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Sleep apnea is a global public health concern, but little research has examined this issue in low- and middle-income countries, including Samoa. The purpose of this study was to examine the sample prevalence and characteristics of sleep apnea using a validated home sleep apnea device (WatchPAT, Itamar) and explore factors that may influence sleep health in the Samoan setting. This study used data collected through the Soifua Manuia (“Good Health”) study, which investigated the impact of the body mass index (BMI)-associated genetic variant rs373863828 in CREBRF on metabolic traits in Samoan adults (sampled to overrepresent the obesity-risk allele of interest). A total of 330 participants 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/m2, 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 moderate to severe sleep apnea (defined as ≥15 events/hr) in 54.9 %, 31.5 %, and 34.5 % of the sample, respectively. Sleep apnea was more severe in men (e.g., AHI 3 % ≥15 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. Multiple linear regression linked a higher number of events/hr to higher age, male sex, higher BMI, higher abdominal-hip circumference ratio, and geographic region of residence. Further research and an increased focus on equitable and affordable diagnosis and access to treatment are crucial to addressing sleep apnea in Samoa and globally.

ObjectivePredicting neonatal survival is essential for targeting interventions to reduce neonatal mortality. Pacific Islanders have been underrepresented in existing prediction tools and have unique, maternal obesity-related risk factors for both preterm birth and neonatal mortality. Using neonatal sex, birth weight, and gestational age, we developed a graphical tool for neonatal survival among Pacific Islander singletons in the United States.MethodsBirth-infant death data files from the United States National Center for Health Statistics were used (2014-2018). Pacific Islander mothers and singletons without congenital anomalies born between 22-36 gestational weeks were included. Poisson regression models were used to predict neonatal mortality (ResultsOf the 5192 included neonates, the neonatal mortality rate was 2.0%; 43.5% of mothers had pre-pregnancy obesity, and 16.5% of neonates were born large-for-gestational age. Birth weight and gestational age had a non-linear association with neonatal death, and their interaction was included in the model. Retaining neonatal sex, models with gestational age at birth or both birth weight and gestational age at birth performed better than the model with birth weight only.ConclusionThis is the first graphical tool for neonatal survival prediction among preterm-born Pacific Islander singletons in the United States. Using only neonatal sex, birth weight, and gestational age, this graphical tool is a straightforward reference for survival among groups of neonates with similar characteristics.

Background Globally, rapid economic development, urbanisation, and nutrition transitions have led to rising levels of malnutrition in all forms. Aim The study objective was to document the prevalence of overweight/obesity, underweight, stunting, and anaemia among Samoan children in 2019–2020. Subjects and methods Children from the Ola Tuputupua’e “Growing Up” in Samoa study at ages 5–11 years with complete physical assessments were included. Overweight/obesity, underweight, and stunting were classified using World Health Organisation Z-scores for body mass index-for-age (BMIZ> +1), weight-for-age (WAZ

Summary: Background: Identifying novel epigenetic signatures associated with serum immunoglobulin E (IgE) may improve our understanding of molecular mechanisms underlying asthma and IgE-mediated diseases. Methods: We performed an epigenome-wide association study using whole blood from Framingham Heart Study (FHS; n = 3,471, 46% females) participants and validated results using the Childhood Asthma Management Program (CAMP; n = 674, 39% females) and the Genetic Epidemiology of Asthma in Costa Rica Study (CRA; n = 787, 41% females). Using the closest gene to each IgE-associated CpG, we highlighted biologically plausible pathways underlying IgE regulation and analyzed the transcription patterns linked to IgE-associated CpGs (expression quantitative trait methylation loci; eQTMs). Using prior UK Biobank summary data from genome-wide association studies of asthma and allergy, we performed Mendelian randomization (MR) for causal inference testing using the IgE-associated CpGs from FHS with methylation quantitative trait loci (mQTLs) as instrumental variables. Findings: We identified 490 statistically significant differentially methylated CpGs associated with IgE in FHS, of which 193 (39.3%) replicated in CAMP and CRA (FDR < 0.05). Gene ontology analysis revealed enrichment in pathways related to transcription factor binding, asthma, and other immunological processes. eQTM analysis identified 124 cis-eQTMs for 106 expressed genes (FDR < 0.05). MR in combination with drug-target analysis revealed CTSB and USP20 as putatively causal regulators of IgE levels (Bonferroni adjusted P

Summary: Identifying population-specific genetic variants associated with disease and disease-predisposing traits is important to provide insights into the genetic determinants of health and disease between populations, as well as furthering genomic justice. Various common pan-population polymorphisms at CETP associate with serum lipid profiles and cardiovascular disease. Here, sequencing of CETP identified a missense variant rs1597000001 (p.Pro177Leu) specific to Māori and Pacific people that associates with higher HDL-C and lower LDL-C levels. Each copy of the minor allele associated with higher HDL-C by 0.236 mmol/L and lower LDL-C by 0.133 mmol/L. The rs1597000001 effect on HDL-C is comparable with CETP Mendelian loss-of-function mutations that result in CETP deficiency, consistent with our data, which shows that rs1597000001 lowers CETP activity by 27.9%. This study highlights the potential of population-specific genetic analyses for improving equity in genomics and health outcomes for population groups underrepresented in genomic studies.

Abstract 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.

