Grandparent caregiving role in Filipino American families

Grandparent caregiving role in Filipino American families

Merle R. Kataoka-Yahiro

Abstract: The purpose of this preliminary study was to explore the Filipino American grandparent caregiver role of grandchildren. This descriptive qualitative study utilized three data collection methods: demographic information sheet, focus group, and field notes. The Filipino American grandparents were recruited from a church in Honolulu, Hawaii. Thematic analysis was used to analyze narrative data. Filipino American grandparents view the grandparenting caregiving role as a normative process rather than a burden in which families take on responsibilities as part of cultural beliefs and norms such as pakikisama, utang na loob, and authoritarianism. Pakikisama is family unity and closeness and Utang na loob is mutual reciprocity the give and take” and obligation in relationships.

Keywords: Grandparent Caregivers, Filipino-American Families

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Approximately 6 million grandparents are living with their grandchildren (U.S. Census Bureau, 2000a). For many grandparents, caring for their grandchildren has become a full-time responsibility that has created multiple stressors and major life changes (Davidhizar, Bechtel, & Woodring, 2000; Kelley & Damato, 1995). Filipino Immigrants to the U.S. have the highest percentage (27%) of Asian American grandparents who are living with their own grandchildren under 18 years or age and who are responsible for their grandchildren (28%) (U.S. Census Bureau, 2000b,c). When the members of the Filipino nuclear family or extended family migrate to the U.S., they usually live together because the family is a major source of emotional, moral, and economic support. Many elders become surrogate parents and homemakers for their grandchildren when both parents are employed (Philippine Nurses Association of America, 2000). The family collectively provides a unique system of care for family members from birth to end of life (Barringer, Gardner, & Levin, 1995; Lantican & Corona, 1992; Santos, 1983). Filipinos strongly identify with their nuclear and extended family and the needs and welfare of the family come before those of the individual (Espiritu & Wolf, 2001; Jones, 1996; Tompar-Tiu & Sustento-Seneriches, 1995).

The majority of Filipino Americans currently living in the U.S. are first-generation Americans challenged with the difficulties of acculturation (Lee, 1997). Often there is a cultural gap between grandparents and grandchildren which may result in intergenerational conflicts when the children become more assertive about their Western acculturation towards individuality (Tompar-Tiu & Sustento Seneriches, 1995).

Although Filipino American grandparents play an integral role as caregivers to their grandchildren, they may also care for grandchildren at the expense of their own health. Filipino American elders have a higher incidence of diabetes and higher risk factors for coronary heart disease such as hypercholestremia and hypertension compared with Whites (Ryan, Shaw, Pliam et al., 2000). They also have a higher percentage of cases of schizophrenia as a diagnosis compared with other Asian groups (Bjorck, Cuthberston, Thurman et al., 2001). This article will (a) discuss the limited literature related to caregiving role among Asian Americans, in general, and Filipinos specifically, (b) describe a preliminary study which examines the role of Filipino grandparents as caregivers for their grandchildren, and (c) relate the findings of these grandparent caregivers from a cultural context.

Literature Review

The literature on the caregiving role among Asian Americans is very limited. The only published study of Asian American grandparents to date that the authors are aware of is by Tam and Detzner (1998). They explored the role of Chinese American grandparents and found that grandparents typically provided child assistance. Grandmothers were a source of child care when both parents were working and many acted as substitute parents. Some parents did not perceive the grandparent involvement in childrearing as positive because of their acculturation and assimilation to American values.

The majority of the caregiving studies investigating Asian American or Filipino American families, however, have focused on the women’s caregiving for their elderly parents. In Goodman’s study (1990) of three women of Japanese and Chinese descent, identified the common themes of family centrality, balance of multiple obligations, and norms of reciprocity and competence. Jones (1995) explored cultural influences on the caregiving role among Filipino American women who cared for their elderly parents and found that respect and honor were central components for the caring for and providing for types of care. She identified categories such as gratitude, indebtness, obligation, responsibility, reciprocity, satisfaction, and paying back which contributed to the core category of paying respect.

Another study (Jones, 1996) investigated the relationship between role identity, role integration, sense of coherence, coping strategies, and perceived health in ten Chinese and ten Filipino American women who cared for elderly parents. This research reported a significant relationship between role identity and psychological well-being and between role integration, total physical symptoms, and psychological well-being. She concluded the balance between stress and satisfaction associated with their roles influences the caregivers’ health.

