Hong Wai Lin. / "July 2004." / Thesis (Ph.D.)--Chinese University of Hong Kong, 2004. / Includes bibliographical references (p. 181-211) / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web. / Abstracts in English and Chinese.

Doctor of Philosophy / This study explores the health beliefs and preventive health behaviours of older Hong Kong Chinese people resident in Australia. Participation in physical activity was used as the case study. There were two frameworks used to shape the research. Because of their perceived influence on the health beliefs and practices of Hong Kong Chinese people, the traditional Chinese philosophies of Confucianism, Taoism, and Buddhism provided the philosophical framework. The Theory of Planned Behaviour provided a theoretical framework for understanding the target group's preventive health behaviour. Data was collected by means of in-depth interviews, participant observation and case study. Twenty-two informants were interviewed, their transcripts analysed, summarised and typologised, identifying six states of physical activity participation. Findings demonstrated that this target group possessed a holistic view of health, with food taking a special role in preventive care and self-treatment at times of illness. The Cantonese terms used to denote “physical activity” caused confusion among the target group. Most interpreted it as meaning deliberate planned body movement, strength-enhancing activities or exercise, although some did see it as including mundane daily activities and chores. Lack of time, no interest and laziness were reported as the main reasons for low participation in deliberate planned physical activity. Cultural, social and environmental determinants were the intrinsic and extrinsic factors influencing attitudes toward physical activity, as well as perceived social supports and perceived control over physical activity participation barriers. To a large extent, these interactive determinants of health were rooted in the three traditional Chinese philosophies mentioned above. The thesis concludes by arguing that rather than simply advocating activities designed for other populations, health promotion strategies and education need to create links to the traditions of this target group and also clarify their conception of physical activity.

This thesis addresses the issue of comfortable and functional living environments to provide seniors with opportunities for "age in place," that is, living in one's own house after retirement. Such living environments enhance seniors' life satisfaction since the majority of seniors prefer to stay in their own houses and live independently. In order to create suitable environments for seniors, professionals need to examine the relationships between seniors' housing behaviors and their living environments. Studying seniors' housing behaviors is particularly timely now as the first generation of baby boomers enters retirement and begins making increasingly large demands for adequate housing. This exigency emphasizes the urgent need for attention and understanding toward seniors' housing behaviors. This thesis investigates two groups of factors- physical abilities and medical conditions - which influence seniors' housing behaviors, examines characteristics of the groups, and compares the influences of the groups on seniors' housing behaviors according to hypotheses that the more problems the elderly have, the more effect these problems will have on adapting or changing housing. The thesis used data collected by Eleanor Palo Stoller, Ph.D. (with the support of a grant from the National Institute on Aging) from subjects who were elderly Finnish American retirees and other European American retirees in Florida. The results supported the assumption that the more functional and health problems the elderly have, the more changes the elderly will make to their houses. The thesis suggests further areas for research and ways to enhance seniors' housing arrangements. / Graduation date: 2005

This study evaluated the impact of receiving a home-delivered meal on the quality of life and nutritional risk of elders who were unable to attend congregate meal sites and who were unable to safely prepare a hot meal. Forty-three subjects on a waiting list were matched with a group currently receiving home-delivered meals. Matching criteria were functional needs measure, age, gender, and living arrangement.Home visits were conducted to collect the data and verify demographic information. Nutritional risk was assessed by the Nutrition Screening Initiative's Determine Checklist. Quality of life was measured across various domains including a global quality of life self-rating, mental health appraisal, functional ability, and food enjoyment. Two tailed t-tests failed to show differences in quality of life and nutritional risk between the groups at the 0.05 level of significance.In addition, the study reviewed the resources for meal preparation and grocery shopping possessed by the meal non-recipients that allowed them to remain at home without a meal provided. A significant difference was seen in the number of resources reported for meal preparation assistance with the meal non-recipient group reporting more informal resources. / Department of Family and Consumer Sciences

Doctor of Philosophy / This study explores the health beliefs and preventive health behaviours of older Hong Kong Chinese people resident in Australia. Participation in physical activity was used as the case study. There were two frameworks used to shape the research. Because of their perceived influence on the health beliefs and practices of Hong Kong Chinese people, the traditional Chinese philosophies of Confucianism, Taoism, and Buddhism provided the philosophical framework. The Theory of Planned Behaviour provided a theoretical framework for understanding the target group's preventive health behaviour. Data was collected by means of in-depth interviews, participant observation and case study. Twenty-two informants were interviewed, their transcripts analysed, summarised and typologised, identifying six states of physical activity participation. Findings demonstrated that this target group possessed a holistic view of health, with food taking a special role in preventive care and self-treatment at times of illness. The Cantonese terms used to denote “physical activity” caused confusion among the target group. Most interpreted it as meaning deliberate planned body movement, strength-enhancing activities or exercise, although some did see it as including mundane daily activities and chores. Lack of time, no interest and laziness were reported as the main reasons for low participation in deliberate planned physical activity. Cultural, social and environmental determinants were the intrinsic and extrinsic factors influencing attitudes toward physical activity, as well as perceived social supports and perceived control over physical activity participation barriers. To a large extent, these interactive determinants of health were rooted in the three traditional Chinese philosophies mentioned above. The thesis concludes by arguing that rather than simply advocating activities designed for other populations, health promotion strategies and education need to create links to the traditions of this target group and also clarify their conception of physical activity.

