Purpose: In the United States one in six Asian Indians (AI) is diagnosed with type 2 diabetes and the prevalence of diabetes in AI (between ages 45-79) in the San Francisco Bay Area is 29%. Although culturally distinct issues have been anticipated, only a few studies have examined AI beliefs and practices regarding diabetes. The purpose of this study was to explore and understand cultural commonalities and differences in illness management in AIs. Aims of this study were to describe: 1) Beliefs about causal factors and diabetes management 2) Daily challenges and supports encountered in managing type 2 diabetes; 3) Culturally specific practices (religious, dietary and physical activity) that affected type 2 diabetes; 4) Commonalities and differences by gender differences that impacted type 2 diabetes. The overall goal was to provide an interpretive account of the daily activities, challenges and barriers faced by AI in managing their diabetes in their everyday lives.

Approach: Interpretive phenomenology (IP) guided the research design and analysis. In-depth narrative and explanatory data about health beliefs and practices was gathered through open–ended interviews. A convenience sample of 12 adult participants (50% female) between the ages of 40-79 who self-identified as first generation AI, diagnosed with type 2 diabetes, low income with average duration of U.S. residency of 20 years were recruited via public announcements and in person presentations at Sikh Temples. Each participant was interviewed twice in English or Punjabi to learn illness understandings including cause, culturally specific practices, supports and barriers to illness management.

Results: The high prevalence of diabetes in the AI community led participants to express a sense of inevitability for developing the disease. Participants uniformly suggested that social and environmental causes outweighed hereditary or biological causes for their diabetes although beliefs were gender-specific. Female participants named stressors that disrupted family harmony and overwhelming family responsibility, and a lack of quality communication with their physicians as contributing to their diabetes. Male participants suggested that employment stresses and poor diet were causal. Diabetes management was complicated by dietary, cultural and social practices. Lack of knowledge, poor access to medical care and immigration further hindered diabetes control.

Conclusion: Efforts in prevention and community outreach programs are needed as the AI population increases in the United States. Public health initiatives that increase early screening and awareness of diabetes may improve diabetes and its complications in the AI community. Culturally specific diabetes prevention programs for AI, assistance in managing social and environmental contributors to diabetes must be addressed alongside lifestyle (diet and exercise) changes.

The purposes of this hermeneutic phenomenological study were to 1) understand Asian American families' everyday caregiving practices for a person with mental illness and 2) understand how mental health care providers provide care for AA patients and families. AA was defined as immigrants from Korea, China, and Japan and their descendents.

The specific aims were to 1) examine patterns of family caregiving practices for mentally ill family members among AA families as observed by mental health care providers 2) provide a systematic articulation of Confucianism as manifested in the AA family caregiving practices and describe how Confucianism is modified as families acculturate to the United States, 3) identify the particular difficulties perceived by mental health care providers and some strategies they use to cope with these difficulties, and 4) examine patterns of practice among mental health professional providing care for AA patients and families.

Participants were comprised of twenty providers who have treated mentally ill AA patients and families in the past 5 years in the San Francisco Bay Area. Data were collected through fact-to-face, in-depth interviews. In addition, field notes and memos were also included in the analysis.

Study findings are consistent with the current knowledge of strong family supports in the AA population. However, the study findings emphasize that AA family caregiving practices should be understood in a much more complex manner. The study findings also highlight that a strong Confucian emphases on the family is still present among AA families, particularly in issues around caregiving and communication among family members.

Narratives from practitioners illustrate the clinical reality of cultural competency and describe providers' practices when caring for mentally ill AA patients and their families. Such detailed illustrations provide insight for novice practitioners or those who have limited opportunity to work with this population. The findings of this study support some current guidelines while challenging others. For example, the emphasis on short-term result oriented solutions was problematized because it ignored the chronic nature of mental illness. This study found that providers had to cover broader and more complicated material in psychoeducation for AAs than current literature recommended.

Exploring the Expression of Pain by Limited English Proficient Latino Immigrants in Language and Culturally Discordant Health Encounters

The purpose of this interpretive study was to explore the expression of GI pain by non-English-speaking (NES)/ limited-English-proficient (LEP) Latino immigrants in language and cultural discordant health encounters. Language discordance prevents NES/LEP Latinos from reporting symptoms of abdominal pain to a provider. Furthermore, the extent of this communicative inability was correlated with negative health care outcomes such as longer wait times before receiving primary clinical assessment for acute GI symptoms in the emergency room.

Method. Interpretive phenomenology guided the design and analysis. Two in-depth individual interviews were conducted with a purposive sample of 13 adult Latino participants who had LEP, a history of GI pain, and treatment in U.S. health care. Participants were undocumented, Central Valley residents who were reluctant to participate in research due to fears of deportation. Interviews focused on the history of present illness, beliefs about their illness and treatments needed, and direct narratives regarding receipt of health care in the U.S. for their GI pain.

