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Drug use and diabetic disease in American Samoa: a quality study
Twenty-two percent of adult Samoa (AS) suffer from terminal kidney transplant. The best way to manage diabetics is through changes in diets and lifestyles and stringent drug use. The use of medicines and thus the use of medicines may be affected by this. The aim of this survey is to investigate the experience and understanding of the use of antidiabetic drugs and related behavioural convictions among adult patients with diabetic and health care-related illness.
Sixty-nine focal groups were carried out with 39 AS adult diabetics and one-on-one surveys with 13 diabetic healers. Topics of drug use and intake were diagnosed. Patient and provider reports that barrier such as drug embarrassment and concerns about drug cost have a negative effect on drug use, while culture and commitments have both positive and negative effects on drug use.
The results help to illustrate the link between drug use and adult cultures with diabetic disease and underline the importance of continuous research within this group. Diabetic disease is a major disease affecting 220 million people worldwide. The number of people with diabetic disease is expected to have doubled by 2030, affecting 439 million or 7 million people.
7% of all adults. Diabetics are associated with an elevated level of risks of cardiovascular diseases, strokes, neuropathy, retainopathy and mortality and thus with very high health outcomes. The United States has 11. 3% of the adult population, 20 years and older, diabetes, and in 2007 the United States spent more than $174 billion on it.
It is likely that diabetes-related disease will cause further increases in disease susceptibility, death and health costs. Recent modernised countries such as the Pacific Islands have disproportionate levels of diabetic prevalence[4, 5]. In 2002, for example, almost 22% of adult on US Samoa soil had 11.
3 percent in the less modernised Samoa country in 2003. Research is therefore necessary to enable the adjustment of current intervention to this culture as well. It will examine some of the culture prospects for taking drugs for treating diabetic diseases in this environment. Managing diabetics is a complex and lengthy procedure that is often a major challenge for the patient and health care provider.
Regimes embrace diet/witness change and severe drug adhesion and blood sugar tests[3, 6, 7]. People suffering from diabetics need to understand their state of health enough to be able to interact with vendors and transform what they and their vendors know into effective self-management. In comparison to people with severe diseases, people with chronical diseases such as diabetics have lower drug intake levels, especially after the first 5-6 months.
It is likely because antidiabetic drugs have a preventive effect and do not offer the beneficial benefits associated with immediate symptomatic alleviation. Cramer  systematically reviewed trials that covered compliance with diabetic drugs and found that 36-93% of adult patients with diabetic drugs (i.e., orally administered hypoglycaemic drugs, insulin) were adhering to their drugs.
Since non-compliance with drugs is associated with an elevated risks of unwanted incidents, hospitalisation and mortality, research has been looking for ways to increase compliance by identification of features associated with it. Compliance with medicines is linked to the following characteristics: younger ages, women's sex, higher levels of educational attainment, ethnic origin from Europe, the West, high socio-economic standing, fear or depressive disorder, ease of treatment, high drug awareness, high levels of medical competence, high levels of societal assistance and the use of several drug-reminder strategies[8, 11-17].
On the other hand, non-compliance with medicines is specifically associated with specific issues such as poor medical coverage, impediments to good nutrition and physical activity, poor healthcare skills, culture disparities, oblivion and other priorities[8, 18, 19]. There is a strong link between non-compliance and the discovery of at least one obstacle to drug use[15, 20].
To better understanding non-compliance, scientists have studied the drug roles of people with diabetes[16, 18, 21, 22]. Mann et al.  examined predicts for compliance with diabetic drugs in US city pediatricians. Respondents were asked about their opinions on diabetics and antidiabetic drugs using surveys.
Compliance with antidiabetic drugs was assessed using the moralisky drug liability scale. The results showed that 25% of our clients had bad drug use. A low level of drug use was associated with the belief that diabetics only occur when levels of glycemia are high, the use of drugs when levels of glycemia are high, concerns about the side effect of diabetic drugs, low self-confidence in managing diabetics, and the sense that taking drugs is hard.
