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Mental health services engagement in Pacific Islander/Polynesian communities

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Mental health services engagement in Pacific Islander/Polynesian communities

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Mental Health Services Engagement in Pacific Islander/Polynesian Communities
by
Helen Gaoteote Iese

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

August 2021

© Copyright by Helen Gaoteote Iese 2021
All Rights Reserved

The Committee for Helen Gaoteote Iese certifies the approval of this Dissertation

Dr. Briana Hinga
Dr. Ashley Kelly
Dr. Bryant Adibe, Committee Chair

Rossier School of Education
University of Southern California
2021

iv
Abstract
Polynesians/ Pacific Islanders have disproportionately higher rates of suicide. This study utilizes
Clark and Estes (2008) gap analysis framework to better understand the effects of cultural
adherence on the mental health of Polynesians/Pacific Islanders. This study evaluates the
knowledge, motivation, organizational, and social influences that contribute to this
demographic's underutilization of mental health services. A qualitative approach was designed to
collect data that comprised of eight one-on-one interviews. Knowledge, motivation, and
organizational gaps were identified and recommendations were made based on the data collected
and existing empirical research.

v
Dedication
To my late father, high-talking chief Sua Moni Gaoteote who unexpectedly passed in December
2020, one semester before I completed this program. He was a champion of his family, his
church, and education for his community. He inspired me to be a better person, stronger and
smarter than what those around me might believe. He instilled in me as a young child that as a
Samoan female, I would have to work harder than my peers in school and work to succeed, but
that I could do it if I believed in myself. He taught me never to be afraid, to push for what I knew
in my gut and my heart was right, and never forget to give glory and praise to God, our Father,
the Almighty. He was an amazing dad, and I will carry his memory with me until my last breath.
Rest well until we meet again dad, I hope I made you proud.

vi

Acknowledgements
First, I want to acknowledge and give thanks to God, our Father the Almighty, for blessing
me with an amazing support system, the courage to apply to this program, and the resolve to
complete it. Through his glory all things are possible. Praise thee.
Thank you to my incredible and God-fearing husband, Iese Elia Iese, for supporting me
through this journey. For always believing in me when I did not believe in myself. For encouraging
and pushing me forward when I felt that I could not carry on. I do not want to know where I would
be without you. I love you.
Thank you to my amazingly resilient and strong mother, Senerita Moni Gaoteote. Your
faith in me and drive for perfection in all that you do has served as an example for my life and the
lives of my children. Mom, thank you for your prayers and guidance. Our family would be nothing
without you. You are our everything. I love you.
To my sisters and brothers by blood and by heart; my nieces and nephews whom I love and
cherish, thank you all for your endless support. Your belief in me is often undeserving. Thank you
for trusting me even when you may disagree. You are all a priceless blessing in my life, and I got
you all forever.
I want to give a special thank you to my children. You are all too young to read this now,
but one day I hope you understand how much you changed your mother’s life. How your presence
alone makes me a better person. How your giggles and hugs are a daily reminder of how favored
I am and what is profoundly important in this life. You are and will forever remain mommy’s little
loves.
Lastly, I would like to acknowledge my committee who were instrumental in my journey.
Thank you Dr. Adibe and Dr. Kelly for creating a safe place to share tears, frustration, and the

vii

gamut emotions as I worked through this dissertation journey. Thank you to Dr. Hinga, for the
critical role you played in this process.

viii

Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgements ........................................................................................................................ vi
List of Tables .................................................................................................................................. 1
List of Figures ................................................................................................................................. 2
Chapter One: Introduction to the Study .......................................................................................... 3
Context and Background of the Problem ............................................................................ 3
Purpose of the Study ........................................................................................................... 4
Overview of Theoretical Framework and Methodology .................................................... 6
Research Questions ............................................................................................................. 7
Definitions........................................................................................................................... 7
Organization of the Dissertation ......................................................................................... 8
Chapter Two: Review of the Literature .......................................................................................... 9
PI/Ps and Mental Health ..................................................................................................... 9
Cultural Perception of Mental Health ................................................................................. 9
Barriers to Health: Cultural Collectivism ......................................................................... 11
Barriers to Health: Educational Attainment and Use of Mental Health Services ............. 12
Impact of Underutilization ................................................................................................ 18
Clark and Estes (2008) Gap Analysis Framework ............................................................ 21
Conclusion ........................................................................................................................ 25
Chapter Three: Methodology ........................................................................................................ 27
Research Questions ........................................................................................................... 28

ix

Research Design and Methodology .................................................................................. 28
Data Collection Process .................................................................................................... 30
Conclusion ........................................................................................................................ 32
Chapter Four: Results or Findings ................................................................................................ 33
Significance and Validation .............................................................................................. 33
Chapter Five: Recommendations .................................................................................................. 43
Conclusion ........................................................................................................................ 48
References ..................................................................................................................................... 49
Appendix A ................................................................................................................................... 53
Appendix B ................................................................................................................................... 54

1

List of Tables
Table 1 Degrees by A/PI (Asian/Pacific Islander) students ......................................................... 14
Table 2 Length of stay (LOS) vs. Cost of stay (COS) .................................................................. 17
Table 3 PI/P (Pacific Islander/ Polynesian) Suicides.................................................................... 20
Table 4 Participant Demographics ............................................................................................... 34

2

List of Figures
Figure 1 Conceptual Framework .................................................................................................. 25

3

Chapter One: Introduction to the Study
There is a high prevalence of mental illness among people of Pacific Islander
(PI)/Polynesian (P) descent (Kwan, et al., 2019). In the Pacific Islander (PI)/ Polynesian (P)
cultures, a strong negative stigma is associated with mental illness (Allen, et al., 2016). For many
PI/P cultures, mental illness is such an alien concept that there are no words in their native
languages for mental illness or depression (Rafai, 2016). One of the reasons PI/Ps abstain from
seeking mental illness assistance is cultural mistrust, a possible explanation for their
underutilization of available mental health services (Lopez, Barrio, Kopelowics, Vega, 2012).
Compared to Euro-Americans, Asian and PI Americans utilize mental health services at a
relatively lower rate (Matsuoka, Breaux, Ryujin, 1997), though the suicide rates within this
group are disproportionately high (Steward-Withers, O’Brien, 2006). Failure to use mental health
services in the PI/P communities may lead to higher rates of domestic violence, substance abuse,
incarceration, and suicide for this group (Kaholokula, 2007). This study examines the role that
education or the lack of plays in the underutilization of mental health services, the impact
cultural norms have on individual’s motivation to seek mental health care, and how healthcare
organizations contribute to the obstacles this population faces when seeking assistance for mental
illness. Additionally, it addresses the effects of perceived racism and discrimination on the
mental wellness of the PI/P population.
The purpose of this examination is to understand why this problem exists among the PI/P
community and what viable solutions exist to help address this problem.
Context and Background of the Problem
The 2018 U.S Census details that of California’s 39.46 million total residents, 15.8%
identify as Asian/Pacific Islander. Approximately 13.9% of the Asian/Pacific Islander
4

community in California report living with a mental health condition. Obstacles to receiving care
for mental health persist, such as language barriers and negative cultural stigma
(EachMindMatters.org,2020). Healthcare organizations/providers' understanding of the
'collectivism' mentality of PI's will raise awareness and enable culturally appropriate care. PI's
place emphasis on the well-being of the community, as their cultures believe individuals draw
strength from their communities (Firth, 2013). The SFGate (2001) reports that the Bay Area has
one of the largest PI/P populations in California with the highest numbers in Hayward, East Palo
Alto, and Vallejo.
The study is in varying cities of the San Francisco Bay Area, Northern California. The
participants include PI/P adults between the ages of 18-70. These individuals are either immigrants
to the United States or were born in the United States to immigrant parents or grandparents. PI/P
cultures stay close to their origins and avoid the “westernization” of their traditions and culture.
Collectivism is a fundamental principle of PI/P cultural identity; it is a close social
interconnectedness through intimate interpersonal relationships within the family and community
units (Singelis, 1994). Write text here. The number and content of all subheadings will depend on
your chair and the design of your study.
Purpose of the Study
Strong negative stigmas influence the cultural perception of mental illness in PI/P
communities (Allen, et al., 2016). Per Allen, et al., (2016), in PI/P culture, mental illness is a sign
of weakness and can bring shame to one’s family. Several areas are important aspects to examine
this problem, including cultural perception, cultural collectivism, educational attainment, costs of
quality healthcare, lack of cultural sensitivity in healthcare, and systemic racism in healthcare.
An individual who acts outside of cultural norms can embarrass family members; consequently
5