Role involvement, role integration, and perceived health were examined in 29 Chinese and 21 Filipino American women caregivers of elderly parents (Jones, Jaceldo, Lee, Zhang, & Meleis, 2001). Role integration was positively associated with perceived health in the Filipino group but not the Chinese group. Role satisfaction was consistently high in both groups, and role satisfaction and psychological well-being were significantly, correlated for the combined group and for the Filipino caregivers. Total role stress was significantly correlated with overall health in the combined group. They concluded that support may be more effective than efforts to decrease the extent of role involvement. In general, studies of Asian American caregiving role (Dilworth-Anderson, Williams, & Gibson, 2002) are rare and, more specifically, studies on Filipino American grandparenting caregiving role are nonexistent.

Purpose

When the literature is very limited about a topic and no adequate theories exist to explain the behavior of a particular group, an inductive approach is appropriate to explore how a group of people defines their reality. Our goal was to investigate and uncover previously unarticulated problems for Filipino American grandparent caregivers and to explain the variation within the group. Preliminary exploration of a problem approaches the problem from the ground up or from practice to theory. The purpose of this descriptive qualitative study was to explore the cultural context of the Filipino American grandparent caregiving role of grandchildren and its affect on their health. A goal of this study was to discover what the relevant issues were related to the grandparent caregiving role of grandchildren and their health as perceived by six Filipino American grandparents. These questions were based on the personal experience of two of the three researchers and information found in the literature. The interview explored the following questions:

1. What are reasons for caring for your grandchildren on a full-time basis?

2. What are the various ways that you are involved in caring for your grandchildren?

3. What satisfies you as a grandparent?

4. What is difficult about being a grandparent?

5. What type or kind of behavioral problem do you observe while caring for your grandchildren?

6. How has caring for your grandchildren affected time for yourself?

7. How has caring for your grandchildren affected your health (ie. emotional and physical health)?

METHODOLOGY

Method/Design.

This is a descriptive qualitative study design to be considered as preliminary work leading to an expanded qualitative study.

Informants.

Filipino American grandparents were recruited into the study from a church in Honolulu, Hawaii. The eligibility criteria included Filipino American grandparents (a) who cared for their grandchildren on a routine basis (more than 30 hours per week), (b) who spoke English and or Ilokano, (c) who were biological grandparents to their grandchildren, (d) who were born in the Philippines and immigrated to the U.S., and (e) whose grandchildren were born in the U.S. and were between the ages of 0 to 18 years of age with no previous history of medical or psychiatric problems.

The researchers planned to have two focus groups with six to eight grandparents, however, after several months of recruitment, the researchers settled for one focus group of six due to time and budgetary constraints. Six grandparents did not or could not participate because (a) they were busy caring for their grandchildren, (b) the time was not conducive, (c) transportation to the interview site was difficult, or (d) they were not comfortable participating in a research study. The sample size is a limitation to this study and the results should therefore be considered as preliminary work. This exploratory focus group interview is a first step for an expanded qualitative study. The findings from this preliminary study will guide the development of a second phase including in-depth case studies with participant observation and one to one interviews with grandparents.

The informants of this study were six Filipino American grandparents who cared for their grandchildren on a full-time basis ranging from 30 hours to 80 hours per week. All of the grandparents were born in the Philippines, immigrated to the U.S., and were able to speak and converse in both English and Ilokano. The majority owned their own homes and resided with their grandchildren in a three-generational household. Their ages ranged from 58 to 69 years of age, most were married or widowed, and Catholic or Christian. They lived in the U.S. between three to 41 years, were retired or unemployed, and most had some high school or college education. The annual household income ranged from $10,000 to $50,000 with an average income of approximately $30,000. The number of people living in each household ranged from six to ten.

They were biological grandparents to their grandchildren and cared for two to eight grandchildren at a time. These grandparents had seven to twelve grandchildren in all and more likely were related to their grandchildren through their daughter rather than son. The grandchildren were between the ages of six months to eighteen years of age, and they were all born in the United States. There were more female grandchildren than male, and their parents were either married, separated, divorced, or not married.

Data Collection Procedures.

