"There are still broken or fragmented systems": Qualitative assessment of needs to strengthen adolescent mental health services in American Samoa

Mental health challenges appear common among adolescents in American Samoa. There is a community-identified need to better understand the health burden and identify opportunities to strengthen the mental health system to better meet adolescent mental health needs. The goal of this qualitative study was to gather community stakeholders' perceptions of common mental health problems among adolescents in American Samoa, identify existing services for adolescent mental health, and highlight strength-based opportunities to enhance care. Using the Fa'afaletui research framework, semi-structured in-depth interviews (n = 28) were conducted between October 2020 and February 2021 using Zoom. Key informants were adults living in American Samoa, sampled for diversity in profession, age, gender, education, and region of residence. Transcripts were coded in duplicate and analysed using deductive thematic analysis. Participants reported that suicide, depression, anxiety, and post-traumatic stress disorder are the conditions of highest burden. Participants identified an impressive amount of infrastructure and community mobilization, but also limitations in these services in addressing adolescents' health needs. Four themes arose related to the need to: (1) strengthen existing infrastructure; (2) reduce barriers to treatment access; (3) improve sustainability; and (4) encourage collaboration among leaders. Policymakers should prioritize the allocation of resources to strengthen infrastructure, public education, and stakeholder collaboration to improve adolescent mental health in American Samoa.

Culturally Competent Interventions for Child Sexual Abuse: A Scoping Review of the Literature and the Implications for American Samoa

Significant stigma regarding child sexual abuse exists in American Samoa. Although cultural interventions may help prevent child sexual abuse, very little is known about such interventions. Therefore, through a scoping review process, this study aimed to gain a broad understanding of past and current culturally tailored interventions to prevent child sexual abuse. Because no studies examine interventions to prevent child sexual abuse in American Samoa specifically, the reviewed literature investigates interventions in different cultures. The literature search initially identified 180 relevant articles. After applying inclusion and exclusion criteria, nine studies met the eligibility criteria for review. Extracted data from these articles included the country or population, sample, study methods, children's age, intervention type, and details about the intervention. Results suggest that culturally tailored interventions for preventing child sexual abuse exist in various countries and cultural contexts. Results highlight that child sexual abuse prevention interventions are effective if translated into the native language. Findings from this study highlight the importance of using a culturally tailored approach to addressing child sexual abuse and can help guide the development of new interventions. Although more research on the prevention of child sexual abuse in American Samoa is needed, the results of this study might inform the development of culturally tailored interventions for the region.

Community Perspectives on Contraception in the Context of Zika Virus in American Samoa and the Commonwealth of the Northern Mariana Islands

The prevention of unintended pregnancy was identified as a primary prevention strategy to reduce Zika-related adverse birth outcomes during the 2016-2017 Zika virus outbreak. The Centers for Disease Control and Prevention in partnership with local health agencies conducted formative research to guide the development of culturally appropriate messages and materials to increase awareness of the prevention of unintended pregnancy as a strategy to decrease Zika-related adverse outcomes in American Samoa and the Commonwealth of the Northern Mariana Islands (CNMI). Nine focus groups (N=71) were conducted with women and men aged 18-44 years living in American Samoa and CNMI. Semi-structured interview guides were used to explore participants' knowledge and perceptions of Zika, family planning, and contraception; barriers and facilitators to access contraception and use; and information sources and contraception decision-making. Trained staff from local organizations co-moderated each focus group. Thematic analysis was conducted with NVivo 10. Participants had mixed knowledge about Zika virus and its relation to pregnancy and birth defects. Women and men had varied knowledge of the full range of contraceptive methods available in their jurisdiction and identified barriers to contraceptive access. Social factors including stigma, gender roles, and religion often deterred participants from accessing contraceptive services. Participants highlighted the need for culturally appropriate and clear messaging about contraceptive methods. Results demonstrate the feasibility of conducting formative research as an effective strategy for understanding community perspectives on unintended pregnancy prevention in the context of the Zika virus outbreak to develop health communication materials.

