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.

Program Infrastructure the Key to Success: A Pilot Crosswalk Installation to Promote Walkability, Pedestrian Safety, and Physical Activity in the U.S. Virgin Islands.

BACKGROUND & AIMS: While physical inactivity can contribute to chronic diseases, regular activity like walking can help prevent them. In 2010, one in three adults in the U.S. Virgin Islands (USVI) was physically inactive, higher than most U.S. states and territories. There are few walkable destinations and sidewalks along streets in the USVI. Since community- and street-scale design features can influence walking, we convened a 3-day walkability institute in the USVI to (1) learn about physical activity and best practices for design and (2) develop public health infrastructure that supports implementation. Island teams were formed to develop and implement a territory-wide action plan, focused on passing a Complete Streets policy, and demonstration projects on the islands of St. Croix, St. John, and St. Thomas to advance and pass this policy. An example of the demonstration projects and their significance is the completed one in St. Croix, which is the focus of this article. METHODS: Island teams applied critical components of functioning program infrastructure as described in the Component Model of Infrastructure (CMI) such as engaged data, multilevel leadership, responsive plans and planning, and networked partnerships. We evaluated whether a crosswalk installation in St. Croix could alter driver and pedestrian behavior and create a safer environment for pedestrians. Observers recorded pedestrian crossing time, driver speed, and other behaviors before and after crosswalk installation. RESULTS: Pedestrians took significantly fewer average seconds to cross the street in the postdemonstration period (9.83) compared with predemonstration (13.4) (p = .03). Average car speed declined between the predemonstration (24.3) and long-term demonstration periods (p < .01) and from the postdemonstration (24.7) to the long-term demonstration period (18.2) (p < .01). A greater percentage of pedestrians used the crosswalk to cross the street between the postdemonstration (12.5%) and long-term demonstration periods (53.7%) (p < .01). IMPLICATIONS: The demonstration project in St. Croix shows that improvements to built environment infrastructure can increase safety for pedestrians, thus improving walkability in the USVI. We discuss the importance of CMI elements observed in the success of the St. Croix demonstration and its effectiveness in promoting a Complete Streets policy and the lack of these elements on St. John hindering progress there. Public health practitioners can apply the CMI to future physical activity promotion projects in the USVI and other settings as having functioning program infrastructure helps overcome challenges including natural disasters and a global pandemic and can achieve progress toward sustained policy and systems change.

How the Commonwealth of the Northern Mariana Islands stalled COVID-19 for 22 months and managed its first significant community transmission.

Objective: The Commonwealth of the Northern Mariana Islands (CNMI) is a remote Pacific island territory with a population of 47 329 that successfully prevented the significant introduction of coronavirus disease (COVID-19) until late 2021. This study documents how the response to the introduction of COVID-19 in CNMI in 2021 was conducted with limited resources without overwhelming local clinical capacity or compromising health service delivery for the population. Methods: Data from COVID-19 case investigations, contact tracing, the Commonwealth's immunization registry and whole genome sequencing were collated and analysed as part of this study. Results: Between 26 March 2020 and 31 December 2021, 3281 cases and 14 deaths due to COVID-19 were reported in CNMI (case fatality rate, 0.4%). While notification rates were highest among younger age groups, hospitalization and mortality rates were disproportionately greater among those aged > 50 years and among the unvaccinated. The first widespread community transmission in CNMI was detected in October 2021, with genomic epidemiology and contact tracing data indicating a single introduction event involving the AY.25 lineage and subsequent rapid community spread. Vaccination coverage was high before widespread transmission occurred in October 2021 and increased further over the study period. Discussion: Robust preparedness and strong leadership generated resilience within the public health sector such that COVID-19 did not overwhelm CNMI's health system as it did in other jurisdictions and countries around the world. At no point was hospital capacity exceeded, and all patients received adequate care without the need for health-care rationing.

Assessing the progress on the implementation of policy and legislation actions to address the Non-Communicable Diseases crisis in the Pacific.

AIM: To assess the progress on the implementation of Non-Communicable Diseases (NCD) related policies and legislations in the Pacific Island Countries and Territories (PICTs). MATERIALS AND METHODS: The Pacific Monitoring Alliance for NCD Action (MANA) Dashboard was used to assess the progress on the implementation. The MANA Dashboard includes 31 indicators across four different domains such as leadership and governance; preventative policies and legislations; health system response programs; and monitoring This progress assessment was conducted between 2019 and 2020 for all 21 PICTs. The data were analyzed and compared with the baseline status (2018) report and presented across four different domains of the MANA dashboard. RESULTS: This progress assessment found that PICTs overall have made advancements in a number of areas, particularly the establishment of a national multi-sectoral NCD taskforce; implementation of referenced approaches to restrict trans-fat in the food supply in national documents; and fiscal measures to affect access and availability to less healthy foods and drinks. However, the strengths of actions varied across PICTs, and most are categorised as low strengths. Measures which had the most limited progress in implementation include policy and legislation that restrict alcohol advertising; tobacco industry interference; marketing of foods and non-alcoholic beverages to children; and marketing for breast milk substitutes. CONCLUSIONS: This progress assessment further highlights that while PICTs continue to make progress, NCD policy and legislation gaps still exist, both in terms of weaknesses of existing measures and areas that have had little attention to-date. These require urgent actions to scale up NCD related policies and legislation at regional and national level.