This study utilized three methods for data collection (a) a demographic information sheet, (b) a focus group, and (c) field notes. The grandparent demographic information included the number of grandchildren cared for, living arrangements, time spent with grandchildren, relation to grandchildren, their age, how long lived in the U.S., marital status, employment, number of people in the household, religion, annual household income, and education. The information regarding grandchild(ren) included gender, age, and the marital status of grandchildrens’ parents.

A focus group guide constructed by the researchers consisted of seven questions related to caregiving role and health status. The consent form, demographic information sheet, and questions for the focus group were translated and back-translated (Brislin, 1970; Jones & Kay, 1992) to assure cross-cultural equivalence. Forward translation from English to Ilokano dialect was done by a bilingual, bi-literate translator followed by back-translation from Ilokano to English by a different bilingual, bi-literate translator. Field notes were used to record comments made by the researcher and two research assistants before, during, and after the focus group (Roper & Shapira, 2000) to help confirm and supplement narrative data.

A church priest and key informant at a church in Honolulu, Hawaii assisted the researchers to recruit six grandparents who expressed interest in the study in response to clergy announcements. Prior to the focus group, the eligibility criteria and consent form were read to the potential informants. Those who agreed to be part of the study signed the consent form, and completed the demographic information sheet. Each participant received a gratuity of $20.00.

Two researchers and two research assistants conducted the focus group. The researcher who conducted the interview was of the same ethnicity as the grandparents and could converse fluently in both English and Ilokano. The focus group, which took approximately one hour, was audio-taped, transcribed to a typed manuscript by the researcher, and the text was audited for accuracy. Questionable portions of transcript were read while simultaneously listening to the recorded interviews and examining the recorded notes. Transcriptions were corrected. Although the interviewer was prepared to conduct the focus group in either English or Ilokano, the informants preferred to have the discussion in English.

Data Analysis

Qualitative thematic analysis was used to analyze narrative data and identify themes and patterns in the data. The unit of analysis for this research was thematic units which are phrases, sentences or groups of sentences with a unifying meaning or theme. Related phenomena and themes were grouped into categories and given a conceptual name, a procedure common in qualitative research (Strauss & Corbin, 1998).

The three researchers initially read and analyzed the transcripts of the interviews independently. The principles described by Strauss and Corbin (1998) guided the data analysis. The three authors did line by line reading of the text. Rationale and examples to guide themes into specific categories were developed as data were analyzed. The overall process was a constant comparison of data and emerging themes. Through the coding procedures, significant data were given labels denoting categories. The researchers focused on the key issues (themes) that emerged from the data and became categories of interest. After the initial analysis, the researchers used a group process for thematic analysis and to, refine the conceptualization of the informants experiences. Intercoder reliability was evaluated to reduce subjectivity and enhance consistent interpretation by discussion and debate of common themes among the three authors.

Findings

Consistent with the literature, the majority of the Filipino American grandparents in this study were less acculturated than their grandchildren and this contributed to the challenges of parenting and disciplining by the grandparents. The households were large and included several generations. The grandparents had preexisting health problems such as asthma, diabetes, hypertension, and cardiac problems.

A major theme that emerged in this study was the view of the informants that the grandparent caregiving role was a “natural role expectation.” Three sub-themes that arose were based on Filipino cultural beliefs and norms namely (a) Pakikisama–family unity and closeness (b) Utang na loob–mutual reciprocity “the give and take” and obligation in relationships, and (c) authoritarianism (being responsible role models, elders are highly valued, and respect for authority figures) (Espiritu & Wolf, 2001; Goodman, 1990; Jones, 1995; Lee, 1997; Leininger, 1991; Teruya & Wong, 1975; Tompar-Tiu & Sustento-Seneriches, 1995). Health issues that came into existence during the time of caring for their grandchildren were back problems, sleep deprivation, and stress.

Pakikisama (Family Unity and Closeness)

An important theme expressed by the informants was that caring for their grandchildren was a positive and natural role expectation that brings family unity and closeness. A Filipino American grandmother explained that she is a caregiver in order to help my daughter cause I have to help because I am there. I am the grandmother. It’s natural that I do.

Another grandparent described the closeness by stating both parents are working so nobody can take care of children … and cannot hire babysitters … It is so expensive now a days…If you retire too it is Rood … have someone to play with … it is a joy. Similarly, another grandparent agreed that when you see them happy … then you are happy [and] that will be love.

