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Welina aloha,

Welcome to the first issue of the Hawai‘i Journal of Public Health.  Why a new public health journal for Hawai‘i?  First, this Journal offers public health professionals, academics, students, and even members of the public from Hawai‘i and the Pacific a venue for publishing their Hawai‘i and Pacific-based research in a publication which is targeted at Hawai‘i and the Pacific.  This aim is particularly true for the three thousand staff members of the Hawai‘i  State Department of Health, where Director Chiyome Leina‘ala Fukino sees the Journal as an essential tool for workforce improvement.

 What is the Journal?  As the name states, we are a Journal of public health.  Our focus is on all disciplines of public health, from chronic disease to environmental, maternal and child health to infection control.  We aim to improve the quality of public health practiced everywhere in Hawai‘i and the Pacific by providing a forum for students, practitioners and the public to share their research and learn about the research and best practices of others.  We are not a journal of clinical medicine.

 While we welcome submissions from any location, our focus is on Hawai‘i and the Pacific.  Specifically, we hope that the research, policies and commentary published in the Journal will be a resource for public health practitioners, students and the public in Hawai‘i and the Pacific.  At the same time, public health is global, and we recognize the substantial links of Hawai‘i and the Pacific to locations such as the continental United States.  Thus, we particularly encourage submissions from authors concerning populations from Hawai‘i and the Pacific who have settled in other areas.

 Although our Journal will remain a high-quality, peer-reviewed publication, we also recognize the need to encourage first-time authors to publish.  Thus, we will work with authors to make their work publishable, if at all possible.  While maintaining high standards, we believe that we should facilitate, rather than be a barrier to, publication.  To this aim, we offer a wide variety of formats, from the traditional original research articles to brief reports, student submissions, and a discussion section where issues of public health can be debated.

 We are particularly grateful to all the section editors and peer reviewers, without whose help this Journal is not possible.

 Mahalo for your interest in the first issue of the Hawai‘i Journal of Public Health, and we look forward to your participation in this new endeavor.

 Me ka ha‘aha‘a,

 Kawika Liu and Andrew Grandinetti

Co-editors, Hawai‘i Journal of Public Health.

 A Few Thoughts on Public Health and Our Healthcare Crisis
Chiyome Leinaala Fukino, MD

¹Hawaii State Department of Health

 Public Health is something of a mystery to most people.  In the minds of many, the services and purposes of public health and clinical medicine are essentially the same.  The confusion is understandable because in many states, public health departments have become the “provider of last resort”, assuring access to direct healthcare services for vulnerable populations such as the mentally ill, homeless and uninsured. 

 By definition, Public Health protects and improves the health of communities through education, promotion of healthy lifestyles, and research to prevent disease and injury.  By contrast, Clinical Medicine maintains or restores the health of individuals through study, diagnosis and treatment of individual patients. 

 Regulatory functions of Public Health in Hawaii assure that our communities have clean air, clean water, safe food, safe drinking water, proper sewage treatment and appropriate solid and hazardous waste disposal.  We license many types of healthcare facilities and certify practioners in various public health related professions.  We work with many community partners to solve current health and safety problems and practice with them in preparation for future natural or man made disasters and disease outbreaks.  These are just a few of the activities of the Hawaii State Department of Health.

 It is no secret that healthcare in the United States is in crisis, providing some of the best and some of the worst healthcare the world has to offer!  Many are not happy with the ways things are right now, but clearly, this is the healthcare industry that we built.  Rushing to enact healthcare reforms based on perceived benefits of nationalized health care systems in other countries without unbiased evaluations of their advantages and disadvantages, as well as appropriate consideration of our own unique cultural, legal and political differences will only serve to aggravate an already bad situation.

 An effective partnership of the two great health houses—Public Health and Clinical Medicine, must be forged if we are to solve our nation’s “healthcare crisis”.   

