Americans and Native Hawaiian and Other Pacific Islanders
Tongan Americans are also part of a rapidly growing Native Hawaiian and Other Pacific
Islander (NHOPI) population in the U.S. that are suffering from the same issues as other immigrant groups (Braden & Nigg, 2016; Subica et al., 2017). The NHOPI population was one of the fastest-growing race groups between 2000 and 2010 (Hixson et al., 2012). The Tongan
American population is fraught with social issues in the United States. Its low education level is
7
among these concerns. According to Tui'one et al. (2010), few Tongans are pursuing higher education. A study among Tongan Americans found that only 9% of Tongans across the United
States have attained a bachelor's degree or higher, compared with the national average of 25%
(Tui'one et al., 2010). The high rate of poverty among Tongan Americans is also a growing concern. The median Tongan family income is $46,261, as compared with the total U.S. population’s median income of $50,046, and an estimated 44% of Tongans in California live at
200% of the federal poverty level (Harris & Jones, 2005; Tanjasiri et al., 2015). An aim of this study is to explore the association between the aforementioned social issues and the dietary behaviors among the Tongan American participants.
Hidden Population
The combination of low population numbers and the aggregation of Tongan American health data and statistics with the overall Native Hawaiian and Other Pacific Islanders (NHOPI) ethnic groups has diminished their visibility to health professionals, promoters, and researchers in the U.S. public health system (Stafford, 2010). In 1997, the Office of Management and
Budget adopted new standards (Office of Management and Budget, 1997) for classifying race and ethnicity and provided a standard classification for record-keeping, collection, and presentation of data on race and ethnicity. Of the changes, the most prominent for Tongan
Americans was the disaggregation of the health data for NHOPI. The paucity of public health data collected about NHOPI have traditionally been overshadowed because they were combined with much larger data sets about Asian Americans (Stafford, 2010). Although there are pros and cons to aggregating the data, health researchers agreed that the aggregation distorted the true picture of the NHOPI health needs and statistics (Stafford, 2010). Likewise, aggregation of the
Tongan American health needs and statistics with those among the NHOPI further diminished
8
their visibility to those in the public health system. Researchers have stressed that with relatively small population sizes, Pacific Islanders (Tongan Americans) are invisible to public health professionals, promoters, and researchers, and as a result vital resources have not been made available to assess and respond to their particular health needs (Panapasa et al., 2012; Stafford,
2010).
Cultural Tailoring
According to Dutta (2007) cultural tailoring is defined as shaping a health message that recognizes and reinforces a group's cultural values, beliefs, and behaviors and builds upon those to give context and meaning to the message about a given health problem or behavior. Likewise, cultural tailoring involves paying attention to the embeddedness of human health behavior in the cultural context and social structure (Krumeich et al., 2001). Although the understanding of the factors and attitudes that are associated to adopting healthy dietary behaviors is vital to informing culturally tailored health messages, the high rates of chronic disease among Tongan Americans suggests that they are a “hidden population” to the U.S. public health system (Shaghaghi,
Bhopal, & Sheikh, 2011)
The U.S. federal government devised the Healthy People 2020 program to address growing health disparities in the country but has neglected Tongan American health needs (Koh et al., 2011). For example, a successful culturally tailored health program was initiated among
Alaska Native adults to help reduce the high rates of chronic disease among their population.
Satterfield (2016) described the program and explained that the Traditional Foods Project was founded to promote ambitious efforts to connect traditional ecological knowledge to health promotion and diabetes prevention among Native Alaskan adults (Satterfield, 2016). Such efforts included education, prevention efforts, tailored health communications and messages to
9
reach underserved populations at risk for chronic diseases, and collaboration with the health care systems to increase their use to improve health and promote early screenings and detections
(Jaber et al., 1996; Nam et al., 2011). As an outcome, the Native Alaskan adult population has benefited by following the Healthy People objectives to eliminate health disparities and achieve health equity. However, due to their status as a hidden population, the incidence of chronic disease will continue to increase among Tongan Americans (Panapasa et al., 2012) unless research is done to promote culturally tailored strategies to reduce the high incidence of chronic disease.
Tongan American Dietary Behaviors
Tongan American adults are among a NHOPI population whose dietary practices fare worse than other ethnicities by most measures (Kim et al., 1998; Ren et al., 1999). Schmidt
(2007) conducted a study among Tongan Americans and concluded that they are practicing unhealthy dietary behaviors, such as a high intake of calories (>2000), sugars, and energy-dense foods high in trans fats, such as fast foods, fried chicken, and corned beef, in addition to the high intake of sugary beverages. Unhealthy dietary behaviors among Tongan Americans are an underlying cause of the high prevalence of chronic diseases among this population. According to Mack and Ahluwalia (2003), the establishment of unhealthy dietary behaviors is among the significant risk factors for and major causes of chronic disease. Unfortunately, nothing has been done to explore the dietary experiences among Tongan-American adults to understand the modifiable factors associated with this population’s current dietary behaviors.
Health Disparities and Dietary Behaviors
Obesity and Dietary Behaviors
10
Obesity has become an increasingly detrimental health problem in the United States
(Mitchell et al., 2011). Globally, the World Health Organization [WHO] defines obesity as an abnormal or excessive fat accumulation that poses an imminent risk to health (WHO, 2000). The primary causes of overweight and obesity are increased calories due to unhealthy dietary behaviors in addition to a sedentary lifestyle that causes an imbalance between the calories consumed and the calories expended (Mitchell et al., 2011). Over the past two decades, obesity has increased worldwide and remains highest in the United States (Arroyo-Johnson & Mincey,
2016). Flegal et al. (2010) found that obesity prevalence increased from 15% to 34% among
U.S. adults between 1976–1980, and from 2007–2008.
Obesity is a worldwide epidemic that affects all backgrounds and ethnicities and is reaching epidemic proportions (O'Neill & O'Driscoll, 2015). Obesity rates are also higher among Latinos (47.0%) and Blacks (46.8%) compared to Whites (37.9%) (Curley, 2019).
Jacobson et al. (2002) suggested that targeting the factors associated with adopting healthy dietary behaviors is critical to informing future culturally targeted interventions among a growing minority population, such as Tongan Americans, in the United States moving forward.
Diabetes and Dietary Behaviors
There is an association between dietary behaviors and the onset and reduction of risk of chronic diseases such as type II diabetes (Wild et al., 2004). According to Yannakoulia (2006), there is a link between an individual’s dietary behaviors and the etiology of type II diabetes.
Researchers also point to the onset of type II diabetes and the practice of unhealthy dietary behaviors (Yannakoulia, 2006). For example, a study analyzing data from over 1,480 adults with a self-reported diagnosis of type II diabetes concluded that the majority of the participants who
11
were overweight did not follow the recommended dietary guidelines for fat and fruit consumption (Nelson et al., 2002).
The nutritional guidelines posit that healthy dietary behaviors are vital to the management of type II diabetes to help achieve optimal blood glucose levels, reduce hypoglycemic episodes, and maintain healthy growth and development (Yannakoulia, 2006). Huang et al. (2010) evaluated the effect of dietary control on glycemic control and macronutrient intake in type II diabetic patients and found an improvement in glucose control, energy, and carbohydrate intake among those study participants who chose to improve their dietary behaviors. Despite the benefits of healthy dietary behaviors, studies showed that a low percentage of individuals with type I and II diabetes were meeting guidelines for fruit and vegetable consumption, none were meeting guidelines for whole-grain use, and fewer than 10% were meeting guidelines for saturated fat consumption (Silvis, 1992). An estimation suggests that the incidence of diabetes will increase to over 400 million people by 2030 unless something is done to address the underlying causes of the disease (Wild et al., 2004).
Healthy and Unhealthy Dietary Behaviors
Healthy Dietary Behaviors
There is strong evidence that healthy dietary behavior plays a role in the prevention of major diseases, including obesity and obesity-related diseases (Yu et al., 2016). Healthy dietary behavior refers to the choice of a healthy dietary pattern at an appropriate calorie level to achieve healthy body weight and support nutrient adequacy (Skerrett & Willett, 2010). These healthy dietary recommendations also include the consumption of low sugars, saturated fats, and sodium
(Adamson & Mathers, 2004; Skerrett & Willett, 2010). Kushi et al. (2006) determined that adopting and sustaining healthy dietary behaviors, including eating a low-fat diet, fruits, and
12
vegetables, and low-fat dairy, are vital to reducing the risk of obesity and other chronic diseases.
He et al. (2004) found that higher consumption of fruits and vegetables was evident among those with a healthier lifestyle, in addition to a 25% lower risk of becoming obese among the study participants. Slattery (2004) demonstrated that rectal cancer rates were inversely associated with the consumption of fruit, vegetable, and whole-grain product intake.
The adoption of healthy dietary behaviors can also have a profound impact on health outcomes (Carbone & Zoellner, 2012). Miura et al. (2004) established that a diet high in fruit and vegetables, and low in most meats, was found to reduce the relative risk of developing high blood pressure among middle-aged men. Although meat is an essential component of the human diet, Jiménez-Colmenero et al. (2001) pointed out that an understanding of the actual content in meat is critical to a healthy consumption as some meat products contain fat, fatty acids, cholesterol, sodium, nitrites, etc., which can affect health. Despite the health benefits, little has been done to give voice to participants’ stories of how their dietary behaviors around food and food preparation evolved.
Unhealthy Dietary Behaviors
The rising prevalence of diseases can be attributed, in part, to unhealthy dietary behaviors
(Ford et al., 2016). Sleddens et al. (2015) referred to dietary behaviors as a person’s food choice and consumption. According to Cheung et al. (2018), unhealthy dietary behaviors include high intake of calories, fat, sugar, and salt, in addition to insufficient consumption of fruits and vegetables. There is an emphasis on unhealthy dietary behaviors because the disproportionate rates of obesity, chronic disease, and death attributable to obesity are primarily a result of unhealthy diets (Mitchell et al., 2011). Panagiotakos et al. (2006) provided evidence that dietary behaviors that include a high intake of red meat, sweets, and fried foods contribute to increased
13
risk of insulin resistance and type II diabetes. A 2010 report revealed that a high intake of white rice was associated with an increased risk of type II diabetes among Japanese women (Nanri et al., 2010).
There is also supporting epidemiological evidence that shows a relationship between unhealthy dietary behaviors and chronic disease. In 2012, an estimated 45.6% cardiometabolic deaths were due to excess intake of sodium and processed meats and low intake of a healthy diet
(Baldock et al., 2012). According to the U.S. Department of Agriculture Dietary Guidelines for
Americans, healthy dietary behaviors consist of a high intake of fruit and vegetables in addition to a lower intake of sugar, salt, and fat (DeSalvo et al., 2016). Bibbins-Domingo et al. (2010) assessed the benefits of a lower dietary intake of salt of up to 3 g/day (1200 mg/day of sodium) and estimated that a decline of 3 g/day in intake could improve quality of life and lower medical costs. Despite the risks of unhealthy dietary behaviors, only 14% and 8% of adults in the U.S. meet the recommendations for fruit and vegetable intake respectively (…).
Factors Associated with Dietary Behaviors
Despite the benefits of adopting healthy dietary behaviors, there is an interplay of factors to explore when considering a change in dietary behavior (Pearson et al., 2017; Satia et al., 2005;
Townsend et al., 2001). According to the Social-Ecological Model (SEM), dietary behaviors are a result of a complicated interaction between conflicting internal and external factors at the individual, environmental, sectoral, and cultural levels that often shape the desire to eat, the decision about when and what to eat, and the tendency to select specific foods to consume
(Kalucka et al., 2019). However, nothing has been done to explore the dietary experiences among Tongan-American adults to better understand the interplay of factors associated with the dietary behaviors of Tongan Americans.
14
Researchers also posit that targeting the modifiable factors associated with an individual’s dietary behaviors is vital to prevention efforts (Putnam & Allshouse, 1999;
Townsend et al., 2001). For example, studies have shown a negative association between stress and dietary behaviors. Torres and Nowson (2007) found that the onset of stress made it difficult to adopt healthy dietary behaviors by concluding that individuals experiencing chronic life stress had a higher preference for energy and nutrient-dense foods, such as sugars and fats. A body of evidence also shows that obtainment and consumption of unhealthy foods is strongly patterned according to socioeconomic status (SES). Studies show that people with low socioeconomic status purchase less nutritious, energy-dense foods that are often cheaper sources of calories
(Darmon & Drewnowski, 2008; Giskes et al., 2010; Pechey et al., 2013) due to the lower cost.
On the other hand, those with a higher SES have been shown to have higher diet quality that is associated with higher diet cost (Bernstein et al., 2010; Lee et al., 2011; Pechey et al., 2013).
Therefore, the SEM will serve as the framework for exploring the dietary experiences of
Tongan-American adults. It will provide an understanding of the modifiable factors at the individual, environmental, sectoral, and cultural levels that are associated with adopting healthy dietary behaviors among Tongan Americans.
Theoretical Framework
Social Ecological Model
There is mounting evidence that multiple factors at the individual, environmental, sectoral, and cultural levels are associated with dietary behaviors and health outcomes (Acheson,
1998; Sallis & Glanz, 2006). Thus, the Social-Ecological Model (SEM; see Figure 1) offers insight into how layers of influence intersect to shape a person’s dietary behavior and, afterward, his or her health outcomes. Bronfenbrenner’s (1979) original conception of the ecological model
15
was designed to account for the multifaceted and interactive effects of personal and environmental factors as opposed to the traditional sole focus on intrapersonal factors (Sallis et al., 2015). Contrary to most health behavior theories, which focus predominantly on variables specifically at the intrapersonal level, the SEM (Bronfenbrenner, 1979; McLeroy et al., 1988) argues that the shaping of individual behavior occurs at multiple levels. Researchers have since refined the model to its current form, which will guide the present study to explore the associations between individual and contextual factors and consider dietary behaviors as products of various influences at the individual, environmental, sectoral, and cultural levels
(Braden & Nigg, 2016).
Therefore, a brief description of these factors will highlight the possible associations. At the individual level, each element is unique to each individual, such as gender, stress, perceptions, socioeconomic status, and health literacy. At the environmental level, the home is a central focus. In some cases, the home environment can influence healthy behaviors, such as when parents model healthy dietary behaviors, as opposed to unhealthy behaviors, such as having low accessibility to healthy foods due to various reasons (Savage et al., 2007).
Regardless, Drewnowski (2004) emphasized the importance of exploring the offering of food and the reasons for doing so in the home. At the sectoral level, a specific focus on the government, marketing strategies, and impact of colonization will come into focus. More specifically, this study explores policies that are associated with dietary behaviors. Scott and
Vallen (2019) stated that it is vital that research approach the relationship between food and health through a broad lens to identify the role that marketing and public policy has in preserving and promoting well-being. Finally, the role of culture and cultural norms will make up the final level of the SEM framework. Research shows that dietary behaviors are deeply entrenched
16
aspects of cultural norms, which are rules that govern thoughts, beliefs, and behaviors, in addition to patterns that are prevalent and accepted within a community and society (Santiago-
Torres et al., 2014; Shier et al., 2016).
As a limitation, the framework does not determine the type of association between the factors at the stated levels of influence and dietary behaviors. In some cases, elements can have a positive or negative association. Therefore, this study will provide some depth through face-to- face interviews of Tongan American adults to explore their dietary experiences to provide an in- depth understanding of their dietary behaviors.
Figure 1
Social Ecological Model
Note. Adapted from Addressing Obesity Disparities: Social Ecological Model, by Centers for
Disease Control and Prevention, Division of Nutrition, Physical Activity, and Obesity, National
Center for Chronic Disease Prevention and Health Promotion, 2015
17
(https://www.cdc.gov/violenceprevention/publichealthissue/socialecologicalmodel
.html).
Individual Level Factors
The association between individual factors, which include gender, stress, perceptions, socioeconomic status, and health literacy, and dietary behaviors are unique to an individual
(Kamphuis et al., 2015). By understanding the role that individual factors play in a person’s dietary behavior, future intervention efforts will be able to focus on providing resources to help build the foundation for nutrition and develop programs to enhance the population’s knowledge, attitudes, and motivation to make healthier dietary choices. However, it still unclear how the individual factors are connected to the dietary behaviors of Tongan Americans.
Gender
Food choices are an area in which consistent behavioral differences occur between genders (Wardle et al., 2004). Numerous studies have shown that boys and men eat fewer fruits and vegetables, choose fewer high-fiber foods, eat fewer low-fat diets, and consume more sugar- sweetened drinks than do women (Serdula et al., 2004). Studies also show that men assess healthy dietary behaviors as less critical than women do (Wardle et al., 2004). According to
Stephen and Sieber (1994), women’s diets tend to be higher in micronutrients, including critical vitamins, then men’s foods. High rates of micronutrient deficiency are standard among obese individuals and may often influence the onset of type II diabetes. Wardle et al. (2004) examined the four-food-choice dietary behaviors among a large sample of young adults from 23 countries and tested two possible explanatory mechanisms for the gender differences, concluding that women had a higher likelihood of dieting and more significant beliefs in the importance of healthy diets in comparison to men. However, it is unclear whether this association holds among
18
Tongan Americans. This study will seek to understand the association between gender and dietary behaviors among Tongan Americans.
Stress
The literature suggests that there is a strong association between a person's dietary behavior and stress (Martin et al., 2009). Yet little has been done to explore the role that stress might have on dietary behaviors among Tongan Americans. According to Scott et al. (2012), stress refers to a real or perceived threat to homeostasis, which may contribute to the development of obesity. Stress can come in various fashions and may be related to work, personal problems, or even work-related events (Cartwright et al., 2003). Regardless of its origins, stress is a common problem that we all have to deal with in our lives, some more than others. In response to stress, individuals may also use food to reduce psychological distress
(Torres & Nowson, 2007). Stress can lead to unhealthy dietary habits and behaviors that are underlying causes of obesity. It can have the effect of making people skip or forget to eat their meals. Studies show that overly stressed people tend to pick up this unhealthy dietary habit of skipping meals more than resorting to eating junk food to soothe their hunger (Kim et al., 2012).
According to Bayol et al. (2007), obesity is associated with a high intake of junk foods rich in energy, fat, sugar, and salt combined with a dysfunctional control of appetite. Studies also show that overeating might disguise more troublesome types of distress, such as being fired from numerous jobs, financial issues, and other events that enable individuals to avoid thinking about the problems mentioned above (Cartwright et al., 2003). It is critical that this study explores the lives and experiences of Tongan Americans to better understand the stressors they encounter and the associations those stressors might have with their dietary behaviors.
Perceptions
19
The successful promotion of healthy dietary behaviors must include an understanding of the perceptions and experiences associated with adopting a healthy diet (Paquette, 2005).
Paquette (2005) defines perceptions of healthy eating as a person’s meanings, understanding, views, attitudes, and beliefs about healthy diet, eating for health, and healthy foods. Millstein et al. (1993) stressed that understanding the association between the perceptions of healthy dietary behaviors among various ethnicities is essential because it influences behaviors. The Western perception of a healthy diet often refers to the recommendations by the Dietary Guidelines for
Americans, which includes a high intake of fiber, fruits, and vegetables, etc., in addition to the low consumption of sugar, salt, and soda (DeSalvo et al., 2016). As such, health promotion efforts often cite these guidelines to promote healthy dietary behaviors.
On the other hand, the perception of healthy dietary behaviors varies among different racial ethnicities. For example, Bell et al. (2001) found that Samoan knowledge of healthy dietary behaviors does not align with the Western understanding. These authors conducted a study within a Samoan community in New Zealand to see if having a “knowledge” of fat content in foods and eating behavior would impact the population’s fat, fruit, and vegetable intake. They concluded that the Samoan perception of healthy dietary behaviors was tied to the upholding of their cultural norms and eating customs, including the consumption of food for traditional purposes such as weddings, funerals, church gatherings, and family events. In the end, the study highlighted the essential nature of understanding the perception of healthy dietary behaviors.
Thus, one of the aims of the current study is to understand the Tongan American perception of healthy dietary behaviors.
Socioeconomic Status
20
Previous studies have shown that socioeconomic status (SES) can have a positive or negative relationship to diet quality (Groth et al., 2001). Those with a higher SES can facilitate the consumption of healthier foods, which often have a higher cost. There is mounting evidence that healthy food is significantly more expensive than unhealthy alternatives (Rao et al., 2013).
Inglis et al. (2005) found that individuals with high SES tend to follow a diet that is more in line with the dietary guidelines for health than that consumed by those of lower socioeconomic status. Living in poverty or having low SES is seen as a challenge to adopting healthy dietary behaviors. Andreyeva et al. (2010) argued that it would be difficult for those with low SES to adopt healthy dietary behaviors because of the cost of healthy foods. Smith and Brunner (1997) reported that individuals with lower SES are more likely to consume diets high in fat, low in nutrients, and with lower intakes of fruits and vegetables. A meta-analysis found that, on average, the healthiest diets cost $1.48 more per day compared with the least healthy diets (Rao et al., 2013). This discrepancy in price is an underlying reason that consumers of lower SES, who are price-sensitive, might choose to purchase a larger quantity of unhealthy foods.
If unhealthy food is more affordable than a healthy diet—even slightly more—it is likely that food purchases tend to be more harmful, the resulting dietary behavior is poorer (Pondor et al., 2017), and the risk of chronic health problems increases (Guo et al., 2004). For individuals whose primary concern regarding access to food is to avoid hunger, and whose nutritional interests are secondary, the cost of food is a significant consideration when deciding between unhealthy and healthy dietary behaviors. The cost of food also makes it challenging to meet the mandates and guidelines set forth by the United States Food and Drug Administration to consume a higher intake of fruits and vegetables (DeSalvo et al., 2016). Dubowitz et al. (2008) stressed that those with low SES show decreased consumption of fruits and vegetables. As a
21
result, studies are repeatedly finding that people of smaller SES groups possess unhealthy dietary behavior that increases the risk of obesity and other chronic diseases (Menigoz et al., 2016). An exploration of the dietary experiences of Tongan Americans is vital to an effective understanding of the link between SES and their current dietary behaviors (McMullin et al., 2008).
