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Background: Tuberculosis (TB) incidence rates in the Republic of the Marshall Islands are among the highest in the world, 480/100,000 in 2017. In response, the Health Ministry completed islandwide screening in Ebeye Island in 2017. Methods: Participants were interviewed to obtain TB history, exposures, and symptoms. TB assessment included chest radiography with sputum collection for GeneXpert® MTB-RIF if indicated. TB diagnosis was made by consensus of visiting TB experts. Participants were also screened for Hansen's disease (HD) and diabetes mellitus (DM). For persons aged ≥21 years, blood pressure, cholesterol, and blood glucose were assessed. Results: A total of 5,166 persons (90.0 % of target population) completed screening leading to the identification of 39 new cases of TB (755/100,000) and 14 persons with HD (270/100,000). DM was detected in 1,096 persons (27 %), including in 351 persons not previously diagnosed. The rate of hypertension was 61 % and of hypercholesterolemia was 15 %. New or prevalent TB diagnosis was associated with newly diagnosed or history of DM (aOR 4.68, 2.15-10.20). Conclusions: In Ebeye, an integrated TB screening campaign found TB, HD, DM, and hypertension. TB and DM were strongly associated.

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Popular media often positions the Marshall Islands as especially vulnerable to environmental shocks and shifts. This framing overlooks sources of vulnerability, local resilience, and within country differences. To better understand relationships between social, economic, and cultural shifts and vulnerability and resilience in the Marshall Islands, this study draws on interviews with internal migrants and members of government and civil society to investigate perceptions of vulnerability and resilience in outer islands and Majuro. Findings reveal sharp perceived differences. Participants largely tied vulnerability on outer islands to increasingly variable environmental conditions affecting natural resource-dependent livelihoods and vulnerability on Majuro to the cash economy. In both urban core and rural outer islands, participants linked vulnerability to interdependencies far beyond the Marshall Islands. By evaluating historical and external influences and spatial heterogeneity, this study supports a nuanced understanding of vulnerability and resilience within archipelagic countries critical to policy development.

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Background: Given the lack of healthcare access in the Republic of the Marshall Island (RMI) and the potential for complications related to type 2 diabetes mellitus (T2DM) and hypertension, it is crucial to examine these conditions among Marshallese in the RMI. Objectives: This study aims to identify the proportion of Marshallese adults in the RMI with undiagnosed T2DM and hypertension. Design: Using a community-based participatory research approach, screening events were conducted at 20 churches in Majuro Atoll. Methods: Participants completed a questionnaire and biometric data measures, including hemoglobin A1c and blood pressure. Results: Among participants with blood pressure data (N = 528), 11.9% had readings indicative of hypertension, and 38.1% were undiagnosed. Among participants with hemoglobin A1c (HbA1c) data (N = 450), 45.3% had readings indicative of T2DM, and 39.2% were undiagnosed. Conclusion: This study utilized a community-based participatory research approach that promotes equitable and ethical research. Results reaffirm the need to identify strategies for increasing healthcare access and for research to address health disparities in the RMI.

Study using data collected during health screenings in the Republic of the Marshall Islands (RMI) to identify the number of Marshallese people with undiagnosed diabetes and/or high blood pressure The Republic of the Marshall Island (RMI) is a nation located in the Pacific Ocean between Hawai'i and New Zealand. The RMI was the location of nuclear testing by the United States (US) in the 1940s and 1950s, changing the diet of Marshallese people, and leading to a high rate of type 2 diabetes and high blood pressure. However, healthcare in the RMI is less available than in the US, meaning Marshallese people may not be aware if they have these chronic conditions. The goal of our study was to determine the prevalence of undiagnosed type 2 diabetes and high blood pressure among participants in church-based health screenings in the RMI. The study team found that 38.1% of people with readings indicating type 2 diabetes and 39.2% of people with readings indicating high blood pressure were undiagnosed. These results show there is additional work needed in the RMI to increase access to healthcare services.

