Assessing the system of services for chronic diseases prevention and control in the US-affiliated Pacific Islands: introduction and methods.

Chronic diseases are among the most costly and, in part, preventable health problems that share common behavioral risk factors. Data related to the prevalence of chronic diseases, such as diabetes, their risk factors, and the description of the capacity of the health and medical care system to address these problems are limited in the US-affiliated Pacific Islands (USAPI). This paper presents the background and methods used in conducting comprehensive assessments of the health care systems in ten sites across the USAPI. The principles used as the basis for conducting these assessments included capacity building and skills training. The methods included identifying the on-site Needs Assessment Team (NAT), developing the conceptual model; archival data collection; key informant interviews; reviewing data and documents to identify the key problems and issues to be prioritized; and reviewing and prioritizing the problems and issues.

An assessment of non-communicable diseases, diabetes, and related risk factors in the territory of American Samoa: a systems perspective.

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in American Samoa and describes the burden of selected NCDs (ie, diabetes, heart disease, hypertension, stroke, and chronic kidney disease); and assesses the system of service capacity and activities regarding service delivery, data collection and reporting as well as identifies the issues needing to be addressed. Findings reveal that nutrient-poor diet, lack of physical activity, and other lifestyle behaviors are associated with overweight and obesity and subsequent NCDs that impact the morbidity and mortality of the population. The leading causes of death include heart disease, diabetes, cancer and stroke. Population surveys show that 93% of the adults are overweight or obese and 47% have diabetes. Among public school children, 44.6% are overweight or obese. Other data show that between 2006 and 2010, there was a 33% increase in the number of patients receiving hemodialysis. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCDs. There is a paucity of health plans, policy and procedure manuals, coordination among providers, and lack of common standards of care. The combined administrative and clinical system of service needs were identified and prioritized. They include the need for a Territory-wide health strategy and plan, need for standards of care, and a need for collaborative team approach for the treatment and management of patients with diabetes and other chronic diseases.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Federated States of Micronesia, State of Chuuk: a systems perspective.

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Federated States of Micronesia, State of Chuuk and describes the burdens due to selected NCDs (diabetes, heart disease, hypertension, stroke, chronic kidney disease); and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifying the issues that need to be addressed. There has been a 9.2% decline in the total population between 2000 and 2010. Findings of medical and health data reveal that diabetes, myocardial infarction, and septicemia are the leading causes of death and lower limb surgical procedures and amputations was a major problem that was addressed with a foot care education program to prevent amputations. No data were available on the prevalence of diabetes among the population of Chuuk. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCDs. There is a lack of policy and procedure manuals, coordination among providers, and common standards of care. There is no functional data system to identify and track patients with diabetes and other chronic diseases. Priority issues and problems were identified for the clinical, administrative, and data systems.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Republic of the Marshall Islands, Kwajelein Atoll, Ebeye Island: a systems perspective.

Non-communicable diseases (NCD) have been declared a health emergency in the US-affiliated Pacific Islands (USAPI). This assessment, funded by the National Institutes of Health, was conducted on Ebeye Island of Kwajelein Atoll, Republic of the Marshall Islands (RMI) to describe the burdens due to selected NCD (diabetes, heart disease, hypertension, stroke, chronic kidney disease); assess the system of service capacity and activities for service delivery, data collection, and reporting; and identify the key issues that need to be addressed. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors lead to overweight and obesity and subsequent NCD that impact the morbidity and mortality of the population. Population survey of the RMI show that 62.5% of the total population is overweight or obese with a dramatic increase from the 15-24 year old (10.6%) and the 25-64 year old (41.9%) age groups. The leading causes of death were septicemia, renal failure, pneumonia, cancer, and myocardial infarction. Other findings show gaps in the system of administrative, clinical, and support services to address these NCD. All health care in Ebeye is provided in one setting and there is collaboration, coordination, and communication among medical and health care providers. The Book of Protocols for the Kwajalein Atoll Health Care Bureau provides the guidelines, standards, and policy and procedures for the screening, diagnosis, and management of diabetes and other NCDs. Based on these findings, priority issues and problems to be addressed for the administrative, clinical, and data systems were identified.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Republic of the Marshall Islands, Majuro Atoll: a systems perspective.