Health Literacy
The level of health literacy of an individual can have a positive or negative influence on dietary behaviors. Carmona (2005) defines health literacy as the individual’s ability to access, understand, and use health-related information and services to make appropriate dietary decisions. According to Rothman et al. (2006), health literacy is a facilitator to selecting healthy foods, in particular to reading and understanding food labels, which often contain dietary guidelines. Therefore, health literacy is the degree to which individuals can obtain, process, and understand necessary health information and services needed to make appropriate dietary decisions. In the United States, 36% of adults have inadequate health literacy skills (Kutner et al., 2006), which makes it challenging for individuals to intake and comprehend health information (Carbone & Zoellner, 2012).
It can be difficult for those struggling with low levels of health literacy to adopt healthy dietary behaviors. Speirs et al. (2012) explored the relationship between health literacy and dietary behavior among a sample of low-income participants and found that those with low health literacy rates displayed poor dietary behavior. In another study, Cha et al. (2014) assessed the relationships between health literacy, self-efficacy, food label use, and nutritional quality in young adults aged 18–29 and found that self-efficacy and health literacy were predictors of food label use, which positively predicted dietary quality. The study reported that those with low health literacy use food labels significantly less than the high health literacy group did. The
22
findings suggest that strategies to enhance health literacy, self-efficacy, and food label use should be developed to improve dietary behavior and to promote positive health outcomes (Cha et al., 2014). It will be interesting to hear about the dietary experiences of Tongan Americans and explore the type of association that health literacy might have on their dietary behaviors.
Environmental Settings
Strategies to support the adoption of healthy dietary behavior should begin with assessing the role of the home and physical environment in individuals’ dietary behaviors (Santiago-Torres et al., 2014). Sallis and Glanz (2006) pointed out that the home and physical environment, which includes proximity and accessibility to foodservice establishments, can have a positive
(facilitate) or negative (barrier) association with dietary behaviors (Shier et al., 2016). These settings can determine what foods are available to choose from and consume.
Home Environment
The learning and conditioning of dietary behaviors happen in the context of the home environment, where dietary behaviors are learned and incorporated (Tosatti et al., 2017). Studies show that the home environment is both a barrier and a facilitator to the adoption of healthy dietary behaviors (Savage et al., 2007). This environment is where family members learn what and how much to eat based on the transmission of cultural and familial beliefs and practices surrounding dietary behavior (Savage et al., 2007). According to Reicks et al. (2015), adolescents consume 63%–65% of their daily calories at home. Consequently, it is critical to explore the role that the home environment might play in the dietary behaviors of Tongan
American adults.
Food availability in the home can also influence the adoption of healthy dietary behaviors. Food availability refers to access to sufficient quantities of food consistently (Shier et
23
al., 2016). Shier et al. (2016) discovered that access to fruits and vegetables, sugar-sweetened beverages, and snack foods largely determined the dietary behaviors of children at home. The authors also pointed out that having greater access to healthy foods in the house would improve the choice and consumption of healthy foods. Hence, the literature shows that access to healthy foods in the home is vital to the adoption of healthy dietary behaviors. On the other hand,
Dammann and Smith (2010) argued that an association exists between limited food availability and irregular consumption patterns, such as nighttime eating, and unhealthy dietary behaviors in the home. The research has yet to understand the inner workings of a Tongan American household; thus, this study will be the first to fill this gap by interviewing Tongan Americans to understand their dietary experiences in the home.
Physical Environment
The physical environment encompasses a range of physical elements that are part of the community structure and are associated with the quality and provision of food to the people in their immediate surroundings (Sallis et al., 2012). Access to and availability of healthy foods in the physical environment have been associated with better dietary behaviors, while, on the contrary, access to unhealthy food outlets, such as fast-food restaurants and convenience stores, can lead to high energy, sugar, and saturated fat intakes, which have been linked to increases in the prevalence of obesity (Ding et al., 2012). Studies show that there is an unequal distribution of access to healthy foods in the physical environment. Morland et al. (2002) assessed the distribution of food stores and foodservice locations by neighborhood wealth and racial segregation and concluded that poor and minority communities were without equal access to a range of healthy food choices and stores when compared with wealthy locations. Inagami et al.
(2006) also established that shopping for groceries in a more disadvantaged neighborhood meant
24
having less access to healthy foods, in addition to increased access to unhealthy snacks (e.g., candy, chips, sugar-sweetened drinks) at a lower cost. It is necessary to understand the dietary experiences among Tongan Americans to explore the association between their physical environment and food availability in their immediate surroundings.
Sectors of Influence
The promotion of a healthy food environment requires the involvement of multiple sectors, including food systems that promote diversified and balanced healthy dietary behaviors
(WHO, 2000). Sectors include operations, such as government policies and marketing, that play an essential role in helping individuals form their dietary behavior, to the degree to which people have access to foods or are influenced by societal norms through marketing or the media (Binks,
2016).
Governmental Policies
Given the significant health care and economic burden of diet-related illness, a coordinated national food and nutrition policy strategy should be a priority for all governments
(Pomeranz et al., 2018). Policies are ideas and plans set forth by a government that are legally binding and used for making decisions (Kraak et al., 2005; Novak & Brownell, 2012).
Governments can use a spectrum of policies ranging from voluntary to mandatory. These include a bill (proposed law), law/act/statute (approved by legislative and executive branches), agency implementation (interpretation, application, regulation), court decision, guideline
(recommendation, not mandatory), or directive (internal to an institution; Olsho et al., 2016;
Pomeranz et al., 2018). For example, Olsho et al. (2016) found that dietary behaviors among low-income residents on the Supplemental Nutrition Assistance Program (SNAP) saw improvements, including an increased intake of fruits and vegetables due to government
25
incentives such as the U.S. Department of Agriculture Healthy Incentives Pilot (HIP), which offered rebates to low-income residents. Policies can be regressive for those with lower SES, but progressive because of the benefits to health and nutrition (Olsho et al., 2016). Peñalvo et al.
(2017) also found that fiscal interventions to improve food pricing showed promising outcomes to improve diets, reduce cardiovascular disease and diabetes (cardiometabolic diseases; CMD), and address health disparities.
Food Advertisement Regulation
On a political level, regulation and self-regulation of advertising toward targeted populations are instruments that can limit its influence on food preferences (Reisch & Jani,
2012). Likewise, advertising has been implicated in the declining quality of the American diet, but much of the research has been conducted primarily on children rather than adults
(Zimmerman & Shimoga, 2014). Although each of the “4 P’s” of marketing—product (Moss,
2013), place (Fox et al., 2009), price (Young & Nestle, 2002), and promotion (Sutherland et al.,
2010)—has contributed to the erosion of the American diet, that part of promotion that comprises television advertising has undoubtedly played a significant role (Harris et al., 2009;
Zimmerman & Bell, 2010). According to Brester and Schroeder (1995), even among adults, food advertising has strong effects. In a study, Zimmerman and Shimoga (2014) tested the effects of televised food advertising on adult food choice. Participants (N = 351) were randomized into one of four experimental conditions: participants were randomized into two conditions (i.e., exposure to food advertising vs. exposure to non-food advertising), and then participants in each condition were randomized into two conditions (i.e., exposure to a task cognitively demanding vs. exposure to a task not cognitively demanding) (Zimmerman &
Shimoga, 2014). The number of unhealthy snacks chosen was subsequently measured along
26
with the total calories of the snacks chosen. The study found that participants who were exposed to food advertising wanted 28% more unhealthy snacks than those exposed to non-food advertising, with a total caloric value that was 65 calories higher (Zimmerman & Shimoga,
2014). The effect of advertising was substantial and significant among those assigned to the high-cognitively demanding group: 43% more unhealthy snacks and 94 more total calories.
Zimmerman and Shimoga (2014) concluded that televised food advertising has substantial effects on individual food choice. Exploring the role of policies and advertising on dietary behavior among Tongan American adults will provide necessary feedback to inform culturally targeted intervention strategies.
Social and Cultural Norms
Traditional Preparation of the Food
The traditional preparation of the Tongan food contributed to their healthy dietary behaviors. According to Caperon et al. (2019), dietary behaviors refers to the preparation and the consumption or acquisition of healthy food which impacts the ability to eat healthily. Thus, before migration, traditional Tongan dietary behaviors were centered around the cultural preparation of the food. A Tongan proverb depicted the importance of food preparation in the
Tongan culture, it reads, “poto 'i hono fisifisi'i kae vale 'i hono fokifokihi," skilled in flicking but unskilled in turning (Shumway, 1988). Shumway (1988) noted that the proverb pointed to individuals who are good at constantly checking on the yam to see if it is cooked by flicking it, but has little skill when it is time to cook over the fire. It also referred to someone who is quick to eat but slow or lazy to cook (Shumway, 1988). Traditionally, the roasting of yams required constant attention such as spinning the yams in order to cook all sides evenly (Ka'ili, 2008;
Shumway, 1988). In this case, the traditional preparation of food required hard work, diligence,
27
and constant attention. As a result, Tongans consumed a healthy diet. Veatupu et al. (2019) noted that the traditional Tongan diet mainly consisted of fruits and vegetables, fish, and minimal consumption of meats. Thus, the traditional healthy dietary behaviors contributed to their overall health and well-being. Hesketh and Campbell (2010) found that a diet rich in fruits and vegetables lowered the risk of chronic diseases such as diabetes, heart disease, and obesity. It is critical to explore the dietary experiences of Tongan Americans to understand the transition between the traditional cultural diet to a Westernized diet.
Cultural Meaning of Food
Food is important for nutrition, but it also has other cultural meanings to humans (Cassel,
1957; Levine et al., 2016). Culture is a system of shared understandings that shapes a person’s own experience (Caprio et al., 2008). Culture also refers to the learned system of values, rules, and plans that are critical when making dietary behavior decisions (Caprio et al., 2008). A person’s culture can influence various aspects of his or her life, including views on health, eating behaviors, and activity patterns (Caprio et al., 2008). In some cultures, food is essential (Lin &
Mao, 2015). For others, food can be nostalgic and provide meaningful connections to one's family, faith, or sense of place (Crowther, 2018). Ka'ili (2008) suggested that Tongans traditionally saw food as a means to build connections with family, friends, and the high chiefs.
Tongans also traditionally valued the sharing of food. According to Ka'ili (2008), this sharing is an integral part of the traditional Tongan culture. However, it is unclear whether Tongan
Americans value food in the same cultural way. Thus, it is vital to assess how Tongan
Americans perceive the meaning of food and how it might relate to their dietary behaviors.
Impact of Colonization on Traditional Food Practices
28
It is essential to explore the impact of colonization on traditional Tongan food practices.
Colonization is a violent process that fundamentally alters the way of life of the colonized
(Weerasekara et al., 2018). A look at the history of colonization shows that the early settlers in
Tonga once marveled at the benefits of traditional indigenous foods, but with time and the influence of European settlers, Tongans began to use food differently (Newman & Elton, 2016).
Early records from European visitors to the Tongan islands made references to the excellent health and physical standards of the Tongan people (Evans et al., 2003). The traditional Tongan diet contributed to their good health and well-being (Ka'ili, 2008). Tongans ate taro, ufi, manioke, fruits, and vegetables. They also consumed large amounts of fish because of their skills as fishermen. However, they ate meat sparingly. The consumption of meat was mainly to provide energy to fulfill the day’s obligations. Tongans lived a subsistence lifestyle, producing only what they needed to survive (Burley, 1998). Tongan men were tasked with cultivating the land, hunting, and fishing for food, while Tongan women did the cooking, cleaning, and home maintenance. However, the migration of Tongans to the United States saw the impact of colonization on their dietary behaviors, resulting in disproportionate rates of chronic diseases among Tongan Americans.
Today, the colonization of the Tongan diet has since shifted it from a traditional Tongan diet to a Western diet. The fundamental issues to be dealt with regarding dietary transition include Westernization. Westernization is a process by which societies come under or adopt the
Western culture in areas such as dietary behaviors and traditional knowledge of food and its preparation (Weerasekara et al., 2018). Diamond (2013) maintained that a Western diet consists of high levels of refined sugars, salt, saturated fats, and sugar-sweetened beverages. The shift from a traditional diet to a Western diet is an underlying cause of high rates of chronic disease
29
(DiNicolantonio et al., 2016). Biomedical and clinical evidence also suggests that two out of three adults suffer from obesity due to the overconsumption associated with a Western diet, which is a significant cause of obesity (Argueta & DiPatrizio, 2017; Myles, 2014). However, little is known about the reasons for the shift in dietary behaviors among Tongan Americans.
Hence, this study will identify and examine potential variables related to the impact of colonization on dietary behaviors among Tongan Americans.
Using the SEM to Explore the Dietary Experiences of Tongan Americans
Although the evidence points to the health benefits of adopting healthy dietary behaviors, multiple factors at the individual, environmental, sectoral, and cultural levels can pose challenges and benefits to implementing behavioral change (Kamphuis et al., 2015) among Tongan
American adults. The evidence consistently shows that an exploration of the dietary experiences will shed light on the potential factors at the multiple levels mentioned above is an effective strategy for promoting adoption of healthy dietary behaviors.
There is also a critical need to explore the dietary experiences and attitudes that contributed to chronic diseases to understand better the dietary behaviors of Tongan American adults because of these behaviors’ associations with the population’s health outcomes (Panapasa et al., 2012; Tui’one et al., 2010). Accordingly, the current study aims to explore the dietary experiences of Tongan Americans to understand better their dietary behaviors. The Social-
Ecological Model will serve as the framework of this study. Findings will serve as critical health-related information that will inform the future of culturally targeted interventions among the Tongan American population (Ka'ili, 2008; Vakalahi, 2011).
30
Chapter 3
Statement of problem
There is accumulating evidence that dietary behaviors play a significant role in the high incidence of obesity and chronic disease (Campbell et al., 1994). Yu et al. (2016) noted that the majority of these diseases are a result of long-term patterns of unhealthy behavior that can be altered by favorable changes in healthy dietary behaviors. Despite this knowledge, the unhealthy dietary behaviors among Tongan American adults (Schmidt, 2007) suggest that there are unknown individual, environmental, sectoral, and cultural factors that are making it difficult for this group to adopt healthy dietary behaviors. Therefore, the current study seeks to explore the dietary experiences of Tongan Americans to understand better the associations between the individual, environmental, sectoral, and, social and cultural variables and the adoption of healthy dietary behaviors among the participants. The findings will inform future culturally targeted prevention and intervention strategies among this population.
Purpose of Study
The purpose of this study is to understand better the dietary experiences and attitudes of
Tongan Americans that contribute to the disproportionate rates of obesity and other chronic diseases among Tongan American adults. The literature suggests that there is an interplay between factors associated with the adoption of a healthy dietary change (Guo et al., 2004).
Unfortunately, little research has been done to explore Tongan American dietary experiences and better understand the associations between the various levels of the SEM and the adoption of healthy dietary behaviors. According to the SEM, there are potential factors at the individual, environmental, sectoral, and cultural levels that are associated with adopting healthy dietary behaviors. Thus, this study intends to provide a holistic view of the participant's dietary
31
experiences through their personal stories and lived experiences to understand better their attitudes and dietary behaviors that contribute to the high rates of chronic diseases.
Study Goals and Research Question
Study Goals
The goals of this study are to (1) explore the Tongan American dietary experiences to explore their dietary behaviors and attitudes that contributed to chronic diseases; (2) utilize the findings to inform future culturally appropriate interventions to help reduce the disproportionate rates of obesity; and (3) to raise the awareness about how adopting the Western fast-food diet has led to steady erosion of their health.
Overall Proposed Research Questions
1. What are the perceived barriers to adopting healthy dietary behaviors among Tongan
American adults?
2. What are the perceived facilitators to adopting healthy dietary behaviors among Tongan
American adults?
32
Chapter 4 Methodology
Methods
Selection of Appropriate Methodology
The central research purpose of this study was to interview the participants to learn more about the factors associated with a healthy dietary change among Tongan Americans. The need for inside perspectives from the experiences of Tongan American participants was the underlying reason for choosing a qualitative methodology as opposed to a quantitative approach that is entrenched in a positivistic philosophy. A literature search to date showed that no studies have interviewed Tongan American adults to explore the dietary shift that occurred form the arrival of the first-generation Tongan immigrant until now. The lack of qualitative inquiries has hampered research to inform future prevention efforts or to improve the poor health outcomes among this growing population. The majority of previous health research has focused on improving the health or addressing the health needs of the overarching Native Hawaiian and Other Pacific
Islanders (NHOPI) population (Kaholokula et al., 2013; Morisako et al., 2017; Moy et al., 2012) while neglecting Tongan Americans, who are among the NHOPI ethnic subcategories.
The grounded theory methodology was chosen because it provided a systematic process to gain an in-depth understanding of the dietary experiences of Tongan Americans. When seeking to understand the lived experiences of a group of people, a quantitative approach is inadequate to capture and interpret the meanings that the Tongan American participants assign to their experiences (Foley & Timonen, 2015). Thus, the grounded theory method provided a systematic procedure that enabled a rigorous process researcher could follow to explore, refine, and develop their ideas and intuitions about the data (Charmaz, 2012). Grounded theory, an
33
inductive reasoning methodology, rooted in the experiences of the Tongan American participants.
The grounded theory methodology was also chosen because it would allow the Tongan
American participants to be the key stakeholders and enabled them to share their firsthand experiences and insights about the phenomenon under study; more importantly, it validated their voices (Charmaz, 2006; Foley & Timonen, 2015). The participants in this study are viewed specifically as social actors in constant interaction with their world and living a reality for which only they can describe its meaning (Charmaz, 2006). Grounded theory provided the framework for inductive data analysis of participants’ stories.
Study Participants
A total of twelve interviews were conducted of adult Tongan American men and women about their lived experiences in both Hawai'i and Utah to explore the factors associated with implementing a healthy dietary change. More specifically, the participants for this study were persons who (a) self-identified as Tongan American; by citizenship, (b) self-identified as a male or female (c) were over age 18 at the time of the study, (c) were current residents of the specific target areas of either Utah or Hawai'i, (d) expressed interest in participating in an interview, and
(e) provided written consent to participate (Appendix A). To allow multiple perspectives, the study participants represented diverse genders, ages, and geographical locations to reflect the differences in dietary experiences. By including various views in this research is critical because it offers a systematic way to compare and contrast diverse perspectives and to build detailed and substantial descriptions of the lived experiences of Tongan Americans (Santoro, 2014).
Sampling
34
A non-probability, purposive sampling technique was used to recruit the initial participants for the study. Purposive sampling involves identifying and selecting individuals or groups of individuals who are knowledgeable about or experienced with the phenomenon of interest (Creswell, 1998) and can address the research question (Glaser & Strauss, 2017).
Bernard (2017) also stressed the importance of participants’ availability and willingness to engage and their ability to convey their experiences and opinions in a transparent, expressive, and reflective manner. Following this principle, as a self-identified Tongan American, I utilized my extensive social networks within the Tongan communities in both Utah and Hawai'i to recruit the initial participants for the study. A flyer (Appendix B) was given to the Bishops, Elder’s
Quorum Presidents, and Relief Society Presidents of congregations attending the Church of Jesus
Christ of Latter-Day Saints. The church is made up predominantly of Tongan American patrons.
I also solicited participants through the use of social networks and through recruiting at the local
Pacific Islander community events in both locations.
The snowball sampling technique was also utilized. Snowball sampling is a highly efficient sampling technique that allows for the study of hard-to-reach or hidden populations
(Waters, 2015). It is also an appropriate sampling tool to employ when focusing on sensitive or private matters (Biernacki & Waldorf, 1981). Snowball sampling was suitable for this study due to the cultural and political sensitivities involved with the nature of discussing individuals’ and families’ dietary behaviors. Once the initial Tongan American participants completed the interview, they were asked to submit the name of someone who may able to consent to participate in an interview and may meet the specific inclusion criteria for the study.
The use of the Tongan American participants’ network to recruit other Tongan
Americans was an essential aspect of this study that fostered a sense of trust in the research
35
process while allowing the participants to act as gatekeepers for the Tongan community. In the end, a total of 12 Tongan Americans volunteered and consented to participate in the study. A hand recorder was used to capture the audio for the 12 interviews, which were then transcribed in preparation for the data analysis process.
Demographic Survey
Before conducting the interviews with the research participants of this study, a short demographic questionnaire was administered (Appendix C). Understanding the demographic characteristics of participants provides a richer context for understanding the collected data, and serving as the foundation to analyze the data (Rosenthal, 2016; Tracy, 2019). The questionnaire for the study consisted of a short list of questions used to gather demographic information (e.g., income, chosen home location, marital status, and gender) from each participant. The questionnaire was also used to solicit height and weight data to assist with the calculation of a
BMI score for each participant. These data were used to provide context for the qualitative responses.
Semi-Structured Interviews
The data were collected through extensive one-on-one semi-structured interviews with the participants. The use of semi-structured interviewing is consistent with the grounded theory approach as it allowed flexibility for the interviewer to pursue issues of particular significance related to the overall research question (Duffy et al., 2004; Rose, 1994). Each interview was conducted in the client's preferred language (English or Tongan); a translator was not necessary as the primary researcher was able to speak and understand both the Tongan and English languages. The length of the interview was approximately 60–90 minutes. The interviews were
36
conducted and analyzed over three months (from December 2019 to February 2020) to achieve data saturation.
The semi-structured interviews consisted of eleven questions (Appendix D) to elicit the expansion of participants' responses and to obtain additional data as needed (Merriam, 1998).
Sample questions included, "What is it like for you to live as a Tongan American in the United
States?" and "What is the difference between the traditional Tongan diet and your current diet?"
All participants answered questions regarding personal and family experiences with their dietary behaviors. To minimize risk, ensure protection, and guarantee voluntary participation, the research proposal for this study was submitted to and approved by the Institutional Review
Board of the University of Hawai'i Committee on Human Studies (CHS#201900340).
