An Assessment of Non-Communicable Diseases, Diabetes, and Related Risk Factors in the Federated States of Micronesia, State of Kosrae: A Systems Perspective

Abstract

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 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.

Introduction

This paper presents findings from an assessment of the capacity of the administrative, clinical, support, and data systems to address the problems of non-communicable diseases (NCD) including diabetes and its risk factors in the Federated States of Micronesia, State of Kosrae during August 22–26, 2011. Data and information were obtained through review of existing plans, reports and documents; interviews were conducted with selected key informants; issues and needs were identified and groups of administrators and clinicians were used to define the priorities. (See article in this issue: Assessing the System of Services for Chronic Disease Prevention and Control in the US-affiliated Pacific Islands: Introduction and Methods).² This work was funded by the National Institutes of Health, Institute on Minority Health and Health Disparities.

Geography of the Federated States of Micronesia and the State of Kosrae

The Federated States of Micronesia (FSM) is an island nation consisting of approximately 607 islands in the Western Pacific. Although the area encompassing the FSM, including its Economic Exclusive Zone, is very large, the combined total land area is only 271 square miles with an additional 2,776 square miles of lagoon area. The 607 islands vary from large, high mountainous islands of volcanic origin to small atolls. The FSM consists of four geographically separate states: Chuuk, Kosrae, Pohnpei and Yap.

The State of Kosrae is the only single-island state in the Federated States of Micronesia (FSM) and the furthest southeastern point of the four FSM states. It is located at approximately 5° N Latitude and 163° E Longitude, about 370 miles north of the equator and almost 3,000 miles southwest of the State of Hawai'i. The Island of Kosrae is the second largest inhabited island in the FSM with a land area of approximately 42.3 square miles. Kosrae has three distinct geographic features—mountains, jungle, and mangrove forests—ringed by miles of white sandy beaches. Mountains are steep and rugged, and are covered by dense tropical vegetation. Several mountain peaks rise over 2,000 feet above sea level, and account for about 70% of the land area. The interior part of the island is characterized by high steep rugged mountain peaks, with Mount Finkol being the highest point of Kosrae at 2,064 feet above sea level. Because of the steep rugged mountain peaks, all of the communities are coastal communities and are connected by paved roads. Travel around Kosrae Island is not difficult and it is possible to drive from one end of the island to the other end in approximately two hours of easy driving. The island is surrounded by low-lying reefs and mangrove swamps. The state is divided into the four municipalities of: Lelu, Malem, Utwe, and Tafunsak. The community of Walung (approximate population of 200 residents), part of Tafunsak municipality, is isolated and only accessible by a half-hour boat ride at high tide or a steep un-paved gravel road. The capitol of Kosrae is Tofol where the majority of the government buildings and offices, the single high school, and the Kosrae State Hospital are located. Also found in Tofol are the offices of private businesses including the FSM Telecommunication, banks, restaurants, and small retail stores.^3–7

Population and Characteristics of the Population

Analysis of data from the 2000 Population Census and the 2010 Preliminary Census shows there has been a decline in the population of 1,070 residents (13.9%) between the two census enumerations.^7,8 The data reveal that the largest proportion of the declines are among the youngest (under 20 years of age) and young adult age groups (25–44 years of age). A possible explanation of this decline among these age groups is that young couples and their children are emigrating out of Kosrae. More important are the significant increases in the absolute number of residents in the 45–74 years of age categories who are at higher risk of morbidity and mortality due to chronic diseases and their complications. The impact of the shift in the age distribution of the population is the potential need for additional resources as this older population seeks services for their chronic conditions.

The Year 2010 Preliminary Census population count of the State of Kosrae stands at 6,616 residents with 3,352 (50.7%) males and 3,264 (49.3%) females. Of the total population, 2,160 (32.6%) reside in Lelu municipality, 1,300 (19.6%) reside in Malem, 983 (14.9%) in Utwe, and 2,173 (32.8%) in Tafunsak municipality. The median age in the State of Kosrae in 2000 was 18.5 years⁸ and in 2010 the median age is 21.5 years.⁹

Morbidity and Mortality Data

Outpatient Visits for Diabetes and Hypertension

These data were provided in a conversation with H. Palik, Medical Records Office (August 23, 2011). Table 2 shows the number and proportion of outpatient visits for selected ICD-10 Codes to include visits for diabetes and visits for hypertension. In 2009, there were a total of 26,226 visits to the outpatient clinic for all causes. Of these visits, 1,730 (6.6%) were for patients seen with the diagnosis of diabetes. In the same year there were 1,598 (6.1%) outpatient visits for essential hypertension or hypertension with heart or renal diseases. Overall, in 2009, 12.7% of the outpatient visits were for patients with diabetes or hypertension. In 2010, of the 26,731 total visits, 1,826 (6.8%) were for patients with diabetes and 1,549 (5.8%) were for patients with hypertension for a total of 12.6% of the visits for diabetes or hypertension.

Table 2.

