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.

Lessons from the Field: Lessons from Yap - Changing Government and Cultural Practice Through Public Health Policy.

The heavy burden of non-communicable diseases (NCD) in Yap State, Federated States of Micronesia overwhelms the resources of this small population. Traditional cultural practices strongly influence all aspects of life, especially in the remote outer islands. The traditional Chiefs must grant permission to perform any type of health outreach or services for about one-third of the population. One key cultural practice promotes tobacco and alcohol use. The Yap Comprehensive Cancer Control Program, in collaboration with other entities in public health, systematically engaged the traditional Chiefs, resulting in a landmark policy that paved the way for other system and environmental interventions to reduce the risks of developing NCD.

Lessons from the Field: Going Local-Everybody Wins.

Pacific Islanders suffer from chronic diseases attributed largely to an overconsumption of processed foods. As a response, the CDC-funded Racial and Ethnic Approaches to Community Health (REACH) Go Local Project in Yap, Federated States of Micronesia (population: 12,000) sought to create a food intervention that would not only increase access to fresh, local foods, but benefit food vendors as well for a sustainable effect. For this program, a number of markets were chosen for selling any fresh local produce, meat, and catch. These markets agreed to allow purchasers of healthy local food of a minimum amount to be entered into a monthly raffle. Monthly winners received fresh food gift certificates while participating markets received a gift upon certificate redemption. REACH and partners distributed healthy island recipes and nutrition information at these partner markets. Formative evaluation examined customer and vendor satisfaction through interviews and surveys, and tracking of healthy food purchases and customer demographics were garnered via raffle information. Brief interviews with customers and vendors revealed favorable reactions to the Go Local Project. People enjoyed winning and vendors found satisfaction in promoting health through their businesses.

Building Capacity for Caregiver Education in Yap, Micronesia.

The US Affiliated Pacific Islands have an urgent need for family caregiver education to prevent caregiver burnout and strengthen the existing culture where seniors are cared for at home by their families. The Pacific Islands Geriatric Education Center conducted a 32-hour family caregiver train-thetrainer workshop in partnership with the Yap Department of Health Services and the Yap Area Health Education Center (AHEC) from October 16 - 20, 2017. Twenty-seven participants including community health workers, peer educators, health assistants, nurses, and physicians were trained as instructors. Confidence in caregiving increased following the training and feedback was extremely positive. Competence in geriatric syndromes was improved after attending the workshop (P < .001). Lessons from the field revealed an immense value of adding home visits to the training practicum as well as the need to translate caregiving handouts into the outer island languages. Yap AHEC is committed to offering this course as part of caregiver education at the hospital and in the community.

Cancer management in the Pacific region: a report on innovation and good practice.

Pacific island countries and territories (PICTs) face the challenge of a growing cancer burden. In response to these challenges, examples of innovative practice in cancer planning, prevention, and treatment in the region are emerging, including regionalisation and coalition building in the US-affiliated Pacific nations, a point-of-care test and treat programme for cervical cancer control in Papua New Guinea, improving the management of children with cancer in the Pacific, and surgical workforce development in the region. For each innovation, key factors leading to its success have been identified that could allow the implementation of these new developments in other PICTs or regions outside of the Pacific islands. These factors include the strengthening of partnerships within and between countries, regional collaboration within the Pacific islands (eg, the US-affiliated Pacific nations) and with other regional groupings of small island nations (eg, the Caribbean islands), a local commitment to the idea of change, and the development of PICT-specific programmes.

Randomized controlled trial evaluating the utility of urine HPV DNA for cervical cancer screening in a Pacific Island population.

