THE PERCEPTION OF PHYSICAL ACTIVITY AND SOCIAL SUPPORT FOR PHYSICAL ACTIVITY AMONG NATIVE HAWAIIANS 55 YEARS AND OLDER A DISSERTATION SUBMITTED TO THE GRADUATE DIVISION OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN NURSING MAY 2012 By Verna L. Hanashiro Dissertation Committee: Clementina Ceria-Ulep, Chairperson Dianne Ishida Alice Tse Colette Browne Mary Oneha Keywords: physical activity, social support, Native Hawaiian COPYRIGHT ii DEDICATION I dedicate this dissertation to the many persons in my life, both seen and unseen, who have inspired me to strive to reach for my full potential and achieve the seemingly impossible. I am thankful for the support of my family who has gone before me, my three children and their spouses, the unending joy of my two wonderful Native Hawaiian grandchildren, who made the need for this study even more imperative to me, and the many friends who supported me in this endeavor throughout the last few years. I am indebted to my mini-church members, who came beside me in prayer to our Lord and Savior, who was always there even during the darkest times. I am especially indebted to my husband, Steve, who has provided me with unending love, patience, and daily support with the activities of our life to enable me to fulfill my dreams. iii ACKNOWLEDGMENTS I would like to acknowledge and express my gratitude to chairperson, Dr. Clementina Ceria-Ulep, and members, Dr. Dianne ishida, Dr. Alice Tse, Dr. Collette Browne, and Dr. Mary Oneha, of my Dissertation Committee for their support, guidance, and willingness to share their knowledge and time with me during this significant transformational journey during the past four years. I would also like to acknowledge the staff of Alu Like Inc. Ke Ola Pono No Na Kupuna Program (KOPP), Elizabeth Meahl, Director of KOPP, Hanakia Tui, Manager, Lisa Moala, Program Specialist, and Kaulana Kaauwai, Program Specialist, who allowed me to become a part of their program and enter the lives of their wonderful kupuna to gain invaluable insights and knowledge about the Native Hawaiian culture so rich in aloha and caring for others. I am also indebted to May Akamine, Executive Director, Waimanalo Health Center, and her staff for their initial formative and ongoing support of this project, and to Mary Oneha, Chief Operations Officer of Waianae Coast Comprehensive Health Center, for her valuable time spent with me sharing her knowledge of her culture and challenging me to reframe my thinking to include a Native Hawaiian perpective. iv ABSTRACT Significance: The benefits of physical activity on healthy aging and longevity have repeatedly been identified. Despite these known benefits, sedentary living is a serious and pervasive health problem among older adults throughout the United States, including the Native Hawaiian older adult population in Hawaii. Previous research has identified social support as a major facilitator for participation in physical activity. Purpose: The purpose of this study was to examine the perception of physical activity and social support for physical activity among Native Hawaiians 55 years of age and older. Method: This qualitative, exploratory study involved an ethnographic approach utilizing two focus groups consisting of a purposive sample of 8 to 9 Native Hawaiian participants, ranging in age from 67 to 89 years, recruited from two separate rural Oahu, Hawaii communities surrounding two health centers that focus on Native Hawaiian health care. The study also included participant observation at a nutritional and recreational program for Native Hawaiians over the age of 60. Key members of the health centers, nutrition and exercise program, and the Native Hawaiian community were involved in planning the study, recruiting participants, and validation of data. Results: The five domains of culture, physical activity, social support, exercise, and purpose in life emerged from the study data.The following four major cultural themes emerged from the data of the domains: 1) It is necessary to maintain health (ola pono) to achieve the main purpose in life of helping (kokua) and caring for (malama) others and continuing to perpetuate the Native Hawaiian culture by practicing and sharing Native Hawaiian cultural values and practices with others. 2) Participation in physical activity is necessary to maintain optimal health and function, and 3) culturally sensitive social v support and 4) an environment or “place” supportive of culturally congruent physical activity is essential to encourage participation in physical activity. Implications: This study can serve as formative research for future studies with the aims of developing culturally congruent Native Hawaiian interventions and programs, and developing or adapting instruments to measure social support as a motivator for participation in physical activity by Native Hawaiian older adults. vi TABLE OF CONTENTS Page cknowledgments……………………………………………………………….. iv bstract………………………………………………………………………….. v ist of ables…………………………………………………………………….. x List of igures……………………………………………………………………. xi Chapter 1: ntroduction…………………………………………………………... 