Gestational Diabetes Mellitus Prevalence, Screening, and Treatment Practices in American Samoa, 2016

Gestational diabetes mellitus (GDM) is a serious pregnancy complication and understudied public health issue in American Samoa. The goals of this study were to (1) estimate the prevalence of GDM in American Samoa, (2) evaluate current screening practices for GDM, and (3) evaluate obtainment of GDM treatments in 2016. This cross-sectional study used 3 data sources: electronic health records, a labor and delivery logbook, and the American Samoa Department of Health (ASDOH) Maternal and Children's Health (MCH) Postpartum database. Out of 995 women with a singleton birth in American Samoa during the study period, 60.1% (n=598) completed a glucose tolerance test for GDM. Of these women, 41.8% (n=250) completed the testing within the recommended 24-28 weeks gestation timeframe. The estimated prevalence of GDM was 14.0% (95% confidence interval: 11.2-16.8) but has many limitations due to missing data. There were 4 treatments analyzed: nutrition counseling, insulin, metformin, and diabetes counseling. Of all women diagnosed with GDM (n=84), 76% were prescribed any of the 4 treatments. However, only 52% of those women obtained the treatment prescribed. Access to testing and treatment needs to be expanded to provide adequate prenatal care to women in American Samoa.

Potential use of antibodies to provide an earlier indication of lymphatic filariasis resurgence in post-mass drug administration surveillance, American Samoa

OBJECTIVES

Under the Global Programme to Eliminate Lymphatic Filariasis (LF), American Samoa conducted seven rounds of mass drug administration between 2000 and 2006. The territory passed transmission assessment surveys (TAS) in 2011 (TAS-1) and 2015 (TAS-2). In 2016, the territory failed TAS-3, indicating resurgence. This study aims to determine if antibodies (Ab) may have provided a timelier indication of LF resurgence in American Samoa.

METHODS

We examined school-level antigen (Ag) and Ab status (presence/absence of Ag- and Ab-positive children) and prevalence of single and combined Ab responses to Wb123, Bm14, Bm33 Ags at each TAS. Pearson's chi-squared tests and logistic regression were used to examine associations between school-level Ab prevalence in TAS-1 and TAS-2 and school-level Ag status in TAS-3.

RESULTS

Schools with higher prevalence of Wb123 Ab in TAS-2 had higher odds of being Ag-positive in TAS-3 (odds ratio [OR] 24.5, 95% CI:1.2-512.7). Schools that were Ab-positive for WB123 plus Bm14, Bm33 or both Bm14 and Bm33 in TAS-2 had higher odds of being Ag-positive in TAS-3 (OR 16.0-24.5).

CONCLUSION

Abs could provide earlier signals of resurgence and enable a timelier response. The promising role of Abs in post-mass drug administration (MDA) surveillance and decision making should be further investigated in other settings.

Period Prevalence of Rheumatic Heart Disease and the Need for a Centralized Patient Registry in American Samoa, 2016 to 2018

Background

Rheumatic heart disease (RHD) is a severe, chronic complication of acute rheumatic fever, triggered by group A streptococcal pharyngitis. Centralized patient registries are recommended for RHD prevention and control, but none exists in American Samoa. Using existing RHD tracking systems, we estimated RHD period prevalence and the proportion of people with RHD documented in the electronic health record.

Methods and Results

RHD cases were identified from a centralized electronic health record system, which retrieved clinical encounters with RHD International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) codes, clinical problem lists referencing RHD, and antibiotic prophylaxis administration records; 3 RHD patient tracking spreadsheets; and an all‐cause mortality database. RHD cases had ≥1 clinical encounter with RHD ICD‐10‐CM codes, a diagnostic echocardiogram, or RHD as a cause of death, or were included in RHD patient tracking spreadsheets. Period prevalence per 1000 population among children aged <18 years and adults aged ≥18 years from 2016 to 2018 and the proportion of people with RHD with ≥1 clinical encounter with an RHD ICD‐10‐CM code were estimated. From 2016 to 2018, RHD was documented in 327 people (57.2%: children aged <18 years). Overall RHD period prevalence was 6.3 cases per 1000 and varied by age (10.0 pediatric cases and 4.3 adult cases per 1000). Only 67% of people with RHD had ≥1 clinical encounter with an RHD ICD‐10‐CM code.

Conclusions

RHD remains a serious public health problem in American Samoa, and the existing electronic health record does not include all cases. A centralized patient registry could improve tracking people with RHD to ensure they receive necessary care.