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AIMS: The aim of this study is to assess and document engagement in type 2 diabetes mellitus (T2DM) self-care behaviors and self-reported diabetes knowledge among Marshallese adults living in the Republic of the Marshall Islands (RMI). METHODS: The study uses data from a T2DM health screening study completed in the RMI; survey and biometric data were captured as part of the health screenings. Study objectives were examined using descriptive statistics to describe the characteristics of the participants, their diabetes self-care behaviors, and their levels of self-reported diabetes knowledge. RESULTS: Results indicate many Marshallese diagnosed with T2DM did not engage in adequate self-care behaviors, including blood sugar checks and foot examinations. Participants reported having forgone needed medical care and medication due to issues with cost and/or access, and participants reported low levels of diabetes knowledge. CONCLUSIONS: The results demonstrate the need for further work in improving engagement in diabetes self-care by Marshallese living in the RMI. Increased engagement in self-care and diabetes education programs may help Marshallese with T2DM to improve control of their glucose and avoid long-term health complications, as well as reduce costs to the healthcare system.

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@#Objective: A study was conducted to determine the seroprevalence of chronic hepatitis B virus (HBV) infection among children and their mothers on Kwajalein Atoll in the Marshall Islands two decades after routine vaccination was introduced in the 1990s. Mothers’ knowledge and attitudes towards HBV disease and vaccination were also assessed. Methods: Results of a national seroprevalence survey conducted in 2016–2017 and antenatal records were used to determine the prevalence of HBV seropositivity in children aged 6–8 years and their biological mothers. The associations between demographic, social and vaccination-related factors and seropositivity were explored using Fisher’s exact tests. Results: HBV seroprevalence was 0.3% in children and 6.8% in their mothers (during pregnancy). Coverage of timely HBV vaccination was 90.3% for the birth dose and was significantly associated with factors related to place of residence (P < 0.001), place of birth (P < 0.001) and number of antenatal visits (P < 0.001). Maternal attitudes towards infant vaccination and antenatal screening were largely positive (95.8% and 96.7%, respectively) despite low vaccination rates (20.9%) among mothers. Knowledge levels were low for disease complications, treatment and transmission. Discussion: Prevalence of HBV in children and mothers residing on Kwajalein Atoll in 2016–2017 was lower than the national average for the Marshall Islands. Timely birth dose administration appears to have been effective in preventing mother-to-child transmission of HBV in this setting and should be promoted in remote settings where antiviral therapy is not available. Provision of out-of-cold-chain HBV vaccines should be considered to improve access in remote settings.

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Background: The Republic of the Marshall Islands (RMI) faces a high prevalence of type 2 diabetes (T2DM). Objectives: The aim of the study is to document the health of Marshallese with and without a T2DM diagnosis to inform future interventions. Design: Data are from screenings collected in preparation for a diabetes education intervention. Data, including HbA1c, random glucose, cholesterol, weight, and self-rated health, were collected. Methods: Kruskal-Wallis and Fisher's exact tests were used to identify differences in participants with and without T2DM diagnosis. Results: There were significant differences in both HbA1c level (P ⩽ .0001) and glucose level (P ⩽ .0001) between the diagnosed T2DM and non-diagnosed T2DM groups, as well as diastolic blood pressure (P = .0179), systolic blood pressure (P = .0003), and pulse pressure (P = .0023). There were no differences in weight, body mass index (BMI), high density lipoprotein (HDL), low density lipoprotein (LDL), total cholesterol, or self-rated health. Marshallese without a T2DM diagnosis have signs of insulin resistance, including elevated glucose and triglyceride levels. Conclusion: The results indicate a need for a socioecological approach to T2DM interventions, and interventions in the RMI should consider inclusion of blood pressure and cholesterol management. There is a need for interventions to prevent prediabetes and its progression to T2DM.

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Migration as adaptation implies agency, yet environmental and non-environmental factors and their interactions may limit the availability of adaptation options, including migration. This study investigates migration agency in the Marshall Islands, particularly the role of geographic isolation and climate change. Interviews with internal migrants living in Majuro and members of government and civil society reveal how social, economic, cultural, and environmental factors shape migration contexts. Results suggest that geographic isolation-related factors may increase likelihoods of simultaneously more compelled and more constrained moves, particularly as climate change impacts increase. Climate change-related impacts on resource-dependent livelihoods may compel migration in search of new economic opportunities. However, worsening environmental conditions may also exacerbate cost-related migration constraints by reducing the resources available to support migration.