Outpatient Visits for Diabetes and Hypertension, Kosrae State Hospital, Kosrae, FSM, 2009 – 2010

Service Code	2009 (Visits = 26,226)		2010 (Visits = 26,731)
	n	%	n	%
E10.0–10.9 (Type 1 Diabetes)	87	0.3	7	<0.1
E11.0–11.9 (Type 2 Diabetes)	1501	5.7	1791	6.7
E14.0–14.9 (Unspecified)	142	0.5	28	0.1
Subtotal (Diabetes)	1730	6.6	1826	6.8
I10.0–10.9 (Essential hypertension)	1474	5.6	1372	5.1
I11.0–13.9 (Hypertension, heart renal disease)	124	0.5	177	0.7
Subtotal (Hypertension)	1598	6.1	1549	5.8
Total Visits (Diabetes and Hypertension)	3328	12.7	3375	12.6

Data source: Personal communication, H. Palik (August 23, 2011)

Leading Causes of Death

These data were provided in a conversation with H. Palik, Medical Records Office (August 23, 2011). Mortality data were aggregated for 2008-2010 and crude mortality rates per 100,000 population were calculated based on the Kosrae 2000 census of 7,686 residents. The overall crude mortality rate for 2008–2010 was 750.3/100,000 population. The leading causes of death were metabolic (173.5), followed by circulatory (121.4), infectious (82.4), neoplasm (73.7), and respiratory (56.4).

Medical Referrals

Data were provided in a conversation with S. Jackson (August 24, 2011), MiCare Representative and Coordinator of Off-Island Referrals. Data for off-island medical referrals were reviewed for 2008–2010 for patients who are insured and uninsured. Data for uninsured patients who were referred for off-island medical care was limited to the total number of patients referred each year—10 per year in 2008 and 2009, and 6 in 2010. The number of patients referred for off-island medical care who were insured under the MiCare Insurance Program has increased from 27 patients in 2008 to 33 patients in 2009 to 36 patients in 2010. Table 4 shows referrals by diagnosis and year. During this time period, the highest proportion of patients was referred for orthopedic conditions (25.0%), followed by cancer (20.8%), ophthalmology conditions (14.5%) and cardiac conditions (8.3%). Cross-referencing the referral data with patients known to the DPCP, revealed that, seven patients (25.9%) in 2008, nine patients (27.3%) in 2009, and six (16.2%) patients in 2010 were also being treated for diabetes.

Table 4.

Off-Island Medical Referral, Insured and Uninsured Patients, Kosrae State, FSM, 2008–2010

Diagnostic Category	2008		2009		2010		Total
	n	%	n	%	n	%	n	%
Cardiac	4	14.8	2	6.1	2	5.6	8	8.3
Ophthalmology	3	11.1	4	12.1	7	19.4	14	14.5
Orthopedic	7	25.9	10	30.3	7	19.4	24	25.0
Cancer	6	22.2	5	15.2	9	25.0	20	20.8
Renal	0	0.0	4	12.1	2	5.6	6	6.3
Gastrointestinal	0	0.0	4	12.1	2	5.6	6	6.3
Neurology	2	7.4	1	3.0	0	0.0	3	3,1
Other	5	18.5	3	9.1	7	19.4	15	15.6
Total	27	100	33	100	36	100	96	100

Data source: Personal communication, S. Jackson (August 24, 2011)

Population-Based Surveillance Data

NCD Risk Factors STEPS Report

Kosrae State is in the process of completing the NCD Risk Factors STEPS survey and anticipates that all of the required measurement data will be collected by the end of September 2011. Locally collected data available at the time of the assessment is presented below.

Global Youth Tobacco Survey — Federated States of Micronesia, 2007

The Global Youth Tobacco Survey (GYTS) was conducted in all four FSM states; a total of 1,363 students ages 13–15 participated and the data were aggregated for analysis and reporting for FSM.

Tobacco use among the youth in FSM is high with almost half (45.6%) having ever tried cigarette smoking (56.2% among boys and 34.7% among girls). Over one-quarter of the students (28.3%) are current smokers. Of never smokers, 30.1% reported being likely to initiate smoking in the next year. The data also show the difficulties in cessation in that 83.2% of the current smokers report having tried to quit tobacco use without success and 86.5% state that they want to stop smoking. Educational efforts to reduce smoking among youth is evidenced by 41.4% of the students reporting having been taught about the dangers of tobacco smoke and 47.1% were taught about the effects of smoking during the past year. The data for exposure to environmental tobacco smoke show that 60.7% of the students report exposure to smoke from others in the home, 48.8% have one or more parent who smoke and 71.3% report exposure to smoke in public places. Overall, 32.5% of the students think smoking should be banned in public places.¹⁰

Kosrae Youth Tobacco Mini-Survey

The Kosrae Substance Abuse and Mental Health Program and Tobacco Control Program conducted the Kosrae Youth Tobacco Mini-Survey in 2008 and 2009 and it is presented here as a source of local data. Unfortunately, the results from the GYTS and the 2008 and 2009 Mini-Surveys, cannot be directly compared with each other because of the major differences in the survey methodology, the recruitment process, and age ranges of the participants. C. Tosie, Substance Abuse and Tobacco Program Coordinator (August 21, 2011) provided the Tobacco Mini Survey 2008 Fact Sheet (unpublished). The 2008 Kosrae Youth Tobacco Mini-Survey was a school-based survey of all students in grades 7, 8, and 9, conducted in March 2008 with a total of 505 students, all under 18 years of age. The data on prevalence revealed that 41% of students tried cigarette smoking and that 10% first tried smoking cigarettes before they were 9 years of age. The data also showed that 17% of the students smoke more than 10 days a month and 18% smoke more than two cigarettes per day. For betel nut use, the data showed that 16% were less than 9 years of age when they first chewed betel nut and 46% use tobacco products when they chew betel nut. Assessing the data for cessation of cigarette smoking, 28% of the students wanted to stop smoking now, 32% tried to quit smoking during the past year, and 48% have received advice or help to quit smoking.