Interview Procedures
Interviews of interested participants were scheduled at a time and location that offered convenience and a sense of confidentiality to the participant (e.g., the participant's home, local church building, or work office). All interviews were also conducted face-to-face. The benefit of conducting all interviews in person was immense as I was able to capture verbal and nonverbal cues, to keep the focus on the topic, and to adequately capture the emotions and behaviors of the participants. I also started each interview by identifying myself as a doctoral student at the
University of Hawai'i and a self-identified Tongan American to build a good rapport. As the first step in the interview process, participants were asked to complete a short demographic questionnaire. The semi-structured, open-ended questions were framed to provide participants with the flexibility to talk freely and to respond openly to queries (Merriam, 1998). Probing questions were also used, when necessary, to encourage participants to elaborate on or clarify their responses (Brooks, Rubin & Rubin, 1996) or to explore their experiences further (Seidman,
37
1991). The audio recordings were then carefully transcribed verbatim because accurate transcripts are critical for valid analysis and interpretation of the data (Mishler, 1991).
Transcription
I transcribed the digital audio recordings for each of the interviews and designated a unique identifier to manage the confidentiality and anonymity of each participant. Once the transcriptions were completed, I reviewed the recordings with the corresponding transcripts for integrity and accuracy. The digital audio recordings were then uploaded and logged into a secure location.
The interviews were erased from the recording devices once the audio files had been stored on a secure server with a password-protected security code to ensure confidentiality. Any other handwritten or printed transcripts that were transcribed or translated were then locked in a safe location within my office. In terms of Tongan translation, I was able to translate the audio from the participants who spoke fluent Tongan into the written English transcriptions. The translation and transfer of the data onto a secure server were vital to maintaining confidentiality.
Data Analysis
I transcribed, reviewed, and revised all of the interviews for accuracy before coding.
Once the transcripts were complete, they were uploaded to the NVivo 12 software for coding.
NVivo is qualitative data analysis software that aids with organization, analysis, and detection of insights in unstructured data (Castleberry, 2014). NVivo 12 features an analysis tool for unstructured qualitative research that assists the researcher in analyzing the qualitative interview data. Coding is the crucial link between data collection and the analysis of the findings
(Charmaz, 2012). The coding process was used to identify concepts, similarities, and conceptual reoccurrences in data, in addition to creating the basis of the analysis (Charmaz, 2006). The
38
coding also helped to define the data and the next step in dealing with the narratives and meanings of the experiences described through the lens of the Tongan American interviewees.
Thus, the method of analysis for this grounded theory study consisted of the open, axial, and selective coding processes (Corbin & Strauss, 2007).
Open Coding
The initial step in analyzing the qualitative data included the open coding method. Open coding is used to break down the data into smaller units, and then organize these into categories and subcategories (García-Sánchez et al., 2019). Open coding is also the part of the data analysis that centers on the conceptualization and categorization of phenomena through rigorous data analysis (Ellis et al., 1992). This analysis aimed to grasp the core idea of each part and to develop codes to describe it. In this first step of open coding, the data was broken into smaller pieces and analyzed. Thus, open coding involved breaking down the data, applying codes with
"conceptually similar events/actions/interactions," and organizing them into emerging codes
(Ellis et al., 1992). The emerging codes that resulted were categorized to define patterns and identify connections (Jorgensen, 2001). The overall goal of open coding was to develop multiple codes to describe the data. In order to reach this goal, sensitizing questions were posed regarding the data during analysis. This process led to the creation of newly emerging codes (Ellis et al.,
1992; see Appendix E).
Axial Coding
The next step included the axial coding method. Creswell (1998) indicated that axial coding is assembling the data in new ways after open coding. The focus of axial coding is on investigating the relationships found during the open coding process and reassembling the data
(Strauss & Corbin, 1998). With the completion of open coding, the transition to axial coding
39
involved the redefinition and categorization of the data to create distinct categories and subcategories for selective coding (Strauss, 1987). This process required continuous analysis, cross-referencing, and refining of the data (Williams & Moser, 2019). I conducted a careful, systematic review and constant comparison of the data to decrease the number of general concepts (open coding) and to organize them into categories. During axial coding, “categories are related to subcategories to form a precise and complete explanation of the emerging codes found during open coding” (Strauss & Corbin, 1998). As a result, the outcome of the axial coding analysis of the participants’ interviews highlighted the barriers and facilitators to implementing a healthy dietary change as the two major categories. Also, the outcome highlighted multiple related subcategories under the aforementioned major categories: the barriers included (1) home and community environment, (2) convenience, (3) time management,
(4) stress, (5) health literacy, and (6) the media; and the facilitators included (1) social support,
(2) family meals, (3) meal planning and preparation, (4) individual health benefits, and (5) resiliency (see Appendix F).
Selective Coding
The selective coding procedure is the final step of the data analysis method that connects the findings from the open and axial coding processes to provide an overall narrative of the participant’s dietary experiences with a core category as the central theme. Selective coding is the course of integrating and refining categories discovered during the open and axial coding processes (Strauss, 1987). The first step in that process is to select a core category that will then be systematically related to other categories (Ellis et al., 1992; Pandit, 1996;). Integrating the categories is similar to axial coding, but the level of analysis is more abstract and does not
40
represent individual voices or cases, but a collective voice. As a result, from the selective coding process, a core category will be discovered.
The process of discovering the “core category” in grounded theory includes the constant comparative method (Hallberg, 2006). The constant comparative method is a process in which every part of the data, i.e., emerging codes, categories, properties, and dimensions as well as different parts of the data, are constantly compared with all other parts of the data to explore variations, similarities, and differences in the data (Hallberg, 2006). Strauss and Corbin (1998) identified the following criteria for choosing a center or core category: (a) it must be central, that is, all other major categories can relate to it; (b) it must appear frequently in the data; and (c) there is no forcing of data. More importantly, the constant comparative method of grounded theory allows the researcher to explore content and meaning in the data without strict rules that are too rigid for grounded theory research (Hallberg, 2006). Therefore, the selection of the core category will inform the central tenet of the narratives in this study.
Narrative Analysis
A key tenet of selective coding is informing a narrative analysis around the core category as the theme. A narrative analysis are the stories of the participants that gives meaning to their dietary experiences, and more importantly, to implement their stories as qualitative data so support the overall findings (Emden, 1998). Bruner (2004) claimed that participants narratives
(that is, knowledge derived from stories) was as vital as paradigmatic knowledge (knowledge gained from science) in allowing people to make sense of their experiences in the world.
Therefore, the essential idea is to develop a narrative around a core category in which everything else is draped. According to Borgatti (2005), there is a belief that such a core category is connected to every concept in the participants narratives. In this case, the connection between
41
the core category and the identified barriers and facilitators from the axial and coding processes will be displayed in the narrative analysis. The ultimate purpose is to identify a core concept to use in future health strategies to reduce the disproportionate rates of chronic disease among
Tongan American adults.
In the end, the narrative analysis will provide an intimate look into the cultural transition that occurred prior to and after Tongan Americans migrated from Tonga to the United States.
More importantly, the narratives will be used to summarize the findings from the open, axial, and selective coding processes, including the core category, to highlight a core concept to be used as the central focus in future efforts to reduce the disproportionate rates of chronic disease among
Tongan Americans (Borgatti, 2005). According to Michael et al. (2017), a core concept is built up from a set of component ideas. Thus, understanding the core concept is vital as it will then be used to inform future areas of health prevention research among Tongan Americans (Michael et al., 2017).
42
Chapter 5 Findings
The findings from this study provided an intimate glance into the lives of Tongan
Americans to lend understanding to the familial, cultural, social, and environmental nuances of their dietary behavior and, more specifically, to the transition that occurred with their dietary behaviors from their traditional to Westernized diet. Semi-structured interviews and elements of the grounded theory method, such as storytelling, were used to draw firsthand experiences from the participants. Storytelling has a role in all stages of grounded theory methodology (Cangelosi
& Witt, 2006). Thus, the findings highlighted the (1) home and physical environment, (2) convenience, (3) time management, (4) stress, (5) health literacy, and (6) the media as barriers; and (1) social support, (2) family meals, (3) meal planning and preparation, (4) individual health benefits, and (5) resiliency as facilitators to adopting healthy dietary behaviors among Tongan
American adults.
Barriers to Adopting Healthy Dietary Behavior
Home Environment
The home environment was described as a barrier to a healthy dietary change because of multiple elements. The home environment is composed of characteristics within the family that influence or shape dietary behaviors including various parental factors, health knowledge, food availability, role modeling, and food practices (Hendrie et al., 2013). Thus, the exploration of the home environment is critical because the home environment is essential to the development of dietary behaviors (Lindsay et al., 2018; Morales & Berkowitz, 2016). For one participant, the experiences of growing up in a home with food insecurity are connected to the unhealthy food availability in her home as an adult.
43
I am able to provide my kids with a different lifestyle. I think the biggest difference I
can see is the way that I eat. Back then, I can remember wondering at night when my
next meal might be. But now, I can eat whatever and whenever, I want. My pantry right
now at home has a lot of junk food and it looks like a Costco. We have so much junk.
Saimin, cookies, granola bars, candy, a lot of cereal, Nutella buckets, mayonnaise, and
ketchup.
Another participant, from Utah, described how they often ordered take-out foods for family meals.
We have definitely simplified the process of cooking in my home. Especially with all the
new tools and gadgets we have available now a days. I love to use the delivery apps. But
it’s important to know that every restaurant uses a different app. For example, if I want
wingers I would use grub hub. If I wanted McDonalds then I would use Uber Eats, then
Door Dash if I wanted a specific meal from a sit-down restaurant. I just love the
convenience of using the apps, it makes it easier for me to feed my family.
This participant, from Hawai'i, shared how the modernization of the Tongan-American diet was prevalent in his home.
When it comes to actually making the meals in my home I think my wife and I cook
about 50/50 or we share half the load. To be honest, I am a modernized, Costco, rapid
style chef in my home. I firmly believe in microwavable foods or foods that I can take
out of a box and cook for about thirty minutes.
Physical Environment
44
The study focused on Tongan American participants in both Utah and Hawai'i and found that despite the differences in location, all twelve participants indicated that they lived in a community environment with easy access to unhealthy fast food. The location is critical because accessibility to restaurants within a two-mile radius of home addresses was predictive of fast food consumption (Jeffery et al., 2006). Studies also showed that living closer to fast food is linked to unhealthy dietary behaviors (Powell et al., 2006; Sturm & Datar, 2005). A participant from Utah emphasized the ease of access to unhealthy food choices in the community:
I have so many options and choices to pick from that it’s easy to get a meal whenever I
want one. If I want a burger, I can easily have one in minutes. There are also literally
five other burger spots near me.
Another participant from Utah also shared how the close proximity and access to unhealthy fast food restaurants made unhealthy dietary behaviors a realistic option:
The availability of foods is everywhere. If I wanted to eat something, I would just simply
drive down the road. At the same time, a lot of the stores around my house are open late,
so I always have a place to go if I get a late-night food craving.
This participant reported that living in Utah made the prospect of eating traditional Tongan food difficult due to the proximity to stores offering foods from the Pacific Islands: “I have to drive far just to get the taro leaves, manioke, or pulu masima because there is only one Tongan food store in Utah County.” Tongan American participants living in both Hawai'i and Utah shared similar experiences of having access to unhealthy food options in the community. For this participant, the close proximity of fast-food restaurants in her rural town of La'ie, Hawai'i, made the decision to eat out much more convenient.
45
Right now, the most convenient thing for me is to eat at whatever is close, or within
walking distance. I usually go to McDonald’s or whatever else is close by, such as Taco
Bell, Seven Brothers, or other restaurants like L & L’s Barbeque or whatever is actually
close for me to walk.
Another participant, also from the same rural town in Hawai'i, explained how having little access to healthy and affordable grocery stores is a problem:
I don’t like going to shop at Foodland because the food is so expensive. But since town
is an hour away and I have no car, I have no choice but to buy the expensive ingredients
or to just eat a hamburger from McDonald’s, which is cheaper. That’s why it is difficult
to eat healthy foods.
Convenience
Participants frequently spoke about the role of convenience in eating at fast-food restaurants, which were a quicker and more accessible option for meals and a barrier to a healthy dietary change. The participants’ dependence on convenient fast food is specifically a barrier because most fast foods offer little to no nutritional value. For example, researchers found that fast food includes such items as hamburgers, french fries, pizza, and soda, which are generally viewed as energy-dense and low-nutrient foods and tend to be high in sugar and saturated fat
(Wang et al., 2016). For this participant, convenience was connected to unhealthy food accessibility:
I always joke that the easiest meal is to cook fast food. I mean all I do is simply drive up
to a window, choose my foods, then pull forward, pay, and pick them up. It is so much
easier to pull up to a window and pay for food that is already prepared.
46
For some participants, the increased accessibility to fast-foods is also a barrier to healthy dietary change because of their busy schedules. For this participant, the convivence and availability of fast-foods was also connected to unhealthy dietary choices:
In the U.S. food is very accessible. If I want a hamburger, I just go through the drive
thru. I can also get fries and a coke, and ice cream just as easily… But like I said before,
in the U.S., I can just pull up to a window and pretty much get whatever I want at any
time. To be honest, the fast food is also very yummy.
For some participants, the increased use of food applications is also a barrier to healthy dietary change because of their convenience. An app is usually available on mobile devices such as an iPhone, Android, or iPad (Majeed-Ariss et al., 2015). Some common food delivery apps discussed by the participants included GrubHub, DoorDash, UberEATS, and Postmates. For this participant, the convenience of using food apps for meals was also connected to unhealthy dietary choices. This participant stated:
It is so easy to provide meals for my family with apps such as doordash and Ubereats,
they actually bring you what you want! You don’t have don’t go anywhere. It literally
simplifies my access to any type of food that I like. I know that I like it because I don’t
need to get dressed up to go out and eat, or interact with anyone if I don’t feel like it. I
actually think its unhealthy too. I mean, I can lay in my bed and eat without moving an
inch anytime I want too. I can do everything from my phone. I know that I try to avoid
using the app, but the convenience sometimes makes it such a great alternative.
The results show that most of the participants consume their meals outside of their homes because of the convenience. The dependency on convenient foods is a barrier to healthy dietary behaviors because of poor nutritional quality. Foods that are convenient mostly refers to the
47
preparation and consumption of meals from fast-food restaurants, ordering take-out, and corner markets, and connected to unhealthy dietary quality. Therefore, this study concludes that future efforts to promote healthy dietary behaviors should explore the decision-making process of choosing meals among Tongan American adults.
Time Management
It is no secret that one of the most common barriers to eating well revolves around finding time to prepare meals consistently (Larson et al., 2006). Taking time to prepare and eat regular meals is associated with higher diet quality and improved health outcomes (Larson et al.,
2006). All the participants spoke about the difficulties of finding time to make healthy meals.
One participant stated:
I am just so busy. I mean, I honestly don’t even need to cook. I have church obligations
and other things pop up, like family stuff, that take up so much of my time. I can easily
go to a buffet to feed my family.
When discussing the lack of time to prepare healthy meals, some of the participants pointed out that implementing a healthy diet was difficult due to both spouses working. One participant noted, “I think it would hard for me to implement a healthy meal. I have more options and the convenience is a plus. It would also be difficult because my wife and I are both working.”
Another participant also spoke about lack of time as a barrier to adopting a healthy diet change:
“My wife and I both have to work to keep up with our financial stability. We barely have time to make a healthy full-course meal.”
Participants spoke about their difficulties with time management and having to fulfill multiple obligations such as attending church, caring for family, and other responsibilities.
48
These ultimately made it difficult for the participants to prepare a healthy home-cooked meal and thus increased the likelihood of consuming unhealthy foods, as this participant stated:
My kids’ practices take up a lot of my time. My husband also coaches my boys and often
finishes at seven o’clock at night. My girls also finish their practices at eight o’clock at
night. By this time, we typically go out to eat because we are too tired to cook.
Another participant also pointed to lack of time management as a barrier to adopting a healthy diet:
There are just too many distractions. I can’t think of how to free up four hours a day just
to cook. I am just too busy with my life and with my kids’ busy schedules, so the thought
of making a full-course meal for dinner every night is kind of overwhelming.
Stress
All 12 participants spoke about having to deal with stress in their lives. Stress is a common problem that all people have to deal with (Barnes & Cassidy, 2018). This trend promoted the overeating of calorie-dense and nutrient-poor foods (Wadden et al., 2002). The participants pointed out that stress from work made it difficult to implementing a healthy diet.
This participant spoke specifically about work-related pressures and made the connection between the pressure and personal dietary behaviors:
Whenever my wife and I have a stressful and tiring day at work, we usually come home
without a desire to cook. The last thing we need is to come home and deal with another
stressor. I mean, I don’t want to wait an hour or so for food if I am mad or stressed out.
This participant also described his experience with stress at work:
49
For me, it’s the constant pressure of going to work and knowing that I am never going to
climb the ladder for a promotion. Plus, I have to deal with fake people. So, it’s just a lot
of knowing what I have to deal with at work.
The majority of the participants in Utah also described the connection between their experiences with stereotyping, prejudice, discrimination, and racism and the onset of stress. These participants spoke candidly about their experiences of prejudice and racism. One participant said:
I remember that as a kid, my dad would tell me not to wear hats at night to avoid looking
like a gangster, or to always wear my seatbelt in case the police pulled us over. I know
that White parents don’t ever need to tell their children the same thing.
Another participant connected racism toward Tongan Americans with a sense of inferiority:
I think people look down on me as a Tongan American sometimes, especially the
Caucasians. They treat me like I don’t know as much because I am Tongan. It feels like I
am a second-class citizen in the United States because I am not White.
These experiences with discrimination and prejudice also increased the stress levels for this participant:
I think people label me as a Tongan American. They just don’t know about me or my
Tongan culture. I feel that it makes others look at me like I am different. I just don’t get
the prejudice and racism. I honestly don’t let it get to me. I just know what it looks like
and understand that I have to act a certain way and accept it or I will get myself in
trouble, which is kind of stressful.
Unfortunately, the onset of stress led some participants to adopt unhealthy coping mechanisms. Dallman (2010) noted that the onset of stress is linked to dietary behaviors and the
50
increased intake of unhealthy “comfort foods.” Research shows that people under stress have consumed excessive amounts of unhealthy foods to either avoid or deny stressful situations
(Lindquist et al., 1997). A cross-sectional study in the United States found a connection between experiences of racial discrimination and obesity (Gee et al., 2008). This participant maintained that she turns to unhealthy foods as a coping mechanism to deal with her stress:
I usually run to food that is comforting and helps me get through a lot of things.
Unfortunately, the food is mostly unhealthy. I usually eat out at fast food places like Café
Rio or Panda Express to cope with my stress.
Health Literacy
During the interviews, many participants in the study remarked that struggles with health literacy were barriers to implementing a healthy dietary change. Health literacy refers to the capacity to access, process, or interpret health information to make effective health decisions
(Kuczmarski et al., 2016). A growing body of evidence has linked limited health literacy to poor health knowledge, behaviors, and outcomes (Oates & Paasche-Orlow, 2009; Volandes &
Paasche-Orlow, 2007). Health literacy is strongly linked to literacy. Literacy is defined as an individual’s ability to read, write, and speak in English, and understand and solve problems at levels of proficiency necessary to function on the job and in society… (Peerson & Saunders,
2009). Members of racial and ethnic minority groups often struggle with limited health literacy
(Zanchetta & Poureslami, 2006). Similarly, the findings showed that first- and second- generation Tongan Americans struggled with low levels of health literacy. As a first-generation
Tongan in the United States, one participant pointed to the difficulties of mastering the English language as a barrier to a healthy diet change: “With limited English, I can’t really speak to what makes a healthy meal. I mean, when I go shopping, some of the ingredients are still new to me.”
51
On the other hand, a second-generation Tongan American participant described his struggles with health literacy as the inability to conceptualize a healthy diet and as a barrier to adopting healthy dietary habits: “I think that eating healthy means eating fruits and vegetables. I am not really sure about what is healthy or not. I just know that I think that I am eating healthy anytime I eat some kind of salad.” For this second-generation participant, the difficulty with defining a healthy diet was a barrier to both his food choice and dietary practices:
I would like to know more about what a balanced meal is. Right now, I have no idea of
what it is. I know in school they would show me a food pyramid and say that I should eat
all the foods in the picture. But I don’t remember anything about what it means.
Media
The participants spoke about the influence of media as a barrier to implementing a healthy dietary change. Harris et al. (2009) found that the prevalence of increasing consumption of low-nutrient, calorie-dense foods is connected to advertisement of unhealthy food on television. This participant stated that the commercialization and influence of the media were a barrier to healthier dietary change:
It is hard to maintain a healthy diet because of the influence of the media and those
around me. Everything about food has become commercialized. Even the food
advertisements are making the food more attractive. I know that sometimes I see a
commercial about some food and then a minute later, I am at the store or restaurant
looking for the food.
Another participant referred to the influence of media on their dietary choices and behaviors.
52
It is hard to maintain a healthy diet because of the influence of the media and those
around me. I know that sometimes I see a commercial about some food and then minute,
I am at the store or restaurant looking for the food.
When speaking about the media and their diet, a first-generation participant maintained that the media was associated with a dietary behavior change. She stated:
I watch tv and learn about what I should be eating. I just saw something on tv last week
that says that I shouldn’t eat bread, so I just stopped.
This study found that the influence of the media is a barrier to healthy dietary behaviors.
The majority of the participants noted that there are targeted marketing strategies from the media, including the internet, television, and radio, that target the Tongan American population.
The participants also described how the current marketing strategies promote a Western ideology of food that is often cheap, unhealthy, and accessible. This strategy has mainly been effective among Tongan Americans because of the lack of connection that the participants have to their traditional Tongan diets. Ultimately, the findings show that the media's influence is a barrier to the healthy dietary behaviors of Tongan Americans. Thus, future efforts would benefit by understanding and targeting the connection between the media and other factors associated with their dietary behaviors.
Facilitators to Adopting Healthy Dietary Behavior
Social Support
The majority of the participants explained how social support from friends and family happens in the form of establishing connections and modeling or sharing a target behavior to help improve adherence to healthy dietary practices (Morisky et al., 1985). This first-generation
53
Tongan American described how, as a child, he was able to see his grandparents’ model traditional dietary habits and behaviors prior to migrating to the United States:
I remember seeing my grandpa work in the bushes all day, preparing and harvesting
crops and fishing. I would help him plant crops all the time. We planted a lot of fruits
and vegetables. I also remember going to school with a coconut basket with oranges to
eat and coconut juice to drink. There was very little meat in my diet. The foods I ate as
a child in Tonga were always fresh.
