The Protection Gap - Diagnosis, Treatment Status, and Disease Control for People with Diabetes and Hypertension in the US-Affiliated Pacific Islands.

Hypertension and diabetes are major causes of disability and mortality in the US-Affiliated Pacific Islands (USAPI). Control of these conditions has the potential to avert much of the burden of non-communicable diseases in the region. To realize this potential, people living with hypertension and diabetes must be identified and receive treatment of sufficient intensity to control their blood pressure and blood glucose. Data from recent cross-sectional surveys conducted in 5 jurisdictions-Pohnpei, Palau, Kosrae, Marshall Islands and American Samoa-were used to estimate the adult prevalence of hypertension and diabetes as well as diagnosis awareness, treatment, and control status of the adults with these conditions. In addition to traditional prevalence indicators, the authors provide a novel presentation of non-communicable disease (NCD) data, using the concept of "protection gaps", defined as the number of people living in a community who have an NCD for which effective control is not attained. The protection gap is determined by applying survey-derived population prevalence estimates to the community's population size using census data. The protection gap is further divided into 3 groups: (1) case-finding gap-those who are unaware of their conditions; (2) tracking and outreach gap-those who are aware of their condition but not receiving treatment; and (3) treatment efficacy gap-those who are receiving treatment but whose disease is not under control. The findings show a large protection gap, with a majority of adults living with hypertension (80.8%) and diabetes (91.6%) not having their condition under control. The case-finding gap accounts for more than half of these, followed by treatment efficacy, and tracking and outreach gaps. These findings can guide public health strategies and monitoring for control of hypertension and diabetes in the USAPI region.

Progress and strength of response against noncommunicable diseases in the US-affiliated Pacific Island jurisdictions, 2010-2021.

Objective: To determine the effectiveness of the response to the 2010 declared regional noncommunicable diseases (NCDs) emergency in nine US-affiliated Pacific Island jurisdictions. Methods: Vital statistics and risk prevalence surveys were retrospectively reviewed using 14 standardized NCD risk, prevalence and death rate indicators to measure changes in health status over time. NCD risk and prevalence change scores were derived from subsets of these indicators, and NCD composite death rates were examined. An NCD strength-of-intervention score derived from a standardized regional monitoring tool provided measures for assessing responses aimed at curbing risk factors, prevalence and death rates. Associations between the strength-of-intervention score and changes in health status were examined. Results: Pairs of values were available for 97 of 126 individual comparisons for 14 core indicators in nine jurisdictions. The composite mean prevalence of all risk factors across the jurisdictions between baseline and follow-up (26.7% versus 24.3%, P = 0.34) and the composite mean diabetes and hypertension prevalence (28.3% versus 28.2%, P = 0.98) were unchanged, while NCD death rates increased (483.0 versus 521.9 per 100 000 per year, P < 0.01). The composite strength-of-intervention score for the region was 37.2%. Higher strength-of-intervention scores were associated with improvements in health indicators. Discussion: Despite some improvements in selected NCD indicators at the jurisdiction level, there was no significant overall change in the prevalence of risk factors, diabetes and hypertension, and death rates have continued to increase since the NCD emergency declaration. However, the adoption of public sector NCD interventions was associated with improvements in health indicators.

'Hybrid Survey' approach to non-communicable disease surveillance in the US-Affiliated Pacific Islands.

In 2010 the US-Affiliated Pacific Islands (USAPI) declared a regional state of health emergency due to the epidemic of non-communicable disease (NCD) and an NCD monitoring and surveillance framework was developed that includes adult NCD risk factor and disease prevalence indicators to be collected every 5 years using a population-based survey. On evaluation of existing data from adult population-based NCD surveys, it was found that there was a lack of valid, available and consistently collected data. Therefore, a new model was developed to combine various indicators and survey tools from different partner agencies into one survey. After the report was endorsed by local health leadership, a dissemination workshop was conducted. In 2015 (baseline for Hybrid Survey implementation), three out of nine jurisdictions (33.3%) had completed a population-based survey in the past 5 years. Four (44.4%) had no adult prevalence data at all, two (22.2%) had data sets from their surveys and four (44.4%) had at least two surveys ever collected that could be used for comparison. As of 2020, all nine jurisdictions have, or are in the process of completing an adult population-based survey. Eight (88.9%) have data sets from their surveys, and five (55.6%) have at least two surveys collected that can be used for comparison. This Hybrid Survey model has helped to improve adult NCD surveillance in the USAPI by more efficiently using limited resources. This model could be considered in other small island nations, or rural areas where adult NCD surveillance is challenging.

