Dietary assessment methodology and reporting in Pacific Island research: a scoping review protocol.

OBJECTIVE: This scoping review aims to identify and describe the methods used to collect and analyze dietary intake data in residents of Pacific Island countries. INTRODUCTION: Dietary assessment explores associations between dietary factors and health outcomes. In regions, including the Pacific Islands, where diet-related, non-communicable diseases are increasing, this is a growing area of research. As this information is used to inform food and nutrition policies and practice, accurate collection, analysis, and interpretation of dietary assessment data relies on robust methods. A greater understanding of how nutrition studies are designed can strengthen the evidence on nutrition and health in Pacific Island settings and inform future research approaches. INCLUSION CRITERIA: The scoping review will consider studies published in peer-reviewed journals, including quantitative and qualitative study designs and gray literature, including government reports, research and technical reports, theses and dissertations that measure and/or assess dietary intake in resident populations of the Pacific Island member countries of the Secretariat of the Pacific Community: American Samoa, Commonwealth of the Northern Mariana Islands, the Cook Islands, the Federated States of Micronesia, French Polynesia, Guam, the Independent State of Papua New Guinea, the Independent State of Samoa, the Kingdom of Tonga, New Caledonia, Niue, Pitcairn Islands, the Republic of Fiji, the Republic of Kiribati, the Republic of the Marshall Islands, the Republic of Nauru, the Republic of Palau, the Republic of Vanuatu, Solomon Islands, Tokelau, Tuvalu, and Wallis and Futuna. METHODS: There will be no time limit and searches will be conducted in PubMed, CINAHL, CABI, Scopus, Cochrane Library, and Web of Science. Results will be limited to English-language articles. Data will be extracted independently by two reviewers into a charting table. Results will be presented graphically and with tables accompanied by a narrative summary.

A case of a critically injured diver with multiorgan failure and severe pulmonary overinflation syndrome in a resource-limited setting.

A diver practicing controlled emergency ascent training on the island of Guam suffered bilateral pneumothorax, pneumomediastinum, coronary arterial gas embolism, and developed multiple organ dysfunction syndrome. Due to limitations of available resources he was medically managed in the intensive care unit until he could be transferred to University of California San Diego for definitive management. We provide an account of our management of the patient, the pathophysiology of injury as well as a review of the safety of recreational diving skills training, current standards of practice and potential pitfalls when considering proper management of a critically injured diver.

Prevalence and Predictors of Overweight and Obesity among Young Children in the Children's Healthy Living Study on Guam.

This study is part of the Children's Healthy Living program in U.S. Affiliated Pacific region. The objectives were to estimate overweight and obesity (OWOB) prevalence and identify possible related risk factors among ethnic groups in Guam. In 2013, 865 children (2-8 years) were recruited via community-based sampling from select communities in Guam. Children's demographic and health behavior information; dietary intake; and anthropometric measurements were collected. Logistic regression, odds ratio, t-tests, and chi-square tests were used to determine differences and assess covariates of OWOB. The results indicate that 58% of children were living below the poverty level, 80% were receiving food assistance, and 51% experienced food insecurity. The majority of children surveyed did not meet recommendations for: sleep duration (59.6%), sedentary screen-time (83.11%), or fruit (58.7%) and vegetable (99.1%) intake, and consumed sugar sweetened beverages (SSB) (73.7%). OWOB affected 27.4% of children. Children affected by OWOB in this study were statistically more likely (p = 0.042) to suffer from sleep disturbances (p = 0.042) and consume marginally higher amounts (p value = 0.07) of SSB compared to children with healthy weight. Among Other Micronesians, children from families who considered themselves 'integrated' into the culture were 2.05 (CI 0.81-5.20) times more likely to be affected by OWOB. In conclusion, the OWOB prevalence among 2-8-year-olds in Guam was 27.4%; and compared with healthy weight children, children with OWOB were more likely to have educated caregivers and consume more SSBs. Results provide a basis for health promotion and obesity prevention guidance for children in Guam.

Lessons from the Field: Guam Salt Reduction Campaign.