Results. Participants’ perceived barriers to communicating GI illness concerns included undocumentedness, fear of deportation, personal healthcare beliefs and practices, lack of insurance, low health care literacy, and limited income. Participants reported receiving ineffective/fractured care, and feeling uncared for by doctors. Discriminatory practices, largely because of their ethnicity, LEP and low income were commonplace. Aids to communicating GI illness concerns included trust, time, attention, respect, consistent follow up care, and doctors who showed concern. Latino coping processes included following western medicine advice and prescriptions, as well as reliance on folk medicine, God, and family. Despite these coping strategies, participants experienced considerable untreated pain, delayed or ineffective diagnostic work-ups and limitations on diagnostic tests (i.e., EGD) because of their LEP, insurance status and/or immigration status.

Conclusion: Structural and interpersonal barriers were identified by Latino immigrants regarding communicating GI illness concerns in situations of language and cultural discordance. Improvements at both the interpersonal and institutional levels are required to begin to address the disparities in health care expressed by this population.

THE IMPACT OF HEALTH CARE ACCESS ON THE COMMUNITY REINTEGRATION OF MALE PAROLEES Elizabeth Marlow ABSTRACT Of the 784,400 individuals released from prison in 2005, most were likely to have not finished high school, have limited employment skills, represent ethnically diverse and marginalized communities, and have multiple health problems. These individuals often have long criminal histories and their time in the free world is punctuated by frequent reincarcerations. The purpose of this study was to understand how health care access affects the community reintegration of male parolees. The specific aims were to: examine the health beliefs and practices regarding general health care and specific medical conditions from the parolee's perspective; identify the perceived barriers and facilitators parolees encountered in accessing community health care services; describe the impact of health care access on reintegration from the parolee's perspective; and identify specific events in the parolee's life that may have affected his reintegration. Hermeneutic phenomenology guided the study conduct and data analysis. Data were collected via repeat individual interviews with chronically ill male parolees 40 to 65 years of age. Thirty-two in-depth interviews with 17 participants were completed. Study results included: structural barriers to health care; personal and group responses to interacting with health care while on parole and how these interactions facilitated or diminished reintegration efforts; social barriers and facilitators to health care participation, e.g. the influence of a clinican's caring professional demeanor on participation in clinical care; the role that addiction disorders play in the need to access and utilize health care; and the influence of institutional and criminal adaptations, e.g. interpersonal distrust, social isolation and institutional dependence, on reintegration efforts. These findings suggest a need for new ways of conceptualizing reintegration that includes health more centrally in the processes of success or failure. The health care system has the potential be a positive influence in these individuals' lives. In order to effectively support and care for chronically ill individuals on parole, the health care system, as an institution and as individual clinicians, must begin to integrate the problems and issues of long-term involvement in street and prison life into its evaluation and treatment of these individuals.

Diabetes presents a major public health problem worldwide and in the United States. Diabetes is among one of four non-communicable diseases being targeted by the World Health Organization. It is estimated that there are 422 million adults living with diabetes worldwide, that is 1 in 11 people. Likewise, 1 out of 11 people in the U.S. have diabetes, a total of 29 million people. The American Diabetes Association in the U.S. has created standards for the medical care and diabetes self-management education and support (DSMES) for people with diabetes. Over the last 20 years DSMES has proven effective in improving physiological and psychosocial outcomes. Despite this, only half the people living with type 2 diabetes are currently at goal for their A1C and only 48% ever attend a program for DSMES. Shared Medical Appointments (SMA) have been proposed as one way of redesigning care to bridge this gap. Evidence from the last 15 years supports the implementation of SMA. This dissertation presents three manuscripts. The first is an integrative literature review on the effectiveness of SMA in treating type 2 diabetes. The second, describes the cultural adaptation process of ALDEA, (Latinos con Diabetes en Acción), a culturally adapted SMA program for Latinos with type w diabetes. The third manuscript describes the ALDEA SMA study. This is a six-month study of the effectiveness of ALDEA, a culturally adapted SMA clinic, for adult Latinos with type 2 diabetes, to improve hemoglobin A1C (A1C), low density lipoprotein (LDL) and blood pressure, compared to usual primary care (UPC). This quasi-experimental matched-controlled study included measures at baseline, 3 and 6 months. Results showed that after six months of treatment, SMA participants had achieved target A1C and had significantly greater reductions in mean A1C values compared to UPC . There were no statistically significant differences in the percentage of participants who achieved target LDL and blood pressure at 6 months between ALDEA and UPC. Results are clinically significant and provide initial evidence that ALDEA is an effective program that can potentially reduce health disparities in diabetes outcomes for adult Latinos.

