Conducting formative research during a pandemic threat to inform the development of an obesity prevention social and behaviour change communication strategy in Tonga.

ISSUE ADDRESSED: The global epidemic of obesity is overtaking many parts of the world with the Pacific Islands at particular risk. Tonga population surveys identify significant increases in overweight and obesity with Social and Behaviour Change Communication (SBCC) offering opportunities for curbing the rise in non-communicable diseases. Formative research was conducted during the Covid-19 pandemic to assess stakeholder and program beneficiary needs and wants toward an obesity prevention SBCC strategy in Tonga. METHODS: Semi-structured interviews with 17 key informants and 18 focus group discussions (N = 168) were conducted in Tongatapu. Data analysis was conducted on Nvivo 2020 qualitative software with desk research of secondary data supporting in-field findings. RESULTS: Potential barriers to behavioural compliance included social/cultural norms, poor attitudes; low motivation and capability; and vulnerabilities of gender and other social determinants. Opportunities included the Tongan collective mindset and the desire for greater social interaction and fun. Strong political will to affect change was apparent with the need to consider targeting to youth, social mobilisation of communities through empowering messaging, and an integrated range of activities. CONCLUSIONS: Co-design in the formative research process was able to be fostered via online communication processes to overcome the challenges of Covid-19 travel restrictions. The innovative approach provided a number of learnings including identification of national and regional priorities and improved efficiencies in SBCC planning, implementation and evaluation. SO WHAT?: Formative research adopting co-design approaches with stakeholders and program beneficiaries can provide optimal engagement and ownership in the SBCC strategy including insights into messaging approaches.

Child morbidity as described by hospital admissions for primary school aged children in Tonga 2009-2013.

AIMS: To describe inpatient utilisation patterns for primary school aged children in Tonga. METHODS: We described admissions for children aged 5-11 years to the main hospital in Tonga from January 2009 to December 2013. Rates with 95% confidence intervals (CI) were compared using rate ratios (RR). RESULTS: There were 1,816 admissions. The average annual admission rate was 20.2/1,000 (95% CI 19.3-21.1). Hospital admission rates were higher in younger than older children (5-7 versus 8-11 years, RR=1.28, 95% CI 1.18-1.41) and in boys than girls (RR=1.52, 95% CI 1.38-1.68). Injury and poisoning (28%), non-respiratory infectious diseases (19%), respiratory conditions (16%), abdominal/surgical conditions (13%) and dental (9%) were the most frequent admission reasons. A larger proportion of younger versus older children were hospitalised for dental (16% vs 1%, P<0.001) or respiratory conditions (18% vs 14%, P=0.02). A larger proportion of older children were hospitalised for abdominal/surgical conditions (15% vs 11%, P=0.008), other infectious diseases (21% vs 17%, P=0.04), other conditions (10% vs 6%, P<0.001) and cardiac conditions (2% vs 1%, P<0.001). CONCLUSIONS: In children 5-11 years in Tonga, 85% of admissions were for five groups of conditions. These data inform priority areas for healthcare spending and enable comparisons over time and between different Pacific countries.

Erroneous inflation of diabetes prevalence: Are there global implications?

Comparison of the prevalence of type 2 diabetes mellitus (T2DM) in adults aged 25-64 years in selected Pacific Island countries using whole blood and plasma glucose cut-off points. Unit records of STEPwise approach to Surveillance (STEPS) surveys obtained from Fiji, Samoa, and Tonga Ministries of Health; T2DM prevalence recalculated using whole blood and plasma cut-off points. Shaded bars indicate T2DM prevalence based on correct glucose cut-off points for the glucose meter used (fasting blood glucose [FBG] ≥6.1 mmol/L for early surveys1,3,5 ; fasting plasma glucose [FPG] ≥7.0 mmol/L for later surveys),2,4,6 whereas open bars show T2DM prevalence based on incorrect glucose cut-off points (FPG ≥6.1 mmol/L for later surveys).2,4,6 Highlights Incorrect glucose cut-off points were applied to the Fiji 2011, Samoa 2013, and Tonga 2012 STEPS surveys. This doubled the actual T2DM prevalences compared to using the correct glucose cut-off points. The errors occurred due to modern glucose meters producing measurements in plasma-equivalent concentrations from whole blood samples. The incorrect whole blood glucose cut-off (≥6.1mmol/L) was applied instead of the correct plasma glucose cut-off (≥7.0mmol/L). This error likely affects other Pacific states, and may have global ramifications.

Diabetes and Obesity Trends in Tonga Over 40 Years.

Disparate population surveys of type 2 diabetes mellitus (T2DM) have been conducted in Tonga for 4 decades. This study standardizes these surveys to enable assessment of T2DM and obesity trends in Tongans aged 25 to 64 years over 1973-2012, and projects T2DM prevalence to 2020 based on demographic and population weight changes. Eight surveys were standardized to the nearest census to produce nationally representative estimates. Linear period trends and prevalence projections to 2020 were produced using random-effects meta-regression. Over 1973-2012, T2DM prevalence increased from 5.2% to 19.0% (1.9%/5 years) and obesity prevalence from 56.0% to 70.2% (2.7%/5 years). T2DM prevalence period projection to 2020 is 22.3%. Based on modeling using body mass index, T2DM prevalence in 2020 could have been 12.7% and 16.8% in 2020 had mean population weight been 1 to 4 kg lower than 2012 levels.

Mortality trends in Tonga: an assessment based on a synthesis of local data.

