When researchers work together with community members to conduct studies to address health disparities, both groups reap the benefits, says a new paper from University of Hawaiʻi at Mānoa researchers.

The study was published in the March issue of the Hawaiʻi Journal of Medicine & Public Health.

Katherine Yang, a recent master’s graduate from the UH Office of Public Health Studies and a current PhD student in epidemiology, and her colleagues conducted detailed interviews with 12 leading local experts. The goal is to learn about their experiences in using a community-based participatory research (CBPR) approach to improve health outcomes and promote health equity.

“In CBPR, researchers take the time to get to know their communities by being present and listening to their concerns and priorities,” Yang said. “Our analysis showed that CBPR can serve as a bridge between academic researchers and the communities that they study.”

CBPR projects involve community members not as research “subjects,” but as active participants and co-leaders in all research phases. Community members work closely with researchers to conduct the study from beginning to end.

Research that uses a CBPR approach starts with an issue that is important to the community, values reciprocal learning and benefits and promotes social action. 

For example, in one project, researchers who were developing a substance abuse prevention program worked with ōpio (teenagers) in a rural Hawaiian community. The teens took pictures of things that represented Native Hawaiian values to them, and then worked with the researchers to use the photos in designing a public health intervention to prevent substance use.

In another example, UH researchers worked with Waimānalo families to construct sustainable aquaponics systems, which the families then used to enhance their access to fresh vegetables, fruit and fish. They also learned how to prepare healthy meals.

“Community members feel engaged when they know their voices matter and that research is relevant to their experiences, concerns and priorities,” said Jane J. Chung-Do, an associate professor with UH public health and co-author of the paper. “We wanted to better understand what makes these projects successful and what we can work on to advance CBPR in Hawai‘i.”

Analysis of the interviews revealed that a key component for CBPR projects is for researchers to build and sustain relationships and trust within the community. Other important findings were the development of a sense of ownership that community members felt about the project, and the strength-based approach of CBPR that values knowledge and the unique experiences of each community.

However, there are challenges in promoting CBPR. For example, it is difficult to secure funding for this type of research, which can take longer than conventional research approaches to studying community health. Research grants are often time-limited, and funding agencies typically do not allow for the time needed to build relationships and trust between university researchers and the community. 

Since the authors noted that their study was small, the next steps would be to expand the study to include perspectives of community partners who have been involved in CBPR and to investigate other factors that might promote CBPR success and, subsequently, improve health.

“Hawai‘i’s close-knit communities make it an ideal place to conduct CBPR projects,” Yang said. “CBPR projects are growing in Hawaiʻi, and we believe that meaningful community participation in research has the potential to promote health equity.”

In addition to Yang and Chung-Do, co-authors include Kathryn L. Braun, director of UH public health, and current and former public health students including Loren Fujitani, Alyssa Foster, Shannon Mark, Yuito Okada, Zeyana Saad-Jube and Fadi Youkhana.

Other co-authors are Kevin Cassel, UH Cancer Center; Scott K. Okamoto, UH Cancer Center and Hawaiʻi Pacific University; Susana Helm and Claire Townsend Ing, both at the John A. Burns School of Medicine; Christy Nishita and Lana Sue Ka‘opua, Myron B. Thompson School of Social Work; Kristine Qureshi, School of Nursing and Dental Hygiene; Peter J. Mataira, Hawai‘i Pacific University; and Karen Umemoto, University of California at Los Angeles.

Tearing of the uterus is a serious complication in pregnancy that can lead to bleeding, shock and even death. Uterine rupture is very rare in the United States but is more common in low-income nations. A study from University of Hawaiʻi at Mānoa public health researchers that examined data from two countries in West Africa shows that women whose labor slows down or stops altogether, resulting in the need to be transferred to a higher-level hospital, are at increased risk of uterine rupture.

Researchers led by Rebecca Delafield, a PhD student with the Office of Public Health Studies in the Myron B. Thompson School of Social Work, looked at data from the medical records of nearly 85,000 women who gave birth over the course of one year in Senegal and Mali. The researchers found that 569 of the women had suffered a uterine rupture while giving birth.

“The fact that uterine rupture is so rare in high-income nations demonstrates that it is largely preventable,” said Delafield. “We wanted to find out what increases the risk of suffering a uterine rupture for women. A better understanding of the factors involved could point to ways to prevent this outcome and possibly save lives.”