One of the most significant things that Public Health does is to focus on prevention efforts now in order to reduce the need for expensive tertiary healthcare services later.  Good nutrition, regular physical activity and abstinence from tobacco and other illicit drugs are health habits that greatly improve the quality and duration of our lives, no matter what our gene pool may be.  These good health habits are well understood by the health savvy, but for many adults, consistent educational outreach is needed to improve health knowledge and counteract decades of physical neglect.  Early education of our children in environments supportive of these good health habits is essential! 

 Public Health in Hawaii must take an active role in shaping our natural environment and helping individuals to shape their personal environments to enable consistent application of good health habits which decreases future demand for Clinical Medicine services. 

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Health Disparities in Hawai‘i:  Part 1
David MKI Liu¹, R Kekuni Blaisdell[1], Nia Aitaoto^{2 ,1}Office of Health Equity, Hawai‘i State Department of Health, Office of Public Health Studies, John A Burns School of Medicine, University of Hawai‘i  at Mānoa
²Department of Native Hawaiian Health, John A Burns School of Medicine, University of Hawai‘i  at Mānoa
³Papa Ola Lōkahi

Abstract

Objective:  Although the United Health Foundation ranked Hawai‘i as the third healthiest state in the United States in 2007, this status is not shared equally among the peoples of Hawai‘i.  Studies have identified disparities in breast cancer screening, body mass index (BMI), the use of mental health services by women with depressive symptoms, adherence to antihypertensive medications, breast cancer management and breast cancer survival, in addition to many other health areas.  Lacking, however, is a comprehensive examination of health disparities across the most populous ethnic groups in Hawai‘i – Native Hawaiians, Caucasians, Japanese, Chinese, and other Pacific Islanders.  This series presents these data, beginning with an introduction and continuing to present data on disparities on obesity, diabetes, cardiovascular disease, and other chronic illnesses.More

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Academic Public Health at the University of Hawaii at Manoa
Jay Maddock

Department of Public Health Studies, John A Burns School of Medicine, University of Hawai‘i at Mānoa.

It gives me great pleasure to see this inaugural issue of the Hawaii Journal of Public Health.  The journal provides another strong link between the public health academic and practice communities in Hawaii.  Over the past few years, several linkages have been made between the Office of Public Health Studies and the Hawaii Department of Health to better address public health issues.  This includes the Science Officer’s Program, Hawaii Health Data Warehouse, the Healthy Hawaii Initiative and several student practical experiences.  We look forward to additional academic-practice linkages in the future. More

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Modelling accessibility to primary health care using a spatial accessibility index and a need index

 Nasser Bagheri¹, George L. Benwell¹, Alec Holt¹

 ¹Department of Information Science, University of Otago, New Zealand

 Abstract

Objectives:  This research developed an integrated approach for modelling accessibility to primary health care (PHC) services using a spatial accessibility index and a need index.

Methods:   New Zealand and World Health Organisation (WHO) rules were used to determine optimum levels of minimum travel time and modelling high need groups.  A two-step Floating Catchment Area (FCA) method was used to calculate spatial accessibility index based on travel time.  NZDep2001 score was also used to model high health need people and generating the need index.  Then, spatial and need indices combined into one framework by using math tool in ArcInfo version 9.2.

Results:  The results of this study have shown that some parts of north and central Otago (with a population of 4048 that comprises about 5.4 percent of the total rural Otago population) do not meet the WHO rules and New Zealand guidelines for access to primary health care (during business hours).  The paper showed that people living in some areas of central rural Otago suffers from long travel time and high need to PHC facilities.