they may isolate themselves, adding to existing feelings of depression or low self-worth. To
understand the PI/P community's aversion to seeking assistance from an outsider, healthcare
providers must have a rudimentary understanding of their culture to lessen the utilization gap
(Smith, Trimble, 2015).
Another contributing factor to this problem is the cost of quality health care. For those
that receive mental health services, the total healthcare costs are significantly higher than those
that choose not to seek treatment (Unutzer et al., 2009). In 2003, the Committee on
Understanding and Eliminating Racial and Ethnic Disparities in Health Care identified
discrimination as a significant concern affecting ethnic health disparities (Chen, 2005). This data
correlates with a follow-up report by the U.S Office of the Surgeon General (2001) to their 1999
report on mental health utilization, showing racial inequities in mental health service utilization.
Exorbitant costs of mental health care, cultural norms, and racial inequities may be contributing
to PI/P's aversion to utilizing these services.
Few studies within the United States examined mental health access and care for PI/Ps.
However, such studies occurred in other areas with high PI/P populations. New Zealand
(Ministry of Health, 2013) reports 500 suicides per year, though the suicide mortality for Pacific
Islanders occurs at a lower rate in comparison to the population; their numbers are three times
higher in contrast to European New Zealanders. Tiatia-Seath et al. (2017), in a longitudinal study
over a 17-year period (1996-2003) of suicide trends for PIs living in New Zealand, demonstrated
a strong correlation between suicide and mental illness. Suicide prevention efforts and effective
mental health treatment plans within this population are relevant to lower their growing number
of suicides because of mental illness, however the messaging to these communities must be
culturally sensitive to be effective (Steward-Withers, O’Brien, 2006). Compared to Euro
6

Americans, Asian and PI Americans utilize mental health services at a relatively lower rate
though the suicide rates within this group are disproportionately high (Matsuoka, et al., 1997).
Asian/ Pacific Islanders (API's)typically rely on themselves to deal with psychological
issues before turning to friends or family. If the problem persists, families or individuals consult
the community and religious leaders before seeking the assistance of mental health professionals
(O'Brien, Broddy, & Hardy, 2007).
Overview of Theoretical Framework and Methodology
This study is based on the Clark and Estes (2008) gap analysis framework that identifies
root causes of performance gaps between current and desired future state. The framework
provides a gradational gap analysis of performance goals, analyzes, and determines the cause(s)
of performance gaps, and identifies and implements solutions to close the gaps (Clark & Estes,
2008). Clark and Estes (2008) describe the three causes of performance gaps: knowledge and
skills, motivation, and organizational barriers.
Clark and Estes’s (2008) KMO framework is the lens through which the study will
examine the problem of practice. The study will explore PI/P’s knowledge, motivation, and
organizational influences surrounding their underutilization of mental health services. This
examination will consider how adhering to cultural values impacts PI/P adults in terms of mental
illness. It will also review other factors that may impede the use of mental health services by this
group. The study will consider varying factors outside of cultural customs that contribute to
PI/P’s underutilization of mental health services and the prevalence of mental illness in this
demographic.

7

Research Questions
The following questions guide the research:
1. What are the knowledge, motivation, and organizational issues associated with the
underutilization of mental health services by PI/P communities?
2. What are the recommendations regarding KMO factors for improving mental health
utilization within the PI/P group?
Definitions
The following word and terms appear throughout the remainder of this study. As such,
the definitions and citations from relevant literature explain their meaning as utilized within this
study.
API
An individual of Asian or Pacific Islander descent (Srinivasan & Guillermo, 2000).
Maori
The indigenous Polynesian people of New Zealand (Durie, 2002).
PI/P
An individual of Pacific Islander and Polynesian descent (Spickard & Fong, 1995).
Samoa(n)
Samoa is an island country and archipelago in Polynesia. A Samoan is an indigenous
person from these islands (Freeman, 1983).
Tonga(n)
Officially named the Kingdom of Tonga, Tonga is a Polynesian sovereign state and
archipelago. A Tongan is an indigenous person from these islands (Groube, 1971).
8

Polynesia(n)
Polynesia encompasses a vast area in the east-central Pacific Ocean. The area is
triangular with the Hawaiian Islands at its apex, New Zealand in the west, and Easter Island in
the east. Within the triangle are several island nations that include Samoa, American Samoa,
Tonga, Fiji, and Tahiti (Kahn, Kiste, & Suggs, 2018).
Organization of the Dissertation
Chapter One includes an introduction to the PI/Polynesian culture related to mental health
and provides a background on Polynesian culture and underutilization and access to mental
health services. Chapter Two discusses the literature related to proposed causes for the
underutilization of mental health services within the PI/P communities. Chapter Three highlights
the methods used in the collection and analysis of the data. Chapter Four analyzes the data as it
relates to the research questions in chapter one. Chapter Five summarizes the study and provides
interpretation for community and healthcare leaders on how to best approach this problem.

9

Chapter Two: Review of the Literature
Chapter two discusses literature regarding the underutilization of mental health services
within the PI/P communities and the consequences of these gaps. This chapter will also explore
the cultural perception of mental health by PI/Ps, examine the existing literature on PI/Ps and
mental health, and review the impact of mental health on PI/P individuals and their family units.
PI/Ps and Mental Health
Though Native Hawaiians and other Pacific Islanders are the third fastest growing
demographic in the United States, little is known about their general health status and even less
regarding their mental health, except that they appear to be high risk for suicide, substance abuse,
and depression (Subica, et al., 2019). A study in Los Angeles County which has a rapidly
growing rate of PI/Ps (over 65,000), reported that over a two-year period, only four individuals
enrolled in a PI/P, county specific, integrated care program (Subica, et al., 2019). Because of
these types of incidents of resistance, little is known about PI/Ps and their need for services.
Cultural Perception of Mental Health
Cultural beliefs around mental health are deeply rooted in the PI/P community. Rafai
(2016) describes PI/P cultures as associating mental illness and mental health treatment with a
strong negative stigma, preferring a traditional path to recovery by strength through community,
reconnecting with environmental elements, and the physical and spiritual dimension. An intense
sense of collectivism exists within this demographic that originates from strong familial ties
(Puku’i, 1989.) The entire family collaboratively mitigates issues or problems, in contrast to
Western cultures that favor individual action (Allen, Kim, Smith, Hafoka, 2016). PI/Ps often turn
to respected, elderly community members for advice and guidance when dealing with conflicts
or problems, including mental health concerns (Firth, 2013). When treating the native people of
10

New Zealand, known as the Maori, mental health providers first consult with the Kaumatua
(male and female elders) before working with individuals who suffer from mental health issues
(O’Brien, Broddy, Hardy, 2007). McLaughlin and Braun (1998) explain that in the Samoan
culture, religious leaders work collaboratively with a Matai (family chief/leader) to make
decisions within a family, including decisions around medical issues and mental health. In these
cases, the matai is present. At the same time, healthcare providers share the details of the
patient's diagnosis and treatment plan, unlike in Western cultures where after reaching a certain
age, the patient is the decision-maker and diagnosis and treatment plans are confidential
(McLaughlin & Braun, 1998).
In the United States, PI/Ps are often in the same categories with their Asian neighbors to
the north of their island countries for things such as census counts. Before the year 2000, the
United States Office of Management and Budget grouped PIs with Asians for census bureau
population surveys, listing 'Asian/Pacific Islander' as an option to indicate race. This category
later split into two after the 2000 census, 'Asian' and 'Native Hawaiian and Other Pacific Islander'
(United States Census Bureau, 2000). Asian and PI/Ps are among the fastest-growing racial
groups in the United States (Ube & Sue, 1991). A nationwide study shows that Asian Americans
and PI/Ps in all states and territories besides Colorado underutilized mental health services
(Matsuoka, Breaux, Ryujin, in press). It is worth noting that there is far less empirical research
regarding the utilization of mental health services among these two ethnic groups than any other
group (Vega & Rambaut, 1991).
Asian and PI/P cultures have similar views relative to mental illness and seeking
treatment. When individuals display behaviors considered awkward or outside of social norms,
families and caregivers are ashamed and avoid seeking help (Lee & Faran, 2004). Lee and Faran
11