Obstructed labor strong predictor of uterine rupture

The data showed that the likelihood of a woman experiencing a uterine rupture increased with the number of times she had given birth. Women in the sample who had given birth five or more times were nearly eight times more likely to suffer a uterine rupture compared with women who had given birth once.

But the strongest single factor that influenced a woman’s risk of uterine rupture was “obstructed labor,” meaning that her labor had slowed down or stopped.

“We were not surprised to see obstructed labor was a strong predictor of uterine rupture,” Delafield said. “But what this study also shows is that, in addition to obstetric factors, health system factors increase the likelihood of uterine rupture in this population.”

The women in the study who had obstructed labor and were transferred to a higher-level hospital were 46 times more likely to experience a uterine rupture compared with women who did not have obstructed labor and did not need to be referred to the higher-level hospitals.

Findings support health-system improvements

Said Delafield, “Our findings suggest that women would benefit from improvements in the health systems in these settings. By improving the quality of care at the smaller, local hospitals or by transferring patients with obstructed labor more quickly, women might receive the care they need in time to prevent uterine rupture.”

The study was published November 1 in the journal BMC Pregnancy and Childbirth. Delafield’s co-authors include Catherine Pirkle, an assistant professor with the UH Office of Public Health Studies, and Alexandre Dumont, a researcher at the Research Institute for Development in Marseille, France.

Imagine that you had to choose between living your life with only the goods available in the 1950s (say goodbye to your cell phone), or living with only the health outcomes of that time (you’d live 11 years less, on average). Which would you pick?

Most people would choose the latter, which is why, in a paper published in The BMJ medical journal, the point is made that investments in improving a country’s public health should not be overshadowed by obsession over gross domestic product (GDP).

GDP represents the value of all goods and services produced in a country within one year. It does not include any measure of non-economic conditions, such as the quality of schools or the environment, or length of people’s lives.

“GDP undervalues the true worth of human health,” says Victoria Fan, lead author and assistant professor in the Office of Public Health Services in the Myron B. Thompson School of Social Work at the University of Hawaiʻi at Mānoa. “There are other measures that can provide a fuller picture of the value of investing in health.”

Although GDP is often cited by political leaders and economists as the definitive measurement of well-being, it falls far short of capturing the value of human life.

“GDP can tell us whether the economy is growing, but it doesn’t tell us anything about how healthy and safe people are in their day-to-day lives,” said Fan. “Being healthy and safe, and living in a fair and equitable society, are important components of people’s freedom to live their lives how they truly want to.”

Other measurements better illustrate the value of health, said Fan, citing “value of life years” (VLYs) or the estimate of how much people value living longer. The question offering a choice between material goods and longer life was posed by Yale economist William Nordhaus as one way to measure VLYs.

“We think that GDP should be used alongside other indicators of progress, such as life expectancy, which captures other aspects of well-being,” said Fan.


For same-sex male couples, the first few months of a new relationship are a crucial time to communicate about sexual health and HIV prevention, according to new findings from public health researchers at the University of Hawaiʻi at Mānoa. The research may ultimately help to lower new HIVinfections for this group.

For the study, same-sex male couples were sought through advertising on Facebook. A total of 722 men (representing 361 couples) were enrolled in the study, and completed a questionnaire asking about the timing of when they first discussed their HIV status, had sex without a condom, and if and when they had reached an agreement about whether or not they would have sex with anyone else.

The results showed that more than half of the men had talked about their HIV status on the first day of their relationship, and more than 80 percent had talked about it during the first two weeks. The results also showed that about one quarter of the men reported having sex without a condom on the first day of their relationship, and about 60 percent reported doing so during the first three months. However, there were some differences based on the men’s and couples’ HIV-status.

“In our study, we wanted to look at same-sex males couples and determine, within their relationships, when they start having conversations about their HIV status, when they start having sex without a condom, and deciding what kind of relationship they want,” said Jason Mitchell, lead author of the study and an assistant professor with the UH Mānoa Office of Public Health Studies in the Myron B. Thompson School of Social Work. “Knowing this timeline could give the public health research community ideas for ways to intervene to help improve HIV prevention efforts for same-sex male couples in the U.S. and abroad.”

