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Raísa Barbosa de Andrade,1 Catherine M Pirkle,2 Tetine Sentell,2 Diego Bassani,3 Marlos Rodrigues Domingues,4 Saionara MA Câmara1,5 1Postgraduate Program in Public Health, Faculty of Health Sciences of Trairi, Federal University of Rio Grande do Norte, Natal, Brazil; 2Office of Public Health Studies, University of Hawaii at Mānoa, Honolulu, HI, USA; 3Department of Paediatrics, Faculty of Medicine & Dalla Lana School of Public Health University of Toronto, Toronto, ON, Canada; 4Postgraduate Programme in Physical Education, Federal University of Pelotas, Pelotas, Brazil; 5Postgraduate Program in Rehabilitation Sciences, Faculty of Health Sciences of Trairi, Federal University of Rio Grande do Norte, Natal, BrazilCorrespondence: Saionara MA CâmaraFaculdade de Ciências da Saúde do Trairi, Universidade Federal do Rio Grande do Norte, Rua Teodorico Bezerra, s/n, Centro, Santa Cruz, RN, BrazilTel +55 84 99480-6888Email saionaraaires@gmail.comBackground: Adolescent pregnancy is a public health concern worldwide, particularly in low-income settings. Adolescent mothers face higher risks during pregnancy and delivery compared to adult mothers and yet, may also experience worse quality of obstetrical care. This study evaluates adherence to meeting Brazilian recommendations for prenatal care by comparing first-time adolescent versus adult mothers in a rural, low-income setting.Methods: Using data from the Adolescence and Motherhood Research (AMOR) project, we evaluated adherence to national recommendations as documented in the prenatal cards of 39 adolescents (13– 18 years) and 37 adults (23– 28 years) from a low-income area in northeast Brazil. Recommendations included ≥ 6 prenatal consultations, gestational age ≤ 12 weeks at the first visit, participation in 3 educational activities, 2 serology for syphilis (VDRL) and HIV, 1 Toxoplasmosis serology, 2 urine tests, 2 blood glucose and 2 hemoglobin/hematocrit (Hb/Ht) exams. Chi-square tests were used to compare the proportions of adolescents and adults with a record of these procedures in the prenatal cards.Results: Compared to adult women, the adolescent group had lower attainment of almost all recommended components of prenatal care compared to the adult group, with statistically significant differences for 2 blood glucose tests (46.2% vs 78.4%; p=0.004), 2 VDRL tests (30.8% vs 54.1%; p=0.040), 2 Hb/Ht exams (35.9% vs 83.8%; p< 0.001), and at least 6 consultations (84.6% vs 100%; p=0.013).Conclusion: Despite greater health risks of adolescent fertility, the prenatal cards of adolescent mothers presented a poorer record of adherence to recommendations for adequate prenatal care compared to adult mothers from a low-income setting of Brazil. Health policies for both health professionals and the target population are needed to ensure adequacy of prenatal care and appropriate risk reduction for this vulnerable population.Keywords: prenatal care, delivery of health care, health records, personal, pregnancy in adolescence

Issue: Postpartum depressive symptoms may be more prevalent and/or severe in vulnerable populations., Background: Postpartum depression represents a serious mental health problem associated with maternal suffering. Despite the relevance and clinical implications of investigating pain during pregnancy and the association with postpartum depression, there is limited research on this topic., Aim: We evaluated the association between pain during pregnancy and postpartum depression symptoms in adolescent and adult women., Methods: This study included 86 pregnant women (42 adolescents aged 13 to 18 years and 44 adults aged 23 to 28 years) from Trairi region, Northeastern Brazil. The evaluation of pain intensity and postpartum depression symptoms was conducted using the validated instruments of the Pelvic Pain Assessment Form and Edinburgh Postnatal Depression Scale (EPDS), respectively. Mann-Whitney and Kruskal-Wallis tests compared depressive symptoms in relation to pain status., Findings: Overall, pregnant women reporting moderate to intense pain presented more depressive symptoms, with emphasis to "deep pain with intercourse" (p = .09), "burning vaginal pain after sex" (p = .01), "pelvic pain lasting hours or days after intercourse" (p = .06), and "pain with urination" (p = .09). When stratified by age group, significant associations were found only for the adolescents., Discussion: Our results suggest that women reporting pain in different daily situations have higher EPDS scores., Conclusion: Pain during pregnancy is associated with postpartum depression symptoms, mainly among adolescents. Adequate screening and pain management during pregnancy may improve women's quality of life., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Adolescent childbirth is associated with worse physical function over the long-term. Differential loss of muscle strength during pregnancy and postpartum for adolescents compared to adults may be one explanation for this, but research examining these differences is lacking. The objective of this study as to assess hand grip strength and hip adduction muscle strength in adolescents and adults during pregnancy and postpartum. A prospective cohort study was carried out with adolescent (13 to 18 years) and adult (23 to 28 years) primigravid women. Assessments were performed at three timepoints: before the 16th gestational week, during the third trimester, and between the fourth and sixth week postpartum. Hand grip strength (continuous and muscle weakness if ≤ 20.67 kgf) and hip adductor measures (continuous and muscle weakness if ≤ 13.8 kgf) were assessed using dynamometry. Generalized estimating equations modelled longitudinal relationships between muscle weakness and age group. More adolescents had hip adductor weakness than adults in the third trimester of pregnancy (62.5% vs. 31.8%, p < 0.005), which was corroborated by the longitudinal analyses. For all women, there were higher odds of hip adductor weakness in the third trimester (OR = 4.35; p< 0.001) and postpartum (OR = 9.45; p < 0.001) compared to the 16th gestational week. No significant difference in HGS was observed between age groups or across the different timepoints. The higher proportion of hip adductor weakness among adolescents may indicate a need for resistance training during and after pregnancy and physical therapy if weakness or injury is noted., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Santos et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Context: Robust associations have been identified between fertility during adolescence and the disablement process, including pathologies, impairments, functional limitations and disability. Limited theoretical or empirical research considers how and why such relationships exist generally or with the individual associated components of disablement., Objective: To consolidate and critically evaluate literature to describe testable, theory-based hypotheses to guide future research on the mechanisms by which fertility during adolescence contributes to disablement., Methods: Targeted literature review of research from diverse global settings contextualised in two well-accepted theoretical frameworks in life-course epidemiology: the cumulative risk model and the critical period approach., Results: Five hypothesised causal pathways linking adolescent fertility to disablement in later life are described: 1) Causal relationship initiated by fertility during adolescence; 2) Common cause(s) for both , such as adverse childhood experiences; 3) Contributing cause(s) to adolescent fertility; 4) Interaction between adolescent fertility and other risk factors; and 5) Critical period effects unique to adolescence. Most research on the topic is on pathologies versus functional limitations and disability., Conclusion: We highlight promising research avenues to inform future research and interventions on adolescent fertility and the disablement process. This work provides theoretical clarity, identifies research gaps, and offers hypotheses-testing opportunities for future research.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in rapid and drastic changes to daily lives, posing a threat to residents' mental health and well-being. Filipinos are disproportionately impacted by COVID-19 and have one of the highest COVID-19 prevalence in Hawai'i. The COVID-19 pandemic has been associated with a rise in mental health concerns, yet little is known about the impact on the mental health of Filipinos in Hawai'i. Using publicly available polling data from the SMS Community Pulse Survey, this study sought to describe the mental distress experienced by Filipino residents during the COVID-19 pandemic. Data were collected from an online panel of Hawai'i residents over 4 timepoints (May 5-10; June 11-17; July 31-August 8; October 19-31, 2020). Compared to non-Filipinos, a higher proportion of Filipinos reported feeling stress and sadness during 3 of the 4 timepoints. Across all timepoints, Filipinos were more likely to respond affirmatively to mental health indicators (62.5%). Similarly, Filipinos reported food insecurity in higher proportions relative to non-Filipinos in most timepoints, particularly notable in Timepoint 4 where 33.0% of Filipino respondents reported food insecurity. These findings suggest that Filipinos would benefit from social policy and community-supported initiatives to address social determinants of health, reduce chronic stress, and prevent further mental health disparities., Competing Interests: None of the authors identify a conflict of interest., (©Copyright 2024 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Background: Hypertension awareness and control are understudied among older adults in middle-income countries, with limited work contextualizing awareness and control across layers of influence (individual to the community). Research on hypertension in Latin America is acknowledged as insufficient., Objectives: This study applies the socioecological model (SEM) to examine individual, interpersonal, institutional, and community factors related to hypertension awareness and control in older adults residing in Brazil and Colombia. It identifies groups of older adults more likely to be unaware of their condition and/or to have challenges achieving hypertension control., Methods: We analyzed International Mobility in Aging Study data of 803 community-dwelling adults 65-74 years from study sites in the two most populous countries in South America. The study framework was the socioecological model. Logistic regression models identified factors associated with hypertension awareness and control., Conclusions: Hypertension was prevalent in both samples (>70%), and awareness was high (>80%). Blood pressure control among diagnosed respondents was low: 30% in Brazil and 51% in Colombia. Factors across the socioecological model were associated with awareness and control, with notable differences across countries. Those with diabetes (OR 4.19, 95%CI 1.64-10.71) and insufficient incomes (OR: 1.85, 95%CI 1.03-3.31) were more likely to be aware of their hypertension. In Colombia, those reporting no community activity engagement were less likely to be aware compared to those reporting community activities. In Brazil, it was the opposite. Women (OR 1.66, 95%CI 1.12-2.46) and those reporting strolling shops and stores (OR 1.80, 95% CI 1.09-3.00) were significantly more likely to have their hypertension under control. In Brazil, those 70-75 were significantly less likely to have their hypertension under control compared to their younger counterparts. In Colombia, this was not observed. This paper highlights the importance of theory-based studies within unique Latin American contexts on hypertension and suggests novel opportunities for intervention., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2023 The Author(s).)