Another survey by Mann et al.  evaluated information and convictions about diabetic and diabetic drugs in low-income racial/ethnic minority groups with adiabetes. More than half said they could "feel" when their sugar level was "high", but thought it was only high when it was >200 mg/dl. Almost a third of the respondents thought that a doctor could treat them from it.
With regard to medicines, 23% thought they would not need to take their medicines if sugar level was above average, 39% said they were anxious about possible side effect of medicines, 16% were afraid they would become addicts and 18% said it was hard to take medicines. The results of these studies[18, 22] are not consistent with a chronical pattern of diabetic diseases, as people report treating their diabetics as an urgent rather than a chronical one.
Clinical research should focus on patient and provider convictions and misunderstandings about drug use and diabetic medicine as many of them may be amenable. The research should examine the perception of diabetic sufferers and suppliers in terms of understanding and belief about diabetic and diabetic drugs in order to identify possible misjudgements and understanding possible obstacles on both sides.
The results can be used to enhance diabetic control and drug use. The use of medicines and thus the taking of medicines can also be influenced by the culture. Harmony in Polish culture such as Samoa, Tonga and Tuvalu is a major part of our overall well-being, so that we are not regarded as fit if our relations are not in order.
People from Polynesia have often expressed a plurality of attitudes towards healthcare or are affected by West and the Tradition. Since many Pacific Islanders have grown up in West Africa and are therefore subject to West medicine, they can learn from both local and West Asian convictions about both. The Samoans' belief in disease in Samoa and New Zealand was evaluated by Norris et al.  to see how they use both conventional and traditional treatments and cures.
Writers report that Samoans have two disease management regimes (traditional vs. Western) and they often try and mistake which diseases are Samoan and which diseases are occidental, depending on which treatments are used. It is particularly important because it is believed that Samoan diseases are best dealt with by Samoan drugs, while diseases of the West or Palagia such as diabetics are best dealt with by West medicines.
In Samoan culture, the writers also report that members of the Samoan families often interfere with the individual's belief in what a disease is and how it should be cured. As a result, certain culture factors can have an impact on drug use and thus on drug use. There is no known research that has investigated the belief in the use of drugs in Samoan adult patients, neither in the Samoan Islands nor in the various major Samoan countries to which Samoan societies belong (e.g. USA, New Zealand, Australia).
This analysis is part of a wider survey collecting quality information on diabetic treatment (barriers and intermediaries to diabetic care) of American Samoan adult patients with diabetic disease and diabetic service provider in a Samoa Municipal Medical Centre. It was a major milestone in the culture translations of a diabetic interventional study[see 26, 27].
The focus of this paper is specifically on information related to drug use, in particular how it overlaps with the Samoan cultures and practice in adult people with oncology. Therefore, the attendees include suppliers and diabetic medicine sufferers. In this paper, we compare the perception of drug use and drug care professionals with the expectations that the results would influence drug use interventions in this multiculturalized world.
Sixty-nine Samoan American adult types 2 sufferers and 13 individuals were interviewed by health service professionals. We were looking for both patients' and providers' prospects in order to find out more about the obstacles and simplifications in the field of diabetic treatment. Attendees in the focal group were chosen from the Tafuna Family Health Center (TFHC) American Samoa Patients' Register and encouraged to attend.
The TFHC is a medical centre run by the US Department of Public Hospitals in Samoa and referred to by the US Office of Public Hospitals as a municipal sanator. Recruiting from a register of socio-demographic descriptions for participating in focal groups, we looked for a balanced mix of sex, ages and village communities in the clinic's area.
Each of the individually interviewed medical care provider interacting with diabetic clients was interviewed. The course has been endorsed by the Institutional Review Boards of Brown University and the American Samoa Department of Health. In Samoan, US-Samoan volunteers carried out focal groups and one-on-one English language interviewing by Brown University sales representatives.