Non-communicable diseases (NCD) have been identified as a health emergency in the US-associated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Republic of the Marshall Islands, Majuro Atoll and describes the burdens due to selected NCD (diabetes, heart disease, hypertension, stroke, chronic kidney disease); and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifying the issues that need to be addressed. Findings reveal that the risk factors of poor diet, lack of physical activity, and risky lifestyle behaviors are associated with overweight and obesity and subsequent NCD that are significant factors in the morbidity and mortality of the population. The leading causes of death include sepsis, cancer, diabetes-related deaths, pneumonia, and hypertension. Population-based survey for the RMI show that 62.5% of the adults are overweight or obese and the prevalence of diabetes stands at 19.6%. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCD. There is no policy and procedure manual for the hospital or public health diabetes clinics and there is little communication, coordination, or collaboration between the medical and public health staff. There is no functional data system that allows for the identification, registry, or tracking of patients with diabetes or other NCDs. Based on these findings, priority issues and problems to be addressed for the administrative, clinical, and data systems were identified.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Republic of Palau: a systems perspective.

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Republic of Palau and describes the burden due to selected NCD (diabetes, heart disease, hypertension, stroke, chronic kidney disease); and assesses the system of service capacity and current activities for service delivery, data collection, and reporting as well as identifying the issues that need to be addressed. There has been a 7.1% increase in the population between 2000 and 2010. Significant shifts in the age groups show declines among children and young adults under 34 years of age and increases among adult residents over 45 years of age. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors are associated with overweight and obesity and subsequent NCD that play a significant role in the morbidity and mortality of the population. The leading causes of death include heart disease and cancer. A 2003 community household survey was conducted and 22.4% of them reported a history of diabetes in the household. A survey among Ministry of Health employees showed that 44% of the men and 47% of the women were overweight and 46% of the men and 42% of the women were obese. Other findings show significant gaps in the system of administrative, clinical, and support services to address these NCD. Priority issues and needs for the administrative and clinical systems were identified.

Assessing the health care system of services for non-communicable diseases in the US-affiliated Pacific Islands: a Pacific regional perspective.

Non-communicable diseases (NCD) have been recognized as a major health threat in the US-affiliated Pacific Islands (USAPI) and health officials declared it an emergency.1 In an effort to address this emergent pandemic, the Pacific Chronic Disease Council (PCDC) conducted an assessment in all six USAPI jurisdictions which include American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Federated States of Micronesia (FSM), Guam, the Republic of the Marshall Islands (RMI) and the Republic of Palau to assess the capacity of the administrative, clinical, support, and data systems to address the problems of NCD. Findings reveal significant gaps in addressing NCDs across all jurisdictions and the negative impact of lifestyle behaviors, overweight, and obesity on the morbidity and mortality of the population. In addition, stakeholders from each site identified and prioritized administrative and clinical systems of service needs.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Federated States of Micronesia, State of Kosrae: a systems perspective.

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI). This assessment, funded by the National Institutes of Health, was conducted in the Federated States of Micronesia, State of Kosrae and describes the burdens due to NCDs, including diabetes, and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifying the issues that need to be addressed. There has been a 13.9% decline in the population between 2000 and 2010. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors lead to overweight and obesity and subsequent NCD that are a significant factor in the morbidity and mortality of the population. Leading causes of death were due to nutrition and metabolic diseases followed by diseases of the circulatory system. Data from selected community programs show that the prevalence of overweight and obese participants ranged between 82% and 95% and the rate of reported diabetes ranged from 13% to 14%. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCD. There is no functional data system that is able to identify, register, or track patients with diabetes. Priority administrative and clinical issues were identified that need to be addressed to begin to mitigate the burdens of NCDs among the residents of Kosrae State.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Territory of Guam: a systems perspective.

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the US Territory of Guam and describes the burdens due to NCD, with an emphasis on diabetes; and assesses the system of service capacity and current activities for service delivery, data collection, and reporting as well as identifying the issues that need to be addressed. There has been an increase of 2.6% in the total population between 2000 and 2010. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors are associated with overweight and obesity. The leading causes of death include heart disease, cancer, and cerebrovascular accidents. Population surveys show that 9.1% of the adult population in 2009 reported being diagnosed with diabetes. Other data reports show that of the adults, 35.4% were overweight and 25.9% were obese; and among youth, 30% were overweight or obese. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address NCDs and diabetes. There is no Territory-wide health plan to address the prevention and control of NCDs including diabetes. There are no common standards of care or policy and procedures that are used by all the various medical and health care providers. Based on these findings, priority issues and needs were identified for the administrative and clinical systems.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Federated States of Micronesia, State of Yap: a systems perspective.

