Vaccine-Associated Shifts in SARS-CoV-2 Infectivity Among the Native Hawaiian and Other Pacific Islander Population in Hawaii.

Native Hawaiians and other Pacific Islanders (NHPIs) across the country have experienced significant disparities because of the COVID-19 pandemic. The Pacific Alliance Against COVID-19 used a community-based participatory approach involving academic and community partners to expand sustainable COVID-19 testing capacity and mitigate the severe consequences among NHPI communities in Hawaii. We describe the approach of this one-year study, some of the results, and how the data are being used to inform next steps for the communities. Clinical Trials.gov identifier: NCT04766333. (Am J Public Health. 2022;112(S9):S896-S899. https://doi.org/10.2105/AJPH.2022.306973).

Best Practices for Conducting Clinical Trials With Indigenous Children in the United States.

We provide guidance for conducting clinical trials with Indigenous children in the United States. We drew on extant literature and our experience to describe 3 best practices for the ethical and effective conduct of clinical trials with Indigenous children. Case examples of pediatric research conducted with American Indian, Alaska Native, and Native Hawaiian communities are provided to illustrate these practices. Ethical and effective clinical trials with Indigenous children require early and sustained community engagement, building capacity for Indigenous research, and supporting community oversight and ownership of research. Effective engagement requires equity, trust, shared interests, and mutual benefit among partners over time. Capacity building should prioritize developing Indigenous researchers. Supporting community oversight and ownership of research means that investigators should plan for data-sharing agreements, return or destruction of data, and multiple regulatory approvals. Indigenous children must be included in clinical trials to reduce health disparities and improve health outcomes in these pediatric populations. Establishment of the Environmental Influences on Child Health Outcomes Institutional Development Award States Pediatric Clinical Trials Network (ECHO ISPCTN) in 2016 creates a unique and timely opportunity to increase Indigenous children's participation in state-of-the-art clinical trials.

Disparities in Elevated Body Mass Index in Youth Receiving Care at Community Health Centers.

Childhood obesity has increased significantly in the United States. Racial subgroups are often grouped into categories in research, limiting our understanding of disparities. This study describes the prevalence of obesity among youth of diverse racial and ethnic backgrounds receiving care at community health centers (CHCs). This cross-sectional study describes the prevalence of elevated body mass index (BMI) (≥85th percentile) and obesity (≥95th percentile) in youth aged 9 to 19 years receiving care in CHCs in 2014. Multilevel logistic regression estimated the prevalence of elevated BMI and obesity by age, race/ethnicity, and sex. Among 64 925 youth, 40% had elevated BMI and 22% were obese. By race, obesity was lowest in the combined Asian/Pacific Islander category (13%); however, when subgroups were separated, the highest prevalence was among Native Hawaiians (33%) and Other Pacific Islanders (42%) and the lowest in Asians. By sex, Black females and Hispanic and Asian males were more likely to be obese. By age, the highest prevalence of obesity was among those aged 9 to 10 years (25%). Youth served by CHCs have a high prevalence of obesity, with significant differences observed by race, sex, and age. Combining race categories obscures disparities. The heterogeneity of communities warrants research that describes different populations to address obesity.

Promoting Optimal Native Outcomes (PONO) by Understanding Women's Stress Experiences.

A growing body of evidence links stress with mental illness and chronic disease. Existing scales of women's stress fail to capture the daily stressors of low-income, rural women. We explored the psychosocial stressors of local women residing in a rural Hawaii community with a large Native Hawaiian and Other Pacific Islander population. We recruited women, aged 18-35 years, at a community health center. We convened four focus groups to elicit information about women's stress. We identified key themes from the focus group data to generate questions that target concerns raised by participants. These were corroborated by additional focus groups. Thirty-six women participated in the study. Seven stressor themes emerged: intimate relationships-limited partner assistance, gender stereotype; family and home life-feeling like an outsider, lack of respect; childrearing-quality and affordable childcare, conflicting discipline styles; time for self-never-ending duties, being too tired to relax; neighborhood environment-safety concerns, not feeling part of the community; workplace-workload and transportation obstacles; and finances-making ends meet and arguments about money. Women in this study articulated a broad range of daily stressors. Sociocultural factors leading to feeling like an outsider within their own family, intercultural marriage conflicts, and perceptions of community discrimination are not included in other published scales. Our focus group investigations thus provided critical knowledge for developing a community-relevant scale. This is a prerequisite for developing and testing innovative intervention strategies designed to reduce stress in this population. We believe that reducing stress is necessary to mitigate the negative effects of stressors on physical and mental health among women in this rural community.