A Samoan way of life]; (2) convictions and obstacles in connection with proposed interventions strategy; and (3) convictions and obstacles in connection with advice on the treatment of diabetic diseases and self-management. From time to time during the focal groups, attendees asked their diabetic needs. Moderators and other members of the Samoan language community translate the scripts of the group.
Ambiguous parts were emphasized and checked in the Samoan transcriptions by Samoan researchers. However, for the purpose of this script, only those sections relating to the wide range of drug use and compliance with diabetic drugs have been encoded into more specialised classes. Topics related to drug use and the interface between Samoan civilization and drug use were addressed in this work.
Samoan Samoans with relapsing-remitting kidney disease were the main target group for this study (N?=N?). There was a big difference in training, with some having received no training and others up to 16 years of age. Many of them also told about a broad spectrum of years since the disease was detected; some recently discovered that they had diabetics, while many have known about their disease for many years.
It' remarkable that many of the target group sufferers could have had diabetic for years without it. Refer to Chart 1 for more demographics for focal group patient information. Health service provider (N =N ) were predominantly women (N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N =N) Health care professionals included nursing staff, doctors, emergency services and an administrative officer with a medical history.
The results were many years of training and expertise in dealing with people with diabetics. In addition, most (N =N , 85%) of health care professionals report at least 5 years of working with diabetic people. Chart 2 provides more detailled demographics information for service suppliers who have conducted one-on-one interview.
Thirteen commentaries (from 12 different patients) from members of the focal group were concerned about possible side effect of drugs. They also found that their fears about side effect often resulted in drug non-compliance. People often voiced insecurity about what constitutes high vs. low glucose and how they could use drugs to monitor their glucose levels.
Indeed, 11 commentaries (11 patients) related to this concern: I don't see why it does[blood sugar] - sometimes it goes up and sometimes down. Four people in five commentaries on the high price of diabetic drugs in American Samoa ($10 co-payment). You found that the drug price is an obstacle to taking drugs.
A number of families who live outside the islands have purchased and shipped drugs, while others have described that the supply of Samoan drugs (e.g. sour-sop leaf juice) in conjunction with high drug prices (e.g. inulin, glucophage) has prevented them from taking their prescription diabetic drugs.
Because it is too costly here in Samoa our strip and injection systems are supplied by our children off the Isle. Every time a tutor says that there is a beautiful Samoan remedy somewhere, I will immediately get a can. The Samoan culture has influenced the adhesiveness of many people.
In particular, they noted the importance of following the advice of health service providers to honour their family and God. Twelve people in 17 commentaries said they should endorse their doctors' proposals for the treatment of their diabetic disease. "In 14 commentaries, 10 people found that they should take charge of themselves to honour God or their family.
He created our body to know the issues and the things we are to do. A lot of focal group participants report non-compliance with medicines due to conflict with the families, culture commitments or beliefs in Samoan medicines. Seven respondents said that the Samoan preferences for conventional medicines were an obstacle to compliance with West medicines.
In addition, they report that commitments to the Samoan host families or folk culture such as fa'alavelave (a Samoan life cycle celebration) could influence compliance. At the moment I like to take the Samoan sheets. I think there are those who do not believe in the prescription but are willing to take Samoan medicines; but in my opinion our kind of illness (diabetes) does not work with Samoan medicines.
If there is a fa'alavelave, for example in my wife's household, and there is no cash to do things, then your BP rises and your glucose rises.... I think this is one of the main causes of the illnesses and their development, that this illness comes quickly to us Samoans.
From all 13 surveys of health care service companies, the following five topics were selected and saturated. Health care companies have described possible causes of non-compliance with drugs in their diabetic population. For many vendors, it felt that they were not adhering to medicines because they did not fully comprehend how and when to take their medicines (23 comments/10 vendors).
Furthermore, some vendors thought that drugs might not bind them because they "didn't care" (eight comments/five vendors). Other people feared that they were not used to taking drugs to treat diseases (seven comments/five providers). You ( the patients) do not understand the right moment to take the medicine and the right moment to take the food.