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A questionnaire survey was conducted in the Marshall Islands among 308 citizens of Majuro in order to analyze the factors that led them to immigrate. Using the results from the questionnaire items that indicate the motivations for emigration as independent variables, we extracted the factors with significantly high correlation coefficients; they suggest that the desire to escape from the many obligations within the family and regional community are predominant push factors for migrating overseas while the economic disparity between the United State and their home countries are predominant pull factors. Independently, the Permutation Feature Importance was used to extract the salient factors motivating migration, which provides similar results. Furthermore, the result of structural equation modeling verified the hypothesis that an escape from many obligations and economic disparity is a major motivation for migration at a significance level of 0.1%.

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Introduction: Striking health disparities exist in the Republic of the Marshall Islands (RMI). The RMI has one of the highest age-adjusted type 2 diabetes mellitus (T2DM) rates in the world (23.0%) compared to global (9.3%) and United States (US; 13.3%) rates. We conducted health screenings including clinical indicators of T2DM and hypertension among Marshallese in the RMI. Methods: Screenings were conducted at 20 churches on Majuro Atoll. Participants completed questionnaires and biometric data collection assessing glycated hemoglobin (HbA1c), blood pressure, and body mass index. Results: Screenings included 528 participants and showed a high prevalence of T2DM, obesity, and hypertension. One-third of participants were referred to the non-communicable disease clinic. The percent of adults in this study with T2DM-indicative HbA1c (48.5%) is higher than observed at the national level (23.0%). Discussion: Results highlight the need for non-communicable disease-related programs in the RMI.

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Background: The Republic of the Marshall Islands (RMI) has a high rate of type 2 diabetes mellitus (T2DM). To address the high rate of T2DM, we tested a culturally adapted family model of diabetes self-management education and support (F-DSMES). We report the results of the 12-month post-intervention data collection and describe the lessons learned from the delivery of the F-DSMES intervention. Methods: Recruitment took place in four churches in Majuro and included 10 h of content delivered over 8-10 weeks. Forty-one participants with T2DM were included. The primary study outcome was glycemic control measured by a change in HbA1c. We also conducted participant interviews to document the participant-reported barriers encountered during the F-DSMES intervention. Results: Participants did not show improvements in their biometric markers; however, participants did show improvement on multiple measures of diabetes knowledge and family support. We identified five areas to improve future interventions: 1) issues with recruitment, retention, and attendance; 2) needing help accessing information and additional healthcare provider counseling; 3) struggles with adhering to diet recommendations; 4) difficulty getting exercise, and 5) improving lessons within the intervention. Conclusion: Although the biomarker data did not show improvement, valuable information was gained to improve the development of larger-scale trials. The results provide evidence of the need for these trials and the desire of participants to continue pursuing this effort. Others doing similar work in other low-to-middle income countries will need to take into consideration the potential barriers and facilitators within participants' social and physical environments.

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This interdisciplinary study falls within the realm of ethnoscience thanks to its resorting to the scientific methods behind the Micronesian canoe voyaging in search of bioimaging tools for the early prediction of cell fate in response to a therapy. Two distinct indigenous methods for navigation across the ocean were assessed as bridges for correlating (i) the interaction of oceanic swells near atolls with the way microcurrents in the cell culture dish may shape the morphology of cells, and (ii) the spatial arrangement of cultured cells with the canoe voyaging from one island to the next. Both methods effectively predicted the cell fate at early time points in the treatment with superparamagnetic nanoparticles, when the adverse effects were still reversible and not apparent yet at the levels of cell morphology, proliferation rate or confluence. The mattang chart, the most fundamental and theoretical of navigational devices used in the Marshallese seafaring tradition, was used to measure subtle morphological changes occurring in cells due to the treatment. The cells subjected to the treatment were consistently withdrawing their bodies from the areas of intense swell interaction activity on the superimposed mattangs. Given that the cytoskeletal microfilaments defining the features of control cells were largely filling up these areas, this metric proved useful for deducing the course of the treatment at its early stages. The same deduction was proven feasible with the use of a Carolinian navigational technique based on the concept of the etak, in which case the distances traversable between cells in a population subjected to the treatment were divisible to a significantly higher number of etaks than the same distances in the population of control cells. Therefore, treating cells and their nuclei as analogous to Pacific atolls navigable to and fro with the use of imaginary microscopic canoes and the navigational principles native to the Marshall and the Caroline Islands proves as a clever, but also very effective cell fate prediction approach, which various branches of biomedical science could take advantage of. These practical benefits notwithstanding, this conceptual study was performed primarily with a goal to spark the interest in studying these and other ancient ethnoscientific inventions as potential addenda to the broad repertoire of techniques used in biomedical and other sciences to combat some of their greatest challenges.