Building School-Academic Partnerships to Implement COVID-19 Testing in Underserved Populations.

OBJECTIVE: In April 2021, the US government made substantial investments in students' safe return to school by providing resources for school-based coronavirus disease 2019 (COVID-19) mitigation strategies, including COVID-19 diagnostic testing. However, testing uptake and access among vulnerable children and children with medical complexities remained unclear. METHODS: The Rapid Acceleration of Diagnostics Underserved Populations program was established by the National Institutes of Health to implement and evaluate COVID-19 testing programs in underserved populations. Researchers partnered with schools to implement COVID-19 testing programs. The authors of this study evaluated COVID-19 testing program implementation and enrollment and sought to determine key implementation strategies. A modified Nominal Group Technique was used to survey program leads to identify and rank testing strategies to provide a consensus of high-priority strategies for infectious disease testing in schools for vulnerable children and children with medical complexities. RESULTS: Among the 11 programs responding to the survey, 4 (36%) included prekindergarten and early care education, 8 (73%) worked with socioeconomically disadvantaged populations, and 4 focused on children with developmental disabilities. A total of 81 916 COVID-19 tests were performed. "Adapting testing strategies to meet the needs, preferences, and changing guidelines," "holding regular meetings with school leadership and staff," and "assessing and responding to community needs" were identified as key implementation strategies by program leads. CONCLUSIONS: School-academic partnerships helped provide COVID-19 testing in vulnerable children and children with medical complexities using approaches that met the needs of these populations. Additional work is needed to develop best practices for in-school infectious disease testing in all children.

Common Data Element Collection in Underserved School Communities: Challenges and Recommendations.

OBJECTIVES: To provide recommendations for future common data element (CDE) development and collection that increases community partnership, harmonizes data interpretation, and continues to reduce barriers of mistrust between researchers and underserved communities. METHODS: We conducted a cross-sectional qualitative and quantitative evaluation of mandatory CDE collection among Rapid Acceleration of Diagnostics-Underserved Populations Return to School project teams with various priority populations and geographic locations in the United States to: (1) compare racial and ethnic representativeness of participants completing CDE questions relative to participants enrolled in project-level testing initiatives and (2) identify the amount of missing CDE data by CDE domain. Additionally, we conducted analyses stratified by aim-level variables characterizing CDE collection strategies. RESULTS: There were 15 study aims reported across the 13 participating Return to School projects, of which 7 (47%) were structured so that CDEs were fully uncoupled from the testing initiative, 4 (27%) were fully coupled, and 4 (27%) were partially coupled. In 9 (60%) study aims, participant incentives were provided in the form of monetary compensation. Most project teams modified CDE questions (8/13; 62%) to fit their population. Across all 13 projects, there was minimal variation in the racial and ethnic distribution of CDE survey participants from those who participated in testing; however, fully uncoupling CDE questions from testing increased the proportion of Black and Hispanic individuals participating in both initiatives. CONCLUSIONS: Collaboration with underrepresented populations from the early study design process may improve interest and participation in CDE collection efforts.

Rapid growth from 12 to 23 months of life predicts obesity in a population of Pacific Island children.

