The US-Affiliated Pacific Islands (USAPIs) face chronic public health workforce shortages, impacting sustainable health systems. In response, the Pacific Island Health Officers' Association (PIHOA) health leadership called for the establishment of a regional public health workforce training program. The Pacific Public Health Fellowship Program (PPHFP) was developed through a partnership between PIHOA and the US Centers for Disease Control and Prevention. PPHFP is the first regional cross-cutting public health fellowship model implemented across the USAPIs, aiming to create a sustainable and competent local public health workforce pipeline. PPHFP is a 2-year, mentorship and competency-based model providing full-time experiential training and placement in local health departments, combined with structured mentorship, comprehensive curriculum, and an individualized work plan mapped against 45 public health core competencies. In 2025, an independent mixed-methods impact evaluation was conducted for PPHFP Fellows in the first 5 cohorts. Results indicate strong satisfaction and local workforce retention rates. Overall program satisfaction was 100% among all Fellows (n=43) and host site supervisors (n=35). Among graduates (n=27), 81% secured local USAPI public health positions, and a further 11% enrolled in health-related university-led education in the Pacific region. Fellows addressed health priorities, through the delivery of 27 projects establishing new health registries, dashboards, standard operating procedures, and other interventions influencing data-driven decisions. Evaluation findings demonstrate PPHFP as an effective model for strengthening a local public health workforce pipeline in resource-limited Pacific Islands. Additionally, strengthening transition planning to the workforce, expanding mentorship structures, and introducing a dual-track model may support long-term workforce sustainability.
Sharps injury is an occupational hazard to health care workers with risk of exposure to bloodborne infectious diseases. The Belau (Palau) National Hospital (BNH) Infection Prevention and Control (IPC) Protocol recommends initial blood work on the day of injury, followed by 4 follow-up appointments after 1, 2, 3, and 6 months, and clearance blood work after 12 months. Health care workers with 12-month blood work that indicates no new infection are considered to have completed clearance from exposure to bloodborne diseases. The objective of this research study was to examine factors affecting completion of sharps injury clearance at BNH from 2013 to 2024. Data were collected from the IPC program and the electronic health record sharps injury registry. From 2013 to 2024, 88 health care workers sharp injuries were included in the study and 30 (34%) completed clearance. The proportion of health care workers that completed clearance was similar across demographic characteristics, length of employment, and whether they had previously reported a sharps injury. Among health care workers who attended all 4 follow-up appointments, 100% (n=8) completed clearance. Among health care workers who missed at least 1 of their follow-up visits, 28% (n=22) completed clearance. Health care workers who attended the 6-month appointment had higher odds of completing clearance (OR 5.6, 95% CI [1.9, 16.2]) than those who did not attend the 6-month appointment. These findings indicate the need to strengthen IPC program efforts by providing appointment reminders to all health care workers who sustain sharps injuries, and educating new and existing staff about the IPC sharps injury clearance protocol.
Cesarean section (CS) rates have risen dramatically over the past 2 decades at Ebeye Hospital, located in the Republic of the Marshall Islands. This study aimed to (1) determine the CS rate from 2003-2023 and (2) among 2023 CS cases, determine stated indications for each CS, and evaluate if each CS had appropriate clinical documentation to justify the CS within the medical record in accordance with WHO guidance. The Ebeye Hospital Maternal and Child Health (MCH) clinical registry was used to determine CS rates from 2003-2023 and paper chart reviews were conducted for all 2023 CS cases. The CS rate at Ebeye Hospital has increased from 3% in 2003 to 29% in 2023. Among 217 total deliveries performed at Ebeye Hospital from January to December 2023, 29% (n=62) were CS births. Of these, 63% lacked clinical documentation in the medical record to support the CS. The most common indications lacking clinical documentation within the medical record to support the CS included repeat CS (n=13), fetal distress (n =6), and preeclampsia/eclampsia (n=8). Planned CS cases accounted for 72% of cases lacking clinical documentation to support a CS. Within medical records, key deficiencies in clinical documentation to justify the CS included missing or incomplete documentation of cardiotocograph, partographs, amniotic fluid assessments, and clinical histories such as prior CS delivery details. Strengthening clinical documentation is critical to improving maternal and neonatal outcomes in Ebeye. These findings support the need for targeted clinical training and quality assurance measures in obstetric care at Ebeye Hospital.