Research shows that men who have sex with men (a group that includes men who are gay, bisexual, questioning their sexual identity or orientation, or heterosexual but having sexual encounters with other men) have elevated rates of HIV infection. Epidemiological estimates from other studies indicate that between 33 to 66 percent of men who have sex with men acquire HIV while in a same-sex relationship, and that this risk is attributed to the sexual behaviors they engage in with their primary partner.

“The new findings suggest that many couples find it important to communicate about their HIV status before they first engage in sex without a condom,” Mitchell said. The new data provide researchers with a good summary of the timing of when these events occur within same-sex male couple relationships, he said.

Mitchell and his research team secured funding from the National Institute of Mental Health via an R21 grant, which is intended to encourage exploratory/developmental research. Their goal is to apply these findings toward the development of a web-based “decision aid” aimed at helping same-sex male couples in new relationships create a plan on how best to reduce their risk for HIV. The researchers will also test this decision aid to determine whether couples find it useful and effective.

The new study was published on October 8 in The Journal of Sex Research. Mitchell’s co-authors on the study include Yan Yan Wu, an assistant professor of public health at UH, and Kristi E. Gamarel, an assistant professor with the University of Michigan School of Public Health.

As women age, their ability to get around affects their quality of life. A new study shows that older women’s physical functioning declines more rapidly if they develop urinary incontinence, according to public health researchers at the University of Hawaiʻi at Mānoa.

Catherine Pirkle and Yan Yan Wu, both assistant professors in the Office of Public Health Studies in the Myron B. Thompson School of Social Work, collaborated with researchers in Brazil, Colombia and Canada to recruit approximately 900 women in their sixties and seventies from those three countries plus Albania. About 25 percent of women over age 60 experience urinary incontinence.

Study participants completed a short test of physical functioning, which included measuring the speed of their usual walking pace, checking their balance and testing how fast they could stand up from a chair. The women also completed a questionnaire about their health, which included a query about whether they had experienced any leakage of urine in the past week. After two years, the women repeated the physical functioning test.

Pirkle said the researchers were surprised by how much physical function had decreased over a two-year period in women who had reported experiencing urine leakage at the study’s start.

“The loss of physical function in this group was quite large and happened very rapidly,” said Pirkle. “We know that, as women age, they tend to experience more functional limitations and disability than men do. But the reasons for this gender gap are not clear.”

Cycle of incontinence and decreasing physical activity

Wu said one supposition is that women who experience incontinence start to engage in less physical activity out of fear of losing urine. This could lead to a vicious cycle, as a reduction in physical activity leads to worsening incontinence and overall health.

But it’s possible that other factors, such as giving birth to many children, may contribute to both urinary incontinence and a physical performance decline. Pirkle and Wu said the next step for the research team is to look at whether women’s reproductive lives, such as the number of children they have and their history of gynecological or obstetric problems, influence their risk of incontinence, as well as other health outcomes of importance to older women.

The study was published in the September 2018 Journal of Aging and Health. Pirkle and Wu’s collaborators on the study include Luana Caroline de Assunção Cortez Corrêa and Saionara Maria Aires da Câmara of the Federal University of Rio Grande do Norte in Brazil; Afshin Vafaei of Lakehead University in Canada; and Carmen-Lucia Curcio of Universidad de Caldas in Colombia.

Introduction of highly active antiretroviral therapy (HAART) has significantly decreased deaths in HIV-positive children, most of whom were infected from pregnancy or breastfeeding. Before, HIV-positive children rarely lived past their fifth birthday; today, they are living into their teenage years. As a result, parents and health care providers struggle to decide how and when to tell an adolescent that he/she is HIV-positive.

Researchers from the Office of Public Health Studies at the University of Hawaiʻi at Mānoa explore this dilemma in a paper published in the American Medical Association Journal of Ethics this month, “Should There Be a Disclosure Mandate for Physicians Caring for Perinatally Infected Adolescents Who Don’t Know Their HIV Serostatus?” First author Sabhyta Sabharwal wrote the paper during a class when she was an MPH student at the University of Hawaiʻi at Mānoa with her instructor and assistant professor Victoria Y. Fan, ScD, SM. Jason W. Mitchell, PhD, MPH, assistant professor, is also a co-author on the paper. Sabharwal is currently a medical student at Tufts University School of Medicine in Boston, Massachusetts.

This paper highlights current gaps in HIV disclosure policies for adolescents in America. Currently, the law does not require providers or caregivers to tell minors that they are HIV-positive. In some states, the physician needs parental consent before they can tell a minor that he/she is HIV-positive.