Comparison of Immunochromatographic Test (ICT) and Filariasis Test Strip (FTS) for Detecting Lymphatic Filariasis Antigen in American Samoa, 2016

Circulating filarial antigen (Ag) prevalence, measured using rapid point-of-care tests, is the standard indicator used for monitoring and surveillance in the Global Program to Eliminate Lymphatic Filariasis. In 2015, the immunochromatographic test (ICT) was replaced with the filariasis test strip (FTS), which has higher reported sensitivity. Despite differences in sensitivity, no changes in recommended surveillance targets were made when the FTS was introduced. In 2016, we conducted lymphatic filariasis surveys in American Samoa using FTS, which found higher Ag prevalence than previous surveys that used ICT. To determine whether the increase was real, we assessed the concordance between FTS and ICT results by paired testing of heparinised blood from 179 individuals (63% FTS-positive). ICT had 93.8% sensitivity and 100% specificity for identifying FTS-positive persons, and sensitivity was not associated with age, gender, or presence of microfilariae. Based on these findings, if ICT had been used in the 2016 surveys, the results and interpretation would have been similar to those reported using FTS. American Samoa would have failed Transmission Assessment Survey (TAS) of Grade 1 and 2 children with either test, and community prevalence would not have been significantly different (4.1%, 95% CI, 3.3-4.9% with FTS vs. predicted 3.8%, 95%, CI: 3.1-4.6% with ICT).

'Tausi Feagaiga: Impacting Health Care in an Island Nation

The 'Tausi Feagaiga (Covenant Keeper) project was a partnership between community organization Pacific Youth and Community Development, faith-based organization Roman Catholic Diocese of Samoa-Pago Pago, and higher learning institute University of Hawaii John A. Burns School of Medicine. Over the course of 5 years from 2016 - 2020, 125 caregivers were trained in family caregiving. Fa'a Samoa, or the Samoan way supports traditional values of tausi matua encouraging caring for your elders. Training was conducted through an intensive workshop followed by practicum at Hope House, Catholic Diocese home for the aged. Confidence in caregiving increased following the training and feedback was extremely positive. Competence in geriatric syndromes was improved after attending the workshop (p<0.0001). Technical assistance was provided to create jobs for newly trained caregivers and sustainability through reimbursement from government health insurance Medicaid. Hope House received the designation of Medicaid Assisted Living Facility provider. 'Tausi Feagaiga transformed the lives of the residents of Hope House and elders in the community.

Genetic epidemiology of lymphatic filariasis in American Samoa after mass drug administration

Over 892 million people in 48 countries are at risk of infection by nematodes that cause lymphatic filariasis. As part of the Global Programme to Eliminate Lymphatic Filariasis, mass drug administration is distributed to communities until surveillance indicates infection rates are below target prevalence thresholds. In some countries, including American Samoa, lymphatic filariasis transmission persists despite years of mass drug administration and/or has resurged after cessation. Nothing is known about the population genetics of Wuchereria bancrofti worms in Polynesia, or whether local transmission is persisting and/or increasing due to inadequate mass drug administration coverage, expansion from residual hotspots, reintroduction from elsewhere, or a combination. We extracted DNA from microfilariae on blood slides collected during prevalence surveys in 2014 and 2016, comprising 31 pools of five microfilariae from 22 persons living in eight villages. We sequenced 1104 bp across three mitochondrial markers (ND4, COI, CYTB). We quantified parasite genetic differentiation using variant calls and estimated haplotypes using principal components analysis, F-statistics, and haplotype networks. Of the variants called, all but eight were shared across the main island of Tutuila, and three of those were from a previously described hotspot village, Fagali'i. Genotypic data did not support population genetic structure among regions or villages in 2016, although differences were observed between worms collected in Fagali'i in 2014 and those from 2016. Because estimated haplotype frequency varied between villages, these statistics suggested genetic differentiation, but were not consistent among villages. Finally, haplotype networks demonstrated American Samoan sequence clusters were related to previously published sequences from Papua New Guinea. These are, to our knowledge, the first reports of W. bancrofti genetic variation in Polynesia. The resurgent parasites circulating on the main island of American Samoa represent a single population. This study is the first step towards investigating how parasite population structure might inform strategies to manage resurgence and elimination of lymphatic filariasis.

Demographic, socioeconomic and disease knowledge factors, but not population mobility, associated with lymphatic filariasis infection in adult workers in American Samoa in 2014

Background

Prevalence of lymphatic filariasis (LF) antigen in American Samoa was 16.5% in 1999. Seven rounds of mass drug administration (MDA) programmes between 2000 and 2006 reduced antigen prevalence to 2.3%. The most efficient methods of surveillance after MDA are not clear, but testing specific at-risk groups such as adults may provide earlier warning of resurgence. The role of migration from LF endemic countries in maintaining transmission also needs investigation. Few studies have investigated knowledge about LF and how that relates to infection risk. This study aims to investigate associations between socio-demographics, population mobility, disease knowledge and LF infection risk.