Cervical cancer, caused primarily by human papillomavirus (HPV), causes substantial health burden in the Republic of Palau. Despite availability of the HPV vaccine through a school-based vaccination program for girls beginning in 5th grade, HPV vaccination coverage in Palau has declined since 2020. To understand why, this descriptive cross-sectional study analyzed data from the first opportunity for vaccination for all 5th grade girls enrolled at Koror and Babelthaob schools between August 1, 2020 and June 30, 2024. Data were retrieved from the Ministry of Education, School Health Program, and national Immunization Information System (IIS). The proportion of 5th grade girls who returned the consent form, responses to the HPV vaccine consent question, and vaccination coverage with at least 1 dose were analyzed. Among girls enrolled in Palau elementary schools during the period (n=467), although most consent forms were returned (n=434, 93%) and most girls (n=326, 70%) received consent for HPV vaccination, only 42% (n=198) received at least 1 dose of HPV vaccine according to IIS. Responses were missing for the HPV vaccine consent question on 17% of returned forms (n=73). Refusal of the vaccine was uncommon on returned forms (n=35, 8%), but there was an increase in refusals in the latest school year (n=25, 24% of 2023-2024 returned forms). An investigation into the process from the consent form to vaccination outreach in the schools is needed to understand why girls who received consent for vaccination did not receive the vaccine according to IIS. Improving the school-based vaccination program is critical to achieve 90% HPV vaccination coverage and reduce the cervical cancer burden in Palau.
On June 1, 2023, Palau launched the electronic Palau Entry Form for travelers to integrate health surveillance capabilities with standard border control requirements. This study evaluated whether electronic data collection improved data completeness, operational efficiency, and overall system performance and acceptability compared to paper-based data collection. A comparative analysis was used, comparing quantitative data from paper forms from 2018-2019 (n=65 535) and electronic forms from 2024 (n=80 060). Primary data was also collected from a survey administered to Palau entry system management stakeholders (n=23) during July-August 2025. Data completeness improved with electronic forms compared to paper forms: field completion proportions for key tourism-related questions increased, such as purpose of travel (4.4% increase) and accommodation type (10.8% increase), and traveler's health information was newly captured. Most stakeholders agreed that electronic form data was more complete (83%) and data processing times were faster (78%). Most stakeholders also agreed that electronic forms were more cost-effective than paper forms, particularly for printing (78%) and storage (57%) costs. Overall system acceptability was satisfactory, with 83% of stakeholders supportive of continuing with electronic forms and 74% reporting the transition from paper to electronic forms was smooth and that electronic forms made their jobs easier. This study demonstrated that Palau, a small island country, can successfully implement digital transformation in border management and health surveillance systems. Electronic data collection offered clear advantages in data capture capabilities and cross-agency functionality, informing future digital transformation decisions, and contributing to best practices for similar technology transitions in resource-limited settings, such as Palau.
In the Republic of Palau, breast cancer screening rates are low, and many women needing diagnostic follow-up after a mammogram do not receive it. This descriptive retrospective study evaluated the completeness and timeliness of follow-up for screening mammograms requiring follow-up among women aged 40-74 years in Palau's Breast and Cervical Cancer Early Detection Program (BCCEDP) from July 2019 to June 2024. The databases used in this study were the Cancer Screening and Tracking System (CaST) and the Case Manager workbook. Descriptive statistics were used to determine the proportion of mammogram results requiring follow-up by age group and program year, the proportion of those requiring follow-up that received it by age group, program year; and Breast Imaging-Reporting and Data Systems (BI-RADS) categories; and the duration of follow-up among those who received follow-up by BI-RADS categories. Chi-square tests were used to determine statistical significance. Findings show that 17.1% of mammogram results requiring follow-up had no completed follow-up over the 5 years, with the proportion increasing over time, reaching 30.9% in the 2023-2024 program year (P<.001). This was highest among those in BI-RADS 5 (highly suggestive of malignancy) at 38.5% (P<.006). Additionally, only 51.5% of mammogram results requiring follow-up achieved resolution within the program's target of ≤60 days. These delays and incomplete follow-ups reveal major gaps in patient tracking, communication, and care coordination within the screening continuum. Strengthening routine monitoring of follow-up indicators is recommended to support continuous quality improvement.