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Climate change threatens global mangroves, which are already among the world's most impacted ecosystems. Vulnerability components of exposure, sensitivity and adaptive capacity were evaluated on mangroves of atoll settings on Jaluit Atoll, in the Marshall Islands, assessing spatial changes of mangrove cover 1945-2018/19, sea-level trends 1968-2019, and reviewing available information. Inland mangrove depressions occur on Jaluit, as well as coastal lagoon margin mangroves, and both were assessed using the same methods. Spatial analysis results showed both inland and coastal mangroves have increased in area. Inland mangroves on eight of Jaluit's islands mostly expanded after 1976 from 40 to 50 hectares, with progradation and tidal creek infill closing lagoon connections. Shoreline mangroves showed 88-100% of transects prograding 0.1-0.51 m year-1 and 0-11.5% of transects eroding 0-0.18 m year-1. Assessment of a combination of aerial/satellite images, literature and on-the-ground photos indicated that the mangroves are in healthy condition. Vulnerability assessment results showed both inland and coastal mangroves to have similar strengths and weaknesses in resilience, with intrinsic areas of vulnerability persisting during increased future sea level rise, limited sediment supply and extremely low elevations. Supplementary Information: The online version contains supplementary material available at 10.1007/s11273-022-09878-0.

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BACKGROUND: Pacific Islanders in the United States have lower initiation rates and shorter duration of exclusive breastfeeding compared to other racial/ethnic groups. RESEARCH AIM: To describe infant feeding beliefs and experiences of Marshallese living in the United States. METHODS: We used a prospective and cross-sectional exploratory, descriptive qualitative design with Marshallese participants (N = 36) residing in the United States between July 2019 and July 2020. Data were collected at 6-8 weeks postpartum. Our qualitative analytic approach integrated inductive and deductive techniques. RESULTS: Participants' mean age was 27.1 years (SD = 6.1), and 88.9% (n = 32) were born in the Marshall Islands. A majority of participants were single, widowed, or in an unmarried partnership (n = 28, 77.8%). Most participants had a high school education or lower (n = 30, 83.3%). Mean household size was 7.2 (SD = 2.8). Fewer than half of participants had no health insurance (n = 14, 38.9%), and almost all participants (91.7%) did not work at the time of data collection. Two themes emerged: 1) infant feeding initiation and practices; and 2) concerns over breastfeeding in public. The majority of participants' infants received both human milk and formula. Participants described beliefs that breastfeeding in public was against American customs, which influenced their decision about breastfeeding in public. CONCLUSIONS: Our study was the first to document infant feeding beliefs and experiences of Marshallese living in the United States at 6-8 weeks postpartum. Findings will inform future health education programs.

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We present plutonium (Pu) and uranium (U) isotopic fingerprints (or signatures) in environmental samples collected at Bikar Atoll. Bikar is the second -most northern atoll of the Republic of the Marshall Islands, and therefore an important reference point to evaluate the extension of the regional fallout from the Pacific Proving Grounds (PPG) in Bikini and Enewetak Atolls. Previous studies have shown that regional fallout from atmospheric nuclear weapon testing (NWT) in Bikini and Enewetak has resulted in elevated levels of fallout radionuclides in this atoll. In order to optimally interpret the isotopic fingerprints, we compare our results with data obtained in eleven certified reference materials, representing different contamination sources. As well as 238Pu, 239Pu, 240Pu, 241Pu, 238U and 235U, this study also encompasses less commonly reported radionuclides such as 242Pu, 244Pu and 236U. We show the importance of combining numerous fingerprints for improved assessment of the source of a nuclear contamination. In samples from Bikar, Pu and U isotope ratios were found to vary within narrow ranges. Pu and U fingerprints suggest that regional fallout from the Castle Bravo test in March 1954 was the main source of the contamination. This was further confirmed by two different age dating approaches that estimated 1954 as the year of the contamination. We demonstrate that use of an exponential function to approximate the yield of heavy radionuclides in thermonuclear explosions with increasing mass is a valid approach for estimating the age of a contamination. We show that, if sufficient radionuclide activity concentration measurement results with low uncertainties are available, this method is robust.