Abstract Background The ImPrEP México demonstration project is the first to distribute free HIV pre-exposure prophylaxis (PrEP) to men who have sex with men (MSM) and transgender women living in Mexico. In Mexico City, MSM who are also male sex workers (MSWs) face a disproportionately high risk of HIV infection. PrEP is highly effective for HIV prevention, yet “real-life” implementation among MSWs is a challenge due to the unique adherence barriers faced by this population. Methods This study uses the RE-AIM implementation science framework to characterize the unique barriers to and facilitators of PrEP uptake among MSWs in Mexico City. We conducted 9 in-depth key informant interviews and 2 focus group discussions with MSWs across 5 clinic and community sites. Qualitative data were analyzed using inductive, open coding approaches from grounded theory. We supplemented findings from the primary qualitative analysis with quantitative indicators derived from ImPrEP program records to describe the current Reach of the ImPrEP program among MSWs in Mexico City and the potential for wider PrEP Adoption among other high-risk populations in Mexico. Results The Reach of the ImPrEP program was 10% of known HIV-negative MSWs in Mexico City. Program Reach was lowest among MSWs who were street-based sex workers, of lower socioeconomic status, migrants from other states and self-identified as heterosexual. Barriers to program Reach included limited PrEP knowledge, HIV-related stigma, and structural barriers; facilitators included in-person program recruitment, patient-centered care, and spread of information through word of mouth among MSWs. Two out of the four eligible institutions had adopted the ImPrEP protocol. Barriers to wider program Adoption included HIV- and sexual identity– related stigma, protocol limitations, and lack of a national policy for PrEP distribution; facilitators of Adoption included existing healthcare infrastructure, sensitized providers, and community support from non-governmental organizations. Conclusions Increasing the ImPrEP program’s Reach among MSWs will depend on improving PrEP education and addressing HIV-related stigma and access barriers. Future Adoption of the ImPrEP program should build on existing clinical infrastructure and community support. Creation of a national policy for PrEP distribution may improve the Reach and Adoption of PrEP among highest-risk populations in Mexico.

Summary: Current understanding of lipid genetics has come mainly from studies in European-ancestry populations; limited effort has focused on Polynesian populations, whose unique population history and high prevalence of dyslipidemia may provide insight into the biological foundations of variation in lipid levels. Here, we performed an association study to fine map a suggestive association on 5q35 with high-density lipoprotein cholesterol (HDL-C) seen in Micronesian and Polynesian populations. Fine-mapping analyses in a cohort of 2,851 Samoan adults highlighted an association between a stop-gain variant (rs200884524; c.652C>T, p.R218∗; posterior probability = 0.9987) in BTNL9 and both lower HDL-C and greater triglycerides (TGs). Meta-analysis across this and several other cohorts of Polynesian ancestry from Samoa, American Samoa, and Aotearoa New Zealand confirmed the presence of this association (βHDL-C = −1.60 mg/dL, pHDL-C = 7.63 × 10−10; βTG = 12.00 mg/dL, pTG = 3.82 × 10−7). While this variant appears to be Polynesian specific, there is also evidence of association from other multiancestry analyses in this region. This work provides evidence of a previously unexplored contributor to the genetic architecture of lipid levels and underscores the importance of genetic analyses in understudied populations.

Background Diagnoses of Type 2 Diabetes in the United States have more than doubled in the last two decades. One minority group at disproportionate risk are Pacific Islanders who face numerous barriers to prevention and self-care. To address the need for prevention and treatment in this group, and building on the family-centered culture, we will pilot test an adolescent-mediated intervention designed to improve the glycemic control and self-care practices of a paired adult family member with diagnosed diabetes. Methods We will conduct a randomized controlled trial in American Samoa among n = 160 dyads (adolescent without diabetes, adult with diabetes). Adolescents will receive either a six-month diabetes intervention or a leadership and life skills-focused control curriculum. Aside from research assessments we will have no contact with the adults in the dyad who will proceed with their usual care. To test our hypothesis that adolescents will be effective conduits of diabetes knowledge and will support their paired adult in the adoption of self-care strategies, our primary efficacy outcomes will be adult glycemic control and cardiovascular risk factors (BMI, blood pressure, waist circumference). Secondarily, since we believe exposure to the intervention may encourage positive behavior change in the adolescent themselves, we will measure the same outcomes in adolescents. Outcomes will be measured at baseline, after active intervention (six months post-randomization) and at 12-months post-randomization to examine maintenance effects. To determine potential for sustainability and scale up, we will examine intervention acceptability, feasibility, fidelity, reach, and cost. Discussion This study will explore Samoan adolescents’ ability to act as agents of familial health behavior change. Intervention success would produce a scalable program with potential for replication in other family-centered ethnic minority groups across the US who are the ideal beneficiaries of innovations to reduce chronic disease risk and eliminate health disparities.

