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Introduction: A strong public health workforce is necessary to maintain the health and well-being of any community. Currently, the ability of the public health workforce to meet demand is being challenged in Hawai'i and the Pacific. This is due, in part, to the downsizing of the public health program at the University of Hawai'i (UH) in the year 2000. Knowing the current perceptions of the community in regards to public health and identifying ways to attract more students to public health are essential in reversing this trend., Materials and Methods: Students from a class on needs assessment and program planning at the UH Department of Public Health Sciences assessed public health education needs. The class first conducted a literature review, focus groups, and interviews to inform the development of an on-line survey. The survey was sent to 200 individuals, including current public health students, faculty, workers, employers, and alumni., Results: Of the 200 individuals invited to participate in the on-line survey, 128 (64%) responded. Almost half of the respondents were >50 years of age, and another 19% were between ages 41 and 50. Of the 118 who responded to this question, 85 had degrees in public health (80%from UH), and 62% had worked in public health for at least 10 years. However, only 50% of the total respondents knew that UH Masters of Public Health (MPH) and the Masters of Science (MS) programs were accredited. Forty percent or more of public health workers noted continuing education needs in 1) policy development and program planning skills, 2) analytical skills, 3) leadership and systems thinking skills, and 4) financial planning and management skills. Fully 43 of the respondents would consider applying to a DrPH program at UH, and 27 public health workers without an MPH would consider pursuing one. However potential students noted lack of time and timing of classes as barriers to attending school. Specific ideas for attracting students to public health were provided. Respondents also called for a greater commitment to public health from top leadership at UH and in Hawai'i., Discussion: Findings confirm a need for a strong public health education program in Hawai'i and a lack of awareness about the MPH and MS programs at UH. Expanding options and opportunities for public health education will require better marketing and a cohesive commitment to public health education at UH.

Background: Healthcare workers in many parts of the U.S.-Affiliated Pacific Islands (USAPI) have limited access to continuing education. Barriers to traditional on-site continuing education programs include the diversity of educational needs, limited health staffing, the distances between islands and associated high travel costs. A pilot evaluation of distance education modalities was conducted among USAPI healthcare workers., Methods: Three distance education modalities (live videoconference, live audioconference and a recorded computer-based format) were evaluated in comparison to live lecture during two separate half-day educational programs in Pohnpei, Federated States of Micronesia, in June 2004. Participants from the USAPI included 59 nurses, doctors, dentists and other healthcare workers who were assigned to different educational modalities for two training modules (diabetes/oral health and metabolic syndrome). We conducted pre-and post-tests and obtained participant feedback., Results: Comparison of pre-test and post-test scores showed statistically significant score increases among the live lecture and videoconference group for the diabetes/oral health module and among all three distance education modalities for the metabolic syndrome module. Participants expressed a high degree of interest in each of the distance education modalities. Computer-based training was well-accepted even by health workers with little prior computer experience., Conclusions: This pilot study validates the ongoing development and evaluation of distance education resources as part of a comprehensive approach to improving continuing education in the USAPI. The results have been used to guide continuing education efforts in the region.

The Pacific Diabetes Today Resource Center (PDTRC) was established in 1998 to assist communities in Hawai'i, American Samoa, Guam, Commonwealth of the Northern Mariana Islands, Republic of Palau, Federated States of Micronesia, and the Republic of the Marshall Islands to develop, implement, and evaluate community diabetes prevention and control activities. Between 2000 and 2002, PDTRC provided training and on-going support in 11 communities. This article includes case-study descriptions from each site, suggesting that in the first four years of this five-year project, PDTRC helped Pacific communities increase public awareness about diabetes, expand collaboration and partnership, develop the training capacities of local health leaders, sponsor new activities related to diabetes prevention and control, and secure new resources for their communities.

Previous examinations of breast cancer and survival in Hawai'i's 5 major ethnic groups have found that Native Hawaiian women have the highest breast cancer mortality rates. Although ethnic disparities in survival are reduced when age and stage at diagnosis are controlled for statistically, prior studies could not explain ethnic variation in survival among women who were diagnosed at the same stage. We examined variations in breast tumor characteristics for a multiethnic sample of 4,583 women diagnosed in 1990-1997 by stage and age group and extended previous multivariate analyses by adding a new prognostic variable: estrogen receptor (ER) and progesterone receptor (PR) status. Logistic regression was used to examine the influence of age, stage, and hormone status on 5-year survival. With a few exceptions, greater proportions of Native Hawaiian women were diagnosed both in later stages of disease and at earlier ages compared to women of other ethnicities, and smaller proportions of Native Hawaiians survived 5 years post diagnosis in each stage and age group. Surprisingly, greater proportions of Native Hawaiian women in all age groups had ER/PR positive tumors, which is a prognostic indicator for better, not worse, survival. Native Hawaiian women had an increased risk of death and Japanese women had an increased chance of survival after controlling for age, stage, and ER/PR status. Future studies should examine other reasons for better survival of Japanese women and worse survival of Native Hawaiian women, including socioeconomic status, access to health insurance, adequacy of recommended screening frequency, co-morbid conditions, treatment appropriateness and compliance, and genetic markers of tumor aggressiveness.