This participant shared how the support of her husband is a form of social support that promotes or facilitates healthy dietary behaviors. Research shows that the relationship between married and romantic partners is an active facilitator of healthy diet behaviors (Smith & Christakis,
2008). Therefore, when speaking about the support of her spouse as a facilitator to a healthy dietary change, this participant stated:
In my home, my husband and I work together on what to eat in the home. We actually go
shopping together. We have actually just started doing this dieting plan together so we
try to eat a balanced meal together as we strive to be as healthy as we can.
Another participant also spoke about how social support from a spouse played a vital role in the facilitation of healthy dietary practices:
I feel like the support of my wife motivates me to eat healthy. I think the support and just
knowing that we are in this together is a huge lift and motivator for me to stay the course
with healthy eating.
Social relationships are also a form of social support from friends that can significantly influence dietary behaviors (Christakis & Fowler, 2007). This participant stated that being around family and friends facilitated healthy dietary behaviors, such as gaining access to
54
traditional Tongan foods: “I think the majority of my experiences with eating Tongan food were from Tongan events such as weddings, baptisms, or birthday parties. I know that we Tongans would feast on the traditional Tongan foods during those occasions.”
Family Meals
The majority of participants described making time to prepare and eat family meals together as critical to the facilitation of healthy dietary behaviors. Family meals have received a lot of attention from researchers who have found that eating breakfast, lunch, and dinner together promotes healthy dietary behaviors (McIntosh et al., 2010). Consequently, this participant explained how vital it was for her to both prepare and promote family time to eat together and how it facilitated healthy dietary habits:
I don’t find cooking family meals to be hard. If you love what you are doing, the
balancing part is mainly getting all the right ingredients and foods in to make everyone
happy. So, that’s why it’s not hard. I just want to make sure to alternate the foods. Some
nights I would do Tongan foods, or American foods, or Hispanic foods. I am not a big
fan of fast foods. My memories of growing up involved cooking. I would rather prepare
foods for everyone. My children now will often hold out from eating out and wait to
come home to eat because they are so accustomed to eating at home. If I had a choice
between fast food or home-cooked foods, I would rather stay home and eat.
For this participant, finding the time and working together with a family member in the home to make a home-cooked meal was associated with a healthy dietary outcome:
My wife and I take pride in cooking different dishes and trying new ingredients. There is
always a salad and dessert with every meal that we have in my home. My wife also
makes it a point to have something healthy to eat with every meal. For example, last
55
night for dinner, I had a little portion of meat, a nice salad, and a healthy option. I mean,
there are just so many options.
This study found that the influence of the media is a barrier to healthy dietary behaviors.
The majority of the participants noted that there are targeted marketing strategies from the media, including the internet, television, and radio, that target the Tongan American population.
The participants also described how the current marketing strategies promote a Western ideology of food that is often cheap, unhealthy, and accessible. This strategy has mainly been effective among Tongan Americans because of the lack of connection that the participants have to their traditional Tongan diets. Ultimately, the findings show that the media's influence is a barrier to the healthy dietary behaviors of Tongan Americans. Thus, future efforts would benefit by understanding and targeting the connection between the media and other factors associated with their dietary behaviors.
Meal Planning and Preparation
The majority of the participants pointed to the importance of meal planning and preparation, including researching healthy foods, as a potential tool to offset time scarcity and therefore encouraged home meal preparation with improved diet quality (Ducrot et al., 2017).
This participant spoke about the importance of meal preparation, which included researching healthy foods, identifying those within her social support system for assistance, and planning, as facilitators to her healthy dietary practices:
I think that eating healthy starts with being diligent and doing research. I look up stores
that have the foods I need. I also use word of mouth. I reach out to Tongans to help me
find the best place for certain Tongan ingredients, which often requires more planning
56
and time. I like to learn what kind of food is out there so I can avoid certain types of food
that make me sick.
Another participant described how being a stay-at-home mom has allowed time to prepare healthy home-cooked meals for her family: “I am a stay-at-home mom and I go online to find recipes and different meals to cook for my family. I like to try new meals.”
The participants described how meal planning and preparation facilitated healthy dietary behaviors. The meal planning and development included researching foods, planning meals with family members and friends, and prioritizing the importance of planning and preparing home- cooked meals for the family. The results also showed that upon the completion of the planning process, participants that prepared home-cooked meals were also associated with healthy dietary behaviors. The findings highlighted the importance of having family members assist with the preparation of food. Therefore, family involvement in the planning and preparation of food is a crucial facilitator to future efforts to promote healthy dietary behaviors among Tongan
Americans.
Health Benefits
The majority of participants referred to the acquisition of the physical health benefits of adopting a healthy diet as an underlying reason to adopt healthy dietary behaviors. There is an extensive reference list of scientific knowledge supporting the link between health benefits and healthy dietary behaviors (Ascherio et al., 1999; Glade, 1999; Stampfer et al., 2000). For example, it is also well documented that chronic diseases such as obesity, diabetes, and hypertension can be modified or prevented by making dietary changes (Schulze et al., 2018).
Participants stressed the importance of improving one’s health as a facilitator to eating healthy:
57
I go to the doctor’s every six months for a routine checkup. I need to stay on top of that
because of my family health history. I know that eating healthy is a main avenue to
keeping up with my health.
Another participant spoke about the importance of being healthy for her kids as a reason to adopt healthy dietary habits: “I’m trying to eat healthier by thinking of my end goals. I am always thinking about my kids and how I want to be healthy for them. My kids are everything.”
The results indicated that participants health benefits facilitated the adoption of healthy dietary behaviors. The majority of the participants described their experiences with eating a healthy diet and improved physical and mental health. The findings showed that participants could make a connection between the consumption of healthy foods, drinking water, and minimizing the intake of unhealthy foods with improved health. They described experiencing lower levels of blood pressure, increased mental awareness, and improved health outcomes.
Despite the benefits, the majority of participants have reverted to consuming unhealthy dietary behaviors. Yet, the results show that future health benefits can facilitate dietary change. Thus, future efforts to promote healthy dietary behaviors should provide education on health benefits associated with a healthy dietary change.
Resilience
Adopting healthy dietary behaviors plays a significant part in the prevention and treatment of chronic disease. In recent years, there has been progress in the development of behavioral strategies to enhance healthy lifestyle behaviors. However, the rates of obesity in our country are escalating, which suggests that modifying dietary behavior has proven to be very difficult (Wing et al., 2001). A participant in the study noted:
58
I always set a New Year’s resolution to eat healthily. But it is never easy or consistent. I
usually stay on it for a month, then I quit. I think everyone gives up on their goals after a
month.
One of the problems is that individuals are often discouraged by a sense of failure in their attempt to change behaviors (Izydorczyk et al., 2019). Thus, although the literature has yet to explore in depth the connections between resilience and dietary behavior, it should be noted that resilience is central to the capacity to handle stressful situations, such as adopting new dietary behaviors. Resilience is also vital to overcoming failures and obstacles in life. In this sense, it is referred to as the capacity (Taormina, 2015) to bounce back after adversity (Southwick &
Charney, 2018). For this participant, being resilient is a trait that was modeled in his home growing up, a quality he can rely on when looking to implement a healthy dietary change:
I grew up in a home with low income. My parents worked hard and overcame so many
obstacles. My parents took any type of job, mostly construction and live-in care of the
elderly, to make ends meet. They were willing to do anything to provide for my family.
Another participant also described the resilience it took to overcome hardships and how being resilient can assist with change:
The hardest part about living in the U.S. for me is being unable to find steady work to
provide for my family or any help from any type of welfare services, so I pretty much
work hard and fight every day for survival.
The findings revealed that the resilience of the participants facilitated healthy dietary behaviors. Resilience refers to the capacity (Taormina, 2015) to bounce back after adversity
(Southwick & Charney, 2018). The majority of the participants shared similar stories of having to overcome difficulties associated with living in the U.S. as immigrants. They described
59
experiencing racism, discrimination, poverty, unemployment, and low educational outputs.
However, the results also showed how the participants utilized their willpower and strength to fight through adversity. Likewise, the participants are continually battling with the difficulties of making a dietary change by showing resilience and making incremental changes to achieve better health by adopting healthy dietary behaviors.
Core Category
After a constant comparison of the findings of the open and axial coding process was completed, I employed the selective coding process of grounded theory to choose one category, traditional preparation of the food, as the core category, and will relate all other categories to it as part of the summary analysis of the narratives.
Summary Analysis of the Narratives
Pre-Migration the traditional preparation of the food. The findings revealed that before migration, the traditional preparation of food mainly occurred in the home environment.
The findings revealed that the preparation and the quality of the traditional family meals were the result of a collective process in which family members each had a traditional role to fulfill. The participants described how they learned the importance of hard work, fulfilling cultural roles, and the preparation of the foods from their Tongan elders. In essence, the preparation was just as necessary and important as the meal itself. Two of the first-generation participants (> 65) offered an intimate look into the traditional preparation of the food. They described:
Cultural Gender Roles. The men did the cooking in Tonga. The ladies in Tonga don’t prepare the umu, the men are supposed to do it. The women stay in the home and clean the house, organize the kids, do the laundry. Or they sometimes would make fine mats. But I have seen that times have changed. In traditional times, the men would be in charge of the cooking. I
60
actually grew up seeing this in action. My grandpa made the umu, roasted the pig, went fishing, and grilled all the food that he caught. He was a hard worker. I saw him work in the bush all day, preparing the crops, fishing, and then coming home to prepare the umu. It was just a normal way of life for my grandparents.
Farming. I can remember my grandpa always farming when I was a child. My cousins and I would help him out in the farm and my grandma in the home. Both of my grandparents did not work. They lived on my grandpa’s family land. We went to the farm every day to plant and harvest food to eat. That was just the lifestyle back in the early days of Tonga.
Another participant stated:
We would plant kumala and hopa; my grandpa didn’t have a big farm. We also planted
ufi and watermelon. I remember always planting fruits and vegetables. I had the most fun
harvesting crops. We planted so many types of food. I miss those days.
Traditional Preparation of Diet: My grandpa told me that we made food like my ancestors
of old. I would tunu [barbecue] it. I would make a fire, then put whatever I want on top,
then I would take it out and eat it. I sometimes would add pure coconut milk for taste and
for energy. Another way we did it was by umu. We would dig a hole, put the food inside
and then place hot rocks or heat on top of it and wait for it to cook. My grandpa taught
me how to make my first umu when I was four years old.
As a result, the traditional preparation of the food contributed to their healthy dietary behaviors, and more specifically, healthy home-cooked meals. Studies have confirmed that eating home-cooked meals more frequently was associated with better diet quality and improved health outcomes (Mills et al., 2017).
61
Fresh and Organic Foods. I had access to papayas, coconuts, and water to drink every day. My grandpa always cooked oysters from the ocean over a hot fire. We never ate food from the store. We mostly lived off of organic food. I only ate fresh foods. I know that I only ate corned beef on special occasions back then. We were eating good food. I think that’s the best type of food on earth, and I actually want to eat some of that right now, today. I also remember eating sea cucumbers. We cooked the papayas in the pot and would drink the vai lesi. Or, would we would cook the young coconuts with the meat of the coconut scraped out into a pot. Those are the types of foods that my grandfather fed me, which is very similar to the traditional Tongan diet.
When speaking about fresh foods, another participant stated: The foods that I ate as a
child were always fresh. I can remember watching my meals being made right in front of
me. Everything was fresh. Fresh from the land and fresh from the sea. I can also
remember picking food, peeling it, cooking it, and eating all of it. I mean, how much
more organic can meals get? And every day was the same.
Thus, the traditional healthy dietary behaviors contributed to their overall health and well-being before their migration to the United States. Researchers have found that healthy dietary behaviors contributed to the prevention of chronic diseases (Schulze et al., 2018).
Likewise, healthy dietary behaviors can optimize both short- and long-term health and can reduce the risk of many health conditions (Schulze et al., 2018). A participant recalled growing up in Tonga and rarely hearing about chronic diseases because of the traditional dietary behaviors. She said:
Healthy Tongan Society and Health Benefits. I also think about the health benefits.
Thinking back to my childhood in Tonga, you rarely heard about any type of chronic illnesses
62
such as diabetes, cancers, heart disease, or other illnesses that we see nowadays because of the way we ate. Especially, high blood -pressure.
Another participant describing the health benefits stated: I would say the traditional
Tongan diet is very healthy. Nothing can replace the organic foods that the traditional
Tongan diet has to offer. There is no chemical or anything to make the food taste
processed. For me, I also think it is healthy because I rarely get sick when I was a kid
back on the islands. I remember playing all day and night in the rain and not even feeling
sick. I actually miss eating ota, tunu moa, and fresh fish. Oh, the Tongan way of eating is
such a beautiful diet. The local remedy I used growing up was to add some kind of
leaves to my diet to stay healthy. I wish that I could go back to the traditional way of
eating, drinking coconut milk and eating all that organic stuff.
Stress Due to Migration. The stress of migrating disrupted the traditional preparation of the food in the home. Bhugra and Becker (2005) noted that individuals who migrate experience various stressors that can impact their mental well-being, including adjustment to a new culture, such as the loss of cultural norms, religious customs, and social support systems, and changes in personal identity. Researchers found that immigration is a disruptive event with multiple implications for health (Tuggle et al., 2018). For instance, Tuggle et al. (2018) found that stressors, including family separation, acculturation, job insecurity, restricted social mobility, stigmatization, and marginalization, shape immigrant health in numerous ways.
As such, the first-generation Tongan-American participants described how the migration process was stressful both individually and to their families. The findings revealed that the integration process was made stressful due to the language barrier, low socioeconomic status,
63
low-paying jobs, limited upward social mobility, and discrimination. They described the various barriers with adjusting to a new culture:
Language Barrier. This participant described how the language barrier was associated
to the struggles with adjusting to life in America. I didn’t have that much opportunity
back in Tonga in terms of education, making a living, finding good jobs. So, I have
enjoyed the opportunity of living in the United States with my family. You know most of
us first-generation Tongans that come from the islands struggle. I had to struggle with
the language barrier and finding a job that would hire a Tongan immigrant.
Low Socioeconomic Status: This participant also described how low-education made it
hard to provide a living for the family. Being a Tongan in the United States is hard
especially when you are looking for work and have little education. My husband was a
handyman and construction worker his whole life. He would work for his friends,
members from church, and anyone who would give him work. But he did it and was able
to provide for our family. I remember that when my husband got paid, he would pay all
of our bills, leaving us with two dollars for the next few weeks.
Limited Upward Social Mobility. Another participant stated that life as a first-
generation Tongan immigrant was difficult considering the multiple challenges to
success. The struggles of surviving as an immigrant were hard. I was unable to reach
some of my personal goals of pursuing education or high-paying jobs because of my
citizenship status. I did not have U.S. citizenship. I was unable to get a loan from the
government for my schooling, I couldn’t find legal work for my family, and I was unable
to get any support from any type of welfare services. So, I pretty much worked hard and
fought every day for survival. That was the most difficult part.
64
Discrimination. This participant described her experiences with discrimination and how
it contributed to the difficulties with adjusting to life in America. I worked at a nursing
home in Idaho. My job in Idaho was tough because I was not used to that type of work. I
had to watch the elderly. My limited English made it difficult for me to communicate or
connect with my co-workers. What I remember the most about my jobs is that they all
paid poorly. I think the most I made at one time was about $4.50 an hour. The lowest I
made was about $3.00 an hour. I don’t think I thought about whether it was fair at the
time, but I feel like I was being cheated. But I had no choice. I didn’t finish college, and
my family lived in such small communities with little work available. Plus, I had to find
a job with hours that would allow me to rush home to pick up my kids from school and to
figure out a way to make dinner for my family.
As a result, the findings showed that the stressors associated with migration had disrupted the dietary behaviors in the Tongan-American home. As this participant stated:
Unhealthy Dietary Practices. In my home, with my own family, I did most of the
cooking. My husband was always out working. Plus, since my family didn’t have much,
I pretty much made whatever we had to put food on the table. There was no such thing as
planning a menu or healthy options. I told my family that we eat what we have; whatever
is in there, that’s it. My husband and I tried our best to buy foods that our kids would eat.
My husband and I could eat anything and be fine. I remember going weeks just eating
my kids’ leftovers to help save money for the family. If there were no leftovers, my
husband and I would just wait until the next day to eat.
Post-Migration. Stress and Unhealthy Dietary Behaviors: The findings showed that although time has passed since the migration of first-generation Tongan immigrants, very little
65
has been done to reduce the stressors among Tongan Americans. Thus, Tongan Americans are turning to unhealthy foods to cope with their stress. These participants stated:
Stress from Work. I think what makes my diet unhealthy—and growing up, I have seen
this a lot—is that I can plan to have a good diet and eat food that is good, but if stressors
happen in the home, they make my diet go unhealthy. On top of that, stress from work,
or from whatever is going on, can make a diet unhealthy. You can plan to eat healthy,
but if you go to work and have a bad day, things will pile up and when things get
stressful, I rely on comfort foods to help me. I often turn to food as a personal coping
mechanism. So, I think external stressors can lead to an unhealthy diet. For me,
personally, it’s a constant battle trying to finish schooling while going to work and
knowing that you are never going to climb the ladder for a promotion. Plus, I have to
deal with people that will smile in front of you, but don’t have the best intentions for you.
So, it’s just a lot of knowing what you are dealing with at work, and knowing when and
how to leave work at work.
Stress from School. I tend to go with what I prefer, what makes me comfortable, and
what makes me happy. Especially if you are stressed, or homesick, you would tend to go
with the unhealthy type of food. I had a bunch of assignments due for class one time that
stressed me out. I told myself that if I finished my work, I could treat myself to
McDonald’s and get a good burger. So, I guess I use the food as motivation. Sometimes
if I feel stressed about school, then I will find ice cream because it would help to calm me
down.
Busy Schedules. I recently tried to stop buying foods with sugar and unhealthy
ingredients for my home, but I noticed that I was always in a bad mood, angry, and
66
couldn’t function without my sweets. I actually quit eating sugary foods last year. I literally stopped cold turkey. Unfortunately, it didn’t last long. I quickly went back to eating sugary foods once things got stressful with my kids and their hectic schedules. We just know that we are going to eat out whenever we are out on the road for kids’ games, school activities, or just doing something out of the home, which is very often. That’s my life. Think about it: my husband and I both work the same schedule, and when we get off, we are often busy with our kid’s games, athletic activities, or church duties. The last thing we want to do when we are all out is cook, so we always stop somewhere to eat for convenience. After we eat, we come home and just knock out because we are so tired.
Stress from Childhood [Navigating Dual Cultures]. My lifestyle as a Tongan
American is rooted in my experiences of trying to navigate two cultures. Trying to balance a Tongan culture while learning to adapt to the American way of life is not easy.
I remember learning how to speak English in elementary school in the United States. I was teased a lot in the first grade, which actually pushed me to learn the language even more. Even now, I can feel the emotional stress of my experiences of trying to be an
“American.” On top of that, my family was not financially stable, though thankfully we had many family and friends who have helped us along the way. We were raised in a tight-knit family. Being Tongan American also meant that family comes first in all that we do. I centered my life on taking care of my parents, my siblings, and my family. I took on more responsibilities in the family when my dad fell ill. My parents struggled over the years and I found work to help my parents make ends meet. Although we didn’t have much, my parents instilled in us the value of hard work, perseverance, and living
67
life to the fullest. We were also involved in many school and church activities. Being
Tongan American meant that God is center of all.
Dealing with Racism: Racism was new at first, but I just got used to it. Growing up in
Utah, I would always feel like I was being discriminated against because I was a Tongan.
You see a lot of it in Utah. You can also feel it as you go around places in Utah. People here tend to stereotype you before they even know you. For me, I just—I don’t know—I just don’t let it get to me. I figure that that’s just the way it is. I just can’t, like, get mad at it all the time because one day, I just might go crazy. So, I just know what it is and looks like and understand that I have to act a certain way and accept it or I will get myself in trouble, which is kind of stressful.
When speaking about dealing with racism, another participant shared: I remember that I had an experience with a Delta worker racial profiling me. I was so mad that I actually sought legal advice to deal with the employee. Just talking about it stresses me out. I feel like I get racially profiled because I am brown. I don’t think it’s because I am Tongan. I think people in Utah see brown and make a judgment. But to be honest, I usually turn to food to deal with my stress. I actually turn to food for anything… I just know that food is comforting and helps me through a lot of things.
Stress from Multiple Obligations. I also have a number of other responsibilities outside of work that I have to tend to. Remember, in order to make it in America, Tongan
Americans have to work extra hard to survive. Regardless, I do think it can be possible to go back to the traditional diet. But for me personally, I think that it might be too much.
I have church obligations and other things that pop up like family stuff. The convenience of eating out makes it so easy. All I have to do is go down the street. I live near so many
68
fast food restaurants, which all have cheap and tasty menu items. To be honest, we try to
cook, but it’s hard. Especially because it’s only us two. We only have to plan meals for
my wife and myself. We always end up spending a lot of money at Costco or Sam’s
Club and letting the food go to waste. So, we figure that we can go eat dollar meals from
McDonald’s to save time and money. It just makes sense.
Preparation of the food in a Tongan-American Home
Despite the ongoing stressors and other barriers to eating healthy home-cooked meals, the participants revealed that they have been able to maintain the traditional preparation of the food in the home that has contributed to healthy dietary behaviors. Traditions remain one of the few practices that belong to a person (Foliaki, 1997). According to Foliaki (1997), maintaining cultural traditions contributes to improved health outcomes. These participants shared:
Multi-generational Households. I think it is easier for me to maintain the traditional
Tongan diet because I live with my parents. I am the oldest daughter, which brings about
cultural roles that I must follow. In this sense, when making food for them, I try to make
it taste the same as what I remember. I don’t know if the younger Tongan generation has
this luxury. Just recently, I asked my dad what he wanted to eat and he said anything.
Since I know what he likes, I made him a nice chicken soup with potatoes. I also made a
nice lamb curry on the side. I actually made sure that it had the traditional taste that both
he and I are accustomed to eating.
Spousal Support. My wife and I take pride in cooking different dishes and trying new
ingredients. There are always a salad and a dessert with every meal that we have in my
home. My wife also makes it a point to have something healthy to eat with every meal.