(2004), state that Korean caregivers avoid seeking assistance for their elderly displaying signs of
dementia because they were afraid or ashamed of a dementia diagnosis for their loved one. They
explain that Asian and PI/P cultures do not view mental illness, including depression, as a
treatable disease. Cultural interpretation of illness as a personal weakness also plays a
considerable role in assistance-seeking behavior by PI/Ps (Lee & Faran, 2004). Due to the beliefs
and customs of PI/Ps heavily influencing their view of the world, efforts to counsel or provide
medical assistance to this group without acknowledging their cultural beliefs is purposeless. For
mental health providers to be successful with this group, they must approach PI/Ps with a
collectivistic strategy like that in New Zealand (Allen & Smith, 2015).
Though cultural perception of mental illness may be the most significant deterrent to
seeking mental health assistance for PI/Ps, several other barriers exist for this group to access the
help they need, primarily in the realm of healthcare.
Barriers to Health: Cultural Collectivism
Cultural collectivism emphasizes connectedness to others, the significance of social
perception, and the importance of maintaining relationships (Yeh, Inman, et al., 2006). Yeh,
Inman, et al., (2006) explain that an essential element of collectivism coping is familial support.
Though there is insufficient research on distress coping methods within PI/P culture, research
studies of Asian American families coping methods during times of distress found that this group
utilized spiritual collectivistic coping, which includes seeing tragedy through a lens of religious
teaching (Heppner, 2006). A disconnect can occur when PI/Ps, familiar with collectivistic coping
methods, receive a treatment plan that advocates individualistic methods; they may feel rejected
and fail to implement cognitive therapy (Allen, Smith, 2015).
12

Several factors contribute to the underutilization of mental health care by PI/Ps, cultural
beliefs and norms stand as one of the more significant, closely followed by several gaps in
education, as well as quality and costs of healthcare.
Barriers to Health: Educational Attainment and Use of Mental Health Services
A study conducted by Juarez, Samoa, Chung, and Seto (2010) regarding the disparities in
health and access to care among Asian and PI/Ps in Hawai'i, showed that higher education levels
were associated with better mental and physical health. According to a study by the University of
Hawai'i, Manoa (1994) high school graduation rates by Samoans (a PI/P subgroup) in Hawai'i is
among the lowest in the state. In addition to education issues, PI/Ps have the highest infant
mortality rate and lowest immunization rates, maternal substance abuse, and obesity rates (UHM,
1994). The need for higher education within the PI/P group is evident in the data available;
lessening the knowledge gap will increase mental wellness and provide this group with qualified
mental health professionals who are culturally competent and welcome by the community.
Education assessments often find that PI/Ps demonstrate a lack of support and culturally
competent educators. The Native Hawaiian Education Assessment of 1993 found that Native
Hawaiian students scored lower than national norms on standardized tests, were behind their
non-Hawaiian classmates when starting school due to a lack of parent support in prenatal and
early childhood educational programs, exceed non-Hawaiian students in excessive absentee
rates, and had more demand for special needs services with an emphasis on substance abuse and
violence prevention (Kamehameha, 1993). A vital issue for schools serving diverse populations
is that most often, the educators are from the dominant culture, with different beliefs and values
than their students, leading to misunderstanding and misjudging ethnic minority students (Leung,
1990). A proposed solution is 'cultural competency' defined as a set of attitudes, behaviors, and
13

policies that come together in a system of professionals to work effectively in cross-cultural
settings (Cross, Bazon, Dennis, Isaacs, 1989). In the United States, particularly the state of
Hawaii, where the PI/P population is higher than any other state, PI/Ps have significantly lower
enrollment numbers in higher education (Ah-Sam, Robinson, 1998). There is a critical need for
PI/P social workers, mental health counselors, law enforcement officers, and other professionals
to represent the majority demographic, however, there are few qualified applicants due to low
levels of education and training, English language proficiency, and cultural adjustment difficulty
in the workplace (University of Hawai'i Manoa, 1994).
Table 1 displays the number and percentages of degrees earned at the University of
Hawai'i, Manoa by students of Asian/Pacific Islander ethnicity from the fiscal year 1987 through
1995. The number of PI/P students matriculating over eight years at the University of Hawai'i
represents the smallest number of students within the subcategory, Asian/ Pacific Islander. This
number is disproportionately low as the PI/P demographic are the third largest ethnic group in
Hawaii (Kaholokula, 2007).

14

Table 1
Degrees by A/PI (Asian/Pacific Islander) students
A/PI Ethnicity 1987-
1988
1988-
1989
1989-
1990
1990-
1991
1991-
1992
1992-
1993
1993-
1994
1994-
1995
1987-
1995
(%)
Grand Total 3286 3834 3784 3753 3850 4127 4168 4280 100.0
A/PI Subtotal 2547 2457 2533 2454 2450 2642 2665 2691 64.7
Pacific Islander 47 53 48 47 37 63 61 52 1.3
Japanese 1345 1257 1237 1218 1134 1168 1151 1105 30.4
Chinese 537 510 496 479 531 553 595 590 13.6
Korean 80 101 107 81 89 115 104 115 2.5
Filipino 185 215 246 236 266 281 286 336 6.5
Hawaiian 164 141 192 164 190 234 232 263 5.0
Other Asian 99 100 114 123 100 113 124 117 2.8
Mixed PI 90 80 93 106 103 115 112 113 2.6

Note. Degrees Earned by Students of Asian/Pacific Islander (A/PI) Ethnicity at University of
Hawai’i, Manoa from FY 1987-1995.

Compared to the rest of the United States (U.S.), the census in 2017 reported 23.3% of
PIs had attained a bachelor's degree or higher, however this number drops to 17.7% among
single race PIs.
Additional Barriers to Use of Health Care
15

In the United States (U.S.), an estimated 8% of PI/Ps do not have health insurance,
compared to 6.3% of non-Hispanic Whites, with an estimated 17.3% living at the poverty line
compared to 10.4% of non-Hispanic Whites (Office of Minority Health, 2018). According to
data provided by the Office of Minority Health (2018), PI/Ps make up less than 1% of the
population but have significant gaps in health disparities with one of the highest rates of
smoking, diabetes, obesity, alcohol consumption, cancer, and heart disease in the United States.
The Maori represent 14.5% of New Zealand's inhabitants but experience mental health
issues disproportionately to the non-Maori population (Statistics New Zealand, 2001). The
Mental Health Commission (1998) in New Zealand understands that to be successful in treating
these indigenous peoples, mental health providers must consider Maori culture when developing
treatment strategy. Health reforms that started in the early 90's has given mental health providers
access to the Kaumatua (male and female elders), Kuia (wise elder women) and Koroua (elder
men) as consultants (New Zealand Mental Health Commission, 1998). The development of
Maori-led and managed mental health services have significantly multiplied over the last several
years, showing a notable increase in the utilization of services by Maoris and a gradual slowing
in the suicide rate for this PI/P subgroup (Ellis, Collings, 1997). In other parts of the world, PI/Ps
face different systemic access barriers than those in New Zealand relevant to mental health
services.
In Canada, immigrants that include PI/Ps, experience tangible barriers to utilizing mental
health services. Salami, Salma, and Hegadoren’s (2017), the study of access and utilization of
mental health services for immigrants and refugees, show that many experience high financial
costs of accessing counseling services, transportation barriers, and a lack of childcare for those
needing to attend therapy sessions. Their study also identifies community-based mental health
16

services as high priced and rarely covered by public health insurance. Per Salami, Salama and
Headoren (2017), this often deters immigrants, including PI/Ps, from seeking out and utilizing
these services.
A study of length and cost of hospital stay in the United States for psychotic disorders by
Bessaha, Shumway, et al., (2017) show that Asian and PI/P patients have the lowest admission
rate of all participant’s ethnicities.
Lack of cultural sensitivity and high cost of these services is a known barrier to
utilization for this group. Understanding how to effectively maneuver around cultural values is
essential in closing the gap in service utilization (Smith & Trimble, 2015). The country of Samoa
recently developed a partnership model approach to mental health care described by Enoka, et
al., (2013) as a 3-part model. The model consists of a mental health nurse that goes to a patient’s
family’s home and explains the patient’s illness while asking the family to work collaboratively
with the patient on their treatment plan; personally addressing the family’s concerns and
allowing them to tell their story in their own words, and finally allowing the family to determine
what they believe the root cause of the problem could be and what actions should be taken
(Enoka, et al., 2013). The Samoa Nurses Association reports that the move to community-based
care has improved recovery, individualized care, medication compliance, and communication
between the family and medical staff (Enoka, 2001). Creating affordable community-based
options for mental health and following the example in New Zealand and Samoa of incorporating
cultural competency in the development of mental health assistance programs may yield higher
utilization rates among this population in the United States other parts of the world.

17

Table 2
Length of stay (LOS) vs. Cost of stay (COS)
Variable LOS Model COS Model
Fixed effect Coeff SE P Coeff. SE P
Intercept (Constant) 11.29 .24 <.001 8.96 .02 <.001
Age .03 .002 <.001 .003 .000 <.001
Women (Ref: Men) .69 .04 <.001 .07 .002 <.001
Race (Ref: White)
African American -.58 .05 <.001 -.04 .002 <.001
Hispanic -.46 .08 <.001 -.02 .004 <.001
A/PI 1.13 .19 <.001 .10 .009 <.001
Native American .68 .30 .02 .02 .02 .26
Other .24 .18 .19 .02 .007 .01

(Bessaha, Shumway, et al., 2017)
Note. Multilevel model results for length of stay (LOS) and cost of stay (COS) among 677,684
patients hospitalized with a primary diagnosis of a psychotic disorder, 2003-2011.