BACKGROUND: Rapid growth (RG) in early childhood has been associated with increased risk of obesity. The specific intervals when risk is highest have not been well examined and may help identify modifiable risk factors. OBJECTIVE: To determine the correlation between RG in consecutive time intervals during the first 2 years of life with obesity at 4-5 years. METHODS: This was a retrospective study of children attending the largest community health center in Hawaii. Children, aged 4-5 years, with a pre-kindergarten (PreK) well-child physical examination were included; data were abstracted from medical charts. ANALYSES: Children were classified as overweight (BMI for age/sex 85-94%) or obese (BMI for age/sex > or = 95%). Moderate and severe rapid growth was defined as an increase in weight-for-height z-score of .67-1.0 SD and > or = 1.0, respectively. Relationship between RG and PreK obesity was assessed using logistic regression analyses. RESULTS: 389 children were included: 66% Hawaiian, 21.6% Samoan and 12.3% Filipino. At the PreK 19.6% were obese, and 20.9% were overweight. Severe RG from 12 to 23 months was strongly associated with PreK obesity (OR 4.36, 95% CI 1.85-10.27). Of children with severe RG from 12-23 months, 48% were obese at PreK compared with 16.7% of children with moderate RG and 19.3% of children without RG. CONCLUSION: Rapid growth between 12 and 23 months, a key period of nutritional transition in toddlers, was strongly associated with obesity at 4 to 5 years of age in this high-risk population of Pacific Island minority subgroups.

Opposing Role of Trust as a Modifier of COVID-19 Vaccine Uptake in an Indigenous Population.

Native Hawaiians and other Pacific Islanders (NHPIs) were disproportionately impacted by COVID-19 and remain significantly under-vaccinated against SARS-CoV-2. To understand vaccine hesitancy, we surveyed 1124 adults residing in a region with one of the lowest vaccination rates in Hawaii during our COVID-19 testing program. Probit regression analysis revealed that race/ethnicity was not directly associated with the probability of vaccine uptake. Instead, a higher degree of trust in official sources of COVID-19 information increased the probability of vaccination by 20.68%, whereas a higher trust in unofficial sources decreased the probability of vaccination by 12.49% per unit of trust. These results revealed a dual and opposing role of trust on vaccine uptake. Interestingly, NHPIs were the only racial/ethnic group to exhibit a significant positive association between trust in and consumption of unofficial sources of COVID-19 information, which explained the vaccine hesitancy observed in this indigenous population. These results offer novel insight relevant to COVID-19 mitigation efforts in minority populations.

A Qualitative Study on the Motivators, Barriers and Supports to Participation in a Pediatric Produce Prescription Program in Hawai'i.

Produce prescriptions that provide vouchers to individuals to purchase fresh FVs at a specified retail outlet have the potential to positively impact food security status, diet, and chronic disease risk. However, maximizing program participation is vital to ensuring program success. This research describes motivators, barriers, and support for participation in a child produce prescription program among a population of Native Hawaiian and Other Pacific Islanders, who are underrepresented in this field of research. This qualitative grounded theory study was nestled within a quasi-experimental pilot intervention trial and included semi-structured interviews with pediatric program participants. Twenty-five interviews were conducted, which represented one-third of program participants. The top support factors for program participation included: ease of voucher use, program convenience, health center/pediatrician endorsement and positive communications with farmers' market vendors. Key motivators for program participation were produce enjoyment, child support, financial support, and positive impacts on family. Three themes emerged consistently as barriers to participation amongst participants, (1) difficult use of vouchers, (2) conflicting schedules, and (3) online market concerns. (4) Conclusions: This research offers insight into policy implications as the number of produce prescription programs has grown. These findings suggest that key program design characteristics can enhance and support program participation.

Dynamics of Trust and Consumption of COVID-19 Information Implicate a Mechanism for COVID-19 Vaccine and Booster Uptake.