C. Tosie, Substance Abuse and Tobacco Program (August 21, 2011) provided the Kosrae Youth Tobacco Survey 2009 Fact Sheet (unpublished). The 2009 Kosrae Youth Tobacco Mini-Survey was a community-based survey conducted in July 2009 and a total of 530 youths (age 15–36 years) volunteered to participate in the survey. The data on prevalence of smoking revealed that 57% of the participants experimented with smoking cigarettes and 4% tried smoking before 9 years of age. The data also showed that 19% of the participants smoke more than 10 days a month and 21% smoke more than two cigarettes per day. For betel nut use, the data showed that 11% were less than 9 years of age when they first chewed betel nut and 63% use tobacco products when they chew betel nut. The data on cessation of current smokers revealed that 33% want to stop smoking now, 37% have tried to quit smoking during the past year and 50% have received advice or help in trying to quit smoking.

Kosrae State Worksite Wellness Program

The Wellness Program was initiated in April 2011 and recruits participants from all the state government offices. Services that are provided include nutrition, physical activity, and wellness counseling; screening of BMI, blood sugar, and blood pressure; re-screening of initial positive screening tests; and referral to a physician when indicated. These data were provided in a conversation with N. Tolenoa (August 23, 2011), Administrator for the Division of Preventive Health Services. There are a total of 377 participants in the program that have completed the screening. However, it is estimated that over 50% of the participants with an abnormal screening test do not return for re-screening and follow-up.

The data in Table 7 for BMI reveal that that 82% of the participants are overweight or obese — 53% of the participants are obese and 29% are overweight. The measurement of blood sugar shows that 13% of the participants are diabetic while 18% are pre-diabetic. Blood pressure measurements reveal that 7% of the participants are hypertensive and 22% are pre-hypertensive.

Table 7.

Kosrae State Wellness Program, Kosrae, FSM, 2011

Indicator	n	%
Body Mass Index (n=377)
Obese (BMI [kg/m2] ≥30.0)	201	53
Overweight (BMI [kg/m2] ≥25.0 – 29.9)	111	29
Healthy weight (BMI [kg/m2] ≥18.5–24.9)	54	14
Underweight (BMI [kg/m2]<18.5	11	3
Blood Sugar (n=377)
Diabetic (FBS≥126 mg/dl)	50	13
Pre-diabetic (FBS ≥110 and <126 mg/dl)	66	18
Normal (FBS <110 mg/dl)	261	69
Blood Pressure (n=377)
Hypertension (BP ≥140/90 mmHg)	27	7
Pre-hypertension (BP ≥120–139/80–89 mmHg)	82	22
Normal (BP <120/80 mmHg)	268	71

Data source: Personal communication, N. Tolenoa (August 23, 2011)

Community Health Clubs

As part of the nutrition and physical activity initiative of the current administration in Kosrae in early 2011, the Health Department mobilized residents to participate in community-based activities that will encourage fitness and a healthy lifestyle. In a conversation with N. Tolenoa (August 23, 2011), Administrator for the Division of Preventive Health Services, there were a total of 322 participants who originally signed up to participate in the Community Health Clubs, however, measurements for only 142 participants were obtained and are presented in Table 8. The data for BMI reveal that overall, 92% of the participants were obese or overweight with twice as many participants (66%) in the obese category than in the overweight category (26%). When the BMI data are stratified by individual communities, 90% of the participants in Tafunsak, 96% in Malem, 97% in Lelu, and 100% of the participants in Utwe were obese or overweight with the majority of the participants in the obese category. Overall, 14% of the participants were identified as diabetic and 6% as hypertensive.

Table 8.

Community Health Clubs, Kosrae State, FSM, 2011

Indicator	Tafunsak (n=30)		Malem (n=52)		Lelu (n=36)		Utwe (n=24)		Total (n=142)
	n	%	n	%	n	%	n	%	n	%
Body Mass Index (BMI)
Obese (BMI [kg/m2] ≥30.0)	16	53	38	73	23	64	17	71	94	66
Overweight (BMI [kg/m2] ≥25.0–29.9)	11	37	12	23	12	33	7	29.2	42	26
Obese+Overweight (BMI [kg/m2] ≥25.0)	27	90	50	96	35	97	24	100	136	96
Healthy weight (BMI [kg/m2] ≥18.5–24.9)	3	10	2	4	1	3	0	0	6	4
Measurements
Diabetic (FBS≥126 mg/dl)	8	27	4	8	6	17	2	8	20	14
Hypertensive (BP ≥140/90 mmHg)	2	7	3	6	2	6	1	4	8	6

Data Source: Personal communication, N. Tolenoa (August 23, 2011)

Diabetes Specific and Related Data

Diabetes Prevalence

Although no population-based assessment of diabetes prevalence was available during the assessment, the Worksite Wellness Program showed that among the 377 participants 13% had diabetes and 18% had pre-diabetes. In the Community Health Clubs 14% of the adults had diabetes. The DPCP is not able to provide data on the prevalence of diabetes among the population.