Systematic Racism in Health Care
Experiences of racism or discrimination can be mentally traumatic for individuals of any
background. Though considered a ‘model minority’ for economic and educational success,
(Sabato, 2016), Asians and PI/Ps report ongoing experiences of racism and discrimination. A
study by Kaholokula (2007) describes that native Hawaiians experience high levels of depression
18

due to perceptions of discrimination and racism. At the apex of the Polynesian triangle, the
islands of Hawaii have experienced significantly more acculturation than most other Polynesian
islands due to its recent statehood in 1959 (Kaholokula, 2007). Barbee (2002) states that there is
a need for psychiatric nurses to acknowledge that racism is profoundly detrimental to the mental
health of millions of individuals. According to Griffith et al., (2007), institutionalized racism in
health care directly contributes to poor health outcomes and unequal access to care by people of
color. Jones (2000) describes that racism and discrimination in healthcare can manifest in several
ways, including lack of protocol for patient follow-ups or outreach, complex referral,
appointment procedures, and inappropriate services or resource materials. Mounting empirical
research indicates that racial discrimination is a critical determinant of an individual's well-being.
A strong relationship exists between experiences of racism and negative mental health symptoms
such as depression, psychological distress, and anxiety (Priest, et al., 2013). Increasing cultural
competency and the implementation of antiracism training may help mitigate these obstacles for
PI/Ps in healthcare.
Impact of Underutilization
In the United States, the U.S Public Health Service (1999) noted that suicide has become
the fastest-growing cause of death for American youth. Else, Andrade, and Nahulu (2007)
conducted a literature review on Asian and PI/P populations in Hawai’i and found that not only
are the rates of completed suicide among PI/Ps some of the highest in the world, but Native
Hawaiian young adults have a higher rate of suicide than the national average. Every three days,
there is a successful suicide in Hawai’i (Galanis, 2006). Else, Andrade, and Nahulu’s (2007)
study identifies that suicide behaviors among PI/Ps require an understanding of acculturation.
Data shows a higher risk of suicide-related behaviors correlates to high cultural affiliation.
19

Studies show a strong correlation between the number of PI/Ps that commit suicide and
mental illness. There are an estimated 500 suicides per year in New Zealand (Ministry of Health,
2013). Though the suicide mortality for PI/Ps occurs at a lower rate than the population, their
numbers are three times higher than European New Zealanders. Tiatia-Seath, Lay-Yee, and Von
Randow (2017) conducted a longitudinal study over a 17-year period (1996-2013) to show trends
in suicides of PI/Ps living in New Zealand. Their research showed that PI/Ps between the ages of
12-18 years were three times more likely to attempt suicide at a rate of 8.6% than the Europeans
living in New Zealand at 2.7%. Their research also identified that Samoans made up the largest
group for PI/P suicides at 35.5% of these 16.1% were related to mental or behavioral disorders
compared to 13.1% of all suicides in New Zealand. Though Tiatia-Seath, Lay-Yee, and Von
Randow’s (2017) study show a higher rate of suicide due to mental illness among the Samoan
population, collectively, PI/Ps and Asians continue to show increases in the number of successful
suicides and suicide attempts. Scholars theorize that Asian and PI/Ps underreport suicide and
suicide attempts due to cultural injunction of bringing embarrassment or shame to their families
(Choi, Rogers, Werth, 2009).
The suicide statistics provided by the New Zealand Ministry of Health (2013) are the
most recent numbers available. The study longitudinal study conducted by Tiatia-Seath, Lay-
Yee, and Von Randow (2017) reviewing trends of suicide in PI/P communities in New Zealand
is the most recent empirical research of this nature.

20

Table 3
PI/P (Pacific Islander/ Polynesian) Suicides

Note. PI/P (Pacific Islander/ Polynesian) Suicides per year by ethnicity in New Zealand, January
1996-December 2013.

Year Samoan Cook
Islands
Tongan Other
Pacific
Total
Pacific
Total NZ
2001 12 4 3 3 22 508
2002 8 7 1 2 18 470
2003 5 9 2 7 23 522
2004 5 3 4 3 15 494
2005 8 5 4 4 21 515
2006 9 3 4 5 21 524
2007 11 3 4 7 25 501
2008 7 6 6 10 29 518
2009 8 6 6 8 28 512
2010 8 6 3 5 22 534
2011 6 7 11 1 25 493
2012 10 6 7 6 29 550
2013 7 6 3 5 21 509
Total 104 71 58 66 299 6650

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The abundant social and cultural pressures on PI/Ps presented in this literature indicate
their high suicide rates (Tuck, Yank, 2014). This problem warrants research as research may
compel change.
Clark and Estes (2008) Gap Analysis Framework
The conceptual framework for this study is based on the 2008 Clark and Estes gap
analysis framework. This framework identifies the gaps between an organization or entity’s
current state and desired future state. This research-based framework describes the reasons for
these gaps as knowledge, motivation, organizational, and social influences (Clark & Estes,
2008).
This framework explicitly examines the position of PI/Ps and their declarative knowledge
regarding mental health and the metacognitive knowledge surrounding help-seeking behavior
within this group. The following section will examine motivational factors, primarily self-
efficacy, that can influence the achievement of the goal. Lastly, the study will explore the
achievement setting surrounding PI/P culture and the social and organizational influences.
Knowledge
Because of the disproportionate number of suicides within PI/P communities around the
world and a high prevalence of untreated mental illness, PI/Ps must be knowledgeable of what
mental illness is and what they can do about it as a community. Ensuring educators have cultural
competency when educating PI/Ps and promoting higher education in this community may help
produce PI/P mental health workers, social workers, and educators that are critically in need to
represent this demographic (University of Hawai’i Manoa, 1994). Beyond educating PI/P
students on the benefits of mental health upkeep, healthcare providers can be a valuable source
of knowledge for this community.
22

Primary care physicians and other health care providers can be valuable resources for
PI/Ps. By utilizing established rapport to promote mental health services during routine office
visits and physical exams, primary care physicians can educate PI/P patients on the significance
and validity of a healthy mental state (Ta, Von, Gielen, et al., 2007). The increase in knowledge
of mental health for this community can increase their motivation to seek assistance.
Motivation
Clark and Estes (2008) describe motivation as something that ‘keeps us moving, and tells
us how long to spend on a task.' In the case of PI/Ps and mental health, the strong negative
stigma around mental health is often why this group lacks the motivation to seek mental illness
assistance (Rafai, 2016). The familial and cultural pressures commonly experienced in PI/P
communities directly contribute to an individual's avoidance of seeking help to avoid ‘shaming
one’s family’ (Lee & Faran, 2004). Provided the resources described in the knowledge section
above, PI/Ps could build up the motivation and self-efficacy to obtain help for mental illness and
help for others in their community.
Bandura (1977) describes self-efficacy as the belief that one can complete necessary steps
to attain the desired goal. For PI/Ps, their culture places a large emphasis on religion and the
capability of divine intervention to heal all ailments including mental illness (Rafai, 2006). This
belief lowers the motivation of PI/Ps to seek professional assistance, and instead they turn to
religion and prayer to address their mental health struggles. Gallimore and Goldenberg (2001),
state that opinions and views exchanged during social interactions can impact one's self-efficacy.
As such, biases and negative stigmas around mental health discussed in social, religious,
familial, and community settings can impact the self-efficacy of PI/Ps.
23

Organizational and Social Factors
This section will examine organizational and social factors that serve as barriers to
mental health assistance for PI/Ps. Clark and Estes (2008) describe that culture, weak structure
and policies, and insufficient resources can contribute to organizational gaps. Studies have
shown that the high costs of mental health services deter marginalized groups, including PI/Ps,
from seeking assistance (Salami, Salm, & Hegadoren, 2017). Examination of cultural
competency within healthcare is also necessary to access organizational barriers. A study by
Borrow, et al., 2011 shows that a lack of cultural sensitivity in healthcare is a barrier often seen
when considering immigrant populations such as PI/Ps. Though processes by The Mental Health
Commission (1998) in New Zealand took active steps to train providers on cultural competencies
around PI/Ps, and proactively sought to incorporate PI/P culture in treatment plans saw notable
increases in utilization of services by this group.
The hierarchy of PI/P communities and families can be compared to the structure of
many organizations. Enoka, et al., (2013) describe the structure of PI/P communities to resemble
a pyramid comprised of either a religious or family leader at the top, followed by family or
community elders who have a higher level of power to make decisions, and the rest of the
community at the bottom; these individuals take direction from the two tiers above them. The
buy in and endorsement of community leaders to seek professional mental health assistance can
positively affect utilization numbers in this community.
Moreover, there are social factors to consider when examining this problem, such as the
cultural environments in which PI/Ps are born. Clark & Estes (2008) describe culture as multi-
dimensional and is both conscious and unconscious. They state that culture is a conduit for
describing goals, beliefs, and values learned by people over time (Clark & Estes, 2008). For
24