IntroductionMulticomponent interventions can reduce cardiometabolic disease (CMD) risk factors in childhood; however, little synthesis of the literature has taken place in the Pacific region. Pacific Islanders experience a disproportionately high prevalence of CMD risk factors, yet interventions have been slow to reach many communities. We present this protocol for a scoping review to identify and summarize existing multicomponent interventions to address CMD risk in Pacific Islander children.Materials and methodsEligible interventions will (1) address CMD risk factors (including but not limited to obesity, hyperglycemia, dyslipidemia, elevated blood pressure, and/or health behaviors) in 2-to-12-year-old Pacific Islander children, and (2) be multi-component (including at least two lifestyle/behavior change strategies to address CMD risk factors). To investigate existing interventions for adaptation and potential use in Pacific Islander communities, we will search Scopus, MEDLINE ALL (Ovid), EMBASE (Ovid), Yale-licensed Web of Science Core Collection, Cochrane Library, CINAHL (EBSCOhost), ProQuest Dissertations & Theses Global, Global Health (EBSCO), non-indexed Pacific journals, grey literature, government reports, and clinical trial registrations. The Joanna Briggs Institute Manual for Evidence Synthesis and the Preferred Reporting Items for Scoping Reviews will guide data extraction, evidence mapping, synthesis, and reporting of information including study population, intervention components, behavioral changes, health and implementation outcomes, theoretical frameworks, and evaluation measures.Ethics and disseminationFormal ethical approval is not required. The dissemination strategy will include peer-reviewed journal publications and presentations. Synthesis of existing multicomponent interventions for Pacific Islander children will help to identify best practices that could be replicated, adapted, or combined.

In Samoa, adult Type 2 diabetes prevalence has increased within the past 30 years. Patient preferences for care are factors known to influence treatment adherence and are associated with reduced disease progression and severity. However, patient preferences for diabetes care, generally, are understudied, and other patient-centered factors such as willingness-to-pay (WTP) for diabetes treatment have never been explored in this setting. Discrete Choice Experiments (DCE) are useful tools to elicit preferences and WTP for healthcare. DCEs present patients with hypothetical scenarios composed of a series of multi-alternative choice profiles made up of attributes and levels. Patients choose a profile based on which attributes and levels may be preferable for them, thereby quantifying and identifying locally relevant patient-centered preferences. This paper presents the protocol for the design, piloting, and implementation of a DCE identifying patient preferences for diabetes care, in Samoa. Using an exploratory sequential mixed methods design, formative data from a literature review and semi-structured interviews with n = 20 Samoan adults living with Type 2 diabetes was used to design a Best-Best DCE instrument. Experimental design procedures were used to reduce the number of choice-sets and balance the instrument. Following pilot testing, the DCE is being administered to n = 450 Samoan adults living with diabetes, along with associated questionnaires, and anthropometrics. Subsequently, we will also be assessing longitudinally how preferences for care change over time. Data will be analyzed using progressive mixed Rank Order Logit models. The results will identify which diabetes care attributes are important to patients (p < 0.05), examine associations between participant characteristics and preference, illuminate the trade-offs participants are willing to make, and the probability of uptake, and WTP for specific attributes and levels. The results from this study will provide integral data useful for designing and adapting efficacious diabetes intervention and treatment approaches in this setting.

The epidemiology of preterm birth among Pacific Islanders is minimally understood. The purpose of this study was to estimate pooled prevalence of preterm birth among Pacific Islanders and to estimate their risk of preterm birth compared to White/European women. We searched MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Library, CINAHL, Global Health, and two regional journals in March 2023. Observational studies were included if they reported preterm birth-related outcomes among Pacific Islanders. Random-effects models were used to estimate the pooled prevalence of preterm birth with 95% confidence interval (CI). Bayes meta-analysis was conducted to estimate pooled odds ratios (OR) with 95% highest posterior density intervals (HPDI). The Joanna Briggs Institute checklists were used for risk of bias assessment. We estimated preterm birth prevalence among Pacific Islanders in the United States (US, 11.8%, sample size [SS] = 209,930, 95% CI 10.8%-12.8%), the US-Affiliated Pacific Islands (USAPI, SS = 29,036, 6.7%, 95% CI 4.9%-9.0%), New Zealand (SS = 252,162, 7.7%, 95% CI 7.1%-8.3%), Australia (SS = 20,225, 6.1%, 95% CI 4.2%-8.7%), and Papua New Guinea (SS = 2,647, 7.0%, 95% CI 5.6%-8.8%). Pacific Islanders resident in the US were more likely to experience preterm birth compared to White women (OR = 1.45, 95% HPDI 1.32-1.58), but in New Zealand their risk was similar (OR = 1.00, 95% HPDI 0.83-1.16) to European women. Existing literature indicates that Pacific Islanders in the US had a higher prevalence of preterm birth and experienced health inequities. Learning from New Zealand's culturally-sensitive approach to health care provision may provide a starting point for addressing disparities. The limited number of studies identified may contribute to higher risk of bias and the heterogeneity in our estimates; more data is needed to understand the true burden of preterm birth in the Pacific region.

ABSTRACT: 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.