Background: This real-world evaluation considers an algorithm designed to detect patients with potentially undiagnosed hypertension, receiving routine care, in a large health system in Hawai'i. It quantifies patients identified as potentially undiagnosed with hypertension; summarizes the individual, clinical, and health system factors associated with undiagnosed hypertension; and examines if the COVID-19 pandemic affected detection., Methods and Results: We analyzed the electronic health records of patients treated across 6 clinics from 2018 to 2021. We calculated total patients with potentially undiagnosed hypertension and compared patients flagged for undiagnosed hypertension to those with diagnosed hypertension and to the full patient panel across individual characteristics, clinical and health system factors (eg, clinic of care), and timing. Modified Poisson regression was used to calculate crude and adjusted risk ratios. Among the eligible patients (N=13 364), 52.6% had been diagnosed with hypertension, 2.7% were flagged as potentially undiagnosed, and 44.6% had no evidence of hypertension. Factors associated with a higher risk of potentially undiagnosed hypertension included individual characteristics (ages 40-84 compared with 18-39 years), clinical (lack of diabetes diagnosis) and health system factors (clinic site and being a Medicaid versus a Medicare beneficiary), and timing (readings obtained after the COVID-19 Stay-At-Home Order in Hawai'i)., Conclusions: This evaluation provided evidence that a clinical algorithm implemented within a large health system's electronic health records could detect patients in need of follow-up to determine hypertension status, and it identified key individual characteristics, clinical and health system factors, and timing considerations that may contribute to undiagnosed hypertension among patients receiving routine care.

Objectives: Adolescent childbirth is associated with older adult adverse health outcomes that negatively affect mobility function, but these associations have not been studied globally in large samples of reproductive-age women. This study examines the association between age at first childbirth and mobility disability in national surveys from low-income and middle-income countries, and hypotheses that adolescent childbirth is associated with mobility disability., Design: Cross-sectional analysis., Setting: Population health surveys from 2013 to 2018 containing mobility disability measures among ever-pregnant women ages 15-49. These included 13 Demographic Health Surveys from Haiti, Pakistan, Uganda, Cambodia, Colombia, South Africa, Timor-Leste, Albania, Gambia, Maldives, Peru, Senegal and Yemen and 1 Maternal Health Survey from Ghana., Participants: The sample included 157 988 women ages 15-49 years., Primary Outcome Measure: Adolescent childbirth was defined as 10-19 years of age. Poisson regression models were used to estimate prevalence ratios (PRs) of mobility disability among women who first gave birth during adolescence and in adult life (ages 20-45 years) in each country and across the whole sample. Countries were also analysed according to the use of standard and non-standard mobility disability measures. Covariates included current age, urban/rural residence, education and household wealth., Results: Prevalence of adolescent childbirth (17.5%-66.2%) and mobility disability (0.32%-21.45%) varied widely across countries. Adolescent childbirth was significantly (p<0.05) associated with greater mobility disability in six of eight countries using standard disability measures. Among the six countries that did not use standard disability measures, none showed a statistically significant association between adolescent childbirth and mobility disability. Considering the whole sample and adjusting for all covariates, women who gave birth during adolescence had greater prevalence of mobility disability (pooled PR 1.19, 95% CI 1.06-1.31)., Conclusions: This analysis suggests a moderate and consistent association of adolescent childbearing with subsequent mobility disability., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The Republic of the Marshall Islands (RMI) has been affected by marine pollution from militarization and urbanization. To address concerns raised by the Marshall Islands Marine Resources Authority, this study examined concentrations of dissolved contaminants in reef and pelagic fishes in the RMI and assessed potential associated risks. Metals, organochlorine pesticides, polychlorinated biphenyls (PCBs), and polycyclic aromatic hydrocarbons (PAHs) were examined in reef and pelagic fishes from six atolls: Kwajalein, Majuro, Jaluit, Utirik, Rongelap, and Wotje. Clear trophic patterns emerged for metals. Total arsenic was highest in higher trophic level reef fishes, particularly in the camouflage grouper (Epinephelus polyphekadion) (>100 μg g -1 total As), but inorganic arsenic was negligible in higher trophic levels and showed an inverse trend with the highest percentages present in parrotfishes and herbivores. Copper and mercury were elevated in higher trophic level reef and pelagic fishes, respectively, and the maximum mercury concentrations (6.45 μg g -1 in Gymnosarda unicolor) were among the highest reported in the Pacific. Conversely, cadmium and lead were highest in lower trophic levels, like surgeonfishes and parrotfishes. PCBs were more clearly linked to locations and were highest at two atolls with military history (Kwajalein and Jaluit) (>U.S. EPA Screening Value of 2.5 ppb). PAHs were ubiquitous across taxa (detected in 97% of samples), but the highest concentrations were in lower trophic levels. Organochlorine pesticides were detected at very low concentrations that do not likely pose a risk. We compare concentrations to established thresholds for human health and find that - for specific locations and species - contaminant concentrations may pose a risk to fish and other marine taxa, as well as human consumers. This study provides baseline information that aids the development of marine conservation and public health recommendations and addresses a data gap that persists for marine pollution throughout the Pacific Islands., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Latin America has notably elevated rates of adolescent fertility and obesity in women. Although numerous studies document associations between adolescent fertility and obesity across the life course, the pathways explaining their association are insufficiently theorized, especially regarding the factors in Latin America that may underpin both. Additionally, much of the existing research is from high-income countries, where fertility and obesity are trending down. In this paper, we review the various complex pathways linking adolescent fertility and obesity, highlighting research gaps and priorities, with a particular focus on Latin American populations. We carefully consider pregnancy's distinct impact on growth trajectories during the critical period of adolescence, as well as the cumulative effect that adolescent fertility may have over the life course. We also articulate a pathway through obesity as it may contribute to early puberty and thus, to adolescent fertility. If obesity is a cause of adolescent fertility, not a result of it, or if it is a mediator of early-life exposures to adulthood obesity, these are critical distinctions for policy aiming to prevent both obesity and early fertility. Research to better understand these pathways is essential for prevention efforts against obesity and undesired adolescent fertility in Latin America., (© 2022 New York Academy of Sciences.)