PI/Ps, their culture blankets them in the belief that mental illness is taboo and help-seeking
behavior makes an individual appear weak (Lee & Faran, 2004). To increase their utilization of
mental health services, they must overcome knowledge, motivational, organizational, and social
factors.
The figure below illustrates the stakeholder’s (PI/Ps needing mental health assistance or
experiencing mental illness symptoms) obstacles to utilizing mental health services and the
outcome for this group because of these barriers. Stakeholders face these obstacles, categorized
into KMO as shown in the above figure, which ultimately results in disproportionate rates of
suicide in this group and poor mental health. For the stakeholder to receive needed care, they
must first overcome motivational obstacles such as a solid negative cultural stigma and self-
efficacy. Do they believe they can seek assistance? Addressing knowledge gaps, do they know
what mental health professionals are and what they do? Do they recognize when they need help,
and do they know how to go out and get help? Consider organizational obstacles like the cost of
treatment and language barriers, and lastly, apprehensions around discrimination. The often
results of not overcoming these obstacles are PI/Ps who may suffer from mental illness and it
could manifest in forms of domestic abuse, substance abuse, and suicide (Steward-Withers,
O’Brien, 2006).

25

Figure 1
Conceptual Framework

Conclusion
Chapter two examined the culture of PI/Ps, specifically related to their strong negative
stigma on mental illness and resistance to seeking help outside of their families and
communities. Additionally, the chapter explores barriers in education and healthcare that further
increase gaps in the utilization of mental health services. The chapter also highlights successful
strides made in New Zealand and Samoa around cultural competency in healthcare and how this
approach has increased the utilization of mental health services by PI/Ps in these countries.
Finally, examining the gaps that currently exist for these peoples to access and utilize mental
26

health services, examining the effects of discrimination and racism on their mental health, and
the often outcome of these collective obstacles being suicide is assessed.
Chapter three reviews the significance of understanding the experiences of PI/Ps who
have diagnosed and undiagnosed mental health issues, their encounters with mental illness
through family and in their communities, and to provide background information on the research
design and methodology.

27

Chapter Three: Methodology
Mental illness includes a variety of conditions. Some of these encompass depression,
stress, anxiety, bipolar and psychotic disorders, which are all tied to poor health outcomes (Scott,
etl al., 2016). Low rates of utilization of mental health services in the United States and other
countries is a concern (Substance Abuse and Mental Health Services, 2018), particularly among
ethnic minorities (Allen, Smith, Kim, Hafoka, 2016). Negative cultural stigmas perceived as real
barriers and low mental health literacy are some of the reasons tied to low utilization of mental
health services by minority populations, including PI/Ps (Cheung, Snowden, 1990).
In 2016, the United States (U.S.) Census Bureau reported that 1.5 million United States
residents identify themselves as PI/Ps. The state of Hawaii is home to the largest PI/P population,
followed closely by California, Washington, Texas, and Utah (U.S Census, 2012). When data is
disaggregated in existing research, Native Hawaiians had higher hospitalization rates due to
schizophrenia than Filipinos, Japanese, and Chinese in the study. However, when aggregated,
AAPI's had lower rates of schizophrenia than their Caucasian counterparts (Sentell, et al., 2013).
This shows that combining the PI/P demographic with the Asian demographic can skew data
relevant to identifying issues specifically relevant to the PI/P group.
In a survey by the United States Census Bureau and the National Center for Health
Statistics (2017), compared to single-race Asians, PI/Ps were likely to experience more
psychological distress in the last 30 days. This survey also shows that 4.1% more of PI/Ps
experience psychological distress compared to 3.1% of the country's population. This problem is
critical to address because by not decreasing the organizational disparities and cultural barriers
that contribute to PI/Ps underutilization of mental health services, PI/Ps will continue to struggle
28

with attaining higher education levels, professional careers and lower disproportionately high
suicide and mental illness rates.
Research Questions
1. What are the knowledge, motivation, and organizational issues associated with the
underutilization of mental health services by PI/P communities?
2. What are the recommendations regarding KMO factors for improving mental health
utilization within the PI/P group?
Research Design and Methodology
This study utilizes a qualitative research methodology aligned with the recommendations
of Merriam and Tisdell (2016). It will consist of in-person interviews of PI/P adults between the
ages of 18-70. Using Merriam and Tisdell’s (2016) qualitative research approach, the study will
provide a clear picture of the unique situations the PI/P community finds itself in related to the
context of mental illness. As Merriam and Tisdale (2016) describe, the study is not to predict an
outcome but to devise a feasible solution by understanding the realistic nature of the setting.
The core of this study was based on the data retrieved from eight personal interviews and
direct information from the participants. It centered on gaining quality data versus a high
quantity of data (Weiss, 1994). Additionally, personal interviews in a natural setting (of the
participant's choosing) best allowed the participants to freely share their experiences while
giving the interviewer the opportunity to observe their non-verbal cues and mannerisms
(Creswell & Creswell, 2018). Interviewing PI/Ps of varying ages, genders, and backgrounds
increased understanding of PI/P experiences with mental illness.
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Site Selections and Participants
A popular PI/P church in Northern California’s Bay Area was the best site to recruit
participants. The church is a Christian denomination sanctuary that hosts several services for
PI/Ps on Sundays and various community events during the week. Their services on Sundays
begin with a Samoan service, followed by a Tongan and Fijian service. During the week, they
host youth group events, language classes, bible studies, and marriage classes for each of these
PI/P groups in addition to Native Hawaiian and Maori. The participants recruited from these sites
helped the researcher answer the research questions (Creswell, Creswell, 2018). The researcher
also contacted PI/P clubs at local community colleges in the area, known to have large
populations of PI/P students. The researcher also attempted to recruit participants by posting the
study in online PI/P forums and to social media sites that cater to PI/Ps.
The target population for this study were individuals of PI/P ethnic descent whose
upbringings were in PI/P households; there will be no requirement that participants must be
single race PI/Ps. The study targeted participants born in the United States and those who
immigrated to the United States. Age requirements for participants were 18 years and older, and
there was no gender requirement.
Sample Size
The sampling for the study was purposeful and sought a sample size of 8-12 adult PI/P
individuals who are willing to give private interviews relative to their experiences with mental
health. These experiences were personal, or behaviors and practices witnessed within their
families and communities. I interviewed hour to hour and half long interviews with eight adult
PI/Ps who volunteered for this study. Five of the participants were born in the United States, the
30

other three were born in various South Pacific Island countries. All participants currently live in
the United States and ranged in age from eighteen to sixty-seven.
Instrumentation
The face-to-face interviews allowed a better understanding of each participant's
experiences with mental illness. I conducted the interviews of the participants, observed their
behavior, and gathered and interpreted the information (Creswell & Creswell, 2018). Before
beginning each interview I reviewed the interview protocol with each participant to create
transparency regarding the study's purpose, their role, and rapport. Each participant also received
an information sheet stating the purpose of the study as well as how their information will
contribute to the goal of the study. Each participant was given the opportunity to choose a
pseudonym for the study. For those that did not choose a pseudonym, one was provided for them
to protect their privacy. An unstructured interview method was utilized. This allowed for the
interviews to appear more conversational and elicit more honest responses from the interviewees
(Creswell & Creswell, 2018).
Data Collection Process
Approval from the Internal Review Board (IRB) of the University of Southern California
was obtained to conduct this study. With IRB approval, I placed phone calls and/or sent emails to
several religious leaders in the area, as well as to PI/P clubs and groups on local college
campuses to generate interest in the study and ask for assistance in seeking participants. Also,
advertisements of the study were posted to PI/P community forums and sent to PI/P social media
sites. The interview protocol began with introductions, an explanation as to the purpose of the
study, and collecting a signed informed consent document from the interviewee (Creswell,
Creswell, 2018). I explained to each participant that they may decline to answer certain questions
31