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Federated States of Micronesia, State of Yap, and describes the burdens due to diabetes and other NCDs (heart disease, hypertension, stroke, chronic renal disease), and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifying the issues that need to be addressed. There has been a 1.2% increase in the population between 2000 and 2010; however, there was a significant increase in the 45-64 year old age group. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors lead to overweight and obesity and subsequent NCD that are a significant factor in the morbidity and mortality of the population. The leading causes of death include cancer, heart disease, and diabetes. Local household surveys show that 63% to 80% of the adults and 20.5% to 33.8% of the children were overweight or obese. The surveys also showed that 23% of the adult population had diabetes and 35% were hypertensive. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCD. There is a policy and procedure manual that guides the NCD staff. There is no functional data system that is able to identify, register, or track patients with diabetes and other NCDs. Priority administrative and clinical issues were identified.

An assessment of non-communicable diseases, diabetes, and related risk factors in the commonwealth of the Northern Mariana Islands: a systems perspective.

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Commonwealth of the Northern Mariana Islands (CNMI) and describes the burdens due to NCDs, with an emphasis on diabetes, and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifies the issues that need to be addressed. There has been a 22.7% decline in the population between 2000 and 2010. Findings of medical and health data reveal that the risk factors of lifestyle behaviors lead to overweight and obesity and subsequent NCD. The leading causes of death are heart disease, stroke and cancer. The 2009 BRFSS survey reveals that the prevalence rate for diabetes was 9.8%. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCDs. There is no overall health plan to address NCDs or diabetes, there is little coordination between the medical care and public health staff, and there is no functional data system to identify, register, and track patients with diabetes. Based on the findings, priority issues and problems to be addressed for the administrative system and clinical system are identified.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Federated States of Micronesia, State of Pohnpei: a systems perspective.

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Federated States of Micronesia, State of Pohnpei and describes the burden due to selected NCD (diabetes, heart disease, hypertension, stroke, chronic kidney disease); and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifies the issues that need to be addressed. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors lead to overweight and obesity and subsequent NCD that are significant factors in the morbidity and mortality of the population. Leading causes of death were due to heart disease, diabetes, cancer, and hypertension. Population survey data show that 32.1% of the adult population had diabetes with a higher rate among women (37.1%) when compared to men (26.4%). The data also showed that 73.1% of the adult population was overweight or obese. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCD. There is no overall planning document for the prevention and control of NCDs or diabetes. There is evidence of little communication among the medical and health care providers which leads to fragmentation of care and loss of continuity of care. Based on some of the findings, priority issues and problems that need to be addressed for the administrative and clinical systems are identified.

Chronic disease surveillance systems within the US Associated Pacific Island jurisdictions.

In recent years, illness and death due to chronic disease in the US Associated Pacific Islands (USAPI) jurisdictions have dramatically increased. Effective chronic disease surveillance can help monitor disease trends, evaluate public policy, prioritize resource allocation, and guide program planning, evaluation, and research. Although chronic disease surveillance is being conducted in the USAPI, no recently published capacity assessments for chronic disease surveillance are available. The objective of this study was to assess the quality of existing USAPI chronic disease data sources and identify jurisdictional capacity for chronic disease surveillance. The assessment included a chronic disease data source inventory, literature review, and review of surveillance documentation available from the web or through individual jurisdictions. We used the World Health Organization's Health Metric Network Framework to assess data source quality and to identify jurisdictional capacity. Results showed that USAPI data sources are generally aligned with widely accepted chronic disease surveillance indicators and use standardized data collection methodology to measure chronic disease behavioral risks, preventive practices, illness, and death. However, all jurisdictions need to strengthen chronic disease surveillance through continued assessment and expanded support for valid and reliable data collection, analysis and reporting, dissemination, and integration among population-based and institution-based data sources. For sustained improvement, we recommend investment and technical assistance in support of a chronic disease surveillance system that integrates population-based and institution-based data sources. An integrated strategy that bridges and links USAPI data sources can support evidence-based policy and population health interventions.

Diabetes today in the Pacific: reports from the field.

The Pacific Diabetes Today Resource Center (PDTRC) was established in 1998 to assist communities in Hawai'i, American Samoa, Guam, Commonwealth of the Northern Mariana Islands, Republic of Palau, Federated States of Micronesia, and the Republic of the Marshall Islands to develop, implement, and evaluate community diabetes prevention and control activities. Between 2000 and 2002, PDTRC provided training and on-going support in 11 communities. This article includes case-study descriptions from each site, suggesting that in the first four years of this five-year project, PDTRC helped Pacific communities increase public awareness about diabetes, expand collaboration and partnership, develop the training capacities of local health leaders, sponsor new activities related to diabetes prevention and control, and secure new resources for their communities.