Objective: Gout disproportionately affects older Pacific Islander and Black populations relative to White populations. However, the ethnic-specific determinants remain understudied within these groups, as well as within other ethnicities. We examined gout incidence and associations with behavioral factors, including diet, alcohol, and smoking, within a large multiethnic population of older adults from the Multiethnic Cohort Study, which linked prospective cohort data to Medicare gout claims between 1999-2016., Methods: Using samples of Black (n = 12,370), Native Hawaiian (n = 6459), Japanese (n = 29,830), Latino (n = 17,538), and White (n = 26,067) participants, we conducted multiple Cox regressions, producing hazard ratios (HRs) and 95% CIs., Results: Relative to White individuals, Native Hawaiians had the highest risk of gout (HR 2.21, 95% CI 2.06-2.38), followed successively by Black and Japanese participants, whereas Latino individuals had a lower risk of gout (HR 0.78, 95% CI 0.73-0.83). Alcohol use was associated with an increased risk, with significantly greater effects observed among Japanese participants drinking ≥ 3 drinks per day (HR 1.46, 95% CI 1.27-1.66), or > 5 beers per week (HR 1.29, 95% CI 1.17-1.43), compared to White individuals ( P interaction < 0.001). Former smokers with ≥ 20 pack-years had an increased risk (HR 1.14, 95% CI 1.06-1.22). Higher dietary quality was associated with a decreased gout risk, with the largest effect observed among White participants (HR Q5vsQ1 0.84, 95% CI 0.79-0.90), whereas vitamin C was weakly associated with a decreased risk of gout only among Japanese individuals (HR 0.91, 95% CI 0.85-0.98)., Conclusion: Overall, notable ethnic differences were observed in both gout risk and associations with modifiable behavioral factors. Our findings offer crucial insights that may improve precision in preventing and managing gout., (Copyright © 2022 The Journal of Rheumatology.)

This study examines total hemoglobin (THB) trajectories during pregnancy and postpartum and associated factors among adolescents and adults from a low-income community. This is an observational, longitudinal study, part of the Adolescence and Motherhood Research (AMOR) project, performed between 2017 and 2019 in the Trairi region of Rio Grande do Norte state, Brazil. The THB levels of 100 primigravida adolescents and adults were monitored up to 16 weeks of gestation, in the third trimester, and 4-6 weeks postpartum, along with socioeconomic characteristics, anthropometrics, and health-related variables. Mixed-effect linear models evaluated the trajectories of THB and the associated factors. THB levels decreased between first and second assessments and increased between the second and postpartum assessments. For the adolescent cohort, the rebound in THB concentration between the third trimester and postpartum was not enough to make up for the initial losses, as occurred in the adult cohort. For the adult group, higher THB levels were associated with pregnancy planning and good self-rated health. Race was marginally associated to THB levels, with black/brown women presenting higher concentrations in the adolescent and lower concentration in the adult group. Special attention to prenatal care among pregnant adolescents should consider their higher risk of anemia and its negative effects.

Native Hawaiian and Pacific Islander populations have been disproportionately affected by COVID-19 (1-3). Native Hawaiian, Pacific Islander, and Asian populations vary in language; cultural practices; and social, economic, and environmental experiences, † which can affect health outcomes (4). § However, data from these populations are often aggregated in analyses. Although data aggregation is often used as an approach to increase sample size and statistical power when analyzing data from smaller population groups, it can limit the understanding of disparities among diverse Native Hawaiian, Pacific Islander, and Asian subpopulations ¶ (4-7). To assess disparities in COVID-19 outcomes among Native Hawaiian, Pacific Islander, and Asian populations, a disaggregated, descriptive analysis, informed by recommendations from these communities,** was performed using race data from 21,005 COVID-19 cases and 449 COVID-19-associated deaths reported to the Hawaii State Department of Health (HDOH) during March 1, 2020-February 28, 2021. †† In Hawaii, COVID-19 incidence and mortality rates per 100,000 population were 1,477 and 32, respectively during this period. In analyses with race categories that were not mutually exclusive, including persons of one race alone or in combination with one or more races, Pacific Islander persons, who account for 5% of Hawaii's population, represented 22% of COVID-19 cases and deaths (COVID-19 incidence of 7,070 and mortality rate of 150). Native Hawaiian persons experienced an incidence of 1,181 and a mortality rate of 15. Among subcategories of Asian populations, the highest incidences were experienced by Filipino persons (1,247) and Vietnamese persons (1,200). Disaggregating Native Hawaiian, Pacific Islander, and Asian race data can aid in identifying racial disparities among specific subpopulations and highlights the importance of partnering with communities to develop culturally responsive outreach teams §§ and tailored public health interventions and vaccination campaigns to more effectively address health disparities., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Catherine M. Pirkle is the principal investigator of the Social Epidemiology Evaluation Contract funded by the Hawaii State Department of Health. No other potential conflicts of interest were disclosed.