and can end the interview at any time for any reason. I took handwritten notes while also
utilizing a recording device to ensure accuracy. The participants gave their permission for the use
the recording device before the start of the interview. When the interview was completed, each
participant was thanked and acknowledged for their participation. I also re-assured the
participants of the confidentiality of the interview.
Because an audio recording device captured the interviews, and hand-written notes, the
analysis of the data began with the transcription of the information on the recording device and
the typing and cataloging of the field notes to ensure accuracy (Creswell, Creswell, 2018). In
reviewing the data, I made the necessary decisions to narrow the study by disregarding any
information that was not relevant to the research questions or purpose of the study (Merriam,
Tisdell, 2016). The data was aggregated into smaller units by theme and category relative to the
purpose of the study. The data collected was sorted and organized in a qualitative software
program that coded the data.
Positionality
According to Merriam and Tisdell (2016), positionality considers the relationship
between the researcher and factors such as ethnicity, education, class, and personal experiences
of study participants that may impact the research. As a member of the PI/P community, I had to
maintain awareness of my own assumptions and biases in relationship to the study to respect the
personal experiences of the participants.
Due to the specificity of this topic and PI/P mistrust of community outsiders, the nature
of this study required an individual from the PI/P community to conduct the research. I believed
I was able to conduct this research as a Samoan woman who works in healthcare. It was my
32

understanding the participants in this study were comfortable enough to share their personal
experiences with mental health.
Conclusion
Chapter 3 outlines the methodology, site and population selection, data collection
process, and data analysis for the study. Qualitative research methods such as one-on-one
interviews are how the necessary data was captured to support the study and answer the research
questions. Utilizing open-ended and probing questions were the primary data collection methods
that were used to understand the participant’s experiences.
Chapter 4 will provide the results of the data collected from the interviews and any
reoccurring themes identified while analyzing the data.

33

Chapter Four: Results or Findings
This chapter presents data gathered through eight semi-structured interviews of PI/P
participants ranging between the ages of 18-70. All participants live in the continental United
States. Data collected was analyzed to identify common themes. Data collected from the one-on-
one interviews was explored using content analysis. The research utilizes Clark and Estes (2008)
gap analysis framework to explore PI/P’s knowledge, motivation, and organizational influences
surrounding their underutilization of mental health services. It also uncovers how adhering to
cultural values impact PI/P adults in terms of mental illness and factors that impede mental
health services by this group. Lastly, it unveils factors outside of cultural customs that contribute
to PI/P’s underutilization of mental health services.
Significance and Validation
The repetition of the same concept by five of the eight respondents is assumed to have
significance as this represents most of the respondents. It likely reflects that this type of activity
is generally more common (Gibbs, 2018). The participants provide insight into PI/P culture, but
do not represent the collective views of all PI/Ps. The interviews were semi-structured and
participants shared their memories and recollections of events past, and their opinions and
thoughts on possible solutions. Respondent validation was performed to ensure the study's
internal validity by eliminating misinterpretation (Merriam, Tisdell, 2016).

34

Table 4
Participant Demographics

Knowledge Findings
The study examined two types of knowledge findings, declarative and factual.
Declarative knowledge is selective and is not conscious until it is retrieved by cues such as
questions (Ten Berge Timon, Van Hezewijk Rene, (1999). Factual knowledge is the knowledge
of basic elements and terminology related to a specific topic to solve a problem (Krathwohl,
2001; Rueda, 2011). Four common themes emerged. They are discussed sequentially.
Declarative Knowledge
Two themes emerged from the data collected. 7 of the 8 participants described their
knowledge of professional assistance being scarce for PI/Ps and expensive. The other theme
described by 8 of the 8 participants was the belief that prayer and strong religious faith treat
mental illness.
Name Gender Ethnicity Birth Country
Norma Female Samoan United States
Leilani Female Tongan New Zealand
Wanda Female Hawaiian United States
Sarah Female Samoan United States
Laura Female Samoan United States
Opal Female Tongan United States
John Male Samoan Samoa
James Male Tuvaluan/Samoan Samoa
35

Accessibility. PI/Ps have limited understanding of the costs for mental health treatment
and believe services are not accessible to them due to high costs. 7 of the 8 participants discussed
that many PI/Ps do not seek professional assistance due to absorbent costs, though none had ever
sought professional assistance. Participant Norma shared her perception that professional
assistance would be expensive and unrealistic, “I don’t know how much it would cost to see a
therapist, but you feel like that is a rich people thing and our family just does not have the
resources to spend on seeing a therapist when we have so many mouths to feed.” Similarly,
participant James stated, “I don’t think about getting help. Where would we even go and how
much would it be? I hear therapists are expensive and I think that’s a lot of the reason why PI/Ps
just don’t go looking for that information.” Two other respondents shared that these types of
services are not available in their communities. Sarah explained that there are many types of
doctor’s offices in her community, but none advertise psychiatry or behavioral health services.
Similarly, Opal explained, “we have a ton of dental offices, optometry offices and others but I
have never seen an ad for mental health or the words ‘Mental Health’ on a building in our
community, I’ve lived here my entire life.”
Religion as a Treatment Option. The topic of religion was iterated by every participant
in the study. Each described that religion plays a major part in their families and culture. Sarah
stated, “there is nothing prayer can’t heal in our culture, and that includes mental issues. This is
what we are taught from a young age, and we pass that down to our children. God has gotten us
through a lot, and I do not need to see a therapist.” Similarly, James explained, “many have
shared personal struggles and feelings of depression with me. We pray together, talk things
through, and I check on them often. They are all doing well and did not need professional help.”
All of the participants were asked what they would do if a family member of friend were ill to
36

which they all responded they would treat them at home with over-the-counter remedies and take
them to the local hospitals if their conditions worsened. When asked why an individual who
might be suffering from a mental illness not be taken to a hospital their responses varied. 2 of the
8 respondents answered, “I don’t know”. The other 6 collectively responded with variations of
their culture’s belief that mental health can be treated with prayer, meditation, or strong mental
grit whereas physical illness such as a broken bone or need for surgery need professional medical
attention.
Factual Knowledge
The data suggested that participants did not have strong factual knowledge of resources
available to assist with mental health and their rights to equitable and affordable care. The data
also shows a low factual knowledge or patient rights to privacy and confidentiality.
Resource Knowledge. Opal asked, “Where would we go? If you go to the emergency
room, they don’t help you unless you’re suicidal at which point they’ll hold you against your will
and your family will find out.” Similarly, Wanda expressed, “I’ve never spoken with a therapist
and I don’t really know where I would go to find one. I guess I could Google what is available in
my area, but I don’t know if they would take my insurance or what I would need to be seen.”
Participant Leilani stated, “I know there is an anonymous suicide help line because they
advertise it on tv, but what about if you’re not suicidal? Who do you call if you just want to talk
to someone about how you’re feeling for things like depression or anxiety?” The data suggests
that having more knowledge on how to gain or access services may increase utilization.
Patient Rights. All 8 of the participants expressed concerns of privacy and information
they might share with a therapist becoming known to their communities or family. Participant
James shared, “I know there are counselors at school for our kids, but I tell mine not to talk to
37

them. They don’t know our culture and would probably misinterpret what they say. I don’t need
child protective services knocking at my door”. Participant Wanda indicated, “I can’t risk what I
tell someone in confidence getting out. How am I supposed to know this person won’t tell my
story to someone else? Even if the therapist is not PI/P, maybe they have friends who are and if
they choose to share my story with them, word will surely get back to my family.”
There were no distinctive correlations between factual knowledge and age, gender,
country of birth, or ethnicity. 7 or the 8 participants shared similar experiences and
understanding of factual knowledge regardless of these factors.
Motivation Findings
The study examined two types of motivational influences, self-efficacy and attribution.
Self-efficacy refers to a participant’s belief that they can seek treatment for mental illness if they
choose to. Attribution is a participant’s belief that the success or failure of professional
assistance is attributed to their being PI/P. Four themes emerged and are listed sequentially.
Self-Efficacy
The data shows that the participants struggled with feeling of self-efficacy or self-worth
when considering professional assistance for mental health.
Feelings of Deficiency. All 8 participants shared a mentality of self-deficiency when
considering seeking professional assistance. Participant Sarah conveyed, “I felt for a long time
that I needed to talk to a professional about feelings of depression I was experiencing but when I
told my sisters they encouraged me not to seek help because it meant that I was too weak to deal
with my problems on my one.” Comparably, participant Laura described being told by family
members that she did not need to seek professional assistance to deal with mental issues she was
38