On the one hand, disclosure may cause psychological distress, social stigma, or social isolation to the minor. On the other hand, adolescence is a time when children are more likely to engage in risky behaviors and if a minor does not know they are HIV-positive, they can have unprotected sex and infect unknowing partners. Furthermore, adolescents living with HIV could face criminal penalties if they fail to tell sex partners about their HIV-status once they turn 18.

For these reasons, physicians should be legally allowed to tell adolescents of their HIV serostatus, even if parental consent is not granted.

Additional details about this paper can be found here:


Understanding healthcare terminology is critical to patient education and engagement, but healthcare vocabulary that may be familiar to clinicians and researchers is often not understood, or is misunderstood, by patients.

In a study recently published in the Maternal and Child Health Journal, University of Hawaiʻi at Mānoa public health researchers found a lack of understanding of common obstetric terms used to measure maternal healthcare quality among women who recently gave birth on Oʻahu.

“Our research team interviewed 400 pregnant women to learn about their thought process and experiences in selecting a hospital to deliver their babies. We also assessed their understanding of terms often used to compare hospital quality in childbirth,” said Mary Guo, lead author and alumna of the UH Mānoa Office of Public Health Studies(OPHS) graduate program. “Our data showed that many women lacked understanding of some very important terminology around childbirth outcomes.”

The interviews took place between July 2013 and January 2015.

In one example, the research team found that almost 40 percent of participants did not know or misunderstood “episiotomy,” which is a surgical incision made during delivery, as opposed to a natural tear. Possible complications for women following an episiotomy include infections, pain during sex in the months after delivery and fecal incontinence.

Most women are likely to care about such obstetric outcomes, but first need to know what these words mean. Some demographic factors were significantly associated with less comprehension of obstetric terminology, including being younger, having less education and identifying as Filipino, Japanese, Native Hawaiian or other Pacific Islander.

“The finding that many women were unfamiliar with important terminology around quality of healthcare in childbirth is significant. This highlights areas where improvement in patient education is needed,” said Tetine Sentell, co-author and associate professor in OPHS. “More efforts are also needed to address knowledge gaps to achieve health equity across education, age and race/ethnicity.”

For example, Sentell said physicians should use layman's terms when communicating with patients. Also, healthcare providers should not assume that patients who nod in response or remain silent fully understand the relevant health information being conveyed.

Actively confirming patient understanding is important, Sentell emphasized.

The study was funded by the Agency for Healthcare Research and Quality.


To lower the high rate of heart disease among Filipino-Americans, the community needs heart health interventions rooted in Filipino cultural values, according to a new analysis by public health researchers at the University of Hawaiʻi at Mānoa.

Filipino-Americans comprise 20 percent of the growing Asian-American population and are overrepresented in important workforces, including healthcare and the military. Cardiovascular disease is the leading cause of death among Filipino-American males and second among Filipino-American females.

Further, they have a high prevalence of hypertension and behavioral risk factors associated with these cardiovascular and other chronic conditions, such as obesity, alcohol consumption and physical inactivity.

Filipino-Americans place a high importance on family relationships and often hold gatherings and celebrations with traditional foods. The community also values spirituality, caring for others and a tradition of obligation and reciprocity.

“We found that incorporating these values into interventions is an effective way to improve heart health,” said Professor Kathryn L. Braun, who worked on the study and is the director of the UH Office of Public Health Studies. Lead researcher on the study, Jermy-Leigh Domingo, is a recent UH Mānoa public health graduate.

For their analysis, the authors looked at eight previous studies that involved healthcare workers using culturally tailored interventions to increase Filipino-Americans’ participation in heart disease prevention programs. The researchers looked at whether these interventions worked and also identified their key components. Four of the previous studies were done in Hawaiʻi, while the others were performed on the mainland.

“In some interventions, healthcare workers offered suggestions for small changes that could be made in serving traditional Filipino foods, such as grilling fish rather than frying it,” Braun said.

Other interventions focused on a recognition of the importance of family relationships. For example, since turning down food is frowned upon, it is vital to get the whole family on board for support rather than focusing on the single individual with heart disease, the researchers said.

Few interventions involved finding ways to increase physical activity, however, dancing is popular among Filipino-Americans and may be an area to target in future studies.