Methods

In 2014, we surveyed 670 adults aged 16–68 years (62% female) at two worksites in American Samoa. Sera were tested for LF antigen and antibodies (Bm14 and Wb123) by rapid test and/or ELISA. Multivariate logistic regression was used to assess association between seromarkers and demographic factors, household socioeconomic status (SES), residence, travel history, and knowledge of LF.

Results

Overall, 1.8% of participants were positive for antigen, 11.8% for Bm14, 11.3% for Wb123 and 17.3% for at least one antibody. Recent travel outside American Samoa was not associated with positivity for any seromarker. Men had higher seroprevalence than women for all outcomes (any antibody: adjusted odds ratio (aOR) = 3.49 (95% CI: 2.21–5.49). Those aged over 35 years (compared to 15–24 years) had higher prevalence of Bm14 antibody (aOR = 3.75, 3.76 and 4.17 for ages 35–44, 45–54 and ≥ 55 years, respectively, P < 0.05). Lower SES was associated with seropositivity (antigen: aOR = 2.89, 95% CI: 1.09–7.69; either antibody: aOR = 1.51, 95% CI: 1.12–2.05). Those who knew that mosquitoes transmitted LF had lower Wb123 antibody prevalence (aOR = 0.55, 95% CI: 0.32–0.95).

Conclusions

Opportunistic sampling of adults at worksites provided an efficient and representative way to assess prevalence and risk factors for LF in American Samoa and in hindsight, foreshadowed the resurgence of transmission. Risk of LF infection, detected by one or more serological markers, was not related to recent travel history, but was strongly associated with male gender, older age, lower SES, and lack of knowledge about mosquito transmission. These results could guide future efforts to increase MDA participation.

Research Capacity Strengthening in American Samoa: Fa'avaeina le Fa'atelega o le Tomai Sa'ili'ili i Amerika Samoa

Capacity-building partnerships are central to the sustainable development goals (SDGs), the UN's blueprint for achieving global health equity. The UN Permanent Forum on Indigenous Issues endorses the SDG and underscores the need for global partnerships that respect local leadership and culture. Innovations that weave or integrate Indigenous and Western knowledges are emphasised. These recommendations guided the INdigenous Samoan Partnership to Initiate Research Excellence (INSPIRE). INSPIRE is led by investigators from American Samoa and supported by US co-investigators. In project year one, INSPIRE queried: What weaving approaches are feasible for promoting community access to INSPIRE's research hub and for training Indigenous researchers? Weaving procedures involved interlacing Samoan and Western knowledges. Cultural tailoring strategies were used to customise communications. Formative evaluation suggests the feasibility of INSPIRE's efforts. Evidential tailoring provided information on American Samoa (A.S.) social determinants of health; trainees indicated increased research commitment. Linguistic and sociocultural relevance tailoring were positively received; trainees reported increased interest in research praxis and initiated an A.S. research capacity-strengthening model. Social work assured knowledge parity in development/delivery of the training curriculum and culturally safe discussions on social determinants of health, territorial status and Samoan survivance. Findings are context-specific yet offer considerations for capacity-strengthening partnerships seeking to advance health equity.

Racial and Ethnic Variations in Mortality Rates for Patients Undergoing Maintenance Dialysis Treated in US Territories Compared with the US 50 States

BACKGROUND AND OBJECTIVES

In the United States mortality rates for patients treated with dialysis differ by racial and/or ethnic (racial/ethnic) group. Mortality outcomes for patients undergoing maintenance dialysis in the United States territories may differ from patients in the United States 50 states.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective cohort study of using US Renal Data System data included 1,547,438 adults with no prior transplantation and first dialysis treatment between April 1, 1995 and September 28, 2012. Cox proportional hazards regression was used to calculate hazard ratios (HRs) of death for the territories versus 50 states for each racial/ethnic group using the whole cohort and covariate-matched samples. Covariates included demographics, year of dialysis initiation, cause of kidney failure, comorbid conditions, dialysis modality, and many others.

RESULTS

Of 22,828 patients treated in the territories (American Samoa, Guam, Puerto Rico, Virgin Islands), 321 were white, 666 were black, 20,299 were Hispanic, and 1542 were Asian. Of 1,524,610 patients in the 50 states, 838,736 were white, 444,066 were black, 182,994 were Hispanic, and 58,814 were Asian. The crude mortality rate (deaths per 100 patient-years) was lower for whites in the territories than the 50 states (14 and 29, respectively), similar for blacks (18 and 17, respectively), higher for Hispanics (27 and 16, respectively), and higher for Asians (22 and 15). In matched analyses, greater risks of death remained for Hispanics (HR, 1.65; 95% confidence interval, 1.60 to 1.70; P<0.001) and Asians (HR, 2.01; 95% confidence interval, 1.78 to 2.27; P<0.001) living in the territories versus their matched 50 states counterparts. There were no significant differences in mortality among white or black patients in the territories versus the 50 states.

