OBJECTIVETo evaluate the effectiveness of a culturally adapted, primary care–based nurse–community health worker (CHW) team intervention to support diabetes self-management on diabetes control and other biologic measures.RESEARCH DESIGN AND METHODSTwo hundred sixty-eight Samoan participants with type 2 diabetes were recruited from a community health center in American Samoa and were randomly assigned by village clusters to the nurse-CHW team intervention or to a wait-list control group that received usual care.RESULTSParticipants had a mean age of 55 years, 62% were female, mean years of education were 12.5 years, 41% were employed, and mean HbA1c was 9.8% at baseline. At 12 months, mean HbA1c was significantly lower among CHW participants, compared with usual care, after adjusting for confounders (b = −0.53; SE = 0.21; P = 0.03). The odds of making a clinically significant improvement in HbA1c of at least 0.5% in the CHW group was twice the odds in the usual care group after controlling for confounders (P = 0.05). There were no significant differences in blood pressure, weight, or waist circumference at 12 months between groups.CONCLUSIONSA culturally adapted nurse-CHW team intervention was able to significantly improve diabetes control in the U.S. Territory of American Samoa. This represents an important translation of an evidence-based model to a high-risk population and a resource-poor setting.

Purpose The examination of implementation process in translation research can inform other interventions’ modifications for different socio-cultural contexts. The purpose of this paper is to answer key implementation questions of a primary-care based, nurse-community health worker (CHW) team intervention to support type 2 diabetes self-management, as part of a randomized trial: 1) How was the evidence-based model adapted? 2) How were CHWs trained and supervised? 3) What was fidelity to protocols? 4) What were intervention costs? Lessons learned during implementation are also discussed. Methods Descriptive data are given on intervention delivery, CHW visit content, patient safety and intervention costs, along with statistical analyses to examine participant characteristics of higher attendance at visits. Results In the intervention sample (n=104), 74% (SD 16) of planned intervention visits occurred, guided by an algorithm-based protocol. Higher risk participants had a significantly lower dose of their weekly assigned visits (66%), than those at moderate (74%) and lower risk (90%). Twenty-eight percent of participants moved to a lower risk group over the year. Estimated intervention cost was $656 per person. Participants with less education were more likely to attend optimal percent of visits. Conclusions A nurse-CHW team can deliver a culturally adapted diabetes self-management support intervention with excellent fidelity to the algorithm-based protocols. The team accommodated participants’ needs by meeting them whenever and wherever they could. This study provides an example of adaptation of an evidence-based model to the Samoan cultural context and its resource-poor setting.

In American Samoa (AS), nearly 22% of adults have type 2 diabetes. Diabetes is best managed by diet and lifestyle modifications and strict medication adherence. Cultural aspects might affect medication-taking beliefs, and thereby influence medication adherence. This study aims to explore diabetes medication-taking experiences and knowledge and related cultural beliefs in AS adults with diabetes and healthcare providers. Six focus groups were conducted with 39 AS adults with diabetes and individual interviews were performed with 13 diabetes healthcare providers. Data were transcribed and analyzed using NVivo 8 software. Themes pertaining to medication taking and adherence were identified. Patients and providers reported that barriers such as confusion about medications and concern about medication costs negatively influence medication taking, while cultural values and obligations both positively and negatively impact medication adherence. These findings help elucidate the relationship between medication-taking beliefs and culture in AS adults with diabetes and highlight the importance of continued research within this population.

Objective To describe the utilization of prenatal care in American Samoan women and to identify socio-demographic predictors of inadequate prenatal care utilization. Methods Using data from prenatal clinic records, women (n=692) were categorized according to the Adequacy of Prenatal Care Utilization Index as having received adequate plus, adequate, intermediate or inadequate prenatal care during their pregnancy. Categorical socio-demographic predictors of the timing of initiation of prenatal care (week of gestation) and the adequacy of received services were identified using one way Analysis of Variance (ANOVA) and independent samples t-tests. Results Between 2001 and 2008 85.4% of women received inadequate prenatal care. Parity (P=0.02), maternal unemployment (P=0.03), and both parents being unemployed (P=0.03) were negatively associated with the timing of prenatal care initation. Giving birth in 2007–2008, after a prenatal care incentive scheme had been introduced in the major hospital, was associated with earlier initiation of prenatal care (20.75 versus 25.12 weeks; P<0.01) and improved adequacy of received services (95.04% versus 83.8%; P=0.02). Conclusion The poor prenatal care utilization in American Samoa is a major concern. Improving healthcare accessibility will be key in encouraging women to attend prenatal care. The significant improvements in the adequacy of prenatal care seen in 2007–2008 suggest that the prenatal care incentive program implemented in 2006 may be a very positive step toward addressing issues of prenatal care utilization in this population.

