Hawai‘i Journal of Health& Social Welfare
A Journal of Pacific Health & Social Welfare
February 2021, Volume 80, No. 2, ISSN 2641-5216
HAWAI‘I JOURNAL WATCH

23

SOCIOECONOMIC AND BEHAVIORAL FACTORS ASSOCIATED WITH
OBESITY ACROSS SEX AND AGE IN HONIARA, SOLOMON ISLANDS

24

AN ANALYSIS OF HEALTHY FOOD ACCESS AMONGST WOMENIN PERI-URBAN HONIARA

33

Karen Rowan MS

Chihiro Tsuchiya MHS; Takuro Furusawa PhD; Samo Tagini RN;
and Minato Nakazawa PhD

Penny Farrell PhD; Anne Marie Thow PhD; Mia Rimon MPPM; Andy Roosen PhD;
Pavle Vizintin MIPH; and Joel Negin PhD
INSIGHTS IN PUBLIC HEALTHInterdisciplinary Student Team from University of Hawai‘i at Mānoa inthe HI-EMA Community Care Unit: Identifying Needs in the Pandemic
and Learning Together

Sydney Unciano BS; Angel Lynn Talana BS; Fary Maldonado MPA; Kira Oyama RN, MSN;
Chelsea Emma Apo RN; Kristine Qureshi PhD,RN,CEN,PHNA-BC,FAAN;
Lee Buenconsejo-Lum MD, FAAFP; Rachel Burrage MSW,PhD;
Robin Arndt MSW,LSW; and Tetine Sentell PhD

41

Hawai‘i Journal of Health & Social Welfare
ISSN 2641-5216 (Print), ISSN 2641-5224 (Online)

Aim:
The aim of the Hawai‘i Journal of Health & Social Welfare is to advance knowledge
about health and social welfare, with a focus on the diverse peoples and uniqueenvironments of Hawaiʻi and the Pacific region.
History:
In 1941, a journal then called The Hawai‘i Medical Journal was founded by the
Hawai‘i Medical Association (HMA). The HMA had been incorporated in 1856
under the Hawaiian monarchy. In 2008, a separate journal called the Hawai‘i Journalof Public Health was established by a collaborative effort between the Hawai‘i State
Department of Health and the University of Hawaiʻi at Mānoa Office of Public HealthStudies. In 2012, these two journals merged to form the Hawaiʻi Journal of Medicine& Public Health, and this journal continued to be supported by the Hawai‘i State
Department of Health and the John A. Burns School of Medicine.
In 2018, the number of partners providing financial backing for the journal expanded,and to reflect this expansion the name of the journal was changed in 2019 to the
Hawai‘i Journal of Health & Social Welfare. The lead academic partners are now
the six units of the UH College of Health Sciences and Social Welfare, including
the John A. Burns School of Medicine, UH Public Health, the Thompson School ofSocial Work & Public Health, the School of Nursing and Dental Hygiene, the UH
Cancer Center, and the Daniel K. Inouye College of Pharmacy. Other partners are the
Hawai‘i State Department of Health and the UH Office of the Vice Chancellor for
Research. The journal is fiscally managed by University Health Partners of Hawai‘i.

The HJH&SW Today:
The Hawai‘i Journal of Health & Social Welfare is a monthly peer-reviewed journal. Full-text articles are available on PubMed Central. The HJH&SW cannot beheld responsible for opinions expressed in papers, discussion, communications, oradvertisements. The right is reserved to reject editorial and advertising materials
that are submitted. Print subscriptions are available for an annual fee of $250.Pleasecontact the journal for information about subscriptions for locations outside of theUS. ©Copyright 2021 by University Health Partners of Hawai‘i (UHP Hawai‘i).
Co-Editors:
S. Kalani Brady MD, MPH
Tonya Lowery St. John PhD, MPH
Editor Emeritus:
Norman Goldstein MD
Associate Editors:
Lance K. Ching PhD, MPH
David Easa MD
Charles Kelley MD
Robert Pantell MD
Daniel Hu PharmD
Alyssa Yang MPH
Copy Editors:
Tiana Garrett-Cherry PhD, MPH
Satoru Izutsu PhD
Managing Editor:
Karen Rowan MS
Assistant Editors:
Kathleen Connolly PhD
Jessica S. Kosut MD
Jannet Lee-Jayaram MD
Tricia Mabellos DrPH
Sarah Momilani Marshall PhD, MSW
Jacob T. Pennington MPH
Fadi Youkhana MPH
Susan Young DHA, MSA, RN
Contributing Editors:
Kathleen Connolly PhD, John A. Burns School of Medicine
Sophia Kim PhD, MSW, Thompson School of Social Work		

& Public Health
Shane Morita MD, PhD, UH Cancer Center
Michele N. Nakata JD, Hawai‘i State Department of Health
Jarred Prudencio PharmD, Daniel K. Inouye College of Pharmacy
Kristine Qureshi PhD, School of Nursing and Dental Hygiene
Tetine L. Sentell PhD, UH Public Health

Journal Production Editor:
Drake Chinen BA, AAS

Executive Leadership Committee:
Mary G. Boland DrPH, RN, FAAN, School of Nursing and Dental Hygiene
Jerris R. Hedges MD, MS, MMM, John A. Burns School of Medicine
Randall Holcombe MD, MBA, UH Cancer Center
Lola H. Irvin MEd, Hawai‘i State Department of Health
Velma Kameoka PhD, UH Office of the Vice Chancellor for Research
Carolyn Ma PharmD, Daniel K. Inouye College of Pharmacy
Noreen Mokuau DSW, Thompson School of Social Work & Public HealthTetine Sentell PhD, UH Public Health
Editorial Board:
S. Kalani Brady MD, MPH, Drake Chinen BA, AAS,
Lance K. Ching PhD, MPH, Kathleen Connolly PhD, David Easa MD,
Tiana Garrett-Cherry PhD, MPH, Daniel Hu PharmD,
Satoru Izutsu PhD, Charles Kelley MD, Sophia Kim PhD, MSW,
Jessica S. Kosut MD, Jannet Lee-Jayaram MD,
Tonya Lowery St. John PhD, MPH, Sarah Momilani Marshall PhD, MSW,
Tricia Mabellos DrPH, Shane Morita MD, PhD, Michele N. Nakata JD,
Robert Pantell MD, Jacob T. Pennington MPH, Jarred Prudencio PharmD,
Kristine Qureshi PhD, Karen Rowan MS, Tetine L. Sentell PhD,
Alyssa Yang MPH, Fadi Youkhana MPH, Susan Young DHA, MSA, RN
Statistical Consulting:
Biostatistics & Data Management Core, JABSOM,
University of Hawai‘i (http://biostat.jabsom.hawaii.edu)
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Hawai‘i Journal Watch
Karen Rowan MS

Highlights of recent research from the University of Hawai‘iand the Hawai‘i State Department of Health
New Compounds Identified in Mauna Kea Soil

Soil from the top of Mauna Kea contains fungi that may produce
anti-cancer or cancer preventative compounds. Researchers including Shugeng Cao PhD, of the Daniel K. Inouye College of
Pharmacy, studied a fungal strain called Aspergillus terreus FS107
from a soil sample using high performance liquid chromatography(HPLC). Six compounds were isolated, including 2 new compounds
that the researchers named tryptoquivaline W and tryptoquivaline
X. Their structures were determined using mass spectrometry andnuclear magnetic resonance analysis. The researchers then tested
the activity of the compounds against human cancer cells. Amongthe 4 known compounds, 2 inhibited the activity of NF-κB, atranscription factor involved in the cellular response to stress. The
researchers concluded these compounds may potentially mediatea cancer chemopreventive response in human cells.
•

Zaman KAU, Hu Z, Wu X, Cao S. Tryptoquivalines W and X, two new compounds from a
Hawaiian fungal strain and their biological activities. Tetrahedron Lett. 2020;61(14):151730.
doi:10.1016/j.tetlet.2020.151730

Factors Associated with Survival of Rare Liver
CancerCancer of the liver and bile ducts, called combined hepatocellularand cholangiocarcinoma (HCC/CC), is an aggressive cancer withgenerally poor prognosis. Researchers including Eric Wien MD,of the John A. Burns School of Medicine, examined data from theSurveillance, Epidemiology, and End Results (SEER) database on
497 patients with HCC/CC from 2004 to 2015. Results showed
median survival was 6 months. Multivariate logistic regression
showed that tumor size of less than 50 mm, undergoing surgical resection, and undergoing liver transplant were associatedwith 5-year survival. Patients in the Asian/Pacific Islander group
had a significantly higher rate of surgical resection comparedwith non-Asians (35.7% vs 21.1%), and a higher rate of 5-year
survival (15.4% vs 8.0%). The greater prevalence of hepatitis B
in Asia may play a role – it may prompt surveillance and earlier
detection, or the virus may lead to cancers that develop without
co-occurring cirrhosis, allowing for more surgical management.
The researchers concluded that further study is needed to explain
racial/ethnic differences and the role of underlying liver diseasein patients with HCC/CC.
•

Sempokuya T, Wien EA, Pattison RJ, Ma J, Wong LL. Factors associated with 5-year survivalof combined hepatocellular and cholangiocarcinoma. World J Hepatol. 2020;12(11):1020-1030.
doi:10.4254/wjh.v12.i11.1020

An App Can Facilitate HPV Vaccination

Young men who have sex with men (MSM) face a higher prevalenceof human papillomavirus (HPV) related diseases. Researchers
led by Holly Fontenot PhD, of the School of Nursing and Dental
Hygiene, developed an app to reach young MSM, deliver HPV

information, and facilitate vaccination. Participants ages 18-26 wererecruited over 6 months via ads on an MSM dating app. Among
338 potential participants who accessed the study web page, 42
downloaded the app. Usage data showed participants primarily
accessed the app’s educational components and the app’s functions
to book appointments, set reminders, or access directions to clinics.
Of the 35 participants who were unvaccinated, not up-to-date, or
not reporting status, 8 (23%) used the app to facilitate receiving
the HPV vaccine. The findings show that an app can help youth
develop action plans and facilitate health behaviors.
•

Fontenot HB, White BP, Rosenberger JG, et al. Mobile app strategy to facilitate human papillomavirus vaccination among young men who have sex with men: Pilot intervention study. J
Med Internet Res. 2020;22(11):e22878. doi:10.2196/22878

Bile Acid Metabolism May Play a Rolein Alzheimer’s Disease

Many metabolic processes are altered in people with Alzheimer’s
disease (AD). Researchers including Wei Jia PhD, of the University of Hawaiʻi Cancer Center, used data from post-mortem brain
samples to create transcription profiles of genes involved in themetabolism of cholesterol and bile acids. From the profiles, theresearchers analyzed metabolic activity in various brain regions.
Results showed that the transport of the amino acid taurine, thesynthesis of bile acids, and the metabolism of cholesterol differedsignificantly between the brains of people with AD compared withcognitively normal individuals. Moreover, the researchers identified transcription factors that interact with these genes. They also
found evidence suggesting bile acids from the gut are transported
to the brain. The researchers concluded more research is neededon bile acid metabolism in AD.
•

Baloni P, Funk CC, Yan J, et al. Metabolic network analysis reveals altered bile acid synthesis
and metabolism in Alzheimer’s disease. Cell Rep Med. 2020;1(8):100138. doi:10.1016/j.
xcrm.2020.100138

More Frequent Visits to a Chiropractor May
Help with Chronic Pain

For patients with chronic low back or neck pain who are under
the care of a chiropractor, visits more than once per week may
be linked with better improvement. Researchers including Eric
Hurwitz DC, PhD, with the Office of Public Health Studies,
conducted a prospective study with 1665 patients over a 3-month
period. Results showed patients’ ratings of pain decreased slightly
but significantly over the study period. Those with higher levelsof pain and disability had more frequent visits, and those who saw
their chiropractor more than once weekly showed significantly
faster improvement. The findings suggest that patients may reacha plateau, or level of maximum therapeutic improvement, and that
visits more often than once weekly are needed to maintain thatlevel of improvement.
•

Herman PM, Edgington SE, Sorbero ME, Hurwitz EL, Goertz CM, Coulter ID. Visit frequency
and outcomes for patients using ongoing chiropractic care for chronic low-back and neck pain:
An observational longitudinal study. Pain Physician. 2021;24(1):E61-E74.

