Filling the gaps in the COVID-19 pandemic response: medical personnel in the US military health system.

BACKGROUND: The COVID-19 pandemic was an unprecedented public health emergency that heavily affected the healthcare workforce. Although the Military Health System (MHS) has robust capabilities and was able to deploy medical staff to support civilian hospitals during the crisis, it too was adversely impacted by personnel issues. We aimed to identify and address gaps in understanding the impact of the COVID-19 pandemic on healthcare personnel in the MHS. METHODS: We conducted semi-structured key informant interviews with 28 MHS stakeholders, including policymakers, program managers, and healthcare providers. We recruited respondents using purposive and snowball sampling until we reached thematic saturation. Interviews were conducted virtually from December 2022 to March 2023 and coded by deductive thematic analysis using NVivo. RESULTS: Burnout and mental health concerns across the workforce increased during the pandemic, although some felt military culture facilitated resilience. Reduction in personnel was noted and slow hiring processes and noncompetitive wages hindered hiring, contributing to staffing shortages. Initial disruptions occurred in training and skills readiness, although these issues were reduced over time. Concerns remain about newer trainees' preparedness and teaching staff's availability in the MHS. CONCLUSION: This study uniquely assessed the impact of the COVID-19 pandemic response on the MHS healthcare workforce through in-depth key informant interviews. Multi-pronged strategies are needed to promote personnel well-being in complex healthcare systems like the MHS.

Supporting the nation in crisis: the military health system's role in enhancing public health capacity through public-private partnerships.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic caused significant global disruptions to the healthcare system, which was forced to make rapid changes in healthcare delivery. The pandemic necessitated closer collaboration between the US civilian healthcare sector and the military health system (MHS), resulting in new and strengthened partnerships that can ultimately benefit public health and healthcare for the nation. In this study, we sought to understand the full range of partnerships in which the MHS engaged with the civilian sector during the COVID-19 pandemic and to elicit lessons for the future. METHODS: We conducted key informant interviews with MHS policymakers and advisers, program managers and providers who were affiliated with the MHS from March 2020 through December 2022. Key themes were derived using thematic analysis and open coding methods. RESULTS: We conducted 28 interviews between December 2022 and March 2023. During the pandemic, the MHS collaborated with federal and local healthcare authorities and private sector entities through endeavours such as Operation Warp Speed. Lessons and recommendations for future pandemics were also identified, including investment in biosurveillance systems and integration of behavioural and social sciences. CONCLUSIONS: The MHS rapidly established and fostered key partnerships with the public and private sectors during the COVID-19 pandemic. The pandemic experience showed that while the MHS is a useful resource for the nation, it also benefits from partnering with a variety of organizations, agencies and private companies. Continuing to develop these partnerships will be crucial for coordinated, effective responses to future pandemics.

Associations between fasting glucose rate-of-change and the missense variant, rs373863828, in an adult Samoan cohort.

BACKGROUND: The A allele of rs373863828 in CREB3 regulatory factor is associated with high Body Mass Index, but lower odds of type 2 diabetes. These associations have been replicated elsewhere, but to date all studies have been cross-sectional. Our aims were (1) to describe the development of type 2 diabetes and change in fasting glucose between 2010 and 2018 among a longitudinal cohort of adult Samoans without type 2 diabetes or who were not using diabetes medications at baseline, and (2) to examine associations between fasting glucose rate-of-change (mmol/L per year) and the A allele of rs373863828. METHODS: We describe and test differences in fasting glucose, the development of type 2 diabetes, body mass index, age, smoking status, physical activity, urbanicity of residence, and household asset scores between 2010 and 2018 among a cohort of n = 401 adult Samoans, selected to have a ~2:2:1 ratio of GG:AG: AA rs373863828 genotypes. Multivariate linear regression was used to test whether fasting glucose rate-of-change was associated with rs373863828 genotype, and other baseline variables. RESULTS: By 2018, fasting glucose and BMI significantly increased among all genotype groups, and a substantial portion of the sample developed type 2 diabetes mellitus. The A allele was associated with a lower fasting glucose rate-of-change (ß = -0.05 mmol/L/year per allele, p = 0.058 among women; ß = -0.004 mmol/L/year per allele, p = 0.863 among men), after accounting for baseline variables. Mean fasting glucose and mean BMI increased over an eight-year period and a substantial number of individuals developed type 2 diabetes by 2018. However, fasting glucose rate-of-change, and type 2 diabetes development was lower among females with AG and AA genotypes. CONCLUSIONS: Further research is needed to understand the effect of the A allele on fasting glucose and type 2 diabetes development. Based on our observations that other risk factors increased over time, we advocate for the continued promotion for diabetes prevention and treatment programming, and the reduction of modifiable risk factors, in this setting.