Utang na loob (Reciprocity and Obligation)

The Filipino American grandparents were very involved with the grandchildren’s daily care to the extent that their caregiving role was seen as reciprocity and obligation to the family. The Filipino American grandparents in this group were involved in child care including activities of diapering, feeding, helping with school work, playing, driving them to activities, shopping, washing clothes, and giving money or buying things (ie. clothes, shoes). One grandparent stated:

“Please don’t feel bad about taking care of your

grandchildren. I have eight grandchildren … five live

with me and three are from my other daughter. She

is a nurse and works night shift … so I take care [of

them during] night time … When size comes home … I

take care [of them] because she has to go to sleep,

huh? … All [I] take care of them … cook for them,

wash the clothes … I drive them around … It’s an

obligation … It’s my daughter, so I guess, if your

daughter cannot accept you … yeah … who will help

them?”

Authoritarianism (being responsible role models, elders are highly valued, respect for authority figures)

Grandparents in this study, felt a need to contribute to their grandchildren’s development and future. This group obtained great satisfaction by making a contribution to the children’s development and their future and the opportunity of being a role model. They indicated that contributing to their growth, the ability to see them grow-up, and seeing their achievement were great sources of satisfaction.

This cultural norm has created differences in perception and expectations between grandparents and grandchildren. Adhering to the cultural norm of authoritarianism, the grandparents in this study expected the grandchildren to be respectful, obedient, and appreciative. They expressed difficulties related to parenting and disciplining (ie. sibling fights, providing emotional support, finding time to satisfy the needs and completing all the tasks for all the grandchildren, use of the television, setting limits, handling demanding behavior, and delaying immediate gratification).

Parenting and Disciplining

Several informants described the difficulties of parenting and disciplining. One area of concern was sibling fighting as one grandparent stated:

“… Well [the] difficulty is fighting with each

other … You don’t know where to go [to take

sides] … or all kids [are] deciding to kick

somebody … Take each side with explanation … Your

opinion is right … and so is yours … You have [to

make] the same decision again … Otherwise they will

be confused.”

Providing emotional support was an important parenting role assumed by these grandparents. As one of the grandparents explained that:

“It is kind of hard sometimes but one particular

grandson … He is the closest to me … He cannot leave

the house without hugging me … He is the one that

tells me his problem[s] and doesn’t tell morn. However,

he often needs emotional support. I have to give

him extra pep talk … he is so difficult…. When he is

good he is good. He wants to be the boss of all the

brothers and sisters…. He is the one that answers

[back] to the grandpa, too …”

This grandmother was worried about the child’s tendency to be controlling and disrespectful but yet required great deal of emotional support.

In addition, juggling the parenting roles was challenging as one suggested:

“Sometimes they get angry! with each other … and I

now it … but I cannot do two things at the same

time … I also cook their food … and [they say] I like

this one … I like that one …”

This grandmother appeared frustrated at not being able to meet the needs of all her grandchildren at the same time.

The majority of the informants had conflicts regarding the use of the television. One grandparent expressed views similar to others:

Yes, watching TV … They like to watch their own

programs … before you stop them … they go to the

other TV.”

Everyone joined in laughter and nodded their heads. One grandparent described an issue of setting limits:

“… Even [when] you tell them come home early

[They say] … yes, mom [grandma] … Oh my God,

they come home 10 o’clock p.m … 11 o’clock

p.m … They go out … That’s our problem … We don’t

know what happened to them … outside the house

[and] … We have a hard time now they are teenagers

already …”

She shook her head and her eyes looked down as she expressed her frustration. Another grandparent described her grandchildren’s demanding behavior and her dilemma about the grandchildren wanting the same things:

“[Grandma] if you give that to–[grandchild],

you have to give [it to] me also …”

This grandmother replied “Can you wait until the paycheck come[s]?”

Another grandmother explained demanding behaviors related to using money as:

“You do this one and I give you money … You never

do anything … ah … that is not fair you know…. but

you have to do something too so I can give you

money … The other one [problem is] … the clothes … I

cannot buy all one time you know … How many of

you … [There are] three of you. How much [does]

one pair of shoes [costs]? … Because they want $100

shoes … $80 shoes … I cannot afford that

one … yeah … You like [these shoes]

now? … No … No … So you better wait [on the shoes

for] … two or three months … I say … These [are] good

$20.00 shoes.”