Conclusion:  The paper illustrated the “accessibility index” as a tool to model the level of spatial accessibility of people to primary health care.  A “need index”, as a surrogate tool for illustrating accessibility to primary health is also modelled.  Then it is indicated that a better approach is to combine the spatial accessibility and need indices together.  More

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Promoting Science-Based Approaches to Teen Pregnancy Prevention
Judith F. Clark¹

¹Hawai`i Youth Services Network

Abstract

Background. Hawai`i ranks 12<sup>th</sup>  in the nation for teen pregnancy prevalence.  Native Hawaiian and Pacific Islanders demonstrate a disproportionate share of teen pregnancies, accounting for more than 60% of the total teen births. Local organizations lacked the organizational capacity and funding to conduct needs assessments, select appropriate interventions, or evaluate results of teen pregnancy prevention programs.  Youth workers had little knowledge of science-based programs and often believe that programs developed elsewhere will not work in Hawai`i.

Purpose.  To address these issues, the Hawai`i Youth Services Network (HYSN) has worked with Hawai`i-based organizations since 2005 to build organizational capacity to select, implement and evaluate science-based approaches to teen pregnancy prevention.

Approaches.  HYSN helps organizations assess community needs, develop goals and objectives, assess programs for community fit, make culturally appropriate adaptations to curricula, and implement, evaluate, and sustain their efforts.  HYSN also provides intensive training and customized technical assistance, develops peer support, and identifies and removes barriers for organizations that want to offer more effective programs. 

Findings. At the beginning of the project, few, if any, Hawai`i organizations were using science-based programs, and none were conducting evaluation.  After two years, at least eight organizations have selected and implemented science-based curricula aimed at preventing teen pregnancy, and we are evaluating the effectiveness with Hawaiian, Pacific Islands, and Asian youth. 

Discussion. This project demonstrates the critical importance of building peer support and offering ongoing training and technical assistance to build capacity to implement effective programs for the prevention of teen pregnancy. More

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Examination of bed bug (Cimex lectularius Linnaeus) infestations on the island of Oahu, Hawaii
Victoria J. Fickle¹, Pingjun Yang¹, Gregory K. Olmsted¹

¹Hawaii State Department of Health, Vector Control Branch

 Abstract: Bed bug (Cimex lectularius Linnaeus) infestations have been increasing over the past several years in the continental United States.  This study identified a similar rise in bed bug infestations on the island of Oahu, Hawai’i and followed up to characterize the local situation.  The amount of calls and complaints regarding bed bugs to the Hawai’i State Department of Health, Oahu Vector Control Branch (DOHVCB) and Pest Control Companies (PCCs) increased in 2007 as compared to 2006.  Eighteen pest management professionals (PMPs) were interviewed by phone in follow up.  The number of sites treated for a company ranged from 2 to 650 in 2007, with a mean of 95.31 sites treated. Residential facilities were most commonly serviced by PMPs, shelters much less often.  Eighteen employees from 16 shelters were then also interviewed using a different, in-person survey form.  Eleven of these shelters had experienced a bed bug infestation, two of which were still affected at the time of the interview.  Sixty-four percent of shelters’ infestations were limited to one incident, 87.50% of these were able to quickly eliminate infestations.  To be able to contain an infestation in shelters such as these, training staff on prevention measures is critical.  With the overall rise in infestations, updated public information is essential. More

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Examining the predictive value of the theory of planned behavior and stages of change on fruit and vegetable intake

Daniela S Kittinger¹, Sarabibi T Mayet¹, Sonya Niess¹, Jamie Kopera¹, Stefan Keller¹, Jay Maddock¹.

 (1) Department of Public Health Studies, John A Burns School of Medicine, University of Hawai‘i at Mānoa.

Abstract

Objective: Most research examining the Theory of Planned Behavior(TPB) and the Transtheoretical model’s stages of change(SOC) in predicting fruit and vegetable(FV) intake has been cross-sectional in nature. The aim of this study was to investigate the strength of these variables in predicting FV consumption and SOC after one year.