Background Recent studies in adults indicate that cold-induced temperature change of supraclavicular skin corresponds with brown adipose tissue (BAT) thermogenesis. Aim This study examined the feasibility of using thermography to assess temperature changes in infants aged 18–25 months after mild cooling. Further, this study sought to evaluate whether cold exposure induces a thermal response suggestive of BAT activity underlying the supraclavicular region. Subjects and Methods Changes in maximum skin temperature at the supraclavicular and interscapular regions were determined using thermal imaging following a mild 5-minute cooling condition (by removal of clothes in a climate-controlled room) in 67 Samoan infants. Temperature changes of the forehead and hand, known BAT-free regions, served as indicators of cooling efficacy. Results Infants with increased hand and forehead temperatures after cold exposure were excluded from analysis, reducing the effective sample size to 19 infants. On average, forehead (p

Background The “Foafoaga O le Ola (Beginning of Life)” study is a prospective birth cohort of n = 160 Samoan mother-infant dyads established in 2017–2018. A primary study aim is to explore how a missense variant at CREBRF rs373863828 impacts growth in early life, given its association with increased body size but lower risk of diabetes in adult Samoans. Here, we examine body size and composition by genotype among toddlers aged 18.7–24.5 months. Methods Height, weight, head circumference, mid-upper-arm circumference, and abdominal circumference, as well as subscapular, triceps, iliac crest and thigh skinfold thickness were measured among 107 toddlers with known rs373863828 genotype; 42 of these toddlers completed dual-energy X-ray absorptiometry (DXA) scans from which body composition (total body less head fat mass, lean mass, bone mass, % fat mass and % fat-free mass) was estimated. Results After controlling for sex and age, toddlers with at least one copy of the CREBRF minor allele (AA/AG) were 1.31 cm taller (SE = 0.64, p = 0.045) than toddlers with the GG genotype. Conclusion Whether greater linear growth in early childhood could contribute to the metabolically protective effects associated with the CREBRF variant in adulthood should be explored in future studies.

Objective To explore how respondents with common chronic conditions—hypertension (HTN) and diabetes mellitus (DM)—make healthcare-seeking decisions.Setting Three health facilities in Nakaseke District, Uganda.Design Discrete choice experiment (DCE).Participants 496 adults with HTN and/or DM.Main outcome measures Willingness to pay for changes in DCE attributes: getting to the facility, interactions with healthcare providers, availability of medicines for condition, patient peer-support groups; and education at the facility.Results Respondents were willing to pay more to attend facilities that offer peer-support groups, friendly healthcare providers with low staff turnover and greater availabilities of medicines. Specifically, we found the average respondent was willing to pay an additional 77 121 Ugandan shillings (UGX) for facilities with peer-support groups over facilities with none; and 49 282 UGX for 1 month of medicine over none, all other things being equal. However, respondents would have to compensated to accept facilities that were further away or offered health education. Specifically, the average respondent would have to be paid 3929 UGX to be willing to accept each additional kilometre they would have to travel to the facilities, all other things being equal. Similarly, the average respondent would have to be paid 60 402 UGX to accept facilities with some health education, all other things being equal.Conclusions Our findings revealed significant preferences for health facilities based on the availability of medicines, costs of treatment and interactions with healthcare providers. Understanding patient preferences can inform intervention design to optimise healthcare service delivery for patients with HTN and DM in rural Uganda and other low-resource settings.

Background Pregnancy dietary intake may be associated with newborn body composition, a predictor of future obesity. In Samoa, an energy-dense diet contributes to an alarming prevalence of adult obesity. Identifying associations between pregnancy nutrition and infant body composition in this setting may guide strategies to mitigate intergenerational transmission of obesity risk. Aim To examine dietary macro- and micronutrient intake of Samoan women during the third trimester of pregnancy and associations with infant body composition. Subjects and methods At 34–41 weeks of gestation, we measured dietary intake from the prior month using a Food Frequency Questionnaire (FFQ). Dual-energy X-ray absorptiometry (DXA) measured infant body composition at 1–14 days. We used multivariable linear regression models accounting for confounders to identify independent effects of nutrient intake on infant body composition. Results After adjusting for maternal body mass index, age, gravidity, infant age, and sex, a respective 0.2 g increase and 0.2 g decrease in infant bone mass was associated with fibre and saturated fat intake. Increased protein intake was associated with 0.02 g decrease in bone mass. Conclusions While maternal dietary intake was not associated with infant adiposity or lean mass, we observed an effect on bone mass whose role in regulating metabolic health is overlooked.

The Samoan population has experienced rapid increases in the prevalence of non-communicable diseases (NCDs) and NCD risk factors over the last 30 years. However, understanding how increased awareness and treatment of these conditions in reducing disease burden remains understudied. Using data from a longitudinal study (2010–2019) of cardiometabolic health among Samoan adults, we assess the impact of a referral for elevated blood pressure (BP) on changes in BP, physician’s diagnoses of hypertension and medication use, body mass index (BMI), and other risk factors for elevated BP. Analyses compared adult Samoans (n = 328) who in 2010 either (1) received a referral for elevated BP (BP ≥ 140/90 mmHg) or (2) had measured BP indicative of pre-hypertension (BP ≥ 120/80 mmHg) but were not referred. Data were analysed using linear and logistic regression, paired T- and McNemar’s tests, and Wilcoxon Rank Sum assessments. Referrals in 2010 significantly increased the odds of reporting a physician’s diagnosis of hypertension (OR 2.16; 1.18, 3.95) and hypertension medication use (OR 3.52; 1.86, 6.73) in 2018; however, referrals, medication use, and diagnoses were not associated with BP values or reduced odds of having elevated BP. Despite the referral having positive effects on hypertension-related health care, our results demonstrate that other factors are influencing effective BP/hypertension control. We advocate for greater engagement of health researchers with local health sector actors to improve the probability that researcher-provided health referrals will result in long-term health improvements.