CONCLUSIONS

Mortality rates for patients undergoing dialysis in the United States territories differ substantially by race/ethnicity compared with the 50 states. After matched analyses for comparable age and risk factors, mortality risk no longer differed for whites or blacks, but remained much greater for territory-dwelling Hispanics and Asians.

Using naturally occurring climate resilient corals to construct bleaching-resistant nurseries

Coral reefs are threatened by global bleaching, spurring a need to improve upon reef restoration practices. Yet the strong capacity for corals and their symbionts to acclimatize to their local environment has brought into question whether or not corals that are temperature tolerant in one setting will lose that tolerance elsewhere. We show that variation in bleaching resilience among intraspecific colonies is maintained in novel environments for four species, and can be used to construct bleaching-resistant coral nurseries for restoration. By focusing on the host genotype and symbiont genus and its importance in stock selection, we demonstrate a path forward for reef restoration in the face of climate change.

Ecological restoration of forests, meadows, reefs, or other foundational ecosystems during climate change depends on the discovery and use of individuals able to withstand future conditions. For coral reefs, climate-tolerant corals might not remain tolerant in different environments because of widespread environmental adjustment of coral physiology and symbionts. Here, we test if parent corals retain their heat tolerance in nursery settings, if simple proxies predict successful colonies, and if heat-tolerant corals suffer lower growth or survival in normal settings. Before the 2015 natural bleaching event in American Samoa, we set out 800 coral fragments from 80 colonies of four species selected by prior tests to have a range of intraspecific natural heat tolerance. After the event, nursery stock from heat-tolerant parents showed two to three times less bleaching across species than nursery stock from less tolerant parents. They also retained higher individual genetic diversity through the bleaching event than did less heat-tolerant corals. The three best proxies for thermal tolerance were response to experimental heat stress, location on the reef, and thermal microclimate. Molecular biomarkers were also predictive but were highly species specific. Colony genotype and symbiont genus played a similarly strong role in predicting bleaching. Combined, our results show that selecting for host and symbiont resilience produced a multispecies coral nursery that withstood multiple bleaching events, that proxies for thermal tolerance in restoration can work across species and be inexpensive, and that different coral clones within species reacted very differently to bleaching.

Dapsone Resistance in Leprosy Patients Originally from American Samoa, United States, 2010-2012

Skin biopsies from US leprosy patients were tested for mutations associated with drug resistance. Dapsone resistance was found in 4 of 6 biopsies from American Samoa patients. No resistance was observed in patients from other origins. The high rate of dapsone resistance in patients from American Samoa warrants further investigation.

Zika virus in American Samoa: challenges to prevention in the context of health disparities and non-communicable disease

BACKGROUND

Zika virus (ZIKV) is linked to deleterious foetal and neonate outcomes. Maternal exposure to ZIKV through mosquitoes and sexual fluids creates a public health challenge for communities and policymakers, which is exacerbated by high levels of chronic non-communicable diseases in American Samoa.

AIM

This study aimed to identify structural barriers to ZIKV prevention in American Samoa and situate them within locally relevant cultural and epidemiological contexts.

SUBJECTS AND METHODS

This study assessed knowledge, attitudes and access to ZIKV prevention among 180 adults in American Samoan public health clinics. It queried knowledge about pre-natal care, protection against mosquitoes and condom use.

RESULTS

Women were most likely to identify pre-natal care as important. The majority of participants were able to identify how to prevent mosquito bites, but may have been unable to follow through due to socioeconomic and infrastructure limitations. Few participants identified condom use as a preventative measure against ZIKV. Prevention misconceptions were most pronounced in women of low socioeconomic status.

CONCLUSIONS

These findings reinforce the need for a multi-pronged approach to ZIKV. This study highlights the need for information on culturally specific barriers and recognition of additional challenges associated with dual burden in marginal populations where social inequalities exacerbate health issues.

Predictors of prenatal care satisfaction among pregnant women in American Samoa

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.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1563-6) contains supplementary material, which is available to authorized users.

Prevalence and risk factors associated with lymphatic filariasis in American Samoa after mass drug administration

BACKGROUND

In 2000, American Samoa had 16.5% prevalence of lymphatic filariasis (LF) antigenemia. Annual mass drug administration (MDA) was conducted using single-dose albendazole plus diethylcarbamazine from 2000 to 2006. This study presents the results of a 2007 population-based PacELF C-survey in all ages and compares the adult filarial antigenemia results of this survey to those of a subsequent 2010 survey in adults with the aim of improving understanding of LF transmission after MDA.