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The Bikar and Bokak Atolls, located in the northern Marshall Islands, are extremely isolated and consist of pristine marine and terrestrial ecosystems. Both atolls may have experienced significant radioactive deposition following the nuclear weapon testing conducted at Bikini and Enewetak proving grounds. Here we report activity concentrations of artificial radionuclides (239Pu, 240Pu, 241Pu, 241Am, 137Cs and 90Sr) in marine and terrestrial samples collected from Bikar and Bokak Atolls. Artificial radionuclides in soil from the Majuro Atoll are also reported and form a radiological baseline against which the levels at the other atolls can be compared. We observed low levels of artificial radionuclides in soil from Majuro and Bokak, but significantly higher levels in soil from Bikar. The residual radioactivity in the Bikar environment is comparable to the levels previously reported for other nearby atolls, including Taka and Utrik, but lower than for Rongerik, Rongelap, Bikini and Enewetak. An analysis of 240Pu/239Pu isotope ratios and estimations of the dates of contamination from 241Am/241Pu activity ratios both indicated that the Bikar Atoll was contaminated mainly by radioactive fallout from the Castle Bravo test in 1954. We compare the results of our measurements at Bikar and Bokak to data from other atolls in the Marshall Islands and to regions of the world affected by both global and regional fallout from atmospheric nuclear weapons testing and nuclear accidents.

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BACKGROUND: The study aimed to estimate the prevalence and associated factors of cancer screening among men and women in the general population in Marshall Islands. METHODS: The national cross-sectional sub-study population consisted of 2,813 persons aged 21-75 years (Median = 37.4 years) from the "2017/2018 Marshall Islands STEPS survey". Information about cancer screening uptake included Pap smear or Vaginal Inspection with Acetic Acid (=VIA), clinical breast examination, mammography, faecal occult blood test (FOBT), and colonoscopy. RESULTS: The prevalence of past 2 years mammography screening was 21.7% among women aged 50-74 years, past year CBE 15.9% among women aged 40 years and older, past 3 years Pap smear or VIA 32.6% among women 21-65 years, past year FOBT 21.8% among women and 22.3% among men aged 50-75 years, and past 10 years colonoscopy 9.1% among women and 7.3% among men aged 50-75 years. In adjusted logistic regression, cholesterol screening (AOR: 1.91, 95% CI: 1.07-3.41) was associated with past 2 years mammography screening among women aged 50-74 years. Blood pressure screening (AOR: 2.39, 95% CI: 1.71-3.35), glucose screening (AOR: 1.59, 95% CI: 1.13-2.23), dental visit in the past year (AOR: 1.51, 95% CI: 1.17, 1.96), binge drinking (AOR: 1.88, 95% CI: 1.07-3.30), and 2-3 servings of fruit and vegetable consumption a day (AOR: 1.42, 95% CI: 1.03-1.95) were positively and high physical activity (30 days a month) (AOR: 0.56, 95% CI: 0.41-0.76) was negatively associated with Pap smear or VIA screening among women aged 21-65 years. Higher education (AOR: 2.58, 95% CI: 1.02-6.58), and cholesterol screening (AOR: 2.87, 95% CI: 1.48-5.59), were positively and current smoking (AOR: 0.09, 95% CI: 0.01-0.65) was negatively associated with past 10 years colonoscopy uptake among 50-75 year-olds. CONCLUSION: The study showed a low cancer screening uptake, and several factors were identified that can assist in promoting cancer screening in Marshall Islands.