HAWAI‘I JOURNAL OF HEALTH & SOCIAL WELFARE, FEBRUARY 2021, VOL 80, NO 2
23

Socioeconomic and Behavioral Factors Associated with Obesity
Across Sex and Age in Honiara, Solomon Islands
Chihiro Tsuchiya MHS; Takuro Furusawa PhD; Samo Tagini RN; and Minato Nakazawa PhD
Abstract
The Solomon Islands is currently experiencing a change in disease burdens,
from communicable to non-communicable diseases. Obesity is one of theleading non-communicable diseases causing death. Urgent action is needed
to decrease the high economic and personal costs associated with obesity.
This study proposes to determine behavioral and socioeconomic factors associated with obesity among different sex and age groups in an urban areaof the Solomon Islands. In 2016, a cross-sectional study was conductedamong adults aged 20 to 80 in Honiara, the capital of the Solomon Islands.
Anthropometric measurements and a survey of socioeconomic status (SES)
and behavioral status were conducted among 176 participants using aquestionnaire. Multiple linear regression analysis was used to identify thesocioeconomic factors significantly associated with higher body mass index(BMI) by age group. The study found a high prevalence of overweight (34%)
and obesity (48%) in both sexes. Multiple linear regression analysis foundthat having a high-income level and being married were positively associatedwith higher BMI among young adults. In the middle age groups, the highest
income level was positively associated with higher BMI. Young and middleaged adults with a high SES might consume higher calorie food, contributing
to weight gain, but this needs confirmation. Moreover, getting married mightlead to more consistent meals and weight gain among the young age group.
These findings suggest that health professionals have to consider the influence of income level and marital status on lifestyle choices when planninginterventions that promote healthy lifestyles.

Keywords
Non-communicable diseases, Solomon Islands, obesity, developing countries,
factor analysis, risk behavior

Abbreviations
BMI = body mass index
FDSK = food diversity score Kyoto
NCDs = non-communicable diseases
PIC = Pacific Island countries
SD = standard deviation
SES = socioeconomic status
Introduction
It has been estimated that of the 57 million deaths worldwide in2016, 72% were caused by non-communicable diseases (NCDs)
such as cardiovascular disease, cancer, chronic respiratory disease, and diabetes.1 More than 78% of the mortality occurs in
low-and middle-income countries that suffer the double burdenof NCDs and communicable diseases.1

Overweight and obesity are serious risk factors that contributeto cardiovascular disease, diabetes, and cancer. The PacificIslands countries (PICs) region is composed of 22 countries
and territories across Polynesia, Micronesia, and Melanesia.
The highest prevalence of obesity and type 2 diabetes in theworld is found there.2 The Solomon Islands is one of the PICs
that has experienced a striking rise in the prevalence of obesity.3
According to Friedlaender et al, obesity was not recognized asa problem in the 1960s.4 However, after independence from
British rule in 1978, Eason, et al (1987), observed adult obesityin the urban areas of Western province.5 According to the 1989
National Nutrition Survey in the Solomon Islands, only 11%of the women were considered overweight and 3.5% obese.3
However, by 2016, according to the World Health Organization, the prevalence of being obese among women was 25%
and among men 16%.1 Currently, NCDs are estimated to cause
69% of the Solomon Islands’ total deaths.1
Since the end of World War II, the political and economic changes
experienced in the PICs have been widely described.6 Dramatictransitions in the food environment due to modernization, migration, and urbanization have occurred in the Solomon Islands
since independence from British rule.6 These transitions have, inturn, dramatically impacted dietary intake and physical activity,
causing an increase in obesity and NCDs in the islands.5 The dietof the Solomon Islands was traditionally based on root crops,
fruits, seafood, vegetables, coconut products, and various nuts.7
However, consumption of higher energy-density refined cereals, animal products, oil, and processed foods has significantly
increased.7 This nutrition transition is associated with the risingburden of NCDs.7 Rising incidence of NCDs in the Solomon
Islands is also impacted by other factors, including negative
lifestyle behaviors seen in unbalanced diets, lack of physicalactivity, drinking, and smoking.7 Another factor is that obesity
is widely considered to affect people of lower socioeconomic
status (SES) more than those of higher SES worldwide.8
The distribution of health-related behaviors is usually affectedby age and gender.9 Considering gender-and age-specific socioeconomic status and behavioral patterns might help healthprofessionals focus on early prevention programs on the mostimportant and cost-effective risk factors. However, there is little
information about the factors associated with obesity by sex
in the Solomon Islands. Therefore, the objective of this study
is to determine the socioeconomic and behavioral factors as-

HAWAI‘I JOURNAL OF HEALTH & SOCIAL WELFARE, FEBRUARY 2021, VOL 80, NO 224sociated with obesity differentiated by sex and age in an urban
setting in the Solomon Islands to develop effective obesity
prevention techniques.
Methods
Study Area and Population
The Solomon Islands is part of the Melanesian group of countries located in Oceania, northeast of Australia. According to
the Solomon Islands National Statistics Office, in 2019, its
population was approximately 680 806, with 13% living in
Honiara, the capital, situated in the main province of Guadalcanal (Figure 1).10
Design and Subjects
A cross-sectional study was conducted with 176 participantsin an area health center in Honiara. The study recruited adultoutpatients aged 20 or over at the clinic with informed consent
and without incentives. The subjects were patients visiting theclinic between July 1 and 31, 2016. The subjects were recruited
through a convenience sampling of general department patients,
an outpatient facility that provides diagnosis, treatment, injections, and counseling services. Pregnant participants were

excluded. The following items were investigated for all subjects: anthropometric measurements and interviews on socioeconomic status. A semi-structured, interviewer-administeredquestionnaire was divided into 3 sections: socio-demographic
characteristics with 5 questions, nutrition status with 11 questions, and lifestyle behavior with 3 questions. The anthropometric measurements took 10 minutes, and the interview took
30 minutes. The cultural acceptability of the questions was
confirmed through a pilot study with several local people. The
surveys were conducted through one-on-one interviews by aJapanese researcher fluent in Pidgin, the common language of
the Solomon Islands.
Anthropometric Measurements
Height was measured using a 0.1 cm precision Seca 213 Portable Stadiometer (model 213, SECA, Germany). Weight wasmeasured using a 0.1 kg precision portable scale (BC-705N,
TANITA, Japan).
The participants were asked to wear minimal clothing and no
shoes or socks. Body composition was defined using bodymass index (BMI) in kg/m2, and normal weight was defined as
BMI lower than 25, overweight as BMI 25–29.9, and obesity
as BMI higher than 30.11

Figure 1. Map of the Solomon Islands

Map Source: file:///C:/Users/PC5/Downloads/Solomon_Islands_Regions_map.pdf

HAWAI‘I JOURNAL OF HEALTH & SOCIAL WELFARE, FEBRUARY 2021, VOL 80, NO 2
25

Socioeconomic Status
A one-on-one interview was conducted with a questionnaire of
22 questions to obtain data consisting of age, sex, occupation,
marriage status, household income level, and education level
between July 1 and July 31, 2016. Age was categorized into 3
groups: young adult (20–39 years), middle adult (40–59 years),and older adult (60 years or older) following the National Healthand Nutrition Examination Survey in the United States.12
Education level was categorized into 2 groups: low, consistingof those who did not go to school or only completed primaryschool or less, and high, those who went to secondary school orhigher. Income level was categorized into 3 groups: low, middle,
and high. The Wages and Benefits Survey, conducted by the
Solomon Islands Chamber of Commerce and Industry, whichtargeted approximately 80% of the Solomon Islands private
sector workforce, revealed the average employee wage per hourby skill level: unskilled (8.8 Solomon Islands dollars [SBD]),casual (12.5SBD), clerical (14.7SBD), skilled (28.0SBD, andmanagement (54.0SBD).13 Thirty-seven percent of employees
worked 7 hours per day, and 67% worked 8 hours per day.13
Based on the survey, the casual and unskilled employees werecategorized as the low-income group earning 999SBD or lessevery 2 weeks.13 Skilled and clerical were categorized as the
middle-income group earning 1000SBD to 2999SBD every 2
weeks.13 Management were classified in the high-income group,with earnings over 3000SBD every 2 weeks.13
Behavioral Status
A one-on-one interview was conducted with a questionnaire
which consisted of items regarding smoking (Never, 1–2 days/
week, 3–4 days/week, 5–6 days/week, 7 days/week) with thequestion “How many days per week did you smoke during thepast week?” and alcohol drinking behavior (Never, 1–2 days/
week, 3–4 days/week, 5–6 days/week, 7 days/week) with thequestion “How often did you drink alcohol during the past
week?” following a questionnaire from a previous study.7 We
did not ask about betel chewing in our interviews. Exercise
frequency was estimated using the rapid assessment of physical activity scale, a useful tool to assess physical activity usedby a previous study in the Solomon Islands.7,14 The question
items were carefully checked by multiple specialists in this area
for content validity. The questionnaire seemed suitable for theSolomon Islands people because most respondents gave valid
answers with few omissions in the pilot study.
Nutrition Status
Nutrition status was investigated using the 11-item Food Diversity Score Kyoto (FDSK) questionnaire, which was developed
to easily assess nutritional intake in a community setting withoutcomplex measuring or the necessity to remember exact details.15
It covers all basic food items eaten in the Solomon Islands andhas been used successfully in the Solomon Islands, China,
Thailand, and Japan; and thus, was deemed appropriate for our
survey.7,16–20 The questionnaire consists of 11 food items (grains,potatoes, vegetables, meat, fish, dairy products, eggs, beans,seaweed, fruits, nuts) and asks the frequency of consumptionof these foods in an average week over the previous 6 months(Hardly eat [0 days/week], Sometimes [1–2 days/week], Often[3–4 days/week], Everyday [6–7 days/week]).
Ethical Considerations
This study was conducted following the guidelines of the Declaration of Helsinki and was approved by the Ethics Committee ofKobe University (project number 475) and the Solomon Islands
Health Research and Ethics Review Board, Ministry of Healthand Medical Services (HRE No. 034/16). All participants were
provided written information outlining the nature and purposeof the study, and oral informed consent was obtained from allparticipants.
Statistical Analysis
Statistical analyses and calculations were conducted using R
software with the EZR package. 21 Student’s T-test and Chisquared test were used for univariate comparisons between
men and women. Students’ T-test and Fisher’s exact test wereused for univariate comparisons among age groups. Multiple
regression analysis was used to identify separate age groupfactors significantly associated with higher BMI among explanatory variables, including education level, income level,
occupation, and marriage status, while the effects of age andsex were adjusted.
Results
Sample Size and Characteristics by Sex
Sample means and proportions of the characteristics of theparticipants (n = 176) were calculated separately for men andwomen (Table 1). The participants were 43% (n = 75) men and
57% (n = 101) women. Mean age was 43 ± 15 years among
men and 40 ± 12 years among women. Significant differences
between the sexes were observed in BMI, weight classification, education level, and occupation. The mean BMI was
significantly greater in women (32 ± 6) than in men (29 ± 5)
(P < .001). The prevalence of overweight was 41% amongmen, and 29% among women and obesity was 35% among
men and 58% among women, and women had a significantly
higher prevalence of obesity (P = .006). Men had significantly
higher education levels (P = .033) and were more likely to be
employed compared to women (P < .001).

