Feasibility of Healthy Beverages Policies in American Samoa and Federated States of Micronesia: Water and Coconut Water Only Community Interventions.

American Samoa and the Federated States of Micronesia (FSM) are two small Pacific Island nations that have some of the highest noncommunicable disease (NCD) mortality rates in the world. Supported by church leaders to address obesity as an NCD risk factor, American Samoa, and Chuuk and Kosrae States of FSM selected the implementation of healthy beverages as a nutrition intervention through a water- and coconut water-only pledge in church events. The consumption of water and coconut water was tracked. Across 105 church events in the three jurisdictions, the count of water bottles before and after events decreased from 142.8 to 22.3, the number of coconuts before and after events decreased from 19.6 to 1.2, and cups of water before and after events decreased from 52.9 to 7.6. The promotion of healthy beverages in church settings holds promise in the Pacific as a feasible, accessible, and culturally responsive nutrition approach, given limited access to other nutritional alternatives, e.g., fresh fruits and vegetables. Supplemental health promotion messaging to maintain knowledge and attitudes about healthy is recommended for future scaling up.

Lessons from the Field: Going Local-Everybody Wins.

Pacific Islanders suffer from chronic diseases attributed largely to an overconsumption of processed foods. As a response, the CDC-funded Racial and Ethnic Approaches to Community Health (REACH) Go Local Project in Yap, Federated States of Micronesia (population: 12,000) sought to create a food intervention that would not only increase access to fresh, local foods, but benefit food vendors as well for a sustainable effect. For this program, a number of markets were chosen for selling any fresh local produce, meat, and catch. These markets agreed to allow purchasers of healthy local food of a minimum amount to be entered into a monthly raffle. Monthly winners received fresh food gift certificates while participating markets received a gift upon certificate redemption. REACH and partners distributed healthy island recipes and nutrition information at these partner markets. Formative evaluation examined customer and vendor satisfaction through interviews and surveys, and tracking of healthy food purchases and customer demographics were garnered via raffle information. Brief interviews with customers and vendors revealed favorable reactions to the Go Local Project. People enjoyed winning and vendors found satisfaction in promoting health through their businesses.

Randomized controlled trial evaluating the utility of urine HPV DNA for cervical cancer screening in a Pacific Island population.

BACKGROUND: Non-invasive, self-collection sampling methods for human papillomavirus (HPV) DNA detection have the potential to address logistical and cultural barriers to Pap screening, particularly in under resourced settings such as Yap state in the Federated States of Micronesia - a population with low levels of screening and high incidence of cervical cancer. METHODS: A randomized controlled trial was conducted among adult women in Yap to compare cervical HPV DNA in self-collected urine and clinician-collected liquid cytology. Adult women aged 21-65 (n=217) were randomized by the order of sample collection. Concordance of HPV DNA, evaluated by the Roche Linear Array, was compared in paired self-collected urine and clinician-collected liquid cytology samples. The sensitivity and specificity of urine HPV DNA for prediction of cervical HPV and abnormal cytology was also evaluated. p16 in urine cytology samples was additionally assessed. RESULTS: Overall, HPV DNA detection was significantly lower in urine than cervical samples for any HPV (27.8% and 38.3%, respectively) and high-risk HPV (15.1% and 23.8%, respectively). For paired samples, there was moderate agreement for the overall study population (Kappa=0.54, 95% confidence interval CI=0.40-0.68) and substantial agreement for women >40 years (Kappa=0.65, 95% CI=0.46-0.85). The sensitivity and specificity of urine for the detection of cervical high-risk HPV was 51.0% and 96.2%, respectively. The sensitivities of HPV DNA in urine and liquid cytology for prediction of abnormal cytology (ASCUS/LSIL/HSIL) were 47.4% (95% CI=31.0-64.2) and 57.9% (95% CI=40.8-73.7), respectively; specificities were 92.0% (95% CI=86.9%-95.5%) and 83.5% (95% CI=77.2-88.7). Urine p16 was poorly correlated with urine HPV DNA positivity. CONCLUSIONS: Urine is less sensitive but more specific than directed cervical sampling for detection of cytologic abnormalities and may have utility for screening in older populations within low-resource communities when clinically-collected samples cannot be obtained.

Cancer risk reduction in the US Affiliated Pacific Islands: Utilizing a novel policy, systems, and environmental (PSE) approach.