Diabetes and Tuberculosis

F. Waguk, Tuberculosis Program Coordinator (August 23, 2011) provided the most current data from the Tuberculosis Program. There are few documented cases of patients with active tuberculosis infection in Kosrae State ranging from 11 in 2008 to 3 patients in 2010. The staff of the Tuberculosis Program and the Diabetes Program work closely together to assure that all patients diagnosed with tuberculosis are screened for diabetes. From 2008 to 2010, none of the patients with active tuberculosis who were screened were identified with diabetes.

Amputation

M. Mongkeya (August 23, 2011), Diabetes Program Nurse, obtained the data for lower limb surgical debridement and amputations performed at the Kosrae State Hospital from the surgery logbook for 2008 through 2010. The data reveal that although the number of patients with amputations has remained relatively stable during the three years, the number of patients requiring surgical debridement has decreased from 107 to 65.

Renal Dialysis

There are currently no renal dialysis services available in Kosrae State and these services are not covered by the MiCare insurance plans. Patients that require renal dialysis obtain these services on their own. Because these services are self-referred, there are no data on the number of patients who require or receive renal dialysis services.

Description of the Administrative System

Legislation and Regulations

The Ninth Kosrae State Legislature, on February 19, 2010, adopted a resolution (L.R. No. 9-253, LD. 1) asking the Kosrae State Government to recognize the urgent need to improve the diet of the people of Kosrae by not ordering imported and processed food or foods manufactured from imported processed ingredients for consumption during meetings and events sponsored by the Kosrae State Government.

The Ninth Kosrae State Legislature, on October 7, 2010, passed a bill for an act (L.B. No. 9-250, L.D. 1) known as the Indoor Clean Air Act of 2010 to regulate and prohibit smoking in enclosed public spaces in the State of Kosrae. Other laws that impact tobacco use include the prohibition of sales of tobacco products to minors and the prohibition of sales of single cigarettes.

The Office of the Governor, on February 14, 2011, issued Gubernatorial Directive No. 2011-05, “GO LOCAL” Health and Fiscal Initiative, to all Kosrae State Government Department Directors and Agency Heads that endorses Resolution No. 9-253, LD.1 and directs all Departments and Agencies to require venders and caterers to utilize local foods, drinks, and plates when providing food for State sponsored events and activities. Utilizing local foods, drinks, and plates will reduce the costs associated with hosting events and contribute to reducing our dependency on imports. The Directive also encourages consideration of healthy alternatives to imported, processed, sugar and fat-ladened convenience foods.

The Office of the Governor, on March 9, 2011, issued a memorandum, Employee Physical Fitness Program, to all Department and Agency Heads that established a physical exercise program for executive branch employees. The program includes a regularly scheduled one-hour period during the workweek where employees are allowed time to engage in personal physical exercise and organized team sport activities. The program will be coordinated with the Sports Council and the Department of Education so that the gymnasium and sporting equipment are made available for employee use.

Planning Documents

There is one major planning document ‘ The Kosrae NCD Framework, 2009–2011 that was developed as part of the FSM National NCD Program efforts to bring the four states together to develop the National FSM NCD Plan. The Kosrae NCD Framework includes the following goals and objectives:

Goal 1: Improve organization and coordination of NCD prevention and control activities with objectives: (1) Establish a Non-Communicable Diseases Unit in the Division of Preventive Services, Department of Health Services; (2) Establish an NCD coalition that includes all existing coalitions in the state targeting tobacco, alcohol, cancer, diabetes and other healthy lifestyle promotion activities; (3) Establish a non-governmental organization for healthy lifestyle promotion in Kosrae.

Goal 2: Promote interventions that reduce modifiable risk factors of NCD including tobacco use, unhealthy diet and physical inactivity: (1) Establish baseline data on NCD risk factors utilizing the STEPS survey; (2) Create a smoke-free environment through introduction and strengthening of laws regarding tobacco exposure and sales; (3) Reduce consumption of foods high in saturated fat, trans-fatty acids, free sugars and salt by 2% from baseline data established by STEP Survey; (4) Organize a forum on healthy diet and physical activity policies at state, municipal, and social settings in Kosrae. State policy makers, municipal leaders, church leaders and family representatives should be invited to participate in the forum; (5) Inform at least 40% of 12 and older population in Kosrae on negative consequences of salt, fat, sugar and tobacco; (6) Decrease by 1% the number of obese and overweight people in Kosrae; (7) Establish sustainable financing program to support community-initiated activities and programs.

Goal 3: Prevent onset and minimize complications from cardiovascular disease, cancers, chronic respiratory disease and diabetes with objectives: (1) Improve NCD registry system in Kosrae; (2) Increase by 2%, the level of awareness in disease and symptom management; (3) Establish low resource screening programs for chronic diseases.