This scoping review examines the literature on pregnancy and perinatal outcomes among Pacific Islander women in the United States (U.S.) and U.S.-affiliated Pacific Islands. Our aim was to identify research that disaggregated Pacific Islanders from other population groups. We conducted a systematic search of MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), and PsycINFO (Ovid) databases and a hand-search of grey literature. Forty-eight articles published between January 2010 and June 2020 were included. The majority of studies were conducted in Hawaii and utilized clinical record data. Infant outcomes were more commonly reported than maternal outcomes. We highlighted several limitations of the existing literature that included aggregation of Pacific Islanders with Asian American and other ethnic groups; limited comparison between Pacific Islander sub-groups; inadequate definitions of the nationality and ethnic composition of Pacific Islander groups; a lack of hypothesis-driven primary data collection and clinical trials; and underrepresentation of Pacific Islanders in population-based studies. Researchers should address these limitations to improve pregnancy and perinatal outcomes among Pacific Islanders, who comprise the second fastest growing ethnic minority in the U.S.

Summary: Background: Samoa is a Pacific Island country facing one of the highest burdens of non-communicable disease globally. Methods: In this study, we apply a cascade-of-care approach to understand gaps in the awareness, treatment, and control cascade of diabetes and hypertension in a cross-sectional, convenience sample of 703 young, high-risk Samoan adults (29.5-50.9 years). Findings: Non-communicable diseases were prevalent in the study sample: 19.5% (95% CI: 16.6%-22.7%) of participants had diabetes; 47.6% (95% CI: 43.7%-51.4%) presented with pre-diabetes or diabetes; 31.0% (95% CI: 27.5%-34.6%) had hypertension; and nearly 90% (95% CI: 86.7%-91.5%) had overweight or obesity. Among those with diabetes and hypertension, only 20.5% (95% CI: 13.9%-28.4%) and 11.8% (95% CI: 7.8%-16.9%) of participants were aware of their condition, respectively. Only 0.8% (95% CI: 0.0%-4.2%) of all participants with diabetes had achieved glycemic control; only 2.8% (95% CI: 1.1%-6.1%) of those with hypertension achieved control. Interpretation: We found a significant burden of diabetes and hypertension in Samoa, exceeding the recent prevalence estimates of other low- to middle-income countries by nearly two-fold. A severe unmet need in both detection and subsequent control and monitoring of these chronic conditions exists. Our results suggest that the initial diagnosis and surveillance stage in the cascade of care for chronic conditions should be a major focus of primary care efforts; national screening campaigns and programs that leverage village and district nurses to deliver community-based primary care may significantly impact gap closure in the NCD cascade. Funding: This study was supported by the U.S. National Institutes of Health R01HL140570 (PIs: McGarvey and DeLany); AR was supported by NIH FIC D43TW010540; HK and AR-C were supported by the Minority Health and Health Disparities International Research Training (MHIRT) Program at Brown University, NIH Grant # 5T37MD008655.

IntroductionFamily-level psychosocial factors appear to play a critical role in mediating the intergenerational transmission of trauma; however, no review article has quantitatively synthesized causal mechanisms across a diversity of trauma types. This study aims to systematically consolidate the epidemiological research on family-level psychosocial mediators and moderators to ultimately produce causal diagram(s) of the intergenerational transmission of trauma.MethodsWe will identify epidemiological peer-reviewed publications, dissertations, and conference abstracts that measure the impact of at least one psychosocial family-level factor mediating or moderating the relationship between parental trauma exposure and a child mental health outcome. English, French, Kinyarwanda, and Spanish articles will be eligible. We will search MEDLINE, PsycINFO, PTSDpubs, Scopus, and ProQuest Dissertations and Theses and will conduct forward citation chaining of included documents. Two reviewers will perform screening independently. We will extract reported mediators, moderators, and relevant study characteristics for included studies. Findings will be presented using narrative syntheses, descriptive analyses, mediation meta-analyses, moderating meta-analyses, and causal diagram(s), where possible. We will perform a risk of bias assessment and will assess for publication bias.DiscussionThe development of evidence-based causal diagram(s) would provide more detailed understanding of the paths by which the psychological impacts of trauma can be transmitted intergenerationally at the family-level. This review could provide evidence to better support interventions that interrupt the cycle of intergenerational trauma.Trial registrationSystematic review registration: PROSPERO registration ID #CRD42021251053.

It is estimated that 116 million children were born worldwide in the first nine months of the COVID-19 pandemic. Given the critical importance of early life for neurodevelopment, and evidence suggesting that prenatal maternal stress and early childhood adversity negatively impact neurodevelopment, it is alarming that many pregnant women and new mothers are experiencing high levels of pandemic-related stress. Research and proactive mental health policy is needed to minimize the impact of the COVID-19 pandemic on the future mental health of a global cohort of newborns and infants.