69
For example, last night for dinner, I had a little portion of meat, a nice salad, and a
healthy option. I mean there are just so many options.
Stay-at-Home Mom. Today, although I can afford to eat different foods at any time, I
still believe in cooking at home and finding time to make sure that a meal is ready for my
family every day. I am able to be a stay-at-home mom. My husband is able to provide
for us. Because of that, I have the means to buy anything to give my family choices. I
also have the time to prepare any type of meal [breakfast, lunch, and dinner] for my
immediate and extended family members. I think the biggest thing for me is to provide
choices. The meals in my home are typically balanced. I make it a priority to provide
healthy options both in the home and on the plate. These options include vegetables,
fruits, cheese, grains, and other healthy alternatives. I can see the difference in the meals
that I make for my family and how it blesses my life. It also helps me to not take
anything for granted.
Healthy Diet and Mental Well-Being
Numerous studies have identified the importance of adopting healthy dietary behaviors and having family support as buffers against stressors. According to Plant and Stephenson
(2009), giving your body the nutrition, it needs is a positive step to combating stress. Likewise,
Ajake (2017) found that improving one’s diet and eating balanced nutritional meals throughout the day will help the body build resistance and strength. Another key factor to reducing stress is having a strong family support system. A strong family system will buffer negative stresses in life. This participant stated:
Mental-Health. I also know that when I eat well, I feel good. In turn, I look good. Then
when you look good, you start to get compliments from everybody. I think it also helps
70
my mental state because everyone loves compliments. But I know that when I am not
eating well, I struggle to sleep at night. I know that my husband has been able to sleep
better at night since he changed his eating habits. He is a source of strength. I like how
he continues to push forward for himself and for us.
Conceptual Map of Findings
The conceptual map of the findings below (Figure 1) is a diagram of concepts to assist with presenting the study's results. A concept map is a graphic representation that illustrates the suggested relationships between the concepts. According to Kinchin (2000), concept maps promote higher-level thinking skills by assisting researchers with prioritizing the selected ideas and the organization of the new and previous information. Thus, this study's conceptual diagram highlighted the importance of exploring Tongan-American dietary experiences to understand the connection with the disproportionate rates of chronic diseases (Panapasa et al., 2012). The findings showed a dietary shift in which the participants' current Western diet supplanted the traditional Tongan diet. The change in dietary behaviors is connected to unhealthy dietary behaviors among the majority of the Tongan-American participants. Therefore, the conceptual map indicates that future efforts to promote healthy dietary behaviors must explore the listed barriers and facilitators on the conceptual map.
Figure 2
Conceptual Map of Findings
71
Summary of Findings
The purpose of this study was to understand better the dietary experiences and attitudes of Tongan Americans that contribute to the disproportionate rates of obesity and other chronic diseases among Tongan American adults. To achieve this goal, the research questions guiding this study were (1) what are the specific barriers to adopting healthy dietary behaviors among
Tongan American adults? and (2) what are the specific facilitators to adopting healthy dietary behaviors among Tongan American adults? Previous studies have reported on the disproportionate rates of obesity and chronic disease experienced by this population (Panapasa et al., 2012). However, they have lacked an in-depth qualitative exploration of the dietary experiences that contributed to the high disease frequencies.
Therefore, in the current study, I used a grounded theory method because of its concrete and structured guidelines and flexible approach to analyzing the data (Charmaz, 2006). More importantly, as an exploratory method, grounded theory was well suited for investigating the
72
lives of Tongan Americans, which have attracted little prior research attention (Milliken &
Morrison, 2003). After analyzing the data, I concluded that the findings show that there are complex factors involved with the dietary behaviors among Tongan Americans. In the process, I was also able to identify the multiple barriers as well as facilitators to adopting healthy dietary behaviors across the various levels of the Sociological Ecological Model, which served as the theoretical framework for the study. Overall, the extent of factors in this study is noteworthy, particularly when considering that little has been done to explore the culture, lives, and dietary experiences of this population and inform culturally tailored health strategies that will lower rates of chronic disease.
Hence, the findings revealed that there are complex behaviors involved with dietary behaviors. The following summary describes the various nuances between with the Tongan
American dietary behaviors the facilitators and barriers to adopting healthy dietary behaviors among Tongan American adults using the SEM, including variables at the individual, environmental, sectoral, and socio-cultural levels, as the framework. In this study, the results showed that the key findings were connected to one or more levels of the SEM. Therefore, following is a list of the key and novel findings.
Individual Level
The barriers and facilitators found at this level correspond to the findings of previous studies. Such studies have pointed out that stress can often be a barrier to healthy eating. Kim et al. (2012) concluded that people under stress tend to adopt unhealthy dietary behaviors by resorting to junk food as a coping mechanism. Similarly, Cartwright et al. (2003) found that stress from work can contribute to unhealthy dietary habits. In this study, all the participants (N
= 12) described how work-related stress and discrimination made it more enticing to eat
73
unhealthy foods to cope with their stress, which then became a barrier to adopting healthy dietary behaviors. Future studies should explore common coping mechanisms among Tongan
Americans to understand how they might connect to dietary behaviors and health outcomes.
Also included in the literature was the vital connection between health literacy and dietary behaviors. Carbone and Zoellner (2012) explained that inadequate health literacy made it challenging for individuals to gather and comprehend information. In this study, health literacy was a barrier to adopting healthy dietary behaviors among first-generation Tongan Americans because they had a difficult time with the English language. On the other hand, Rothman et al.
(2006) argued that health literacy could be a facilitator in selecting healthy foods. In this study, a few of the second-generation participants who mastered the English language were able to use that knowledge to choose healthier foods.
Again, Groth et al. (2001) maintained that socioeconomic status (SES) could be either a barrier or a facilitator to adopting healthy dietary behaviors. Inglis et al. (2005) concluded that those with a higher SES consumed a healthier diet than those with a low SES. In this study, the first-generation participants reported that having a low SES post-migration made it difficult for them to put food on the table and led to serving family meals that were often cheap, unhealthy, or premade. Conversely, the majority of the second-generation participants also reported unhealthy dietary behaviors despite higher SES as adults. Future studies should explore the association between SES and dietary behaviors among Tongan Americans.
This study reported some novel findings regarding individual factors associated with the adoption of healthy dietary behaviors by Tongan American adults. It indicated that time management is related to healthy dietary behaviors (Larson et al., 2006). Studies show that prioritizing time to prepare personal or family meals is vital to adopting healthy dietary
74
behaviors (Larson et al., 2006). Taking the time to make and eat regular meals is also associated with higher diet quality (Larson et al., 2006). In this study, the majority of participants struggled with time management due to work, family, and church commitments, which complicated the decision to adopt healthy dietary behaviors. On the other hand, the results showed that proper time management was connected to planning, preparing, and cooking healthier meals. In this study, the participants utilized their extra time to cook with family or plan future meals.
Fernandez et al. (2019) argued that healthy dietary choices are not a matter of knowledge or motivation, but available time. However, for most participants, time management was a barrier to adopting healthy dietary behaviors.
Possible mechanisms to explain the findings at the individual level may be related to the intergenerational experiences with integrating into American culture. Integrating refers to the ability of first-generation immigrants to adapt to their new society. Studies showed that first- generation immigrants experienced more stress than later generations (Padilla et al., 1985).
Likewise, Singleton and Krause (2009) found that first-generation immigrants struggled with the language barrier, which contributed to low health literacy rates and low SES (Van Hook &
Balistreri, 2007). Therefore, in this study, difficulties with integration among first-generation
Tongan Americans contributed to their high stress levels, low health literacy, and low SES, which contributed to unhealthy dietary behaviors and poor health outcomes.
On the other hand, research showed that second-generation immigrants who were born in the United States could adapt more naturally to the American culture (Jukkala et al., 2009).
However, studies showed that second-generation immigrants still had to deal with the stress of navigating through racism and discrimination (Berry & Hou, 2017). Future studies would benefit from exploring the integration experiences of first- and second-generation immigrants to
75
the United States to better understand how their individual experiences are connected to their dietary behaviors and health outcomes.
Physical Environment
The findings in this study are in accordance with those related to the effects of physical environment explored in other studies. Studies showed that the physical environment could have either a positive or a negative association with dietary behaviors (Sallis & Glanz, 2006). Ding et al. (2012) maintained that the availability of foods in the physical environment is linked to dietary behaviors. Likewise, studies have found that the physical environment for minority communities lacks equal access to healthy food choices when compared with wealthy neighborhoods (Ding et al., 2012). In this study, the findings confirmed that the physical environment was a barrier to healthier dietary behaviors among Tongan American participants in both Utah and Hawai'i. The participants also shared that both physical environments acted as barriers to adopting healthy dietary behaviors. In this study, a few of the participants in Hawai'i shared that they lived in a rural community with very little access to healthy dietary options because of their distance from the nearest supermarket (with healthy options), which was about an hour's drive each way. Whelan et al. (2018) found that rural and disadvantaged communities had less access to affordable and nutritious food, affecting both food security and the health of rural residents. Similarly, in a previous study, researchers also found a relationship between proximity to unhealthy food choices and unhealthy dietary behaviors (Hearst et al., 2012).
Home Environment
The participants in this study reported that unhealthy food availability and food insecurity in the home environment were barriers to adopting healthy dietary behaviors. Food availability refers to having access to food consistently (Shier et al., 2016). Research showed that greater
76
access to healthy food increases the choice and consumption of foods (Shier et al., 2016). On the other hand, Dammann and Smith (2010) found an association between unhealthy food availability and consumption of unhealthy foods. In this study, the majority of the participants reported that the food availability in their homes consisted of junk foods, sodas, snacks, and microwaveable foods. Similarly, research showed that food insecurity is also a barrier to adopting healthy dietary behaviors. In a study of low-income adults, Leung et al. (2012) found that food insecurity was associated with a higher risk of obesity and a higher BMI. In the current study, first-generation participants reported having low food security directly after migrating to the United States. Similarly, the majority of the second-generation participants recalled experiences with food insecurity as children of immigrants.
This study reported some novel findings regarding the home environment and the adoption of healthy dietary behaviors among Tongan Americans. Savage et al. (2007) argued that the home environment is where the learning and facilitation of dietary behaviors occurs and where the transmission of cultural and family beliefs around dietary behaviors is discussed. In a previous study, Lindsay et al. (2018) found that the home environment influenced the diet among the majority of the participants in the study.
The appropriate mechanism to explain food insecurity or availability in the home may be socioeconomic status. In a previous study, Nagata et al. (2015) investigated the relationship between SES and food insecurity and confirmed an association between them. In this study, the first-generation participants described how living in poverty and food insecurity as new immigrants to the United States was a barrier to adopting healthy dietary behaviors. Similarly, the participants reported that food availability was connected to their SES. In a previous study,
MacFarlane et al. (2007) found that a lower SES was associated with unhealthy food availability;
77
in contrast, a higher SES was associated with healthy food availability in the home environment.
Similarly, in this study, the participants reported that having either a lower or higher SES contributed respectively to unhealthy or healthy food availability in the home environment.
Sectors of Influence
These findings are consistent with other studies that explain how the government sector can influence policies to curb specific marketing to targeted populations (Graff et al., 2012).
Studies show that aggressive food and beverage marketing has fueled the obesity epidemic
(Graff et al., 2012). According to Graff et al. (2012), in 2010, the U.S. government spent approximately $2 billion on marketing sugary, fatty, and salty products to the public. Therefore, repeated calls to the government have been made to curb the marketing of unhealthy food (Graff et al., 2012). In a previous study, health research showed that policies could reduce obesity among young minority children and concluded that a policy proposal to tax sugary beverages, ban child-directed fast-food advertising, and promote funding for after-school physical activity programs would be most effective (Bascuñán, & Cuadrado, 2017). Likewise, in this study, the findings showed that policies had an impact on Tongan Americans. For example, the 1965 immigration policy change had a significant impact on the Tongan American population (Keely,
1971). The immigration act allowed large groups of Tongans to immigrate to the United States
(Ka'ili, 2008). The findings showed that among the unintended consequences of this policy was a disruption to the traditional preparation of the food which contributed to their healthy dietary behaviors.
Cultural and Social Norms
The facilitators and barriers found in this study agree with previous studies of the association between social and cultural norms and dietary behaviors. Caprio et al. (2008)
78
maintained that culture could influence a person's view on dietary behaviors. In another study,
Ka'ili (2008) stressed that food is an integral part of the Tongan culture. Research showed that immigrants who move to a different environment tend to eat foods that are similar to those of that environment (Perignon et al., 2017). Similarly, in this study, the first-generation participants described how eating traditional Tongan foods facilitated healthy dietary behaviors. Likewise, the participants described how social support from their family members facilitated healthy dietary behaviors. Studies show that parents shape children's early experiences with food and eating (Savage et al., 2007). In a previous study, Santiago-Torres et al. (2014) concluded that children modeled the same dietary behaviors they observed in their parents. In this study, the first-generation participants described their experiences of fishing, farming, and working to prepare their daily healthy home-cooked meals. However, the difficulties of integrating into the
United States made it difficult for them to continue modeling those behaviors. Conversely, the second-generation Tongan Americans grew up with food insecurity and unhealthy dietary behaviors.
This study reported some key findings regarding social and cultural norms associated with the adoption of healthy dietary behaviors. The results showed that reconnecting with the traditional Tongan identity and its associated cultural norms, values, and actions promotes healthier dietary practices and behaviors. On the other hand, the findings showed that Tongan
American adults have adopted Western cultural norms, values, and behaviors because they were socialized into American ways.
79
Chapter 6 Discussion
The aim of this study was to understand better the dietary experiences and attitudes of
Tongan Americans that contribute to the disproportionate rates of obesity and other chronic diseases among Tongan American adults. In the process, this dissertation has shown that Tongan
Americans are among a growing immigrant population with both mental and physical needs, and yet, little has been done to address the growing mental and health concerns because they are still considered a “hidden population” due to their small overall population (Shaghaghi, Bhopal, &
Sheikh, 2011). The findings from this study indicated that Tongan Americans are eating out at fast food restaurants, ordering takeout, or going to the nearest convenience store more often than cooking meals at home. A key finding is that Tongan Americans are choosing those options as a coping mechanism to dealing with their stress. Researchers have found a strong relationship between stress and unhealthy eating (Cvetovac & Hamar, 2012). Unfortunately, the decision to eat an unhealthy diet has contributed to the high incidences of obesity and other chronic disease among Tongan-American adults. Likewise, another study revealed that participants’ health issues were connected to their unhealthy dietary behaviors (Kuźbicka & Rachoń, 2013).
Therefore, this dissertation recommends that future efforts include facilitating education among
Tongan Americans to discuss positive coping mechanisms for dealing with stress. This is especially critical since mental illness is viewed as a taboo in the Tongan culture (Foliaki, 1997).
Thus, it is vital that future health strategies navigate the sensitive topic of mental health to effectively address the growing health disparities among Tongan Americans.
Study Limitations
80
This study has many limitations as it is the first was the lack of research in the area of
Tongan health issues. The majority of the Tongan references in this study are taken from historical records, with little or no data to support them. Similarly, the study made multiple references to the subsuming of the health data and statistics of Tongan Americans as part of the
NHOPI ethnic population and how this prevents Tongan Americans from getting the research, funding, and attention that they desperately need.
A further limitation is a lack of diversity in the sample in that the majority of the participants were from Utah and Hawai'i, with a large population of LDS members. Future studies should seek to include multiple Tongan perspectives, including different religious affiliations and demographic locations.
Finally, the current research could benefit from a quantitative methodology. A mixed- method approach would have been able to introduce evidence-based instruments to test the stress levels and other mental health disturbances of the participants (Frantz & Holmgren, 2019). This would benefit efforts to reduce stress by identifying the main sources. Regardless of the limitations, this study is able to provide an intimate look into the lived experiences of Tongan-
American adults to explore ways to reduce the high incidence of chronic disease among this population.
Implications for Social Work Policy, Research, and Practice
Future action should focus on policy measures to further disaggregate the Tongan-
American health statistics from the NHOPI category. The subsuming of the Tongan-American health needs and statistics under the NHOPI classification has made the group invisible to the
U.S. public health system. As a “hidden population”, Tongan Americans have been kept from receiving necessary resources to combat the increasing rates of disease. Thus, future
81
policymaking should focus on the further disaggregation of Tongan-American health data and statistics from the NHOPI population. Proposing proper plans is vital to their receiving the necessary funding and research to facilitate culturally tailored health strategies to reduce the disproportionate rates of chronic disease among the Tongan-American population.
Future research should explore if Tongan Americans’ unhealthy dietary behaviors are connected to suffering from post-traumatic stress disorder (PTSD). Perreira and Ornelas (2013) concluded that 35% of immigrants experienced trauma during migration, and that 9% of adolescents and 21% of adults were at risk for PTSD. In this case, the majority of the participants were able to recall their childhood experiences of dealing with food insecurity and watching their parents struggle with integrating into the United States. For example, the majority of the participants shared similar stories as this participant, who stated:
Childhood Experiences: I also remember having a Tongan father who was very
traditional, who carried the mentality that men hunt and women cook, but with both of
them being students, he would still expect my mom to make the meals. Looking back, it
was hard since my mother did not like to cook very much. I knew that this caused many
arguments in my home growing up because some days my dad was okay with it, and
other days he would just blow up. I saw so many different feelings and emotions
involved regarding who cooked and what was cooked in my home. Looking back, my
parents fought a lot over food and meals in the home. My dad would get mad at my mom
if his meals weren’t ready or prepared the way he desired. On the other hand, my mom
was busy with school, kids, and house chores on top of not liking to cook, which was a
recipe for disaster. I couldn’t understand why my dad was difficult when it came to
making meals. That’s why I had to learn how to cook from young. Because I didn’t want
82
to see my mom and dad fight and argue a lot. I made sure to help my mom whenever she
was in the kitchen. I was tired of seeing my dad mad. I think my diet today is driven by
my fear of seeing my parents fight when I was younger. I mean, how could he expect my
mom to have time to cook if she was also trying to help our struggling family? So, time,
cooking, and resources were a big issue related to meals in my home as a child.
Future research efforts to address the disproportionate rates of chronic diseases should also explore the level of physical activity among Tongan-Americans. Physical activity contributes to the development of healthy lifestyles and the reduction in chronic disease incidence (Hallal et al., 2006). Evidence over the past 20 years from a variety of sources, including epidemiological, and intervention studies have documented that physical activity, diet, and combined activity and diet interventions can alleviate the progression of chronic disease and also lead to the reverse of the current disease (Roberts & Barnard, 2005; Wallace et al., 2018).
Thus, future efforts to eradicate the high incidences of chronic diseases among Tongan-
Americans should explore the levels of physical activity, in addition to their dietary behaviors.
Finally, future social work practices should focus on integrating the Tongan-American family (i.e., nuclear and extended) when implementing strategies to improving dietary behaviors.
The findings highlighted the importance of having family support when looking to change dietary behaviors. Likewise, the results revealed that the culture in a Tongan-American home is unique and that garnering family support is vital to any future successes in restoring the home as the primary environment for adopting healthy dietary behaviors and ultimately reducing the disproportionate rates of chronic disease among the Tongan-American population.
83
References
Abdulmumeen, H. A., Risikat, A. N., & Sururah, A. R. (2012). Food: Its preservatives, additives
and applications. International Journal of Chemical and Biochemical Sciences, 1, 36-47.
Acheson, D. (1998). Independent inquiry into inequalities in health report. The Stationery
Office.
Adamson, A. J., & Mathers, J. C. (2004). Effecting dietary change. Proceedings of the Nutrition
Society, 63(4), 537–547. https://doi.org/10.1079/PNS2004395
Ajake, U. E. (2017). Manage your stress: A practical approach. Friesen Press.
Alissa, E. M., & Ferns, G. A. (2017). Dietary fruits and vegetables and cardiovascular diseases
risk. Critical Reviews in Food Science and Nutrition, 57(9), 1950-1962.
Andreyeva, T., Long, M. W., & Brownell, K. D. (2010). The impact of food prices on
consumption: A systematic review of research on the price elasticity of demand for food.
American Journal of Public Health, 100(2), 216–222.
Argueta, D. A., & DiPatrizio, N. V. (2017). Peripheral endocannabinoid signaling controls
hyperphagia in western diet-induced obesity. Physiology & Behavior, 171, 32–39.
Arroyo-Johnson, C., & Mincey, K. D. (2016). Obesity epidemiology worldwide.
Gastroenterology Clinics of North America, 45(4), 571–579.
https://doi.org/10.1016/j.gtc.2016.07.012
Ascherio, A., Katan, M. B., Zock, P. L., Stampfer, M. J., & Willett, W. C. (1999). Trans fatty
acids and coronary heart disease. New England Journal of Medicine, 340, 1994–1998.
Baldock, K., Paquet, C., Howard, N., Coffee, N., Hugo, G., Taylor, A., Adams, R., & Daniel, M.
(2012). Associations between resident perceptions of the local residential environment
84
and metabolic syndrome. Journal of Environmental and Public Health, 1-11.
https://doi.org/10.1155/2012/589409
Barnes, M. S., & Cassidy, T. (2018). Diet, exercise and motivation in weight reduction: The role
of psychological capital and stress. JOJ Nurse Health Care, 9(5), 1–6.
Bascuñán, J., & Cuadrado, C. (2017). Effectiveness of sugar-sweetened beverages taxes to
reduce obesity: Evidence brief for policy. Medwave, 17(08), e7054-e7054.
https://doi.org/10.5867/medwave.2017.08.7054
Bayol, S. A., Farrington, S. J., & Stickland, N. C. (2007). A maternal “junk food” diet in
pregnancy and lactation promotes an exacerbated taste for “junk food” and a greater
propensity for obesity in rat offspring. British Journal of Nutrition, 98(4), 843–851.
Bell, A., Swinburn, B., Amosa, H., & Scragg, R. (2001). A nutrition and exercise intervention
program for controlling weight in Samoan communities in New Zealand. International
Journal of Obesity, 25(6), 920–927. https://doi.org/10.1038/sj.ijo.0801619
Bernard, H. R. (2017). Research methods in anthropology: Qualitative and quantitative
approaches. Rowman & Littlefield.