Tobacco use is a public health concern in the Republic of Palau, where cigarette smoking and betel nut chewing with tobacco are highly prevalent. In 2013, Palau enacted the Fiscal Year 2014 Budget Act with Section 26 that established an excise tax on tobacco products beginning in 2014. This study assessed the impact of the tobacco tax on adult and youth tobacco use prevalence, tobacco importation, and household tobacco expenditure between 2010 and 2024. Data were extracted from 3 adult population-based surveys (2011, 2016, 2023), 3 youth census surveys (2013, 2017, 2022), annual tobacco imports data (2010-2024), and 2 Household Income and Expenditure Surveys (2013, 2024). Among youth, there was a significant decline between 2013 to 2022 in the prevalence of betel nut chewing with tobacco by 69.5% (36.4% to 11.1% [P<.001]), cigarette smoking by 51.6% (35.3% to 16.9% [P<.001]), and any tobacco use by 51.6% (54.8% to 26.5% [P<.001]). Among adults, there was a significant decline between 2011 to 2023 in cigarette smoking by 36.4% (36.0% to 22.9% [P<.001]) and betel nut chewing with tobacco by 11.9% (49.6% to 43.7% [P<.001]), but the overall prevalence of any tobacco use remained stable. Annual tobacco imports decreased significantly by 28.6% from 2010 to 2024, however, average household tobacco expenditure increased from 2.4% to 3.1% of total household spending from 2013 to 2024. Despite the excise tax, tobacco use in Palau remains high, highlighting the necessity for sustained policy interventions, including periodic tax increase with adjustment for inflation and the expansion of evidence-based cessation programs.
The Pacific Island Health Officers Association supports health workforce capacity building in the United States-Affiliated Pacific Islands by implementing a Field Epidemiology Training Program (FETP) called Strengthening Health Interventions in the Pacific (SHIP). This study presents a secondary analysis of survey and interview data from a 2023 mixed-methods external evaluation to identify and examine stakeholder perspectives on the program. Quantitative survey data from 83 respondents were analyzed using descriptive statistics, with Wilcoxon signed-rank tests used to compare retrospective self-assessed proficiency ratings. Qualitative data from 52 key informant interviews and open-ended survey responses were analyzed using thematic coding. Analysis identified 6 themes grouped within 2 domains: the SHIP learning model and participant skills development and application. Stakeholders identified workplace-based learning, academic accreditation, inclusion of non-communicable disease epidemiology, and support from supervisors and instructors as important features of the learning model. Survey respondents reported high satisfaction with the program, frequent application of SHIP-acquired skills in routine public health practice and outbreak response, and significant improvements in retrospective self-assessed proficiency across all competencies (P<.001). Because competency ratings were retrospective self-assessments, the findings reflect perceived rather than objectively measured improvements in proficiency. Nevertheless, the consistency of the quantitative and qualitative findings suggests that FETPs may benefit from aligning training with workplace responsibilities, incorporating local disease priorities into the curriculum, providing recognized academic accreditation, and investing in strong instructional and supervisory support. The model may offer lessons for strengthening epidemiology capacity in small island jurisdictions and other resource-constrained public health settings.
Social Work in Action is a solicited column from the social work community in Hawai'i. It is edited by HJHSW Contributing Editor Sophia Lau PhD, of the Thompson School of Social Work and Public Health at the University of Hawai'i at Mānoa.
