It has been widely reported that COVID-19 disproportionately impacts several communities in Hawaiʻi, including Pacific Islanders and Filipinos. But less attention has been given to the role of chronic disease. High underlying rates of illnesses such as heart disease and diabetes have put these groups at elevated risk of contracting and dying from COVID-19.

Chronic diseases typically associated with middle age and older adulthood are common in young people needing hospital care in Hawaiʻi, according to public health researchers from the University of Hawaiʻi at Mānoa. More than a quarter of hospitalized youth and 12 percent of youth who visited an emergency department had at least one chronic condition such as diabetes, chronic kidney disease or high blood pressure. The study was published in Preventing Chronic Disease, which is sponsored by the Centers for Disease Control and Prevention.

“It’s likely that our results reveal only the tip of the iceberg, because chronic conditions are often underdiagnosed in young people,” said Tetine Sentell, lead author on the study and director of the Office of Public Health Studies (OPHS) in the Myron B. Thompson School of Social Work. “Importantly, we found that the rates of chronic conditions start to increase at age 9, which means we have to start early with our prevention efforts. Chronic disease management programs should be designed with the needs of children, teens and young adults in mind.”

“Health care providers need to be aware that chronic disease is common among youth needing hospitalization and should work closely with them and their families to effectively manage these conditions,” said Catherine Pirkle, an associate professor in OPHS and co-author of the study. “Efforts are needed building from community strengths, knowledge and relationships across the lifespan, starting as early as pregnancy and throughout childhood, to prevent chronic disease.”

At-risk groups

Young Native Hawaiians appear at particular risk in youth and early adulthood. Of all hospitalized children or young adult patients, 25 percent were Native Hawaiian. However, among the hospitalized patients who had asthma, 38 percent were Native Hawaiian, and among those with diabetes, 31 percent were Native Hawaiian. Higher rates of chronic conditions were also seen in other Pacific Islanders and Filipinos. Of all hospitalized patients, 13 percent were other Pacific Islander, and 15 percent were Filipino. But among the hospitalized patients with hypertension, 21 percent were other Pacific Islander and 18 percent were Filipino. Of the hospitalized patients with diabetes, 19 percent were other Pacific Islander and 16 percent were Filipino. These are higher than population averages for these groups.

Previous research has shown that Native Hawaiians, Filipinos and other Pacific Islanders were at risk for chronic disease at earlier ages in adulthood than other racial/ethnic groups. This new study quantifies how this trend is reaching into youth.

“This information will help us take next steps to addressing chronic disease earlier in life,” said May Okihiro, a pediatrician at the Waiʻanae Coast Comprehensive Health Center and assistant professor in pediatrics at UH Mānoa’s John A. Burns School of Medicine (JABSOM). “Culturally grounded interventions, such as those that include community and family and connect people with the land or ocean may be relevant for reducing chronic disease rates in Native Hawaiian, other Pacific Islander and Filipino populations.”

For the study, Sentell and her co-authors pulled data on all inpatient and emergency department visits statewide for children and young adults ages 5 to 29 during 2015 and 2016. After excluding visits related to pregnancy, they analyzed data from 13,514 inpatient stays and 228,548 emergency department visits over the two-year period. The authors were also able to estimate the costs associated with these hospitalizations and the proportion paid by Medicaid.

Sentell and Pirkle’s co-authors on the study included Michelle Quensell, L. Brooke Keliikoa and Émilie Corriveau, all of OPHS; So Yung Choi, JABSOM; and Lance Ching, Hawaiʻi State Department of Health.

In Albanian, “Si je?” means “How are you?” Public health researchers at the University of Hawaiʻi at Mānoa asked exactly that question of an innovative new health program in Albania. Their analysis shows how one country is making progress toward a goal of preventing chronic diseases like diabetes and heart disease on a national level. Their findings hold lessons for other locations, including Hawaiʻi.

A global effort is underway to prevent chronic diseases, rather than focus on treating people once they become ill. Toward this goal, the small European country of Albania launched an innovative health program in 2015, called “Si je?” which encourages middle-age adults to go to their local community health center every year for a free check-up. The program is aimed at shifting healthcare resources toward disease prevention through personal contact with primary healthcare providers.

“Right now, there is a growing understanding worldwide that in order for a nation to be healthy, it has to have a health system that aims to prevent chronic diseases, not just treat patients once they are sick,” said Tetine Sentell, lead author of the study and an associate professor with UH Mānoa Office of Public Health Studies in the Myron B. Thompson School of Social Work. “Our new study shows that the Si Je? program is working—it is building a culture of prevention and health in Albania.”

Study results and challenges

Researchers analyzed the screening database created from this program and conducted interviews with 15 health center directors. Results showed that about 270,000 people got a checkup during the program’s first year, which is more than a quarter of the number of people who were eligible. The program also successfully strengthened links between communities and health centers and had higher-than-expected participation rates in rural communities. As in Hawaiʻi, family members were important motivators to getting check-ups and screening.

But challenges remain. The researchers noted a need for greater participation among some groups. For example, men had lower participation than women.

Building a culture of prevention

The study found that Albania, like Hawaiʻi, seeks to build a culture of prevention that will reduce health inequities by increasing patient-centered relationships with clinicians and the healthcare system and by diversifying the primary healthcare workforce to meet community needs.

“Lessons can be learned by studying country-wide transformative programs such as Si Je? that extend far beyond Albania,” said Catherine M. Pirkle, assistant professor of public health and a co-author of the study.

“For example, the activities to reinforce community-clinical linkages resemble similar efforts in Hawaiʻi, which may help us here as we seek to strengthen the relationships and bridges between our primary care centers with the communities they serve,” Pirkle said.

The study was published online November 30 in Prevention Science and is a collaborative outcome from Sentell’s Fulbright Specialist program stay in Tirana, Albania in January 2017.