The number of hospitalizations with an obesity diagnosis have increased among youth in the past two decades, yet remain understudied, particularly among racial/ethnic minority groups. The purpose of this study was to characterize obesity prevalence among children, adolescents, and young adults receiving inpatient care in Hawai'i acute care hospitals during 2015-2016. This study analyzed statewide administrative data from a racially and ethnically diverse population. Participants (N = 7,751) included Hawai'i residents aged 5-29 years receiving inpatient care, excluding those hospitalized due to pregnancy. Recorded height and weight were used to calculate body mass index (BMI) and classify obesity. Primary or secondary diagnoses for obesity were assessed. A multivariable logistic regression model was used to determine characteristics associated with obesity, including race/ethnicity-sex interaction, age group, insurance payer, and county of residence. Based on BMI, 28.4% (2,202/7,751) of patients had obesity. However, an obesity diagnosis was present only in 40.4% (889/2,202) of patients with obesity based on BMI (11.9% of all patients). In the multivariable model, compared to whites, the odds of having obesity were highest among Pacific Islanders [adjusted odds ratio (aOR) = 4.07, 95% CI(3.16-5.23)] and Native Hawaiians [aOR = 2.16, 95% CI(1.75-2.67)] for females, and among Pacific Islanders [aOR = 5.39, 95% CI(4.27-6.81)], Native Hawaiians [aOR = 2.36, 95% CI(1.91-2.91)], and Filipinos [aOR = 2.08, 95% CI(1.64-2.64)] for males. Obesity was also associated with age group, but not insurance payer type or county of residence. These findings support the need for greater attention to obesity in the inpatient setting and equity-focused interventions to reduce obesity among younger hospitalized patients., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Author(s).)

This study investigated the association of lifestyle factors and polygenic risk scores (PGS), and their interaction, on type 2 diabetes mellitus (T2D). We examined data from the U.S. Health and Retirement Study, a prospective longitudinal cohort of adults aged 50 years and older, containing nationally representative samples of Black and White Americans with precalculated PGS for T2D (N = 14 001). Predicted prevalence and incidence of T2D were calculated with logistic regression models. We calculated differences in T2D prevalence and incidence by PGS percentiles and for interaction variables using nonparametric bootstrap method. Black participants had approximately twice the prevalence of Whites (26.2% vs 14.2%), with a larger difference between the 90th and 10th PGS percentile from age 50 to 80 years. Significant interaction (pinteraction = .0096) was detected between PGS and physical activity among Whites. Among Whites in the 90th PGS percentile, T2D prevalence for moderate physical activity was 17.0% (95% CI: 14.8, 19.6), 6.8% lower compared to no/some physical activity (23.8%; 95% CI: 20.4, 27.5). T2D prevalence was similar (~10%) for both groups in the 10th PGS percentile. Incident T2D in Whites followed a similar pattern (pinteraction = .0325). No significant interactions with PGS were detected among Black participants. Interaction of different genetic risk profiles with lifestyle factors may inform understanding of varying inventions' efficacy for different groups of people, potentially improving clinical and prevention interventions., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In January 2020, Hawai'i became the second state with a healthy default beverage (HDB) law, requiring restaurants to offer HDBs with their children's meals. This observational study presents baseline characteristics of restaurants with a children's menu and meal. The study describes pre-law beverage options to inform future HDB policy language, implementation, and evaluation. Between November and December 2019, data were collected from a statewide sample of unique restaurants ( N = 383) with health inspection permits. Restaurants were assessed separately for a children's menu and meal using website reviews, telephone calls, and in-person visits. Meals were evaluated for pre-law beverage type and compliance. Logistic regression was used to estimate the likelihood of having a children's menu and meal. Most of the restaurants were full-service (70.2%) and non-chains (67.9%). While 49.3% of restaurants had a children's menu, only 16.7% had a children's meal. Significant predictors of having a children's menu were being full-service, national/international or local chains, neighbor island (non-Honolulu) locations, and hotel locations. Only being a national/international chain significantly predicted having a children's meal. Although 35.9% of children's meals offered a non-sugar-sweetened beverage (SSB) option, only 3.1% offered law-compliant beverages. Inclusion of an SSB default option (60.9%) and not specifying the type of default beverage were the predominant factors for pre-law non-compliance. Results support the need for HDB regulations, especially for national/international chains, which were most likely to have children's meals, and provide data to inform policies in other jurisdictions., Competing Interests: Conflicts of Interest No financial disclosures or conflicts of interest are reported by the authors of this paper., (© JHEAL, 2021.)

Shortly after a healthy default beverage (HDB) law took effect in Hawai'i, requiring restaurants that serve children's meals to offer healthy beverages with the meals, the COVID-19 pandemic struck. Efforts to contain the virus resulted in changes to restaurants' operations and disrupted HDB implementation efforts. Economic repercussions from containment efforts have exacerbated food insecurity, limited access to healthy foods, and created obstacles to chronic disease management. Promoting healthy default options is critical at a time when engaging in healthy behaviors is difficult, but important, to both prevent and manage chronic disease and decrease COVID-19 risk. This commentary discusses COVID-19's impact on restaurant operations and healthy eating, and the resulting challenges and opportunities for this promising health promotion intervention.

(1) Background: There are persistent racial/ethnic disparities in cesarean delivery in the United States (U.S.), yet the causes remain unknown. One factor could be provider bias. We examined medical indications for cesarean delivery that involve a greater degree of physician discretion (more subjective) versus medical indications that involve less physician discretion (more objective) to better understand factors contributing to the higher rate among Micronesian, one of the most recent migrant groups in the state, compared to White women in Hawai'i. (2) Methods: A retrospective chart review was conducted to collect data on 620 cesarean deliveries (N = 296 White and N = 324 Micronesian) at the state's largest maternity hospital. Multivariate regression models were used to examine associations between maternal and obstetric characteristics and (1) subjective indication defined as non-reassuring fetal heart tracing (NRFHT) and arrest of labor disorders, and (2) objective indication defined as all other indications (e.g., malpresentation). (3) Results: We found that Micronesian women had significantly higher odds of cesarean delivery due to a subjective indication compared to White women (aOR: 4.17; CI: 2.52-6.88; P < 0.001; N = 619) after adjusting for multiple covariates. (4) Conclusion: These findings suggest unmeasured factors, possibly provider bias, may influence cesarean delivery recommendations for Micronesian women in Hawai'i.

Objectives: To investigate a 4-year longitudinal relationship between falls, recurrent falls, and injurious falls, according to different levels of life-space mobility (LSM)., Methods: Longitudinal analysis of an international cohort study. The participants were older adults from the International Mobility in Aging Study (IMIAS) aged between 65 and 74 years at baseline. Three waves of data (2012, 2014, 2016) were used. Fall history during the past year was recorded. Recurrent fallers were identified as those who fell at least twice and injurious fallers as participants who required medical attention. LSM measurements included Total Life-Space (LS-C), Maximal Life-Space (LS-M), Assisted Life-Space (LS-A), Independent Life-Space (LS-I) and Restricted Life-space (LS-ID) scores. Generalized estimation equation (GEE) models were used to determine whether life-space mobility measures and their change over time differed between recurrence of falls and injurious falls., Results: At baseline, the prevalence of falls in the last year was 28%. 11.8% reported recurrent falls and 2.6% had serious injurious falls in the last year preceding the assessments. Recurrent fallers were more likely to be female, with insufficient income and, with comorbidities. GEE models showed that life-space mobility was lower among those with recurrent falls or serious injurious falls compared to those who never fell, but the rate of change did not differ over the 4-year follow-up except for the LS-A and LS-I scores, where some improvements were observed over time., Conclusions and Implications: Falls were independently associated with a decrease in LSM over 4 years. Targeting older adults with recurrent and injurious falls with appropriate interventions may improve community mobility and social participation.