Funding and Resources

Funding for the prevention and control of diabetes and other chronic diseases is limited in the State of Kosrae. The FSM National NCD Program receives funds from the Centers for Disease Control and Prevention — Division of Diabetes Translation and further allocates funds to the four states. The Kosrae Diabetes Program receives funds for diabetes personnel and educational and screening supplies to implement community outreach, awareness, and education. This program provides activities to improve nutrition and physical activity in the communities. Other funding comes from the US Compact Agreement funds for the salary of four Outreach Workers who work 12 hours per week for the diabetes program providing home-bound services, counseling, and follow-up services for patients with diabetes in the community.

Policy and Procedure Manual

The Prevention and Management of Diabetes in the Federated States of Micronesia: A National Consensus Position, 2001 addresses the continuum of diabetes prevention and care to include: prevention of Type 2 diabetes, detection and diagnosis of Type 2 diabetes, care of people with diabetes, detection and management of diabetes complications, and general care. The Kosrae Diabetes Program Policy and Procedure Manual addresses the procedures for operations of the diabetes clinic; however, the manual was written in 2002 and is currently not in use. Plans are being made to review and update the manual.

Health Insurance

The Federated States of Micronesia National Government Employees' Health Insurance Plan (FSMNGEHIP) came into effect in 1984, just as the FSM was forming as a nation. The original health plan was designed as a social safety net to provide benefits for health care services, including diagnosis, treatments, surgery, and hospitalization. Eligibility was limited to employees of the FSM National Government. In 1990 the FSM Congress enacted legislation to expand the eligibility to include all the State Government employees and other agencies' employees, and also allowed the employee to enroll their dependents and members of their household. In 1994, the FSM Congress passed PL 8-133 to further extend the health insurance coverage to employees in the private sector, and other non-government organizations and their dependents. Today, the health plan is known as MiCare and is extending medical coverage for the entire workforce of the FSM, both public and private. In January 2006, the President signed into law an amendment extending eligibility to students attending post secondary institutions in the FSM. The MiCare Health Insurance Plan consists of three (3) options: Basic Option (BA) covers health care services and medical treatments rendered locally, Supplemental Resident Option (SR) provides the benefits under BA and, in addition, includes referral to an off-island health care facility, and Supplemental Non-Resident Option (SNR) covers all the benefits under BA and SR, however, is available only to employee, staff and their dependents who are placed in government offices outside of the FSM. Table 11 shows the premiums required for each of the plans as of January 2012.¹¹ According to the MiCare Health Insurance Plan office, as of August 2011, there are a total of 2,525 primary subscribers and household members (about 38% of the population) in Kosrae State covered by the health insurance plans.

Table 11.

MiCare Health Insurance Biweekly Premiums, FSM, 2010

Plan Option	Employee Share (48%)	Employer Share (52%)	Biweekly Premium
Basic Option (BA)	$6.86	$7.44	$14.30
Supplemental Residential Option (SR)	$15.58	$16.87	$32.45
Supplemental Non-Resident Option (SNR)	$21.38	$23.17	$44.55

Data source: MiCare, Federated States of Micronesia¹¹

Partnerships and Collaborations

Because of the unique situation in Kosrae (single island state and relatively small population), when community-based outreach, awareness, and educational activities are planned, the appropriate public health programs work together to share resources, coordinate activities, and minimize confusion in the community.

Research

There are no current research projects being conducted in Kosrae. There are two research projects that have been conducted and are described below:

(1) Information for a cancer prevention research project was obtained from a PowerPoint presentation, Breast and Cervical Cancer Prevention Seeking Behaviors and Recommendations for Kosraean Women (August 10, 2010) by the Kosrae Comprehensive Cancer Control Partnership in collaboration with the Department of Family Medicine and Community Health and Department of Public Health Services of the John A. Burns School of Medicine, University of Hawaii. The study methodology included six focus groups and interviews with 14 individual women to identify health-seeking behaviors of Kosraean women and to develop breast and cervical cancer prevention health communication messages and programming. Common themes were identified and led to the following recommendations for health communication messages: (a) Promote exercise, healthy eating, low stress; (b) Have courage to seek check-ups and results; (c) Have courage to seek out health information; (d) Educate and inform on “real causes” and symptoms of breast and cervical cancer; (e) Taking care of health, like other important things in life, requires planning and prioritizing; and (f) Staying healthy doesn't have to cost much if we are resourceful.

Recommendations for prevention programming included: (a) Provide services to promote awareness within communities; (b) Incentives and motivation to practice prevention is needed; (c) Have a regular schedule for screening checkups; (d) Increase ease of access to services.

