The politics of food in the Pacific: coherence and tension in regional policies on nutrition, the food environment and non-communicable diseases.

OBJECTIVE: Our study analysed evolving regional commitments on food policy in the Pacific. Our aim was to understand regional priorities and the context of policy development, to identify opportunities for progress. DESIGN: We analysed documentation from a decade of regional meetings in order to map regional policy commitments relevant to healthy diets. We focused on agriculture, education, finance, health, and trade sectors, and Heads of State forums. Drawing on relevant political science methodologies, we looked at how these sectors 'frame' the drivers of and solutions to non-communicable diseases (NCD), their policy priorities, and identified areas of coherence and tension. SETTING: The Pacific has among the highest rates of non-communicable diseases in the world, but also boasts an innovative and proactive response. Heads of State have declared NCD a 'crisis' and countries have committed to specific prevention activities set out in a regional 'Roadmap'. Yet, diet-related NCD risk-factors remain stubbornly high and many countries face challenges in establishing a healthy food environment. RESULTS: Policies to improve food environments and prevent NCD are a stated priority across regional policy forums, with clear agreement on the need for a multi-sectoral response. However, we identified challenges in sustaining these priorities as political attention fluctuated. We found examples of inconsistencies and tension in sectoral responses to the NCD epidemic that may restrict implementation of the multi-sectoral action. CONCLUSION: Understanding the priorities and positions underpinning sectoral responses can help drive a more coherent NCD response, and lessons from the Pacific are relevant to public health nutrition policy and practice globally.

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.

Cancer control in small island nations: from local challenges to global action.

Cancer is a leading cause of death in small island nations and is forecast to increase substantially over the coming years. Governments, regional agencies, and health services of these nations face daunting challenges, including small and fragile economies, unequal distribution of resources, weak or fragmented health services, small population sizes that make sustainable workforce and service development problematic, and the unavailability of specialised cancer services to large parts of the population. Action is required to prevent large human and economic costs relating to cancer. This final Series paper highlights the challenges and opportunities for small island nations, and identifies ways in which the international community can support efforts to improve cancer control in these settings. Our recommendations focus on funding and investment opportunities to strengthen cancer-related health systems to improve sharing of technical assistance for research, surveillance, workforce, and service development, and to support small island nations with policy changes to reduce the consumption of commodities (eg, tobacco and unhealthy food products) that increase cancer risk.

Cancer control in the Pacific: big challenges facing small island states.

This Series paper describes the current state of cancer control in Pacific island countries and territories (PICTs). PICTs are diverse but face common challenges of having small, geographically dispersed, isolated populations, with restricted resources, fragile ecological and economic systems, and overburdened health services. PICTs face a triple burden of infection-related cancers, rapid transition to lifestyle-related diseases, and ageing populations; additionally, PICTs are increasingly having to respond to natural disasters associated with climate change. In the Pacific region, cancer surveillance systems are generally weaker than those in high-income countries, and patients often present at advanced cancer stage. Many PICTs are unable to provide comprehensive cancer services, with some patients receiving cancer care in other countries where resources allow. Many PICTs do not have, or have poorly developed, cancer screening, pathology, oncology, surgical, and palliative care services, although some examples of innovative cancer planning, prevention, and treatment approaches have been developed in the region. To improve cancer outcomes, we recommend prioritising regional collaborative approaches, enhancing cervical cancer prevention, improving cancer surveillance and palliative care services, and developing targeted treatment capacity in the region.

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.

Tobacco Smoking in Islands of the Pacific Region, 2001-2013.

We provide an overview of tobacco smoking patterns in Pacific island countries and territories to facilitate monitoring progress toward the goal of a Tobacco-Free Pacific by 2025. We examined data from 4 surveys conducted in the region between 2001 and 2013, including the STEPwise approach to surveillance for adults (25-64 years); the Global School-Based Student Health Survey and the Global Youth Tobacco Survey (students 13-15 years); and the Youth Risk Behavior Surveillance System (grade 9-12 students) in United States affiliated Pacific Islands (USAPIs). Adult smoking prevalence ranged from less than 5% of women in Vanuatu to almost 75% of men in Kiribati. Smoking prevalence among students (13-15 years) ranged between 5.6% and 52.1%. There were declines in smoking among youths in many USAPIs. To achieve the tobacco-free goal and reduce disease burden, accelerated action is needed to align national legislation with international agreements and build capacity for tobacco control at all levels.

Assessing the Status of Diabetes Associations in the Pacific: A Starting Point for Strengthening Associations to Manage Diabetes.

This study aimed to assess the status of national diabetes associations in the Pacific Island Countries and Territories as a starting point for strengthening their development and effectiveness in the prevention and control of diabetes. This cross-sectional study was conducted in 21 Pacific Island Countries and Territories using a structured questionnaire that gathered information from national non-communicable diseases prevention and control focal persons on diabetes associations, organizational structure, funding sources, and ongoing activities to address diabetes. The overall status of national diabetes associations was assessed using standardized criteria. Of the 21 countries surveyed, 18 (86%) responded. Of these, 12 (67%; American Samoa, Northern Mariana Islands, Federated States of Micronesia, French Polynesia, Fiji, Guam, Nauru, Papua New Guinea, Marshall Islands, Solomon Islands, Tonga, and Vanuatu) have a national diabetes association. Half of the existing associations are fully functioning, while the remainder is either partially functioning or not functioning. Only 50% of existing associations have a regular funding source, and many lack clear visions and workable governance structures. This study fills a knowledge gap on the current status of associations and forms a baseline from which associations can be strengthened. It also draws attention to the need for Pacific leaders to invest and engage more in civil societies for better and effective diabetes care for all.