Understanding the Roles, Responsibilities, and Factors for Success of Health Equity Officers in Health Care Settings: A Qualitative Study.

CONTEXT: Recent national guidelines aimed at addressing equity in health care settings have contributed to an increase in equity officer positions, yet little is known about their roles, responsibilities, or strategies for engaging in health equity work. OBJECTIVE: To understand the roles and responsibilities of equity officers, as well as facilitators and barriers to their success. DESIGN: In-depth semi-structured interviews with selected respondents from the Equity Officer National Study. SETTING: Hospitals and health care systems across the United States. PARTICIPANTS: Twenty-six equity officers who had responded to the Equity Officer National Study survey. MAIN OUTCOME MEASURES: The interview guide explored strategies, facilitators, and barriers for engaging in health equity work in hospitals/health systems and communities. RESULTS: The job roles described by participants fell into 4 categories: community benefits/relations, population/community health, workforce, and health equity. Equity officers described key areas to support success at the individual equity officer level: knowledge and expertise, professional skills, and interpersonal skills; at the hospital level: leadership, workforce, infrastructure and resources, and policies and processes; at the community level: leadership and partnerships; and at the system level: requirements and regulations, investment and resources, and sociocultural and political characteristics of the community. These key areas have been organized to create a Framework for Equity Officer Success. CONCLUSIONS: The Framework for Equity Officer Success should be incorporated into hospital board, community stakeholder, and policymaker discussions about how to support health equity work in hospitals and health care systems.

Accelerometer-Based Estimates of Physical Activity and Sedentary Time Among Samoan Adults.

BACKGROUND: The prevalence of obesity-related cardiometabolic disease in Samoa is among the highest globally. While physical activity is a modifiable risk factor for obesity-related disease, little is known about physical activity levels among adult Samoans. Using wrist-worn accelerometer-based devices, this study aimed to characterize physical activity among Samoan adults. METHODS: Samoan adults (n = 385; 55% female, mean [SD] age 52 [10] y) wore Actigraph GT3X+ devices for 7 to 10 days. General linear models were used to examine mean daily minutes of sedentary time, light physical activity, and moderate to vigorous physical activity by various participant characteristics. RESULTS: Time spent in moderate to vigorous physical activity did not differ statistically between men (88 [5] min; 95% confidence interval [CI], 80-97) and women (78 [4] min; 95% CI, 70-86; P = .08). Women, however, spent more time than men in light physical activity: 380 (7) minutes (95% CI, 367-393) versus 344 (7) minutes (95% CI, 329-358; P < .001). While there were no differences in physical activity by census region, education, or occupation among women, men in urban areas spent significantly less time in moderate to vigorous physical activity than those in peri-urban and rural areas (P = .015). Women with class II/III obesity spent more time in sedentary activities than those with healthy weight or overweight/class I obesity (P = .048). CONCLUSIONS: This study characterizes physical activity among Samoan adults and highlights variation by sex, urbanicity, and weight status. In providing initial device-measured estimates of physical activity in Samoa, this analysis establishes a baseline from which the success of future attempts to intervene on physical activity may be assessed.