The impact of COVID-19 on public health systems in the Pacific Island Countries and Territories.

The Pacific Island Countries and Territories (PICTs) have experienced the coronavirus disease (COVID-19) pandemic in different ways and with different timelines, with some experiencing large outbreaks leading to high levels of morbidity and mortality with significant strain on health systems, while others have had no local transmission or delayed transmission until after vaccine rollouts started. Regardless of COVID-19 trends, the pandemic has had a large impact on the social, political, and economic landscape in the Pacific, the effects of which are still being understood. However, the pandemic has also put renewed focus and investment into public health systems and provided an opportunity for the PICTs to build on existing systems and recent capacity strengthening to improve public health in the Region. Funding: Leila Bell was supported by an Australian Government Research Training Program (RTP) Scholarship. Other funding sources had no role in paper design, data collection, data analysis, interpretation, or writing of the paper.

Gestational Diabetes Mellitus Prevalence, Screening, and Treatment Practices in American Samoa, 2016.

Gestational diabetes mellitus (GDM) is a serious pregnancy complication and understudied public health issue in American Samoa. The goals of this study were to (1) estimate the prevalence of GDM in American Samoa, (2) evaluate current screening practices for GDM, and (3) evaluate obtainment of GDM treatments in 2016. This cross-sectional study used 3 data sources: electronic health records, a labor and delivery logbook, and the American Samoa Department of Health (ASDOH) Maternal and Children's Health (MCH) Postpartum database. Out of 995 women with a singleton birth in American Samoa during the study period, 60.1% (n=598) completed a glucose tolerance test for GDM. Of these women, 41.8% (n=250) completed the testing within the recommended 24-28 weeks gestation timeframe. The estimated prevalence of GDM was 14.0% (95% confidence interval: 11.2-16.8) but has many limitations due to missing data. There were 4 treatments analyzed: nutrition counseling, insulin, metformin, and diabetes counseling. Of all women diagnosed with GDM (n=84), 76% were prescribed any of the 4 treatments. However, only 52% of those women obtained the treatment prescribed. Access to testing and treatment needs to be expanded to provide adequate prenatal care to women in American Samoa.

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.

COVID-19 Containment Ship Model: A Case Study for Pacific Island Response.

The Republic of the Marshall Islands, American Samoa, the Federated States of Micronesia, and the Republic of Palau have been without any COVID-19 community transmission since the beginning of the global pandemic. The Commonwealth of the Northern Mariana Islands has experienced modest community transmission, and Guam has had significant COVID-19 community transmission and morbidity. Although several of these United States Affiliated Pacific Island jurisdictions made difficult strategic choices to prevent the spread of COVID-19 which have been largely successful, the built environment and the population density in the urban areas of the Pacific remain inherently conducive to rapid COVID-19 transmission. Rapid transmission could result in devastating health and economic consequences in the absence of continued vigilance and long-term strategic measures. The unique COVID-19 vulnerability of islands in the Pacific can be modeled through examination of recent outbreaks onboard several United States Naval ships and other marine vessels. The environmental characteristics that pose challenges to infection control on an isolated naval ship are analogous to the environmental characteristics of these Pacific island communities. Considering a collection of case studies of COVID-19 transmission on ships and applying to Pacific Island environments, provides a heuristic, easily accessible epidemiologic framework to identify methods for interventions that are practical and reliable towards COVID-19 containment, prevention, and control. Using accessible evidence based public health policies, infection risk can be decreased with the objective of maintaining in-country health and social stability. These case studies have also been examined for their relevance to current discussions of health care infrastructure and policy in the Pacific Islands, especially that of vaccination and repatriation of citizens marooned in other countries. The need for aggressive preparation on the parts of territories and nations not yet heavily exposed to the virus is critical to avoid a rapid "burn-through" of disease across the islands, which would likely result in catastrophic consequences.

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'.

'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.

Building Capacity for Logic Models and Evaluation Planning Using Canoe-building Concepts.