Methods: A random-digit dial phone panel survey was administered in spring of 2006(T1) and followed up in fall of 2007(T2). Participants were English-speaking adults residing in the state of Hawaiʻi. Data included the 722 participants who were not meeting the 5-a-day recommendation at baseline. TPB variables(attitudes, perceived behavioral control(PBC), and social norms) were assessed, with stage of change(SOC), substituted for intention. Self efficacy, barriers, and dietary behavior were also measured. Various analyses were run investigating the predictive value of these variables on future FV intake.

Results: Without accounting for baseline FV intake, self efficacy and PBC significantly predicted whether or not the 5-a-day recommendation was reached, and self efficacy and barriers significantly predicted the number of servings consumed at follow up. However, when previous FV intake was accounted for, this variable explained most of the variance in behavior, rendering all other variables non-significant predictors. Some evidence was found supporting the temporal notion inherent in the SOC construct, namely that more people progressed forward through the stages than regressed backward. However, the majority of people in both the pre-contemplation and preparation stages tended to remain in that stage at T2.

Conclusion: After controlling for potential confounding variables, the TPB constructs and stages of change were not significant predictors of future FV intake. Some support was seen for SOC progression. More

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Objective:

Publicly funded health and human services increasingly require the use of nationally-endorsed programs, therefore we review these youth drug prevention programs through the lens of Hawaii based practitioners. This review indicated a chasm in contextually relevant programs and practices created for or by Native Hawaiian, Asian-American, and other Pacific Peoples. This problem is outlined and then we describe a rationale for using participatory research to develop practice-based evidence in drug prevention that is contextually relevant to youth, their families and communities, and youth-serving organizations in Hawai‘i. Practice-based evidence refers to locally designed, implemented, and evaluated practice; thus providing evidence about what is working (and how) for a specific context. Contextual relevance refers both to ethnocultural significance, and place based neighborhood and community dynamics.  More

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Joseph A Sliman¹, Bardwell J Eberly³, Dana Ann Tamashiro², , Precilia S Calimlim²,

^{A. Christian Whelen 2,3}

 ¹Navy Environmental and Preventive Medicine Unit Six, Pearl Harbor, Hawai‘i.

²State Laboratories Division, Hawaii State Department of Health, Pearl City, Hawai‘i.

³Microbiology Services, Department of Pathology, Tripler Army Medical Center, Honolulu, Hawai‘i.

 Abstract

Objective:  Investigate colonization and risk factors associated with an outbreak of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue infections (SSTI) on a United States Navy surface ship.

Methods:  Descriptive survey of outbreak population characteristics and culture–based surveillance of the ship population for colonization with Staphylococcus aureus.

Results:  Eighty-five percent (266/313; 85%) of the crew were included in the study, although all 296 available members consented to surveillance questionnaire and cultures (296/313; 94.6%).  Seventy-three (73/266; 27.4%) were colonized with S. aureus, 18 of which were MRSA (18/73; 24% and 18/266; 6.8%).  Pulsed-field gel electrophoresis (PFGE) revealed all strains were pulsed-field type (PFT) USA 300.  Key factors within the past 12 months included antibiotic use (OR=2.88, p=0.036), medical care (OR=3.32, p=0.011), or history of skin problems (OR=2.73, p=0.032). 

Conclusions:  Surveillance indicated a surprising rate of CA-MRSA carriage among sailors assigned to this ship, which was likely associated with the SSTI infections among crew members while previously at sea. Important risk factors in this confined population included recent access to outpatient healthcare services. The PFGE types were USA 300, which is commonly community-associated, and not a healthcare-associated strain by definition. 

Implications:  In addition to its established public health importance in SSTI within civilian communities, this report demonstrates the increasing role of CA-MRSA as an emerging pathogen among military populations.  Hawaii’s large military population and strategic location underscores the potential impact of drug-resistant staphylococcus infections on military readiness in the Pacific. More

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Kathleen Kromer Baker¹, Alvin T. Onaka¹, Brian Horiuchi¹, James Dannemiller².

¹Office of Health Status Monitoring, Hawai‘i State Department. of Health.