Bernstein, A. M., Bloom, D. E., Rosner, B. A., Franz, M., & Willett, W. C. (2010). Relation of
food cost to healthfulness of diet among US women. The American Journal of Clinical
Nutrition, 92(5), 1197–1203.
Berry, J. W., & Hou, F. (2017). Acculturation, discrimination and wellbeing among second
generation of immigrants in Canada. International Journal of Intercultural Relations, 61,
29–39.
Bhugra, D., & Becker, M. A. (2005). Migration, cultural bereavement and cultural
identity. World Psychiatry, 4(1), 18.
85
Bibbins-Domingo, K., Chertow, G. M., Coxson, P. G., Moran, A., Lightwood, J. M., Pletcher,
M. J., & Goldman, L. (2010). Projected effect of dietary salt reductions on future
cardiovascular disease. New England Journal of Medicine, 362(7), 590–599.
Biernacki, P., & Waldorf, D. (1981). Snowball sampling: Problems and techniques of chain
referral sampling. Sociological Methods & Research, 10(2), 141–163.
https://doi.org/10.1177/004912418101000205
Binks, M. (2016). The role of the food industry in obesity prevention. Current Obesity Reports,
5(2), 201–207.
Borgatti, S. (2005). Introduction to grounded theory. Analytic Tech. Retrieved March 16, 2020,
from http://www.analytictech.com/mb870/introtogt.htm
Braden, K. W., & Nigg, C. R. (2016). Modifiable determinants of obesity in Native Hawaiian
and Pacific Islander youth. Hawai'i Journal of Medicine & Public Health, 75(6), 162–
171.
Brester, G. W., & Schroeder, T. C. (1995). The impacts of brand and generic advertising on meat
demand. American Journal of Agricultural Economics, 77(4), 969–979.
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and
design. Harvard University Press.
Brooks, F. B., Rubin, H. J., & Rubin, I. S. (1996). Qualitative interviewing: The art of hearing
data. The Modern Language Journal, 80(4), 555. doi:10.2307/329757
Bruner, J. (2004). Life as narrative. Social research: An international quarterly, 71(3), 691-710.
Burley, D. V. (1998). Tongan archaeology and the Tongan past, 2850–150 BP. Journal of World
Prehistory, 12(3), 337–392.
86
Campbell, M. K., DeVellis, B. M., Strecher, V. J., Ammerman, A. S., DeVellis, R. F., & Sandler,
R. S. (1994). Improving dietary behavior: The effectiveness of tailored messages in
primary care settings. American Journal of Public Health, 84(5), 783–787.
Cangelosi, P. R., & Witt, K. J. (2006). Teaching through storytelling: An exemplar. International
Journal of Nursing Education Scholarship, 3(1), 1–7.
Caperon, L., Arjyal, A., Puja, K. C., Kuikel, J., Newell, J., Peters, R., Prestwich, A., & King, R.
(2019). Developing a socio-ecological model of dietary behaviour for people living with
diabetes or high blood glucose levels in urban Nepal: A qualitative investigation. Public
Library of Science One, 14(3), e0214142. https://doi.org/10.1371/journal.pone.0214142
Caprio, S., Daniels, S. R., Drewnowski, A., Kaufman, F. R., Palinkas, L. A., Rosenbloom, A. L.,
& Schwimmer, J. B. (2008). Influence of race, ethnicity, and culture on childhood
obesity: implications for prevention and treatment: a consensus statement of Shaping
America's Health and the Obesity Society. Diabetes Care, 31(11), 2211-2221.
Carbone, E. T., & Zoellner, J. M. (2012). Nutrition and health literacy: A systematic review to
inform nutrition research and practice. Journal of the Academy of Nutrition and Dietetics,
112(2), 254–265.
Carmona, R. H. (2005). Improving Americans’ health literacy. Journal of the American Dietetic
Association, 105(9), 1345.
Cartwright, M., Wardle, J., Steggles, N., Simon, A. E., Croker, H., & Jarvis, M. J. (2003). Stress
and dietary practices in adolescents. Health Psychology, 22(4), 362–369.
Cassel, J. (1957). Social and cultural implications of food and food habits. American Journal of
Public Health, 47(6), 732–740.
87
Castleberry, A. (2014). NVivo 10 (Version 10) [Computer software]. QSR
International. https://www.qsrinternational.com/nvivo-qualitative-data-analysis-
software/support-services/nvivo-downloads
Centers for Disease Control and Prevention (CDC). (2015). The social-ecological model: A
framework for prevention. Retrieved March, 2017, from
https://www.cdc.gov/violenceprevention/publichealthissue/social-ecologicalmodel.html
Cha, E., Kim, K. H., Lerner, H. M., Dawkins, C. R., Bello, M. K., Umpierrez, G., & Dunbar, S.
B. (2014). Health literacy, self-efficacy, food label use, and diet in young adults.
American Journal of Health Behavior, 38(3), 331–339.
Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative
analysis. Sage.
Charmaz, K. (2012). The power and potential of grounded theory. Medical Sociology Online,
6(3), 2–15.
Cheung, L. T., Chan, R. S., Ko, G. T., Lau, E. S., Chow, F. C., & Kong, A. P. (2018). Diet
quality is inversely associated with obesity in Chinese adults with type 2
diabetes. Nutrition Journal, 17(1), 63.
Christakis, N. A., & Fowler, J. H. (2007). The spread of obesity in a large social network over 32
years. New England Journal of Medicine, 357(4), 370–379.
Cook, J., Cook, J. R., & Beaglehole, J. C. (1999). The journals of Captain Cook. Penguin UK.
Corbin, J., & Strauss, A. (2007). Basics of qualitative research: Techniques and procedures for
developing grounded theory (3rd ed.). Sage.
Creswell, J. W. (1998). Qualitative inquiry and research design: Choosing among five
traditions. Sage.
88
Crowther, G. (2018). Eating culture: An anthropological guide to food. University of Toronto
Press.
Curley, A. L. (2019). Population-based nursing: Concepts and competencies for advanced
practice. Springer Publishing Company.
Cvetovac, M., & Hamar, S. (2012). Stress and unhealthy eating in a college sample. Proceedings
of the National Conference of Undergraduate Research 2012.
https://www.ncurproceedings.org/ojs/index.php/NCUR2012/article/view/185/161
Dallman, M. F. (2010). Stress-induced obesity and the emotional nervous system. Trends in
Endocrinology & Metabolism, 21(3), 159–165.
Dammann, K., & Smith, C. (2010). Food-related attitudes and behaviors at home, school, and
restaurants: Perspectives from racially diverse, urban, low-income 9- to 13-year-old
children in Minnesota. Journal of Nutrition Education and Behavior, 42(6), 389–397.
https://doi.org/10.1016/j.jneb.2009.09.003
Darmon, N., & Drewnowski, A. (2008). Does social class predict diet quality? The American
Journal of Clinical Nutrition, 87(5), 1107–1117.
DeSalvo, K. B., Olson, R., & Casavale, K. O. (2016). Dietary guidelines for Americans. Journal
of the American Medical Association, 315(5), 457-458.
Diamond, J. (2013). The world until yesterday: What can we learn from traditional societies?
Penguin.
Ding, D., Sallis, J. F., Norman, G. J., Saelens, B. E., Harris, S. K., Kerr, J., Rosenberg, D.,
Durant, N., & Glanz, K. (2012). Community good environment, home food environment,
and fruit and vegetable intake of children and adolescents. Journal of Nutrition Education
and Behavior, 44(6), 634-638. https://doi.org/10.1016/j.jneb.2010.07.003
89
DiNicolantonio, J. J., Lucan, S. C., & O’Keefe, J. H. (2016). The evidence for saturated fat and
for sugar related to coronary heart disease. Progress in Cardiovascular Diseases, 58(5),
464–472.
Drewnowski, A. (2004). Obesity and the food environment: Dietary energy density and diet
costs. American Journal of Preventive Medicine, 27(3), 154–162.
Dubowitz, T., Heron, M., Bird, C. E., Lurie, N., Finch, B. K., Basurto-Dávila, R., Hale, L., &
Escarce, J. J. (2008). Neighborhood socioeconomic status and fruit and vegetable intake
among whites, blacks, and Mexican Americans in the United States. The American
Journal of Clinical Nutrition, 87(6), 1883-1891. https://doi.org/10.1093/ajcn/87.6.1883
Ducrot, P., Méjean, C., Aroumougame, V., Ibanez, G., Allès, B., Kesse-Guyot, E., Hercberg, S.,
& Péneau, S. (2017). Meal planning is associated with food variety, diet quality and body
weight status in a large sample of French adults. International Journal of Behavioral
Nutrition and Physical Activity, 14(1). https://doi.org/10.1186/s12966-017-0461-7
Duffy, K., Ferguson, C., & Watson, H. (2004). Data collecting in grounded theory—some
practical issues. Nurse Researcher, 11(4), 67–78.
Dutta, M. J. (2007). Communicating about culture and health: Theorizing culture-centered and
cultural sensitivity approaches. Communication Theory, 17(3), 304–328.
Ellis, C., Strauss, A., & Corbin, J. (1992). Basics of Qualitative Research: Grounded Theory
Procedures and Techniques. Contemporary Sociology, 21(1), 138. doi:10.2307/2074814
Emden, C. (1998). Conducting a narrative anlysis. Collegian, 5(3), 34-39.
Englberger, L., Halavatau, V., Yasuda, Y., & Yamazaki, R. (1999). The Tonga healthy weight
loss program 1995–97. Asia Pacific Journal of Clinical Nutrition, 8(2), 142-148.
90
Evans, M., Sinclair, R. C., Fusimalohi, C., Laiva'a, V., & Freeman, M. (2003). Consumption of
traditional versus imported foods in Tonga: Implications for programs designed to reduce
diet-related non-communicable diseases in developing countries. Ecology of Food and
Nutrition, 42(2), 153–176.
Fernandez, M. A., Marquis, M., Desroches, S., Turcotte, M., & Provencher, V. (2019). Full-time
employment, diet quality, and food skills of Canadian parents. Canadian Journal of
Dietetic Practice and Research, 80(2), 63–71.
Flegal, K. M., Carroll, M. D., Ogden, C. L., & Curtin, L. R. (2010). Prevalence and trends in
obesity among US adults, 1999–2008. Journal of American Medical Association, 303(3),
235–241.
Foley, G., & Timonen, V. (2015). Using grounded theory method to capture and analyze health
care experiences. Health Services Research, 50(4), 1195–1210.
Foliaki, S. (1997). Migration and mental health: The Tongan experience. International Journal
of Mental Health, 26(3), 36-54.
Ford, M. C., Gordon, N. P., Howell, A., Green, C. E., Greenspan, L. C., Chandra, M., Mellor, R.
G., & Lo, J. C. (2016). Obesity severity, dietary behaviors, and lifestyle risks vary by
race/ethnicity and age in a Northern California cohort of children with obesity. Journal of
Obesity, 2016, 1-10. https://doi.org/10.1155/2016/4287976
Fox, M. K., Gordon, A., Nogales, R., & Wilson, A. (2009). Availability and consumption of
competitive foods in US public schools. Journal of the American Dietetic Association,
109(2), S57–S66.
Frantz, A., & Holmgren, K. (2019). The work stress questionnaire (WSQ) – Reliability and face
validity among male workers. BioMedicine Central Public Health, 19(1), 1580.
91
García-Sánchez, F. J., Martínez-Vizcaíno, V., & Rodríguez-Martín, B. (2019). Barriers and
facilitators for caregiver involvement in the home care of people with pressure injuries: A
qualitative study. Public Library of Science One, 14(12).
Gee, G. C., Ro, A., Gavin, A., & Takeuchi, D. T. (2008). Disentangling the effects of racial and
weight discrimination on body mass index and obesity among Asian Americans.
American Journal of Public Health, 98(3), 493–500.
Giskes, K., Avendaňo, M., Brug, J., & Kunst, A. E. (2010). A systematic review of studies on
socioeconomic inequalities in dietary intakes associated with weight gain and
overweight/obesity conducted among European adults. Obesity Reviews, 11(6), 413–429.
Glade, M. J. (1999). Food, nutrition, and the prevention of cancer: A global perspective.
American Institute for Cancer Research/World Cancer Research Fund, American Institute
for Cancer Research, 1997. Nutrition, 15, 523–526.
Glaser, B. G., & Strauss, A. L. (2017). Discovery of grounded theory: Strategies for qualitative
research. Routledge.
Graff, S., Kunkel, D., & Mermin, S. E. (2012). Government can regulate food advertising to
children because cognitive research shows that it is inherently misleading. Health
Affairs, 31(2), 392-398.
Green, L. W. (1984). Modifying and developing health behavior. Annual Review of Public
Health, 5(1), 215–236.
Groth, M. V., Fagt, S., & Brøndsted, L. (2001). Social determinants of dietary habits in
Denmark. European Journal of Clinical Nutrition, 55(11), 959–966.
Guo, X., Warden, B. A., Paeratakul, S., & Bray, G. A. (2004). Healthy eating index and obesity.
European Journal of Clinical Nutrition, 58(12), 1580–1586.
92
Hallal, P. C., Victora, C. G., Azevedo, M. R., & Wells, J. C. (2006). Adolescent physical activity
and health. Sports Medicine, 36(12), 1019-1030.
Hallberg, L. R. (2006). The “core category” of grounded theory: Making constant
comparisons. International Journal of Qualitative Studies on Health and Well-
Being, 1(3), 141–148.
Harris, J. L., Bargh, J. A., & Brownell, K. D. (2009). Priming effects of television food
advertising on eating behavior. Health Psychology, 28(4), 404.
Harris, P. M., & Jones, N. A. (2005). We the people: Pacific islanders in the United States (Vol.
26). U.S. Department of Commerce, Economics and Statistics Administration, U.S.
Census Bureau.
He, K., Hu, F. B., Colditz, G. A., Manson, J. E., Willett, W. C., & Liu, S. (2004). Changes in
intake of fruits and vegetables in relation to risk of obesity and weight gain among
middle-aged women. International Journal of Obesity, 28(12), 1569-1574.
https://doi.org/10.1038/sj.ijo.0802795
Hearst, M. O., Pasch, K. E., & Laska, M. N. (2012). Urban v. suburban perceptions of the
neighbourhood food environment as correlates of adolescent food purchasing. Public
Health Nutrition, 15(2), 299-306. https://doi.org/10.1017/s1368980011002114
Hendrie, G., Sohonpal, G., Lange, K., & Golley, R. (2013). Change in the family food
environment is associated with positive dietary change in children. International Journal
of Behavioral Nutrition and Physical Activity, 10(1), 4. doi: 10.1186/1479- 5868-10-4
Hesketh, K. D., & Campbell, K. J. (2010). Interventions to prevent obesity in 0–5-year old’s: An
updated systematic review of the literature. Obesity, 18(S1), S27-S35.
93
Hixson, L. K., Hepler, B. B., & Kim, M. O. (2012). The Native Hawaiian and other Pacific
Islander population: 2010. U.S. Department of Commerce, Economics and Statistics
Administration, U.S. Census Bureau.
Huang, M.-C., Hsu, C.-C., Wang, H.-S., & Shin, S.-J. (2010). Prospective randomized controlled
trial to evaluate effectiveness of registered dietitian-led diabetes management on
glycemic and diet control in a primary care setting in Taiwan. Diabetes Care, 33(2), 233–
239. https://doi.org/10.2337/dc09-1092
Inagami, S., Cohen, D. A., Finch, B. K., & Asch, S. M. (2006). You are where you shop:
Grocery store locations, weight, and neighborhoods. American Journal of Preventive
Medicine, 31(1), 10–17.
Inglis, V., Ball, K., & Crawford, D. (2005). Why do women of low socioeconomic status have
poorer dietary behaviours than women of higher socioeconomic status? A qualitative
exploration. Appetite, 45(3), 334–343.
Izydorczyk, B., Sitnik-Warchulska, K., Lizińczyk, S., & Lipiarz, A. (2019). Psychological
predictors of unhealthy eating attitudes in young adults. Frontiers in Psychology, 10, 590.
Jaber, L. A., Halapy, H., Fernet, M., Tummalapalli, S., & Diwakaran, H. (1996). Evaluation of a
pharmaceutical care model on diabetes management. Annals of Pharmacotherapy, 30(3),
238–243.
Jacobson, T. A., Morton, F., Jacobson, K. L., Sharma, S., & Garcia, D. C. (2002). An assessment
of obesity among African-American women in an inner-city primary care clinic. Journal
of the National Medical Association, 94(12), 1049–1057.
94
Jeffery, R. W., Baxter, J., McGuire, M., & Linde, J. (2006). Are fast food restaurants an
environmental risk factor for obesity? International Journal of Behavioral Nutrition and
Physical Activity, 3(1), 2.
Jiménez-Colmenero, F., Carballo, J., & Cofrades, S. (2001). Healthier meat and meat products:
Their role as functional foods. Meat Science, 59(1), 5–13.
Jorgensen, U. (2001). Grounded theory: Methodology and theory construction. International
Encyclopedia of the Social & Behavioral Sciences, 1, 6396–6399.
Jukkala, A., Deupree, J. P., & Graham, S. (2009). Knowledge of limited health literacy at an
academic health center. The Journal of Continuing Education in Nursing, 40(7), 298–
302.
Kaeppler, A. L. (1971). Eighteenth century Tonga: New interpretations of Tongan society and
material culture at the time of Captain Cook. Man, 6(2), 204–220.
Kaholokula, J. K., Townsend, C. K., Ige, A., Sinclair, K. A., Mau, M. K., Leake, A., Palakiko,
D., Yoshimura, S. R., Kekauoha, P., & Hughes, C. (2013). Sociodemographic,
behavioral, and biological variables related to weight loss in native Hawaiians and other
pacific islanders. Obesity, 21(3), E196-E203. https://doi.org/10.1002/oby.20038
Ka'ili, T. O. (2008). Tauhi Vā: Creating beauty through the art of sociospatial relations
(Publication no. AAT 3303375) [Doctoral dissertation, University of Washington].
ProQuest Dissertations & Theses Global.
Kalucka, S., Kaleta, D., & Makowiec-Dabrowska, T. (2019). Prevalence of dietary behavior and
determinants of quality of diet among beneficiaries of government welfare assistance in
Poland. International Journal of Environmental Research and Public Health, 16(3), 501.
https://doi.org/10.3390/ijerph16030501
95
Kamphuis, C. B., de Bekker-Grob, E. W., & van Lenthe, F. J. (2015). Factors affecting food
choices of older adults from high and low socioeconomic groups: A discrete choice
experiment. The American Journal of Clinical Nutrition, 101(4), 768–774.
Keely, C. B. (1971). Effects of the Immigration Act of 1965 on selected population
characteristics of immigrants to the United States. Demography, 8(2), 157-169.
Kelly, M. P., & Barker, M. (2016). Why is changing health-related behaviour so difficult? Public
Health, 136, 109–116.
Kennedy, E. M. (1966). The Immigration Act of 1965. The Annals of the American Academy of
Political and Social Science, 367(1), 137-149.
Kim, J., Bramlett, M. H., Wright, L. K., & Poon, L. W. (1998). Racial Differences in Health
Status and Health Behaviors of Older Adults. Nursing Research, 47(4), 243-
250. https://doi.org/10.1097/00006199-199807000-00010
Kim, H., Lee, N., Lee, J., Choi, Y., Kwak, T., Chung, H. R., Kwon, S., Choi, Y., Lee, S., &
Kang, M. (2012). Meal skipping relates to food choice, understanding of nutrition
labeling, and prevalence of obesity in Korean fifth grade children. Nutrition Research
and Practice, 6(4), 328. https://doi.org/10.4162/nrp.2012.6.4.328
Kinchin, I. M. (2000). Using concept maps to reveal understanding: A two-tier analysis. School
Science Review, 81(296), 41-46.
Koh, H. K., Piotrowski, J. J., Kumanyika, S., & Fielding, J. E. (2011). Healthy people: A 2020
vision for the social determinants approach. Health Education & Behavior, 38(6), 551–
557.
Kraak, V. A., Liverman, C. T., & Koplan, J. P. (Eds.). (2005). Preventing childhood obesity:
Health in the balance. National Academies Press.
96
Krumeich, A., Weijts, W., Reddy, P., & Meijer-Weitz, A. (2001). The benefits of
anthropological approaches for health promotion research and practice. Health Education
Research, 16(2), 121-130.
Kuczmarski, M. F., Adams, E. L., Cotugna, N., Pohlig, R. T., Beydoun, M. A., Zonderman, A.
B., & Evans, M. K. (2016). Health literacy and education predict nutrient quality of diet
of socioeconomically diverse, urban adults. Journal of Epidemiology and Preventive
Medicine, 2(1).
Kushi, L. H., Byers, T., Doyle, C., Bandera, E. V., McCullough, M., Gansler, T., Andrews, K. S.,
& Thun, M. J. (2006). American Cancer Society guidelines on nutrition and physical
activity for cancer prevention: Reducing the risk of cancer with healthy food choices and
physical activity. CA: A Cancer Journal for Clinicians, 56(5), 254-281.
https://doi.org/10.3322/canjclin.56.5.254
Kutner, M., Greenberg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America’s
adults: Results from the 2003 national assessment of adult literacy. U.S. Department of
Education. National Center for Education Statistics.
Kuźbicka, K., & Rachoń, D. (2013). Bad eating habits as the main cause of obesity among
children. Pediatric Endocrinology, Diabetes, and Metabolism, 19(3), 106-110.
Larson, N. I., Perry, C. L., Story, M., & Neumark-Sztainer, D. (2006). Food preparation by
young adults is associated with better diet quality. Journal of the American Dietetic
Association, 106(12), 2001–2007.
Lee, H. M. (2003). Tongans overseas: Between two shores. University of Hawaii Press.
Lee, J. H., Ralston, R. A., & Truby, H. (2011). Influence of food cost on diet quality and risk
factors for chronic disease: A systematic review. Nutrition & Dietetics, 68(4), 248–261.
97
Leung, C. W., Williams, D. R., & Villamor, E. (2012). Very low food security predicts obesity
predominantly in California Hispanic men and women. Public Health Nutrition, 15(12),
2228-2236.