HAWAI‘I JOURNAL OF HEALTH & SOCIAL WELFARE, FEBRUARY 2021, VOL 80, NO 2
26

Demographic and Socioeconomic Characteristics by Sex
and Age Group

Nutrition Status by Age Group
Table 3 shows the results of the eating frequency for each itemfrom the results of FDSK by age group.
Consumption of the food groups which were eaten by over 50%of the participants more than 3 days a week for the young age
group were dairy, fruit, grain, meat; for the middle age group,
fish, grain, potatoes and vegetables; and for the old age group,
fish, grain, potatoes, and vegetables.

Table 2 shows the demographic, socioeconomic, and lifestyle
behavior characteristics stratified for 3 age groups by sex. The
mean BMI was significantly higher among middle-aged men(P=.03). The young adult groups of both sexes had substantiallyhigher education than the middle and old age groups at P<.001
among men and P=.007 among women. Household income wassignificantly higher among middle-aged women (P=.001). In
addition, the old age group among men had significantly higher
unemployment than other age groups (P=.041).

The results showed that the young age group had significantly
higher consumption of dairy food (P<.001), meat (P<.001),
nuts (P=.042), and seaweed (P<.001) than the middle and old
age groups. The young age group also had significantly lower
consumption of fish (P=.004), potatoes (P=.01), and vegetables(P<.001) than the middle and old age groups. There was nodifference in grain consumption across groups.

Regarding lifestyle behavior, young men who smoked or drank
alcohol more than 1 day a week was significantly higher thanfor middle and old age men (P=.032). Young men also hadsignificantly more moderate or vigorous exercise than middle
and old age men (P=.02). Women showed no significant differences in lifestyle behaviors by age group.

Table 1. Socio-demographic and Health Characteristics of Study Participants
Total

Men

Women

n

Mean %n

Mean %n

Mean %

P valued

Age in years (mean±SDa)

17641.3 (13.4)

75

43.4 (15.4)

101

39.7 (11.6).07

BMI (mean±SD)17630.3 (5.7)

75

28.5 (4.8)

101

31.7 (6.0)<.001

Normal weight (BMI < 25)

31

18

18

24

13

13

Overweight (25 ≤ BMI < 30)

60

34

31

41

29

29

Obese (BMI ≥ 30)

85

48

26

35

59

58

Low education(No schooling or Primary school)

92

52

32

43

60

59

High education(Secondary school or higher)

84

48

43

57

41

41

Unemployed

68

39

15

20

53

53

Employee

81

46

49

65

32

32

Employer

27

15

11

15

16

16

Low (Income<1000)

47

27

19

25

28

28

Middle (1000≤Income<3000)

100

57

43

57

57

56

High (Income≥3000)

29

17

13

17

16

16

b

Weight classification (%).006

Educational achievement (%).033

Occupation (%)<.001

Household income (%)c.93

Marital status (%)
Married

151
86
67
89
84
83
.28
Never married/Divorced/Widowed
25
14
8
11
17
17
a
SD = standard deviation; b BMI = body mass index; c Income = Solomon Islands dollar/2 weeks; d P values were calculated using the Chi-squared test and Student’s t-test.

HAWAI‘I JOURNAL OF HEALTH & SOCIAL WELFARE, FEBRUARY 2021, VOL 80, NO 2
27

Table 2. Socio-demographic Characteristics, Health Characteristics and Lifestyle Behaviors by Sex and Age Group
Men
Young age(20-39 years)

Total

Women

Middle age(40-59 years)

Old age(60 and over)

n

Mean
%

n

Mean
%

n

Mean
%

n

Mean
%

75

28.5
(4.8)

33

27.1
(4.4)

26

30.4
(4.9)

16

28.5
(4.3)

Normal weight (BMI < 25)

18

24

11

33

3

12

4

25

Overweight (25 ≤ BMI <30)

31

41

18

55

9

35

4

25

Obese (BMI ≥ 30)

26

35

4

12

14

54

8

50

75

43.4
(15.4)

33

29.5
(5.1)

26

46.3
(4.4)

16

67.3
(6.0)

67

89

26

79

25

96

16

100

Young age(20-39 years)

Total
P

valuedMiddle age(40-59 years)

Old age(60 and over)

n

Mean
%

n

Mean
%

n

Mean
%

n

Mean
%

101

31.7
(6.0)

50

30.8
(5.7)

45

32.4
(6.1)

6

32.6
(8.3)

13

13

8

16

4

9

1

17

29

29

15

30

13

29

1

17

59

58

27

54

28

62

4

67

101

39.7
(11.6)

50

29.9
(5.8)

45

47.6
(5.1)

6

62.0
(2.8)

84

83

41

82

38

84

5

83

17

17

9

18

7

16

1

17

60

59

22

44

33

73

5

83

P

valuedWeight Status
BMIa (mean ± SDb)

.032

.41

Weight classification (%)
.006

.79

Demographic characteristics
Age in years (mean±SD)

.006

<.001

Socio-economic Status
Marital status (%)
MarriedNever married/Divorced/
Widowed

8

11

7

21

1

4

0

0

43

8

24

10

39

14

88

.031

.95

Educational achievement (%)
Low education (No schooling or Primary school)

32

High education (Secondary school or higher)

43

57

25

76

16

62

2

13

41

41

28

56

12

27

1

17

Unemployed

15

20

4

12

4

15

7

44

53

53

29

58

38

84

5

83

Employee

49

65

24

73

16

62

9

56

32

32

10

20

5

11

1

17

Employer

11

15

5

15

6

23

0

0

16

16

11

22

2

4

0

0

Low (Income < 1000)

19

25

9

27

5

19

5

31

28

28

9

18

14

31

5

83

Middle (1000 ≤ Income< 3000)

43

57

18

55

16

62

9

56

57

56

36

72

20

44

1

17

High (Income ≥ 3000)

13

17

6

18

5

19

2

13

16

16

5

10

11

24

0

0

Never

42

57

12

38

14

54

16

100

79

79

34

68

40

89

5

100

1 - 2 days/week

26

35

18

56

8

31

0

0

15

15

12

24

3

7

0

0

3 - 4 days/week

4

5

1

3

3

12

0

0

3

3

2

4

1

2

0

0

5 - 6 days/week

2

2

1

3

1

4

0

0

3

3

2

4

1

2

0

0

7 days/week

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Sedentary or light physicalactivities/week

62

83

23

70

23

89

16

100

97

97

47

94

45

100

5

100

Moderate or vigorous
physical activities/week

13

17

10

30

3

12

0

0

3

3

3

6

0

0

0

0

Never

58

77

22

67

21

81

15

94

95

95

47

94

44

98

4

80

1 - 2 days/day

12

16

10

30

2

8

0

0

2

2

2

4

0

0

0

0

3 - 4 days/week

0

0

0

0

0

0

0

0

1

1

1

2

0

0

0

0

5 - 6 days/week

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

5

7

1

3

3

12

1

6

2

2

0

0

1

2

1

20

<.001

.007

Occupation (%)
.041

.08

Household income (%)c

.90

.001

Lifestyle Behavior
Alcohol frequency (%)

.002

.24

Exercise behavior (%)
.020

.21

Smoking behavior (%)

7 days/week
a

.032

.06

BMI = body mass index; SD = standard deviation; Income = Solomon Islands dollar/2 weeks; P values were calculated using the Chi-squared test and Student’s t-test.
bcd

HAWAI‘I JOURNAL OF HEALTH & SOCIAL WELFARE, FEBRUARY 2021, VOL 80, NO 228

Table 3. Eating Frequency of Each Food Item from based on the Food Diversity Score Kyoto Survey
Total

Food items

Middle age (40-59 years)

Old age (60 and over)

n

%

n

%

n

%

n

%

Hardly eat

56

32

27

33

22

31

7

33

Sometimes

94

54

42

51

39

55

13

62

Often

16

9

9

11

7

10

0

0

P valueb

a

Beans

Dairy

Egg

Fish

Fruits

Grain

Meat

Nuts

PotatoSeaweedVegetablesaYoung age (20-39 years)

Everyday

9

5

5

6

3

4

1

5

Hardly eat

78

45

21

25

39

55

18

86

Sometimes

22

13

12

15

9

13

1

5

Often

21

12

13

16

7

10

1

5

Everyday

54

31

37

45

16

23

1

5

Hardly eat

131

75

57

69

54

76

20

95

Sometimes

33

19

17

21

15

21

1

5

Often

4

2

3

4

1

1

0

0

Everyday

7

4

6

7

1

1

0

0

Hardly eat

59

34

35

42

20

28

4

19

Sometimes

46

26

26

31

14

20

6

29

Often

29

17

11

13

11

16

7

33

Everyday

41

23

11

13

26

37

4

19

Hardly eat

20

12

9

12

9

14

2

10

Sometimes

65

40

25

33

25

38

15

71

Often

25

15

14

19

9

14

2

10

Everyday

52

32

27

36

23

35

2

10

Hardly eat

8

5

3

4

4

6

1

5

Sometimes

35

20

16

19

17

24

2

10

Often

56

32

28

34

21

30

7

33

Everyday

76

43

36

43

29

41

11

52

Hardly eat

73

42

20

24

34

48

19

91

Sometimes

32

18

15

18

15

21

2

10

Often

22

13

17

21

5

7

0

0

Everyday

48

27

31

37

17

24

0

0

Hardly eat

56

32

20

24

24

34

12

57

Sometimes

82

47

39

47

34

48

9

43

Often

15

9

10

12

5

7

0

0

Everyday

22

13

14

17

8

11

0

0

Hardly eat

44

25

28

34

14

20

2

10

Sometimes

53

30

30

36

18

25

5

24

Often

31

18

11

13

13

18

7

33

Everyday

47

27

14

17

26

37

7

33

Hardly eat

112

64

39

47

54

76

19

91

Sometimes

52

30

37

45

13

18

2

10

Often

8

5

4

5

4

6

0

0

Everyday

3

2

3

4

0

0

0

0

Hardly eat

75

43

49

59

25

35

1

5

Sometimes

19

11

11

13

6

9

2

10

Often

23

13

8

10

8

11

7

33

Everyday
58
33
15
18
32
45
11
52
Hardly eat (0 day/week), Sometimes(1-2 days/week), Often(3-4 days/week), Everyday(6-7days/week); b P values were calculated using the Fisher’s exact test.
HAWAI‘I JOURNAL OF HEALTH & SOCIAL WELFARE, FEBRUARY 2021, VOL 80, NO 2
29

.82

<.001

.14

.004

.08

.84

<.001

.042

.010

<.001

<.001

Table 4. Multiple Linear Regression Analysis with Body Mass Index by Age Group
Young age (20-39 years)

Middle age (40-59 years)

Old age (60 and over)β(SE)P valueβ(SE)P valueβ(SE)P valueSex (Men=0, Women=1)

4.0(1.3).003

2.0(1.5).17

6.1(3.6).32

Marriage status (Married=0,
Not married=1)-4(1.4).006-0.4(2.1).87-3.6(7.0).67

Education (Low education=0,
High education=1)

0.3(1.3).90

0.6(1.6).72

2.8(3.9).07(Low=0, Middle=1, High=0)

3.2(1.9).019

2.9(1.7).09

1.1(3.0).44(Low=0, Middle=0, High=1)

4.4(1.9).023

7.5(1.9)<.001

5.8(5.0).14(Unemployed=0, Employee=1,
Employer=0)

1.2(1.5).96-0.8(1.5).73

1.4(2.8).06(Unemployed=0, Employee=0,
Employer=1)

1.3(1.6).46-1.5(2.2)

.49

-

-

Smoking behavior (Never=0,
Yes=1)-1.1(1.7).50

1.8(2.4).46

8.7(6.4).19

Alcohol behavior (Never=0, Yes=1)-0.9(1.2).46-3.2(1.2)

.08

-

-

Exercise behavior (Sedentary or
light=0, Moderate or vigorous=1)

0.9(1.7).59

0.3(3.4)

.93

-

-

a

Household income

OccupationaAdjusted R2β(SE) presented separately for age group.