Innovations to maximise impact of a data for decision-making training programme in the Federated States of Micronesia.

Accurate and timely health information is an essential foundation for strengthening health systems. Data for decision making (DDM) is a training curriculum designed to enhance capacity of health department staff to capture and use high-quality data to address priority health issues. In 2013, the Pacific Public Health Surveillance Network adapted and piloted the DDM curriculum as an 'at work, from work, for work' field epidemiology training programme component for low-income and middle-income Pacific Island jurisdictions. Based on lessons learned from the pilot, we made several innovations, including delivery on-site at each district (rather than bringing trainees to a central location), conducting pre-DDM consultations and ongoing contact with health leaders across the programme, taking more care in selecting trainees and enrolling a larger cohort of students from within each health department. The decentralised programme was delivered in-country at four sites (both at national and state levels) in the Federated States of Micronesia. Following delivery, we performed an external evaluation of the programme to assess student outcomes, benefits to the health department and general programme effectiveness. Of the 48 trainees who completed all four classroom modules, 40 trainees participated in the evaluation. Thirty-two of these trainees completed the programme's capstone field project. Eighteen of these projects directly contributed to changes in legislation, revised programme budgets, changes in programme strategy to augment outreach and to target disease and risk factor 'hot spots'.

Baseline status of policy and legislation actions to address non communicable diseases crisis in the Pacific.

BACKGROUND: Non-Communicable Diseases (NCD) are the leading cause of death in the Pacific Island Countries and Territories (PICTs) accounting for approximately 70% of mortalities. Pacific leaders committed to take action on the Pacific NCD Roadmap, which specifies NCD policy and legislation. To monitor progress against the NCD Roadmap, the Pacific Monitoring Alliance for NCD Action (MANA) was formed and the MANA dashboard was developed. This paper reports on the first status assessment for all 21 PICTs. METHODS: The MANA Dashboard comprises 31 indicators across the domains of leadership and governance, preventive policies, health system response and monitoring processes, and uses a 'traffic light' rating scheme to track progress. The dashboard indicators draw on WHO's best-buy interventions and track highly cost-effective interventions for addressing NCDs. The MANA coordination team in collaboration with national NCD focal points completed Dashboards for all 21 PICTs between 2017 and 2018 in an agreed process. The data were analysed and presented within each area of the MANA dashboard. RESULTS: This assessment found that PICTs are at varying stages of developing and implementing NCD policy and legislation. Some policy and legislation are in place in most PICTs e.g. smoke free environment (18 PICTs), alcohol licensing (19 PICTs), physical education in schools (14 PICTs), reduction of population salt consumption (14 PICTs) etc. However, no PICTs has policy or legislation on tobacco industry interference, controlling marketing of foods and drinks to children, and reducing trans-fats in the food supply, and only 7 PICTs have policies restricting alcohol advertising. Eighteen PICTs implement tobacco taxation measures, however only five were defined as having strong measures in place. Nineteen PICTs have alcohol taxation mechanisms and 13 PICTs have fiscal policies on foods to promote healthier diets. CONCLUSION: This baseline assessment fills a knowledge gap on current strengths and areas where more action is needed to scale up NCD action in a sustained 'whole of government and whole of society approach' in PICTs. The findings of this assessment can be used to identify priority actions, and as a mutual accountability mechanism to track progress on implementation of NCD policy and legislation at both national and Pacific level.

High Prevalence of Non-Communicable Disease Risk Factors among Adolescents in Pohnpei, Micronesia.

Non-communicable disease (NCD) related behaviors among adolescents are on the rise globally and in the Pacific region. To better understand and elucidate the prevalence of NCD risk factors among adolescents in Pohnpei state, Federated States of Micronesia, a cross-sectional study was conducted among secondary school students. Of 2965 students enrolled in the 2015-2016 academic year, 2555 (86.2%) completed the survey, and 2386 (80.5%) were included in the final analysis. Of the survey respondents, 21.7% of students self-reported smoking tobacco in the past 30 days, 30.3% self-reported drinking alcohol in the past 30 days, 40.9% self-reported chewing betel nut in the past 30 days, and 21.2% self-reported chewing tobacco with or without betel nut in the last 30 days. Male students, older students, and public school students had higher prevalence of substance use. Additionally, about 17.3% of students were overweight and 10.1% were obese according to physical measures of height and weight. Female students and private school students had higher prevalence of overweight and obesity than male students, and prevalence of overweight was higher in older age groups. These findings indicate a cohort of adolescents at substantial risk for the development of NCDs and signal an urgent need for public health interventions to address NCD risk factors.