RESULTS

The 2007 C-survey used simple random sampling of households from a geolocated list. In 2007, the overall LF antigen prevalence by immunochromatographic card test (ICT) for all ages was 2.29% (95% CI 1.66-3.07). Microfilaremia prevalence was 0.27% (95% CI 0.09-0.62). Increasing age (OR 1.04 per year, 95% CI 1.02-1.05) was significantly associated with ICT positivity on multivariate analysis, while having ever taking MDA was protective (OR 0.39, 95% CI 0.16-0.96). The 2010 survey used a similar spatial sampling design. The overall adult filarial antigenemia prevalence remained relatively stable between the surveys at 3.32% (95% CI 2.44-4.51) by ICT in 2007 and 3.23 (95% CI 2.21-4.69) by Og4C3 antigen in 2010. However, there were changes in village-level prevalence. Eight village/village groupings had antigen-positive individuals identified in 2007 but not in 2010, while three villages/village groupings that had no antigen-positive individuals identified in 2007 had positive individuals identified in 2010.

CONCLUSIONS

After 7 years of MDA, with four rounds achieving effective coverage, a representative household survey in 2007 showed a decline in prevalence from 16.5 to 2.3% in all ages. However, lack of further decline in adult prevalence by 2010 and fluctuation at the village level showed that overall antigenemia prevalence at a broader scale may not provide an accurate reflection of ongoing transmission at the village level.

Growth and maturation of the redlip parrotfish Scarus rubroviolaceus

This study presents age-based life-history information for the red lip parrotfish Scarus rubroviolaceus based on a 5 year sampling programme from the commercial fishery of American Samoa. Females reached sexual maturity at 31·9 cm fork length (L_F ) and 2·6 years and sex change occurred at 42·3 cm L_F , although not all females change sex through their ontogeny. The maximum observed age was 14 years and c. 65% of the fishery harvest was above the median L_F at sex change.

Household evacuation characteristics in American Samoa during the 2009 Samoa Islands tsunami

Tsunamis represent significant threats to human life and development in coastal communities. This quantitative study examines the influence of household characteristics on evacuation actions taken by 211 respondents in American Samoa who were at their homes during the 29 September 2009 Mw 8.1 Samoa Islands earthquake and tsunami disaster. Multiple logistic regression analysis of survey data was used to examine the association between evacuation and various household factors. Findings show that increases in distance to shoreline were associated with a slightly decreased likelihood of evacuation, whereas households reporting higher income had an increased probability of evacuation. The response in American Samoa was an effective one, with only 34 fatalities in a tsunami that reached shore in as little as 15 minutes. Consequently, future research should implement more qualitative study designs to identify event and cultural specific determinants of household evacuation behaviour to local tsunamis.

Absence of serological evidence of Rickettsia spp., Bartonella spp., Ehrlichia spp. and Coxiella burnetii infections in American Samoa

Little is known about the epidemiology of zoonotic diseases in American Samoa (Pacific). A review of literature did not identify any published information on human Rickettsia spp., Bartonella spp., Ehrlichia spp. or Coxiella burnetii infections in this country. To determine the presence of these diseases, we conducted a serosurvey of American Samoans. The presence of immunoglobulin G antibodies against Rickettsia felis, Rickettsia typhi, Rickettsia conorii, C. burnetii, Bartonella henselae, Bartonella quintana, and Ehrlichia chaffeensis was evaluated by indirect immunofluorescence assay in sera from 197 American Samoan adults. None of the samples had antibodies at a significant level against Rickettsia spp., Bartonella spp., Ehrlichia spp. or C. burnetii (seroprevalence 0%; one-tailed 95% CI 0-1.86%). We cannot conclude that these pathogens are absent in American Samoa but, if present, their prevalence is probably very low. Q fever has been reported worldwide except in New Zealand and French Polynesia; these new data suggest that the prevalence of Q fever is likely to be very low in the Pacific Islands.