Introduction Infants born alive

Skeletal maturity can be used as a biological indicator of the tempo of growth in children and adolescents. We present a description of skeletal maturity from a cohort of white Australian children and describe variation in skeletal maturity based on child age. Participants (n = 71; age 10.5–13.9 years) were recruited from the ‘Healthy, Active Preschool & Primary Years (HAPPY)’ study. Left hand-wrist radiographs were used to determine skeletal maturity using the Tanner-Whitehouse III (TW3) RUS technique. In boys, the mean skeletal maturity offset (bone age – chronological age) was −0.12 ± 0.19 years and 57.9% had delayed skeletal maturity compared to chronological age. Among those with delayed skeletal maturity, the average delay was 0.99 years (range 0.02–2.54 years). In girls, skeletal age was advanced, on average, compared to chronological age by 0.32 ± 0.20 years. Among the 39.4% of girls with delayed skeletal maturity, the average delay was 0.48 years (range: 0.01–2.28). Four children in the sample exhibited a delay in skeletal maturity greater than 2 years. In the context of secular trends towards advanced skeletal maturity observed globally, delayed skeletal maturation in this white, economically privileged cohort are surprising and warrant further exploration.

Background: Low-income countries suffer a growing burden of non-communicable diseases (NCDs). Self-care practices are crucial for successfully managing NCDs to prevent complications. However, little is known about how patients practice self-care in resource-limited settings. Objective: We sought to understand self-care efforts and their facilitators among patients with diabetes and hypertension in rural Uganda. Methods: Between April and June 2019, we conducted a cross-sectional qualitative study among adult patients from outpatient NCD clinics at three health facilities in Uganda. We conducted in-depth interviews exploring self-care practices for hypertension and/or diabetes and used content analysis to identify emergent themes. Results: Nineteen patients participated. Patients said they preferred conventional medicines as their first resort, but often used traditional medicines to mitigate the impact of inconsistent access to prescribed medicines or as a supplement to those medicines. Patients adopted a wide range of vernacular practices to supplement treatment or replace unavailable diagnostic tests, such as tasting urine to gauge blood-sugar level. Finally, patients sought and received both instrumental and emotional support for self-care activities from networks of family and peers. Patients saw their children as their most reliable source of support facilitating self-care, especially as a source of money for medicines, transport and home necessities. Conclusion: Patients valued conventional medicines but engaged in varied self-care practices. They depended upon networks of social support from family and peers to facilitate self-care. Interventions to improve self-care may be more effective if they improve access to prescribed medicines and engage or enhance patients’ social support networks.

Abstract Background Breastfeeding is a critical, evidence-based intervention that addresses malnutrition, improves early childhood development outcomes, and influences long-term maternal and infant health by reducing the non-communicable disease risk. Scaling up breastfeeding is an indisputably strong action countries can take to prevent suboptimal maternal and infant health outcomes. The Becoming Breastfeeding Friendly (BBF) initiative assists countries with scaling up breastfeeding policy and programs. BBF has been successfully implemented within Latin America, Africa, Europe and South-East Asian regions. This study assessed its application in Samoa. Methods In 2018, BBF was implemented in Samoa by a 20 member committee of breastfeeding experts who participated in collecting and utilizing national level data to score the degree of friendliness of Samoa’s breastfeeding environment, identify gaps, and propose policy recommendations to address those gaps. This eight-month process resulted in a public event where priority recommendations were widely disseminated to decision makers and actions agreed upon. Results The total BBF Index score for Samoa was 1.6 out of 3.0, indicating a moderate breastfeeding friendly environment for scaling up policies and programs that protect, promote, and support breastfeeding. Gear total scores indicated that seven of the eight gears were moderately strong within Samoa, while the eighth gear, funding and resources, was weakest in strength. Six prioritized recommendations emerged: 1) development and implementation of a National Breastfeeding Policy and Strategic Action Plan; 2) strengthening monitoring and evaluation of all breastfeeding activities; 3) ratifying the International Labour Organization’s Maternity Protection Convention 2000 (No 183); 4) identifying high-level advocates to champion and serve as role models for breastfeeding; 5) creation of a national budget line for breastfeeding activities; and 6) hiring of a national breastfeeding coordinator and trainer. Decision makers demonstrated commitment by signing the breastfeeding policy for hospitals ahead of the BBF dissemination meeting and electing to move forward with establishing lactation rooms within government ministries. Conclusion Implementation of BBF in Samoa yielded important policy recommendations that will address current gaps in national level breastfeeding support. The BBF consultation process can be successfully applied to other countries within the Western Pacific region in order to strengthen their breastfeeding programs.

Abstract Background The prevalence of hypertension and diabetes are expected to increase in sub-Saharan Africa over the next decade. Some studies have documented that lifestyle factors and lack of awareness are directly influencing the control of these diseases. Yet, few studies have attempted to understand the barriers to control of these conditions in rural settings. The main objective of this study was to understand the challenges to hypertension and diabetes care in rural Uganda. Methods We conducted semi-structured interviews with 24 patients with hypertension and/or diabetes, 11 health care professionals (HCPs), and 12 community health workers (known as village health team members [VHTs]) in Nakaseke District, Uganda. Data were coded using NVivo software and analyzed using a thematic approach. Results The results replicated several findings from other settings, and identified some previously undocumented challenges including patients’ knowledge gaps regarding the preventable aspects of HTN and DM, patients’ mistrust in the Ugandan health care system rather than in individual HCPs, and skepticism from both HCPs and patients regarding a potential role for VHTs in HTN and DM management. Conclusions In order to improve hypertension and diabetes management in this setting, we recommend taking actions to help patients to understand NCDs as preventable, for HCPs and patients to advocate together for health system reform regarding medication accessibility, and for promoting education, screening, and monitoring activities to be conducted on a community level in collaboration with village health team members.