To lessen the salt-intake of people in Guam for the prevention of non-communicable diseases (NCD) associated with a high sodium diet, the Racial and Ethnic Approach to Community Health (REACH) program and NCD Consortium of the Guam Bureau of Community Health Services (BCHS) formed strategies that encourage healthier eating behavior. Project stakeholders, like restaurants, food services establishments, and vendors, removed salt products from dine-in tables, including saltshakers, soy sauce, and finadene. Combined programmatic efforts resulted in support by 47 restaurants out of 140 restaurants that were approached for the salt reduction initiative: the removal of saltshakers and other high sodium-containing condiments from tables, made available only upon a customer's request.

Adolescent Tobacco and Betel Nut Use in the US-Affiliated Pacific Islands: Evidence From Guam.

PURPOSE: To determine the prevalence of, and the risk and protective factors associated with, tobacco product use among adolescents in Guam, a US-Affiliated Pacific Island (USAPI) territory. To examine disparities in risk and protective factors across indigenous and nonindigenous groups. DESIGN: Quantitative; cross-sectional. SETTING: Middle and high schools in Guam. SAMPLE: The Global Youth Tobacco Survey sample included a representative sample of 2449 6th to 12th graders (71% response rate). Sample for the supplemental study included 670 middle school students (76% response rate across randomly selected classrooms). MEASURES: Self-reported measures of lifetime and past 30-day tobacco and betel nut use, social competence, resistance self-efficacy, risk perceptions, friend and family tobacco product use, and ease of access to tobacco products. ANALYSIS: Multilevel logistic regression and analysis of covariance. RESULTS: The prevalence rates of current cigarette, smokeless tobacco, and e-cigarette use among middle school students were 8%, 8%, and 25%, respectively. Ability to resist social pressure to use tobacco/betel nut use was strongly associated with lower likelihood of tobacco (odds ratio [OR] = 0.76; 95% confidence interval [CI]: 0.68-0.84) and betel nut use (OR = 0.74; 95% CI: 0.67-0.82). Indigenous Pacific Islanders scored significantly lower on protective and higher on risk factors. CONCLUSION: Tobacco product use rates among Guam middle school students appear to be 4 to 5 times higher than the US national average rates. There is an urgent need for developing tobacco and betel nut use prevention programs for USAPI youth that are tailored to the needs of indigenous Pacific Islanders.

Toxicity assessment of pollutants sorbed on environmental microplastics collected on beaches: Part II-adverse effects on Japanese medaka early life stages.

While microplastics are present in great abundance across all seas and oceans, little is known about their effects on marine life. In the aquatic environment, they can accumulate a variety of chemicals and can be ingested by many marine organisms including fish, with chronic physical and chemical effects. The purpose of this paper is to evaluate the toxic effects of pollutants sorbed at the surface of environmental microplastics (MPs), collected on various beaches from three islands of the Pacific Ocean. Developmental toxicity of virgin MPs or artificially coated with B[a]P and environmental MPs from Easter Island, Guam and Hawaii was evaluated on embryos and prolarvae of Japanese medaka. Mortality, hatching success, biometry, malformations, EROD activity and DNA damage were analyzed after exposure to DMSO extracts. No toxicity was observed for extracts of virgin MPs whatever the endpoint considered. Extracts of virgin MPs coated with 250 µg.g-1 of B(a)P induced lethal effects with high embryo mortality (+81%) and low hatching rate (-28%) and sublethal effects including biometry and swimming behavior changes, increase of EROD activity (+94%) and DNA damage (+60%). Environmental MPs collected on the three selected islands exhibited different polymer, pollutant and toxicity patterns. The highest toxicity was detected for MPs extract from Hawaï with head/body length and swimming speed decreases and induction of EROD activity and DNA stand breaks. This study reports the possible sublethal toxicity of organic pollutants sorbed on MPs to fish early life stages.

Embracing the Obstetric Imaginary: Chuukese Women, Migration, and Stratified Reproduction.

When a new biomedical hospital was built in Chuuk, women were encouraged to forgo home births and seek obstetric care. Chuuk's infrastructure deteriorated over time, however, and the hospital became known as the place of death. Women maintained faith in obstetric technology despite these conditions; they simply sought better technology in Guam or a US state. Yet, even upon migrating, women continued to suffer disproportionately poor birth outcomes. In this article, I explore how Chuukese women maintained faith in obstetric technology, elucidating the power of the "obstetric imaginary" in the context of neocolonial development, migration, and stratified reproduction.