Levine, C. S., Miyamoto, Y., Markus, H. R., Rigotti, A., Boylan, J. M., Park, J., Kitayama, S.,
Karasawa, M., Kawakami, N., Coe, C. L., Love, G. D., & Ryff, C. D. (2016). Culture and
healthy eating. Personality and Social Psychology Bulletin, 42(10), 1335-1348.
https://doi.org/10.1177/0146167216658645
Liao, Y., Siegel, P. Z., White, S., Dulin, R., & Taylor, A. (2016). Improving actions to control
high blood pressure in Hispanic communities — Racial and Ethnic Approaches to
Community Health Across the U.S. Project, 2009–2012. Preventive Medicine, 83, 11-15.
doi: 10.1016/j.ypmed.2015.11.027
Lin, L., & Mao, P. C. (2015). Food for memories and culture—A content analysis study of food
specialties and souvenirs. Journal of Hospitality and Tourism Management, 22, 19–29.
Lindquist, T. L., Beilin, L. J., & Knuiman, M. W. (1997). Influence of lifestyle, coping, and job
stress on blood pressure in men and women. Hypertension, 29(1), 1–7.
Lindsay, A. C., Wallington, S. F., Lees, F. D., & Greaney, M. L. (2018). Exploring how the
home environment influences eating and physical activity habits of low-income, Latino
children of predominantly immigrant families: A qualitative study. International Journal
of Environmental Research and Public Health, 15(5), 978.
Lipski, E. (2010). Traditional non‐Western diets. Nutrition in Clinical Practice, 25(6), 585–593.
MacFarlane, A., Crawford, D., Ball, K., Savige, G., & Worsley, A. (2007). Adolescent home
food environments and socioeconomic position. Asia Pacific Journal of Clinical
Nutrition, 16(4), 748–755.
98
Mack, K. A., & Ahluwalia, I. B. (2003). Observations from the CDC: Monitoring women's
health in the United States: Selected chronic disease indicators, 1991–2001 BRFSS.
Journal of Women's Health, 12(4), 309–314.
Méjean, C., Lampuré, A., Si Hassen, W., Gojard, S., Péneau, S., Hercberg, S., & Castetbon, K.
(2018). Influence of food preparation behaviors on 5-year weight change and obesity risk
in a French prospective cohort. International Journal of Behavioral Nutrition and
Physical Activity, 15(1). https://doi.org/10.1186/s12966-018-0747-4
Majeed-Ariss, R., Baildam, E., Campbell, M., Chieng, A., Fallon, D., Hall, A., McDonagh, J. E.,
Stones, S. R., Thomson, W., & Swallow, V. (2015). Apps and adolescents: A systematic
review of adolescents’ use of mobile phone and tablet apps that support personal
management of their chronic or long-term physical conditions. Journal of Medical
Internet Research, 17(12), e287. https://doi.org/10.2196/jmir.5043
Makris, A., & Foster, G. D. (2011). Dietary approaches to the treatment of obesity. Psychiatric
Clinics of North America, 34(4), 813-827. https://doi.org/10.1016/j.psc.2011.08.004
Martin, F. J., Rezzi, S., Peré-Trepat, E., Kamlage, B., Collino, S., Leibold, E., Kastler, J., Rein,
D., Fay, L. B., & Kochhar, S. (2009). Metabolic effects of dark chocolate consumption
on energy, gut microbiota, and stress-related metabolism in free-living subjects. Journal
of Proteome Research, 8(12), 5568-5579. https://doi.org/10.1021/pr900607v
McIntosh, W. A., Kubena, K. S., Tolle, G., Dean, W. R., Jan, J., & Anding, J. (2010). Mothers
and meals. The effects of mothers’ meal planning and shopping motivations on children's
participation in family meals. Appetite, 55(3), 623-628.
https://doi.org/10.1016/j.appet.2010.09.016
99
McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on
health promotion programs. Health Education Quarterly, 15(4), 351-377.
https://doi.org/10.1177/109019818801500401
McMullin, J. M., Taumoepeau, L., Talakai, M., Kivalu, F., & Hubbell, F. A. (2008). Tongan
perceptions of cancer. Cancer Detection and Prevention, 32(1), 29-36.
https://doi.org/10.1016/j.cdp.2007.12.004
Menigoz, K., Nathan, A., & Turrell, G. (2016). Ethnic differences in overweight and obesity and
the influence of acculturation on immigrant bodyweight: Evidence from a national
sample of Australian adults. BioMed Central Public Health, 16(1), 1–13.
Merriam, S. B. (1998). Qualitative research and case study applications in education. Jossey-
Bass.
Michael, J., Cliff, W., McFarland, J., Modell, H., & Wright, A. (2017). What does it mean to
“unpack” a core concept? In The Core Concepts of Physiology: A New Paradigm for
Teaching Physiology (pp. 37–44). Springer.
Milliken, F. J., & Morrison, E. W. (2003). Shades of silence: Emerging themes and future
directions for research on silence in organizations. Journal of Management
Studies, 40(6), 1563-1568.
Mills, S., White, M., Brown, H., Wrieden, W., Kwasnicka, D., Halligan, J., Robalino, S., &
Adams, J. (2017). Health and social determinants and outcomes of home cooking: A
systematic review of observational studies. Appetite, 111, 116-134.
https://doi.org/10.1016/j.appet.2016.12.022
Millstein, S. G., Petersen, A. C., & Nightingale, E. O. (Eds.). (1993). Promoting the health of
adolescents: New directions for the twenty-first century. Oxford University Press.
100
Mishler, E. G. (1991). Research interviewing. Harvard University Press.
Mitchell, N. S., Catenacci, V. A., Wyatt, H. R., & Hill, J. O. (2011). Obesity: Overview of an
epidemic. The Psychiatric Clinics of North America, 34(4), 717–732.
https://doi.org/10.1016/j.psc.2011.08.005
Morales, M. E., & Berkowitz, S. A. (2016). The relationship between food insecurity, dietary
patterns, and obesity. Current Nutrition Reports, 5(1), 54-
60. https://doi.org/10.1007/s13668-016-0153-y
Morisako, A. K., Tauali'i, M., Ambrose, A. J. H., & Withy, K. (2017). Beyond the ability to pay:
The health status of Native Hawaiians and other Pacific Islanders in relationship to health
insurance. Hawai'i Journal of Medicine & Public Health, 76(3), 36.
Morisky, D. E., DeMuth, N. M., Field-Fass, M., Green, L. W., & Levine, D. M. (1985).
Evaluation of family health education to build social support for long-term control of
high blood pressure. Health Education Quarterly, 12(1), 35-50.
doi:10.1177/109019818501200104
Morland, K., Wing, S., Diez Roux, A., & Poole, C. (2002). Neighborhood characteristics
associated with the location of food stores and food service places. American Journal of
Preventive Medicine, 22(1), 23-29. doi:10.1016/s0749-3797(01)00403-2
Morris, P. (2014). Polynesians and Mormonism: The Church of Jesus Christ of latter-day saints
in the “islands of the sea”. Nova Religion: The Journal of Alternative and Emergent
Religions, 18(4), 83-101.
Morton, H. (1998). Creating their own culture: Diasporic Tongans. The Contemporary Pacific,
1-30.
Moss, M. (2013). The extraordinary science of addictive junk food. New York.
101
Moy, K. L., Sallis, J. F., Trinidad, D. R., Ice, C. L., & McEligot, A. J. (2012). Health behaviors
of Native Hawaiian and Pacific Islander adults in California. Asia Pacific Journal of
Public Health, 24(6), 961-969. doi:10.1177/1010539511408068
Miura, M., Hirose, M., Miwa, T., Kuwae, S., & Ohi, H. (2004). Cloning and characterization
in pichia pastoris of PNO1 gene required for phosphomannosylation of N-linked
oligosaccharides. Gene, 324, 129-137. https://doi.org/10.1016/j.gene.2003.09.023
Myles, I. A. (2014). Fast food fever: Reviewing the impacts of the Western diet on immunity.
Nutrition Journal, 13(1), 61. https://doi.org/10.1186/1475-2891-13-61
Nagata, J. M., Fiorella, K. J., Salmen, C. R., Hickey, M. D., Mattah, B., Magerenge, R., Milner,
E. M., Weiser, S. D., Bukusi, E. A., & Cohen, C. R. (2015). Around the table: Food
insecurity, socioeconomic status, and instrumental social support among women living in
a rural Kenyan island community. Ecology of Food and Nutrition, 54(4), 358-369.
https://doi.org/10.1080/03670244.2014.995790
Nam, S., Chesla, C., Stotts, N. A., Kroon, L., & Janson, S. L. (2011). Barriers to diabetes
management: Patient and provider factors. Diabetes Research and Clinical
Practice, 93(1), 1–9.
Nanri, A., Mizoue, T., Noda, M., Takahashi, Y., Kato, M., Inoue, M., & Tsugane, S. (2010).
Rice intake and type 2 diabetes in Japanese men and women: The Japan public health
center-based prospective study. American Journal of Clinical Nutrition, 92(6), 1468-
1477. https://doi.org/10.3945/ajcn.2010.29512
Nelson, K. M., Reiber, G., & Boyko, E. J. (2002). Diet and exercise among adults with type 2
diabetes: Findings from the third National Health and Nutrition Examination Survey
(NHANES III). Diabetes Care, 25(10), 1722–1728.
102
Nevanperä, N. J., Hopsu, L., Kuosma, E., Ukkola, O., Uitti, J., & Laitinen, J. H. (2012).
Occupational burnout, eating behavior, and weight among working women. The
American Journal of Clinical Nutrition, 95(4), 934-943.
Newman, L., & Elton, S. (2016). Speaking in cod tongues: A Canadian culinary journey.
University of Regina Press.
Norman, Å., Berlin, A., Sundblom, E., Elinder, L. S., & Nyberg, G. (2015). Stuck in a vicious
circle of stress: Parental concerns and barriers to changing children's dietary and physical
activity habits. Appetite, 87, 137–142. https://doi.org/10.1016/j.appet.2014.12.208
Novak, N. L., & Brownell, K. D. (2012). Role of policy and government in the obesity epidemic.
Circulation, 126(19), 2345–2352. https://doi.org/10.1161/circulationaha.111.037929
Oates, D. J., & Paasche-Orlow, M. K. (2009). Health literacy: Communication strategies to
improve patient comprehension of cardiovascular health. Circulation, 119(7), 1049–
1051.
Office of Management and Budget. (1997). Revisions to the standards for the classification of
federal data on race and ethnicity. Federal Register, 62(210), 58782-58790.
Olsho, L. E., Klerman, J. A., Wilde, P. E., & Bartlett, S. (2016). Financial incentives increase
fruit and vegetable intake among supplemental nutrition assistance program participants:
A randomized controlled trial of the USDA healthy incentives pilot. The American
Journal of Clinical Nutrition, 104(2), 423–435.
O'Neill, S., & O'Driscoll, L. (2015). Metabolic syndrome: A closer look at the growing epidemic
and its associated pathologies. Obesity Reviews, 16(1), 1–12.
103
Padilla, A. M., Wagatsuma, Y., & Lindholm, K. J. (1985). Acculturation and personality as
predictors of stress in Japanese and Japanese-Americans. The Journal of Social
Psychology, 125(3), 295–305.
Panagiotakos, D. B., Pitsavos, C., & Stefanadis, C. (2006). Dietary patterns: A Mediterranean
diet score and its relation to clinical and biological markers of cardiovascular disease risk.
Nutrition, Metabolism and Cardiovascular Diseases, 16(8), 559–568.
Panapasa, S., Jackson, J., Caldwell, C., Heeringa, S., McNally, J., Williams, D., Coral, D.,
Taumoepeau, L., Young, L., Young, S., & Fa’asisila, S. (2012). Community-based
participatory research approach to evidence-based research: Lessons from the Pacific
Islander American health study. Progress in Community Health Partnerships: Research,
Education, and Action, 6(1), 53-58. https://doi.org/10.1353/cpr.2012.0013
Pandit, N. R. (1996). The creation of theory: A recent application of the grounded theory
method. The Qualitative Report, 2(4), 1–14.
Paquette, M. C. (2005). Perceptions of healthy eating: State of knowledge and research gaps.
Canadian Journal of Public Health, 96(3), 15–19.
Pearson, N., Griffiths, P., Biddle, S. J., Johnston, J. P., & Haycraft, E. (2017). Individual,
behavioural and home environmental factors associated with eating behaviours in young
adolescents. Appetite, 112, 35–43.
Peerson, A., & Saunders, M. (2009). Health literacy revisited: What do we mean and why does it
matter? Health Promotion International, 24(3), 285-296.
https://doi.org/10.1093/heapro/dap014
Pechey, R., Jebb, S. A., Kelly, M. P., Almiron-Roig, E., Conde, S., Nakamura, R., Shemilt, I.,
Suhrcke, M., & Marteau, T. M. (2013). Socioeconomic differences in purchases of more
104
vs. less healthy foods and beverages: Analysis of over 25,000 British households in
2010. Social Science & Medicine, 92, 22-26.
https://doi.org/10.1016/j.socscimed.2013.05.012
Peñalvo, J. L., Cudhea, F., Micha, R., Rehm, C. D., Afshin, A., Whitsel, L., Wilde, P., Gaziano,
T., Pearson-Stuttard, J., O’Flaherty, M., Capewell, S., & Mozaffarian, D. (2017). The
potential impact of food taxes and subsidies on cardiovascular disease and diabetes
burden and disparities in the United States. BioMed Central, 15(1), .
https://doi.org/10.1186/s12916-017-0971-9
Perignon, M., Vieux, F., Soler, L. G., Masset, G., & Darmon, N. (2017). Improving diet
sustainability through evolution of food choices: Review of epidemiological studies on
the environmental impact of diets. Nutrition Reviews, 75(1), 2-17.
Perreira, K. M., & Ornelas, I. (2013). Painful passages: Traumatic experiences and post-
traumatic stress among U.S. immigrant Latino adolescents and their primary
caregivers. International Migration Review, 47(4), 976-1005.
Plant, J., & Stephenson, J. (2009). Beating stress, anxiety & depression: Groundbreaking ways
to help you feel better. United Kingdom: Piatkus.
Pomeranz, J. L., Wilde, P., Huang, Y., Micha, R., & Mozaffarian, D. (2018). Legal and
administrative feasibility of a federal junk food and sugar-sweetened beverage tax to
improve diet. American Journal of Public Health, 108(2), 203–209.
Pondor, I., Gan, W. Y., & Appannah, G. (2017). Higher dietary cost is associated with higher
diet quality: A cross-sectional study among selected Malaysian adults. Nutrients, 9(9),
1028.
105
Popovic-Lipovac, A., & Strasser, B. (2015). A review on changes in food habits among
immigrant women and implications for health. Journal of Immigrant and Minority
Health, 17(2), 582–590.
Pottie, K., Dahal, G., Georgiades, K., Premji, K., & Hassan, G. (2015). Do first generation
immigrant adolescents face higher rates of bullying, violence and suicidal behaviours
than do third generation and native born? Journal of Immigrant and Minority
Health, 17(5), 1557-1566.
Powell, L. M., Auld, M. C., Chaloupka, F. J., O’Malley, P. M., & Johnston, L. D. (2006). Access
to fast food and food prices: Relationship with fruit and vegetable consumption and
overweight among adolescents. Advances in Health Economics and Health Services
Research, 17, 23–48.
Putnam, J. J., & Allshouse, J. E. (1999). Food consumption, prices, and expenditures, 1970–97.
U.S. Department of Agriculture, Economic Research Service (Statistical Bulletin no. SB-
965). https://www.ers.usda.gov/publications/pub-details/?pubid=47115
Randall, J. E., Williams, J. T., Smith, D. G., Kulbicki, M., Tham, G., Mou, T. G. M., Labrosse,
P., Kronen, M., Clua, E., & Mann, B. S. (2004). Checklist of the shore and epipelagic
fishes of Tonga. Atoll Research Bulletin, (502), 1-35.
https://doi.org/10.5479/si.00775630.502.1
Rao, M., Afshin, A., Singh, G., & Mozaffarian, D. (2013). Do healthier foods and diet patterns
cost more than less healthy options? A systematic review and meta-analysis. British
Medical Journal Open, 3(12), 1–16.
Reicks, M., Banna, J., Cluskey, M., Gunther, C., Hongu, N., Richards, R., Topham, G., &
Wong, S. (2015). Influence of parenting practices on eating behaviors of early
106
adolescents during independent eating occasions: Implications for obesity prevention.
Nutrients, 7(10), 8783-8801. https://doi.org/10.3390/nu7105431
Reisch, M., & Jani, J. S. (2012). The new politics of social work practice: Understanding context
to promote change. The British Journal of Social Work, 42(6), 1132-1150.
Ren, X. S., Amick, B. C., & Williams, D. R. (1999). Racial/ethnic disparities in health: The
interplay between discrimination and socioeconomic status. Ethnicity & Disease, 9(2),
151–165.
Roberts, C. K., & Barnard, R. J. (2005). Effects of exercise and diet on chronic disease. Journal
of Applied Physiology. 98(1), 3-30.
Rodriguez-Casado, A. (2016). The health potential of fruits and vegetables phytochemicals:
Notable examples. Critical Reviews in Food Science and Nutrition, 56(7), 1097-1107.
Rose, K. (1994). Unstructured and semi-structured interviewing. Nurse Researcher, 1(3), 23-32.
Rosenthal, M. (2016). Qualitative research methods: Why, when, and how to conduct interviews
and focus groups in pharmacy research. Currents in Pharmacy Teaching and
Learning, 8(4), 509-516.
Rothman, R. L., Housam, R., Weiss, H., Davis, D., Gregory, R., Gebretsadik, T., Shintani, A., &
Elasy, T. A. (2006). Patient understanding of food labels. American Journal of Preventive
Medicine, 31(5), 391-398. https://doi.org/10.1016/j.amepre.2006.07.025
Rubalcava, L. N., Teruel, G. M., Thomas, D., & Goldman, N. (2008). The healthy migrant
effect: New findings from the Mexican family life survey. American Journal of Public
Health, 98(1), 78-84. doi:10.2105/ajph.2006.098418
Sallis, J. F., & Glanz, K. (2006). The role of built environments in physical activity, eating, and
obesity in childhood. The Future of Children, 16(1), 89-108. doi:10.1353/foc.2006.0009
107
Sallis, J. F., Floyd, M. F., Rodríguez, D. A., & Saelens, B. E. (2012). Role of built environments
in physical activity, obesity, and cardiovascular disease. Circulation, 125(5), 729-737.
doi:10.1161/circulationaha.110.969022
Sallis, J. F., Owen, N., & Fisher, E. (2015). Ecological models of health behavior. Health
Behavior: Theory, Research, and Practice, 5, 43–64.
Santiago-Torres, M., Adams, A. K., Carrel, A. L., LaRowe, T. L., & Schoeller, D. A. (2014).
Home food availability, parental dietary intake, and familial eating habits influence the
diet quality of urban Hispanic children. Childhood Obesity, 10(5), 408–415.
https://dx.doi.org/10.1089%2Fchi.2014.0051
Santoro, N. (2014). Using a multiple perspectives framework: A methodological approach to
analyse complex and contradictory interview data. Ethnography and Education, 9(2),
127–139.
Satia, J. A., Galanko, J. A., & Neuhouser, M. L. (2005). Food nutrition label use is associated
with demographic, behavioral, and psychosocial factors and dietary intake among African
Americans in North Carolina. Journal of the American Dietetic Association, 105(3), 392–
402.
Satterfield, D. (2016). Health promotion and diabetes prevention in American Indian and Alaska
Native communities—Traditional foods project, 2008–2014. Morbidity and Mortality
Weekly Report Supplements, 65(1), 4–10.
Savage, J. S., Fisher, J. O., & Birch, L. L. (2007). Parental influence on eating behavior:
Conception to adolescence. The Journal of Law, Medicine & Ethics, 35(1), 22–34.
Schmidt, S. (2007). Dietary intake patterns of Tongan Americans in Utah [Unpublished doctoral
dissertation]. University of Utah Press.
108
Schulze, M. B., Martínez-González, M. A., Fung, T. T., Lichtenstein, A. H., & Forouhi, N. G.
(2018). Food based dietary patterns and chronic disease prevention. British Medical
Journal, 361, k2396.
Scott, K. A., Melhorn, S. J., & Sakai, R. R. (2012). Effects of chronic social stress on obesity.
Current Obesity Reports, 1(1), 16–25. https://doi.org/10.1007/s13679-011-0006-3
Scott, M. L., & Vallen, B. (2019). Expanding the lens of food well-being: An examination of
contemporary marketing, policy, and practice with an eye on the future. Journal of
Public Policy & Marketing, 38(2), 127.
Seidman, I. (1991). Interviewing as qualitative research: A guide for researchers in education
and the social sciences. Teachers College Press.
Serdula, M. K., Gillespie, C., Kettel-Khan, L., Farris, R., Seymour, J., & Denny, C. (2004).
Trends in fruit and vegetable consumption among adults in the United States: Behavioral
risk factor surveillance system, 1994–2000. American Journal of Public Health, 94(6),
1014-1018. doi:10.2105/ajph.94.6.1014
Shaghaghi, A., Bhopal, R. S., & Sheikh, A. (2011). Approaches to recruiting ‘hard-to-reach’
populations into research: A review of the literature. Health Promotion
Perspectives, 1(2), 86.
Shepherd, J., Harden, A., Rees, R., Brunton, G., Garcia, J., Oliver, S., & Oakley, A. (2005).
Young people and healthy eating: A systematic review of research on barriers and
facilitators. Health Education Research, 21(2), 239–257.
https://doi.org/10.1093/her/cyh060
109
Shumway, E. B. (1988). Intensive course in Tongan: With numerous supplementary materials,
grammatical notes, and glossary. Institute for Polynesian Studies, Brigham Young
University-Hawaii.
Shier, V., Nicosia, N., & Datar, A. (2016). Neighborhood and home food environment and
children's diet and obesity: Evidence from military personnel's installation
assignment. Social Science & Medicine, 158, 122-131.
https://doi.org/10.1016/j.socscimed.2016.03.043
Silvis, N. (1992). Nutritional recommendations for individuals with diabetes mellitus. South
African Medical Journal= Suid-Afrikaanse Tydskrif Vir Geneeskunde, 81(3), 162-166.