(2) An Assessment of Household Food Security in Kosrae, Federated States of Micronesia was a study based on the problem statement that there was little or no information on household food security, frequency of consumption of certain foods, attitudes and opinions about food, or the expenses regarding food at funerals. The study methods included reported intake of key food items through a food frequency questionnaire, assessment of household income and expenses related to food, responses to questions about the perception of food insecurity. Of the 268 selected households, 212 (79.1%) successfully completed the survey. The results show that 90.1% of households reported having a farm and using it to grow their own food. Income, food expenditure, and funeral expenditures varied widely across municipalities. Funerals in Kosrae are important large-scale events that require food donations for maintaining social relationships; therefore, funeral expenses are a concern for Kosraean families. Nearly 60% of households reported buying food for funerals on credit, and 192 households (95.5%) reported there was too much food at funerals. Food insecurity also varied widely across municipalities, from 58% of households classified as food-insecure in Utwe to only 14% in the comparatively wealthy Lelu. Logistic regression models identified three significant predictors of household food insecurity, all which showed a protective effect: number of funerals attended (OR=0.91, [0.84, 0.99]), consumption of flour products (OR=0.81, [0.68, 0.98]), and consumption of local fish (OR=0.70, [0.57, 0.87]).¹²

Description of Clinical Services System

Medical and Health Professionals and Facilities

Medical and health personnel are available to provide services at the centrally located Dr. Arthur P. Sigrah Memorial Hospital and the Public Health Clinics. There are no medical care services provided in the communities. The 2008 Health Digest for the Federated States of Micronesia lists the administrative staff, medical care staff, public health staff, and support staff for the Kosrae State Hospital and the public health programs. It is important to note that there are no epidemiologists or health planners in Kosrae State.¹³

Outreach and Prevention

Because Kosrae is a single-island state with a relatively small population and limited resources, the staff of the diabetes, tuberculosis, tobacco, and cancer programs collaborate to provide outreach, awareness, and education services in the schools and communities. During 2010, the Department of Health Services initiated two major community-based programs that encourage proper nutrition, physical activity, healthy lifestyles, and fitness — the Worksite Wellness Program and the Community Health Clubs.

Screening and Diagnosis

The strategy to reduce morbidity and premature mortality associated with Type 2 diabetes is to assure early detection through active screening and case finding. Screening services are provided upon request by the patient and in a variety of settings that include outreach activities at community events (Worksite Wellness Program, Community Health Clubs) and regular public health clinic visits. One of the major problems is that there are no consistent standards being used for screening of patients; although there are diabetes and hypertension diagnostic criteria that are consistently used by health and medical care providers.

Treatment and Management

The treatment and management of patients diagnosed with diabetes and hypertension are provided in the public health diabetes clinic. At the Monday diabetes clinic a physician provides medical treatment and management; whereas at the Thursday diabetes clinic a Diabetes Nurse provides screening, education, nutrition and physical activity counseling, foot care screening, and follow-up. For the Monday diabetes clinics, physicians rotate from a team of physicians assigned to the preventive health services. Another finding is that because the physicians are constantly rotating through the clinic, there is little to no continuity of care. In addition, there is no common set of policies and procedures, consistent standards, or criteria used by all providers to assure that the services that the patients are receiving are consistent and comprehensive care.

Description of the Support Services System

Quality Assurance and Continuing Education Program

There are no quality assurance programs in either the Kosrae State Hospital or the Department of Public Health; however, plans are in place for a consultant to work with the staff to develop and implement a Quality Assurance/Quality Improvement program in October–December 2011. There are continuing education (CE) sessions every other week with the physicians presenting current topics at the Kosrae State Hospital for the licensed physicians who are required to obtain 50 Continuing Medical Education credits annually. These CE sessions are also open to licensed graduate nurses who are required to obtain 40 CE credits and licensed practical nurses who need 30 CE credits annually to retain their license to practice.

Diabetes Health Education Materials

The Diabetes Program is currently using culturally appropriate diabetes and other NCD educational materials and brochures in Kosrae. Some examples of the educational materials include: How much do you know about diabetes? (Luhpahkah kom etuh ke Mihsen Suka?); Take Care of Your Feet (Karihngihn Niom in Nwacsnwacs); Hypertension (Srah Fuhlact); Walk 10,000 Steps Every Day; If You Are Pacific Islander, You May Be At Risk for Diabetes; Every Pacific Islander Should Know: You Can Control Your Diabetes (Papa Ola Lokahi, Pacific Diabetes Education Program);¹⁴ and Feet First: Take Care of Your Feet (Micronesian Seminar, unpublished).

Pharmacy Services

Pharmacy services are provided by the Kosrae State Hospital. In addition to the injectable insulins, the available oral medications for diabetic patients include: Glucophage (metformin), Micronase (glyburide), and Glucotrol (glipizide). Major problems reported by the staff are the limited resources to be able to purchase adequate amounts of medication and the consistent shortage of medications because of the lack of coordination between the pharmacy and the medical central supply storeroom that orders the medications.

Laboratory Services

Laboratory services are provided by the Kosrae State Hospital. The laboratory is able to perform the following: blood sugar determination, 2-hour oral glucose tolerance test, hemoglobin A_1c, total cholesterol, high density lipoprotein, triglyceride, creatinine, urea, urinalysis for microalbuminuria. Major problems reported by the staff are the limited resources to be able to purchase adequate supplies and reagents and the shortage of reagents or test kits because of the lack of coordination between the laboratory and the medical central supply storeroom that orders the laboratory supplies and reagents.