Objective: In women, the risk of cardiovascular disease (CVD) is higher in the postmenopausal period. The effect that menopausal type, natural versus surgical, or the age at natural menopause has on CVD needs further investigation. To this end, we assessed the association between menopausal type and timing and the 10-year office-based Framingham Risk Score (FRS) in women from the Canadian Longitudinal Study on Aging., Methods: We included women aged 45 to 85 years from the Canadian Longitudinal Study on Aging Comprehensive cohort of seven Canadian provinces who were menopausal at the time of recruitment and had no prior CVD. Poisson regressions were used to evaluate the association between menopausal characteristics and the FRS. Natural menopause was defined as the cessation of menstrual periods for at least 1 year in women with no history of hysterectomy. Surgical menopause was defined as hysterectomy with or without oophorectomy prior to natural menopause. As main covariates, we examined age, education, province of residency, and hormone therapy., Results: A total of 10,090 women (8,200 natural menopausal and 1,890 surgical menopausal) were eligible for the study. In the multivariable model, surgical menopause was associated with a higher mean FRS compared with natural menopause (CVD risk 12.4% vs 10.8%, P < 0.001). Compared with women with age at natural menopause from 50 to 54 years (CVD risk 10.2%), natural menopause before age 40, 40 to 44, or 45 to 49 had a higher CVD risk (12.2%, 11.4%, and 10.6%, respectively, P < 0.001)., Conclusions: Our study supports an association between menopausal type and timing on CVD risk prediction and highlights the need to be judicious about surgical menopause. Preventative interventions for CVD should be considered in surgical menopausal women and women with an age at natural menopause less than 45 years., Competing Interests: Financial disclosures/conflicts of interest: S.M.A.C. has received funding from Fogarty International Center – National Institute of Health. C.M.P. has received funding from the United States Center for Disease Control, the State Department of Health, and World Bank. The other authors have nothing to disclose., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The North American Menopause Society.)

Albania is a small country on the Balkan Peninsula that recently implemented an innovative primary healthcare program called "Si Je?" (How are you?) which allowed all Albanians aged 40-65 years to receive a free, yearly basic health examination at their local health center. Access to basic primary care is a critical component of a nationwide culture of prevention particularly for the non-communicable diseases that comprise 89% of total deaths in the country. Yet, as in many middle-income countries, a culture of prevention in Albania is often secondary to ensuring basic health infrastructure and healthcare access for those critically in need. Using the social-ecological model as our conceptual framework, this paper provides new insights into the culture of prevention in Albania by analyzing the need for, and implementation of, the Si Je? program using (1) findings from a critical literature review, (2) quantitative data from the database created from this program, and (3) qualitative data from key informant interviews from 15 health center directors. Positive developments towards a culture of prevention include the fact that the Si Je? program has been expanded to those 35-70 years, strengthened links between community and primary care, and participation among rural communities who traditionally have limited primary care access. Challenges include continued urgent health infrastructure needs, politicization of the Si Je? effort, limited participation by some groups (particularly urban men), and regional variations. Despite challenges, Albania appears to be building new infrastructure for a sustainable culture of prevention, particularly around chronic disease.

Objective: To investigate the association between frailty and a summary cardiovascular risk measure (Framingham Risk Score, FRS) in a sample of older adults from different epidemiologic contexts participating in the multicenter International Mobility in Aging Study (IMIAS)., Material and Methods: This cross-sectional study used data from the IMIAS, which is composed of older adults from four different countries (Canada, Albania, Colombia and Brazil). A total of 1724 older adults aged 65-74 years were assessed. Frailty was defined as the presence of 3 or more of the following criteria: unintentional weight loss in the last year, exhaustion, muscle weakness, slowness in gait speed, and low levels of physical activity. The FRS was calculated to estimate the 10-year risk for cardiovascular disease (CVD), based on: sex, age, systolic blood pressure (SBP), and treatment for hypertension, total and high-density lipoprotein (HDL) cholesterol, diabetes mellitus status and smoking habits. Confounders included measures of childhood social and economic adversity, as well as mid-life and adult adversity., Results: After adjustment for adversities which occurred during in early, adult or current life, frail individuals presented higher FRS values (β = 3.81, 95 %CI: 0.97-6.65, p-value <0.001) when compared to robust participants. A statistically significant relationship was also observed in prefrail participants with FRS (β = 1.61, 95 % CI: 0.72-3.02, p-value <0.05)., Conclusion: Frailty and prefrailty were associated to FRS, independent of life course adversities. Screening cardiovascular risk factors should be a target, mainly in those who present frailty syndrome., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Access to cesarean delivery is vital for quality obstetrical care, but the procedure can increase maternal mortality, morbidity, and complications in subsequent deliveries. The objective of this study was to describe obstetrician-gynecologists' (OB-GYNs) perspectives on labor and delivery care for Micronesian women in Hawai'i and possible factors contributing to higher cesarean delivery rates among that racial/ethnic group. The Framework Method guided the analysis of 13 semi-structured interviews with OB-GYNs. Study results indicated that OB-GYNs were more likely to attribute racial/ethnic differences in mode of delivery to challenges resulting from nonmedical factors, particularly communication and negative attitudes toward Micronesian patients, than to medical risk factors. In this study, we explored aspects of care that cannot be captured in medical charts or clinical data, but may impact health outcomes for this population. The findings could help improve care for Micronesian women, with lessons applicable to other racial/ethnic minority groups.

Adequate health literacy is important for strong health outcomes during pregnancy, particularly among mothers with high risk of adverse outcomes related to pregnancy and childbirth. Understanding the health literacy of young pregnant women in low-income settings could support strategies to reduce adverse outcomes in this population. This exploratory study assessed the health literacy of young pregnant adolescents and young adults from a rural area in Northeast Brazil and associated factors such as socioeconomic conditions, adequacy of prenatal care, and social support from family and friends. In this cross-sectional study, 41 pregnant adolescents (13-18 years) and 45 pregnant adults (23-28 years) from the Rio Grande do Norte state, Brazil, were assessed regarding health literacy through the Short Assessment of Health Literacy for Portuguese-Speaking Adults (SAHLPA, score from 0-18, inadequate if <15). Income sufficiency, self-perceived school performance, compliance with recommendations for adequate prenatal care, and social support were also assessed. A linear regression analysis was conducted to evaluate the variables associated with the SAHLPA score. Ninety-five percent of the adolescents and 53.3% of the adults ( p < 0.001) presented inadequate health literacy. Adolescent age (β - 3.5, p < 0.001), poorer self-perceived school performance (β - 2.8, p < 0.001), and insufficient income for basic needs (β - 2.8, p = 0.014) were associated with worse SAHLPA scores. Adolescent mothers have higher rates of inadequate health literacy in this population. Policies are needed to improve access to health information for young populations from rural low-income areas.