BACKGROUND: The Health Directors of the US Affiliated Pacific Islands (USAPI) declared a State of Emergency due to epidemic proportions of lifestyle diseases: cancer, obesity and other non-communicable diseases (NCDs) in 2010. This paper describes the development, implementation, and evaluation of a USAPI policy, system and environment (PSE) approach to address lifestyle behaviors associated with cancer and other NCDs. METHODS: Each of USAPI jurisdictions applied the PSE approach to tobacco and nutrition interventions in a local institution, faith based, or community setting. A participatory community engagement process was utilized to: identify relevant deleterious health behaviors in the population, develop PSE interventions to modify the context in which the behavior occurs in a particular setting, implement the PSE intervention through five specified activities, and evaluate the activities and behavior change associated with the intervention. RESULTS: PSE interventions have been implemented in all USAPI jurisdictions. Current human and financial resources have been adequate to support the interventions. Process and behavior change evaluations have not been completed and is ongoing. Personnel turnover and maintaining the intervention strategy in response due to shifting community demands has been the biggest challenge in one site. CONCLUSION: From 2014 through 2016 the PSE approach has been used to implement PSE interventions in all USAPI jurisdictions. The intervention evaluations have not been completed. The PSE intervention is novel and has the potential to be a scalable methodology to prevent cancer and modify NCD risk in the USAPI and small states.

Acceptability and feasibility of a community based participatory research project comparing cytology and urine HPV DNA testing for cervical cancer screening in Yap, Federated States of Micronesia.

Non-invasive, self-collected sampling methods for HPV DNA detection in women, which are reliable, efficient, and acceptable have the potential to address barriers to cervical cancer screening in underserved communities, including low-middle income countries (LMIC) such as the island nation of the Federated States of Micronesia (FSM). Urine-based HPV testing has not been rigorously evaluated in clinical trials. A pilot community-based participatory randomized control research project evaluated use of urine HPV testing as a more culturally- and human resource appropriate method of cervical cancer screening in Yap State, FSM. Women participated in a cervical screening intervention using pap vs. urine test (N=217). This manuscript described attitudes about screening feasibility and preferences. Stakeholders and women participants were interviewed (N=23), and a survey also evaluated women's screening preferences (N=217). Qualitative content thematic analysis with multiple coders identified themes from interviews on acceptability and feasibility of screening tests. Women research participants were comfortable with the urine test (95%), despite limitations in some to provide samples. While 82.0% indicated that they felt comfortable with Pap smear, they also preferred a clinician (42%) to do the Pap smear, explaining that they preferred having a trained worker instead of themselves to do tests. Women want to be screened but accessibility remains a challenge. Education and training of professionals and community members alike will improve clinical skills, research capacity, knowledge of screening tests and behaviors including prioritizing HPV screening and testing.

Increasing Awareness of Gynecologic Cancer Risks and Symptoms among Asian, Native Hawaiian and Pacific Islander Women in the US-Associated Pacific Island Jurisdictions

Background: Gynecologic cancers are common among Asian/Native Hawaiian/Pacific Islander (A/NH/PI) women. Prevention is important in United States associated Pacific Island jurisdictions (USAPIJ) because there are limited resources to treat cancer. The objective of this study was to educate A/NH/PI women and providers about evidence-based interventions to prevent and control gynecologic cancers in Yap, one of four major islands comprising the Federated States of Micronesia (FSM). This was done through a partnership between Inside Knowledge: Get The Facts About Gynecologic Cancer national campaign and the Yap comprehensive cancer control program, both funded by the Center for Disease Control and Prevention (CDC). Methods: Inside Knowledge educational materials were obtained from the CDC website and used in facilitated educational sessions. Sessions were planned according to leading health education theories, and were implemented and led by local Yap public health practitioners. Pre- and post-session surveys were used to assess changes in gynecologic cancer awareness, confidence and behavioral intentions related to prevention/early detection for gynecologic cancer. Results: Twenty-nine providers and 326 adult women participated in sessions. All participants demonstrated significant increases in knowledge across all measured domains post-session. Public knowledge that HPV causes cervical, vulvar and vaginal cancer increased from 4.9% pre-session to 51.4% post-session (p<0.0001); provider knowledge increased from 17.2% to 96.6% (p<0.0001). Significantly more women identified smoking as a cervical cancer risk factor post-session (increased from 53.8% to 98.7% [p<0.0001]). An average of 61.4% of providers said they were extremely or somewhat confident in their gynecologic cancer knowledge pre-session compared to 91.7% post-session. Conclusion: Targeted education about gynecologic cancer symptoms and risk factors can be effective at increasing awareness, behavioral intention, confidence and knowledge. These increases can lead to more widespread prevention of these five cancers.

Health Beliefs About Tobacco With Betel Nut Use Among Adults in Yap, Micronesia.

Tobacco use is high among Pacific Islanders in general and little tobacco research has been done in Yap, Micronesia. This study aimed to explore perceptions of tobacco use coupled with chewing of betel (areca) nut among adults in Yap using self-administered questionnaires based on the health belief model. A Likert scale (ranging from strongly disagree to strongly agree or very unlikely to very likely) was used to measure susceptibility, severity, benefits, barriers, cues to action, and self-efficacy among individuals aged 18 and older. Older adults felt quitting tobacco or betel nut use would be significantly more difficult because of social reasons and withdrawal problems. Most participants felt susceptible to tobacco-related diseases. These findings possibly indicate a receptive attitude toward any future tobacco use prevention and intervention program. Older Yapese population would need to be especially targeted. Health promotion programs should target smoking behaviors and risk reduction.