Native Hawaiians are underrepresented in health research. They also have expressed dissatisfaction with the way in which many non-native researchers have formulated research questions, conducted research, and disseminated findings about Native Hawaiians. 'Imi Hale - Native Hawaiian Cancer Network was funded by the National Cancer Institute to increase research training and mentorship opportunities for Native Hawaiians. To this end, 'Imi Hale has followed principles of community-based participatory research to engage community members in identifying research priorities and assuring that research is beneficial, and not harmful, to Native Hawaiians. Developing indigenous researchers is a cornerstone of the program and, in its first 4 years 'Imi Hale enrolled 78 Native Hawaiian "budding researchers (called Na Liko Noelo in Hawaiian), of which 40 (68%) have participated in at least one training and 28 (36%) have served as investigators, 40 (51%) as research assistants, and 10 (13%) as mentors on cancer prevention and control studies. The major challenge for Nă Liko Noelo is finding the time needed to devote to research and writing scientific papers, as most have competing professional and personal obligations. Program evaluation efforts suggest, however, that 'Imi Hale and its Na Liko Noelo program are well accepted and are helping develop a cadre of community-sensitive indigenous Hawaiian researchers.

Increasingly, genetic and biomedical researchers are developing protocols to reexamine human tissue specimens that were obtained and stored during clinical care or previous research studies. Although some communities and associations are developing guidelines for human-tissue research, guideline development rarely considers consumer preferences for informed consent and disclosure of results. This study, examining Native Hawaiian preferences for informed consent and disclosure of results (n = 429, 83.2% Native Hawaiian), was modeled after a national study of consumer preferences, allowing comparison between the national sample and the Hawai'i-based sample. The interview schedule included two scenarios on research requiring the re-use of clinically derived and research-derived biological specimens. For each, participants were asked if informed consent should be required: a) in general; b) if the specimen was personally identified; and c) if the specimen was de-identified, or anonymized. Participants were also asked if they would want to know the results of the research and if they would want their doctor to be told. Regardless of how specimens were obtained, 78% of Native Hawaiians would want to be asked for their consent for the re-use of identified specimens and about 35% would want to be consented for the re-use of anonymized specimens. In both cases, Native Hawaiians in the Hawai'i sample were more likely than Whites in the national sample to want an informed consent process. Similar proportions in both samples would want findings from research on stored specimens reported to them (about 90%) and to their physicians (about 80%). These findings call into question the "Common Rule" and the guidelines of the American Society of Human Genetics, which do not require researchers to obtain informed consent for research use of anonymized specimens.

The prevalence of obesity is increasing among all Americans, including Native Hawaiians. Because obesity is a risk factor for major chronic diseases and shortens lifespan, it is important to develop and test interventions to prevent and reduce it. Traditional Hawaiian Diet (THD) programs, conducted over the last two decades, were examined in the context of national information on weight loss and obesity prevention programs. This review reveals that THD programs appeal to Native Hawaiians, especially the education about the health and cultural values of native foods and the support of peers. The majority of participants realize short-term weight loss and improvements in health, but few individuals sustain a significant weight loss. Most participants have difficulty adhering to the THD, citing barriers to accessing fresh, affordable produce and the lack of support systems and environments that embrace healthy eating. Any THD program offered in the future should address these barriers and engage participants for at least a year. This review includes a logic model that can be used to help program providers improve THD programs and increase the rigor of evaluation efforts. Additionally, public health professionals and Native Hawaiians should advocate for environmental changes that will support healthy lifestyles, for example: increase access by Native Hawaiians to the land and ocean; provide land for home, neighborhood and community gardening; support local farmers; remove junk-food vending machines from public buildings (including schools); improve school lunches; and mandate daily, enjoyable physical education classes in schools and after-school programs.