Translation of research advances into clinical practice for at-risk communities is important to eliminate disease disparities. Adult type 2 diabetes prevalence in the US territory of American Samoa is 21.5%, but little intervention research has been carried out there. We discuss our experience with cultural translation, drawing on an emerging implementation science, which aims to build a knowledge base on adapting interventions to real-world settings. We offer examples from our behavioral intervention study, Diabetes Care in American Samoa, which was adapted from Project Sugar 2, a nurse and community health worker intervention to support diabetes self-management among urban African Americans. The challenges we experienced and solutions we used may inform adaptations of interventions in other settings.Translating efficacious health treatments into routine clinical and public health practice to eliminate health disparities for communities at risk is an increasing public health priority. Recent significant advances in diabetes care have the potential to prevent complications from diabetes and improve quality of life, yet these evidence-based practices are not being used in real-world settings. 1,2 Innovations from other cultures or from efficacy studies in academic settings may be ineffective in low-income, minority, or ethnic communities. This is attributable Correspondence should be sent to Judith DePue, EdD, MPH, Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Coro Bldg 5W, One Hoppin St, Providence, RI 02903 (jdepue@lifespan.org). Reprints can be ordered at http://www.ajph.org by clicking the "Reprints/Eprints" link. ContributorsJ. D. DePue originated the overall translation model and intervention and led the writing team. R. K. Rosen originated the qualitative design phases of the study, contributed to writing the sections of the article describing these steps, and contributed to editing throughout. M. Batts-Turner was involved with an earlier study (Project Sugar), advised on translation of protocols and staff training for the current study, and contributed to writing those sections of the article and to editing. N. Bereolos assisted with implementing several phases of the study and contributed to writing lessons learned on study implementation, Step 7 section, and to editing. M.

Objectives To examine the impact of a successful 12 month behavioral intervention to improve diabetes control on healthcare utilization in American Samoa. Methods A cluster randomized design was used to assign 268 diabetes patients to a nurse-community health worker (CHW) intervention or usual care. Hospitalizations, emergency department (ED) and primary care physician (PCP) visits were collected retrospectively for one year prior to, and during, the intervention to assess changes in healthcare utilization. The association of utilization changes with change in HbA1c during the intervention was assessed. Results Adjusted incidence rate ratios (RR) for PCP visits were significantly higher in the CHW relative to the usual care group (RR= 1.71; 95% CI, 1.25–2.33). There was no main intervention effect on ED utilization, but visits in the prior year modified the intervention effect on ED visits. Increased PCP utilization was associated with greater decreases in HbA1c (b=−0.10, se=0.04, p=0.01). Conclusions A culturally adapted CHW diabetes intervention in American Samoa significantly increased PCP visits, and decreased ED visits among those with high ED usage in the prior year. These changes suggest important and beneficial impacts on health system utilization from the diabetes intervention in a low resource and high-risk population.

Background Samoans are recognized for their particularly high body mass index and prevalent adult obesity but infants are understudied. Objective To examine the prevalence of overweight and obesity and determine the contribution of feeding mode to obesogenic growth trajectories in American Samoan infants. Methods Data were extracted from the well baby records of 795 (n=417 male) Samoan infants aged 0-15 months. Mixed-effects growth models were used to produce individual weight and length curves. Further mixed-effects models were fitted with feeding mode (breastfed, formula- or mixed-fed) as a single observation at age four (±2) months. Weight and length values were converted to Z-scores according to the CDC 2000 reference. Results At 15 months, 23.3% of boys and 16.7% of girls were obese (weight-for-length > 95th percentile). Feeding mode had a significant effect on weight and length trajectories. Formula-fed infants gained weight and length faster than breastfed infants. Formula-fed boys were significantly more likely to be obese at 15 months (38.6%) than breastfed boys (23.4%), χ2=8.4, P<0.01, odds ratio=2.05, 95% CI [1.04, 4.05]. Conclusion Obesity in American Samoans is not confined to adults. Obesity prevention efforts should be targeted at early life and promotion of breastfeeding may be a suitable intervention target.

High type 2 diabetes prevalence, associated with recent cultural changes in diet and physical activity, characterizes the U.S. territory of American Samoa. Comorbid diabetes and depression rates are high worldwide and contribute to negative diabetes outcomes; these rates have not been assessed in American Samoa. In this study, six focus groups (FGs) were conducted with 39 American Samoan adults with diabetes; questions on perceptions of diabetes and depressive symptoms were included. Thirteen healthcare staff interviews were conducted to gain further insight into diabetes care in American Samoa. FGs and healthcare staff interviews were translated, transcribed, and entered into NVivo 8 to facilitate analysis. Thematic analysis showed that diabetes patients saw depressive symptoms as directly contributing to high blood sugar. However, these symptoms were rarely mentioned spontaneously, and providers reported they seldom assess them in patients. Many patients and healthcare staff believed the best ways to respond to feelings of depression involved relaxing, leaving difficult situations, or eating. Staff also discussed cultural