This study was designed to explore how Chinese elderly informants with diabetes experience and manage their illness at home. The method used in conducting this study was the phenomenological perspective of qualitative research. The Intent of the study was to understand the human experience of living with diabetes and the sociocultural context in which it is lived. Data collection and analysis ran concurrently. Data were collected through a series of interviews with nine Chinese informants who were diagnosed with late onset diabetes and were undergoing insulin treatment at home. Informants' ages ranged for a 69 to 90 years old. All informants are first generation immigrants in Canada. The specific questions that directed this study addressed the Chinese elderly informants' experience of living with diabetes, the meanings they assigned to living with diabetes, and the ways Chinese informants managed their diabetes. Theoretical sampling guided sample selection and determined sample size. The data were constructed based on a total of 21 interviews with the nine informants. As the researcher explored how the informants lived with diabetes, informants gave detailed accounts of how they viewed diabetes. Within the context of how they viewed diabetes, informants described an entire process they went through to make decisions in everyday life as they sought help and managed their illness. Based on informants' accounts, a decision making model was formulated. Informants gave detailed accounts of each step of the decision-making process, together with descriptions of meanings they assigned to each step. The data showed how informants made sense of their experience as they went through each phase of the decision-making process. The descriptions also revealed an "inner logic" used by informants to direct choices they make regarding health matters. In terms of nursing practice, these findings support the need to attend to client decision-making, from the clients' perspectives. The findings also address nurses' need to reevaluate their professional role in relation to clients' needs and expectations. With regard to nursing research, the findings suggest the need to further explore the topic of decision making from both the clients' and nurses' perspectives. / Applied Science, Faculty of / Nursing, School of / Graduate

The purpose of this dissertation was to understand how genetics, socioeconomic status (SES), and lifestyle factors influence the development of age-related macular degeneration (AMD), glaucoma, and diabetic retinopathy in an adult population in Dallas County. Two hundred fifty-three older adults participated in this study as the sample. Crosstabulation and binary logistic regression were utilized to analyze the data. Results indicated a disparity among participants' test scores, visual health status, and perceptions of their visual impairment and highlighted the fact that many seniors are not educated about age-related retinal disorders. Furthermore, variables reaching statistical significance were consistent with the literature included race/ethnicity, age, having a family history of both AMD and diabetes, frequency of eye exams, and level of education. The results not consistent with the literature as affecting visual health included health insurance, access to health care, body weight, and smoking status. Recommendations for future study included applied research focusing on determining risk factors, raising awareness, educating, and providing early detection of these diseases among low to middle income Caucasian, African American, and Hispanic older adults.

My dissertation focuses on investigating the associations of neighborhood environments—namely, built and social environments—with health among community-dwelling older Americans. The first paper examines groupwide variations in social participation patterns among older adults before and during the COVID-19 pandemic, and if community social cohesion and health during the pandemic were significantly associated with social participation patterns. Using Rounds 9 and 10 longitudinal data from the National Health and Aging Trend Study, I employed latent class analysis to identify the presence of groupwide variations in social participation, before and during the pandemic. I used logistic and linear regressions to examine the associations between social participation patterns, community social cohesion, and health during the pandemic. Results suggested two participation patterns, active and selective participants. Compared to active participants, older adults who were selective in their social participation were more likely to live in less socially cohesive communities and report substantial depressive and anxiety symptoms. In the second paper, I examined cross-sectional and longitudinal relationships between neighborhood physical disorder, low social cohesion, and sleep problems among older Americans. Mediators of health behaviors (i.e., lack of physical activity and social participation) and mental health (i.e., depressive and anxiety symptoms) were also tested in these relationships. Data were derived from three rounds of panel data (Rounds 7-9) from the National Health and Aging Trends Study, involving a sample of 4,029 Americans aged 65 or older. I found statistically significant cross-sectional and longitudinal associations between physical disorder and low social cohesion, and late-life sleep problems. Only cross-sectional mediation effects of health behaviors and mental health were found in the relationship of physical disorder and sleep problems, whereas both cross-sectional and longitudinal associations between low social cohesion and sleep problems were significantly mediated by health behaviors and mental health. In the third paper, I used annual data from the 2015-16 Poverty Tracker study to examine the roles of distance to grocery stores, neighborhood disadvantage, and social cohesion in explaining food insecurity among older adults in New York City. Multiple logistic regressions were conducted to assess these relationships. Results showed that greater distance to grocery stores (0.26–0.75 miles vs. 0.00–0.25 miles) and living in more disadvantaged neighborhoods increased the odds of food insecurity. Community social cohesion was a marginally significant protective factor against food insecurity. The findings of these papers highlighted the associations between the neighborhood environment, social health, sleep quality, and food security status among older adults. These papers also emphasized the potential for environmental policy and social work program interventions to improve the well-being and quality of life among community-dwelling older adults.