The response of the Military Health System (MHS) to the COVID-19 pandemic: a summary of findings from MHS reviews.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic caused major disruptions to the US Military Health System (MHS). In this study, we evaluated the MHS response to the pandemic to understand the impact of the pandemic response in a large, national, integrated healthcare system providing care for ~ 9 million beneficiaries. METHODS: We performed a narrative literature review of 16 internal Department of Defense (DoD) reports, including reviews mandated by the US Congress in response to the pandemic. We categorized the findings using the Doctrine, Organization, Training, Materiel, Leadership, Personnel, Facilities, and Policy (DOTMLPF-P) framework developed by the DoD to assess system efficiency and effectiveness. RESULTS: The majority of the findings were in the policy, organization, and personnel categories. Key findings showed that the MHS structure to address surge situations was beneficial during the pandemic response, and the rapid growth of telehealth created the potential impact for improved access to routine and specialized care. However, organizational transition contributed to miscommunication and uneven implementation of policies; disruptions affected clinical training, upskilling, and the supply chain; and staffing shortages contributed to burnout among healthcare workers. CONCLUSION: Given its highly integrated, vertical structure, the MHS was in a better position than many civilian healthcare networks to respond efficiently to the pandemic. However, similar to the US civilian sector, the MHS also experienced delays in care, staffing and materiel challenges, and a rapid switch to telehealth. Lessons regarding the importance of communication and preparation for future public health emergency responses are relevant to civilian healthcare systems responding to COVID-19 and other similar public health crises.

Association between age at menarche and cardiometabolic risk among Samoan adults.

OBJECTIVES: Recent studies suggest that early menarche may increase cardiometabolic morbidity and mortality. Yet few studies have examined this association in the Pacific Islands, where obesity prevalence is among the highest globally. We sought to examine associations between age at menarche and cardiometabolic risk in Samoa. METHODS: Participants were from the Soifua Manuia study (n = 285, age 32-72 years) conducted in Samoa from 2017 to 2019. Logistic regressions were conducted to estimate odds of obesity, hypertension, diabetes, dyslipidemia, and metabolic syndrome per one-year increase in age at menarche. Linear regressions were conducted to examine associations between age at menarche and continuous measures of adiposity, blood pressure, insulin resistance, and serum lipids. RESULTS: Median age at menarche was 14 years (IQR = 2). After controlling for relevant covariates, each one-year increase in age at menarche was associated with a 15% decrease (OR = 0.85, 95% CI: 0.72-1.01, p = .067) in odds of hypertension, but a 21% increase (OR = 1.21, 95% CI: 1.01-1.45, p = .044) in odds of diabetes and 18% increase (OR = 1.18, 95% CI: 0.98-1.42, p = .081) in odds of high total cholesterol. Each additional year in age at menarche was associated with a 1.60 ± 0.52 kg (p = .002) decrease in lean mass and 1.56 ± 0.51 kg (p = .003) decrease in fat-free mass. CONCLUSIONS: Associations between age at menarche and cardiometabolic risk may be population-specific and are likely influenced by both current and historical nutritional and epidemiological contexts. Prospective studies are needed to clarify the role of childhood adiposity and other early life exposures on age at menarche and subsequent cardiometabolic risk.

Filling the Gaps in the Pandemic Response: Impact of COVID-19 on Telehealth in the Military Health System.

Introduction: As a result of the COVID-19 pandemic, telehealth use became widespread, allowing for continued health care while minimizing COVID-19 transmission risk for patients and providers. This rapid scale-up highlighted shortcomings of the current telehealth infrastructure in many health systems. We aimed to identify and address gaps in the United States Military Health System (MHS) response to the COVID-19 pandemic related to the implementation and utilization of telehealth. Methods: We conducted semistructured key informant interviews of MHS stakeholders, including policymakers, program managers, and health care providers. We recruited respondents using purposive and snowball sampling until we reached thematic saturation. Interviews were conducted virtually from December 2022 to March 2023 and coded by deductive thematic analysis using NVivo. Results: We interviewed 28 key informants. Several themes emerged from the interviews and were categorized into four defined areas of obstacles to the effective utilization of telehealth: administrative, technical, organizational, and quality issues. While respondents had positive perceptions of telehealth, issues such as billing, licensure portability, network connectivity and technology, and ability to monitor health outcomes represent major barriers in the current system, preventing the potential for further expansion. Conclusions: While the shift to telehealth during the COVID-19 pandemic demonstrated robust potential within the MHS, it highlighted shortcomings that impair the utility and expansion of telehealth on a level comparable to that of other large health systems. Future focus should be directed toward generating and implementing actionable recommendations that target these identified challenges in the MHS.