0.2

Association Between Factors for Higher BMI
Table 4 shows the results of multiple regression analysis broken
down by age group. It was found that in the young adult group,
being female (P=.003), being married (P=.006), and being at a
middle-income level or higher (P=.019 among middle income
and P=.023 among high income) were all significantly associatedwith higher BMI. In the middle age group, the highest income
level (P<.001) was significantly associated with higher BMI.
On the other hand, there was no significant factor regarding
higher BMI in the old age group. Regarding lifestyle behavior
factors, there was no significant factor regarding higher BMI
in any age group. Scatter plots showed the linearity, and theresiduals were normally distributed. Variance inflation factorsof all variables were less than 2, so multicollinearity was absent.
Discussion
Demographic Factors
While a previous study conducted countrywide found 16% of
men and 25% of women were obese, the current study focusedon the capital city and found a higher prevalence of obesity
among men and women at 35% and 58%, respectively.1 The
difference in obesity prevalence is possibly due to an effect inthe different study area. The previous study targeted all areas,
including the capital. The obesity prevalence in other provinces
is lower than in the capital city. Alternatively, this study focused

0.2

-0.02

on only people living in the capital city, which is urban, more
economically developed, and exhibits a higher prevalence ofobesity than other parts of the country. Urbanization is known
to be one of the factors that cause significant changes in dietand activity patterns.22 A previous study indicated that PICs are
rapidly becoming more urban as people move to cities to escaperural poverty and get better health and education services.23
Urbanization includes an increased intake of fat, sugar, andrefined carbohydrates.24
The present study found women had significantly higher BMI
than men. This is consistent with previous findings in the Solomon Islands and other developing countries.1,16,25–27 One possible
reason for a higher prevalence of obesity in women may befound in marital status. According to our multiple regression
analysis, being a woman and being married is related to obesity
only in the young adult age group. There was no relation shownin the middle and old age groups.
A previous study in the United States found the reason BMI
increased during marriage was due to the social obligations ofmarriage, indicating couples tend to have regular meals andeat heavier, denser food.28 Birth-giving might also contributethe higher prevalence of obesity among women. According toanother study, pregnancy was a factor in gaining bodyweight.29,30
Solomon Islands has a high fertility rate with more than 4 children per woman.31 This suggests that being pregnant may be a
trigger to gain body weight among young women.

HAWAI‘I JOURNAL OF HEALTH & SOCIAL WELFARE, FEBRUARY 2021, VOL 80, NO 2
30

Food Intake Situation by Gender and Age

Limitations

There was no difference in grain consumption across groups.
A previous study found that rice is chosen as the most frequent
staple food in the Solomon Islands because of its price, shelflife, and ease of preparation.32 The present study also showeda nutrition transition from traditional staples like potatoes toimported rice, bread, and noodles, and this has occurred acrossall age groups in this urban setting.

There were several limitations to this study. First, it is a crosssectional study, which can lead to limited conclusions given thatthe causation between SES and obesity cannot be determined.
Second, the small sample size might also affect the sample’s
margin of error, which lowers its statistical power. Third, thisstudy only looked at the factors of patients who came to theclinic. Thus, the sampling could be biased, and the study did
not have a control group of people who do not go to a clinic.

This study found that traditional foods such as fish, vegetables,and potatoes have been supplemented by animal protein, dairy,
and rice, especially among young adults. Previous studies in the
Pacific indicated a relationship between age and food preferences, with younger people generally preferring to eat imported
processed foods and older people generally preferring local
foods.33 In a recent study, the dietary analysis indicated thaturban residents in the Solomon Islands consumed more refined
grains and processed fish and meats due to the adoption of awestern lifestyle than those still living the traditional lifestyle of
the Solomon Islands.7,16,25 The present study did not look at how
much processed food the young age group consumed, though
it did find that they consumed fewer vegetables and potatoes,
which contribute fiber and micronutrients to the diet than the
middle and old age groups.
A previous study in the Solomon Islands found that consumption of less green leafy vegetables is related to obesity.7 The
prevalence of obesity is forecasted to increase if young adults
continue to pursue a “western” lifestyle.
Socioeconomic Factors for Obesity
In this study, SES was measured by occupation, householdincome, marital status, and education level. The study foundthat BMI was positively associated with income in both theyoung and middle adult groups. This finding was consistent
with other studies. A previous study found that SES, such as
income and property, was positively related to body weight indeveloping countries.34 Conversely, it was just the opposite indeveloped countries.34 Some studies suggest the reason SES has
now become positively associated with obesity in developing
countries; a study conducted in Tonga showed that those withhigher SES found greater availability of imported foods suchas processed foods and fatty imported meats.35 A previous study
conducted in the Solomon Islands found when there is money
available, people buy rice and other imported processed food.36
In the Solomon Islands, increased economic resources mightallow people to buy and eat higher-calorie processed foods,
which contribute to weight gain.

Conclusion
The present study indicates a high prevalence of obesity in both
sexes and found that women have significantly higher BMI thanmen across all age groups. Data from the present study showedthat participants with more than a middle-income level andbeing married were significantly associated with higher BMI
in young adults. In the middle age group, high-income level
was significantly associated with higher BMI. In the Solomon
Islands, higher SES individuals might consume higher-calorie
foods, which contribute to weight gain. The findings strongly
suggest that making an effective plan to develop health promotion programs for young people who have more than a middleincome level or are married is of paramount importance.
Conflicts of Interest
None of the authors identify a conflict of interest.
Acknowledgements
The present study was supported financially by the KAKENHI Grant-in-Aid
for Scientific Research (Project Number: 15H05123 [Takuro Furusawa, Kyoto
University]) of the Japan Society for the Promotion of Science, Japan. I would
also like to thank Mr. Don Moore (Kobe University) for his proofreading.
Authors’ Affiliations:- School of Nursing, Tokyo Medical University, Tokyo, Japan (CT)- Graduate School of Asian and African Area Studies, Kyoto University,
Kyoto, Japan (TF)
- Kukum Clinic, Honiara, Solomon Islands (ST)- Department of Public Health, Kobe University Graduate School of Health Sciences,
Kobe, Hyogo, Japan (MN)
Correspondence to:
Chihiro Tsuchiya MHS; School of Nursing, Tokyo Medical University, Tokyo, Japan,
6-1-1 Shinjuku, Shinjuku-ku, Tokyo 160-8402; Email: chihiro.tsuchiya227@gmail.
com

HAWAI‘I JOURNAL OF HEALTH & SOCIAL WELFARE, FEBRUARY 2021, VOL 80, NO 2
31

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HAWAI‘I JOURNAL OF HEALTH & SOCIAL WELFARE, FEBRUARY 2021, VOL 80, NO 2
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An Analysis of Healthy Food Access Amongst Womenin Peri-urban Honiara
Penny Farrell PhD; Anne Marie Thow PhD; Mia Rimon MPPM; Andy Roosen PhD;
Pavle Vizintin MIPH; and Joel Negin PhD
Abstract
Highly processed and energy-dense foods are contributing to the high andrising rates of non-communicable diseases and nutrient deficiencies in Solomon Islands. Non-communicable diseases currently cause 69% of deaths
in Solomon Islands, and the rate is rising, fuelled in part by limited healthsystem capacity to treat these conditions. Solomon Islands also has thehighest reported undernourishment rate in the Pacific. Recent decades haveseen several factors change the food and economic environment in Solomon
Islands. Importantly, rural-to-urban migration has caused a disconnect between
urban residents and access to land and home gardens. This study aimed to
examine the complexities of nutritious food access in urban Solomon Islands.
Data were collected from 32 women in Honiara, the islands’ capital, using anovel survey instrument. There were 3 important findings: (1) the dominant
influencers of the diet patterns described by participants in this study were
food affordability and access to land on which to grow it, (2) all participants
experienced food insecurity, and (3) reported diet patterns reflected unhealthy
diets which were particularly high in processed and sugary foods. These findings suggest a need for improvements in the food environment in Honiara.

Keywords
diet, Pacific, Solomon Islands, nutrition transition, non-communicable disease,
Pacific Island Countries and Territories

Abbreviations and Acronyms
NCD = Non-communicable disease
PICTs = Pacific Island Countries and Territories

Introduction
Non-communicable diseases (NCDs), including cardiovasculardisease and diabetes, are the leading cause of death and disability
in the Pacific region, imposing significant economic strain, pressure on overstretched health systems, and high levels of societal
loss from premature deaths.1,2 Highly processed, energy-dense
foods containing low amounts of micronutrients contribute to
the high and rising rates of NCDs and nutrient deficiencies
in Pacific Island Countries and Territories (PICTs), including
Solomon Islands.1,3 Solomon Islands is an archipelago country
in the Southwest Pacific with around 1000 islands, with an estimated population of 600 000.4 NCDs currently cause 69% ofdeaths in Solomon Islands, and the rate is rising. The problem
is exacerbated by a limited health system capacity to treat these

diseases.5-7 Solomon Islands also has the highest reported total
population undernourishment rate in the Pacific at almost 14%,
rising 2% in the last decade.8 The country currently faces a
triple burden of malnutrition: nearly 40% of adult women andchildren have anaemia, 33% of children have stunted physicalgrowth, and more than half of adults are overweight or obese.9-12
Recent decades have seen a number of factors change the foodand economic environment in Solomon Islands. Five years ofcivil unrest from 1998 to 2003, the global financial crisis, rapid
population growth, natural disasters, and urbanization contributeto ongoing cultural and economic change.3 Solomon Islands
ranks 152 of 189 countries in the Human Development Index.13
Approximately 80% of people in Solomon Islands live in rural
areas and access food via subsistence agriculture14,15; however,an annual urban population growth of 4.7% has caused a disconnect between urban residents and access to land and homegardens.15-17 Cash poverty is common in Solomon Islands, andfood prices are high relative to monetary earnings.15
There is a significant lack of data on food and nutrition security in PICTs,18 including Solomon Islands. This lack of datais hampering efforts to build effective policies and regulatory
frameworks to improve food systems.3 The present study was
designed to provide policy-relevant insight to start to address
this research gap. The study focuses on women because thereis global evidence that autonomy of women is positively linked
with their household’s nutritional status.19 Women are more
vulnerable to food insecurity than men, and the prevalence ofobesity worldwide is 50% higher in women than in men.20,21
Between 1975 and 2014, increases in body mass index for womenin PICTs were amongst the largest globally.22 Prevalence ofoverweight and obesity is higher in women in Solomon Islands
than in men.7 Importantly, women in Solomon Islands experience strong inequalities in access to resources and control ofhousehold decision making within households.15
This study aimed to understand the nuanced complexities ofnutritious food access in urban Solomon Islands by examining
the following factors: (1) food security and patterns of consumption of key food groups and specific foods, and (2) the mostimportant drivers of diet amongst participants to help informtargeted program and policy design.

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Methods

to classify each participant as household, individual, or childfood insecure.

Study Design
This study was informed by validated tools to collect data on
food security and food consumption patterns.23,24 Data were collected using a structured questionnaire (see Appendix) startingwith questions about demographic characteristics and general
health indicator information. Food security was measured withan adapted Radimer/Cornell tool based on that used by Shoae
et al.23 This tool included a series of questions about household, individual, and child food insecurity, and participants
were asked to answer “always,” “sometimes,” or “never” toeach question. Diet patterns were assessed using a shortened
version of a food frequency questionnaire used in a publishedstudy of 785 adults in Samoa.24 The aim of this data collection
was not to quantify exact dietary intake levels but to ascertain
broad patterns of food consumption in our study participants
to explore the reasons for such diet patterns. Participants werethen asked a series of open-ended questions about their dietpatterns, which explored drivers and barriers to consumptionof a nutritious diet.