Native Hawaiians have high cancer incidence and mortality rates, thus would benefit from timely cancer screening and opportunities to participate in cancer prevention clinical trials. Two-hundred-fifty-four (254) primary care physicians (PCPs) were surveyed for their knowledge, attitudes, and practices related to cancer screening and prevention, clinical trials and participation of Native Hawaiians in them. More than 90% of responding PCPs follow guidelines for breast and cervical cancer screening and counsel patients on smoking cessation, and 75% or greater follow guidelines for colonoscopy/sigmoidoscopy testing and counsel patients on exercise, diet, and weight management. About 60% reported familiarity with at least one of three prevention trials offered at the time of the survey, and 28% reported having referred or recommended patients to cancer prevention trials in the past. Major barriers to discussing trials with patients included lack of awareness on the part of physicians and patients, limited support staff, and time constraints. Less than 30% of respondents were aware of community resources supporting cancer research. This study indicated that Hawai'i PCPs follow national guidelines for cancer screening, and many are aware of ongoing prevention trials. However, additional participation in cancer screening and prevention activities will require attention to reducing logistical barriers and increasing awareness of cancer information and research services.

Diabetes is a growing problem among Pacific Islanders, but few community-based groups in the Pacific are actively working on diabetes prevention and control. The Pacific Diabetes Today Resource Center (PDTRC) was established in 1998 to adapt the Diabetes Today (DT) curriculum for Pacific Island communities in Hawai'i, American Samoa, and Micronesia. To gather data to guide the development of the Pacific Diabetes Today (PDT) curriculum, a year was spent listening to Pacific communities. First, data were gathered from health professionals on how the DT curriculum should be modified. Second, health and community leaders in 11 sites were trained and supported to conduct discussion groups with people affected by diabetes. Third, site coordinators evaluated the discussion group process. A Pacific-wide Advisory Council (AC) was established to guide the project, and the AC used findings from the first year to generate guidelines for staff to follow in adapting the DT curriculum to the Pacific. These guidelines directed staff to: a) realize that Pacific communities need to build awareness about diabetes; b) train and support local community leaders as co-facilitators in the PDT curriculum, using a learn-by-doing approach, with the goal of developing them as independent trainers; c) encourage the involvement of a broad range of community members in PDT training, including the involvement of local physicians to counter medical misconceptions about diabetes; d) give the PDT curriculum a Pacific "look" and "feel;" and e) keep the training logistically flexible to accommodate differences in communities across the region. Other programs and agencies that want to develop training programs in the Pacific may find these listening strategies and guidelines helpful.

Compared to women in other ethnic groups, Native Hawaiian women have the highest breast cancer mortality rates in the state of Hawai'i. Nationally, the five-year relative survival rate for Native Hawaiian women is 9% shorter than for Caucasians and all races. This poor outcome has been attributed, in part, to late-stage detection of cancer in Native Hawaiians, and data suggest that breast cancer screening rates for Native Hawaiian women are relatively low. This study examined breast cancer knowledge, attitudes, and practices (KAP) among Native Hawaiian women, reached through their friendship, community, and organizational networks. Response to an initial KAP survey in 1989-1990 was rewarded by a voucher for a free mammogram. Participation in both the survey (n = 903) and mammogram offer (n = 496) was high. The initial, Time 1 participants were resurveyed in 1999-2000, yielding a sample of 117 women who completed KAP surveys at both time points. After 10 years, changes in women's knowledge and attitudes were minimal. However, remarkable improvements in breast health practices were seen, with 62% of women reporting compliance with American Cancer Society guidelines for mammogram screening in 1999-2000, compared to only 14% in 1989-1990. Findings suggest that breast health practices can be improved through appropriate outreach; encouragement by health professionals; and policies and programs that increase access and affordability.

Native Hawaiians experience disproportionate rates of cancer incidence and mortality both nationally and in their homeland, Hawai'i. 'Imi Hale--the Native Hawaiian Cancer Awareness, Research, and Training Project, a five-year project funded by the National Cancer Institute, is aimed at reducing the burden of cancer among Native Hawaiians. The project's overall goal is to reduce cancer incidence and mortality among Native Hawaiians through the establishment of a sustainable infrastructure to 1) promote cancer awareness within Native Hawaiian communities, and 2) initiate cancer research, training, and control activities. A community-based project, 'Imi Hale emphasizes community participation, respect for cultural values, and the sharing of information, as we believe that a commitment to involve Native Hawaiians in all activities of the project will help assure that the community's awareness, training, and research priorities are addressed. In the first year of operation, cancer awareness activities included the development of culturally sensitive booklets on breast cancer and the provision of cancer education and screening for members of the Association of the Hawaiian Civic Clubs. Research and training activities included focus groups to explore the perceptions and experiences of cancer survivors, surveys to assess research priorities, the identification of Native Hawaiian researchers and the development of pilot research projects. The work of 'Imi Hale is guided by the hope that Native Hawaiians can reverse the negative effects of cancer and leave a powerful legacy and inheritance for future generations based on good health and well-being. 'Imi Hale means "to establish, as a dynasty; to acquire authority, power; to seek and establish an inheritance for one's children; and to form a friendship so close that one feels welcome in the house of the other." "By using our language for a name, we are invoking and honoring our ancestors, our culture, language and restoration as a nation."