This grandmother shook her head. She wanted her grandchildren to appreciate the value of hard work. Her frustration also resulted from her grandchildren wanting expensive things that she could not provide. The grandparents were concerned that their grandchildren were being spoiled, wanting things immediately, and not being able to delay their gratification. One of the grandparents explained:

“They ask for something … you like to give them

[things immediately] right away … huh … They tend

to be spoiled … yeah … and when they want the same

thing again next time … You say no they tend to get

some kind of frustration because they tell [ask] you

again … I think that will affect them when they grow

up”

The grandparent sat there with a concerned look and paused for a moment.

Consequences of Grandparent Caregiving Role

Consequences of grandparent caregiving role relate to maintaining their health and having time for self. These grandparents did not perceive their health and having time for themselves to be significantly altered or affected as a result of caring for their grandchildren. One described the difficulty of managing to find time for self:

“We take time for ourselves when the kids are sleep

[asleep] … not when they are awake … especially the

six month old … [He] already like [likes] to

crawl … [and] like [likes] to discover the corner of

the house … We have to watch him when he is

awake … As soon as the baby goes to sleep … I take

care of myself … fall asleep, too … I hear [a]

cry … OK … I pick up the milk … I change the

diaper … The other kids want to go to this place the

other one want [wants] to go to that place … so you

have to portion your time … I am trying to make the

time for everybody … The other one has to go to music

class the other one goes to the hula class, the

other one goes to karate class …”

Overall they felt that they did have time for themselves. The favorite past times of the grandmothers in this study were shopping and watching a Filipino Television Channel. Grandparents felt they needed to be assertive to gain some time to watch television. A grandmother reported:

“… If I am watching TV [TFC–Filipino

Channel] … [I tall them] you cannot change the

channel … laugh … They get mad at me [and say to

me] … [It’s] Filipino [show]time again … They can

watch TV … when I am not around.”

Filipino American grandparents in this study already had predisposing health problems including asthma, hypertension, diabetes, and cardiac problems before taking care of the grandchildren. They do not attribute their present health status to caring for their grandchildren. Health issues that came into existence during the time of caring for their grandchildren were back problems, sleep deprivation, and stress. Several grandparents in this study made it clear to others in the group that their illness came before caring for their grandchildren and that their grandchildren were not the cause of their health problems. One indicated I have already sickness … I have irregular beating of heart beat ever since [then] that is why I retired early … You know … I feel weak, but I working … I still [am]working now … I have medications.

Another stated “No, because … I have a heart murmur, too. I got my diabetes since [in] 19– … I got the stroke, huh … from the diabetes … That is why I retired early. The third indicated her belief that just because you get [a] problem … [It is] not the grandchildrens’ fault.”

DISCUSSION

Filipino American grandparents reported experiences that were similar to other grandparents in previous studies (Dowdell, 1995; Kelley & Damato, 1995; Minkler, Roe, & Price, 1992; Strawbridge, Wallhagen, Shema, & Kaplan, 1997). Similar experiences were decreasing energy levels, incidences of stress and illness, and symptoms of aging.

Although the grandparents in this study were taking care of two to eight grandchildren at a time on a full-time basis, their overall response to their caregiving role of their grandchildren was positive. They were very involved in caring for their grandchildren and described the difficulties in caring for their grandchildren. It is likely that these grand-parents were stressed based upon the large number of hours caring for their grandchildren, the described difficulties of parenting and disciplining, and their preexisting and existing health needs. However, it is amazing that their overall reaction to caregiving role was not perceived to be a burden. They did not believe that their caregiving role compromised their overall health status and expressed being satisfied with their grandparent caregiving role. Even in stressful and demanding situations, the reaction/perception of an individual to the situation is many times culturally determined (Hurme, 1997). In previous studies when roles are more satisfying than stressful, they tend to exert a more positive affect on health (Douglas, Meleis, & Paul, 1997; Jones, 1995; Meleis, Norbeck, & Laffrey, 1989; Meleis, Norbeck, Laffrey, Solomon, & Miller, 1989). In summary, Filipino American grandparents view the grandparenting caregiving role as a normative process rather than a burden. Families take on responsibilities as result of their cultural beliefs and norms such as pakikisama, utang na loob, and authoritarianism.

The family is greatly valued in the Filipino culture and the persons’ concept of self is strongly identified with his or her nuclear and extended family. Enriquez (1990) stresses that shared identity (ie. sensitivity to and regard for others, respect and concern, helping out, understanding and making up for other’s limitations, rapport and acceptance) is a central core value of all Filipino values. These cultural beliefs and norms were clearly evident in this analysis.