That'?s the most important thing, and sometimes they just don't give a damn. You just don't mind your medications and you just forgot to food and you just start taking it first and you just forgot to take the medications and then you take the medications at the right moment. Samoans, some of them are not very zealous or perhaps they do not comprehend, or have an "I don't care" attitud.
Health care professionals report that diabetic medication is used more often when they feel upset. This perception was described in 14 commentaries by six vendors. The issue is in line with the fact that some vendors believed that non-compliance may be due to patients' lack of familiarity with taking medicines to treat diseases.
They think that the medications you take today for your problems will only cure it, for example, if you have a cutting and the medications you take today - only today and it will do so. They don't know that if you don't take this illness in you now, it will give you more inconvenience.
Twenty commentaries (11 providers) found that in American Samoa diabetic drugs are costly and often diabetic-prone. For example, the high costs of diabetic drugs in American Samoa were an obstacle to taking the drugs. Health care companies also indicated that the chemist generally no longer had any drugs available.
Consequently, drugs were often not available and often the patient could not fill out their prescription. They sometimes stop taking the medication when they run out of cash and they don't have enough cash to replenish. You say: I have no moneys. Drugstore - they always run out of drugs.
The humans are without drugs and all the times we try to upbring them. When you do not have the medicine available because we only have one drugstore in Faga'alu, then please work with the diets and movements during this period.... Here is the diets you use when you are on medications and when you are on this kind of diets without[medication].
Seven health professionals described in 12 commentaries that people prefer to get immediate counseling on how to deal with their diabetic condition. A number of vendors thought that having contact with diabetic treatment could help people understand how to treat themselves with diabetics and how to take medicines. The suppliers also thought that self-care was the responsability of the individual case (nine comments/six participants).
Six vendors in nine commentaries report that out of mutual regard for their family, people should follow the doctors' self-help counsel. "Sometimes you have to tell them the honest truths about what will come if they don't take good personal time. That'?s what you can do by taking good look after yourself.
" When you are diabetics, take your own personal attention, take your own drugs and work out. Non-compliance has been described in the light of familial or culturally responsibilities or belief in Samoan drugs. Health practitioners report that commitments to familial or folk festivals such as Fa'alavelave and faith in the use of Samoan drugs sometimes affect drug intake or use.
Suppliers indicated that patients' commitments to celebration of their families or culture affected their compliance with medication (13 commentaries/10 suppliers). Six vendors in eight commentaries report that people often prefer using Samoan medicine rather than West African drugs to treat diseases, which include diabetics. They ( "patients") don't think about their invoices.
Have you got a medicine - do you have a medicine at home? "You have to take charge of yourself - then you have to take charge of the problem with your whole being. She ( "patients") appreciate the familiy and fa'alavelave and, uh, many other things and they are waiting for them to get more cash and then they come[to appointments].
You ( "patients") will always return to Samoan medicines when your glucose or BP drops. They will then look for an alternate, as Samoan medicines are free and they will again take Samoan medicines instead of the doctor'ss. They[ to the Samoan witch doctor], but they only come back[to the hospital] because of inconvenience.
This paper examined the connection between drug addictions and cultures in American Samoan adult patients with diabetic and diabetic health care-provider. The results showed that obstacles such as uncertainty about how and when to take diabetic drugs and concerns about drug cost have a negative impact on drug use, while adult cultures can act both for and against drug use.
This means that for various reason the patient can follow the counsel of his doctor, while culture and familial convictions can affect both non-compliance and compliance. Many diabetic and diabetic drug companies have said that uncertainty about how and when to take diabetic drugs and concerns about the side effect of drugs are a barrier to drug use.
They were often uncertain about what causes changes in glucose and how to use drugs to control it. Suppliers believed that non-compliance was often due to patient failure to understand how or when to take their medicines, "did not care" or were not used to taking medicines to treat diseases.