Obesity and diabetes have strong heritable components, yet the genetic contributions to these diseases remain largely unexplained. In humans, a missense variant in Creb3 regulatory factor (CREBRF) [rs373863828 (p.Arg457Gln); CREBRFR457Q] is strongly associated with increased odds of obesity but decreased odds of diabetes. Although virtually nothing is known about CREBRF's mechanism of action, emerging evidence implicates it in the adaptive transcriptional response to nutritional stress downstream of TORC1. The objectives of this study were to generate a murine model with knockin of the orthologous variant in mice (CREBRFR458Q) and to test the hypothesis that this CREBRF variant promotes obesity and protects against diabetes by regulating energy and glucose homeostasis downstream of TORC1. To test this hypothesis, we performed extensive phenotypic analysis of CREBRFR458Q knockin mice at baseline and in response to acute (fasting/refeeding), chronic (low- and high-fat diet feeding), and extreme (prolonged fasting) nutritional stress as well as with pharmacological TORC1 inhibition, and aging to 52 weeks. The results demonstrate that the murine CREBRFR458Q model of the human CREBRFR457Q variant does not influence energy/glucose homeostasis in response to these interventions, with the exception of possible greater loss of fat relative to lean mass with age. Alternative preclinical models and/or studies in humans will be required to decipher the mechanisms linking this variant to human health and disease.

Background: In 2020, non-communicable diseases (NCDs) currently account for 40% of deaths in east Africa and are expected to surpass communicable diseases as the leading causes of death in sub-Saharan Africa by 2030. However, there remain many gaps in the provision of high quality, patient-centred NCD service delivery in low-income countries such as Uganda, especially in rural settings. We developed a discrete choice experiment (DCE) to understand how patients with common NCDs, such as hypertension and diabetes, make health-care-seeking decisions. A DCE is a quantitative tool that measures the weight of different factors that affect a decision. Participants are presented with two hypothetical scenarios to choose between. Here we report on the formative, qualitative phase of DCE development. Methods: For this DCE, choice sets consist of two health facilities described in terms of various attributes (factors) that affect decision-making. To develop a locally relevant DCE, we conducted formative qualitative research consisting of 18 in-depth interviews with patients seeking care for hypertension or diabetes, or both, at three health facilities in rural Nakaseke District, Uganda. We purposively selected participants so that each disease and facility were represented. Interviews explored how participants choose which facility to visit and challenges that she or he faces in accessing care or medicines, or both. A team of three researchers coded the interviews using a directed approach to reveal 11 potential attributes on which patients make decisions. After review of the data and analysis with local and international content experts, we narrowed this list to six attributes to be included in the DCE. Findings: The six selected attributes included: provision of education; availability of medicines; transport to the facility; costs associated with treatment; interactions with health-care providers; and presence of peer support groups. Attribute levels encompassed the range of experiences for each attribute as emerged from qualitative analysis. We then developed a full profile, fractional factorial DCE with three surveys. Interpretation: The process of developing this NCD-focused DCE relied on reference to the literature, primary qualitative data collection, and expert consensus to create a tool that would yield actionable data to improve NCD health service delivery in rural Uganda. Little is known about how rural patients in low-income and middle-income countries navigate the health-care system, nor is there much description of how to develop DCEs to investigate patient preferences in these countries. This work will guide public health officials in developing NCD service delivery options and inform investigators on DCE development. Funding: Yale Institute of Global Health Hecht Global Health Faculty Network Award Downs International Health Student Travel Fellowship

In low- and middle-income countries, earlier in economic development, obesity tends to be more prevalent in high socioeconomic resource groups compared to low. Later in development, the distribution of obesity tends to show the opposite pattern, becoming more prevalent in those with low socioeconomic resources. This shift in obesity prevalence tends to occur between a gross national income per capita (GNI) of US$1,000 to $4,000 dollars. Whether a similar pattern occurs in Pacific Island countries has not been well documented. In Samoa, the GNI rose to US$3,200 dollars in 2010 at which time over 80% of adults were overweight or obese. We aimed to understand the association of socioeconomic resources, assessed by household assets, with adult body mass index (BMI) and abdominal circumference (AC) in Samoa. Data were from a genome-wide association study for obesity among 3,370 Samoans aged 24.5-

Background: Young children are particularly vulnerable to malnutrition as nutrition transition progresses. The aim of this study was to examine the adequacy of macro- and micronutrient intake among 2–4.99-year-old Samoan children. Methods: Child dietary intake was measured using a 117-item food frequency questionnaire (FFQ) with a 30-day reference period. Daily total energy and nutrient intake was calculated by multiplying the frequency of daily consumption by the nutrient content of a fixed, standard portion size. Adequacy of macro- and micronutrient intake was determined using age-specific US Dietary Guidelines. Results: Most children met or exceeded recommendations for carbohydrate, fat and protein intake. More than half of the sample were not meeting the Recommended Dietary Allowance (RDA) for calcium (59.0%), 44.6% were not meeting RDA for potassium and intake of vitamin A and E was inadequate among 25.9% and 25.6%, respectively. Eighty per cent of children exceeded the tolerable upper limit for sodium. Adequacy of intake varied by age and census region of residence. Conclusion: Since inadequate dietary micronutrient intake was more common among older children (4–4.99 years) and those in the rural region, intervention should be targeted at those groups.