Lessons learnt from a three-year pilot field epidemiology training programme.

PROBLEM: The Pacific region has widely dispersed populations, limited financial and human resources and a high burden of disease. There is an urgent need to improve the availability, reliability and timeliness of useable health data. CONTEXT: The purpose of this paper is to share lessons learnt from a three-year pilot field epidemiology training programme that was designed to respond to these Pacific health challenges. The pilot programme built on and further developed an existing field epidemiology training programme for Pacific health staff. ACTION: The programme was delivered in country by epidemiologists working for Pacific Public Health Surveillance Network partners. The programme consisted of five courses: four one-week classroom-based courses and one field epidemiology project. Sessions were structured so that theoretical understanding was achieved through interaction and reinforced through practical hands-on group activities, case studies and other interactive practical learning methods. OUTCOME: As of September 2016, 258 students had commenced the programme. Twenty-six course workshops were delivered and one cohort of students had completed the full five-course programme. The programme proved popular and gained a high level of student engagement. DISCUSSION: Face-to-face delivery, a low student-to-facilitator ratio, substantial group work and practical exercises were identified as key factors that contributed to the students developing skills and confidence. Close engagement of leaders and the need to quickly evaluate and adapt the curriculum were important lessons, and the collaboration between external partners was considered important for promoting a harmonized approach to health needs in the Pacific.

Monitoring and accountability for the Pacific response to the non-communicable diseases crisis.

BACKGROUND: Non-communicable diseases (NCD) are the leading cause of premature death and disability in the Pacific. In 2011, Pacific Forum Leaders declared "a human, social and economic crisis" due to the significant and growing burden of NCDs in the region. In 2013, Pacific Health Ministers' commitment to 'whole of government' strategy prompted calls for the development of a robust, sustainable, collaborative NCD monitoring and accountability system to track, review and propose remedial action to ensure progress towards the NCD goals and targets. The purpose of this paper is to describe a regional, collaborative framework for coordination, innovation and application of NCD monitoring activities at scale, and to show how they can strengthen accountability for action on NCDs in the Pacific. A key component is the Dashboard for NCD Action which aims to strengthen mutual accountability by demonstrating national and regional progress towards agreed NCD policies and actions. DISCUSSION: The framework for the Pacific Monitoring Alliance for NCD Action (MANA) draws together core country-level components of NCD monitoring data (mortality, morbidity, risk factors, health system responses, environments, and policies) and identifies key cross-cutting issues for strengthening national and regional monitoring systems. These include: capacity building; a regional knowledge exchange hub; innovations (monitoring childhood obesity and food environments); and a robust regional accountability system. The MANA framework is governed by the Heads of Health and operationalised by a multi-agency technical Coordination Team. Alliance membership is voluntary and non-conditional, and aims to support the 22 Pacific Island countries and territories to improve the quality of NCD monitoring data across the region. In establishing a common vision for NCD monitoring, the framework combines data collected under the WHO Global Framework for NCDs with a set of action-orientated indicators captured in a NCD Dashboard for Action. Viewing NCD monitoring as a multi-component system and providing a robust, transparent mutual accountability mechanism helps align agendas, roles and responsibilities of countries and support organisations. The dashboard provides a succinct communication tool for reporting progress on implementation of agreed policies and actions and its flexible methodology can be easily expanded, or adapted for other regions.

A primer for quality assurance and improvement in Pacific island health services.

Quality assurance and improvement (QA/QI) systems are underdeveloped in Pacific island jurisdictions and building QA/QI capacity is one of the best opportunities for quickly improving performance of health services in the region. There is a variety of styles available for QA/QI in health care organizations and the best approach will vary with the size, scope of practice, and needs of the organization. This report briefly describes the major styles of QA/QI and provides suggestions for QA/QI program approach based on several common Pacific island scenarios.

Quality improvement and the hierarchy of needs in low resource settings: perspective of a district health officer.

District services in developing countries are afflicted with frequent system breakdowns, caused by a combination of resource constraints, limitations of the health workforce, and poorly developed management systems. Narrowly focused, outcome-oriented quality improvement initiatives and sporadic accreditation visits fail to address the most pressing need of district health services- to improve manageability. To improve quality at the district level, attention should be directed first toward this need- by building widely focused systems for ongoing, operational monitoring and response.

Yap assessment for a continuing health care professional development program.