Description of the Data System

There is no overall data system in the Kosrae Department of Health that provides the data and information for all the public health programs. Each program may have its own unique dedicated data system with no coordination or connections between the existing systems. The DPCP currently has an outdated data system that includes 539 records of current patients, inactive patients, and deceased patients. The Diabetes Nurse is currently updating the database by contacting patients, assuring that all data elements are current and re-entering the data into an Access-based proprietary data system developed by Dr. Ralley Jim from Pohnpei State.

The current data system is not functional in that it is unable to generate monthly encounter reports to be sent to the FSM National NCD Program, reports for clinical management and monitoring of patients, or data for analysis to evaluate the outcomes of patients. Plans are being made to implement the Chronic Diseases Electronic Management System (CDEMS) diabetes registry that will allow the reports to be generated.

Conclusions: Prioritized Issues and Needs

Non- communicable diseases, including diabetes, have been identified as an emergency in the US-affiliated Pacific Islands. Some of the highest rates of diabetes and other chronic diseases are experienced by Pacific Islanders. To begin to address this situation, the first step is to identify and describe the burden of chronic diseases and diabetes, describe the programs and agencies responsible for providing the health and medical care to patients, and assess the capacity of the administrative and clinical system of services to provide the infrastructure to address the problems. This report presents the issues and problems that need to be addressed to make a positive impact on the disparities in health caused by NCDs.

There has been a 13.9% decline in the population of Kosrae State between 2000 and 2010. The largest segment of the population to leave are those 44 years and younger with a significant increase in the number of 45–74 year olds - a population at high risk for requiring services for treating and managing chronic diseases. The mortality data reveal that the leading causes of death were due to nutrition and metabolic diseases with diseases of the circulatory system as the second leading cause of death. Data from two community-based health education programs show that the prevalence of overweight and obesity ranged between 82% and 95% and the rate of diabetes ranged from 13% to 14% among the participants. Although chronic disease surveillance system data, local population survey data, vital statistics, and program data exist,¹⁵ there continues to be limited availability of these data and a paucity of published data. Often mortality, morbidity, and risk behavior data across the Pacific jurisdictions cannot be compared because of differences in defining the data elements, data collection methods, and timeliness of reporting.

The description of the system of services reveal there is one major planning document — The Kosrae NCD Framework, 2009–2011 as part of the FSM National NCD Program efforts. There is a Kosrae Diabetes Program Policy and Procedure Manual (2002) that is currently not in use; there is also no common set of standards being used by all health care providers There is no functional data system that is able to identify, track, or monitor patients with diabetes. The pharmacy and laboratory report problems with lack of supplies and equipment.

Based on the findings of this assessment and prioritization of a group of administrators and a group of clinicians, the top three administrative issues in Kosrae include: (1) Need to revise and update the NCD Program policy and procedure manual; (2) Need for protocols to standardize the care for inpatients with diabetes and other chronic diseases; and (3) Need for additional resources to expand PPD screening of clients and patients diagnosed with diabetes for TB. The clinical issues include: (1) Need for criteria and standards for the screening, diagnosis, treatment, and follow-up of patients with pre-diabetes and diabetes and co-morbidities; (2) Need to develop a system and protocols to assure that patients with abnormal initial screening values for diabetes and hypertension are provided with follow-up services; and (3) Need to train community outreach workers on how to implement the concepts of the “GO LOCAL” nutrition initiative; and (4) Need to train a team of providers to implement a team approach to care for patients with diabetes. Tables 13 and 14 list the priority ranking of the issues and needs.

Table 13.

Administrative Issues Priority Ranking

Priority Rank	Administrative Issue/Need	Average Scorea
1	Need to revise and update the NCD Program policy and procedure manual	15.0
2	Need for protocols to standardize the care for inpatients with diabetes and other chronic diseases	17.9
3	Need for additional resources to expand PPD screening of clients and patients diagnosed with diabetes for TB	25.0
4	Need to provide training for the implementation of the CDEMS data system (diabetes data registry)	26.0
5	Need for training on the concepts of social marketing to expand the capacity of staff to effect behavior change in clients and patients	27.2
6	Need for training for analyzing and interpreting data into information	27.8
7	Need to identify and obtain alternative sources of additional resources for the prevention and control of diabetes and related chronic diseases	29.1

^aLower the average score, higher the priority

Table 14.

Clinical Issues Priority Ranking

Priority Rank	Clinical Issue/Need	Average Scorea
1	Need for criteria and standards for the screening, diagnosis, treatment, and follow-up of patients with pre-diabetes and diabetes and co-morbidities	16.0
2	Need to develop a system and protocols to assure that patients with abnormal initial screening values for diabetes and hypertension are provided with follow-up services	21.1
3	Need to train community outreach workers on how to implement the concepts of the “GO LOCAL” nutrition initiative	25.0
4	Need to train a TEAM (physician, nurse, educator, etc…) through the Diabetes Collaborative training to implement a team approach to care for patients with diabetes	25.4
5	Need to address the issue of “rotating physicians” in the Diabetes Clinic (issue of continuity of care)	28.6
6	Need for community-based educators to teach self-management skills to patients with diabetes and their families	32.5
7	Need to have diabetes and other chronic disease specialty training for selected physicians	32.6
8	Need to evaluate and, if appropriate, revise the procedures for purchasing medications and laboratory reagents	34.2

^aLower the average score, higher the priority

Table 1.