Background: Gene-obesogenic environment interactions influence body mass index (BMI) across the life course; however, limited research examines how these interactions may differ by race and sex., Methods: Utilizing mixed-effects models, we examined the interaction effects of a polygenic risk score (PGS) generated from BMI-associated single-nucleotide polymorphisms, and environmental factors, including age, physical activity, alcohol intake, and childhood socioeconomic status on measured longitudinal BMI from the Health and Retirement Study (HRS). HRS is a population representative survey of older adults in the United States. This study used a subsample of genotyped Black (N = 1796) and White (N = 4925) men and women (50-70 years) with measured BMI., Results: Higher PGS was associated with higher BMI. The association between PGS and BMI weakened as individuals aged among White men (P interaction  = 0.0383) and White women (P interaction  = 0.0514). The mean BMI difference between the 90th and 10th PGS percentile was 4.25 kg/m 2 among 50-year-old White men, and 3.11 kg/m 2 among the 70 years old's, i.e., a 1.14 kg/m 2 (95% CI: -0.27, 2.82) difference. The difference among 50- and 70-year-old White women was 1.34 kg/m 2 (95% CI: 0.09, 2.60). In addition, the protection effect of physical activity was stronger among White women with higher PGS (P interaction  = 0.0546). Vigorous physical activity (compared with never) was associated with 1.66 kg/m 2 (95% CI: 1.06, 2.29) lower mean BMI among those in the 90th PGS percentile, compared with 0.83 kg/m 2 (95% CI: 0.37, 1.29) lower among those in the 10th PGS percentile. Interactions were also observed between both PGS and alcohol intake among White men (P interaction  = 0.0034) and women (P interaction  = 0.0664) and Black women (P interaction  = 0.0108), and PGS and childhood socioeconomic status among White women (P interaction  = 0.0007)., Conclusions: Our findings reinforce the importance of physical activity among those with an elevated genetic risk; additionally, other detected interactions may underscore the influence of broader social environments on obesity-promoting genes.

Objective: To examine the association of number of children birthed/fathered with incident heart disease, accounting for socioeconomic and lifestyle characteristics. Methods: We analyzed data from 24,923 adults 50 and older (55% women) in the Health and Retirement Study. Participants self-reported number of children and doctor-diagnosed incident heart disease. Cox proportional hazards models estimated heart disease risk. Results: Compared to women with one to two children, those with five or more had increased risk of heart disease (hazard ratio [HR] = 1.13, 95% confidence interval [CI] = [1.03, 1.25]). Compared to men with one to two children, those with five or more had a marginally increased risk of heart disease (HR = 1.11, 95% CI = [0.99, 1.25]), but this association attenuated in models adjusting for socioeconomic and lifestyle variables. Compared to men with no children, those with five or more retained a borderline significant association in the fully adjusted model (HR = 1.15, 95% CI = [0.99, 1.35]). Discussion: Social and lifestyle pathways appear to link parenthood to cardiovascular health.

Self-measured blood pressure monitoring programs (BPMPs) are effective at controlling hypertension. We examined implementation of self-measured BPMPs at 5 Hawai'i-based Federally Qualified Health Centers (FQHCs). In a process evaluation of these programs, we found that FQHCs developed protocols for self-measured BPMP recruitment and enrollment and provided additional supports to account for their patients' psychosocial needs to achieve blood pressure control, such as lifestyle change education and opportunities through referrals either to on-site or other programs (eg, on-site gym, tobacco cessation program). Common barriers across sites included insufficient material support for blood pressure monitors and data collection; funding, which affects program sustainability; and the lack of an "off-the-shelf" self-measured BPMP intervention. Policy makers and funding organizations should address these issues related to self-measured BPMPs to ensure implementation success.

Background: Self-rated Health (SRH) is regarded as a simple and valid measure of a person's health status, given its association to adverse health outcomes, including low physical performance in older populations. However, studies investigating these associations in low- and middle-income settings are scarce, especially for middle-aged populations. Understanding the validity of SRH in relation to objective health measures in low-income populations could assist in decision making about health policy and strategies, especially in under-resourced settings., Objective: Assess the relationship between SRH and physical performance measures in middle-aged and older women in a low-income setting of Brazil., Methods: This is a cross-sectional study of 571 middle-aged (40-59 years old) and older (60-80 years old) women living in Parnamirim and Santa Cruz in the Northeast region of Brazil. Participants reported their health status and were allocated to the "SRH good" or "SRH poor" groups. The physical performance evaluation included: handgrip strength, one-legged balance with eyes open and closed and chair stand test. The relationship between SRH and physical performance for middle-aged and older women was assessed by quantile regression (modeling medians) adjusted for potential confounders (age, socioeconomic variables, body mass index, menopause status, age at first birth, parity, chronic conditions and physical activity)., Results: Middle-aged women from the "SRH good" group presented better physical performance with 1.75 kgf stronger handgrip strength (95% CI [0.47-3.02]; p = 0.004), 1.31 s longer balance with eyes closed ([0.00-2.61]; p = 0.030), and they were 0.56 s faster in the chair stand test ([0.18-0.94]; p = 0.009) than those who reported "SRH poor". No association was found for balance with eyes open. For older women, there was no evidence of associations between physical performance and SRH., Conclusion: This study showed that SRH is significantly associated with objective measures of physical performance in a sample of low-income middle-aged women. SRH can be an important tool to indicate the need for further evaluation of physical performance among middle-aged women and can be particularly useful for low-income communities., Competing Interests: The authors declare that they have no competing interests., (© 2020 Fernandes et al.)

The Prevent Diabetes, Hawai'i campaign aimed to increase awareness of prediabetes by encouraging adults to take a Diabetes Risk Test and share the results with their doctors or healthcare providers. The campaign was developed based on social marketing principles, and focus groups were used to inform the marketing mix. Television, radio, digital, and print advertisements featured local actor and comedian Frank De Lima, and a website with an online Diabetes Risk Test and resources for patients and providers were promoted in all advertisements. From March 2017 to November 2019, more than 55,000 Hawai'i residents visited the campaign website. Campaign outcomes were assessed through state-added questions to the 2017 Behavioral Risk Factor Surveillance System. Overall, 35.0% of adults said that they remembered seeing or hearing an advertisement featuring Frank De Lima and/or the Prevent Diabetes, Hawai'i message. Five percent of respondents reported taking an online or paper version of the Diabetes Risk Test in the past 12 months, and an additional 19.7% said that they planned to take it. Among those who reported taking the Diabetes Risk Test, 60.2% said they had already spoken to their doctor or other healthcare provider about the test results or risk for type 2 diabetes. The State Department of Health will continue efforts to increase awareness of type 2 diabetes and prediabetes, reach priority populations most at risk, and expand availability of evidence-based lifestyle change programs., (©Copyright 2020 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Background: The Healthy Hawai'i Initiative was created in 2000 with tobacco settlement funds as a theory-based statewide effort to promote health-supporting environments through systems and policy change. Still active today, it is imbedded explicitly in a multi-sectoral, social ecological approach, effectively striving to build a culture of health before this was the name for such an ambitious effort., Methods: From interviews with key informants, we analyze two decades of the Healthy Hawai'i Initiative (HHI) in the context of the Robert Wood Johnson Foundation (RWJF) Culture of Health Action Framework (CHAF). We list HHI accomplishments and examine how the Initiative achieved notable policy and environmental changes supportive of population health., Results: The Healthy Hawai'i Initiative started with an elaborate concept-mapping process that resulted in a common vision about making "the healthy choice the easiest choice." Early on, the Initiative recognized that making health a shared value beyond the initial stakeholders required coalition and capacity building across a broad range of governmental and nonprofit actors. HHI coalitions were designed to promote grassroots mobilization and to link community leaders across sectors, and at their height, included over 500 members across all main islands of the state. Coalitions were particularly important for mobilizing rural communities. Additionally, the Initiative emphasized accessibility to public health data, published research, and evaluation reports, which strengthened the engagement to meet the shared vision and goals between diverse sector partners and HHI. Over the past two decades, HHI has capitalized on relationship building, data sharing, and storytelling to encourage a shared value of health among lawmakers, efforts which are believed to have led to the development of health policy champions. All of these factors combined, which centered on developing health as a shared value, have been fundamental to the success of the other three action areas of the CHAF over time., Conclusions: This evidence can provide critical insights for other communities at earlier stages of implementing broad, diverse, multifaceted system change and fills a key evidence gap around building a culture of health from a mature program in a notably multicultural state.

