Neal A. Palafox

Formative Research to Inform Intervention Development for Diabetes Prevention in the Republic of the Marshall Islands

Formative researchwas conducted in the Republic of the Marshall Islands to help develop a diabetes prevention intervention. Methods included in-depth interviews, semistructured interviews, and direct observation of household behaviors in urban and remote settings. Foods were classified into two main conceptual spheres: foods from the islands/Marshallese foods and imported/American foods. Diabetes (nanimij in tonal) is a highly salient illness and is believed to be caused by foods high in fat and sugar, consumption of imported/American foods, family background, and the atomic bomb testing. Physical activity and eating a traditional diet were viewed as important for preventing diabetes. The traditional belief system links a large body with health, and a thin body with illness; however, perceptions are changing with increased acculturation and education about the health risks of obesity. These findings were used to develop a diabetes prevention home visit intervention currently being implemented and evaluated in Marshallese households.

Relationship of vitamin A deficiency, iron deficiency, and inflammation to anemia among preschool children in the Republic of the Marshall Islands

Introduction: Although vitamin A deficiency, iron deficiency, and inflammation may contribute to anemia, their relative contribution to anemia has not been well characterized in preschool children in developing countries.Objective: To characterize the contributions of vitamin A and iron deficiencies and inflammation to anemia among preschool children in the Republic of the Marshall Islands.Subjects and methods: A community-based survey, the Republic of the Marshall Islands Vitamin A Deficiency Study, was conducted among 919 preschool children. The relationship of vitamin A and iron status and markers of inflammation, tumor necrosis factor-α, α 1-acid glycoprotein, and interleukin-10, to anemia were studied in a subsample of 367 children.Results: Among the 367 children, the prevalence of anemia was 42.5%. The prevalence of severe vitamin A deficiency (serum vitamin A <0.35 μmol/l) and iron deficiency (serum ferritin <12 μg/dl) were 10.9 and 51.7%, respectively. The respective prevalence of iron deficiency anemia (hemoglobin <110 g/l and iron deficiency), anemia with inflammation (anemia with TNF-α>2 pg/ml and/or AGP >1000 mg/l), and severe vitamin A deficiency combined with anemia was 26.7, 35.6, and 7.6%. In multivariate linear regression models that adjusted for age, sex, and inflammation, both iron deficiency (odds ratio (OR) 1.74, 95% confidence interval (CI) 1.08–2.83, P=0.023) and severe vitamin A deficiency (OR 4.85, 95% CI 2.14–10.9, P<0.0001) were significantly associated with anemia.Conclusions: Both iron and vitamin A deficiencies were independent risk factors for anemia, but inflammation was not a significant risk factor for anemia among these preschool children.

Vitamin A deficiency and inflammatory markers among preschool children in the Republic of the Marshall Islands.

BackgroundThe exclusion of individuals with elevated acute phase proteins has been advocated in order to improve prevalence estimates of vitamin A deficiency in surveys, but it is unclear whether this will lead to sampling bias. The purpose of the study was to determine whether the exclusion of individuals with elevated acute phase proteins is associated with sampling bias and to characterize inflammation in children with night blindness.MethodsIn a survey in the Republic of the Marshall Islands involving 281 children, aged 1–5 years, serum retinol, C-reactive protein (CRP), and α1-acid glycoprotein (AGP) were measured.ResultsOf 281 children, 24 (8.5%) had night blindness and 165 (58.7%) had serum retinol <0.70 μmol/L. Of 248 children with AGP and CRP measurements, 123 (49.6%) had elevated acute phase proteins (CRP >5 mg/L and/or AGP >1000 mg/L). Among children with and without night blindness, the proportion with serum retinol <0.70 μmol/L was 79.2% and 56.8% (P = 0.03) and with anemia was 58.3% and 35.7% (P = 0.029), respectively. The proportion of children with serum retinol <0.70 μmol/L was 52.0% after excluding children with elevated acute phase proteins. Among children with and without elevated acute phase proteins, mean age was 2.8 vs 3.2 years (P = 0.016), the proportion of boys was 43.1% vs. 54.3% (P = 0.075), with no hospitalizations in the last year was 11.0% vs 23.6% (P = 0.024), and with anemia was 43.8% vs 31.7% (P = 0.05), respectively.ConclusionsExclusion of children with inflammation in this survey of vitamin A deficiency does not improve prevalence estimates for vitamin A deficiency and instead leads to sampling bias for variables such as age, gender, anemia, and hospitalization history.

CIGUATERA FISH POISONING: REVIEW OF CLINICAL MANIFESTATIONS

Ciguatera is a complex clinical syndrome, caused by a marine bio-toxin, which can affect nearly every system of the human body. The clinical syndrome has characteristic elements in its acute, chronic and recurring forms. The incidence of ciguatera is on the rise, and misdiagnosis is not uncommon. Appropriate identification, management and treatment of ciguatera is dependent on understanding the pathophysiology of the illness, determining the correct form of the illness, and applying the appropriate treatment modalities to that form. More research is necessary to clinically manage ciguatera and the clinical dilemmas it presents.

Site specific cancer incidence in the Republic of the Marshall Islands

There is a paucity of data about cancer in the Republic of the Marshall Islands (RMI), a former U.S. Trust Territory. This study provides the first comprehensive data analysis on the incidence rates for certain cancers in the RMI.