Insights in public health: a tale of two polities: health in Independent and American Samoa

Independent and American Samoa have a shared cultural, genetic, ethnolinguistic, and historical background but have been politically separated since 1899. In this essay, we examine the health of these two polities and identify two key health patterns that have emerged even as American Samoa has achieved a higher per capita income than Independent Samoa. Whereas the gender gap in life expectancy at birth has narrowed in Independent Samoa, this gap has not narrowed in American Samoa and its male life expectancy now lags behind that of Independent Samoa. Neonatal mortality rates in American Samoa are slightly higher than in Independent Samoa. These patterns may be linked to the higher rates of obesity and urbanization observed in American Samoa compared to Independent Samoa, as well as the differing political and institutional arrangements of the two polities. Limited data remains a persistent challenge to conducting analysis of public health in the Pacific islands, particularly in American Samoa.

Mothers' attitudes and beliefs about infant feeding highlight barriers to exclusive breastfeeding in American Samoa

BACKGROUND

In American Samoa, initiation of breastfeeding is almost universal but exclusive breastfeeding, a promising target for obesity prevention, is short in duration.

AIMS

(1) To examine American Samoan mothers' feeding experiences and attitudes and beliefs about infant feeding and (2) to identify potential barriers to exclusive breastfeeding.

METHODS

Eighteen semi-structured interviews were conducted with American Samoan mothers at 16-32 days postpartum. Interviews focused on mother's knowledge and beliefs about infant feeding, how their infants were fed, why the mother had chosen this mode of infant feeding, and how decisions about feeding were made within her social surroundings. A thematic qualitative analysis was conducted to identify salient themes in the data.

FINDINGS

Intention to exclusively breastfeed did not predict practice; most women supplemented with formula despite intending to exclusively breastfeed. The benefits of breastfeeding were well-recognized, but the importance of exclusivity was missed. Formula-use was not preferred but considered an innocuous "back-up option" where breastfeeding was not possible or not sufficient for infant satiety. Identified barriers to exclusive breastfeeding included: the convenience of formula; perceptions among mothers that they were not producing enough breast milk; and pain while breastfeeding. The important support role of family for infant feeding could be utilized in intervention design.

CONCLUSION

This study identified barriers to exclusive breastfeeding that can be immediately addressed by providers of breastfeeding support services. Further research is needed to address the common perception of insufficient milk in this setting.

The contribution of feeding mode to obesogenic growth trajectories in American Samoan infants

What is already known about this subject Samoan adults are recognized for their particularly high body mass index and prevalent obesity. While Polynesians are understudied, in other populations infancy is a critical period in the development of obesity. Breastfeeding has been shown to attenuate obesity risk. What this study adds Samoan infants show remarkably rapid gain in weight but not length in early infancy resulting in a prevalence of overweight and obesity far higher than has been previously reported elsewhere. Breastfeeding is associated with slower weight gain in infancy suggesting that its protective benefits for obesity risk are generalizable outside of European-derived populations.

BACKGROUND

Samoans are recognized for their particularly high body mass index and prevalent adult obesity but infants are understudied.

OBJECTIVE

To examine the prevalence of overweight and obesity and determine the contribution of feeding mode to obesogenic growth trajectories in American Samoan infants.

METHODS

Data were extracted from the well baby records of 795 (n = 417 male) Samoan infants aged 0-15 months. Mixed-effects growth models were used to produce individual weight and length curves. Further mixed-effects models were fitted with feeding mode (breastfed, formula- or mixed-fed) as a single observation at age 4 (±2) months. Weight and length values were converted to z-scores according to the Centers for Disease Control 2000 reference.

RESULTS

At 15 months, 23.3% of boys and 16.7% of girls were obese (weight-for-length > 95th percentile). Feeding mode had a significant effect on weight and length trajectories. Formula-fed infants gained weight and length faster than breastfed infants. Formula-fed boys were significantly more likely to be obese at 15 months (38.6%) than breastfed boys (23.4%), χ(2)  = 8.4, P < 0.01, odds ratio = 2.05, 95% confidence interval (1.04, 4.05).

CONCLUSION

Obesity in American Samoans is not confined to adults. Obesity prevention efforts should be targeted at early life and promotion of breastfeeding may be a suitable intervention target.

Factors affecting household adoption of an evacuation plan in American Samoa after the 2009 earthquake and tsunami

American Samoa is still recovering from the debilitating consequences of the September 29, 2009 tsunami. Little is known about current household preparedness in American Samoa for future earthquakes and tsunamis. Thus, this study sought to enumerate the number of households with an earthquake and tsunami evacuation plan and to identify predictors of having a household evacuation plan through a post-tsunami survey conducted in July 2011. Members of 300 households were interviewed in twelve villages spread across regions of the principle island of Tutuila. Multiple logistic regression showed that being male, having lived in one's home for < 30 years, and having a friend who suffered damage to his or her home during the 2009 tsunami event increased the likelihood of having a household evacuation plan. The prevalence of tsunami evacuation planning was 35% indicating that survivors might feel that preparation is not necessary given effective adaptive responses during the 2009 event. Results suggest that emergency planners and public health officials should continue with educational outreach to families to spread awareness around the importance of developing plans for future earthquakes and tsunamis to help mitigate human and structural loss from such natural disasters. Additional research is needed to better understand the linkages between pre-event planning and effective evacuation responses as were observed in the 2009 events.