The answers to the questions about food access and diet patterns
were analyzed using thematic analysis to determine the mostimportant reasons for dietary patterns.26
The study was approved by Solomon Islands National HealthResearch and Ethics Committee.
Results
Study Demographics
The study participants (n=32) were all women living in suburbs and villages close to Honiara. Table 1 summarizes the
key demographics of the study population. Of note, 71% ofparticipants (n=22) were under the age of 40, and 81% ofparticipants (n=26) cared for their families full time without adirect source of personal income. The average number of years
lived in Honiara was 19, and the average household size was
5 adults and 3 children.

Data Collection

Food Consumption Patterns

The study took place in Honiara, the capital of Solomon Islands.
In-depth interviews were conducted with 32 women with children in their care attending local primary schools. Participants
were recruited using convenience sampling, which was directedby school staff. Invited participants were given detailed information about the study in the form of a participant information sheet
and verbal explanation. Informed consent forms were signed
before each interview commenced. There were no withdrawals from the study. Participants were reimbursed with funds topurchase lunch and bus transport.

Table 2 presents a summary of key food items in participants’reported diet patterns. The most commonly consumed foodgroup was energy foods. Among energy foods, white rice wasconsumed the most, with 86% of participants (n=24) consuming
this daily. The second most commonly consumed food group
was body building food. Fish was the most commonly consumed
body building food; this food was consumed daily by 63% ofparticipants (n=20). Less than a quarter (23%) of participants(n=7) reported consuming fruit daily, and 57% of participants
reported consuming vegetables daily (n=17).

Participants were interviewed individually in a private room.
Interviews were run and transcribed in English by trained
members of the research team. Research assistants were alsopresent and translated the questions and responses into andfrom Solomon Islands Pijin when required.

Cooking Style

Data Analysis
Interview answers were entered into Microsoft Excel. Foodfrequency data were classified into energy foods (carbohydratebased foods), protective foods (fruit and vegetables), and bodybuilding foods (foods high in protein) using the Pacific Guidelines for Healthy Living.25 These guidelines further classify
energy foods into the following categories: “energy foods tochoose” (for example, root crops, whole grains), “energy foods
to limit” (foods high in refined carbohydrate including whitebread and white rice), and “energy foods to avoid” (foods highin fat, highly processed, high in sugar including sugar-sweetened
beverages).25 Food security questionnaire responses were used

Most participants cooked food in fresh coconut cream 3 or moretimes per week (data not shown). The main foods cooked incoconut were cabbage, fish, and starchy vegetables. Most participants cooked foods in oil at least weekly. The most common
cooking oil mentioned was palm oil, and participants also usedpeanut and vegetable oil. The main foods cooked in oil were
fish, cabbage, and chicken. Most participants also preparedfoods in soups at least weekly. The main foods prepared assoups were starchy vegetables and chicken.
Reasons for Diet Patterns
Table 3 demonstrates that the most commonly mentioned reason
for selecting particular types of food for consumption was affordability (84%, n=27). Other reasons given were availabilityof processed food (44%, n=14), availability of land (47%, n=15),
taste (28%, n=9), pursuit of health (19%, n=6), and culture

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(9%, n=3). When participants explained these reasons, somespecific foods were mentioned as illustrative examples. For
example, tinned fish was mentioned in relation to affordability.
White bread, white rice, and tea with sugar were mentioned inrelation to affordability and convenience. Participants noted
noodles were easy to prepare. In addition, Table 3 shows that
63% of participants (n=20) reported that the cooking facilities
available to them influenced the foods they were able to cook.
Participants were not directly asked which cooking facilities
they used, so it was impossible to quantify the most common
cooking facilities used. Still, participants mentioned using
firewood, gas stoves, and earth ovens.

When participants were asked who in their household decides
how much money was spent on food (Table 4), 55% of participants reported a joint decision (n=17, 15 of which was madejointly with the husband). Further, 23% (n=7) reported not
being involved in the decision. Among those who reported not
being involved in the decision, the participant’s husband was
the person most frequently mentioned to be responsible for thisdecision (n=7). Overall, 19% of participants (n=6) reported
being solely responsible for the decision.
Food Security
All participants (n=32, 100%) reported experiencing foodinsecurity in their household (Table 5). The majority (n=29,91%) also reported individual food insecurity, and 24 (75%)
reported child food insecurity.

As shown in Table 3, all participants who responded to thequestion of whether their diets were different from those eatenby their grandparents when they were the same age stated they
were (n=31, 100% of responses). Participant responses describeda shift away from diets high in fresh fruit and vegetables andwild-caught meat eaten in previous generations and towards
diets high in energy-dense processed and convenience foods.
Table 1. Study Participant Demographics (N=32)
Age (years)

n (%)

n (%)

n (%)

n (%)

20 to 29

30 to 39

40 to 49

No Response

5 (16)

17 (55)9 (29)

1

Average Household Size
Occupation
Education
Province of Origin

AdultsChildren530Care for family

Teacher

RetailOther

26 (81)

2 (6)

2 (6)

2 (6)

Primary school

High school

University

No Response

14 (50)11 (39)3 (11)

4

Guadalcanal

MalaitaOther

No Response

6 (19)

23 (72)3 (9)0Average Number Years Livedin Honiara

19

5

Table 2. Reported Frequency of Consumption of Commonly Consumed Foods (N=32)
Daily
n (%)

Food Item

3 Times Per Weekn (%)

Once Per weekn (%)

Less Frequently
Than Once Per Weekn (%)

No Response

Energy Foods
White rice

24 (86)

2 (7)

2 (7)

0 (0)

4

White bread

19 (61)5 (16)

7 (23)0 (0)1Cassava

14 (45)6 (19)

11 (35)0 (0)1Energy foods to limit (eg, doughnuts, pancakes)

17 (53)7 (22)

7 (22)1 (3)0Sugar sweetened hot beverages

19 (63)1 (3)6 (20)

4 (13)2Fish

20 (63)6 (19)

5 (16)1 (3)0Chicken

3 (10)

5 (16)

9 (29)

14 (45)1

Fruit

7 (23)

10 (32)

11 (35)

3 (10)

1

Vegetables

17 (57)8 (27)

4 (13)1 (3)2Body Building Foods

Protective Foods

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Table 3. Key Drivers of Diet Patterns (N=32)
Driver/s of Diet Patterns

Participants Who Describe Driver as Significant
n (%)

Example Quotation

Affordability

27 (84)

We grow our own local sweet potatoes which doesn’t
cost any money (23 year old participant)Availability of land on which to grow food

15 (47)

If I had good soil to grow my own fruits, root crops, andvegetables, I would eat healthy (44 year old participant)Availability of processed food

14 (44)[my grandparents] depended on food from garden. Today,
we live on money and depend on processed food fromthe shop (34 year old participant)Type of cooking facilities available, ease of preparation

20 (63)Yes [the cooking facilities available to me influence thetype of food I prepare], because we only use fire so I tend
to boil, fry, and stew our food (33 year old participant)

Perceived healthiness

6 (19)

Because it is a healthy meal and it is available at home
(35 year old participant)Taste

9 (28)[I consume soda because] it tastes good and is cold (43year old participant)Culture3 (9)Affordability, culture, and availability [have the strongest
influence on my diet patterns] (33 year old participant)Comparison of Diet with Grandparents’ Dietn (%)

No response

Participant diet different from those of grandparents

31 (100)

1

Table 4. Household Decision Making Status (N=32)n (%)

No response

Participant Only

6 (19)

1

Joint Decision
Of those with joint decision (N=17), decision made with husband

17 (55)15 (88)10Someone ElseOf those with decision made by someone else (N=7), decision made by husband

7 (23)
7 (100)

1
0

Table 5. Food Security Status of Participants (N=32)
Food Security Statusn (%)

No responseHousehold food insecurea
Of participants who were household food insecure (N=32), participant has been
concerned household food will run out (Appendix Section 8: Q1)

32 (100)
28 (88)00Individual adult food insecureb
Of participants who were individual food insecure (N=29), participant sometimes
does not eat for whole days at a time (Appendix Section 8: Q10)

29 (91)13 (45)00Child food insecurec
24 (75)0
Of participants who were child food insecure (N=24), participant’s children
6 (25)
0sometimes don’t eat for a whole day (Appendix Section 8: Q15)aHousehold food secure: Answered ‘sometimes true’ or ‘always true’ to one or more question related to household food insecurity(Questions [Q] 1–6 in Appendix Section 8).
b
Individual adult food insecure: Answered ‘sometimes true’ or ‘often true’ in one or more adult-level items (Q7 –Q10 in Appendix
Section 8).
cChild food insecure: Answered ‘sometimes true’ or ‘often true’ in one or more child-level items (Q11–Q15 in Appendix Section 8).

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Discussion
Summary of Results and Likely Implications
Our study aimed to provide policy-relevant insights about accessto a nutritious diet in contemporary Honiara in light of the current
triple burden of malnutrition and the rapid changes to the urban
population size and economy.9,16 This was a methodologicallynovel study in Solomon Islands and the results provide useful
information on the under-researched area of food insecurity
and diet behaviour in Solomon Islands and other PICTs. The 3
most important findings were: (1) the dominant influencers ofthe diet patterns described by participants in this study were
food affordability and access to land on which to grow fruitand vegetables; (2) all participants experienced food insecurity,
meaning they all at least sometimes experienced difficulty accessing nutritious food, and some regularly skipped their own,
or their children’s, meals; (3) reported diet patterns reflectedunhealthy diets which were particularly high in processed andsugary energy foods. There were no obvious patterns between
socio-demographic characteristics, food security status, and dietpatterns observed in this small descriptive study.
These 3 key findings are deeply interconnected and suggest the
study participants are living in a food environment that is notsupportive of good health. The dominant story told by the study
participants was that they did not have the cash to purchaseadequate nutritious food for themselves and their households,
nor access to the land to grow it and that because of thesechallenges with nutritious food access (otherwise defined asfood security), they are consuming inexpensive foods which
are energy-dense, often highly processed, and low in nutrients.
These foods have been implicated as key to the high rates of
NCDs and micronutrient deficiencies in the Pacific.1,3 There isevidence that in a food-insecure environment, consumption ofenergy-dense, highly processed foods is the main mechanism
whereby food insecurity can lead to obesity.27
The diet patterns reported in this small study are consistent
with grey literature reports that people in Honiara generallypurchase food with cash, and as heavily processed, often imported foods are usually less expensive, these are increasingly
becoming the main feature of people’s diets.3,7,17 The findings
from this study reflect reports of a worsening food security situation throughout the Pacific region. Connell reported that foodinsecurity has increased in the region in recent decades—due
to cost, convenience, and prestige, diets are high in imported
and processed foods, especially rice.28
The most frequently reported energy foods consumed by thestudy participants are classified as “energy foods to limit” and“energy foods to avoid” in the Pacific Guidelines25: the mostcommon of these were white bread, white rice, pancakes, anddonuts. Of further concern is that the vast majority of participants

reported consuming sugar-sweetened beverages (usually sugarin tea) at least weekly, and almost two-thirds consumed thisdaily. Sugar-sweetened beverages are classified as energy foodto avoid in the Pacific Guidelines for Healthy Living. There
are several potential poor health consequences of consumingthese “energy foods to limit” and “energy foods to avoid.” Forexample, consuming sugar-sweetened beverages increases therisk of diabetes.29 It is notable that diabetes is now the leading
cause of death and disability in Solomon Islands.30
The diet patterns reported by participants in this study suggestthat fruit and vegetable consumption is likely to be well below
the 5 servings per day recommended in the Pacific Guidelines
for Healthy Living.25 The most recent STEPwise approach tosurveillance, known as STEPS, survey showed that 93% of theSolomon Islands population ate less than 5 servings of fruitand vegetables per day; the average daily consumption was
0.8 servings of fruit and 1.3 servings of vegetables.31 There isevidence from Solomon Islands that households in urban areas
and those with low incomes are vulnerable to insufficient fruitand non-starchy vegetable consumption.32
In Solomon Islands society, food and land are owned collectively – people are socially required to share food and housingwith their extended kin, or Wantok.7 This has implications forthe way resources are distributed and preparing high-volume,
low-cost meals often mean low-nutrient, high-volume foods likerice are sought.7 The participants in this study were generally
from large households. Although a pattern between household
size and diet patterns was not observed in this small descriptive
study, recent research from Solomon Islands found that thoseliving in households with 7 or more people acquired less fruitand non-starchy vegetables than those in small households.32
The relationship between inter-household sharing of resources,
poverty, and food security was not explored in this study but
warrants attention in future research. It has been suggested that
remittance funds sent to the rural population by their Wantok in
Honiara are decreasing due to decreased food affordability in
Honiara17, which demonstrates that urban welfare is connectedwith national development.16
Strengths and Limitations
This study was designed to understand dietary patterns, foodpreferences, and interactions with food environments, not exact
food intake levels. The food frequency questionnaire results offer
indicative descriptive figures only due to the small sample size
and relied on self-reported diet information, which could haveintroduced bias. The question about vegetable consumption did
not distinguish between starchy (an energy food) and non-starchy
vegetables (protective foods). The survey was conducted in
Honiara only, so may not be representative of all urban areas.