Vaccine hesitancy remains a significant barrier to achieving herd immunity and preventing the further spread of COVID-19. Understanding contributors to vaccine hesitancy and how they change over time may improve COVID-19 mitigation strategies and public health policies. To date, no mechanism explains how trust in and consumption of different sources of information affect vaccine uptake. A total of 1594 adults enrolled in our COVID-19 testing program completed standardized surveys on demographics, vaccination status, use, reliance, and trust in sources of COVID-19 information, from September to October 2021, during the COVID-19 Delta wave. Of those, 802 individuals (50.3%) completed a follow-up survey, from January to February 2022, during the Omicron-wave. Regression analyses were performed to understand contributors to vaccine and booster uptake over time. Individuals vaccinated within two months of eligibility (early vaccinees) tended to have more years of schooling, with greater trust in and consumption of official sources of COVID-19 information, compared to those who waited 3-6 months (late vaccinees), or those who remained unvaccinated at 6 months post-eligibility (non-vaccinees). Most (70.1%) early vaccinees took the booster shot, compared to only 30.5% of late vaccinees, with the latter group gaining trust and consumption of official information after four months. These data provide the foundation for a mechanism based on the level of trust in and consumption of official information sources, where those who increased their level of trust in and consumption of official information sources were more likely to receive a booster. This study shows that social factors, including education and individual-level degree of trust in (and consumption of) sources of COVID-19 information, interact and change over time to be associated with vaccine and booster uptakes. These results are critical for the development of effective public health policies and offer insights into hesitancy over the course of the COVID-19 vaccine and booster rollout.

Disparities in Potentially Preventable Emergency Department Visits for Children with Asthma among Asian Americans, Pacific Islanders, and Whites in Hawai'i.

The cost burdens of potentially preventable emergency department visits for pediatric asthma were estimated for Asian Americans, Pacific Islanders, and Whites using Hawai'i statewide 2015-2016 data. The cost burden of the 3234 preventable emergency department visits over the study period was over $1.9 million. Native Hawaiians had the largest proportion (36.5%) of all preventable emergency department visits and accounted for the highest costs for the two years at $709,698. After adjusting for other factors, costs for preventable pediatric-asthma-related emergency department visits differed significantly by age, insurance provider, and island of residency. Reducing potentially preventable emergency department visits would not only improve health disparities among Native Hawaiians compared to other racial or ethnic populations in Hawai'i, but could also generate cost savings for public and private insurance payers.

Insights in Public Health: Ask the Keiki: Perceived Factors that Affect Asthma Among Adolescents from the Wai'anae Coast Using Photovoice.

Hawai'i has among the highest childhood asthma prevalence compared to all other states in the United States. Native Hawaiian children have a higher prevalence of asthma compared other racial/ethnic groups in the state. Photovoice is a method in community-based participatory research that enables participants to use photos to express themselves and advocate on behalf of their community. In this study, students from the Wai'anae Coast used Photovoice to identify perceived factors that affect asthma management. Seven students, ages 14 and 18, with self-reported asthma met virtually, with facilitators, after school once a week for four weeks. Students identified eight factors as positively or negatively impacting the students' asthma and explained how these factors influence their health. The Photovoice results provided an in-depth understanding on the role a student's culture and environment plays in asthma management. Continued efforts to develop asthma education programs tailored to address the specific factors that youth identify as impacting their asthma may be more effective in reducing asthma disparities. Future research should expand on the key themes identified in this study and include continued advocacy efforts among students to improve asthma-related outcomes in this community.

A Comparison of Length of Hospitalization and Costs in Obese and Non-Obese Pediatric Patients at a Single Hospital in Honolulu.

The association of obesity with increased hospital costs and length of stay among hospitalized pediatric patients identified by ICD-9 coding may be underestimated due to underreporting of appropriate ICD-9 coding for obesity status. The objective of this study was to compare these lengths of stay and hospital costs. A retrospective chart review was conducted of pediatric patients admitted from May 2009 to January 2012 at Kapi'olani Medical Center, Honolulu, Hawai'i, with the 20 most common primary admission diagnosis ICD-9 codes. Length of hospital stay and total hospital costs were compared for obese, overweight, and normal-weight patients based on body mass index (BMI), controlling for age, sex, ethnicity, insurance type, diagnosis, and calendar year using logistic regression. Analysis of 730 patients showed 1% of overweight patients and 35% of obese patients were correctly coded with the corresponding ICD-9 code for weight status. Obese patients had 15% longer hospital stays and 19% higher hospital costs than normal weight patients, when controlled for age, sex, ethnicity, insurance type, calendar year, and primary diagnosis. Subgroup analyses of the top 3 most common primary admission diagnoses showed obese patients with asthma had significantly higher hospital costs than normal weight patients. Obesity is an independent risk factor for increasing hospital resource utilization in hospitalized pediatric patients. Documentation of ICD-9 codes for overweight and obesity in this cohort drastically underrepresented the true prevalence of obesity and overweight status in this sample of hospitalized children. Further research is needed to better understand the complex role of obesity in pediatric inpatients, particularly among those with asthma.

