PRL-IHPS Research Focus: Asian/Asian Pacific Islander Health

Photo by Michelle Siu

School-based behavioral interventions prevent adolescent tobacco use in Indonesia

Justin White, PhD, recently completed a study on the effectiveness of a school-based program that tests different behavioral interventions to prevent tobacco use among adolescents in Indonesia. 

While youth smoking has declined worldwide in recent years, the decline has largely been in high-income countries, and nearly 80% of the 41 million smokers aged 15-19 live in low- and middle-income countries (LMICs). Indonesia, which has the highest male smoking prevalence globally, is also one of 10 countries to experience a recent increase in youth smoking. 

Higher tobacco taxes are often an effective way to reduce youth smoking, but have been difficult to pass in Indonesia where tobacco production is a major industry (10% of total tax revenue). Policymakers in Indonesia have a growing interest in non-tax tobacco control strategies, including prevention programs. Working with local government agencies, this study tested a non-monetary incentive program to prevent smoking. Previous incentive-based programs in LMICs have relied almost exclusively on monetary rewards and have rarely targeted adolescents, at a stage when life-long habits often form.  

The school-based field experiment invited middle-school students and their parents to sign a pledge for students to abstain from tobacco use and for parents to monitor their children. To test group incentives, a subset of treated schools also competed against each other for the highest tobacco abstinence rates. The researchers found that the individual pledges increased biochemically verified tobacco abstinence by 4 percentage points; however school competition had no additional impact on tobacco abstinence. This effect was sustained 3 months after the program ended. The findings by Dr. White and colleagues highlight the potential effectiveness of non-monetary incentives to curb risky behaviors among adolescents who face peer pressure and self-control problems. 

Relying on a non-monetary penalty (demerit points and parental notification) kept intervention costs low and improved the chances that the intervention would be sustainable, culturally acceptable, and scalable. As evidence of the sustainability of the program, one of the two districts decided to restart the program on its own after the study had ended. Although health-related incentive programs have tended to be individual in nature, Dr. White and colleagues found that students’ smoking behavior is heavily influenced by their friendship network. Social incentive schemes may be able to mobilize peer influence as a way to shift social norms and deliver social support. 

The Filipino nursing workforce in long term care

The COVID-19 pandemic has had a significant impact on the long-term care nursing workforce.  The pandemic has accelerated the already-challenging work environment for nurses employed in skilled settings, particularly among staff from racial/ethnic minority populations.  Abundant recent research has revealed that structural characteristics including for-profit ownership, personal protective equipment shortages, low staffing levels, and deficiency citations increase the risk of COVID-19 spread in SNFs.  In addition, immigrants and racial/ethnic minority workers have higher risk of transmitting or contracting COVID-19, including via their greater likelihood of working at multiple facilities. 

One of the hardest hit by the pandemic are nurses who are Filipino.  Approximately one third (31.5 percent) of the 213 registered nurses who have died of Covid-19 and related complications are Filipino and more than half of registered nurses of color (54%) who have died to date have been Filipino. Filipinos make up 4 percent of registered nurses in the United States and represent the largest group of foreign-born nurses in the U.S. because of aggressive recruitment efforts, an explicit foreign export nursing policy, and prelicensure programs for exporting Filipino nurses. They comprise an essential nursing workforce in skilled nursing facilities as they report high levels of respect for older people and value physical comfort.  A survey report released by our colleagues at the University of Albany found that nurses trained
in the Philippines reporting the highest job satisfaction and level of support among their peers.  Furthermore, foreign-educated Filipino nurses receive a Baccalaureate degree in nursing making them highly desirable candidates for nursing and management/director positions in skilled nursing facilities.  

In the research of Laura Wagner, PhD, RN, GNP,FAAN, funded by the National Council State Boards of Nursing, she surveyed over 1,400 nurses working in skilled nursing facilities, one-third whom were born and trained in the Philippines.  The findings indicate that facilities with more responding foreign-born, foreign-educated Filipino nurses exhibit higher quality of care regarding physical restraint use when compared with U.S. born, U.S educated and non-Filipino foreign born and educated nurses (read more here).  This study also identified an emerging cohort of nurses in the profession—those nurses who immigrated here and attended U.S. schools of nursing (approximately 18%).  And then there are the multiple generations of U.S.-born Filipino Americans who are also nurses. 

Filipino nurses play a critically important and increasing role in enhancing both the diversity of the workforce, increasing the supply of nurses in the workforce, and an essential role among those who are first generation to college nurses impacting our nation’s health care (read more here). 

Justin White, PhD

Justin White, Ph.D., is Assistant Professor of Health Economics in the UCSF School of Medicine, with joint appointments in the Philip R. Lee Institute for Health Policy Studies and the Department of Epidemiology and Biostatistics. He is also an affiliate of the Center for Tobacco Control Research and Education, the Helen Diller Family Comprehensive Cancer Center, and the Institute for Global Health Sciences at UCSF. Dr. White studies how monetary and non-monetary incentives can be used to promote healthy behavior, informed by research from the field of behavioral economics. His main research focus is chronic disease prevention, notably tobacco cessation.



Laura Wagner, PhD, RN, GNP, FAAN

Laura M. Wagner, PhD, RN, GNP, FAAN is affiliated faculty at the Philip R. Lee Institute for Health Policy Studies,  faculty at Healthforce Center at UCSF and an associate professor in the Department of Community Health Systems and Specialty Director of the Adult Gerontology Primary Care Nurse Practitioner Program. Dr. Wagner’s program of research has focused on improving patient safety and quality improvement skills among nurses. As a result of this work, Dr. Wagner has directly participated on a national panel to develop a standard warning label for portable bedrails and led the development of an international best practice guideline for the use of restraint alternatives.