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The survey was performed before the most recent Pacific
Guidelines for Healthy Living were published, 25 so its recommendations about portions of energy, body building, andprotective foods could not be built into the survey. However,these were used when analyzing the data, thus making thefindings directly applicable to policy makers in the Pacific. The
tool used to measure food security was designed based on thebest available resources; however, there is no validated foodsecurity measurement tool for Solomon Islands.
The question about household decision-making in this study
was simple, and as a result, the responses were likely more
superficial than the lived reality for participants. Although mostparticipants reported they had some say in household decision
making around food purchasing, it should be noted that in
Solomon Islands, “women are responsible for decisions about
raising children, providing food, and running the household,but men have the power to beat them if they get it wrong.”15
More time and attention should be given to this vital but highly
sensitive topic in the future.
Recommendations
The findings of this study call for urgent action in improving access to a nutritious and affordable diet in urban Solomon Islands.
As the combination of rural-urban migration, lack of accessto garden land, low incomes, and high formal unemployment
in urban populations is a serious problem in many PICTs,3,33
the methods and findings from this study have value acrossthe region. The methodology used in this study may have use
as a foundation in gathering further baseline and subsequent
progress information, where food systems interventions andpolicy changes are implemented.
The combined findings of high food insecurity and diets high inprocessed foods match those of other studies from the Pacific.
Connell declared that food insecurity in PICTs is “an increasingly urban problem,” with the solution embedded in broad
economic growth and poverty reduction, 28 and cross-sectoral
action not limited to the agriculture or health sectors. The issue of urban food poverty in Solomon Islands will affect more
and more people as urbanization continues to grow. The rise inurban population size—at a rate of 4.7% per year, faster than
the national growth rate of 2.3%—means that poverty reduction
and provision of basic services are in need of urgent attention
by the national government.16
A 2018 review spanning 172 countries has shown that imports
of processed food and sugar significantly increase average bodymass index.34 The promotion of healthier food imports throughconsideration of nutrition in trade policy design and input of
the health sector in trade policy has strong potential to improve
diets in the Pacific region.35,36

Increased alignment between local agriculture and nutritionand health outcomes is needed at high priority.3 Policies thatprovide support for marketplaces to sell fresh local foods ataffordable prices relative to other foods on the market; and to
facilitate different cooking options for households can increasenutritious food consumption. The findings from this study add
to the small amount of existing evidence from Melanesiancountries that financial and physical access to nutritious foodis an important barrier to its consumption.7,32,37 There is the potential to trial programs that have worked in other countries toaddress these issues. For instance, research from a low-income
area of the United States has shown that an intervention where
mobile markets sell fruit and vegetables, combined with an
education program, significantly increased consumption offruit and vegetables.38
Conflict of Interest
None of the authors identify a conflict of interest.
Acknowledgments
The authors would like to express their thanks to the study participants, theschools through which they were recruited, The Pacific Community Honiara
NCD Warrior team for their support.
Authors’ Affiliations:- Sydney School of Public Health, Edward Ford Building A27, The University ofSydney, NSW, 2006, Australia (PF, PV, JN)- Menzies Centre for Health Policy, Charles Perkins Centre D17, The University ofSydney, NSW, 2006, Australia (AMT)- Pacific Community (SPC). Port Vila, Vanuatu and Honiara, Solomon Islands (MR)- Synergies Ltd, Ngossi Ridge, Honiara, Solomon Islands (AR)Correspondence to:Penny Farrell PhD; Sydney School of Public Health, Edward Ford Building A27,
The University of Sydney, NSW, 2006, Australia;
E-Mail: penny.farrell@sydney.edu.au
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Appendix: Survey Instrument

3.05 Please briefly explain what you do (e.g. study, type of employment, unemployed,care for family at home)
3.06 Number of adults including yourself (18 and over) in household
3.07 Number of children (18 and under) in household
3.08 Did you grow up in Honiara, if not where did you live as a child?
3.09 How long have you been living in Honiara?
3.10 Do you mainly live in Honiara?

Understanding the socio-demographic determinants of access to healthy food
SURVEY INSTRUMENT FOR INDIVIDUAL INTERVIEWSCONFIDENTIAL
Interviewer name
Date
School at which interview conductedParticipant ID
1. Participant consent
1.01 Information sheet given and verbally explained
1.02 Consent form given and signed?
2. Introduction
Thank you for agreeing to participate in this survey. We are Penny Farrell and … and… from The University of Sydney in Australia.
We will ask a series of questions about your diet and the interview will go for aroundan hour.
Your participation is confidential and will not be linked to your child in any way. We will
not share the answers with anyone including your child’s school.
You can interrupt the interview at any point to ask questions, voice concerns or end
the interview if you wish.
There are contact details for our research team on the participant information sheet
which is yours to keep.
3. General information about participant
3.01 Age (in years, as at last birthday):3.02 Sex:
3.03 Village & district live in:Village:
District:
3.04 Could you tell me the final class you graduated from at school or in your education? Circle one of: Did not finish primary school, finished primary school, finished highschool, has university degree)

4. Food frequency questionnaire
We will now work through a list of food items and ask how often (never, <1/month, few
times a month, 1/week, 2-4/week, 1/day, 2-3/day, >4/day) you consume one serve ofeach item. [Refer to printed card]
How often do you eat one serve of:
MEAT
Beef in soy sauce, Beef curry,Tinned Corned beef, Salt beef, BBQ chicken, Fried
chicken, Chicken curry with coconut cream, Chicken in soy sauce, Baked chicken,
Roasted pork (if Y, what cut – or do you eat the whole pig?), Pork baked in earth oven
(if Y, what cut – or do you eat the whole pig?), Fried fish, Boiled fish in coconut cream,
Tinned fish, Fish prepared in any other ways – how often, Other seafood (ask to list),
BBQ lamb chop, Mutton in any other form (if yes, what cut and how is it prepared?),BBQ sausage, Other meat (if yes, what cut and how is it prepared?)
STAPLE/ENERGY
Taro, Potato, Sweet potato, White bread, Wholemeal bread, Cassava, White rice,
Green/cooking banana; If yes, how is it prepared, Coco yam, Yam, Cereal; If any,
what type, Breadfruit
FRUIT & VEG
How often do you eat 1 serve of fruit? [reiterate serve: half a pawpaw or whole guava,
eating banana], How often do you eat 1 serve of vegetables? [reiterate serve: fistful]

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DRINKS
Fruit juice (packaged), Fruit juice (fresh), Cordial drink e.g. Tang e.g. raro or sprim,
Soda can, Tea or coffee WITH milk, Tea or coffee WITH sugar, Young drinking coconut,
Milo, 3 in 1 coffee sachets
SNACKS/TREATS
Lollies, Ice cream, Nuts (e.g. peanuts), Fried snacks, Pizza, Beef burger, Meat pie,
Packaged potato chips, Twisties, Hot potato chips, Instant dried noodle, Pancakes,
Donuts, Cake, Cream biscuits, Cabin crackers, Sausage roll, Cream bun, Coconut bun
5. Summary of commonly eaten foods
5.01 With the most commonly eaten item in each of the 5 categories in the previous
question, why do you eat them – what influences your food choices (if need prompting,rank the most important reasons (affordability, availability, advertising, taste, convenience,
habit, healthiness, or culture) for eating these foods?
5.02 [Show flip card of food pyramid.] This is the guideline for the healthy amounts of eachfood type you should eat. What would help you to eat your meals in these proportions?
5.03 Do you think your overall diet is different to what your grandparents ate when
they were your age? Why?

5. We eat the same food for several daysin a row, because we don’t have enoughmoney to buy different kinds of food
6. I only prepare a few kinds of cheap foodand can’t make different food because I
don’t have enough money
Individual adult items – how often are these true for you?
7. How often are these true for you:(a) I have one meal per day(b) I have 2 meals per day(c) I have 3 meals per day
8. I can’t eat nutritious food because I
don’t have money to buy it
9. Due to lack of money and enough food,I only eat bread, rice or noodles
10. Sometimes I don’t eat all day

6. Ways of preparing food6.01 Which main type of cooking oil do you use and why?
6.02 How often do you cook with coconut?
6.03 Which are the main foods you cook in coconut?
6.04 How often do you fry foods in oil?
6.05 Which are the main foods you cook in oil?
6.06 How often do you prepare (or eat) soup?
6.07 Which are the main foods you prepare in soups?
6.08 List the type of cooking equipment you have at home: (E.g. open fire, small gas burner,oven etc. Do the cooking facilities in your home influence the food you cook?.) How?

Individual child items how often are these true for the children in your care?

7. Food consumption and living situation
7.01 During a typical week day, what do you eat, and where do you get it from? Why
do you choose this food? For example, in the morning after you wake up and before
you leave home, what do you eat and why? [Continue to prompt until participant has
explained source of all foods typically eaten in a day – will ask this open-ended question via interpreter]7.02 What is their role in food purchasing in their household?
7.03 Who decides how money is spent on food in your household? (Participant, joint
decision [with whom]) or someone else’s decision [who])
7.04 What is your household income, including remittances? What proportion of yourhousehold income is from remittances?
7.05 What is your personal income?
7.06 Can you estimate how much money you spend on food each week for yourself?
7.07 Can you estimate how much money you spend on food each week for your family?
7.08 Can you describe what is a healthy meal?
7.09 Can you list ways to make a meal healthier and balanced?
7.10 Please point to the body shape you think looks attractive for men [Show flash card]
7.11 Please point to the body shape you think looks most attractive for women [Showflash card]
7.12 Please point to the body shape you think looks most healthy for men [Show flash card]
7.13 Repeat for most healthy for men and most healthy for women [Show flash card]

14. My child/children have their mealsizes cut because I don’t have enoughmoney to buy food

8. Food security
Participants will be asked to answer the following questions in relation to the past 12
months: (Remind of confidentiality)
Household questions
1. I have been worried that our foodwill run out
2. I have been thinking that I wish I had
more money and I could buy more foodOften true/Sometimes true/Not true

11. I can’t feed my child/children nutritious
food because I don’t have enough money
12. Sometimes my child/children only
have bread or rice because I don’t havemoney to buy more of other foods
13. I know that my child/children sometimes is/are hungry but I don’t have money
to buy more food

15. Sometimes my child/children don’t
eat all day

Household secure: Answered ‘not true’ to all questions
Household insecure: Answered ‘sometimes true’ or ‘always true’ to one or morequestion related to household food insecurity (Q1– Q6).
Individual adult insecure: Answered ‘sometimes true’ or ‘often true’ in one ormore adult-level items (Q7–Q10).
Child food insecure: answered ‘sometimes true’ or ‘often true’ in one or morechild-level items (Q11–Q15).