Characterization of sleep apnea among a sample of adults from Samoa.

Sleep apnea is a public health concern around the world, but little research has been dedicated to examining this issue in low- and middle-income countries, including Samoa. Using data collected through the Soifua Manuia ("Good Health") study, which aimed to investigate the impact of the body mass index (BMI)-associated genetic variant rs373863828 in CREB3 Regulatory Factor ( CREBRF ) on metabolic traits in Samoan adults, we examined the sample prevalence and characteristics of sleep apnea using data collected with a validated home sleep apnea device (WatchPAT, Itamar). A total of 330 participants (sampled to overrepresent the obesity-risk allele of interest) had sleep data available. Participants (53.3% female) had a mean (SD) age of 52.0 (9.9) years and BMI of 35.5 (7.5) kg/m 2 and 36.3% of the sample had type 2 diabetes. Based on the 3% and 4% apnea hypopnea indices (AHI) and the 4% oxygen desaturation index (ODI), descriptive analyses revealed that many participants had potentially actionable sleep apnea defined as >5 events/hr (87.9%, 68.5%, and 71.2%, respectively) or clinically actionable sleep apnea defined as ≥15 events/hr (54.9%, 31.5%, and 34.5%, respectively). Sleep apnea was more severe in men; for example, clinically actionable sleep apnea (≥15) based on the AHI 3% definition was observed in 61.7% of men and 48.9% of women. Correction for non-representational sampling related to the CREBRF obesity-risk allele resulted in only slightly lower estimates. Across the AHI 3%, AHI 4%, and ODI 4%, multiple linear regression revealed associations between a greater number of events/hr and higher age, male sex, higher body mass index, higher abdominal-hip circumference ratio, and geographic region of residence. Our study identified a much higher frequency of sleep apnea in Samoa compared with published data from other studies, but similar predictors. Continued research addressing generalizability of these findings, as well as a specific focus on diagnosis and affordable and equitable access to treatment, is needed to alleviate the burden of sleep apnea in Samoa and around the world.

How Hospitals Are Addressing The Effects Of Racism: A Mixed-Methods Study Of Hospital Equity Officers.

Hospital equity officers have become critical leaders in the effort to address the determinants of health care disparities, including structural racism. In this mixed-methods study, we surveyed a national sample of equity officers and interviewed a subset of respondents to provide additional perspective. About one-half of survey respondents reported at least some obstacles to achieving their health equity objectives, including racist beliefs among people working in their hospitals and health care systems, policies that perpetuate racism, and a lack of staff diversity. To address these challenges, some hospitals are collecting information about instances of racism, reviewing clinical algorithms for evidence of bias, or forming community partnerships. However, in interviews, equity officers pointed out that racism is a public health issue that cannot be adequately addressed solely within the health care system. Given the relative newness of most hospital equity officer positions, our research may be viewed as an early glimpse into the challenges and opportunities of this evolving work.

Validity of anthropometric equation-based estimators of fat mass in Samoan adults.

INTRODUCTION: In 1999, a set of highly accurate Polynesian-specific equations to estimate adult body fat from non-invasive field measures of age, sex, height, and weight (Equation 1), age, sex, height, weight, and bioelectrical impedance analysis (BIA) resistance (Equation 2), and age, sex, height, weight, and the sum of two skinfold thicknesses (Equation 3) were published. The purpose of this study was to evaluate the performance of the equation-based estimators in a sample of Samoan adults recruited 20 years later between 2017 and 2019. METHODS: Age, sex, height, weight, BIA resistance, skinfold thickness, and fat mass as measured using dual energy x-ray absorptiometry (DXA) were available for 432 Samoan adults (mean age 50.9 years, 56% female) seen in 2017/2019. We compared equation-derived fat mass and DXA-derived fat mass using scatterplots and Pearson correlation coefficients. We then updated the equation coefficient estimates in a training set (2/3 of the sample) and evaluated the performance of the updated equations in a testing set (the remaining 1/3 of the sample). RESULTS: Equation-derived fat mass was strongly correlated with DXA-derived fat mass for Equation (1) (r2  = 0.95, n = 432), Equation (2) (r2  = 0.97, n = 425), and Equation (3) (r2  = 0.95, n = 426). Updating the equation coefficient estimates resulted in mostly similar coefficients and nearly identical testing set performance for Equation (1) (r2  = 0.96, n = 153), Equation (2) (r2  = 0.98, n = 150), and Equation (3) (r2  = 0.96, n = 150). CONCLUSIONS: The Polynesian-specific body fat estimation equations remained stable despite changing social and environmental factors and marked increase in obesity prevalence in Samoa.