experiencing due to a sexual assault, but instead came from a line of strong women who could
handle any obstacle through prayer and grit.
All 8 participants felt that showing interest in seeking professional assistance was a sign
of weakness, and would mean they were not strong enough to deal with their issues on their own.
Participant James stated, “if I saw a therapist, it would mean I couldn’t hack it as a Samoan man
and basically am a failure.” Participant Wanda shared, “when my sister went through a divorce
she mentioned wanting to talk to a therapist and family jumped on her, accusing her of being too
weak and that she needs to toughen up.” All 8 participants strongly agreed that PI/Ps perpetuate
ideology that seeking assistance is a sign of inadequacy.
Guilt Complex. Six of the eight participants described experiencing feelings of guilt for
considering or seeking professional assistance for mental health. Participant Norma described an
incident where she had met with a counselor at her university to discuss personal issues of
anxiety she was experiencing. When she disclosed this to her family she was discouraged from
continuing, “When I returned to school from spring break I saw the counselor but kept thinking
of my parents and how guilty I felt for being there so I never went back.” In parallel, participant
Leilani described, “my father was a religious leader in our Tongan community, considering
seeing a therapist would be a betrayal to my father and what he preaches.”
Attribution.
The findings show that attribution may be a barrier for PI/Ps to seek mental health
assistance. All eight participants described PI/P culture as an attributing factor to low utilization
of mental health services.
Obstructive Culture. 8 of the 8 participants shared that professional mental health
assistance for PI/Ps is rivaled by a deep cultural belief that these types of services are
39

unnecessary. Participant John expressed, “behavioral health therapy is a great idea, but I am a
Samoan man. I know that as a Samoan, it’s just not for me.” Participant Sarah described, “I think
a lot of us could benefit from having this type of help, but I don’t think many consider it because
our culture does not support it.” Comparably, Participant Wanda shared, “if you are brought up
in a typical PI/P household, you just don’t talk about mental health. It’s just understood.”
Collectively, all 8 participants expressed that PI/P culture does not encourage the utilization of
mental health services and downplays the significance of mental health.
Familial Obligation. 7 of the 8 participants shared a strong sense of familial obligation
as an attributing factor for low utilization. The extended family is a Herculean social unit in PI/P
culture designed to guide and mediate actions of family. Participant Opal revealed, “Family is
everything in our culture. We have to do what’s best for the whole family, not just ourselves.”
Opal goes on to explain, “getting help from outside of the family, especially if you’re telling
family business to non-family members, is a big no; we have to keep our family’s reputation
intact.” Similarly, participant Laura shared, “When you are a PI/P, you just know that your
family is everything. Whatever you can do for the best of your family is a PI/P’s mission.” This
strong sense of loyalty to the family unit is often what deters PI/Ps from seeking professional
mental health assistance.
Participant James stated, “If you see a professional because of depression or other mental
health issues, the community looks down on your family.” Comparably, participant Leilani
expressed, “I’ve seen people spread vicious rumors telling others not to marry into certain
families because one of theirs committed suicide so their genes must be weak.” Participant Sarah
revealed, “my cousin told family elders she was sexually assaulted by a cousin and instead of
reporting him they just shipped him off to other family so the news would not ruin our family’s
40

reputation.” The findings show the need to protect the family over oneself may contribute to
increased underutilization of mental health services by PI/Ps.
Organizational Findings
The two categories of organizational and social influence are cultural models and cultural
settings. There are two cultural models: the PI/P cultural model (e.g., collectivistic mentality that
the needs of the group supersede that of the individual) and the American/Westernized cultural
model (e.g., the individual has the option to choose when the needs of the individual supersede
those of the group). The cultural settings are healthcare facilities and schools.
Cultural Models
The data suggested that the differences between the PI/P cultural model and
American cultural model could serve as a barrier.
PI/P Cultural Model. The hierarchy of PI/P families and communities can be compared
to organizational structures familiar to Westerners or Americans. John explained, “our family
chief is like the CEO for us. They make all decisions for the family including how families
should address things like mental illness with a family member.” Similarly, Laura described,
“PI/P culture is to convene the family when there are problems, we get direction from our chief.
We do not make decisions individually.” Both Leilani and Opal shared that their families inform
religious leaders of situations before the family chief, “My mom was not fond of our family chief
so she would consult our pastor first and the chief second.” Opal goes on to explain that only a
religious leader can supersede a chief. Contrary to the PI/P cultural model, the American cultural
model places a larger emphasis on the needs of the individual instead of the group.
American Cultural Model. 5 of the 8 participants were born in the United States. Each
shared their experiences balancing their PI/P culture and the American culture. Norma describes
41

when she was in school, “My American friends complained often about chores and other
responsibilities; they only cared about what they wanted and not helping their households.”
Norma appeared physically agitated as she recalled these details. Participant Sarah shared, “I met
with a therapist for a consultation. I spent the whole time explaining my Samoan culture since
she was unfamiliar, figured from there she would not be able to help me.” John explained how
confused he was with American culture when he arrived from Samoa. His first experiences with
American culture were at his first job where he learned quickly it was an ‘every man for himself’
mentality in this country, “at lunch people ate what they brought, some had nothing to eat so I
offered some of what I had. Back home, lunch is like a potluck, we come together and share
what we have.”
Cultural Settings
The data suggested that the cultural settings in healthcare facilities and schools could also
serve as a barrier.
Cultural Knowledge and Expectations in Schools and Health Care. The data
highlights the gap between the PI/P and American culture model. Findings support that it would
be difficult for PI/Ps to receive equitable mental health services if they chose to utilize available
resources. Participant Sarah described having to explain to a high school counselor that her
grades were declining because she had an after-school job and helped to care for her elderly
grandparents. Sarah stated that the counselor’s response to her was, “why do you have to do all
of that, you’re only sixteen and should have fewer adult responsibilities. I didn’t understand what
she meant, she sounded very selfish.” Participant James expressed, “I have not considered ever
seeing a therapist, but even if I did, they wouldn’t understand us. A lot of our issues stem from
42

our culture, how could a Westerner possibly relate?” Some misunderstandings of culture can lead
to serious consequences for PI/Ps.
Participant Norma shared an experience that highlights how misunderstanding of culture
can be damaging to PI/Ps, “my cousin shared more than he should have with a school counselor
about how our family is at home and child protective services was called. It was really scary for
his parents who don’t speak English well.” Norma went on to describe the family chief
explaining to the young adults and children in the family “we do not tell our business to others, if
they are not PI/P they don’t have the capacity to understand our way.” There were no distinctive
correlations between factual knowledge and age, gender, country of birth, or ethnicity.

43

Chapter Five: Recommendations
This study examined the experiences of PI/Ps with mental health and explored possible
reasons for underutilization of services by this population. Presented in this section are proposed
solutions and recommendations that may assist in eliminating the knowledge, motivation, and
organizational gaps that impact the utilization of mental health services by PI/Ps.
This chapter will address the research questions from chapter one utilizing the KMO theoretical
framework and connect the data to the literature from chapter two.
Knowledge
According to Clark and Estes (2008), the path to educating individuals is through
information, education, training, and job aids; The chosen approach should depend on the type of
knowledge needed to accomplish the desired outcome. The two assumed knowledge influences
in this study are declarative and factual knowledge.
Declarative Knowledge
The results of the data analysis indicated the respondents had a low declarative
understanding of their access and rights to equitable mental health resources, and religion as a
viable and effective form of treatment. The analysis did not indicate gaps between age, gender,
ethnicity, or country of birth. The participants responded similarly and shared common themes
when discussing their declarative knowledge. Clark and Estes (2008) describe education and
providing information as tools to enlighten and bring forth understanding of unfamiliar concepts
and ideas. Therefore, educating PI/Ps on the significance and reality of mental illness, sharing
knowledge on effective treatment options, and enlightening PI/Ps on recognizing signs of
escalating or significant mental illnesses can benefit their communities and increase their
44

utilization of these services. Moreover, the partnering of health care providers and community
leaders may substantiate the need to expand declarative knowledge within this group.
Factual Knowledge
Results from the data analysis indicated that the participants have a low factual
understanding of available resources and their right to privacy. According to Clark and Estes
(2008), factual knowledge is the most basic information an individual requires to accomplish a
desired goal. A suggested recommendation is that health care providers, PI/P community centers,
and schools in areas with high PI/P populations provide information pamphlets to members of
the PI/P community outlining available resources in their area while highlighting their rights to
privacy as outlined in the Health Information Portability and Accountability Act (U.S.
Department of Health & Human Services, 2021). Moreover, the pamphlets should be translated
to decrease language barriers.
Motivation
The two assumed motivation influences of this study are self-efficacy theory (Bandura,
1991) and attribution theory (Rueda, 2011). Self-efficacy is defined as an individual’s belief in
their self and their own abilities (Bandura, 1991). Attribution is defined as attributing an
individual’s success or failure to a specific factor or cause (Rueda, 2011).
Self-Efficacy
The data shows that the participants struggled with feelings of low self-efficacy when
considering professional assistance for mental health. Specifically, the participants collectively
shared a lack of confidence when considering professional assistance as help-seeking behavior is
associated with labels of ‘weak’, ‘unworthiness’, and ‘embarrassment’. This gap in motivation
warrants a proposed solution.
45