The results are underpinned by research that highlights the challenge of compliance with self-help behaviours and medicines in all settings[6, 7]. Diabetic patients are largely self-sufficient and must ensure that medicines, nutrition and lifestyles are strictly adhered to throughout their lives[3, 6, 7].
Drug convictions have a major influence on drug use[16, 18, 21]. Utilizing a multi-cultural adult sampling of diabetics from an NYC municipal health center, Mann et al. found that low drug adhesion was foretold by believing that diabetics only occur when levels of glycemia are high, deciding not to take drugs when glycose is common, worrying about side effect of diabetic drugs, low self-confidence in managing diabetics and the sense that drugs are hard to take.
In addition, Mann et al.  told diabetic people that they were concerned about the drug's side effect and drug abuse potentials and found it hard to take. Horns and Weinmen found that people with chronical medicinal diseases were more attached to those who felt medicines were necessary.
On the other hand, those who report drug problems (e.g. fear of long-term effects) were rather unresponsible. Conclusions of the study include that compliance with drugs is dependent on an implied cost-benefit assessment in which people with a history of chronically occurring diseases balance the need for drugs against drug concern, such as side effects.
There are other determinants of drug compliance, such as public-health literacy. The term illiteracy is understood as "the capacity to grasp the information about your condition in order to make good choices about your condition and wellbeing. This concern can be better tackled if diabetic drug companies devote much less effort to discuss patients' drug regimes and apply low-personally illiterate skills such as slower speech, loud readings of directions and verification of comprehension by asking the patient to reiterate what they understand.
In addition, suppliers need to evoke their patients' convictions about the use of medicines and the associated culture to identify doubts or obstacles to the use of medicines. It can be further eased by others on the healthcare staff, as well as nursing, diabetic education and counseling, who all serve to strengthen the same message, so that the load is not just on the doctor.
That is the classical philosphy of the "chronic nursing model", which forms the basis for the present day approaches of municipal healthcare centres to providing treatment for patients. However, healthcare companies have said that the only way to make people take their medicines is to make them uncomfortable. This means vendors described that if certain diabetics are feeling well, some have the wrong perception that their diabetic has been healed and they are skipping dosages or stopping taking their medication.
They too saw that diabetics regard it as a condition that can be healed or ignored. The issue could be affected by the fact that many diabetic people, especially in newer, more modernised countries such as Samoa in the US, are not used to taking drugs to treat diseases.
This is in line with earlier research in other areas that suggests a link between non-compliance with antidiabetic drugs and the patient's perception as an urgent rather than a chronical ailment. 18, 22] said that the views of many of their trial subjects were incompatible with a chronical pattern of diabetic ailments.
As with the preceding topic, further information for diabetic care is needed to increase patients' understanding of diabetic use. Health care service provider must try to cause and amend misunderstandings about taking medicines and coping with illness. The high costs of diabetic drugs in American Samoa have a negative impact on drug use and utilization, according to reports from clinicians and suppliers.
A number of people found that relatives and acquaintances who live outside the country often buy their medicines and provisions for them, while others said that high prices prevent them from taking their diabetic medicines. Suppliers confirmed this and reported that high drug cost is a major obstacle to drug use. Moreover, the suppliers indicated that drug supply is also an important topic, as pharmacies sometimes run out of drugs and pharmacists are not able to fulfil their prescription.
Earlier studies suggest that high drug intake cost is associated with problems[33-37]. In concrete terms, high cost means that the patient either restricts or completely stops taking their drugs. Remarkably, many people who restrict their medicines do not talk to their doctors beforehand, which can have negative consequences.
Therefore, practitioners should be more pro-active in the identification of clients who may have problems with the payment for their medicines. The Samoan people' s culture and convictions influenced compliance with the medicines, both patient and provider were united. The Samoan culture was described by the patient as following self-care and medical counsel for the benefit of the whole household, or to honour them, and in deference to God.