Singleton, K., & Krause, E. (2009). Understanding cultural and linguistic barriers to health
literacy. OJIN: The Online Journal of Issues in Nursing, 14(3), 4.
Skerrett, P. J., & Willett, W. C. (2010). Essentials of healthy eating: A guide. Journal of
Midwifery & Women's Health, 55(6), 492–501.
Slattery, M. L. (2004). Physical activity and colorectal cancer. Sports Medicine, 34(4), 239–252.
https://doi.org/10.2165/00007256-200434040-00004
Slavin, J. L., & Lloyd, B. (2012). Health benefits of fruits and vegetables. Advances in
Nutrition, 3(4), 506–516.
Sleddens, E. F., Kroeze, W., Kohl, L. F., Bolten, L. M., Velema, E., Kaspers, P. J., Brug, J., &
Kremers, S. P. (2015). Determinants of dietary behavior among youth: An umbrella
review. International Journal of Behavioral Nutrition and Physical Activity, 12(1).
https://doi.org/10.1186/s12966-015-0164-x
Smith, G. D., & Brunner, E. (1997). Socio-economic differentials in health: The role of nutrition.
Proceedings of the Nutrition Society, 56(1A), 75–90.
110
Smith, K. P., & Christakis, N. A. (2008). Social networks and health. Annual Review of
Sociology, 34, 405–429.
Southwick, S. M., & Charney, D. S. (2018). Resilience: The science of mastering life's greatest
challenges. Cambridge University Press.
Speirs, K. E., Messina, L. A., Munger, A. L., & Grutzmacher, S. K. (2012). Health literacy and
nutrition behaviors among low-income adults. Journal of Health Care for the Poor and
Underserved, 23(3), 1082–1091. https://doi.org/10.1353/hpu.2012.0113
Stafford, S. (2010). Caught between “the rock” and a hard place: The Native Hawaiian and
Pacific Islander struggle for identity in public health. American Journal of Public
Health, 100(5), 784–789.
Stampfer, M. J., Hu, F. B., Manson, J. E., Rimm, E. B., & Willett, W. C. (2000). Primary
prevention of coronary heart disease in women through diet and lifestyle. New England
Journal of Medicine, 343(1), 16–22.
Stephen, A. M., & Sieber, G. M. (1994). Trends in individual fat consumption in the UK 1900–
1985. British Journal of Nutrition, 71(5), 775–788.
Strauss, A. L. (1987). Qualitative analysis for social scientists. Cambridge University Press.
https://doi.org/10.1017/CBO9780511557842
Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for
developing grounded theory. Thousand Oaks, CA: Sage Publications, Inc.
Sturm, R., & Datar, A. (2005). Body mass index in elementary school children, metropolitan
area food prices and food outlet density. Public Health, 119(12), 1059–1068.
111
Subica, A. M., Agarwal, N., Sullivan, J. G., & Link, B. G. (2017). Obesity and associated health
disparities among understudied multiracial, Pacific Islander, and American Indian
adults. Obesity, 25(12), 2128-2136.
Sutherland, L. A., MacKenzie, T., Purvis, L. A., & Dalton, M. (2010). Prevalence of food and
beverage brands in movies: 1996–2005. Pediatrics, 125(3), 468–474.
Tanjasiri, S. P., Takahashi, L., & Sablan-Santos, L. (2015). Financial distress among Pacific
Islanders in Southern California. AAPI Nexus: Policy, Practice and Community, 13(1),
14–24.
Taormina, R. J. (2015). Adult personal resilience: A new theory, new measure, and practical
implications. Psychological Thought, 8(1) 35–46.
Teruya, S. A., & Bazargan-Hejazi, S. (2013). The immigrant and Hispanic paradoxes: A
systematic review of their predictions and effects. Hispanic Journal of Behavioral
Sciences, 35(4), 486–509.
Torres, S. J., & Nowson, C. A. (2007). Relationship between stress, eating behavior, and obesity.
Nutrition, 23(11–12), 887–894.
Tosatti, A. M., Ribeiro, L. W., Machado, R. H. V., Maximino, P., Bozzini, A. B., Ramos, C. D.
C., & Fisberg, M. (2017). Does family mealtime have a protective effect on obesity and
good eating habits in young people? A 2000–2016 review. The Brazilian Journal of
Mother and Child Health (BJMCH), 17(3), 425–434.
Townsend, M. S., Peerson, J., Love, B., Achterberg, C., & Murphy, S. P. (2001). Food insecurity
is positively related to overweight in women. The Journal of Nutrition, 131(6), 1738–
1745.
112
Tracy, S. J. (2019). Qualitative research methods: Collecting evidence, crafting analysis,
communicating impact. John Wiley & Sons.
Tuggle, A. C., Cohen, J. H., & Crews, D. E. (2018). Stress, migration, and allostatic load: A
model based on Mexican migrants in Columbus, Ohio. Journal of Physiological
Anthropology, 37(1), 1-11.
Tui’one, V., Tulua-Tata, A., Hui, B., & Tisnado, D. M. (2010). Development of the Tongan
American health professionals association: Sharing, mentoring and networking for
community health. Californian Journal of Health Promotion, 8, 73.
U.S. Department of Health and Human Services (2009). Code of federal regulations title 45
public welfare department of health and human services part 46: Protection of human
services. Washington, DC: US Department of Health and Human Services. Retrieved
2019 February 12 from
https://www.hhs.gov/ohrp/sites/default/files/ohrp/policy/ohrpregulations.pdf
Vakalahi, H. F. (2011). Tongan grandparents and grandchildren: The impact of grandparenting.
International Social Work, 54(4), 580–598. https://doi.org/10.1177/0020872810382683
Van Duyn, M. A. S., & Pivonka, E. (2000). Overview of the health benefits of fruit and
vegetable consumption for the dietetics professional: Selected literature. Journal of the
American Dietetic Association, 100(12), 1511-1521.
Van Hook, J., & Balistreri, K. S. (2007). Immigrant generation, socioeconomic status, and
economic development of countries of origin: A longitudinal study of body mass index
among children. Social Science & Medicine, 65(5), 976–989.
113
Veatupu, L., Puloka, V., Smith, M., McKerchar, C., & Signal, L. (2019). Me’akai in Tonga:
Exploring the nature and context of the food Tongan children eat in Ha’apai using
wearable cameras. International Journal of Environmental Research and Public
Health, 16(10), 1681.
Volandes, A. E., & Paasche-Orlow, M. K. (2007). Health literacy, health inequality and a just
healthcare system. The American Journal of Bioethics, 7(11), 5–10.
Wadden, T. A., Brownell, K. D., & Foster, G. D. (2002). Obesity: Responding to the global
epidemic. Journal of Consulting and Clinical Psychology, 70(3), 510.
Wallace, R. G., Twomey, L. C., Custaud, M. A., Turner, J. D., Moyna, N., Cummins, P. M., &
Murphy, R. P. (2018). The role of epigenetics in cardiovascular health and ageing: A
focus on physical activity and nutrition. Mechanisms of Ageing and Development, 174,
76-85.
Wang, Y., Wang, L., Xue, H., & Qu, W. (2016). A review of the growth of the fast food industry
in China and its potential impact on obesity. International Journal of Environmental
Research and Public Health, 13(11), 1112.
Wardle, J., Haase, A. M., Steptoe, A., Nillapun, M., Jonwutiwes, K., & Bellisie, F. (2004).
Gender differences in food choice: The contribution of health beliefs and dieting. Annals
of Behavioral Medicine, 27(2), 107–116.
Waters, J. (2015). Snowball sampling: A cautionary tale involving a study of older drug
users. International Journal of Social Research Methodology, 18(4), 367–380.
Webb, H. J., Zimmer‐Gembeck, M. J., Scuffham, P. A., Scott, R., & Barber, B. (2018). Family
stress predicts poorer dietary quality in children: Examining the role of the parent–child
relationship. Infant and Child Development, 27(4), e2088.
114
Weerasekara, P. C., Withanachchi, C. R., Ginigaddara, G., & Ploeger, A. (2018). Nutrition
transition and traditional food cultural changes in Sri Lanka during colonization and post-
colonization. Foods, 7(7), 111. https://doi.org/10.3390/foods7070111
Whelan, J., Millar, L., Bell, C., Russell, C., Grainger, F., Allender, S., & Love, P. (2018). You
can’t find healthy food in the bush: Poor accessibility, availability and adequacy of food
in rural Australia. International Journal of Environmental Research and Public
Health, 15(10), 2316.
Wild, S., Roglic, G., Green, A., Sicree, R., & King, H. (2004). Global prevalence of diabetes:
Estimates for the year 2000 and projections for 2030. Diabetes Care, 27(5), 1047–1053.
https://doi.org/10.2337/diacare.27.5.1047
Williams, M., & Moser, T. (2019). The art of coding and thematic exploration in qualitative
research. International Management Review, 15(1), 45–55.
Wing, R. R., Goldstein, M. G., Acton, K. J., Birch, L. L., Jakicic, J. M., Sallis, J. F., Smith-West,
D., Jeffery, R. W., & Surwit, R. S. (2001). Behavioral science research in diabetes:
Lifestyle changes related to obesity, eating behavior, and physical activity. Diabetes
Care, 24(1), 117-123. https://doi.org/10.2337/diacare.24.1.117
World Health Organization (WHO) Regional Office for the Western Pacific. (2000). Obesity:
Preventing and Managing the Global Epidemic.
https://www.who.int/nutrition/publications/obesity/9290610441/en/
World Health Organization (WHO) Regional Office for the Western Pacific. (2003). Diet, food
supply and obesity in the Pacific.
http://iris.wpro.who.int/bitstream/handle/10665.1/5387/9290610441_eng
115
Yannakoulia, M. (2006). Eating behavior among type 2 diabetic patients: A poorly recognized
aspect in a poorly controlled disease. The Review of Diabetic Studies, 3(1), 11.
Young, L. R., & Nestle, M. (2002). The contribution of expanding portion sizes to the US
obesity epidemic. American Journal of Public Health, 92(2), 246–249.
Yu, E., Rimm, E., Qi, L., Rexrode, K., Albert, C. M., Sun, Q., Willett, W. C., Hu, F. B., &
Manson, J. E. (2016). Diet, lifestyle, biomarkers, genetic factors, and risk of
cardiovascular disease in the nurses’ health studies. American Journal of Public
Health, 106(9), 1616-1623. https://doi.org/10.2105/ajph.2016.303316
Zanchetta, M. S., & Poureslami, I. M. (2006). Health literacy within the reality of immigrants'
culture and language. Canadian Journal of Public Health/Revue Canadienne de Sante'e
Publique, 97, S26–S30.
Zimmerman, F. J., & Bell, J. F. (2010). Associations of television content type and obesity in
children. American Journal of Public Health, 100(2), 334–340.
Zimmerman, F. J., & Shimoga, S. V. (2014). The effects of food advertising and cognitive load
on food choices. Bio Med Central Public Health, 14(1), 1–10.
https://doi.org/10.1186/1471-2458-14-342
Appendices
Appendix A
Informed Consent to Participate in a Research Project
Title of Study: Exploring the Barriers and Facilitators to Adopting Healthy Dietary Behaviors among Tongan-American Adults
Aloha! My name is Victor Kaufusi and you are invited to take part in a research study. I am a graduate student at the University of Hawai'i at Mānoa in the Myron B. Thompson School of
116
Social Work. As part of the requirements for earning my graduate degree, I am doing a research project.
What am I being asked to do? If you participate in this project, I will meet with you for an interview at a location and time convenient for you.
Taking part in this study is your choice. Your participation in this project is completely voluntary. You may stop participating at any time. If you stop being in the study, there will be no penalty or loss to you. Your choice to participate or not participate will have no repercussions in any way.
Why is this study being done? The purpose of my project is to explore the barriers to adopting healthy dietary behaviors among Tongan-American Adults. The findings will help to reduce the disproportionate rates of chronic diseases among Tongan-Americans by informing future culturally tailored health prevention and promotion efforts that are grounded in a Tongan-American worldview.
What will happen if I decide to take part in this study? The interview will include semi-structured questions. The interview questions will include questions like, “Can you share with me your eating experiences?” There will be two prompts to provide context of the interview, with a total of 10 qualitative open-ended questions interview questions, with five sub questions. There will interviews will be held one-time, each interview will go for about one to two hours in length, using a semi-structured interview guide. The interviews will be tape recorded and transcribed, with the consent of the participant, for accuracy purposes. The procedures will include data collection with the first two participants, then data analysis, followed by data collection with participants three and four, then data analysis. This process will continue until redundancy.
Only you and I will be present during the interview. With your permission, I will audio-record the interview so that I can later transcribe the interview and analyze the responses. You will be one of about 12 people I will interview for this study.
What are the risks and benefits of taking part in this study? I believe there is little risk to you for participating in this research project. You may become stressed or uncomfortable answering any of the interview questions or discussing topics with me during the interview. If you do become stressed or uncomfortable, you can skip the question or take a break. You can also stop the interview or you can withdraw from the project altogether.
There will be no direct benefit to you for participating in this interview. The results of this project may help reduce the disproportionate rates of obesity and chronic diseases among the Tongan-American population by informing future culturally tailored intervention/prevention programs.
117
Privacy and Confidentiality: I will keep all study data secure in a locked filing cabinet in a locked office/encrypted on a password protected computer. Only my University of Hawai'i advisor and I will have access to the information. Other agencies that have legal permission have the right to review research records. The University of Hawai'i Human Studies Program has the right to review research records for this study.
After I write a copy of the interviews, I will erase or destroy the audio-recordings. When I report the results of my research project, I will not use your name. I will not use any other personal identifying information that can identify you. I will use pseudonyms (fake names) and report my findings in a way that protects your privacy and confidentiality to the extent allowed by law.
Compensation: There will be no compensation for this research study.
Future Research Studies: Identifiers will be removed from your identifiable private information.
Questions: If you have any questions about this study, please email me at [[email protected]]. You may also contact my advisor, Dr. Seunghye Hong, via e-mail at [[email protected]]. You may contact the UH Human Studies Program at 808.956.5007 or [email protected]. to discuss problems, concerns and questions; obtain information; or offer input with an informed individual who is unaffiliated with the specific research protocol. Please visit http://go.hawaii.edu/jRd for more information on your rights as a research participant.
If you agree to participate in this project, please sign and date this signature page and return it to: Victor Kaufusi [[email protected]]
Keep a copy of the informed consent for your records and reference.
Signature(s) for Consent:
I give permission to join the research project entitled, “Exploring the Barriers to Adopting Healthy Dietary Behaviors among Tongan-American Adults.” Please initial next to either “Yes” or “No” to the following: (note to researcher - include these options only as appropriate to the study design described on page 1) _____ Yes _____ No I consent to be audio-recorded for the interview portion of this research.
Name of Participant (Print): ______
118
Participant’s Signature: ______
Signature of the Person Obtaining Consent: ______
Date: ______Mahalo!
Appendix B
Recruitment Flyer Research Participants Needed Are you a Tongan-American adult living in Hawai'i or Utah with first- generation Tongan parents? The Tongan Health Study
119
Would like to learn more about the Tongan-American dietary behaviors. Interview Structuring There are 2 parts to this interview. 1. The first part will take 2. The second part will focus on approximately 1-5 minutes and your experience with your consists of a short survey to gather dietary behaviors. In total, information about the interview will probably take 1 to 1 your age, gender, height, and weight. ½ hours.
● A Doctoral student of Tongan descent at the University of Hawai'i at Manoa is conducting this study. ● The Committee on Human Studies at the University of Hawai'i at Manoa is looking into approving the study.
If you’d like to participate in the study, please email at [email protected]
Appendix C
Demographic Survey
Please answer the questions below. You may skip any questions you don’t feel comfortable answering. Thank you again for your participation! Malo’
1. Age: _____ 2. State of residence: ______
120
4. Where were you born? ______
3. Sex: ☐ Male ☐ Female
4. Your household income per year (annual): ☐ less than $19,999 ☐ $19,000 - $39,999 ☐ $40,000 - $59,999 ☐ $60,000 - $79,999 ☐ $80,000 - $99,999 ☐ more than $100,000 ☐ not sure
5. What is your Height? ______
6. What is your Weight? ______
7. What is your Marital Status? 8. ☐ Single ☐ Married ☐ Other
Appendix D
Interview Questions Before the interview begins, the PI will provide the participant with informed consent form and review the consent with the participant. After the participant signs the informed consent and is provided with a copy, the PI will utilize the following interview questions. Participants will be encouraged to speak freely in their language of choice. Probes in this guide will only be utilized as necessary.
1. Please tell me what it was like growing up in the US as a Tongan. 2. What is it like for you to live as a Tongan-American in the United States?
121
3. How similar or different is your current lifestyle to the way that you grew up as a Tongan American? 4. What is the most difficult part about being a Tongan-American in the U.S.? 5. What do you know about the diet of your early ancestors from Tonga? 6. If you were living in Tonga with around the time of your early ancestors, what do you think your diet look like? 7. What do you know about the preparation of traditional Tongan food? 8. How would you compare the traditional way of preparing food to your experiences with making food at home? (difficult, easy) 9. In your opinion, what’s the difference between the traditional Tongan diet and your current diet? 10. Would you consider the traditional Tongan diet to be healthy? Why or why not? 11. Which diet do you prefer? American or Tongan? Why? (this is where you facilitate detail in their story)
After the interview, the researcher will answer any questions the participant may have regarding the interview process or dissemination of results of the study. Participant will be thanked for their time and for their willingness to share their story.
Appendix E
Open Coding Summary: Emerging Codes
1. Immigration 12. Lack of Food Portion Control 2. No knowledge of a balanced meal 13. Lack of Planning 3. Convenient to eat out at fast foods 14. Lack of Time [family schedules, 4. The expensive cost of healthy foods work] 5. Low education 15. Stress from work 6. Skipping Meals 16. Peer Influence 7. Finances 17. Proximity to Healthy Foods 8. Home Environment 18. Refusing Health Advice from 9. Knowledge of a healthy diet 19. Self-Image 10. Lack of Connection to Culture 20. Food Availability 11. Lack of Endurance 21. Stereotyping
122
22. Stress 41. Food Proportions 23. Media 42. Fulfilling cultural obligations 24. The cheap costs of unhealthy foods 43. Goal Driven 25. Failing to adhere to cultural norms 44. Hard Workers 26. Food insecurity 45. Health Benefits 27. Both spouses at work 46. Resilience 28. Scheduling 47. Proper Planning 29. Self-image 48. Building and maintaining 30. Family Difficulties relationships 31. Food advertisements on television 49. Self-Motivation 32. Internet 50. Social Eating 33. Western culture 51. Tongan Cultural Diet 34. Social Media 52. Supportive Spouse 35. Educating about healthy food 53. Supportive Community and Friends Choices 54. Cultural meaning of food 36. Eating a balanced Diet 55. Cooking together as a family 37. Desire to be Healthy 56. Maintaining traditional family roles 38. Education 57. Conducting research on healthy 39. Family Support foods 40. Financial Resources 58. Making healthy food choice
Appendix F
Axial Coding Summary: Major Categories and Subcategories Open Coding: Axial Coding: Axial Coding: % of Participants Emerging Codes Subcategories: with experiences Major Category Cost of Healthy Food Barriers Subcategory 1: 12 out of 12 =100% Failure to adhere to Environment (Home and
123 124
Cultural Norms Community) Home Environment Proximity to Healthy Foods Skipping Meals Peer Influence Food Availability Food insecurity
Finances Barriers Subcategory 2: Convenience 12 out of 12 = 100% Convenient to eat fast foods Working Family Schedules
Lack of Planning Barriers Subcategory 3: Time 12 out of 12 = 100% Lack of Time due to other Management obligations [family] Spouses Working Lack of Connection to Barriers Subcategory 4: Stress 12 out of 12 = 100% Culture Understanding Western Culture Language Barrier Stereotyping Providing for Family Stress from Work Self-Image Family difficulties
No knowledge of a Barriers Subcategory 5: Health 8 out of 12 = 67% Balanced Meal Literacy Education Lack of Knowledge and Understanding of healthy dietary behaviors Lack of Food Portion Control Refusing Health Advice from Professionals
Media Barriers Subcategory 6: Media 8 out of 12 = 67%
124 125
Television Ads Social Media Internet
Table 4: Axial Coding: Facilitators Axial Coding: Axial Coding: # of Participants with Open Coding: Subcategories experiences Emerging Codes Major Category Supportive spouse Facilitators Subcategory 1: Social 12 out of 12= 100% Supportive Community and Support friends Supportive family Members Social eating Building and maintaining Relationships Fulfilling cultural obligations Maintaining traditional family roles Cultural meaning of food Proper planning Facilitators Subcategory 2: Family 10 out of 12 = 83% Food proportions Meals [awareness] Knowledge of and eating a balanced diet Cooking together as a family
Eating the Tongan cultural Facilitators Subcategory 3: Meal 10 out of 12 = 83% Diet Planning Financial Resources Doing research prior to shopping Educating self about healthy foods Avoiding Idleness Making healthy food choices
125 126
Health Benefits Facilitators Subcategory 4: Health 10 out of 12 = 83% Goal Driven Benefits Desire to be Healthy (self and family) Feeling the benefits of eating healthy Education Self-Motivation Facilitators Subcategory 5: Resiliency 8 out of 12 = 67% Resilience Hard Workers
Appendix G
Ethical Practices The rights, needs, values, and desires of the participants will always precede the purposes of the study. To guarantee the safety and well-being of the participants and the protection of their human rights, this study will follow the Protection of Human Subjects Code of Federal
Regulations Title 45 (U.S. Department of Health and Human Services, 2009) to assure that the following safeguards will be used to protect each participant’s rights: (1) participants will be
126 127 advised in writing of the voluntary nature of their participation and that they could withdraw from the study at any time without penalty; (2) the participants will be advised that at any time during the process they could decline to answer any question; 3) a written transcription and interpretations of the data will be made available to the participants; 4) the participant’s rights, interests, and wishes will be considered first when choices are made regarding reporting the data; and 5) the final decision regarding participant’s privacy will rest with the participant.
127