Keiki Produce Prescription (KPRx) Program Feasibility Study to Reduce Food Insecurity and Obesity Risk.

One in 6 US children experience food insecurity, signifying that at some time during the last year their household did not have sufficient food, money, or resources to feed their family. These children experience little intake of fresh fruits and vegetables (FV), a risk factor for chronic disease, including obesity. Produce prescription programs provide vouchers to purchase fresh FV at participating retailers. The Keiki Produce Prescription (KPRx) Program feasibility study was conducted through a partnership between the Waianae Coast Comprehensive Health Center's Pediatrics and Health Promotion Department's Farmers'Market and the University of Hawai'i nutrition faculty. Pediatricians provided patients with a prescription (Rx) to purchase FV from the Farmers' Market ($24 per month for three months). Of the 193 Rx distributed, 125 patients participated in part of the program, while 34 completed the full program. Parents, pediatricians, clinic staff, and community members expressed overwhelming support of the program. Parents of participating children completed an exit interview that identified themes surrounding motivation to participate, benefits to child and family, and future recommendations. It identified the need to improve program retention efforts. Participants reported lifestyle benefits for both the child and family and recommended educational resources. Aresearch protocol was developed to address the following objectives: (1) streamline referrals, (2) enhance retention, (3) quantify program impact, and (4) identify barriers to participation. Subsidies have the potential to increase FV consumption, improve overall health, reduce chronic diseases in adulthood, and result in substantial healthcare cost savings.

Hawai'i IDeA Center for Pediatric and Adolescent Clinical Trials.

As one of 17 clinical sites of the Environmental influences on Child Health Outcomes (ECHO) IDeA States Pediatric Clinical Trials Network (ISPCTN), the Hawai'i IDeA Center for Pediatric and Adolescent Clinical Trials (HIPACT) was established in 2016 to participate in community-valued and scientifically-valid multi-center pediatric clinical trials to improve health and well-being of diverse multi-ethnic populations of Hawai'i. Hawai'i is home to large populations of diverse rural and underserved populations, including indigenous Hawaiian communities and immigrant populations of Pacific Islanders and Asians. Many of these communities experience significant health disparities, made worse by their geographic isolation and many socio-economic factors. In addition to providing opportunities for children and their families to participate in clinical trials, HIPACT's goal is to provide opportunities for junior faculty of the John A. Burns School of Medicine (JABSOM), University of Hawai'i at Manoa, to acquire knowledge about and to develop skills in clinical trials. HIPACT's partners include the Hawai'i Pacific Health with Kapi'olani Medical Center for Women and Children, and Waianae Coast Comprehensive Health Center. HIPACT builds on the experiences gained through partnerships with the Mountain West IDeA Clinical and Translational Research-Infrastructure Network, and Research Centers in Minority Institutions Translational Research Network. Apart from participating in ECHO ISPCTN-sponsored studies, HIPACT junior faculty serve as committee members, Working Group leaders, Protocol Study Principal Investigators (PI) and site study PIs with ECHO ISPCTN. Through participation in ECHO ISPCTN, HIPACT has successfully increased the number of pediatric and maternal-fetal medicine faculty involved in the conduct of clinical trials.

Empowering 'Opio (Next Generation): Student Centered, Community Engaged, School Based Health Education.