Assessment of humaneness using gunshot targeting the brain and cervical spine for cervid depopulation under field conditions.

Population reduction or eradication of domestic or non-domestic species may be required to address their impacts on the environment, other species, or human interests. Firearms are often used to accomplish these practical management objectives, and there is increased concern that the methods used may compromise animal welfare. We document the accuracy and humaneness of gunshot placement to the brain and cervical vertebrae of Philippine deer (Rusa marianna) on Guam during depopulation activities as a model for meeting AVMA standards of euthanasia under field conditions (e.g., animal is not in hand). Deer were shot with a .223 caliber rifle from 10-125 m and approached immediately (<20 s) for assessment. A subset of adult deer was further evaluated for physiological responses including cessation of heart rate, respiration, ocular reflexes, and post-mortem spasms. All deer shot in the brain (n = 132) and upper cervical spine (C1-C3; n = 18) died immediately due to the destruction of the brain or spinal tissue. Shot placements were all within 1.9 cm of the point of aim (i.e., the center of the target region). The accuracy and immediate insensibility resulting from targeting of C1-C3 demonstrates that this is an alternative target site when animal positioning is not optimal for targeting the brain, or there is a need to preserve brain tissue (e.g., Chronic Wasting Disease testing). While targeting of C4 -C7 vertebrae (n = 6) was accurate and resulted in immediate incapacitation, the failure to produce immediate insensibility does not support the use of this shot placement when upper cervical or brain shot placement is an option. It is reasonable to achieve sufficient accuracy to target the brain or upper cervical vertebrae of deer under field conditions and meet standards of euthanasia while accomplishing management objectives.

Disaggregating Asian American and Native Hawaiian and Other Pacific Islander (AANHOPI) Adult Tobacco Use: Findings from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study, 2013-2014.

INTRODUCTION: Tobacco studies often combine data for Asian American and Native Hawaiian and Other Pacific Islander (AANHOPI) subgroups, masking subgroup differences. This study describes tobacco use (ever use and past 30-day use) among some disaggregated AANHOPI subgroups. METHODS: Data are from Wave 1 of the 2013-2014 Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal cohort study of civilian non-institutionalized adults and youth in the USA. The dataset contains a sample of 32,320 adults, of which 1623 identified as being of AANHOPI origin. Asian Americans further identified as being Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, or other Asian. Those who identified as Native Hawaiian, Guamanian or Chamarro, Samoan, and Other Pacific Islander were combined into an NHOPI group. Tobacco measures included ever and past 30-day use of cigarettes, e-cigarettes, cigars (traditional cigar, cigarillos, filtered cigar), hookah, and smokeless tobacco including snus pouches, and pipe tobacco. Unadjusted and adjusted estimates for tobacco use are reported by AANHOPI membership and sex. RESULTS: In general, Asian Indians and Chinese had the lowest and NHOPI had the highest tobacco use prevalence compared to other AANHOPI subgroups. Males generally had higher prevalence compared to females. Prevalence varied by AANHOPI membership and tobacco product. Adjusted prevalence estimates were higher compared to unadjusted estimates for many subgroups, attenuating some unadjusted differences found between AANHOPI subgroups. DISCUSSION: Tobacco use varies by AANHOPI subgroup and product type. Unadjusted and adjusted analyses can be conducted as tobacco use differences in AANHOPI subgroups may be attributed to socio-economic status differences. Treating these distinct subgroups as a monolithic group may contribute to reliance on tobacco prevention and control strategies that may have limited impact on specific subgroups.

Ethnic Inequalities in Psychological Distress: A Population Data Linkage Study on the Pacific Island of Guåhån/Guam.