Objective: The objective of this study is to evaluate the influence of urinary incontinence (UI) on physical performance. Method: In prospective analyses from the International Mobility in Aging Study (IMIAS), 915 women (65-74 years) from Canada, Colombia, Albania, and Brazil were evaluated in relation to self-reported UI (past week) and physical performance (Short Physical Performance Battery [SPPB]), with reevaluation after 2 years. Linear mixed models examined the influence of UI on SPPB, adjusted by covariates (age, study site, education, income sufficiency, body mass index [BMI] and parity). Results: Women reporting some UI presented lower SPPB mean (β = -0.41, p = .009) and a greater reduction (β = -0.53, p = .001) over 2 years than those reporting no UI. Discussion: Compared with no reported UI, some UI was associated with worse and more pronounced declines in physical performance over 2 years. This study highlights the importance of practices to reduce UI to contribute to healthier aging.

Physical activity (PA) among older adults is understudied in middle-income countries. The authors examined the associations of factors across levels of the social ecological model (individual, interpersonal, organizational, and community) with older adults meeting guidelines of 150 min of moderate- to vigorous-intensity PA per week through walking in three middle-income countries: Albania (n = 387), Colombia (n = 404), and Brazil (n = 402). Using 2012 International Mobility in Aging Study data, multivariate logistic regression models identified the following significant associations with meeting PA guidelines through walking (a) individual level: depression (odds ratio [OR] = 0.62, 95% confidence interval, CI [0.45, 0.86]), being female (OR = 0.74, 95% CI [0.56, 0.998]), and high relative education (OR = 1.79, 95% CI [1.33, 2.41]) and (b) interpersonal level: high life partner (OR = 1.38, 95% CI [1.04, 1.83]) and friend social ties (OR = 1.39, 95% CI [1.05, 1.83]). While individual and interpersonal variables were associated with meeting PA guidelines, community-level social and environmental variables were not.

Objective: The aim of this study was to evaluate the association between categories of age at natural menopause (ANM) and gait speed (slowness) and grip strength (weakness), common measures of physical functioning in older women., Methods: We analyzed data from the Canadian Longitudinal Study on Aging, which included participants from seven cities across Canada collected in 2012. The sample was restricted to women who reported to have entered menopause (N = 9,920). Women who had a hysterectomy before menopause were excluded since the age at which this surgical procedure was performed was not available. ANM was categorized into five groups: less than 40 (premature), 40 to 44 (early), 45 to 49, 50 to 54, and more than 54. We conducted linear regressions to assess the association between ANM and gait speed (m/s) and grip strength (kg) adjusting for participant age, education, body mass index, smoking, use of hormone therapy, height, and province of residence., Results: Mean ANM was 49.8 (95% confidence interval [CI]: 49.7-50.0), with 3.8% of women having a premature menopause; the average gait speed was 0.98 m/s (standard deviation: 0.22), the average grip strength was 26.6 kg (standard deviation: 6.39). Compared to women with ANM of 50 to 54, women with premature menopause had 0.054 m/s (95% CI -0.083, -0.026) lower gait speed when adjusting for age and study site. In the fully adjusted model, the association was attenuated, 0.032 m/s (95% CI -0.060, -0.004). ANM was not associated with grip strength., Conclusion: Our study suggests that premature menopause (<40 years) may be associated with lower gait speed (slowness) among Canadian women. No association was observed between ANM and grip strength. Future studies should include a life course approach to evaluate whether social and biological pathways modify the association between age at menopause and physical function in populations from different contexts.

Background: Reproductive history and urogynecological disorders have been associated with limitations in physical function. However, little is known about the relationship between symptoms of urinary incontinence and pelvic organ prolapse, and physical performance. Therefore, the purpose of this study was to examine whether symptoms of urinary incontinence and pelvic organ prolapse are independently associated factors with indicators of lower physical performance in middle-aged women from Northeast Brazil., Methods: This is a cross-sectional study of 381 women between 40 to 65 years old living in Parnamirim, Northeast Brazil. Physical performance was assessed by gait speed, chair stand and standing balance tests. Urinary incontinence and pelvic organ prolapse were self-reported. Multiple linear regression analyses were performed to model the effect of self-reported urinary incontinence and pelvic organ prolapse on each physical performance measure, adjusted for covariates (age, family income, education, body mass index, parity)., Results: In the analysis adjusted for confounders, women reporting urinary incontinence spent, on average, half a second longer to perform the chair stand test (β = 0.505 95% CI: 0.034: 0.976). Those reporting pelvic organ prolapse shortened the balance time with eyes open by 2.5 s on average (β = - 2.556; CI: - 4.769: - 0.343)., Conclusions: Symptoms of pelvic organ prolapse and urinary incontinence are associated to worse physical performance in middle-aged women. These seemingly small changes in physical performance levels are of clinical importance, since these conditions may influence women's physical ability, with implications for other tasks important to daily functioning and should be addressed by health policies targeting women's health and functionality.

In 2014, the Hawai'i State Department of Health (HDOH) received funding from the Centers for Disease Control and Prevention (CDC), via the 1422 Cooperative Agreement, to conduct diabetes prevention and hypertension management. To implement one grant-required strategy-the engagement of community health workers (CHWs) to promote community-clinical linkages-the HDOH partnered with the Hawai'i Primary Care Association and 9 federally qualified health centers (FQHCs). This qualitative evaluation case study sought to understand how 3 of the funded FQHCs engaged CHWs, the types of community-clinical linkages the CHWs promoted, and the facilitators of and barriers to those linkages. Evaluators conducted 2 semi-structured group interviews with 6 administrators/clinicians and 7 CHWs in April 2018. The transcribed interviews were deductively and inductively analyzed to identify major themes. First, CHWs made multiple internal and external linkages using resources provided by the grant as well as other resources. Second, CHWs faced barriers in making community-clinical linkages due to individual patient, geographic, and economic constraints. Third, CHWs have unmet professional needs related to building community-clinical linkages including professional development, networking, and burnout. Reimbursement and payment mechanisms are an all-encompassing challenge to the sustainability of CHW positions, as disease-specific funding and a complete lack of reimbursement structures make CHW positions unstable. Thus, CHWs fulfill a number of grant-specific roles at FQHCs due to this patchwork of funding sources, and this relates to CHWs' experiences of burnout. Policy implications of this study include funding and reimbursement stabilization so FQHCs may consistently engage and support the CHW workforce to meet their patients' complex, diverse needs. More professional development opportunities for CHWs are necessary to build sustainable networks of resources., Competing Interests: The authors report no conflicts to disclose.