BACKGROUND: Non-invasive, self-collection sampling methods for human papillomavirus (HPV) DNA detection have the potential to address logistical and cultural barriers to Pap screening, particularly in under resourced settings such as Yap state in the Federated States of Micronesia - a population with low levels of screening and high incidence of cervical cancer. METHODS: A randomized controlled trial was conducted among adult women in Yap to compare cervical HPV DNA in self-collected urine and clinician-collected liquid cytology. Adult women aged 21-65 (n=217) were randomized by the order of sample collection. Concordance of HPV DNA, evaluated by the Roche Linear Array, was compared in paired self-collected urine and clinician-collected liquid cytology samples. The sensitivity and specificity of urine HPV DNA for prediction of cervical HPV and abnormal cytology was also evaluated. p16 in urine cytology samples was additionally assessed. RESULTS: Overall, HPV DNA detection was significantly lower in urine than cervical samples for any HPV (27.8% and 38.3%, respectively) and high-risk HPV (15.1% and 23.8%, respectively). For paired samples, there was moderate agreement for the overall study population (Kappa=0.54, 95% confidence interval CI=0.40-0.68) and substantial agreement for women >40 years (Kappa=0.65, 95% CI=0.46-0.85). The sensitivity and specificity of urine for the detection of cervical high-risk HPV was 51.0% and 96.2%, respectively. The sensitivities of HPV DNA in urine and liquid cytology for prediction of abnormal cytology (ASCUS/LSIL/HSIL) were 47.4% (95% CI=31.0-64.2) and 57.9% (95% CI=40.8-73.7), respectively; specificities were 92.0% (95% CI=86.9%-95.5%) and 83.5% (95% CI=77.2-88.7). Urine p16 was poorly correlated with urine HPV DNA positivity. CONCLUSIONS: Urine is less sensitive but more specific than directed cervical sampling for detection of cytologic abnormalities and may have utility for screening in older populations within low-resource communities when clinically-collected samples cannot be obtained.

Comprehensive cancer control planning in the Pacific: the Cancer Council of the Pacific Islands a multi-national regional coalition.

INTRODUCTION: In the early 1990s, a comprehensive cancer control (CCC) approach was developed in the United States (US). In 2003, the US-Affiliated Pacific Islands (USAPI) adopted the CCC approach through a regional coalition, the Cancer Council of the Pacific Islands (CCPI). Using the CCC approach, the CCPI developed jurisdiction-specific cancer coalitions and initiated their respective cancer plans. METHODS: The evolution of the CCC approach and the history of the CCPI regional coalition are reviewed. The outcomes of the regional approach for cancer control in the USAPI are described to illustrate the possibilities, value-added and innovation of using a CCC strategy in a multi-national coalition based in a resource-limited environment. RESULTS: The CCC approach enabled the CCPI to (1) harmonize cancer control efforts between the six USAPI jurisdictions, (2) represent the USAPI cancer needs as a single voice, and (3) develop a regional cancer control strategy. Outcomes include (1) a regional cancer registry, (2) three sequential regional CCC plans, (3) leveraged resources for the USAPI, (4) enhanced on-site technical assistance and training, (5) improved standards for cancer screening, (6) evidence-based cancer control interventions adapted for the USAPI. CONCLUSION: The regional CCPI coupled with the CCC approach is an effective engine of change. The CCC strategies enabled navigation of the political, geographic, cultural, and epidemiologic Pacific environment. The regional partners have been able to harmonize cancer control efforts in resource-limited settings. Regional cancer coalitions may be effective in the global arena for cancer control between communities, states, or countries.

A Socio-Ecological Framework for Cancer Control in the Pacific: A Community Case Study of the US Affiliated Pacific Island Jurisdictions 1997-2017.

The United States Affiliated Pacific Island Jurisdictions (USAPIJ) are politically associated to the United States (US) as US Territories (Guam, American Samoa), a US Commonwealth (Commonwealth of the Northern Mariana Islands), and as sovereign nations linked to the US through Compacts of Free Association [Federated States of Micronesia (FSM), Republic of the Marshall Islands (RMI), Republic of Palau (ROP)]. Cervical cancer incidence in the RMI is the highest in the world, mammography services are not available in the FSM and only Guam has on-island oncology services. Cancer risk factors such as obesity, tobacco, and Hepatitis B are prevalent. Twelve years of nuclear testing in the RMI adds to the cancer burden. A community-based, multi-national coalition with multi-system external partners the Pacific Regional Cancer Control Partnership (PRCP) was developed to address cancer prevention and control in the USAPIJ. Through the PRCP, local cancer coalitions, a regional cancer registry, 12 years of regional cancer control plans, and cancer prevention programs and research has been implemented. Methods: The PRCP is the subject of this community case study. The PRCP is analyzed through a socio-ecological theoretical framework to contextualize its typology, building blocks, and management. The respective roles and work of each partner and organization will be described and aligned with the levels of the socio-ecological framework. Results: The USAPIJs evolved a community-focused internal and external regional cancer prevention and control network over 20 years. The function and structure of the PRCP fits within a socio-ecological framework for cancer control. An adaptive management strategy has been used within the PRCP to manage its multi-national, multi-level, and multi-system partners. Conclusion: The PRCP has been able to advance cancer prevention and control programs with a community-centric model that functions in a multi-national, multi-cultural, low-resource, geographically dispersed environment over the last 20 years. The PRCP operates with a structure and management style that is consistent with a socio-ecological framework for cancer control. This case study provides a blueprint for the PRCP organizational structure and a mechanism for its function. The PRCP concept, a community-centric model for cancer control in multi-national resource-limited environments, may be scaled to other global environments.