Changes in Elective and Urgent Surgery Among TRICARE Beneficiaries During the COVID-19 Pandemic.

BACKGROUND: COVID-19 is known to have altered the capacity to perform surgical procedures in numerous health care settings. The impact of this change within the direct and private-sector settings of the Military Health System has not been effectively explored, particularly as it pertains to disparities in surgical access and shifting of services between sectors. We sought to characterize how the COVID-19 pandemic influenced access to care for surgical procedures within the direct and private-sector settings of the Military Health System. METHODS: We retrospectively evaluated claims for patients receiving urgent and elective surgical procedures in March-September 2017, 2019, and 2020. The pre-COVID period consisted of 2017 and 2019 and was compared to 2020. We adjusted for sociodemographic characteristics, medical comorbidities, and region of care using multivariable Poisson regression. Subanalyses considered the impact of race and sponsor rank as a proxy for socioeconomic status. RESULTS: During the period of the COVID-19 pandemic, there was no significant difference in the adjusted rate of urgent surgical procedures in direct (risk ratio, 1.00; 95% CI, 0.97-1.03) or private-sector (risk ratio, 0.99; 95% CI, 0.97-1.02) care. This was also true for elective surgeries in both settings. No significant disparities were identified in any of the racial subgroups or proxies for socioeconomic status we considered in direct or private-sector care. CONCLUSIONS: We found a similar performance of elective and urgent surgeries in both the private sector and direct care during the first 6 months of the COVID-19 pandemic. Importantly, no racial disparities were identified in either care setting.

Correlates of daytime sleepiness and insomnia among adults in Samoa.

Objective: To describe daytime sleepiness and insomnia among adults in Samoa and identify modifiable factors associated with these measures. Design/setting: Cross-sectional analysis of data from the Soifua Manuia ("Good Health") study (n = 519, 55.1% female); Upolu island, Samoa. Methods: Daytime sleepiness and insomnia were assessed with the Epworth Sleepiness Scale (ESS) and the Women's Health Initiative Insomnia Rating Scale (WHIIRS), respectively. Detailed physical, sociodemographic, and behavioral factors were collected. Sleep measures were characterized using multiple linear regression with backwards elimination and a bootstrap stability investigation. Results: Excessive daytime sleepiness (ESS>10) and insomnia (WHIIRS>10) were reported by 20% and 6.3% of the sample, respectively. ESS scores were higher in individuals reporting more physical activity (Estimate=1.88; 95% CI=1.12 to 2.75), higher material wealth (0.18; 0.09 to 0.28), and asthma (2.85; 1.25 to 4.51). ESS scores were lower in individuals residing in periurban versus urban regions (-1.43; -2.39 to -0.41), reporting no work versus day shift work (-2.26; -3.07 to -1.41), and reporting greater perceived stress (-0.14; -0.23 to -0.06). WHIIRS scores were lower in individuals reporting "other" shift work (split/irregular/on-call/rotating) versus day shift work (-1.96; -2.89 to -1.14) and those who perceived their village's wealth to be poor/average versus wealthy (-0.94; -1.50 to -0.34). Conclusions: Participants had a generally higher prevalence of excessive daytime sleepiness, but lower prevalence of insomnia, compared with individuals from high-income countries. Factors associated with sleep health differed compared with prior studies, emphasizing potential cultural/environmental differences and the need for targeted interventions to improve sleep health in this setting.