In 2003, the University of Hawai'i Department of Family Medicine and Community Health entered a 4-year cooperative agreement with the U.S. Health Resources and Services Administration to establish the "Pacific Association for Clinical Training" (PACT). PACT's goal is to develop effective distance education methods to improve the education and skills of healthcare professionals in the U.S.-Affiliated Pacific Island nations. To determine the situation existing in 2004, one of PACT's first projects was to perform site visits to each jurisdiction, conducting needs assessments through interviews with key health care professionals, hospital administrators, and government officials. This article highlights findings of PACT's assessment of YAP State, Federated States of Micronesia. Meant to establish a baseline for future reference, all data are those collected in 2004/2005 and have not been updated.

Interdisciplinary problem-based learning as a method to prepare Micronesia for public health emergencies.

CONTEXT: The University of Hawai'i Pacific Basin Bioterrorism Curriculum Development Project has developed a problem-based learning (PBL) curriculum for teaching health professionals and health professional students about bioterrorism and other public health emergencies. These PBL cases have been incorporated into interdisciplinary training settings in community-based settings, such as in the small island districts of the U.S.-Affiliated Pacific Islands. METHODS: Quantitative and qualitative methods have been utilized in the evaluation of the PBL cases, PBL tutorials, and the accomplishment of learning objectives. FINDINGS: Evaluation of the PBL tutorials demonstrates that PBL is an educational and training modality appropriate for such settings. Participants found it helpful to learn in interdisciplinary groups. The educational process was modified in accordance with local culture. CONCLUSION: PBL is a useful educational modality for settings where healthcare staffing and available resources are limited.

Ulithi Atoll health assessment: a peek at the health of rural Micronesia.

BACKGROUND: The health challenges of Micronesians are generally well known. However most of the health-related data collection occurs in the population centers and relatively little is known about the health of the residents of Micronesia's rural outer islands. This is of particular concern in the Federated States of Micronesia (FSM) where a large portion of the population lives on the outer islands. To gain a better understanding of the health issues facing the isolated outer islands of Micronesia, a health survey was performed on Ulithi Atoll in Yap, FSM. METHODS: A survey was created by the Yap State Department of Health Services and members of the Ulithian community. The survey was carried out on two of the four inhabited islands of Ulithi Atoll in July 2004. Both island communities actively participated in the survey providing translation and data gathering assistance. RESULTS: It was estimated that a >90% response rate for both islands was achieved. Analysis demonstrated that relative to the U.S., the Atoll's population experienced high rates of obesity (45%), hypertension (29%), and smoking (55%). Sixty-six percent of men surveyed reported alcohol use versus 16% of women. Use of alcohol was markedly lower on Fatharai Island where a Chief had mandated abstinence. Preventative health screening was limited with over 80% of women having pap smear in the past 2 years. In addition, the community identified finances and transportation as the main difficulties in accessing healthcare. CONCLUSION: Overall, the research identified a number of health issues that require closer attention, in particular hypertension, overweight, obesity, alcohol misuse, smoking prevalence, betel nut/ tobacco chewing, and domestic violence. There is indication that the community may be ready to address some of these issues. The value of community action within cultural frameworks is apparent, and there may be potential to extend culturally-based approaches to address a broader range of issues.

The Yap AHEC: an update 2002-2006.

The Yap Area Health Education Center (AHEC) is one of three U.S. Health Resources and Services Administration-funded AHEC programs in the U.S.-Affiliated Pacific Island jurisdictions (together with those in Palau and the Commonwealth of the Northern Mariana Islands). The Pacific Island AHECs are administered through the University of Hawai'i, John A. Burns School of Medicine and were founded in response to recommendations for development of the local health workforce by the U.S. Institute of Medicine in its 1998 report, "Pacific Partnerships for Health". The goal of the Yap AHEC is to build human capacity in the health workforce, and thereby strengthen the health service and improve health status for the people of Yap State. An ancillary goal is to pilot test new approaches to health workforce development, which might be shared with others in the region. These goals have been pursued by building partnerships with colleges in the region, with the new Wa'ab Community Health Center project in Yap and the Yap State Department of Health Services to bring formal college programs for students and health service staff to Yap State. To date, formal relationships have been established with five colleges; Palau Community College (PCC), the College of Micronesia-Federated States of Micronesia (FSM), Fiji School of Medicine (Department of Public Health & Primary Care), University of Hawai'i, Hilo, and the University of Alaska, Anchorage. A total of 143 students have been enrolled in 48 courses in several health worker disciplines, including clinical nurses, health assistant/dispensary managers, community health outreach workers, public health program staff pharmacy technicians and x-ray technicians. In addition to facilitating the delivery of courses in Yap, a new 6-course certificate program has been developed for community outreach workers in collaboration with the College of Micronesia, FSM and the Wa'ab Community Health Center (Wa'ab CHC) in order to support the CHC's innovative health service delivery model. The Yap AHEC has also assisted the College of Micronesia-FSM in the World Health Organization sponsored development of a proposal for the establishment of a nursing program, which is based on the decentralized, on-site (DC-OS) nursing training model that has been pilot tested in partnership with PCC at Yap State Hospital.