Non-communicable diseases (NCDs) are the leading causes of death in the United States Affiliated Pacific Islands (USAPIs); US Centers for Disease Control and Prevention funds programs for prevention and control of diabetes, tobacco use, and related chronic disease conditions. To build USAPI programs' capacity in evaluation and surveillance, we held in-person and virtual trainings on evaluation planning and logic models that were tailored with traditional canoe-building themes to be relatable and memorable. Evaluation results suggest the efforts were effective at translating concepts. Additional tools and technical assistance reinforced concepts and resulted in quality evaluation plans. Culturally tailored evaluation tools can be useful and should be developed with population representatives.

An Evaluation of Infertility Among Women in the Republic of Palau, 2016.

Fertility challenges are a personal and important part of a woman's reproductive health and are associated with health and lifestyle factors. Limited data exist on infertility among women in Palau. We describe the lifetime prevalence of self-reported infertility in a nationally representative sample of women in Palau and investigate the association between tobacco and/or betel nut use and infertility. During May-December 2016, a population-based survey of noncommunicable diseases was conducted in Palau using a geographically stratified random sample of households (N=2409). Men and women ≥18 years of age were chosen randomly from each selected household. The prevalence of a self-reported lifetime episode of infertility (having tried unsuccessfully to become pregnant for ≥12 months) was evaluated among 874 women aged ≥18 years by key health and lifestyle factors. Prevalence ratios (PR) and 95% confidence intervals (CI) were calculated. Of 315 women who ever tried to become pregnant, 39.7% (95% CI: 34.2%, 45.3%) reported a lifetime episode of infertility. Prevalence was higher in women of Palauan vs other ethnicity (PR=1.6, 95% CI: 1.1, 2.3), those who self-reported poor/not good vs. excellent/ very good health status (PR=2.1, 95% CI: 1.4, 3.3), and those with a body mass index (BMI) ≥30 vs <30 (PR=1.7, 95% CI: 1.3, 2.2). Adjusted models showed that tobacco and/or betel nut users were almost twice as likely to report infertility versus non-users (PR=1.8, 95% CI: 1.3, 2.5). More research is needed to understand the infertility experiences of women in Palau and to promote lifestyle factors contributing to optimal reproductive health.

Diabetes Prevention and Care Programs in the US-Affiliated Pacific Islands: Challenges, Innovation, and Recommendations for Effective Scale-Up.

PURPOSE OF REVIEW: This review describes some of the unique challenges faced by the US-Affiliated Pacific Islands (USAPIs) in addressing diabetes prevention and care and presents innovative population-level strategies that have been employed to address them. RECENT FINDINGS: Challenges include an unhealthy food environment and a strained health care infrastructure, both compounded by geography. Innovations in addressing these challenges include attempts to modify the food environment, a focus on early life prevention, and task shifting among the health workforce. Many of the successful interventions share a focus on culture, community, and capacity building. Although the USAPIs are uniquely challenged by environmental, structural, and health system barriers, there have been a number of innovative and successful strategies employed that highlight the resilience of these island nations in addressing their current disease burden when provided with the opportunity and resources to do so. Health policies to protect, support, and promote diabetes prevention and care are essential and may be informed by the interventions described.

Investigation of Pediatric Anemia in the Commonwealth of the Northern Mariana Islands.

Objective To report on the prevalence and etiology of pediatric anemia in the Commonwealth of the Northern Mariana Islands (CNMI). Method A retrospective chart review was conducted that included patients up to 19 years of age who presented for well child care and whose hemoglobin or hematocrit was checked in the CNMI from 2014 to 2015. Lab values, diagnoses and treatment plans, patient reported ethnicity, and follow-up results were collected from eligible patients. Results The records for 1483 pediatric patients who had 1584 well child visits were reviewed. The prevalence of anemia amongst all eligible patients was 8.0% (5.4-10.7). This included 292 9 to 18 months old patients, which is estimated to be 40% of the total pediatric population of CNMI in that age group. Among the 9 to 18 months old patients, the prevalence of anemia is 5.5% (2.6-8.4). Etiology of anemia was investigated and of the patients treated with iron, 55.2% had a documented response. The majority of those without documentation of improvement with iron were patients who were lost to follow-up. In addition, a total of 10 patients were found to have an alpha or beta thalassemia variant discovered initially by anemia screening or sibling tracing. Discussion In this United States Commonwealth, prevalence of anemia appears lower than prevalence reported for other independent Pacific Island nations and closer to that of the US. Thalassemia is documented within this population. Limitations to this data were use of a convenient sample that may be hampered by lack of presentation to well-child care. This study will guide future public health studies on anemia prevalence and can guide public health intervention decisions to improve pediatric care in the CNMI.

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.

Disparities in Adverse Perinatal Outcomes Among Pacific Islanders in the Commonwealth of the Northern Mariana Islands.