Research and comprehensive cancer control coalitions

The goal of cancer control research is “to generate basic knowledge about how to monitor and change individual and collective behavior and to ensure that knowledge is translated into practice and policy rapidly, effectively, and efficiently” (Division of Cancer Control and Population Sciences in Cancer control framework and synthese rationale, 2010). Research activities span the cancer control continuum from prevention to early detection and diagnosis through treatment and survivorship (Division of Cancer Control and Population Sciences in Cancer control framework and synthese rationale, 2010). While significant advancements have been made in understanding, preventing and treating cancer in the past few decades, these benefits have yielded disproportionate results in cancer morbidity and mortality across various socioeconomic and racial/ethnic subgroups (Ozols et al in J Clin Oncol, 25(1):146–1622, 2007). It has been a high priority since the beginning of the Comprehensive Cancer Control (CCC) movement to utilize research in the development and implementation of cancer plans in the states, tribes and tribal organizations, territories and US Pacific Island Jurisdictions. Nevertheless, dissemination and implementation of research in coalition activities has been challenging for many programs. Lessons learned from programs and coalitions in the implementation and evaluation of CCC activities, as well as resources provided by national partners, can assist coalitions with the translation of research into practice.

Health Consequences of Disparity: the US Affiliated Pacific Islands

Health disparities and the social determinants of health are often discussed, but their relationship to political forces, the integrity of cultures, social and environmental change, and mental health outcomes are not well understood. Specifically the US Affiliated Pacific Islands Jurisdictions (USPAIJ) is an area of profound isolation and deprivation with a unique sociocultural history. This article provides an overview of health disparities in the US Affiliated Pacific in the context of the environment, and international and state policies. The article explores how the political, economic, social, and environmental context of the USAPIJ shapes health status and provides a “social determinants of health” model for health improvement for the people of the region.

Cancer risk reduction in the US Affiliated Pacific Islands: Utilizing a novel policy, systems, and environmental (PSE) approach

BACKGROUND The Health Directors of the US Affiliated Pacific Islands (USAPI) declared a State of Emergency due to epidemic proportions of lifestyle diseases: cancer, obesity and other non-communicable diseases (NCDs) in 2010. This paper describes the development, implementation, and evaluation of a USAPI policy, system and environment (PSE) approach to address lifestyle behaviors associated with cancer and other NCDs. METHODS Each of USAPI jurisdictions applied the PSE approach to tobacco and nutrition interventions in a local institution, faith based, or community setting. A participatory community engagement process was utilized to: identify relevant deleterious health behaviors in the population, develop PSE interventions to modify the context in which the behavior occurs in a particular setting, implement the PSE intervention through five specified activities, and evaluate the activities and behavior change associated with the intervention. RESULTS PSE interventions have been implemented in all USAPI jurisdictions. Current human and financial resources have been adequate to support the interventions. Process and behavior change evaluations have not been completed and is ongoing. Personnel turnover and maintaining the intervention strategy in response due to shifting community demands has been the biggest challenge in one site. CONCLUSION From 2014 through 2016 the PSE approach has been used to implement PSE interventions in all USAPI jurisdictions. The intervention evaluations have not been completed. The PSE intervention is novel and has the potential to be a scalable methodology to prevent cancer and modify NCD risk in the USAPI and small states.

Policy, System, and Environment Strategies to Promote Physical Activity and Healthy Food Sources to Address Guam's Disparate Non-Communicable Disease Burden

In 2013, the Guam Non-Communicable Disease (NCD) Consortium, Department of Public Health and Social Services, and University of Hawaii collaborated to address Guam’s NCD burden. This field report describes their efforts to implement policy, system, and environmental interventions through the worksite wellness and community garden programs.

A Socio-ecological Framework for Cancer Control in the Pacific: A Community Case Study of the US Affiliated Pacific Island Jurisdictions 1997-2017

The United States Affiliated Pacific Island Jurisdictions (USAPIJ) are politically associated to the United States (US) as US Territories (Guam, American Samoa), a US Commonwealth (Commonwealth of the Northern Mariana Islands), and as sovereign nations linked to the US through Compacts of Free Association [Federated States of Micronesia (FSM), Republic of the Marshall Islands (RMI), Republic of Palau (ROP)]. Cervical cancer incidence in the RMI is the highest in the world, mammography services are not available in the FSM and only Guam has on-island oncology services. Cancer risk factors such as obesity, tobacco, and Hepatitis B are prevalent. Twelve years of nuclear testing in the RMI adds to the cancer burden. A community-based, multi-national coalition with multi-system external partners the Pacific Regional Cancer Control Partnership (PRCP) was developed to address cancer prevention and control in the USAPIJ. Through the PRCP, local cancer coalitions, a regional cancer registry, 12 years of regional cancer control plans, and cancer prevention programs and research has been implemented. Methods: The PRCP is the subject of this community case study. The PRCP is analyzed through a socio-ecological theoretical framework to contextualize its typology, building blocks, and management. The respective roles and work of each partner and organization will be described and aligned with the levels of the socio-ecological framework. Results: The USAPIJs evolved a community-focused internal and external regional cancer prevention and control network over 20 years. The function and structure of the PRCP fits within a socio-ecological framework for cancer control. An adaptive management strategy has been used within the PRCP to manage its multi-national, multi-level, and multi-system partners. Conclusion: The PRCP has been able to advance cancer prevention and control programs with a community-centric model that functions in a multi-national, multi-cultural, low-resource, geographically dispersed environment over the last 20 years. The PRCP operates with a structure and management style that is consistent with a socio-ecological framework for cancer control. This case study provides a blueprint for the PRCP organizational structure and a mechanism for its function. The PRCP concept, a community-centric model for cancer control in multi-national resource-limited environments, may be scaled to other global environments.