Cancer in Chuuk State, Federated States of Micronesia.

The purpose of this study, funded by the National Cancer Institute, was to document the state of cancer awareness and services in Chuuk State, Federated States of Micronesia (FSM) and to begin to identify the need for cancer-care services. Findings suggest that cancer is the third-leading cause of death in Chuuk, 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) improving ICD coding skills and knowledge; 3) increasing public awareness about cancer; 4) establishing an office dedicated to cancer; and 5) increasing screening of high-risk individuals.

Cancer in Pohnpei State, Federated States of Micronesia.

A cancer needs assessment, funded by the National Cancer Institute, was conducted in Pohnpei State (Pohnpei), Federated States of Micronesia (FSM). Findings revealed that cancer is the third leading cause of death in Pohnpei, 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) increasing community awareness about cancer (especially, cervix, breast, liver and lung) and related risk factors; 2) securing funding for cancer prevention and control planning and activities; 3) establishing a fully staffed cancer prevention and control office; 4) building local capacity for cancer cytology; and 5) increasing capacity to obtain and process lab specimens for high-risk patients.

Tobacco use prevention and control: implications for Native Hawaiian communities.

Despite the fact that the State of Hawai'i has the second lowest smoking prevalence rate in the nation, a higher proportion of Native Hawaiians continue to smoke cigarettes. Three data sources are examined and reveal that tobacco use and the health impact of tobacco use disproportionately affects Native Hawaiian adults and youths in Hawai'i. Studies have documented that dissemination of the approaches and methods shown to be effective will reduce the number of young people who become addicted to tobacco, increase the success rate of people trying to quit using tobacco, decrease the exposure of nonsmokers to environmental tobacco smoke, and decrease the burden of tobacco-related diseases and death. Strategies recommended for reducing tobacco use among Native Hawaiians include: (1) the development of collaboration with local school districts to implement school-based prevention programs in conjunction with community-based and media-based activities and (2) the Native Hawaiian Health Programs developing activities to implement the "5 A's" for brief clinical interventions.

Empowerment through community building: Diabetes Today in the Pacific.

The goal of Diabetes Today, a program of the Centers for Disease Control and Prevention (CDC), is to develop coalitions and train coalition members in assessment, planning, and evaluation to address diabetes in their communities. CDC established the Pacific Diabetes Today Resource Center (PDTRC) in 1998 to tailor the program for Pacific Islander communities in Hawaii, American Samoa, Guam, the Commonwealth of the Northern Marianas Islands, the Federated States of Micronesia, the Republic of the Marshall Islands, and Palau. PDTRC's work is guided by the principles of community building and the goal of empowering coalitions to take action around diabetes. Culturally appropriate strategies are used to gain access to the community, transfer knowledge and skills, build coalitions, and provide technical assistance. Evidence of empowerment is seen in increased individual competence, enhanced community capacity, reduced barriers, and improved supports to address diabetes. To maintain the gains of community building in the Pacific, three factors appear critical: an engaged leader, a host agency for the coalition, and continuing access to technical assistance and funds.

Listening to the community: a first step in adapting Diabetes Today to the Pacific.

Diabetes is a growing problem among Pacific Islanders, but few community-based groups in the Pacific are actively working on diabetes prevention and control. The Pacific Diabetes Today Resource Center (PDTRC) was established in 1998 to adapt the Diabetes Today (DT) curriculum for Pacific Island communities in Hawai'i, American Samoa, and Micronesia. To gather data to guide the development of the Pacific Diabetes Today (PDT) curriculum, a year was spent listening to Pacific communities. First, data were gathered from health professionals on how the DT curriculum should be modified. Second, health and community leaders in 11 sites were trained and supported to conduct discussion groups with people affected by diabetes. Third, site coordinators evaluated the discussion group process. A Pacific-wide Advisory Council (AC) was established to guide the project, and the AC used findings from the first year to generate guidelines for staff to follow in adapting the DT curriculum to the Pacific. These guidelines directed staff to: a) realize that Pacific communities need to build awareness about diabetes; b) train and support local community leaders as co-facilitators in the PDT curriculum, using a learn-by-doing approach, with the goal of developing them as independent trainers; c) encourage the involvement of a broad range of community members in PDT training, including the involvement of local physicians to counter medical misconceptions about diabetes; d) give the PDT curriculum a Pacific "look" and "feel;" and e) keep the training logistically flexible to accommodate differences in communities across the region. Other programs and agencies that want to develop training programs in the Pacific may find these listening strategies and guidelines helpful.