Psychological distress and mental illness has been found to be elevated in migrant groups living in sovereign countries, as well as for indigenous people living under colonial or administrative rule. The north Pacific island of Guam is unusual in its ethnic composition as it has no majority ethnic group, has a large indigenous population and remains a territory of the U.S. This study aimed to identify ethnic differences in self-reported psychological distress between the main ethnic groups on Guam. The study uses a cross sectional design with data linkage methodology, drawing on the Guam Census and the Behavioral Risk Factor Surveillance System health survey for Guam. The results showed that the native Chamorro population had worse self-reported psychological distress (defined as a 'mental health condition or emotional problem') than White/Caucasians (OR 2.09, 95% CI 1.52-2.87), particularly for severe distress (OR 3.61, 95% CI 1.33-2.77). This relationship persisted even after adjusting for a wide range of socio-demographic and economic factors (OR 2.58, 95% CI 1.15-5.76). Other Pacific Islanders also had higher psychological distress compared to White/Caucasians, but this association was largely explained by the adjusted factors. The findings are discussed in terms of social and economic disadvantage for Pacific Island peoples on Guam, as well as the impact of colonial administration, disaffection, and lack of autonomy for the Chamorro of Guam. Recommendations are made to improve psychiatric treatment for these groups by considering wider socio-political factors in assessment and treatment, as well as broader implications for the national dialogue on self-determination.

Nursing Leadership in Guam.

Guam, an unincorporated territory of the United States, is one of the ten (10) US Affiliated Pacific Islands. The geographic location in the western Pacific Ocean, as well as the ties to the US position Guam as a strategic hub between the continental US, Asia, and the Pacific region. Health disparities in Guam and the Micronesian region are significant, and the non-communicable disease crisis is worsening, threatening the existing poor health infrastructure on the islands. Migration of islanders from the Micronesian region, whose countries also suffer health disparities, adds to the burden of the weak health care system on Guam. A critical nursing workforce shortage plagues the health care community, and strong nursing leadership is needed to address the problems. Nurse leaders, through many organizations, are working to implement strategies to address the issues facing the islands. Increased collaboration with partners on the island, on the US mainland, and globally, are necessary to effectively address Guam's health care concerns.

Surveillance for Certain Health Behaviors and Conditions Among States and Selected Local Areas - Behavioral Risk Factor Surveillance System, United States, 2015.