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BACKGROUND: Marshallese living in the Republic of the Marshall Islands (RMI) experience significant health disparities, with high rates of type 2 diabetes mellitus. In addition to health disparities, the RMI experienced nuclear testing that exposed inhabitants to nuclear fallout, unethical research practices, and contaminated natural food sources. OBJECTIVES: This research uses a community-based participatory research (CBPR) approach to effectively engage community partners and honor their contributions in all stages of the research. A CBPR approach will leverage culturally situated knowledge and practices of the Marshallese community in the RMI to ensure the success of the research. METHODS: This manuscript describes the methods used to test the feasibility of delivering a culturally adapted family model of diabetes self-management education and support in faith-based organizations in the RMI. CONCLUSIONS: This manuscript describes the protocol for creating working with community partners and implementing a feasibility study in the RMI.

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Adaptation to drought is particularly challenging on remote island atolls, such as those found in the Republic of the Marshall Islands (RMI), a nation of 58,000 populating 29 low-lying coral atolls spread over >2 million km2. Exposure to consecutive atmospheric hazards, such as meteorological floods and droughts diminish scarce water resources and erode the resilience of island communities. Drought impact mitigation measures must supply emergency drinking water to stricken communities, while simultaneously conserving natural sources in order to reduce their vulnerability to subsequent events. Household surveys (n = 298) and focus group discussions (n = 16) in eight RMI communities revealed that 86% of households have experienced drought and 88% reported using multiple water sources to meet normal household needs. With no surface water and a thin freshwater lens (FWL), rainwater collected from rooftops is the most common household water source. The traditional use of carved hollows in the base of coconut trees to collect rainwater ("Mammaks") appears to have been displaced by large rainwater tanks. However, rationing of rainwater for consumption only during drought was widely reported, with private wells supporting non-consumptive uses. Reverse osmosis (RO) desalination units have provided relief during drought emergencies but concerns have been raised around dependency, maintenance challenges, and loss of traditional water practices. Most notably, RO use has the potential to change the anthroposhpere by adversely affecting the FWL; 86% of RO units were installed at island-centre where excessive pumping can cause upconing, making the FWL brackish. Balancing the introduction of desalination technology to mitigate water shortages with maintenance of traditional water conservation practices to preserve the quantity and quality of the FWL is a promising strategy on island atolls that requires further investigation.

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Many low- and middle-income countries are faced with a double burden of malnutrition characterized by a stagnating burden of undernutrition and an increasing prevalence of overweight and obesity often observed both at population and household levels. We used data from the 2017 National Integrated Child Health and Nutrition Survey in the Republic of the Marshall Islands to explore the prevalence of overweight mother-stunted child pairs (mother-child double burden, MCDB). We used bivariate analysis, multivariate logistic regression, and multinomial logistic regression analysis to explore associations between child-, maternal-, and household-level variables and both stunting and MCDB and other types of maternal-child pairs. Our results indicate that nearly three out of four mothers were overweight or obese and one in four households is home to an overweight mother with a stunted child. The risk of child stunting and of MCDB were largely associated with maternal characteristics of lower maternal height, maternal age at birth, years of education, and marital status and household economic status as measured by wealth index and number of household members. These findings support the growing body of evidence showing that the coexistence of high maternal overweight and child stunting (MCDB) has linked root causes to early life undernutrition that are exacerbated by the nutrition transition.

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The prevalence of non-communicable diseases (NCDs) is rapidly increasing in low and middle income countries (LMIC). The Republic of the Marshall Islands is an island country in the Pacific located near the equator and has the third highest prevalence of diabetes in the world, high rates of complications, and early mortality with limited or no resources for tertiary care of these complications. Given the limited resources of the country, there is a need for strategies which emphasize NCD prevention. E-health interventions are becoming more popular in LMICs. A rapid qualitative assessment, involving focus groups, site visits, and key informant interviews, was performed to ascertain community perceptions about the causes of NCDs including diabetes and potential solutions. An assessment of the technology infrastructure was conducted to assess capacity for potential e-health interventions. Thirty local participants were interviewed. Participants identified diabetes as the highest priority NCD with dietary shifts toward imported, processed foods and decrease in physical activity as the major causes. Text messaging and Facebook were found to be widely utilized for personal and public communication. Given the low-tech, low-cost communication mechanisms and widespread use of Facebook, a social media intervention could help support local NCD prevention communications initiatives.

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