1 Background………………………………………………………………. 1 Definition of Terms………………………………………………………. 2 Physical Activity…………………………………………………… 2 Social Support……………………………………………………… 3 otivators and Barriers for hysical ctivity……………………… 4 Racial-Ethnic Minorities and hysical ctivity…………………… 4 Native Hawaiian…………………………………………………… 5 ative awaiian istory………………………………………………… 5 ative awaiian Cultural rauma…………………………………. 7 ative awaiian Cultural Beliefs and ignificant ealth Beliefs………. 9 Social Support among ative awaiians………………………………... 10 Statement of Problem……………………………………………………. 11 Significance of Study……………………………………………………. 14 Purpose of Study…………………………………………………………. 15 Chapter 2: Literature Review…………………………………………………...... 16 hysiological and sychological erits of hysical ctivity………. 17 Motivators and Barriers to articipation in hysical ctivity……… 18 Social Support as Motivation for Physical Activity………………… 20 Racial- thnic inorities and hysical ctivity……………………. 21 Summary..……………………………………………………………….. 26 Gap in esearch…………………………………………………….. 27 Conclusion……………………………………………………………… 27 Chapter 3: Methodology…………………………………………………………. 29 Research Design ……………………………………………………….. 29 Theoretical Support …………………………………………………….. 29 Ecological Model of Native Hawaiian Well-being…………………. 29 Population/Sample……………………………………………………… 32 Gaining Access to the Population………………………………………. 34 Protection of Human Subjects………………………………………….. 3 5 Data Collection…………………………………………………………. 36 Advisory Committee…………………………………………... 37 Focus Groups…………………………………………………... 37 Participant Observation………………………………………... 39 Data Protection………………………………………………………… 40 Data Analysis………………………………………………………….. 41 Trustworthiness………………………………………………………... 41 Credibility……………………………………………………… 41 Dependability and Confirmability…………………………….. 43 ransferability…………………………………………………. 43 vii Chapter 4: Findings……………………………………………………………….. 44 Field Observations……………………………………………………… 44 Community……………………………………………………... 44 Community ealth Centers…………………………………….. 44 Alu Like Kumu Kahi (Elder Services) Ke Ola Pono No Na Kupuna rogram (K )……………………………………... 45 articipant bservation………………………………………………… 46 Alu ike K aimanalo…………………………………….. 46 nvironment……………………………………………… 46 articipants……………………………………………….. 47 lu ike K aianae……………………………………….. 48 nvironment……………………………………………… 48 articipants……………………………………………….. 49 ocus Groups…………………………………………………………… 50 Description of ocus Group nvironment and articipants……. 50 aianae…………………………………………………... 50 aimanalo……………………………………………….. 51 ember check ocus Group essions…………………………. 52 aianae………………………………………………….. 52 aimanalo……………………………………………….. 53 ocus Group articipant Data…………………………………. 53 aianae…………………………………………………. 53 aimanalo………………………………………………. 53 Comparison of Waimanalo and Waianae Focus Group Participants…………………………………………………… 54 Qualitative Data………………………………………………………… 55 Domain of urpose in ife……………………………………... 56 Domain of Physical Activity…………………………………… 60 Kupunas’ Definitions &Perceptions of Physical ctivity………………………………………………… 60 otivation for hysical ctivity………………….. 64 Relationship of Healthy Diet to Physical Activity... 65 Kupunas’ erceptions of nvironment for ………… 66 aianae…………………………………………… 67 aimanalo………………………………………… 67 Domain of xercise…………………………………………….. 68 Kupunas’ Definitions of xercise…………………….. 68 Kupuna’s erceptions of xercise ctivities…………. 70 Domain of Social Support……………………………………… 71 Kupuna’s Definition of ocial upport………………. 72 Characteristics of ocial upport……………………… 72 ources of ocial upport………………………........... 74 ocial upport Distress…………………………… 76 ocial upport for hysical ctivity………………….. 79 ocial upport for xercise…………………………… 80 Domain of Native Hawaiian Culture…………………………… 81 viii Maintaining and Perpetuating Native Hawaiian Cultural Values and ractices……………………. 81 Cultural spects of ocial upport………………. 87 Cultural ense of lace…………………………… 90 Major Cultural Themes……………………………………………… 91 Conceptual Model…………………………………………………... 93 Chapter 5: Discussion of Findings…………………………………………........... 95 Comparison of Study Findings with Literature………………………. 95 Support for Study Findings from Other Racial-Ethnic Minority Studies………………………………………………………………… 101 mergence of tudy’s Conceptual odel …………………………… 103 Recommendations for Future Research……………………………… 105 Implications for Practice……………………………………………... 106 imitations and trengths of tudy…………………………………... 108 Appendix A. ables……………………………………………………………….. 110 ppendix B. igures………………………………………………………………