The Daniel K. Inouye College of Pharmacy Scripts is a column by the University of Hawai'i at Hilo Daniel K. Inouye College of Pharmacy (DKICP). It is edited by Nicole Young, PharmD, BCCCP, Associate Professor and Chair of the Department of Pharmacy Practice.
Leprosy (Hansen's disease) care in late 19th-century Hawai'i involved complex interactions between Western medicine, traditional practices, and diverse patient experiences. This study re-evaluates the contributions of Dr. Masanao Goto, a Japanese physician whose treatment gained significant patient popularity, by focusing on its health and social welfare implications. Utilizing previously under-examined Japanese sources-including family records and hospital documents-alongside Hawaiian and English archives, this historical research analyzes Goto's work in Hawai'i (1885-1895) and the dynamics of cross-cultural medical encounters. The analysis reveals a three-way dynamic between patients seeking relief, a non-Western practitioner offering a holistic paradigm, and a shifting medical establishment that increasingly prioritized bacteriological cures. Dr. Goto's holistic regimen, centered on chaulmoogra oil integrated with Kampō (a system of traditional Japanese medicine adapted from classical Chinese medicine) principles and medicated baths, provided tangible symptomatic relief and profound hope. While initially supported by the Kalākaua administration, his work later clashed with the "reformist" Board of Health following the political upheaval of 1887. Patient support, however, was a powerful force, culminating in an 1894 petition from 861 Kalaupapa residents to appoint him their permanent physician. Dr. Goto's work, embraced by patients, highlights the critical importance of patient-centered perspectives and the agency of non-Western practitioners. The organized patient movement for his care serves as a historical precedent for medical sovereignty, offering valuable insights into integrating diverse medical traditions pertinent to achieving health equity in contemporary Hawai'i.
The demand for colonoscopies has increased over the last few years due to an aging population combined with a post COVID-19 backlog as well as an ongoing rise in younger patients with colorectal cancer (CRC). Quality indicators ensure that high quality colonoscopies are being performed by endoscopists, thus decreasing the risk of post-colonoscopy CRC arising from lesions missed on the index exam. One common outcome measure is known as the adenoma detection rate (ADR), which is the likelihood that an endoscopist will detect a pre-cancerous polyp during colonoscopy. The Artificial Intelligence (AI) program known as computer-aided detection system (CADe) was designed to improve the ADR of endoscopists by helping them identify colon polyps. Previous studies have evaluated the clinical outcomes of CADe but none were conducted in Hawai'i. This study was designed to determine the impact of GI Genius (Medtronic), the first CADe introduced in Hawai'i. Data was collected on aggregate ADR for both male and female patients before and after implementation of GI Genius in several ambulatory surgery centers in Hawai'i and then a cost-estimate analysis was performed. The GI Genius software program resulted in a statistically significant increase in ADR for both male and female patients. Furthermore, the addition of this program was found to be cost-effective when compared with standard colonoscopy alone due to an anticipated decrease in CRC related health care costs. CADe is a promising new tool for endoscopists, but further studies are needed to determine the long-term benefits on CRC incidence and mortality.
Total hip arthroplasty (THA) is the preferred treatment for femoral neck fracture when functional longevity is expected, but congestive heart failure (CHF) is a risk factor for mortality. The hypothesis of this study is that mortality risk increases with disease severity, influencing the choice between total and hemiarthroplasty. This study queried the National Surgical Quality Improvement database for patients treated for an acute, closed, intracapsular femoral neck fracture, identifying 4486 THA and 34 282 hemiarthroplasty recipients. Subjects were stratified by preoperative risk factors, New York Heart Association categories of mild, moderate, and severe CHF, and odds of death within 30 days. The 30-day postoperative mortality rates for total and hemiarthroplasty were 2.1% (n = 95) and 5.4% (n = 1857), respectively. The 30-day postoperative mortality of patients undergoing THA with mild CHF was 14.3%, and moderate CHF was 21.4%., and for patients undergoing hemiarthroplasty with mild CHF was 11.4%, moderate CHF was 13.9%, and severe CHF was 18.4%. Mild (adjusted odds ratio [AOR] 1.63, 95% Confidence Interval [CI] 1.24-2.14), moderate (AOR 2.21, CI 1.49-3.30), and severe (AOR 2.89, CI 1.41-5.93) CHF was associated with death within 30 days of hemiarthroplasty. Mild (AOR 5.37, 95% CI 2.16-13.38) and moderate (AOR 12.00, CI 3.42-42.17) CHF was associated with death within 30 days of THA. Patients with CHF had increased mortality after THA for acute femoral neck fracture, suggesting it is not a modifiable risk factor. Hemiarthroplasty is a reasonable choice with CHF given evidence of unfavorable survival.