Education and health are vital for children to thrive, especially for those from rural and disparate communities. For Native Hawaiians, the indigenous people of the State of Hawai'i, lokahi (balance) frames the concept of ola (health), consisting of physical, emotional, and spiritual health. The foundation of ola is embedded in the cultural values - kupuna (ancestors), 'aina (land), environment, and 'ohana (family). Unfortunately, since westernization, Native Hawaiians have significant health disparities that begin in early childhood and often continue throughout their lifetime. Native Hawaiians also have a history of educational disparities, such as lower high school an college graduation rates compared to other ethnic groups. Social and economic determinants, such as poverty, homelessness, and drug addiction, often contribute to these educational disparities. In rural O'ahu, the Waianae Coast Comprehensive Health Center recently established two school-based health centers at the community's high and intermediate schools to improve student access to comprehensive health services. Recognizing the need to improve student health literacy and address specific health issues impacting the community and students, two health educators were added to the school-based health team. This article describes: 1) the initial steps taken by the health educators to engage and empower students as a means to assess their needs, interests and facilitate student lokahi, ola, and wellness and; 2) the results of this initial needs assessment.

An overview of obesity and diabetes in the diverse populations of the Pacific.

BACKGROUND: Pacific islanders (PI) have some of the highest prevalence of obesity and type 2 diabetes in the world. Data related to PI are often reported as though the group is an aggregate; however, PI are a group of very diverse peoples. OBJECTIVE: To explore the obesity problem in PI by: 1) characterizing the major ethnic groups in the Pacific; 2) describing the most recent US census data on PI and their recent immigration patterns; and 3) synthesizing the literature on obesity in PI and type 2 diabetes mellitus. METHODS: Census information and anthropologic resources on the Pacific Islands and its peoples were obtained through an Internet search. Literature on obesity, diabetes, and body composition in PI were obtained through a systematic analysis of citations listed on Medline. RESULTS: Pacific Islanders (PI) are diverse people, culturally, biologically, and linguistically. Polynesians and some Micronesians have a very high prevalence of obesity and diabetes. Melanesians are among the most diverse ethnic groups in the world. Body mass index (BMI) cut-point values for Polynesians may be inaccurate. CONCLUSIONS AND RECOMMENDATIONS: The cause of obesity and diabetes in PI is unclear. Some factors involved are related to urbanization and migration. Obesity research should distinguish between island ethnicities and not aggregate all PI together. Research is needed to define body fat distribution of Polynesians in relationship to obesity co-morbidities, to determine normal growth of Polynesian children, to determine the relationship between growth abnormalities and adult obesity, and to determine the impact of immigration on PI.

Addressing health disparities by building organizational capacity in the community: a case study of the Wai'anae Coast Comprehensive Health Center.

Native Hawaiians and other residents living in economically disadvantaged communities suffer disproportionately from many health conditions, especially chronic diseases. Reversing this trend requires a comprehensive approach encompassing more than just improvement in healthcare delivery. Indeed, societal changes at multiple levels must occur, including environmental, systems, and policy change, in order to bring about sustainable improvements in community health and wellness. A key strategy to accomplish these upstream changes is an increase in the capacity of community-based organizations to provide leadership in health advocacy, support community health promotion, prioritize resource allocation, and participate in community health research. In disadvantaged communities where health disparities are the most severe, community health centers (CHC) are well positioned to take a pivotal role in these efforts. This report is a case study to describe processes taking place at Hawai'i's largest CHC to build organizational capacity and bring about upstream changes that improve community health and wellness. Ongoing processes at the CHC include (1) Institutional: commitment to address health disparities, expand the CHC research infrastructure, and develop a comprehensive worksite wellness program (2) Collaborative: development of a network of community partners committed to the common goal of improving the health and wellness of community residents, and (3) Systems and Policy: activities to strengthen the CHC's and community's ability to influence systems changes and policies that reduce health disparities. Preliminary results are encouraging although the processes and timelines involved require a long-term commitment in order to affect tangible results that can be measured.