Adapted from Shoae et al. 2007: Is the adapted Radimer/Cornell questionnaire valid to measure
food insecurity of urban households in Tehran, Iran?; Public Health Nutrition: 10(8), 855–861;
and Derrickson et al. The core food security module scale measure is valid and reliable whenused with Asians and Pacific Islanders; The Journal of Nutrition; Nov 2000; 130, 11.

9. Health information
9.01 How frequently do you do exercise where your heart rate is fast for 30 minutes ormore? __ < 1 X a week, __ 1-3 X a week, __ >3 X a week
9.02 Are you pregnant? If pregnant, how many months (number of completed months
if known)
9.03 Have you ever been diagnosed with diabetes? (Y/N)
9.04 Have you ever been diagnosed with heart disease or high blood pressure? (Y/N)
9.05 Alcohol consumption (Y/N)
9.06 If Y: How many times a week do you drink, how many drinks do you have on average when you drink? how many drinks per week on average (1-3; 4-7; 8+)9.07 Do you smoke? (Y/N)

3. When I want to make a meal, thematerials needed for making it haverun out and it’s hard for me to get more
4. I can’t prepare meals that I think arehealthy for my family, because the materials needed to make it have run out, andI don’t have money to buy them again

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Insights in Public HealthInterdisciplinary Student Team from University of Hawai‘i at Mānoa inthe HI-EMA Community Care Unit: Identifying Needs in the Pandemic
and Learning Together
Sydney Unciano BS; Angel Lynn Talana BS; Fary Maldonado MPA; Kira Oyama RN, MSN;
Chelsea Emma Apo RN; Kristine Qureshi PhD,RN,CEN,PHNA-BC,FAAN;
Lee Buenconsejo-Lum MD, FAAFP; Rachel Burrage MSW,PhD;
Robin Arndt MSW,LSW; and Tetine Sentell PhD
Insights in Public Health is a monthly solicited column from the public health community and is coordinated by HJH&SW Contributing Editor Tetine L. Sentell
PhD from the Office of Public Health Studies at the University of Hawai‘i at Mānoa and Contributing Editor Michele N. Nakata JD from the Hawai‘i Department of Health.

Introduction
The COVID-19 pandemic demands new, interdisciplinary collaborations to respond to the crisis and prepare for a transformed
future.1,2 For students in health and social sciences, this presents
not only high demands and new stressors, but also many learning opportunities.3-6 This article describes the experience of theInterdisciplinary Student Team from the University of Hawai‘iat Mānoa (UH Mānoa) who responded as part of the Hawaiʻi
Emergency Management Agency (HI-EMA) Community Care
Team in summer 2020.
HI-EMA is the emergency management agency for the state of
Hawaiʻi.7 The HI-EMA Emergency Support Function 8 (ESF-8)
focuses on public health and medical services in the response.
To respond adequately to the breadth and scope of impacts
related to the COVID-19 pandemic, the HI-EMA COVID-19
ESF 8 Team was expanded in April 2020. One unit establishedunder ESF-8 was Community Care and Outreach (CCO), which
has a key goal to identify vulnerable populations and articulate
their social needs.
The ESF-8 CCO unit includes: a multidisciplinary team offaculty from UH Mānoa in nursing, medicine, social work andpublic health who are ESF-8 CCO unit members; a community
advisory core representing key perspectives; and data analytics support. A total of 5 students from graduate programs insocial work, public health and nursing volunteered to support
the CCO unit as the Interdisciplinary Student Team during the2020 summer. Specifically, the Interdisciplinary Student Teamparticipants were Fary Maldonado (social work), Kira Oyama(nursing), Angel Lynn Talana (public health), Sydney Unciano(public health) and Chelsea Emma Apo (nursing). It is important
to note that the Interdisciplinary Student Team does not claim
to represent official views of HI-EMA.

These students share their insights, activities, and lessons fromtheir urgent and important work to identify and understand community social needs arising from the COVID-19 pandemic. They
describe key projects in which they were involved, provide theirperspectives, including synthesized insights into the pandemic
response, and finally consider how interdisciplinary learning
may be contextualized in terms of the needs of communities
in Hawai‘i now and in the future. There is hope that this work
will provide inspiration, guidance, and information for otherinterdisciplinary student collaborations in Hawai‘i and beyond.
Activities
The Interdisciplinary Student Team accomplished 3 primaryactivities in summer 2020.
Organizational Survey
The ESF-8 CCO Unit was tasked with identifying capacity,needs, and threats to members of the community from the
COVID-19 epidemic in Hawai‘i, as well as making recommendations to mitigate the situation. They first assessed the current
capacity, needs, and threats to agencies that provide health andsocial services in support of the state’s vulnerable populations.
Thus, a survey of community-based health and social service
entities was conducted across the state in spring 2020.8,9 An
executive summary was issued followed by a detailed report.9,10
This survey included 26 questions, including agency/entity
locations, services provided, and population served; the impact
of COVID-19 on the population served; and organizational
capacity and needs as a result of the COVID-19 outbreak in
Hawai‘i. Several questions were open-ended, meaning respondents could type a detailed answer in text. The student teamsupported qualitative data analyses of these answers using

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Dedoose (Version 8.0. 2018. Los Angeles, CA: SocioCultural
Research Consultants, LLC),11 a web-based application thatcan support thematic coding.
First, students looked for common themes across responses
and flagged them with the software. Then, after a discussion
to confirm unique themes and remove overlap, they performed
a second round of refined thematic coding and identified illustrative quotes. They then used the software to quantify andcategorize responses by theme. From this information, the students created the report draft, including describing data, giving
perspectives, and finding quotes to illuminate identified themes.
This supported the unit members, the advisory committee, andthe data analysts in completing the final report. In this process,students were actively engaged in teamwork, exchanging experiences, opinions, and perspectives around social services fromthe perspective of the local entities in the time of COVID-19.

and media reports around the impact of COVID-19 on various
groups, including veterans, health care providers, Filipino
communities, airline employees, and those with mental healthconditions. After considering these groups in some detail, they
synthesized needs around topics of interest to them, culminating in 2 op-eds published in Civil Beat, a local nonprofit news
website. One was about the impact of the pandemic on Filipino
communities in the state and was written by 2 students from thesecommunities.12 The second was from the perspective of healthcare providers and was written by 2 students providing care.13
Other Support
The students also learned about the background of emergency
responses, including the HI-EMA structure, attended virtual unit
meetings on Zoom, and helped pilot test a community-focusedsurvey that was administered in August 2020.13

Public Engagement

Students Perspectives

After spending a great deal of time engaging with the qualitative
analyses from the organizational survey, the student team hada strong sense of the diverse needs in Hawaiʻi communities in
response to the health, social, and economic consequences ofthe pandemic, especially from the organizational perspective.
They then looked more closely at the quickly growing literature

In this section, we share the specific learning experiences of ourInterdisciplinary Student Team members (shown in Figure; Dr.
Tetine Sentell of the UH Office of Public Health Studies, whocoordinated the student team engagement in summer 2020, is
also pictured).

Figure. From left to right, top to bottom: Tetine Sentell, Sydney Unciano, Kira Oyama, Chelsea
Emma Apo, Angel Lynn Talana, and Fary Maldonado at a Zoom team meeting celebrating Kira
Oyama’s completion of her public health nursing master’s degree.

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Fary Maldonado
I am a PhD student at the UH Mānoa Myron B. Thompson
School of Social Work with an interest in development ofinterventions for transitioning veterans as well as communitybased research and cross-cultural issues. By participating in the
project to identify community needs and concerns in the timesof the COVID-19 pandemic, I enhanced the scope of my skills
in community work and research. Being part of a project teamallowed me to practice collaboration, challenge myself with newtasks, and experience interdisciplinary cooperation. Apart from
improving my analytical and data collection skills, I succeeded
in integrating my communication skills when discussing thepossible issues related to COVID-19 health concerns with theteam. Also, the contemplation on the scope of needs in Hawai‘iin the face of the pandemic enriched my professional experience.
The project was a good collaborative learning opportunity.
The high values, ethics, and professionalism shown by eachmember of the team helped me grow and continue to develop
my academic skills. The fact that we all come from different
backgrounds and yet managed to engage in a very productive
manner speaks volumes about the knowledge obtained from ourprograms. Faculty offered valuable mentorship and expertise.
I benefited from observing the way tasks were conceived andaccomplished. The knowledge and skills obtained from working on this project will be a valuable contribution to my futureaccomplishments.
Angel Lynn Talana
I am a Master of Public Health (MPH) student at UH Mānoa
specializing in social and behavioral health sciences (SBHS).
During these past few months, I had the opportunity to work on
this project as part of my practicum and understand Hawaiʻi’scommunity needs in light of the COVID-19 pandemic. This
experience allowed me to garner valuable public health skills
such as interdisciplinary teamwork, project building, data
analysis, and health advocacy – important skills that I willundoubtedly use in future public health practice. By working
with different disciplines such as nursing and social work, theproject brought forth multiple perspectives of the pandemic
and provided opportunity for meaningful discussions of how
we can better serve our communities.
As an MPH SBHS student, I found it meaningful to examine
the socioeconomic impact of this pandemic on our communities
because understanding the community needs allows for better
advocacy for actions and policies that will protect Hawai‘i’smost vulnerable communities. I partnered with my fellow MPH
colleague Sydney Unciano and we passionately advocated for
Filipino health to be examined since Filipinos have been disproportionately impacted by this pandemic.12 It was exciting
to see our perspectives published in Civil Beat.

Public health plays such an important role in our community
health and it has been brought to the forefront because of thispandemic. However, it is also important to know that publichealth efforts will not end when this pandemic subsides andeverything is back to “normal.” Public health will continue toplay an important role in the future and this project has mademe become a better public health professional.
Sydney Unciano
I am also a MPH student specializing in SBHS at UH Mānoa.
As a participant in the HI-EMA interdisciplinary project for mymaster’s practicum project, I had the opportunity to work withstudents from various educational backgrounds. Working in
an interdisciplinary student team with nursing and social work
students introduced me to different care model perspectives.
This experience helped me develop effective communication
skills and taught me how to critically think of different ways
to approach these unprecedented community challenges. Someof the shared responsibilities we had included analyzing qualitative data, creating a formal report of the data analysis, andcompiling a list of informative and helpful resources. Asidefrom collaborating with students from different backgrounds,
one of my favorite parts about this opportunity was being able
to work with my colleague, Angel, and to use my educational
platform to help advocate for Filipino health in the community.12
From this project, I have observed the collaborative and diligent
efforts of my colleagues and leaders from multiple organizations
come together to provide support during this pandemic. I am
appreciative of the support and help of my colleagues during
this project, as well as the mentorship and guidance provided
to direct this project and connect us to various community networks. As the COVID-19 pandemic continues, it is evident that
this emergency will require the insights of various disciplines
at many different levels. I am optimistic that the continuing
efforts of HI-EMA and other associated organizations will beable to provide support during this time of need.
Kira Oyama
I am a graduate student who recently completed my degree in
population health nursing at UH Mānoa. I am also currently
working as a registered nurse at The Queen’s Medical Centerin Honolulu, in the intensive care unit. As a frontline healthcare
worker, I was provided the opportunity to be part of and witness
the COVID-19 response in the acute care setting. This stirred
up a lot of fear and anxiety among the hospital workers as there
were many concerns about adequate staffing and supplies.13
This sparked my interests in the public health approach to thepandemic, and I was granted the opportunity to work with thisinterdisciplinary group of students on understanding community
needs in Hawai‘i during this trying time.