BACKGROUND: Accurate measures of mortality level by age group, gender, and region are critical for health planning and evaluation. These are especially required for a country like Tonga, which has limited resources and works extensively with international donors. Mortality levels in Tonga were examined through an assessment of available published information and data available from the four routine death reporting systems currently in operation. METHODS: Available published data on infant mortality rate (IMR) and life expectancy (LE) in Tonga were sought through direct contact with the Government of Tonga and relevant international and regional organizations. Data sources were assessed for reliability and plausibility of estimates on the basis of method of estimation, original source of data, and data consistency. Unreliable sources were censored from further analysis and remaining data analysed for trends.Mortality data for 2001 to 2009 were obtained from both the Health Information System (based on medical certificates of death) and the Civil Registry. Data from 2005 to 2009 were also obtained from the Reproductive Health System of the Ministry of Health (MoH) (based on community nursing reports), and for 2005-2008, data were also obtained from the Prime Minister's office. Records were reconciled to create a single list of unique deaths and IMR and life tables calculated. Completeness of the reconciled data was examined using the Brass growth-balance method and capture-recapture analysis using two and three sources. RESULTS: Published IMR estimates varied significantly through to the late 1990s when most estimates converge to a narrower range between 10 and 20 deaths per 1,000 live births. Findings from reconciled data were consistent with this range, and did not demonstrate any significant trend over 2001 to 2009.Published estimates of LE from 2000 onwards varied from 65 to 75 years for males and 68 to 74 years for females, with most clustered around 70 to 71 for males and 72 to 73 for females. Reconciled empirical data for 2005 to 2009 produce an estimate of LE of 65.2 years (95% confidence interval [CI]: 64.6 - 65.8) for males and 69.6 years (95% CI: 69.0 - 70.2) for females, which are several years lower than published MoH and census estimates. Adult mortality (15 to 59 years) is estimated at 26.7% for males and 19.8% for females. Analysis of reporting completeness suggests that even reconciled data are under enumerated, and these estimates place the plausible range of LE between 60.4 to 64.2 years for males and 65.4 to 69.0 years for females, with adult mortality at 28.6% to 36.3% and 20.9% to 27.7%, respectively. CONCLUSIONS: The level of LE at a relatively low IMR and high adult mortality suggests that non-communicable diseases are having a profound limiting effect on health status in Tonga. There has been a sustained history of incomplete and erroneous mortality estimates for Tonga. The findings highlight the critical need to reconcile existing data sources and integrate reporting systems more fully to ensure all deaths in Tonga are captured and the importance of local empirical data in monitoring trends in mortality.

Causes of death in Tonga: quality of certification and implications for statistics.

BACKGROUND: Detailed cause of death data by age group and sex are critical to identify key public health issues and target interventions appropriately. In this study the quality of local routinely collected cause of death data from medical certification is reviewed, and a cause of death profile for Tonga based on amended data is presented. METHODS: Medical certificates of death for all deaths in Tonga for 2001 to 2008 and medical records for all deaths in the main island Tongatapu for 2008 were sought from the national hospital. Cause of death data for 2008 were reviewed for quality through (a) a review of current tabulation procedures and (b) a medical record review. Data from each medical record were extracted and provided to an independent medical doctor to assign cause of death, with underlying cause from the medical record tabulated against underlying cause from the medical certificate. Significant associations in reporting patterns were evaluated and final cause of death for each case in 2008 was assigned based on the best quality information from the medical certificate or medical record. Cause of death data from 2001 to 2007 were revised based on findings from the evaluation of certification of the 2008 data and added to the dataset. Proportional mortality was calculated and applied to age- and sex-specific mortality for all causes from 2001 to 2008. Cause of death was tabulated by age group and sex, and age-standardized (all ages) mortality rates for each sex by cause were calculated. RESULTS: Reported tabulations of cause of death in Tonga are of immediate cause, with ischemic heart disease and diabetes underrepresented. In the majority of cases the reported (immediate) cause fell within the same broad category as the underlying cause of death from the medical certificate. Underlying cause of death from the medical certificate, attributed to neoplasms, diabetes, and cardiovascular disease were assigned to other underlying causes by the medical record review in 70% to 77% of deaths. Of the 28 (6.5%) deaths attributed to nonspecific or unknown causes on the medical certificate, 17 were able to be attributed elsewhere following review of the medical record. Final cause of death tabulations for 2001 to 2008 demonstrate that noncommunicable diseases are leading adult mortality, and age-standardized rates for cardiovascular diseases, neoplasms, and diabetes increased significantly between 2001 to 2004 and 2005 to 2008. Cause of death data for 2001 to 2008 show increasing cause-specific mortality (deaths per 100,000) from 2001-2004 to 2005-2008 from cardiovascular (194-382 to 423-644 in 2005-2008 for males and 108-227 to 194-321 for females) and other noncommunicable diseases that cannot be accounted for by changes in the age structure of the population. Mortality from diabetes for 2005 to 2008 is estimated at 94 to 222 deaths per 100,000 population for males and 98 to 190 for females (based on the range of plausible all-cause mortality estimates) compared with 2008 estimates from the global burden of disease study of 40 (males) and 53 (females) deaths per 100,000 population. DISCUSSION: Certification of death was generally found to be the most reliable data on cause of death in Tonga available for Tonga, with 93% of the final assigned causes following review of the 2008 data matching those listed on the medical certificate of death. Cause of death data available in Tonga can be improved by routinely tabulating data by underlying cause and ensuring contributory causes are not recorded in Part I of the certificate during data entry to the database. There is significantly more data on cause of death available in Tonga than are routinely reported or known to international agencies.