PHYSICAL ACTIVITY AND THE BUILT ENVIRONMENT AMONG ADULTS ON OʻAHU A DISSERTATION TO THE GRADUATE DIVISION OF THE UNIVERSITY OF HAWAIʻI AT MĀNOA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN PUBLIC HEALTH MAY 2018 By Siosaia F. Hafoka Dissertation committee: Sara J. Carr, Chairperson Cheryl Albright Jinan Banna Lehua Choy Yan Yan Wu Keywords: Native Hawaiian and other Pacific Islanders, physical activity, active living, Photovoice ACKNOWLEDGEMENTS……………………………………………………………………….ii ABSTRACT……………………………………………………………………………………...iii LIST OF TABLES………………………………………………………………………………..vi LIST OF FIGURES………………………………………………………….....................……...vi CHAPTER 1: INTRODUCTION…………………………………………………………………1 The Built Environment…………………………………………………………………....3 Social Ecological Model…………………………………………………………………..6 Research Question 1……………………………………………………………………..10 Research Question 2……………………………………………………………………..11 Research Question 3……………………………………………………………………..12 CHAPTER 2: PHYSICAL ACTIVITY STATUS OF NATIVE HAWAIIANS AND OTHER PACIFIC ISLANDERS AND THEIR PERCEPTIONS OF THE ENVIRONMENT.................................................................................................15 Physical Activity Among NHPI………………………………………………………….16 Participant Demographics………………………………………………………………..19 Survey Tool………………………………………………………………………………25 Results……………………………………………………………………………………28 Discussion………………………………………………………………………………..41 Conclusion……………………………………………………………………………….44 CHAPTER 3: AN ASSESSMENT OF THE BUILT ENVIRONMENT……………………….47 Purpose of Study….……………………………………………………………………...47 Procedures………………………………………………………………………………..50 Results……………………………………………………………………………………54 Discussion………………………………………………………………………………..59 Conclusion………….……………………………………………………………………63 CHAPTER 4: COMMUNITY PERCEPTINS OF BARRIERS AND FACILITATORS TO BEING PHYSICALLY ACTIVE..........................................................................68 Research Positionality……..……………………………………………………………..68 Purpose of Study…………………………………………………………………………68 Photovoice Methods……………………………………………………………………...72 Procedures………….…………………………………………………………………….75 Results……………………………………………………………………………………76 Discussion………………………………………………………………………………..99 Conclusion…..………………………………………………………………………….103 CHAPTER 5: CONCLUSION……………………………………………………………........107 Summary of Findings….………………………………………………………………..107 Recommendations….…………………………………………………………………...109 Conclusion…..………………………………………………………………………….110 REFERENCES.....................……………………………………………………………...........111 APPENDIX I: INFORMED CONSENT FORMS APPENDIX II: IPAQ-RALPESS SURVEY Acknowledgements I would like to thank my community members in Kahuku, Laʻie, and Hauʻula for their participation in this research. A special thank you to my committee chair, Professor Sara Carr for her guidance and support. I would also like to thank my committee members, Professor Cheryl Albright, Professor Jinan Banna, Professor Lehua Choy, and Professor Yan Yan Wu for their expertise and mentorship throughout the dissertation process. I would especially like to thank my family – without you this would not have been possible. To my parents and grandparents who left their home country of Tonga to pursue higher education, thank you for allowing me to stand on your shoulders and for providing a foundation on which I could pursue this degree. To my wife Losaline, thank you for being my biggest supporter in this doctoral journey. I couldn’t have achieved this without your support. To Spencer, Finau, ‘Ofa, and Siaosi, thank you for your patience in allowing me to spend weekends and late nights at the library. Malo ‘aupito and ‘ofa lahi atu. Abstract The benefits of physical activity have been well documented. It has shown to decrease risks of non-communicable diseases (NCDs) including diabetes, hypertension, and obesity. Native Hawaiians and other Pacific Islanders (NHPI) are among the populations most affected by non-communicable diseases (NCDs). Population studies have also reported that very few NHPIs meet physical activity recommendations of at least 150 minutes of physical activity per week. This dissertation explored the physical activity status of NHPI in a rural community. By using a social ecological approach, this dissertation aimed to: 1) identify the physical activity status of NHPI and their perceptions of the active living environment, 2) assess physical features and amenities, community programs, and policies that promote physical activity, and 3) have community members identify perceptions of the built environment that influence physical activity behaviors. The study in Chapter Two used the International Physical Activity Questionnaire and the Rural Active Living Perceived Environment Support Scale (RALPESS) to capture physical activity and community perceptions. Chapter Three objectively assessed the environment and examined amenities and facilities by performing an audit on 60 street segments. This study showed that Laʻie had the most sidewalks, crosswalks and bike lanes/path segments. The qualitative study in Chapter Four revealed community-specific barriers and facilitators to being physically active. The data from this dissertation reported that a high proportion of NHPI meet physical activity recommendations and that future research should more closely examine the social environment of NHPI communities. List of Tables Table 1. Native Hawaiian and other Pacific Islander populaiton by state.......................................2 Table 2. Aerobic and Strengthening Activities..............................................................................17 Table 3. Community Demographics..............................................................................................19 Table 4. Participant Demographics................................................................................................19 Table 5. Participant Recruitment at Churches...............................................................................22 Table 6. IPAQ Categorical Scoring...............................................................................................26 Table 7. IPAQ Demographic Variables.........................................................................................28 Table 8. Physical Activity by Domain...........................................................................................30 Table 9. Physical Activity by Sex..................................................................................................31 Table 10. Physical activity by Town..............................................................................................31 Table 11. RALPESS Frequencies..................................................................................................33 Table 12. Agreement by Sex..........................................................................................................36 Table 13. Frequency of Participants who Agree............................................................................37 Table 14. Bivariate Summary Statistics.........................................................................................39 Table 15. Multiple Logistic Regression Models............................................................................41 Table 16. Population Description..................................................................................................49 Table 17. TWA Scores...................................................................................................................53 Table 18. TWA Trails....................................................................................................................54 Table 19. PPA Scores....................................................................................................................55 Table 20. Inter-rater Reliability Scores.........................................................................................56 Table 21. Characteristics of Segments in the SSA........................................................................57 Table 22. Parks and Recreation Program.......................................................................................60 Table 23. Observed Community.. .................................................................................................69 Table 24. Photovoice Participant Demographics...........................................................................70 Table 25. Sample Themes..............................................................................................................77 Table 26. CrossFit Koʻolau Membership Fees..............................................................................93 Table 27. Kahuku Categories.........................................................................................................95 Table 28. Laʻie Categories.............................................................................................................95 Table 29. Hauʻula Categories........................................................................................................95 Table 30. Photographs by Category and Town.............................................................................96 List of Figures Figure 1. Social ecological model...................................................................................................8 Figure 2. Research Question 1 will focus on the Social and Individual Environments of the social ecological model............................................................................................................11