The purpose of this study was to investigate the relationship between health attribution and the availability of organized internal resources and response style as measured by the Four Square of the Rorschach Inkblot Test. Forty-two subjects participated in this study. Six major hypotheses were explored in the study. None of the hypotheses was statistically significant. Several factors may have contributed to these results. The small sample size and the homogeneity of the sample limited the investigator's ability to interpret the results of the study. Statistically, health attribution may not be conceptually related to organized internal resources and response style since physical and emotional distress may require different coping mechanisms.

Multiple chronic conditions (MCCs) are defined as two or more health conditions, each requiring treatment and limiting activities for a year or more. In the United States (US), MCCs are more common and costly than any individual chronic condition. The number of adults aged 65 years and older with MCCs is projected to nearly double between 2020 and 2050. Patients with MCCs often experience poor self-reported health and negative symptoms. In addition, they frequently visit emergency departments (EDs) and are hospitalized. Patients with MCCs need ongoing primary care services to manage their symptoms and prevent health deterioration. However, over 20% of the US population (many of whom have MCCs) resides in a primary care Health Professional Shortage Area (HPSA) and experiences poor access to primary care. The growing nurse practitioner (NP) workforce, which is projected to almost double in size between 2018 and 2030, can help meet the demand. Most NPs are trained to diagnose, treat, and manage chronic conditions and can provide a scope and quality of primary care comparable to physicians in many populations. Therefore, if distributed and supported strategically, the NP workforce can meet the complex care needs of patients with MCCs, especially in HPSAs. Maximizing the potential of the NP workforce to deliver MCC care will require enhanced care environments in the practices where NPs work, characterized by administrative support for NP care delivery and autonomous practice, collegial relationships between NPs and physicians, and NP professional visibility. On the other hand, poor NP care environments can negatively affect the quality of chronic disease care. Thus, improving the NP care environments within practices may increase the capacity of the NP workforce to care for MCC patients. Despite the potential of the NP workforce to meet the need for primary care among patients with MCCs, little is known about the impact of NP-delivered primary care models on outcomes in this population. Furthermore, the impact of HPSA status and NP care environments on NPs’ ability to care for patients with MCCs remains poorly understood. Thus, the overall purpose of this dissertation is to produce evidence on NP-delivered primary care models for patients with MCCs and examine the interplay between practice and community factors in shaping outcomes for these patients. In chapter 1, we introduce the unique healthcare needs of patients with MCCs, and the role of NPs in delivering and expanding access to care. In chapter 2, we synthesize the existing evidence on the effect of NP primary care models, compared to models without NP involvement, on cost, quality, and service utilization by patients with MCCs. Our synthesis suggests that NP-delivered primary care has similar or better impacts on outcomes among patients with MCCs compared to care delivered without NP involvement. In chapter 3, we perform secondary data analysis using multiple linked data sources including 1) patient data from the Medicare claims of 394,424 older adults with MCCs, 2) NP survey data on practice characteristics from 880 NPs at 779 primary care practices across five US states, and 3) data on HPSA status of the practice locations from the Health Resources and Services Administration. We examine differences in hospitalization and ED use among patients who receive care from NP practices in HPSAs compared to those in non-HPSAs. We find a higher likelihood of ED use among patients receiving care in NP practices located in HPSAs compared to practices in non-HPSAs, and no difference in the likelihood of being hospitalized. Our results suggest that relieving provider shortages may reduce ED use by MCC patients in HPSA practices that employ NPs, but may be insufficient to lower hospitalization rates unless combined with other interventions. Finally, in chapter 4, we analyze the same linked secondary data source as in chapter 3 to examine the effect of the NP care environment (measured by the NP survey) on the relationship between the HPSA status of the practice location and ED or hospital use among patients with MCCs. We find that the NP care environment moderates the association between primary care provider shortage areas and hospitalization but not ED use. Further analysis reveals that improved NP care environments have a more pronounced association with lowered odds of hospitalization among patients receiving care from practices located in areas with no shortage of primary care providers (i.e., non-HPSAs) compared to those receiving care in practices with provider shortages (i.e., HPSAs). Our findings suggest that improving the care environment may not have the effect of reducing MCC patients’ need for hospitalization unless sufficient providers are also available to care for patients. We suggest that cohesive solution sets addressing practice- and community-level interventions simultaneously may be needed to improve hospitalization outcomes for patients with MCCs. In the concluding chapter of this dissertation, chapter 5, we present a summary of findings, discuss the dissertation’s strengths, limitations, and its contributions to science. In this chapter, we also discuss implications for policy, practice, and directions for future research.