And they also recounted a trend to follow the physician as he or she knows best. The Samoan people' s culture was characterised as that of a patient who prefers to be asked what to do, that the patient is accountable for their self-sufficiency and that they follow the doctors' recommendations on self-sufficiency for the benefit of the whole host population.
Thus, vendors noticed that want to provide immediate counseling in relation to diabetic disease managment. You also thought that self-care was the patient's own personal responsability and thought that they should stick to self-care and medications out of mutual regard for God and their loved ones. However, as shown in our work to date, clients and suppliers have described that non-compliance is often due to familial conflict and responsibilities or old-fashioned culture such as fa'alavelave.
Non-compliance could also be due to faith in Samoan medicines. For example, culture has a positive and negative effect on drug convictions and thus on compliance. There has been speculation that attitudes around good and bad public health have a part to play in understanding information on good and bad public health and making choices about care.
Capstick et al.  in their report on the relation between civilization and healthcare in the Pacific Islands report that for people from Polynesia, healthcare convictions are often pluralist and affected by both the West and conventional societies. Since American Samoa is a recently modernised country, it seemed that the patient base for this trial was both West and tradition.
In Samoa, Norris et al.  suggested that members of the Samoa families often have a say in what makes a disease and how it should be cured. Thus in this collectivistic Samoan environment in particular, it is important that cultural activities play an important part in dealing with diseases. There are several possible causes for the patient to follow the doctor's instructions and non-compliance can be affected by familial requirements.
Suppliers can increase drug compliance by raising awareness among members of the patient's families and supporting the roles of drugs in the treatment of diabetic diseases. Firstly, the focal groups and in-depth discussions were developed to evaluate the obstacles and mediators of diabetic treatment, so that the topic did not relate solely to convictions about drug use and compliance.
Secondly, the focal group analysis was carried out using transcriptions from Samoan into English, so that certain nuances in the target tongue may have been overlooked. Third, this trial was based on the self-report of diabetic people, who may have been prejudiced. In addition, enrolment for target groups was made from a convenient sampling and the opinions of those who approved may or may not be indicative of the whole populations of recipients of TFHC.
After all, compliance with the drugs was not evaluated. It is the first known trial to investigate the link between drug addictions and cultures in American Samoan adult diabetics and diabetic health care professionals. The results suggest that further intervention in the Samoan population should be focused on diabetic awareness to make sure individuals are able to gain an understanding of the basics of diabetics and how they can use medicines, nutritional and lifestyles to address their disease.
Considering that the high costs of medicines are an obstacle to taking medicines as required, it is important to identify those who may have difficulty paying for medicines. Lastly, communications skills development between client and supplier should incorporate ways to evoke culture and/or drug misunderstandings, along with other low-biteracy skills, to help assure better comprehension ofients.
There is currently a randomised, controled study underway in which the aim of the primarily caring teams is to inform the patient about drugs and increase compliance with them. The National Institutes of Diabetes and Digestive and Kidney Diseases (R18-DK075371 to the last author) sponsored this work. Many thanks to Sam Holzman, Ember Keighley, Meaghan House, Michelle Lam, Marissa Roberts, Tupe Siaosi and the Tafuna Family Medical Center for their support in this work.
As the American Samoans are suffering from disproportionate levels of diabetic disease, funds should be focused on implementing cultureally significant measures to enhance diabetic stewardship and inequalities. Prospective intervention in the Samoan population should concentrate on raising awareness of diabetics to make sure the patient understands the basics of diabetics and how they can use medicines, nutritional and lifestyles to cope with their disease.
Suppliers of diabetic medicines are urged to collect patients' opinions about the use of medicines and the associated culture to identify possible misgivings or obstacles to the use of medicines and to change false perceptions about the use of medicines and the treatment of diabetic disease. Nazionale Diabetic Fact Sheet: Nationale Estimate und general information about diabetic and prediabetic diseases in the United States, 2011.