PROBLEM: Chronic conditions and disorders (e.g., diabetes, cardiovascular diseases, arthritis, and depression) are leading causes of morbidity and mortality in the United States. Healthy behaviors (e.g., physical activity, avoiding cigarette use, and refraining from binge drinking) and preventive practices (e.g., visiting a doctor for a routine check-up, tracking blood pressure, and monitoring blood cholesterol) might help prevent or successfully manage these chronic conditions. Monitoring chronic diseases, health-risk behaviors, and access to and use of health care are fundamental to the development of effective public health programs and policies at the state and local levels. REPORTING PERIOD: January-December 2015. DESCRIPTION OF THE SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed landline- and cellular-telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health-risk behaviors, chronic diseases and conditions, access to and use of health care, and use of preventive health services related to the leading causes of death and disability. This report presents results for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico (Puerto Rico), and Guam and for 130 metropolitan and micropolitan statistical areas (MMSAs) (N = 441,456 respondents) for 2015. RESULTS: The age-adjusted prevalence estimates of health-risk behaviors, self-reported chronic health conditions, access to and use of health care, and use of preventive health services varied substantially by state, territory, and MMSA in 2015. Results are summarized for selected BRFSS measures. Each set of proportions refers to the median (range) of age-adjusted prevalence estimates for health-risk behaviors, self-reported chronic diseases or conditions, or use of preventive health care services by geographic jurisdiction, as reported by survey respondents. Adults with good or better health: 84.6% (65.9%-88.8%) for states and territories and 85.2% (66.9%-91.3%) for MMSAs. Adults with ≥14 days of poor physical health in the past 30 days: 10.9% (8.2%-17.2%) for states and territories and 10.9% (6.6%-19.1%) for MMSAs. Adults with ≥14 days of poor mental health in the past 30 days: 11.3% (7.3%-15.8%) for states and territories and 11.4% (5.6%-20.5%) for MMSAs. Adults aged 18-64 years with health care coverage: 86.8% (72.0%-93.8%) for states and territories and 86.8% (63.2%-95.7%) for MMSAs. Adults who received a routine physical checkup during the preceding 12 months: 69.0% (58.1%-79.8%) for states and territories and 69.4% (57.1%-81.1%) for MMSAs. Adults who ever had their blood cholesterol checked: 79.1% (73.3%-86.7%) for states and territories and 79.5% (65.1%-87.3%) for MMSAs. Current cigarette smoking among adults: 17.7% (9.0%-27.2%) for states and territories and 17.3% (4.5%-29.5%) for MMSAs. Binge drinking among adults during the preceding 30 days: 17.2% (11.2%-26.0%) for states and territories and 17.4% (5.5%-24.5%) for MMSAs. Adults who reported no leisure-time physical activity during the preceding month: 25.5% (17.6%-47.1%) for states and territories and 24.5% (16.1%-47.3%) for MMSAs. Adults who reported consuming fruit less than once per day during the preceding month: 40.5% (33.3%-55.5%) for states and territories and 40.3% (30.1%-57.3%) for MMSAs. Adults who reported consuming vegetables less than once per day during the preceding month: 22.4% (16.6%-31.3%) for states and territories and 22.3% (13.6%-32.0%) for MMSAs. Adults who have obesity: 29.5% (19.9%-36.0%) for states and territories and 28.5% (17.8%-41.6%) for MMSAs. Adults aged ≥45 years with diagnosed diabetes: 15.9% (11.2%-26.8%) for states and territories and 15.7% (10.5%-27.6%) for MMSAs. Adults aged ≥18 years with a form of arthritis: 22.7% (17.2%-33.6%) for states and territories and 23.2% (12.3%-33.9%) for MMSAs. Adults having had a depressive disorder: 19.0% (9.6%-27.0%) for states and territories and 19.2% (9.9%-27.2%) for MMSAs. Adults with high blood pressure: 29.1% (24.2%-39.9%) for states and territories and 29.0% (19.7%-41.0%) for MMSAs. Adults with high blood cholesterol: 31.8% (27.1%-37.3%) for states and territories and 31.4% (23.2%-42.0%) for MMSAs. Adults aged ≥45 years who have had coronary heart disease: 10.3% (7.2%-16.8%) for states and territories and 10.1% (4.7%-17.8%) for MMSAs. Adults aged ≥45 years who have had a stroke: 4.9% (2.5%-7.5%) for states and territories and 4.7% (2.1%-8.4%) for MMSAs. INTERPRETATION: The prevalence of health care access and use, health-risk behaviors, and chronic health conditions varied by state, territory, and MMSA. The data in this report underline the importance of continuing to monitor chronic diseases, health-risk behaviors, and access to and use of health care in order to assist in the planning and evaluation of public health programs and policies at the state, territory, and MMSA level. PUBLIC HEALTH ACTION: State and local health departments and agencies and others interested in health and health care can continue to use BRFSS data to identify groups with or at high risk for chronic conditions, unhealthy behaviors, and limited health care access and use. BRFSS data also can be used to help design, implement, monitor, and evaluate health-related programs and policies.

A historical review of the U.S. Navy's busiest recompression chamber in the Pacific theater with a current perspective on caring for civilian divers within its area of responsibility: short communication.

On the island Nation of Guam, the United States Department of Defense has stationed military personnel from every service branch. Guam is utilized as a strategic waypoint for the U.S. military in the Pacific theater. As the largest service branch in the region, the Navy has placed a few Diving Medical Officers in Guam to collectively manage and treat patients with recompression therapy. Guam is also a popular tourist destination, with multiple recreational diving companies certifying individuals who are looking to take advantage of the beautiful warm water and exotic marine life. Unfortunately, with an increase in training and certifying inexperienced divers, came an increase in the operational tempo of the U.S. Navy's recompression chamber on Guam. The recompression chamber on Naval Base Guam (NBG) has been treating patients since 1971. With the only multiplace chamber in the Mariana Islands, Diving Medical Officers, with the accompanying chamber staff, treat military personnel, active-duty sponsored patients and civilian patients. Treating civilian patients by military providers through military treatment facilities presents multiple issues that must be addressed in an effort to provide efficient quality medical care. This article reviews the records, documents, and activity of the NBG chamber over the last four decades. Through the obtained data the information provides projected financial reimbursement from civilian patients. The article also sheds light on areas of needed improvement with regard to data collection, third-party financial collection efforts and the necessity of an inclusive electronic health record (EHR) for military and civilian patients.