The protective effect of rs373863828 on type 2 diabetes does not operate through a body composition pathway in adult Samoans.

OBJECTIVE: The aim of this study was to understand whether the paradoxical association of missense variant rs373863828 in CREB3 regulatory factor (CREBRF) with higher BMI but lower odds of diabetes is explained by either metabolically favorable body fat distribution or greater fat-free mass. METHODS: This study explored the association of the minor allele with dual-energy x-ray absorptiometry-derived body composition in n = 421 Samoans and used path analysis to examine the mediating role of fat and fat-free mass on the relationship between rs373863828 and fasting glucose. RESULTS: Among females, the rs373863828 minor A allele was associated with greater BMI. There was no association of genotype with percent body fat, visceral adiposity, or fat distribution in either sex. In both females and males, lean mass was greater with each A allele: 2.16 kg/copy (p = 0.0001) and 1.73 kg/copy (p = 0.02), respectively. Path analysis showed a direct negative effect of rs373863828 genotype on fasting glucose (p = 0.004) consistent with previous findings, but also an indirect positive effect on fasting glucose operating through fat-free mass (p = 0.027). CONCLUSIONS: The protective effect of rs373863828 in CREBRF, common among Pacific Islanders, on type 2 diabetes does not operate through body composition. Rather, the variant's effects on body size/composition and fasting glucose likely operate via different, tissue-specific mechanisms.

The missense variant, rs373863828, in CREBRF plays a role in longitudinal changes in body mass index in Samoans.

OBJECTIVE: A missense variant, rs373863828, in CREBRF is associated with obesity in Polynesians. We investigate whether rs373863828 and other factors are associated with body mass index (BMI) rate-of-change between 2010 and 2017-19 in Samoans. METHODS: We used sex-stratified models to test whether BMI rate-of-change was associated with rs373863828, baseline BMI, age, residence, physical activity, and household asset score in a cohort study of 480 Samoan adults measured in both 2010 (mean age 43.8 years) and 2017-19. RESULTS: Mean BMI increased from 32.1 to 33.5 kg/m2 in males (n = 220, p = 1.3 ×10-8) and from 35.9 to 37.8 kg/m2 in females (n = 260, p = 1.2 ×10-13). In females, the A allele was associated with a higher rate-of-change (0.150 kg/m2/year/allele, p = 1.7 ×10-4). Across 10-year age groups, mean BMI rate-of-change was lower in older participants. The BMI rate of change differed by genotype: it was, in females with AA genotype, approximately half that seen in GG and AG participants. In females lower baseline household asset scores were associated with a higher rate-of-change (p = 0.002). CONCLUSIONS: In Samoans, the minor A allele of rs373863828 is associated with an increased rate-of-change in BMI in females. On average, BMI of females with the AA genotype increased 0.30 kg/m2/year more than of those with the GG genotype.

C-reactive protein in adult Samoans: Population variation and physiological correlates.

OBJECTIVES: C-reactive protein (CRP) has been associated with adiposity and cardiometabolic disease risk in many populations but remains remarkably understudied in Pacific Islander populations. Here, we provide the first examination of correlates of CRP in adult Samoans (n = 108, ages 35-55 years) to test the hypotheses that CRP exhibits sex-dependent associations with measures of BMI, adiposity, and cardiometabolic disease risks. METHODS: We analyzed associations between measures of adiposity (total fat mass, visceral fat mass, percent total body fat), body mass index (BMI), cardiometabolic risks, behaviors, demographics, and CRP. Unadjusted analyses of CRP were undertaken using Pearson's pairwise, and Spearman's rank correlations; one-way analysis of variance and Kruskal-Wallis tests assessed variables by CRP quartiles. Adjusted analyses of CRP correlates were examined using generalized linear regression. RESULTS: Serum CRP ranged from 0.08 to 13.3 mg/L (median 1.4 mg/L) and varied significantly by sex t (108) = -2.47, p = .015. CRP was weakly to moderately associated with measures of adiposity and BMI (r and ρ ranged between 0.25 and 0.50, p < .05) and some cardiometabolic markers (including HbA1c, fasting insulin, and insulin resistance). CRP was significantly associated with percent body fat in women and men, adjusting for other variables. CONCLUSIONS: These data are among the first to demonstrate CRP correlates in a sample of adult Samoans. CRP differed by sex and was associated with BMI, adiposity, and some cardiometabolic risk markers. These data align with findings in other populations.