²SMS Research, Honolulu, Hawai‘i.

The Hawai‘i Health Survey (HHS) provides useful information to document health disparities.  Prior published information from the HHS indicated health disparities by ethnicity, income, geographic area, and insurance.  However, gender and marital status are less well documented.  Introductory information provided below illustrates that gender and marital status can also be important factors in the health of adults of Hawaii. More

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Improving Cultural Compentency: Smart Strategies for Working with Filipinos
Jeny Bissell¹

 ¹Maui District Health Office, Hawai‘i State Department of Health.

Issue: 

The issues and concerns in the Filipino community are best illustrated in the following “WE BELIEVE STATEMENTS” by the Maui Filipino Working who is Jeny Bissell, Virginia Cantorna, Kim Compoc and Cornelia Soberano. 

One of the primary concerns is that Filipinos are not accessing services and that there is a provisional need for culturally appropriate services in the Filipino community.  More

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Mutual Aid Agreements Between Public and Private- Sector Laboratories
Christopher Lum Lee¹

¹Hawaii State Judiciary

Objective

          The purpose of this discussion is to explain the importance of mutual aid agreements between public and private-sector laboratories in public health incident preparedness and response. This discussion also incorporates the elements of an effective mutual aid agreement, how a mutual aid agreement is to become implemented, and at which point it can be concluded that mutual aid agreements are a best practice today.  more

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Malama I Na Keiki, Ending Non-therapeutic Infant Circumcision Through Education

 Joseph Kassel, N.D., L.Ac¹., Misha Kassel, MD², Clare Loprinzi, Traditional Midwife, CPM^{3  1} Private practice, Holualoa, Hawai‘i, ² Stanford University School of Medicine^{, 3}Mālama I Nā Keiki, Captain Cook, Hawai‘i

The object of our discussion is not that your words will gain victory over mine, or that mine will triumph over yours, but that together, we may discover the perfect truth.” (Socrates)

 Abstract

Medical non-therapeutic infant circumcision began in the nineteen century to prevent masturbation, which was believed to cause disease, by excising the most sensitive part of the genitals, as well as inflicting psychological and physical pain to discourage the practice. Subsequently there have been a number of rationales provided for this procedure, including prevention of sexually transmitted infections, urinary tract infections and, most recently, HIV transmission. These rationales for the procedure have either limited support from flawed research or often contradictory evidence. The surgical removal of healthy tissue from a nonconsenting infant raises ethical and human rights concerns. The foreskin is of importance to male genital health and function throughout the lifespan. The loss of these functions, the pain and potential complications of the procedure, in addition to the above concerns, make it necessary for us to revaluate and discontinue this procedure. More

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The Protective Effect of Circumcision in the Transmission of HIV: A New Perspective on an Old Procedure

Nicole Valcour, Dominic Chow, The Clint Spencer Clinic, John A Burns School of Medicine, University of Hawai‘i at Manoa

In this paper, we set out to address the topic e of adult male circumcision as it is used in the prevention of HIV transmission. As with most issues related to circumcision, arguments on both sides of the debate can be quite compelling. We hope to infuse the discussion with some of the relevant published data on circumcision in southern Africa. In this way, we hope to  raise the level of understanding of the subject generally, and in the process new ideas and concerns might be brought to light on this new application of an historically dynamic and controversial procedure. . Since early in the epidemic of HIV/AIDS, large discrepancies in HIV prevalence within and between countries on the continent of Africa have been noted, and these disparities cannot be readily explained by differences in sexual behavior patterns or the differential presence of STI’s. Neither can the age of the epidemic in the country, nor differences in circulating strains of the virus explain this variation.¹  There is an area of the African continent that has been widely described as the “AIDS Belt”, meaning that the highest prevalence of HIV infection can be found in this area. What has been demonstrated in many cases is that this area of the continent is comprised of societies that do not practice male circumcision. More

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