Patients with diabetes regularly carry out multiple disease-management behaviors-taking prescribed medications, following diet and exercise regimens, self-monitoring their blood glucose concentrations, and coping emotionally with the condition-that may require ongoing support from community and clinical resources. Diabetes self-management education (DSME) is an ongoing, patient-centered process that helps provide the knowledge, skills, and ability for self-care. Evidence suggests that DSME is most effective when reinforced by community resources, through what are called community-clinical resources. We conducted a series of qualitative key-informant interviews with DSME coordinators/managers from all counties in Hawai'i to document the landscape of DSME services in the state, focusing specifically on challenges and recommendations. We analysed the results using the socioecological model in order to chart these factors by levels of influence on health care providers, in terms of service provision, and on patients, in terms of DSME utilization. Many interviewees highlighted concerns about low utilization of DSME services, as well as practical implementation challenges (eg, group versus 1-on-1 sessions). Nonetheless, DSME coordinators/managers offered numerous recommendations to improve DSME across Hawai'i, highlighting opportunities for improved community-clinical linkages. Finally, emergent from the interviews were anxieties about increasing numbers of youth with diabetes and insufficient resources for them in DSME or other community-clinical resources. This paper offers suggestions to expand community-clinical linkages and to adapt services provided by DSME to meet patient and community needs. It is particularly timely as Hawai'i is rapidly increasing the number and diversity of DSME programs available., Competing Interests: None of the authors identify any conflict of interest.

Women experience worse physical function and greater physical decline than men at similar ages. These sex differences are heterogeneous across settings and plausibly linked to gender inequality, with evidence of increasing disadvantage for women in increasingly iniquitous societies. As described in "Age at natural menopause and physical function in older women from Albania, Brazil, Colombia and Canada: A life-course perspective" [Velez et al., 2019] we assessed the association between age at natural menopause (ANM) and objectives markers of physical function (i.e., gait speed and grip strength) in older women from the International Mobility in Aging Study (IMIAS). For all sites combined, women with ANM ≥55 had higher gait speed than those with ANM 50-54. Women with ANM <40 had significantly lower grip strength compared with all other groups. In this article, we describe the region-specific associations between ANM, gait speed, and grip strength in 775 women aged 65-74, from the Southeastern European site (Tirana, Albania), Latin American sites (Manizales, Colombia and Natal, Brazil), and Canadian sites (Kingston, Ontario and Saint-Hyacinthe, Quebec). In region-specific analyses, ANM was associated with grip strength in Albania and Latin America and with gait speed in Albania only. No associations were observed in Canada.

Objective: This study examines the relationship between economic adversity transitions from childhood to older adulthood and older adulthood physical performance among 1,998 community-dwelling older adults from five demographically diverse sites from middle and high-income countries. Method: The principal exposure variable was economic adversity transition. No adversity encompassed not experiencing poverty in both childhood and older adulthood, improved described having only experienced poverty in childhood, worsened captured having experienced poverty in older adulthood, and severe is having experienced poverty in both childhood and older adulthood. The short physical performance battery (SPPB) was used for outcome measures. Analyses of the continuous SPPB score used linear regression, while analysis of a binary outcome (SPPB < 8 vs. ≥8) used Poisson regression models with robust error variance, both adjusting for sex, education, and site location. Result: In sex-stratified models, the SPPB < 8 prevalence rate ratio (PRR) was higher for the severe (PRR: 2.80, 95% confidence interval [CI] = [1.70, 4.61]), worsened (PRR: 2.40, 95% CI = [1.41, 4.09]), and improved (PRR: 1.82, 95% CI = [1.11, 3.01]) groups, compared with those with no adversity in childhood or as adults, but only for females. Discussion: Findings from this study indicate that persistent economic adversity has a negative effect on older adult physical performance, especially among women.

Hawai'i has comprehensive statewide tobacco control policies and was the first US state to raise the minimum age of sale, purchase, and possession of tobacco products to age 21 ("Tobacco 21") in a policy including not just cigarettes, but also electronic smoking devices and other tobacco products. This insights article provides strategic thinking about tobacco control advocacy planning. Specifically, we identify formative factors critical to building and sustaining our cross-sector, statewide advocacy infrastructure that has been able to address many ongoing challenges of tobacco-use prevention and control over time. This can provide new insights for other large-scale tobacco-control advocacy efforts.

Adolescent health is a major global priority. Yet, as recently described by the World Health Organization (WHO), increased recognition of the importance of adolescent health rarely transforms into action. One challenge is lack of data, particularly on adolescent fertility. Adolescent pregnancy and childbirth are widespread and affect lifetime health and social outcomes of women, men, and families. Other important components of adolescent fertility include abortion, miscarriage, and stillbirth. Access to reliable, consistently-collected data to understand the scope and complexity of adolescent fertility is critical for designing strong research, developing meaningful policies, building effective programs, and evaluating success in these domains. Vital surveillance data can be challenging to obtain in general, and particularly in low- and middle-income countries and other under-resourced settings (including rural and indigenous communities in high-income countries). Definitions also vary, making comparisons over time and across locations challenging. Informed by the Adolescence and Motherhood Research project in Brazil and considering relevance to the Southern Eastern European (SEE) context, this article focuses on challenges in surveillance data for adolescent fertility for middle-income countries. Specifically, we review the literature to: (1) discuss the importance of understanding adolescent fertility generally, and (2) highlight relevant challenges and complexity in collecting adolescent fertility data, then we (3) consider implications of data gaps on this topic for selected middle-income countries in Latin America and SEE, and (4) propose next steps to improve adolescent fertility data for evidence-based health promotion in the middle-income country context., Competing Interests: Conflicts of interest: None.

Background: Frailty, a state of vulnerability to poor resolution of homoeostasis after a health stressor, may be a result of cumulative decline in many physiological systems across the life course and its prevalence and incidence rates vary widely depending on the place and population subgroup., Objective: This study aims to examine social and economic factors as predictors of worse frailty status over 2 years of follow-up in a sample of community-dwelling older adults from the International Mobility in Aging Study., Methods: We analyzed 2012 baseline and 2014 follow-up ( n = 1,724) data on participants from a populational-based, longitudinal study conducted in 4 countries (e.g., Brazil, Colombia, Albania, and Canada). Frailty was defined according to the Fried's phenotype and Poisson regression models with robust standard errors were performed to estimate the relative risks of becoming frail., Results: In our study, 366 (21.2%) participants migrated to a worse stage of frailty. After statistical adjustment (e.g., participant age, sex, and study site), insufficient income (RR = 1.40; 95% CI = 1.00-1.96) and having partner support (RR = 0.80; 95% CI = 0.64-1.01) were predictors of incident frailty status., Conclusion: Notably, transitions in frailty status were observed even in a short range of time, with sociodemographic factors predicting incident frailty.