Medication-taking beliefs and diabetes in American Samoa: a qualitative inquiry

In American Samoa (AS), nearly 22% of adults have type 2 diabetes. Diabetes is best managed by diet and lifestyle modifications and strict medication adherence. Cultural aspects might affect medication-taking beliefs, and thereby influence medication adherence. This study aims to explore diabetes medication-taking experiences and knowledge and related cultural beliefs in AS adults with diabetes and healthcare providers. Six focus groups were conducted with 39 AS adults with diabetes and individual interviews were performed with 13 diabetes healthcare providers. Data were transcribed and analyzed using NVivo 8 software. Themes pertaining to medication taking and adherence were identified. Patients and providers reported that barriers such as confusion about medications and concern about medication costs negatively influence medication taking, while cultural values and obligations both positively and negatively impact medication adherence. These findings help elucidate the relationship between medication-taking beliefs and culture in AS adults with diabetes and highlight the importance of continued research within this population.

Incidence of dog bite injuries in American Samoa and their impact on society

INTRODUCTION

In American Samoa, a US Territory in the South Pacific, over half of reported injuries are attributed to dog bites. Despite years of public outcry, little has been done to adequately address these preventable injuries that affect all age groups of both sexes.

OBJECTIVE

To describe a serious public health hazard in American Samoa that may plague other jurisdictions that tolerate a significant free-roaming dog population.

METHODS

A limited data set of outpatient records from 2004 through 2010 from the Territory's only emergency department listing an ICD-9-CM E-code of E906.0 ("dog bite") in the primary E-code field provided a record of dog bite injuries. A survey of 437 adolescents documented their experiences regarding unprovoked dog attacks during the 2010/2011 school year.

RESULTS

The sex/age group with the highest incidence for dog bite treatment was males 55 to 59 years of age (73.1 per 10,000 population per year) followed closely by males 10 to 14 years of age (71.8 per 10,000 population per year). Males aged 5 to 14 years accounted for 23% of all emergency department visits for dog bites. About one-third of adolescents reported having been bitten by a dog between September 2010 and May 2011. About 10% of males and 16% of females attributed the fear of being bitten as a factor preventing them from getting more physical activity.

CONCLUSIONS

Children, adolescents, and the elderly are the most vulnerable to dog bite injuries. Emergency room records may reflect only about a quarter of all such injuries.

IMPLICATIONS

Unprovoked attacks by aggressive, free-roaming dogs degrade quality of life by placing an untenable burden on the health care system and imposing physical and psychological barriers toward a more healthful lifestyle that includes walking, jogging, and bicycling.

Survey on Visual Impairment and Refractive Errors on Ta'u Island, American Samoa

PURPOSE

To assess the prevalence of presenting visual impairment and refractive errors on the isolated island of Ta'u, American Samoa.

METHODS

Presenting visual acuity and refractive errors of 124 adults over 40 years of age (55 male and 69 female) were measured using the Snellen chart and an autorefractometer. This sample represented over 50% of the island's eligible population.

RESULTS

In this survey, all presenting visual acuity (VA) was uncorrected. Of the included sample, 10.5% presented with visual impairment (visual acuity lower than 6/18, but equal to or better than 3/60 in the better eye) and 4.8% presented with VA worse than 6/60 in the better eye. Overall, 4.0% of subjects presented with hyperopia (+3 D or more), 3.2% were myopic (-1 D or less), and 0.8% presented with high myopia (-5 D or less). There was no significant difference between genders in terms of visual impairment or refractive errors.

CONCLUSION

This study represents the first population-based survey on presenting visual acuity and refractive errors in American Samoa. In addition to providing baseline data on vision and refractive errors, we found that the prevalence of myopia and hyperopia was much lower than expected.

How many Samoans? An evaluation of the 1980 census count of Samoans in the United States

"This paper reports the results of applying demographic methods, in combination with assumptions about vital rates and migration, to estimate the total Samoan population of the United States in 1980." The authors conclude that the most plausible estimate of the Samoan population in the United States in 1980 is between 46,600 and 50,800. These estimates are 10 to 17.5 percent higher than the census count.