Chuukese Patients, Dual Role Interpreters, and Confidentiality: Exploring Clinic Interpretation Services for Reproductive Health Patients.

This exploratory study analyzes limited English proficient (LEP) Chuukese patients' perspectives on dual-role interpreters in Guam and Chuuk. Methods included ethnographic observations of encounters with health care workers (HCWs) and 225 female Chuukese patients seeking reproductive healthcare in community health clinics: 126 women in Guam and 99 women in Chuuk. Ethnographic observations were supplemented by semi-structured interviews with 26 HCWs, and life history interviews with 15 Chuukese transnational migrant women. Notes from interview transcripts and observations were analyzed using critical interpretive and grounded theory. Findings demonstrated that Chuukese LEP patients need and at times want interpreters in order to understand their healthcare visits. In the absence of professional interpreters, ad-hoc interpreters (family interpreters and employees of the clinic) are an important resource. However, social and cultural concerns with community confidentiality influenced patient trust of staff interpreters. This lack of trust can limit access to health care overall, as some patients may avoid seeking care to prevent their confidential health information being disclosed. These complexities in interpretation must be considered in order for clinics to provide optimal care for the communities they serve.

State Laws Regarding Indoor Public Use, Retail Sales, and Prices of Electronic Cigarettes - U.S. States, Guam, Puerto Rico, and U.S. Virgin Islands, September 30, 2017.

Electronic cigarettes (e-cigarettes) are the most frequently used tobacco product among U.S. youths, and past 30-day e-cigarette use is more prevalent among high school students than among adults (1,2). E-cigarettes typically deliver nicotine, and the U.S. Surgeon General has concluded that nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain (2). Through authority granted by the Family Smoking Prevention and Tobacco Control Act, the Food and Drug Administration (FDA) prohibits e-cigarette sales to minors, free samples, and vending machine sales, except in adult-only facilities (3). States, localities, territories, and tribes maintain broad authority to adopt additional or more stringent requirements regarding tobacco product use, sales, marketing, and other topics (2,4). To understand the current e-cigarette policy landscape in the United States, CDC assessed state and territorial laws that 1) prohibit e-cigarette use and conventional tobacco smoking indoors in restaurants, bars, and worksites; 2) require a retail license to sell e-cigarettes; 3) prohibit e-cigarette self-service displays (e.g., requirement that products be kept behind the counter or in a locked box); 4) establish 21 years as the minimum age of purchase for all tobacco products, including e-cigarettes (tobacco-21); and 5) apply an excise tax to e-cigarettes. As of September 30, 2017, eight states, the District of Columbia (DC), and Puerto Rico prohibited indoor e-cigarette use and smoking in indoor areas of restaurants, bars, and worksites; 16 states, DC, and the U.S. Virgin Islands required a retail license to sell e-cigarettes; 26 states prohibited e-cigarette self-service displays; five states, DC, and Guam had tobacco-21 laws; and eight states, DC, Puerto Rico, and the U.S. Virgin Islands taxed e-cigarettes. Sixteen states had none of the assessed laws. A comprehensive approach that combines state-level strategies to reduce youths' initiation of e-cigarettes and population exposure to e-cigarette aerosol, coupled with federal regulation, could help reduce health risks posed by e-cigarettes among youths (2,5).

Cancer in Guam and Hawaii: A comparison of two U.S. Island populations.