Evidence-informed process to identify policies that will promote a healthy food environment in the Pacific Islands.

OBJECTIVE: To implement a systematic evidence-informed process to enable Fiji and Tonga to identify the most feasible and targeted policy interventions which would have most impact on diet-related non-communicable diseases. DESIGN: A multisectoral stakeholder group of policy advisers was formed in each country. They used participatory approaches to identify the problem policies and gaps contributing to an unhealthy food environment. Potential solutions to these problems were then identified, and were assessed by them for feasibility, effectiveness, cost-effectiveness and side-effects. Data were gathered on the food and policy environment to support the assessments. A shortlist of preferred policy interventions for action was then developed. RESULTS: Sixty to eighty policy problems were identified in each country, affecting areas such as trade, agriculture, fisheries and pricing. Up to 100 specific potential policy solutions were then developed in each country. Assessment of the policies highlighted relevant problem areas including poor feasibility, limited effectiveness or cost-effectiveness and serious side-effects. A shortlist of twenty to twenty-three preferred new policy options for action in each country was identified. CONCLUSIONS: Policy environments in these two countries were not conducive to supporting healthy eating. Substantial areas of potential action are possible, but some represent better choices. It is important for countries to consider the impact of non-health policies on diets.

Insights in Public Health: COVID-19 Special Column: The Crisis of Non-Communicable Diseases in the Pacific and the Coronavirus Disease 2019 Pandemic.

Globally, coronavirus disease 2019 (COVID-19) is threatening human health and changing the way people live. With the increasing evidence showing comorbidities of COVID-19 and non-communicable diseases (NCDs), the Pacific region, where approximately 75% of deaths are due to NCDs, is significantly vulnerable during this crisis unless urgent action is taken. Whilst enforcing the critical mitigation measures of the COVID-19 pandemic in the Pacific, it is also paramount to incorporate and strengthen NCD prevention and control measures to safeguard people with NCDs and the general population; keep people healthy and minimise the impact of COVID-19. To sustain wellbeing of health, social relationships, and the economy in the Pacific, it is a critical time for all governments, development partners and civil societies to show regional solidarity in the fight against emerging COVID-19 health crisis and existing Pacific NCDs crisis through a whole of government and whole of society approach.

Alcohol use in the Pacific region: Results from the STEPwise approach to surveillance, Global School-Based Student Health Survey and Youth Risk Behavior Surveillance System.

INTRODUCTION AND AIMS: Alcohol use is a leading risk factor for disease and injury in Pacific Island countries and territories (PICT). This paper examines drinking patterns across 20 PICTs. DESIGN AND METHODS: We synthesised published data from the STEPwise approach to surveillance or similar surveys for adults 25-64 years, and from the Global School-Based Student Health surveys and Youth Risk Behavior Surveillance System (YRBSS) for youth. We examined current and heavy drinking, and for adults also frequency of consumption. Using YRBSS, we studied trends in youth alcohol use in US-affiliated PICTs between 2001 and 2013. RESULTS: Alcohol consumption in adults and youth varied considerably across PICTs. In eight PICT populations, over 60% of male adults were current drinkers. Male adults consumed alcohol more frequently and engaged in heavy drinking more than female adults. Similar gender differences occurred in current and heavy drinking among youth. Across 10 PICTs, current drinking prevalence in males 13-15 years ranged from 10% to over 40%. Declines in alcohol use among grade 9-12 students were observed in YRBSS, although the magnitude differed by island and sex. DISCUSSION AND CONCLUSIONS: Alcohol consumption varies widely between PICTs. There are marked gender differences in use and abstention. There is scope in PICTs for implementation of best practice strategies to reduce alcohol-related harm. These need to be gender responsive and cognisant of concerning patterns of youth drinking. Strengthening surveillance of alcohol use and its consequences is vital to inform and monitor the impact of national and regional policies. [Kessaram T, McKenzie J, Girin N, Roth A, Vivili P, Williams G, Hoy D. Alcohol use in the Pacific region: Results from the STEPwise approach to surveillance, Global School-Based Student Health Survey and Youth Risk Behavior Surveillance System. Drug Alcohol Rev 2016;35:412-423].

Noncommunicable diseases and risk factors in adult populations of several Pacific Islands: results from the WHO STEPwise approach to surveillance.

OBJECTIVE: To provide an overview of the prevalence of noncommunicable diseases (NCDs) and their risk factors in several Pacific island countries and territories (PICTs), in accordance with global NCD targets. METHODS: For six risk factors, data for adults (aged 25-64 years) from published reports of the World Health Organization STEPwise approach to NCD surveillance, or methodologically similar surveys, were collated, age standardised and compared across fifteen PICTs. RESULTS: In the majority of PICT populations, more than half of male current drinkers drank heavily and more than 40% of men and 20% of women were current smokers. In 10 populations, about 50% or more of women were insufficiently physically active. Prevalence of hypertension and diabetes exceeded 20% and 25%, respectively, in several populations. Near or more than half of men and women in all populations were overweight; in most, more than one-third of both sexes were obese. CONCLUSIONS: The prevalence of NCDs and risk factors varies widely between PICTs and by sex. The evidence shows the high and alarming present and future burden of NCDs in the region. IMPLICATIONS: Strengthened political commitment and increased investment are urgently required to tackle the NCD crisis, successfully achieve targets and ensure continuing sustainable development in the Pacific islands.