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Through this experience I developed my data collecting andanalyzing skills and enhanced my communication abilities
through writing and teamwork. I was given the opportunity towork with an amazing group of strong, independent, and passionate leaders in the community who are going to continue
doing great work for the community. This experience increased
my appreciation for the job done in the public health sector aswell as highlighted the incredible challenges that come with it.
In what felt like such a short summer session, we accomplishedso much in sharing information with the public and highlighting
community needs. I look forward to seeing the great work myteammates continue to accomplish particularly as we continue
to deal with the short-term and long-term effects of this healthcare crisis.
Chelsea Emma Apo
I am a graduate student with the UH Mānoa School of Nursing
and Dental Hygiene with a background in acute care nursing anda Bachelor of Science in Public Health. As a student, I foundthat the coronavirus pandemic of 2020 presented a unique situation through which I could apply both my nursing and publichealth backgrounds and begin to work with professionals ofother disciplines in my community. I enjoyed having the opportunity to learn more about the effects of this novel outbreak
and to help inform others of the intricacies of needs, responses,
and public health considerations involved. I have always believed that health is the outcome of a multitude of factors, andit was interesting to see those factors and people working in
the professions that affect those factors come together to fight
COVID-19 in Hawai‘i.
Interdisciplinary Engagement and Student
Learning
The direct participation in the work of an interdisciplinary
team was a valuable experience that provided students with anopportunity to observe how emergencies like COVID-19 aremanaged on a community-level, including engagement with theacademic community.14 Interdisciplinary training remains critical to health training for the academic, health care, and publichealth communities in the time of COVID-19 and beyond.15
Challenges noted in the COVID-19 pandemic are interdisciplinary in nature, and their solutions must be as well. For
instance, population mental health needs have expanded dueto the increased level of uncertainty and anxiety related toisolation. This was a top community organization concern,
including access to behavioral health services. The shift totelemedicine services was also a concern, needing solutions
that include providers, the health care system, funders, software,
hardware, translation services, and instructions on the properuse of telehealth technologies. Basic needs (eg, housing, food),
financial concerns, and unemployment were all significant
concerns, as were health disparities. Some populations weredisproportionately impacted, including Pacific Islander andFilipino populations, elder populations, and those with chronic
conditions. We completed our initial organizational survey inApril and May when the scope and timing of the pandemic were
not clear. Schooling and childcare, while ranked as importantby organizations in the earlier survey, have since emerged aseven more critical to discussions. This area needs multi-sector
solutions to keep students, teachers, parents, and family members
safe and healthy, and keep teachers employed.
The idea of interdisciplinary work and interdisciplinary education are not new but are growing in health care and public health.
Even before this pandemic, a renewed focus on interdisciplinary
education emerged when 6 national health profession education
organizations came together in 2009 and committed to “advancing interprofessional learning experiences and promoting teambased care”16 These 6 organization formed the Interprofessional
Education Collaborative (IPEC) which would later expand toinclude 21 associations of health professional schools in 2016.16
The interdisciplinary student team discussed in this paperaligns to World Health Organization’s definition of interprofessional education, which is “when students from two or more
professions learn about, from, and with each other to enableeffective collaboration and improve health outcomes.”17 The
team furthermore demonstrated aspects of the 4 competencies
that fall under the domain of Interprofessional Collaboration:interpersonal teamwork and team-based practice, interprofessional communication practices, values/ethics for interprofessional practice, and roles and responsibilities for collaborative
practice.18 In its vision for the future, the Interprofessional
Education Collaborative sees “Interprofessional collaborative
practice drives, safe, high-quality, accessible, person-centeredcare and improved population health outcomes.”18 This vision isfurther supported in the literature that these teams can improvehealth care quality, including fewer medical errors, lower costs,
and shorter hospital stays for patients.19
Conclusions
Coordinating a safe response to an international emergency is an
unprecedented task that requires a vast array of support from thecommunity and a rapid response to quickly adapt to changing
policies. This Interdisciplinary Student Team provided valuable
contributions to the urgent COVID-19 response, enhanced theirown knowledge and learning, and also helped build a stronger
future for our community with new networks and understandingof new perspectives from collaborative learning opportunities.

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Authors’ Affiliations:- Office of Public Health Studies, Myron B. Thompson School of Social Work andPublic Health, University of Hawai‘i at Mānoa, Honolulu, HI (SU, ALT, TS)- Department of Social Work, Myron B. Thompson School of Social Work and Public
Health, University of Hawai‘i at Mānoa, Honolulu, HI (FM, RB, RA)- School of Nursing and Dental Hygiene at University of Hawai‘i at Mānoa,Honolulu, HI (KO, CEA, KQ)- John A Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (LB)

Acknowledgements
We thank Dr. Steven Hankins, ESF-8 Lead during summer 2020, for sharing
his insights with the Interdisciplinary Student Team even when he had somany responsibilities. We also thank the many distinguished members of ourcommunity advisory panel members for their invaluable insights throughout
this process. A special thanks to So Young Choi and Christine Chaplin for
their support of the community needs survey.
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Hawai‘i Journal of Health & Social Welfare(HJH&SW)
Guidelines for Publication of HJH&SW Supplements
The Hawai‘i Journal of Health & Social Welfare (HJH&SW) partners
with organizations, university divisions, and other research units to
produce topic-specific issues of the journal known as supplements.
Supplements must have educational value, be useful to HJH&SW
readers, and contain data not previously published elsewhere. Eachsupplement must have a sponsor(s) who will work with the HJH&SW
staff to coordinate all steps of the process. Please contact the editors at hjhsw@hawaii.edu for more information if you would liketo pursue creating a supplement.
The following are general guidelines for publication of supplements:
1. Organizations, university divisions, and other research units
considering publication of a sponsored supplement should consult
with the HJH&SW editorial staff to make certain the educational
objectives and value of the supplement are optimized during theplanning process.
2. Supplements should treat broad topics in an impartial and unbiased
manner. They must have educational value, be useful to HJH&SW
readership, and contain data not previously published elsewhere.
3. Supplements must have a sponsor who will act as the guest editorof the supplement. The sponsor will be responsible for every step of
the publication process including development of the theme/concept,
peer review, editing, preliminary copy editing (ie, proof reading
and first round of copy editing), and marketing of the publication.
HJH&SW staff will only be involved in layout, final copy editing
and reviewing final proofs. It is important that the sponsor is awareof all steps to publication. The sponsor will:a. Be the point of contact with HJH&SW for all issues
		 pertaining to the supplement.
b. Solicit and curate articles for the supplement.
c. Establish and oversee a peer review process that ensures		 the accuracy and validity of the articles.
d. Ensure that all articles adhere to the guidelines set forth		in journal’s Instructions to Authors page, especially		 the instructions for manuscript preparation
		 and the statistical guidelines.
e. Obtain a signed Copyright Transfer Agreement for each		 article from all authors.

f. Comply with all federal, state, and local laws, rules, and		 regulations that may be applicable in connection with		 the publication, including ensuring that no protected		 health information appears in any article.
g. Work with the editorial staff to create and adhere to		 a timeline for the publication of the supplement.
h. Communicate any issues or desired changes to the HJH&SW
		 staff in a timely manner.
4. Upon commissioning a supplement, the sponsor will be asked toestablish a timeline for the issue which the sponsor and the HJH&SW
editor(s) will sign. The following activities will be agreed uponwith journal publication to take place no later than 24 months after
signing. Extensions past the 24 months will be subject to additional
fees based on journal publication rates at that time:• Final date to submit a list of all articles, with working titles
		and authors• Final date for submitting Word documents for copy editing• Final date for submitting Word documents for layout• Final date to request changes to page proofs (Please note that		 changes to page proofs will be made only to fix any errors
		 that were introduced during layout. Other editing changes
		 will incur an additional fee of $50 per page.)
5. The cost of publication of a HJH&SW supplement is $5,000 for
an 8-article edition with an introduction from the sponsor or guest
editor. Additional articles can be purchased for $500 each with amaximum of 12 articles per supplement. This cost covers one roundof copy editing (up to 8 hours), layout, online publication with an accompanying press release, provision of electronic files, and indexingin PubMed Central, SCOPUS, and Embase. The layout editor will
email an invoice for 50% of the supplement to the designated editor
for payment upon signature of the contract. The remaining will be
due at the time of publication. Checks may be made out to UCERA.
6. The sponsor may decide to include advertisements in the supplement in order to defray costs. Please consult with the HJH&SW
advertising representative Michael Roth at 808-595-4124 or email
rothcomm@gmail.com for assistance.

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7. Supplement issues are posted on the HJH&SW website (http://
www.hawaiijournalhealth.org) as a full-text PDF (both of the whole
supplement as well as each article). An announcement of its availability will be made via a press release and through the HJH&SW
email distribution list. Full-text versions of the articles will also be
available on PubMed Central.
8. It is the responsibility of the sponsor to manage all editorial,
marketing, sales, and distribution functions. If you need assistance,
please contact the journal production editor. We may be able to help
for an additional fee.
9. The editorial board reserves the right of final review and approvalof all supplement contents. The HJH&SW will maintain the copyrightof all journal contents.
——————————
Sample Workflow and Timeline for a Supplement
1. The sponsor contacts the HJH&SW editors (hjhsw@hawaii.edu)
to discuss the supplement topic, estimated timeline, length and cost.
HJH&SW staff will review the journal requirements for articles andshare our review process with the sponsor. Time frame: 2 weeks
2. The sponsor will complete the draft contract and pay a non-refundable deposit of $2500 or half the contract value. Time frame: 3 days
3. The sponsor will solicit articles for the supplement. Time frame:
3-6 months
Articles must comply with:• Instructions for Manuscript Preparation and Submission
		of Research Articles• Instructions for Manuscript Preparation and Submission
		of Columns• HJH&SW Statistical Guidelines• HJH&SW Style Guide for Native Hawaiian Words and Phrases
		AMA Manual of Style A free summary can be found here.
4. The sponsor will oversee the article selection, peer review, andediting process. We recommend that time be allowed for at least
two rounds of reviews for each article. Time frame: 3-6 months• Ensure that each article includes Institutional Review Board
		 (IRB) review and approval, and a statement disclosing any
		 conflicts of interest.
• Obtain a Copyright Transfer Agreement signed by all authors		 for each article.

5. Optional: During this time, the sponsor can solicit advertisements
for the supplement to help defray costs for publication and/or printing. To initiate this process, the sponsor will work the HJH&SW
advertising representative Michael Roth at 808-595-4124 or rothcomm@gmail.com.
6. The sponsor or their designee will conduct a final review of eacharticle to ensure adherence to HJH&SW guidelines and AMA style.
Time frame: 2 weeks
7. For each article, the sponsor will submit the final Word document
and Copyright Transfer Agreement to the HJH&SW journal production editor. The journal production editor will send the articles
to the copy editor for final journal style review. Copyediting willbe 8 hours per edition plus 1 hour per article for additional articles
purchased. Any additional hours will be billed at $100 per hour.
Time frame: 2 weeks
8. The sponsor will submit the final articles to the layout editor forformatting. Time frame: 1 month
Acting in the role of guest editor, the sponsor will include a column
introducing the supplement.
IMPORTANT: All articles submitted for layout should be in their
finalized form. Page proofs will be returned to the sponsor for theirreview and approval, but changes will only be made to fix any errors that were introduced during the layout process. Any editing orchanges to the text or figures after the initial copy layout will incura fee of $50 per page.
9. The sponsor will review the electronic copy from the layout editor and submit any final corrections. Time frame: 5 working days
10. The layout editor will make the final corrections and provide afinished electronic copy of the supplement to the sponsoring editors
to allow time for printing.
11. The managing editor will work with the sponsor to draft a press
release. Sponsors should contact the managing editor at least 30
days prior to the date of publication to plan and script the press release. Sponsors are encouraged to submit 1-2 photos to accompany
the press release. Note that obtaining signed photo releases is the
responsibility of the sponsor.
12. The supplement will be published online along with the press
release. An electronic copy will be sent to our subscribers andcirculation lists, and the edition will be forwarded to the National
Library of Medicine for indexing and made available for no cost
access to the public.
Revised 2/6/20

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