Acceptability and feasibility of a community based participatory research project comparing cytology and urine HPV DNA testing for cervical cancer screening in Yap, Federated States of Micronesia.

Non-invasive, self-collected sampling methods for HPV DNA detection in women, which are reliable, efficient, and acceptable have the potential to address barriers to cervical cancer screening in underserved communities, including low-middle income countries (LMIC) such as the island nation of the Federated States of Micronesia (FSM). Urine-based HPV testing has not been rigorously evaluated in clinical trials. A pilot community-based participatory randomized control research project evaluated use of urine HPV testing as a more culturally- and human resource appropriate method of cervical cancer screening in Yap State, FSM. Women participated in a cervical screening intervention using pap vs. urine test (N=217). This manuscript described attitudes about screening feasibility and preferences. Stakeholders and women participants were interviewed (N=23), and a survey also evaluated women's screening preferences (N=217). Qualitative content thematic analysis with multiple coders identified themes from interviews on acceptability and feasibility of screening tests. Women research participants were comfortable with the urine test (95%), despite limitations in some to provide samples. While 82.0% indicated that they felt comfortable with Pap smear, they also preferred a clinician (42%) to do the Pap smear, explaining that they preferred having a trained worker instead of themselves to do tests. Women want to be screened but accessibility remains a challenge. Education and training of professionals and community members alike will improve clinical skills, research capacity, knowledge of screening tests and behaviors including prioritizing HPV screening and testing.

Increasing Awareness of Gynecologic Cancer Risks and Symptoms among Asian, Native Hawaiian and Pacific Islander Women in the US-Associated Pacific Island Jurisdictions

Background: Gynecologic cancers are common among Asian/Native Hawaiian/Pacific Islander (A/NH/PI) women. Prevention is important in United States associated Pacific Island jurisdictions (USAPIJ) because there are limited resources to treat cancer. The objective of this study was to educate A/NH/PI women and providers about evidence-based interventions to prevent and control gynecologic cancers in Yap, one of four major islands comprising the Federated States of Micronesia (FSM). This was done through a partnership between Inside Knowledge: Get The Facts About Gynecologic Cancer national campaign and the Yap comprehensive cancer control program, both funded by the Center for Disease Control and Prevention (CDC). Methods: Inside Knowledge educational materials were obtained from the CDC website and used in facilitated educational sessions. Sessions were planned according to leading health education theories, and were implemented and led by local Yap public health practitioners. Pre- and post-session surveys were used to assess changes in gynecologic cancer awareness, confidence and behavioral intentions related to prevention/early detection for gynecologic cancer. Results: Twenty-nine providers and 326 adult women participated in sessions. All participants demonstrated significant increases in knowledge across all measured domains post-session. Public knowledge that HPV causes cervical, vulvar and vaginal cancer increased from 4.9% pre-session to 51.4% post-session (p<0.0001); provider knowledge increased from 17.2% to 96.6% (p<0.0001). Significantly more women identified smoking as a cervical cancer risk factor post-session (increased from 53.8% to 98.7% [p<0.0001]). An average of 61.4% of providers said they were extremely or somewhat confident in their gynecologic cancer knowledge pre-session compared to 91.7% post-session. Conclusion: Targeted education about gynecologic cancer symptoms and risk factors can be effective at increasing awareness, behavioral intention, confidence and knowledge. These increases can lead to more widespread prevention of these five cancers.