This study examined associations between mental health status, physical activity, and sleep among Hawai'i adolescents using data from the 2017-2021 Hawai'i State High School Youth Risk Behavior Survey (YRBS). Mental health outcomes included feelings of sadness/hopelessness and suicidality. Logistic regression models assessed associations between physical activity, sleep, and mental health outcomes, adjusting for covariates including race, bullying, and the COVID-19 pandemic. Sleep duration, sleep location, and physical activity were significantly associated with mental health outcomes. Adolescents who slept longer were less likely to report sadness/hopelessness (6-7 vs. 0-5 hours: adjusted odds ratio [aOR]=0.59, 95% confidence interval [CI]=0.52-0.67; 8+ vs. 0-5 hours: aOR=0.36, 95% CI=0.32-0.41) and suicidality (6-7 vs. 0-5 hours: aOR=0.64, 95% CI=0.54-0.76; 8+ vs. 0-5 hours: aOR=0.38, 95% CI=0.31-0.46). Adolescents without a stable place to sleep had higher odds of suicidality (aOR=1.69, 95% CI=1.29-2.21). Physical activity was also protective; adolescents active for 6-7 days per week had lower odds of sadness/hopelessness (aOR=0.75, 95% CI=0.65-0.87) and suicidality (aOR=0.71, 95% CI=0.61-0.83) compared with those active 0-2 days. Boys had lower odds of both outcomes than girls. Compared with Whites, Filipinos, other Asians, and Pacific Islanders had lower odds of suicidality. Adolescents surveyed during the COVID-19 pandemic had increased odds of sadness/hopelessness. These findings underscore the importance of adequate sleep and physical activity for adolescent mental health, highlight the unique experiences of Hawai'i adolescents, and underscore the need to identify disparities among major adolescent groups to inform mental health prevention and intervention strategies.
Reliable preoperative imaging of femoroacetabular impingement is important for effective diagnosis and treatment. While numerous imaging techniques exist, their relative accuracy remains unclear. The purpose of this study was to evaluate the accuracy of preoperative standard hip radiographs and magnetic resonance imaging (MRI) axial and radial views compared to the gold standard of intraoperative fluoroscopy for cam-type femoroacetabular impingement. Data were collected from 93 patients who underwent femoroplasty for cam deformity between 2015 and 2020 by a single orthopedic surgeon. One-way analysis of variance with post-hoc pair-wise evaluation, Pearson correlation coefficients, and Bland-Altman plots were used to evaluate differences and agreement between the imaging modalities. The fluoroscopic alpha angle (62.3°±7°) was significantly different than the radiographic (58.5°±7.0°; P=.004) and MRI axial angles (52.0°±8.2°; P<.001) but was similar to the MRI radial angle (60.7°±7.9°; P=.9). MRI radial angles had the highest correlation with fluoroscopy (r=.876, P<.001). The analysis revealed a sensitivity of only 27% for radiographic evaluation and a specificity of 41% with MRI axial evaluation. However, MRI radial evaluation displayed a sensitivity of 87% and specificity of 91% for diagnosis of cam deformity in the study population. These findings suggest the alpha angle derived from radial MRI correlated most strongly with intraoperative fluoroscopy. Radial MRI should continue to be the gold standard for preoperative templating and diagnosis of femoroacetabular impingement in symptomatic patients without obvious deformity on radiographs.