Traditional postpartum practices are widely followed by northeast (Isan) Thai women. Poverty, low education, physical distance, inconvenient accessibility to biomedical health care, and influence of seniors in the family kept voices of these women unheard. The purposes of this interpretive phenomenological study are to understand the lived experiences of first-time mothers who follow traditional postpartum practices, to explore the setting of practices, and to reveal how family generates and transmits practices to new mothers. Study was conducted in Sirindhorn district, Thailand, from October 2008 to September 2009. Sixteen pregnant women during third trimester with uncomplicated pregnancy were recruited from prenatal clinic. Data was collected using three methods including two in-depth interviews, several participant observations, and a demographic form. Within-case, across-case, and thematic analysis were used to investigate meanings of traditional practices.

Based on Traditional Thai Medicine, caregivers used food, fire, water, and herbs to rebalance postpartum women's self, including body, mind-heart, and energy. Supervised by caregivers, the women live in hot environment and consume hot food and drink to benefit both maternal and child health. Meanings of practices were revealed and presented through four broad themes. Food practice after childbirth addresses meanings related to certain foods which were encouraged to promote breast milk or discouraged to prevent sickness, which was called phit kam. Postpartum healing through heat demonstrated why lying by the fire was important to Isan women. The fire not only helped them retrieve physical health, but also improved beauty and ensured long term wellness. Hot herbal bath: rebalancing blood and wind systems reflected how and why the caregivers used hot water to promote the women's humoral systems and to heal perineal wounds. Lastly, hot herbal concoctions: tonic and lactating promoter explored local herbs used to make the teas taken by women to prevent and cure phit kam, regain health, and increase breast milk production. The findings provide basic knowledge for determining best health care and preventive health service practices. The goal for the future application of this research is to guide the implementation of care plans in the biomedical health care system with an awareness of cultural practices.

ABSTRACT

Approximately 20 million people suffer from substance abuse disorder in a given year and approximately 7-10 million of them will have co-occurring disorders (COD) of both mental illness and substance abuse. Moreover, 61 percent of those who have COD have not received treatment for either illness. To complicate matters, individuals with COD have higher rates of other chronic health problems (i.e. diabetes), multiple re-hospitalizations and over utilize emergent services. Despite their elevated risk for physical morbidities, there is a dearth of literature that focuses on the impact for those with COD of having multiple physical health disorders. Of concern is how this population copes with medical health issues while at the same time living with a psychiatric illness and substance abuse or dependence.

The purpose of this interpretive study was to understand: (a) the social and structural barriers that individuals with COD encounter in regards to their healthcare; and, (b) how individuals with co-occurring disorders of mental illness, substance abuse, and other chronic medical illnesses manage their illnesses. A purposive sampling of twenty individuals with COD (11 males; 9 females; 65% African American) were recruited from community treatment centers and supportive housing sites. Participants were interviewed for one hour on two occasions. Narrative interviews focused on meanings of health, management of illness and experiences with the healthcare system, were conducted. Thematic and paradigm case analyses were conducted on two occasions. Narrative interviews focused on meanings of health, management of illness and experiences with the healthcare system, were conducted. Thematic and paradigm case analyses were conducted.

Social and structural barriers to improving health included difficulties with interpersonal relationships with healthcare providers. Participants felt they were not heard and/or understood by providers. Additionally, informants described that limited or missing health insurance coverage, support, limited access to mental health services, frequent changes in Medicaid regulations, and increases in share of cost for medications as impasses to their health management. Unstable, unkempt, and crime-ridden housing and neighborhoods were barriers to improving and/or maintaining their health.

Additionally, three distinct patterns of coping with mental illnesses, drug and/or alcohol addiction, and physical chronic illnesses were observed, which included (a) interconnectedness, (b) ambivalence, and (c) waiting in defeat. The three patterns of coping describe the commonalities and differences in individuals' responses to living with COD. Implications for clinical care and social policies are included.

Female-to-Male transgenders (FTM), or transmen, have become an increasing presence in the gay community, especially in San Francisco. However, there is little data regarding how they transitioned into the gay community and the risks for HIV and STDs that they faced when they completed transition. This dissertation is comprised of four papers that examine that situation. The first paper describes the ways in which three decades of the HIV epidemic have impacted sexual behavior and attitudes within the gay community. That is followed by a review of what is known and unknown about the development of sexual differentiation and gender identity, with a specific focus on a variety of intersex conditions. The final two papers present the results of the study "Sexual Identity, Behavior, and Risk Among Female-to-Male Transgender Persons". This study used Interpretive Phenomenology to describe and understand the experience of 17 transmen who were recruited in the San Francisco area. Two lines of inquiry were identified for the study. The first was to describe and understand the variability in sexual orientation and behavior among transmen before and after transition and the use of testosterone. The four distinct groups of steadfast, shifted, aligned, and fluid are identified and described in the third paper. The final paper examines the second line of inquiry. This was to identify the risk present for transmen who transitioned into the gay community. Risks inherent in being part of the gay community as well as aspects of risk that are specific to transmen are discussed.