Scrub typhus, Republic of Palau.

Scrub typhus, caused by Orientia tsutsugamushi, is a severe febrile illness transmitted to humans by trombiculid mites, which normally feed on rodents. The first known outbreak of scrub typhus in Palau occurred in 2001 to 2003 among residents of the remote southwest islands. To determine the extent of scrub typhus distribution in Palau, we tested serum samples from humans and rodents for antibodies to O. tsutsugamushi. Of 212 Palau residents surveyed in 2003, 101 (47.6%) had immunoglobulin G (IgG) antibody titers >1:64, and 56 (26.4%) had concurrent IgG and IgM antibody titers >1:512 and 1:64, respectively. Of 635 banked serum samples collected from Palau residents in 1995, 34 (5.4%) had IgG antibody titers >1:64. Sera collected from rodents (Rattus norvegicus and R. rattus) in 2003 and 2005 were tested, and 18 (28.6%) of 63 had IgG antibody titers >1:64. These findings suggest that scrub typhus is endemic in Palau.

The Palau AHEC--academizing the public health work plan: capacity development and innovation in Micronesia.

The Palau Area Health Education Center (AHEC)--a program of the University of Hawaii's John A. Burns School of Medicine (JABSOM) and based at Palau Community College--was established in 2001 in response to the recommendations of the 1998 Institute of Medicine (IOM) report--Pacific Partnerships for Health--Charting a New Course for the 21st Century1. One of IOM's core recommendations was to promote the training of the primary health care workforce among the U.S.-Associated Pacific Islands. Since its inception in 2001, the Palau AHEC has coordinated overall 37 postgraduate and undergraduate courses in General Practice and Public Health taught by the University of Auckland Faculty of Medicine and Health Sciences and the Fiji School of Medicine's School of Public Health and Primary Care (SPH&PC) in Palau, Yap State, and the Republic of the Marshall Islands. Currently 139 physicians, nurses, health administrators, and environmental health workers are registered as active students in Palau (58), Yap State (22), and the RMI (59). Notably, the Palau AHEC and the SPH&PC have worked in an innovative partnership with the Palau Ministry of Health to operationalize the MOH's public health work plan to implement a comprehensive community health survey of all 4,376 households in Palau, interviewing 79% of the total population, to determine Palau's health indicators. To accomplish this, the SPH&PC developed and taught a curriculum for Palau physicians and public health nurses on how to design the survey, gather, and analyze data in order to develop and implement appropriately responsive intervention and treatment programs to address Palau's old and newer morbidities. In early FY2005, two other Micronesian AHECs--the Yap State and Commonwealth of the Northern Mariana Islands AHECs--were funded through JABSOM administered grants which will also address the primary care training needs of Micronesia's remote and isolated health workforce.

Scrub typhus in the Republic of Palau, Micronesia.

In October 2001, an outbreak of febrile illness began in the southwest islands group of the Republic of Palau. Through October 2003, a total of 15 southwest islanders experienced fever >39.5 degrees C and abdominal distress, both lasting >7 days. Orientia tsutsugamushi, the agent of scrub typhus, was subsequently identified as the cause.

Cancer in Yap State, Federated States of Micronesia.

Little is known about the impact of cancer and the extent of cancer-related services in Yap. The purpose of this study, funded by the National Cancer Institute, was to document the state of cancer awareness and services in Yap and to prioritize cancer-care needs. Findings suggest that cancer is the leading cause of death in Yap, yet cancer-related awareness, prevention, detection, and treatment services are limited. A number of needs were identified, and an action plan was developed based on five priority areas: 1) establishing a cancer registry; 2) increasing awareness of cancer risk, prevention, and detection; 3) expanding cancer screening and detection programs; 4) expanding cancer-related training opportunities for clinical staff; and 5) purchasing cancer-related equipment & supplies.