Osteogenesis imperfecta (OI) is a rare heritable disorder of type I collagen that predisposes patients to recurrent fractures and skeletal deformities. Although fracture management in children with OI has been widely described, guidance for adult patients is comparatively limited. This is a report of the case of a 35-year-old man with OI who sustained right-sided sacroiliac diastasis and pubic rami fractures following a high-energy bicycle accident. The injury was treated with percutaneous screw fixation, achieving satisfactory reduction and stable fixation without perioperative complications. The patient advanced to full weight bearing at 12 weeks, and at 2-year follow-up demonstrated near-baseline function with Visual Analog Scale and Majeed Pelvic Scores that closely approximated those reported in non-OI populations. Radiographs showed no evidence of malunion or nonunion, though he continued to experience chronic low back pain. This case suggests that standard fixation strategies may be effective for selected adults with mild OI phenotypes, provided that preoperative planning accounts for the condition's distinctive biomechanical and hemostatic challenges.
Angiosarcoma is a rare, aggressive malignancy that accounts for less than 1% of sarcomas of bone. Epithelioid angiosarcoma, a subtype, is characterized by pleomorphic cells with vascular differentiation and commonly arises in deep soft tissues of the extremities. Angiosarcoma associated with orthopedic implants or retained foreign bodies, such as ballistic debris, is exceedingly rare. Here, the authors present the case of epithelioid angiosarcoma in a 54-year-old male with a history of a prior proximal femur ballistic injury and intramedullary nail fixation who was initially misdiagnosed with chronic osteomyelitis.
To investigate the effects of circumferential and near-circumferential closed incisional negative pressure wound therapy (ciNPWT) dressings on compartment pressures within varying tissue levels using an ex vivo porcine model. A deceased swine model was utilized, with bilateral hind legs disarticulated and prepared for experimentation. ciNPWT dressings were applied at 100%, 75%, 50%, and 25% circumferential coverage, with negative pressures set at -200 mmHg, -125 mmHg, and -25 mmHg. A STIC pressure monitor device measured pressures at tissue depths of 10 mm, 20 mm, and 40 mm. Measurements were repeated 3 times for each configuration, and the averages were calculated. Compartment pressures increased with greater magnitudes of negative pressure and were highest at superficial tissue layers. The pressure differences between superficial and deeper layers were most pronounced in 25%-75% circumferential configurations, suggesting that non-circumferential dressings create a pressure gradient. These findings align with a compressive rather than a "lift-off" force mechanism. This study highlights ciNPWT's compressive effects, particularly on superficial tissues, and suggests that pressure gradients in non-circumferential configurations may enhance fluid dynamics and wound healing. The findings also support the potential role of ciNPWT in inducing mechanotransduction and angiogenesis. Limitations include the use of an ex vivo model and variability in measurement accuracy. Especially in superficial layers, ciNPWT exerts a compressive force with non-circumferential dressings allowing greater pressure gradients. Future in vivo studies are needed to confirm these findings and further explore the therapeutic mechanisms and potential applications of ciNPWT.
Grappling disciplines have immensely grown in popularity. These martial arts and sports, such as Judo, Brazilian Jiu Jitsu, Sambo, and Mixed Martial Arts, utilize techniques and movements to maintain control, subdue, or submit an opponent. Grappling submissions introduce risk of injury through a variety of specific moves, positions, and mechanisms. Yet grappling disciplines remain relatively niche, shrouded with confusing, non-descriptive terminology and jargon. This often results in a poor understanding of injury mechanisms, anatomic regions injured, and pathophysiologic cause of injury. The lack of basic anatomic and physiologic understanding is a potential barrier to optimal care and future research endeavors by clinicians in a burgeoning patient population. As such, this study aims to provide a concise guide to common grappling submissions, with illustrative examples and pathophysiologic mechanisms, description of anatomic structures at risk, and a literature review of injuries, with intention of improving care, and facilitating future investigative efforts by clinicians.