Abstract Background Community health workers are essential personnel in resource-limited settings. In Uganda, they are organized into Village Health Teams (VHTs) and are focused on infectious diseases and maternal-child health; however, their skills could potentially be utilized in national efforts to reduce the growing burden of non-communicable diseases (NCDs). We sought to assess the knowledge of, and attitudes toward NCDs and NCD care among VHTs in Uganda as a step toward identifying their potential role in community NCD prevention and management. Methods We administered a knowledge, attitudes and practices questionnaire to 68 VHT members from Iganga and Mayuge districts in Eastern Uganda. In addition, we conducted four focus group discussions with 33 VHT members. Discussions focused on NCD knowledge and facilitators of and barriers to incorporating NCD prevention and care into their role. A thematic qualitative analysis was conducted to identify salient themes in the data. Results VHT members possessed some knowledge and awareness of NCDs but identified a lack of knowledge about NCDs in the communities they served. They were enthusiastic about incorporating NCD care into their role and thought that they could serve as effective conduits of knowledge about NCDs to their communities if empowered through NCD education, the availability of proper reporting and referral tools, and visible collaborations with medical personnel. The lack of financial remuneration for their role did not emerge as a major barrier to providing NCD services. Conclusions Ugandan VHTs saw themselves as having the potential to play an important role in improving community awareness of NCDs as well as monitoring and referral of community members for NCD-related health issues. In order to accomplish this, they anticipated requiring context-specific and culturally adapted training as well as strong partnerships with facility-based medical personnel. A lack of financial incentivization was not identified to be a major barrier to such role expansion. Developing a role for VHTs in NCD prevention and management should be a key consideration as local and national NCD initiatives are developed.

Abstract Background Pregnant women in American Samoa have a high risk of complications due to overweight and obesity. Prenatal care can mitigate the risk, however many women do not seek adequate care during pregnancy. Low utilization of prenatal care may stem from low levels of satisfaction with services offered. Our objective was to identify predictors of prenatal care satisfaction in American Samoa. Methods A structured survey was distributed to 165 pregnant women receiving prenatal care at the Lyndon B Johnson Tropical Medical Center, Pago Pago. Women self-reported demographic characteristics, pregnancy history, and satisfaction with prenatal care. Domains of satisfaction were extracted using principal components analysis. Scores were summed across each domain. Linear regression was used to examine associations between maternal characteristics and the summed scores within individual domains and for overall satisfaction. Result Three domains of satisfaction were identified: satisfaction with clinic services, clinic accessibility, and physician interactions. Waiting ≥ 2 h to see the doctor negatively impacted satisfaction with clinic services, clinic accessibility, and overall satisfaction. Living > 20 min from the clinic was associated with lower clinic accessibility, physician interactions, and overall satisfaction. Women who were employed/on maternity leave had lower scores for physician interactions compared with unemployed women/students. Women who did not attend all their appointments had lower overall satisfaction scores. Conclusions Satisfaction with clinic services, clinic accessibility and physician interactions are important contributors to prenatal care satisfaction. To improve patient satisfaction prenatal care clinics should focus on making it easier for women to reach clinics, improving waiting times, and increasing time with providers.

Abstract Background Organophospate flame retardants (PFRs) are chemicals of emerging concern due to restrictions on polybrominated diphenyl ether flame retardant formulations. We describe the occurrence, variability, and predictors of urinary metabolites of PFRs among pregnant women. Methods In 2014–2015, 59 women from Providence, RI provided up to 3 spot urine samples during pregnancy (~12, 28, and 35 weeks’ gestation). We created a pooled urine sample per woman and measured nine relevant metabolites in individual and pooled samples. We used linear mixed models to calculate intraclass correlation coefficients (ICCs) across the 3 measurements and to assess sociodemographic and dietary predictors of PFRs. Results The median (IQR) of bis-2-chloroethyl phosphate (BCEP), bis(1,3-dichloro-2-propyl) phosphate (BDCPP), and diphenyl phosphate (DPhP), the metabolites most frequently detected, from pooled samples were: 0.31 μg/L (0.17–0.54), 1.18 μg/L (0.64–2.19), 0.93 μg/L (0.72–1.97), respectively. We observed fair to good reproducibility for BCEP (ICC = 0.50), BDCPP (ICC = 0.60), and DPhP (ICC = 0.43), and excellent agreement between the urinary flame retardant metabolite concentrations averaged across pregnancy versus pooled urine sample concentrations for BCEP (ICC = 0.95), BDCPP (ICC = 0.89), and DPhP (ICC = 0.93). Adjusting for pertinent sociodemographic factors and gestational week of urine collection, each 1 kg increase in pre-pregnancy weight was associated with greater BCEP (1.1%; 95% CI: 0.1, 2.1), BDCPP (1.5%; 95% CI: 0.3, 2.7), and DPhP (0.5%; 95% CI: 0.0, 1.1). Dietary factors were generally not associated with urinary flame retardant metabolites. Conclusions Urinary concentrations of BCEP, BDCPP, and DPhP were frequently detected among women in this pilot study and had fair reproducibility across pregnancy. Body size may be an important predictor of urinary flame retardant metabolite concentrations.