Improving services for chronic non-communicable diseases in Samoa: an implementation research study using the care cascade framework.

OBJECTIVE: Samoa needs to intensify the response to the growing non-communicable disease burden. This study aimed to assess bottlenecks in the care continuum and identify possible solutions. METHODS: The mixed-methods study used the cascade framework as an analysis tool and hypertension as a tracer condition for chronic non-communicable diseases. Household survey data were integrated with medical record data of hypertension patients and results from focus group discussions with patients and healthcare providers. RESULTS: Hypertension prevalence was 38.1% but only 4.7% of hypertensive individuals had controlled blood pressure. There were large gaps in the care continuum especially at screening and referral due to multiple socio-cultural, economic and service delivery constraints. CONCLUSIONS: In Samoa, care for chronic non-communicable diseases is not effectively addressing patient needs. This calls for better health communication, demand creation, treatment support, nutritional interventions and health service redesign, with a focus on primary healthcare and effective patient and community engagement. Implications for public health: The proposed actions can improve the reach, accessibility, quality and effectiveness of Samoa's chronic care services. Health system redesign is necessary to ensure continuity of care and more effective primary prevention. The findings are useful for other countries in the region facing similar challenges.

Relationships between mental health and diet during pregnancy and birth outcomes in a lower-middle income country: "Healthy mothers, healthy communities" study in Vanuatu.

Poor maternal mental health during pregnancy is associated with adverse birth outcomes, including lower birthweight and gestational age. However, few studies assess both mental health and diet, which might have interactive effects. Furthermore, most studies are in high-income countries, though patterns might differ in low- and middle-income countries (LMICs). OBJECTIVES: To analyze relationships between mental health and diet during pregnancy with birth outcomes in Vanuatu, a lower-middle income country. METHODS: We assessed negative emotional symptoms of depression, anxiety, and stress (referred to as "distress") and dietary diversity during pregnancy, and infant weight and gestational age at birth, among 187 women. We used multivariate linear regression to analyze independent and interactive relationships between distress, dietary diversity, and birth outcomes, controlling for sociodemographic and maternal health covariates. RESULTS: There were no direct linear relationships between dietary diversity or distress with infant birthweight or gestational age, and no curvilinear relationships between distress and infant outcomes. We observed interactive relationships between distress and dietary diversity on birthweight, explaining 2.1% of unique variance (P = .024). High levels of distress predicted lower birthweights among women with low dietary diversity. These relationships were not evident among women with moderate or high dietary diversity. CONCLUSIONS: Relationships between mental health and diet might underlie inconsistencies in past studies of prenatal mental health and birthweight. Results highlight the importance of maternal mental health on birthweight in LMICs. Interactive relationships between mental health and diet might ultimately point to new intervention pathways to address the persistent problem of low birthweight in LMICs.

Relationships between Prenatal Distress and Infant Body Mass Index in the First Year of Life in a Lower-Middle Income Country.

Prenatal stress affects body composition in childhood and later in life. However, few studies assess body composition in infancy. Furthermore, most are in high-income countries and do not consider interactive or curvilinear relationships. We assessed distress and diet during pregnancy via questionnaires among 310 women in Vanuatu, a lower-middle income country. We measured body mass index (BMI) among 54 infants at 4-12 months of age. We analyzed interactive relationships between prenatal distress and diet with BMI Z-scores, and curvilinear relationships between distress and BMI Z-scores. There were no direct linear or interactive relationships between prenatal distress or diet with BMI Z-scores. We observed curvilinear relationships between prenatal distress and BMI Z-scores (p = 0.008), explaining 13.3 percent of unique variance. Results highlight that relationships between prenatal stress and body composition are evident in infancy but might not be detected if only linear relationships are assessed. Analyses in more diverse samples might help to explain inconsistencies in past studies.