“Our research is part of a growing body of evidence that shows that public health efforts that are tailored to reach people of certain cultures are effective in lowering the rates of chronic diseases,” Domingo said. Other factors include the ethnicity of healthcare workers, educational materials and the settings of interventions.

In the wake of a devastating HIV outbreak in a rural Midwestern county, the tone of the news media toward people who use injection drugs changed significantly, according to a new analysis from a public health researcher at the University of Hawai‘i.

Moreover, this shift in the media's tone may have provided the momentum that was needed to change decades-old, outdated government policies, and allow public health agencies to start a syringe exchange program to prevent the further spread of HIV and other diseases, the analysis shows.

"The study showed that the media is really key to creating a frame around how populations are perceived by the public," said David Stupplebeen, the author of the study and a PhD student at the Office of Public Health Studies at the university.

The outbreak struck Scott County, Indiana, in 2015, and was linked to an increase in the use of opioids. In his analysis, Stupplebeen searched for news articles that focused on people who use injection drugs that were published up to 10 years before the outbreak was first reported to the Centers for Disease Control and Prevention. He compared those articles with articles that were published after the outbreak was reported. He examined a total of 372 articles, which were mainly from local newspapers' coverage of the outbreak.

Stupplebeen found that before the outbreak, news stories about people who use injection drugs tended to focus on the crimes that these people committed, painting a picture of them as immoral criminals. But during the outbreak, which ultimately resulted in nearly 200 new cases of HIV in the sparsely-populated county, the tone shifted. The news articles started to bring to light the heartbreaking effects that the opioid-use epidemic had on the people living in an area already plagued by high levels of unemployment and poverty.

"Negative framing of people who inject drugs helped reinforce a stable policy environment, which didn't support syringe exchange programs," Stupplebeen says. "The HIV crisis changed the framing." This change in framing opened the door to the state's decision to allow the county to begin a syringe exchange program, to offer clean needles to people who use injection drugs.

Much research has shown that syringe exchange programs reduce the impact of communicable diseases in the community. However, some policy makers are reluctant to allow such programs over misguided fears that the programs encourage drug use. (They don't.)

"After the outbreak became known, talk turned to getting people into treatment, preventing overdoses, and doing needle exchange," Stupplebeen says.

The analysis will appear in an upcoming issue of the International Journal of Drug Policy.


A mobile app aimed at lowering the HIV-transmission rate among men who have sex with men should include an HIV test location finder and should help men to track their sexual activities, new research from the University of Hawai‘i at Mānoa shows.

For the study, public health researchers conducted in-depth interviews with Spanish-speaking men who have sex with men (a group that includes men who are homosexual, bisexual, questioning their sexual identity or orientation, or heterosexual but having sexual encounters with other men). The researchers asked the men what features they look for in apps, and what aspects of an app would make them likely to use it.

"We know from previous research that there is a need to improve HIV prevention efforts for Latino men who have sex with men in the U.S., and to help these men get tested for HIV and other sexually transmitted infections," said Jason Mitchell, PhD, MPH, an assistant professor with the Office of Public Health Studies at UH. "Mobile apps are a great way to get information and resources out to people, but prior to our research, there weren't any studies that had asked these men what they wanted in an app, and what might motivate them to download an app and keep using it over time," said Mitchell, who is the lead author of the new study.

The researchers recruited men in the Miami area whose primary language was Spanish through Facebook ads and flyers. They interviewed 15 men and then analyzed the transcripts of the interviews, looking for common themes.

When asked what they looked for in apps in general, all of the men said that it was very important to them that apps keep their personal information secure and confidential. Most said they were willing to pay for apps that were useful to them. The men also said they tended to download apps that their friends had used and liked.  

As for an HIV-prevention app, almost all of the men said they would like an app to send them reminders to get tested for HIV on certain dates and show them the nearest location where they could get tested. Most of the men also said they would like the app to send them information about HIV, either through text messages or alerts, and that they would want a feature in the app that would help them keep track of how many sexual partners and encounters they had.

"These findings could help guide future efforts to develop an HIV prevention app for Spanish-speaking men who have sex with men," Mitchell said.

The study will be published in a future issue of the Journal of Medical Internet Research: Public Health & Surveillance. Mitchell's co-authors included researchers Maria Beatriz Torres of Gustavus Adolphus College in Minnesota, Lucy Asmar of the University of Miami Miller School of Medicine in Florida, and Thu Danh and Keith Horvath, both of the University of Minnesota.


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