Implications for Nursing Research, Education, and Practice

Nursing research. Further research is needed to understand the cultural meaning and significance of the grandparent caregiving role and its impact on their health (Burnette, 1999). Future caregiving research should address issues such as cultural beliefs, values, and norms, acculturation, and assimilation and its impact on the caregiving role and health status at the same time there is a need to improve on the theoretical and methodological approaches in this area (Dilworth-Anderson, Williams, & Gibson, 2002).

Nursing education. Nurses would benefit from a comprehensive understanding of emerging ethnically diverse family systems that include grandparents. The curriculum in nursing schools should consider the health and psychosocial needs of grandparents caring for their grandchildren and include both a family and individual approach to nursing care.

Nursing practice. Consideration of the level of acculturation is essential in determining culturally sensitive interventions for populations experiencing health disparities. By targeting and tailoring specific interventions based on level of acculturation health care providers may provide culturally sensitive care. An individual and family life-span developmental perspective would enhance nursing service for ethnically diverse families. Public policies that promote access and services for families in addition to individuals are required (Minkler & Fuller-Thomson, 1999). Health professionals in hospitals and the community can initiate and facilitate culturally-sensitive support groups and parenting and stress management programs (Whitley, White, Kelley, & Yorke, 1999). Public health departments, community mental health centers, divisions of child and family services should include the needs of ethnically diverse grandparents and their grandchildren in their routine community needs assessment (Thomas, Sperry, & Yarbrough, 2000). An understanding of the needs and development of resources for grandparents in ethnically diverse families is essential to facilitate bridging the gap of health disparities among vulnerable populations in the United States.

CONCLUSIONS

One very interesting finding that emerged from this study was that in spite of the great demands of energy required by the caregiving role and the grandparents own health difficulties, all of the grandparents expressed that it was a joy to provide care. One expressed this as “It is fun to be a grandma and grandpa … good experiences … we are lucky that we are grandparents. This conclusion should not deter health professionals from considering that this group does not require support. On the contrary, it requires health care professionals to further ask the questions Are we missing something? How does culture have an impact on actual versus perceived health? Should we be asking more culturally appropriate questions in regards to both family and individual needs?” Are there culturally sensitive approaches to research and practice that we should be addressing based on cultural beliefs and norms? Based on the scope and budget, this study was limited by the small sample size, therefore, it is difficult to make any generalizations from the findings. The findings should be treated as preliminary work leading to more contextual work in this area of study. However, it provides some beginning insight to Filipino American grandparent caregiving role of their grandchildren and their health status.

Table 1. Grandparent Demographics

Category Number of Percentage of

Grandparents Total Group

Gender

Male 1 16.7%

Female 5 83.3%

Marital Status

Married 5 83.3%

Widowed 1 16.7%

Age

50-59 1 16.7%

60-69 5 83.3%

Education

8th grade or less 1 16.7%

some high school 1 16.7%

vocational training 1 16.7%

college degree 3 49.9%

Religion

Christianity/Catholic 6 100.0%

Employed

Retired 3 50.0%

Working Part time 1 16.7%

Unemployed 2 33.3%

Household Income

10,000 – 19,999 2 33.3%

20,000 – 29,999 1 16.7%

over $50,000 3 50.0%

Own House

Yes 4 66.7%

No 2 33.3%

Living with Children

Yes 2 33.3%

No 4 66.7%

How Many People Live in Household?

6 2 33.3%

7 3 50.0%

10 1 16.7%

How Long Lived in U.S.

0-5 years 1 16.7%

21-30 years 3 50.0%

41-60 years 2 33.3%

Acknowledgements: The authors thank Janie Tomihara (Graduate Student) and Alvin Aurelio and Lloyda Pilos (Research Assistants)for their contributions to this study.

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Merle R. Kataoka-Yahiro, DrPH, RNC, APRN is an Assistant Professor at the University of Hawaii at Manoa School of Nursing and Dental Hygiene in Honolulu, HI. Clementina Ceria, PhD, RN is also an Assistant Professor at the University of Hawaii at Manoa in Honolulu, HI. Marian Yoder, EdD. RN is a Professor at San Jose State University School of Nursing in San Jose, CA.

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