Research shows that modeling and positive feedback increase self-efficacy (Pajares,
2006). This suggests that PI/Ps require a PI/P role model or a relatable individual that
understands their culture to advocate for the utilization of mental health services. These
individuals can provide the positive feedback that is lacking in PI/P homes. As such, the
recommendation is to recruit trusted individuals within these communities and to educate them
on the need of mental health services within their community. Clark and Estes (2008) describe an
individual’s belief of their chances to produce a desired outcome directly affects their
motivation. Additionally, Pajares (2006) describes that an individual’s self-efficacy can be
impacted by feedback received during social interactions within varying cultural settings.
Therefore, from a theoretical outlook, schools, healthcare organizations, and PI/P community
centers could help increase self-efficacy in PI/Ps by providing them positive feedback within
their respective settings.
Attribution
The data results suggest that attribution could be a barrier to PI/Ps utilizing mental health
services. Specifically, most of the participants attributed their inability to seek and utilize mental
health services to their PI/P culture. Additionally, many participants described a strong negative
stigma associated with individuals that participant in mental health treatment. As such, a
proposed solution to the attribution barrier is provided. Rueda (2011) suggests that individuals
seek to interpret and attribute the reason of a success or failure to a specific cause. This suggests
that providing PI/Ps with methods of how to build confidence in oneself and to increase self-
efficacy would allow them to attribute their experiences to their effort and knowledge thus
increasing motivation. As such, the recommendation is that schools, healthcare organizations,
46

and PI/P community centers provide PI/Ps with tools, demonstrations, and education on how to
build self-assurance and assertiveness.
Organizational Factors
Two culture models were assumed to be social influences or barriers to PI/Ps utilizing
mental health services: the PI/P cultural model and the American cultural model. Two
organizational influences were assumed to be an influence or barrier, healthcare organizations
and schools. The PI/P cultural model is based on collectivistic ideology (Singelis, 1994) and
views mental health as alien and taboo (Puloka, M.H., 1999); the American cultural model views
mental health as necessary and valid (Mental Health Commission, 1998), thus causing
dissonance between the two models. The PI/P cultural model was assumed to have an influence
on PI/Ps and their experiences in schools and healthcare facilities while the American cultural
model was assumed to have influence on the school and healthcare facility settings.
Cultural Models
The results of the data analysis suggested that both models could serve as barriers to
PI/Ps utilizing professional mental health services. Specifically, participants were divided
between their PI/P culture that emphasizes group mentality, structure, and hierarchy and the
American cultural model encountered when attending school or seeking care. Correlation and
regression analysis showed participant’s responses were not impacted by age, gender, ethnicity,
or country of birth. As such, a recommended solution to the cultural gap should be provided.
It is recommended that a future study focus on the perceived gap of American cultural
model and its effects on individuals from different cultural backgrounds. McLaughlin and Braun
(1998) describe that it is presumed by year 2050 that 50% of United States residents will be non-
Caucasian, though medical standards of healthcare systems are based on Western values
47

promulgated through accreditation agencies such as the American Hospital Association (AHA)
and American Medical Association (AMA). The differences between the cultural models may
lead to gaps in equitable care for PI/Ps. PI/P cultures and their collectivistic style of silent
communication such as bowing of the head or eye contact to express concern can lead to
misunderstanding patient-family dynamics and agreement with plans of care (Marsella, 1993).
As such, it is recommended that healthcare organizations and educational establishments provide
information and training to their staff relative to collectivistic cultures and cultural sensitivity.
Cultural Settings
The result of the analysis suggested that schools and healthcare organizations may serve
as a barrier to the utilization of mental health services by PI/Ps as most of the participants
responded unfavorably towards these establishments. Analysis of the participant’s answers
showed their experiences were heavily due to their PI/P culture. Clark and Estes (2008) describe
that an organization’s risk of failure is greater when the organization’s processes are inadequate,
or if their actions inadequately support their mission and policies. McLaughlin and Braun (1998)
state the study of collectivistic cultures may shed light on the usefulness of shared or negotiated
decision-making models. As such, it is recommended that these organizations conduct a review
of their processes and policies to support cultural awareness and sensitivity.
Collaborative Work
The structure of PI/P communities and families require a collectivistic approach to
solving this problem. Healthcare organizations must partner with community leaders, religious
leaders, and family chiefs to understand PI/P culture. This collaborative work may create viable
and relatable care plans for PI/Ps in need of mental health services as was seen in American
Samoa where behavioral health nurses consulted the family of patients to hear their thoughts on
48

treatment and to work together on the best ways to assist their family members in need (Enoka,
et al., 2013).
Conclusion
Understanding the reasons why PI/Ps underutilize mental health services is imperative to
addressing this problem. This study focused on a group of PI/Ps that were willing to share their
experiences in one-on-one interviews. Through the KMO theoretical framework, this study
provides insight into this problem and recommendations to increase utilization of mental health
services by PI/Ps. The evidence presented in the study supports that cultural adherence by PI/Ps
contributes to their underutilization of mental health services (López, Barrio, Kopelowicz, &
Vega, 2012). The study’s findings support previous empirical research that identifies the
consequences of underutilization in PI/P communities. As such, it is imperative that PI/Ps
understand their rights to equitable care and privacy. PI/P community centers, healthcare
organizations and schools need to provide education and information to these communities
regarding available resources. They should also furnish training and demonstrations to increase
self-efficacy in schools and when seeking care, and to attribute their successes and failures to
effort rather than culture. Moreover, organizations and their respective governing departments
should dedicate resources to create an environment and culture conducive to diversity and
inclusion.
49

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Appendix A
Map of Polynesia Micronesia, and Melanesia.
This study focuses on Pacific Islanders from Polynesia.

54

Appendix B
Interview Protocol
Research Questions:
RQ1. What are the knowledge, motivation, and organizational issues associated with the
underutilization of mental health services by PI/P communities?
RQ2. What are the recommendations regarding KMO factors for improving mental health
utilization within the PI/P group?
Target Population: Pacific Islander/Polynesian adults between the ages of 18-70 years old.

1.What ethnicity are you? (RQ 1; Self identification)

2. Can you please tell me about how your ethnic culture influenced your upbringing? (RQ 1; Self
efficacy)

3. When a family member is sick, what happens? What do you and your family do? Can you
walk me through that? (RQ 1; Motivation)

4. Who would you consult first if you felt that yourself or someone you know was experiencing
symptoms of a mental illness? Why? (RQ 1; Knowledge)

5. In what order do you consult help outside the family? (Example : Trained doctors, healers,
religious figures, etc) can you elaborate? (Why?) (RQ 2; Knowledge & Motivation)
55

6. Would you say that your cultural beliefs affect the way you understand mental illness? How
so? (RQ 1; Knowledge)

7. Would you say that cultural beliefs affect whether or not Polynesians ask for help with mental
health issues? Can you elaborate? (RQ 1; self efficacy)

8. How do you feel about mental illness? (RQ 1; Knowledge)

9. Can you tell me your thoughts on treatment options? (RQ 2; K&M)

10. Are you comfortable discussing mental health with strangers? Friends? Family? Why or why
not? (RQ 1; Self efficacy)

11. Has anyone of the same ethnic background ever shared a mental health issue with you? Can
you tell us about it? If not, why? (Q1; Motivation)

12. Do you believe that people you know of Polynesian descent struggle with mental illness?
How do you think they cope or how have you seen them cope? (Q1; Knowledge)

13. Can you tell me about the last time you heard about or dealt with someone with mental health
issues? Walk me through what happened. (Who told you? What happened?) (Q1; Knowledge)

56

14. Do you think that mental illness in the PI/P community is a problem? (Q1; Knowledge)

15. What you do think can be done to help this community? (Q2; Organizational, Knowledge)

16. Based on what you know and have experienced of PI/P culture, do you believe that cultural
perception of mental illness can be changed? Please explain your answer? (Q2; KMO)

Abstract (if available)

Abstract Polynesians/ Pacific Islanders have disproportionately higher rates of suicide. This study utilizes Clark and Estes (2008) gap analysis framework to better understand the effects of cultural adherence on the mental health of Polynesians/Pacific Islanders. This study evaluates the knowledge, motivation, organizational, and social influences that contribute to this demographic's underutilization of mental health services. A qualitative approach was designed to collect data that comprised of eight one-on-one interviews. Knowledge, motivation, and organizational gaps were identified and recommendations were made based on the data collected and existing empirical research.

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Creator Iese, Helen Gaoteote (author)

Core Title Mental health services engagement in Pacific Islander/Polynesian communities

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2021-08

Publication Date 08/04/2021

Defense Date 06/28/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,Pacific Islander,Polynesian,Samoan

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