INTRODUCTION: Although other studies have found evidence for perinatal health disparities among Pacific Islanders in other regions, no studies have evaluated racial/ethnic disparities in adverse perinatal health outcomes in the small US island territory of the Commonwealth of the Northern Mariana Islands (CNMI). METHODS: We used retrospective cohort data on 8,427 singleton births from 2007 to 2014 at the Commonwealth Healthcare Corporation (CHCC), the only hospital in the CNMI. We used multivariate logistic regression to estimate risk for preterm birth (<37 weeks) and macrosomia (>4,000 g) among the racial/ethnic groups in the CNMI. RESULTS: Indigenous CNMI mothers (Chamorros and Carolinians, hereinafter Chamorro/Carolinian) and other Pacific Islander mothers were significantly more likely to have a preterm birth than Chinese mothers (adjusted odds ratio [AOR] = 2.7; 95% confidence interval [CI], 2.0-3.6 for Chamorro/Carolinians and AOR = 2.9; 95% CI, 2.1-4.1 for other Pacific Islanders). Additionally, Chamorro/Carolinian mothers and other Pacific Islander mothers were also significantly more likely to deliver babies with macrosomia (AOR = 2.4; 95% CI, 1.7-3.5 and 2.3; 95% CI 1.4-3.6 respectively) than Filipino mothers. CONCLUSION: Although underlying causes for these disparities are still unknown, these findings add to the limited knowledge on maternal and neonatal health among Pacific Islanders and provide support for further research and intervention development to aid in reducing racial/ethnic disparities of perinatal health in the CNMI.

Comprehensive Review of Preschool Age Anemia in the Pacific Island Jurisdictions.

Anemia can be an indicator of poor nutrition and health, and it can have significant consequences. Children are disproportionately affected by anemia. This comprehensive review summarizes the available literature on anemia prevalence in young children in the islands of the Oceania region. The anemia prevalence, the criteria used for diagnosis, the date the data was reported, and the types of samples collected were reviewed. Anemia prevalence estimates were reported for eighteen of the Pacific Island Jurisdictions. From the fifteen data sources that were evaluable, anemia prevalence ranged from 12.3% to over 70%. A major limitation in the data is a lack of representative primary data from many of the jurisdictions in the region. Prevalance estimates reported for those jurisdictions are estimated by regression analysis from the World Health Organization (WHO). Moreover, the primary data available does not use standardized reporting criteria. Nevertheless, this review serves as a new baseline for further investigations on the prevalence of anemia and a baseline for evaluating public health prevention and treatment measures to detect and improve anemia prevalence in the Pacific.

Breast and Cervical Cancer Screening in Palau: Have We Improved Early Detection and Survival?

The Breast and Cervical Cancer Early Detection Program (BCCEDP) was first introduced in Palau in 1997. The program's aim is to recruit and screen women for early detection of breast and cervical cancers. An assessment of this screening program was conducted to evaluate its effectiveness, including impact on stage of diagnosis and survival time of patients diagnosed with breast and cervical cancers through both screening and clinical diagnosis. A retrospective cohort study using secondary data from 2004-2013 was conducted. There were 45 women diagnosed with breast or cervical cancer. Due to the small number of cases, a comparison of two time periods was made (2004-2008) and (2009-2013). There were more cancer cases detected through screening (26%) in the earlier time period (2004-2008), as compared to those diagnosed through screening (8%) in the later time period (2009-2013), though this difference was not statistically significant (P=.09). The proportion of breast and cervical cancers diagnosed at an earlier stage (0-3) may have decreased between the two time periods (42% to 23%, P=.3). A greater proportion of women who were diagnosed between 2004-2008 lived longer than 2 years (58%), than women who were diagnosed between 2009-2013 (39%; P=.23). The screening program has not shown improvement over the years despite the measures taken to detect the early onset of breast and cervical cancer, and survival outcomes in Palau remain poor.

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.

Assessment of Gestational Diabetes and Associated Risk Factors and Outcomes in the Pacific Island Nation of Palau.

Objective Gestational diabetes mellitus (GDM) in Palau and across the Pacific Islands is a serious public health issue that is currently understudied. Methods This study was a retrospective cohort study that included 1730 women with a single live birth in Palau between January 2007 and December 2014. Results The overall prevalence of GDM among women in Palau was 5.5%. Women who were older (≥30 years) or obese (BMI ≥30) were more likely to have GDM than women who were younger (<30 years) or non-obese (BMI <30), respectively. When adverse birth outcomes were assessed, women with GDM were found to have significantly higher prevalence of high birth weight infants, cesarean sections, and neonatal deaths when compared to women without GDM. In fact, women with GDM were five times more likely to have a neonatal death than women without GDM (p = 0.008). Conclusion Reducing overall rates of obesity in the population could help reduce rates of diabetes and GDM in Palau. Based on this work, current practices for the identification, monitoring and treatment of women with GDM should be evaluated and strengthened in order to reduce neonatal mortality rates in Palau.