BACKGROUND: Cancer disparities within and across populations provide insight into the influence of lifestyle, environment, and genetic factors on cancer risk. METHODS: Guam cancer incidence and mortality were compared to that of Hawaii using data from their respective population-based, central cancer registries. RESULTS: In 2009-2013, overall cancer incidence was substantially lower in Guam than in Hawaii for both sexes while overall cancer mortality was higher for Guam males. Cervical cancer incidence and prostate cancer mortality were higher in Guam. Both incidence and mortality were higher among Guam men for cancers of the lung & bronchus, liver & intrahepatic bile duct, and nasopharynx; Chamorro men were disproportionately affected by these cancers. Filipinos and Whites in Guam had lower overall cancer incidence compared to Filipinos and Whites in Hawaii. Although breast cancer incidence was significantly lower in Guam compared to Hawaii, women in Guam presented at younger ages and with rarer disease histologies such as inflammatory carcinoma were more prevalent. Guam patients were also diagnosed at younger ages for cancers of bladder, pancreas, colon & rectum, liver & intrahepatic bile duct, lung & bronchus, stomach, non-Hodgkin lymphoma, and leukemia. CONCLUSION: Smoking, infectious agents, and betel nut chewing appear to be important contributors to the burden of cancer in Guam. Earlier onset of cancer in Guam suggests earlier age of exposure to key risk factors and/or a more aggressive pathogenesis. Contrasting cancer patterns within Guam and between Guam and Hawaii underscore the potential influence of genes, lifestyle, and environmental factors on cancer development and progression.

The efficacy of respondent-driven sampling for the health assessment of minority populations.

BACKGROUND: Respondent driven sampling (RDS) is a relatively new network sampling technique typically employed for hard-to-reach populations. Like snowball sampling, initial respondents or "seeds" recruit additional respondents from their network of friends. Under certain assumptions, the method promises to produce a sample independent from the biases that may have been introduced by the non-random choice of "seeds." We conducted a survey on health communication in Guam's general population using the RDS method, the first survey that has utilized this methodology in Guam. It was conducted in hopes of identifying a cost-efficient non-probability sampling strategy that could generate reasonable population estimates for both minority and general populations. METHODS: RDS data was collected in Guam in 2013 (n=511) and population estimates were compared with 2012 BRFSS data (n=2031) and the 2010 census data. The estimates were calculated using the unweighted RDS sample and the weighted sample using RDS inference methods and compared with known population characteristics. RESULTS: The sample size was reached in 23days, providing evidence that the RDS method is a viable, cost-effective data collection method, which can provide reasonable population estimates. However, the results also suggest that the RDS inference methods used to reduce bias, based on self-reported estimates of network sizes, may not always work. Caution is needed when interpreting RDS study findings. CONCLUSIONS: For a more diverse sample, data collection should not be conducted in just one location. Fewer questions about network estimates should be asked, and more careful consideration should be given to the kind of incentives offered to participants.

Surveillance for Certain Health Behaviors and Conditions Among States and Selected Local Areas - Behavioral Risk Factor Surveillance System, United States, 2013 and 2014.

PROBLEM: Chronic diseases and conditions (e.g., heart diseases, stroke, arthritis, and diabetes) are the leading causes of morbidity and mortality in the United States. These conditions are costly to the U.S. economy, yet they are often preventable or controllable. Behavioral risk factors (e.g., excessive alcohol consumption, tobacco use, poor diet, frequent mental distress, and insufficient sleep) are linked to the leading causes of morbidity and mortality. Adopting positive health behaviors (e.g., staying physically active, quitting tobacco use, obtaining routine physical checkups, and checking blood pressure and cholesterol levels) can reduce morbidity and mortality from chronic diseases and conditions. Monitoring the health risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services at multilevel public health points (states, territories, and metropolitan and micropolitan statistical areas [MMSA]) can provide important information for development and evaluation of health intervention programs. REPORTING PERIOD: 2013 and 2014. DESCRIPTION OF THE SYSTEM: The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services and practices related to the leading causes of death and disability in the United States and participating territories. This is the first BRFSS report to include age-adjusted prevalence estimates. For 2013 and 2014, these age-adjusted prevalence estimates are presented for all 50 states, the District of Columbia, the Commonwealth of Puerto Rico, Guam, and selected MMSA. RESULTS: Age-adjusted prevalence estimates of health status indicators, health care access and preventive practices, health risk behaviors, chronic diseases and conditions, and cardiovascular conditions vary by state, territory, and MMSA. Each set of proportions presented refers to the range of age-adjusted prevalence estimates of selected BRFSS measures as reported by survey respondents. The following are estimates for 2013. Adults reporting frequent mental distress: 7.7%-15.2% in states and territories and 6.3%-19.4% in MMSA. Adults with inadequate sleep: 27.6%-49.2% in states and territories and 26.5%-44.4% in MMSA. Adults aged 18-64 years having health care coverage: 66.9%-92.4% in states and territories and 60.5%-97.6% in MMSA. Adults identifying as current cigarette smokers: 10.1%-28.8% in states and territories and 6.1%-33.6% in MMSA. Adults reporting binge drinking during the past month: 10.5%-25.2% in states and territories and 7.2%-25.3% in MMSA. Adults with obesity: 21.0%-35.2% in states and territories and 12.1%-37.1% in MMSA. Adults aged ≥45 years with some form of arthritis: 30.6%-51.0% in states and territories and 27.6%-52.4% in MMSA. Adults aged ≥45 years who have had coronary heart disease: 7.4%-17.5% in states and territories and 6.2%-20.9% in MMSA. Adults aged ≥45 years who have had a stroke: 3.1%-7.5% in states and territories and 2.3%-9.4% in MMSA. Adults with high blood pressure: 25.2%-40.1% in states and territories and 22.2%-42.2% in MMSA. Adults with high blood cholesterol: 28.8%-38.4% in states and territories and 26.3%-39.6% in MMSA. The following are estimates for 2014. Adults reporting frequent physical distress: 7.8%-16.0% in states and territories and 6.2%-18.5% in MMSA. Women aged 21-65 years who had a Papanicolaou test during the past 3 years: 67.7%-87.8% in states and territories and 68.0%-94.3% in MMSA. Adults aged 50-75 years who received colorectal cancer screening on the basis of the 2008 U.S. Preventive Services Task Force recommendation: 42.8%-76.7% in states and territories and 49.1%-79.6% in MMSA. Adults with inadequate sleep: 28.4%-48.6% in states and territories and 25.4%-45.3% in MMSA. Adults reporting binge drinking during the past month: 10.7%-25.1% in states and territories and 6.7%-26.3% in MMSA. Adults aged ≥45 years who have had coronary heart disease: 8.0%-17.1% in states and territories and 7.6%-19.2% in MMSA. Adults aged ≥45 years with some form of arthritis: 31.2%-54.7% in states and territories and 28.4%-54.7% in MMSA. Adults with obesity: 21.0%-35.9% in states and territories and 19.7%-42.5% in MMSA. INTERPRETATION: Prevalence of certain chronic diseases and conditions, health risk behaviors, and use of preventive health services varies among states, territories, and MMSA. The findings of this report highlight the need for continued monitoring of health status, health care access, health behaviors, and chronic diseases and conditions at state and local levels. PUBLIC HEALTH ACTION: State and local health departments and agencies can continue to use BRFSS data to identify populations at risk for certain unhealthy behaviors and chronic diseases and conditions. Data also can be used to design, monitor, and evaluate public health programs at state and local levels.

Demographic Characteristics and Health Status of Transgender Adults in Select US Regions: Behavioral Risk Factor Surveillance System, 2014.

OBJECTIVES: To describe the health status of the transgender population in the United States. METHODS: We used 2014 Behavioral Risk Factor Surveillance System data that comprised a probability sample from 19 US states and Guam (n = 151 456). RESULTS: Bivariate analyses showed that, in comparison with cisgender individuals, transgender individuals had a higher prevalence of poor general health (odds ratio [OR] = 1.7; 95% confidence interval [CI] = 1.2, 2.4), more days per month of poor physical (b = 2.43; 95% CI = 0.61, 4.24; P < .01) and mental (b = 1.74; 95% CI = 0.28, 3.19; P = .02) health, and a higher prevalence of myocardial infarction (OR = 1.7; 95% CI = 1.1, 2.5). In addition, more transgender than cisgender people lacked health care coverage (OR = 1.8; 95% CI = 1.2, 2.7) and a health care provider (OR = 1.5; 95% CI = 1.0, 2.1), and they were less likely to have visited a dentist in the preceding year (OR = 0.7; 95% CI = 0.5, 1.0). However, transgender individuals did not differ from cisgender individuals with respect to prevalence of chronic diseases, cancers, or depressive disorders or in terms of health behaviors such as smoking, binge drinking, and always wearing a seatbelt. CONCLUSIONS: Our findings highlight areas of unmet needs in the transgender population.