Population by Age Group, Kosrae State, FSM, Census 2000 and 2010

Age	2000	2010	Difference	Percent Change
<5	1026	799	−227	−22.1
5–9	953	789	−164	−17.2
10–14	1079	825	−254	−23.5
15–19	939	724	−215	−22.9
20–24	604	556	−48	−7.9
25–34	971	800	−171	−17.6
35–44	880	672	−208	−23.6
45–54	630	717	87	13.8
55–64	325	458	133	40.9
65–74	183	192	9	4.9
75+	96	84	−12	−12.5
Total	7686	6616	−1070	−13.9

Data source: Kosrae Branch Statistics Office, 2000 FSM Census of Population and Housing8 and Federated States of Micronesia, Office of Statistics, Budget and Economic Management, Preliminary Population Counts for FSM 2010 Census⁹

Table 3.

Leading Causes of Death, Kosrae, 2008–2010

Cause of Death	2008	2009	2010	2008–2010	Ratea
Metabolic	22	12	6	40	173.5
Circulatory	14	10	4	28	121.4
Infectious	8	8	3	19	82.4
Neoplasm	6	6	5	17	73.7
Respiratory	7	4	2	13	56.4
Perinatal	3	3	0	6	26.0
Digestive	3	0	3	6	26.0
Skin	3	2	0	5	21.7
Genitourinary	1	2	1	4	17.3
Blood	1	1	2	4	17.3
Other	4	7	20	31	134.4
Total	72	55	46	173	750.3

^aCrude mortality rate/100,000 population. Data source: Personal communication, H. Palik (August 23, 2011)

Table 5.

Global Youth Tobacco Survey, Public Schools Grades 7–11, FSM, 2007

Indictor	% Total	% Boys	% Girls
Prevalence
Had ever smoked cigarettes	45.6	56.2	34.7
Currently use any tobacco product	46.2	51.9	39.8
Currently smoke cigarettes	28.3	36.9	19.8
Currently use other tobacco products	37.0	41.8	32.1
Never smokers likely to initiate smoking next year	30.1	-	-
Exposure to Second Hand Smoke
Live in home where others smoke	60.7	-	-
Around others who smoke outside their home	71.3	-	-
Think smoking should be banned from public places	32.5	-	-
Think smoke from others are harmful	37.0	-	-
Have one or more parents who smoke	48.8	-	-
Cessation - Current Smokers
Want to stop smoking	86.5	-	-
Tried to stop smoking during the past year	83.2	-	-
Have ever received help to stop smoking	91.7	-	-
School Educational Efforts During Past Year
Taught in class of dangers of smoking	41.4	-	-
Discussed in class why people their age smoke	32.0	-	-
Taught in class of the effects of tobacco use	47.1	-	-

Current use — use of tobacco product on one or more of the past 30 days. Data source: Centers for Disease Control and Prevention, Global Tobacco Surveillance System Data¹⁰

Table 6.

Kosrae Youth Tobacco Survey, Kosrae State, FSM, 2008–2009

Selected Indicators	2008 (n=505)	2009 (n=530)
	%	%
Prevalence
Tried or experimented with cigarettes	41	57
First tried cigarette <9 y/o	10	4
Smoke >10 days/month	17	19
Smoke >2 cigarettes/day	18	21
First chewed betel nut <9 y/o	16	11
Use tobacco products with betel nut	46	63
Environmental Tobacco Smoke
Discussed harmful effects of smoking	50	64
Will lose weight when smoking	79	56
Cigarette smoking is harmful to health	50	59
Some close friends smoke cigarettes	48	55
Cessation - Current Smoking
Think second-hand smoke is harmful	52	70
Favor banning smoking in public places	32	48
Want to stop smoking now	28	33
Tried to quit smoking in past year	32	37
Stopped smoking to improve health	35	27
Able to stop if wanted to	27	30
Have received advice/help to quit	48	50

Data source: Personal communication, C. Tosie (August 21, 2011)

Table 9.

Tuberculosis and Diabetes, Kosrae State, FSM, 2008–2010

	2008	2009	2010
PPD Screen	249	179	219
Positive Screen	40	19	34
Active TB	11	2	3
LTBI	9	2	5
Diabetes	0	0	0

Data source: Personal communication, F. Waguk, (August 23, 2011)

Table 10.

Lower Limb Debridement and Amputation, Kosrae State, FSM, 2008–2010

Procedure	2008	2009	2010
Debridement	107	91	65
Amputation	13	11	13
Total	120	102	78

Data Source: Personal communication, M. Mongkeya (August 23, 2011)

Table 12.

Medical and Health Professionals, Kosrae State Department of Health, FSM, 2008

Kosrae State Hospital	Number	Kosrae Division of Public Health	Number
Curative Services		Public Health Clinics
Clinical Medical Services (MD, MO)	10	Medex	0
Clinical Nursing Services (GN, PN/NA)	32	Nursing Services	10
Health Services Administration		Midwife/Nurse Practitioner	0
Director/Deputy Director	1	Dispensary Managers	0
Division of Curative Health Services	1	Nutritionist	0
Division of Administrative Services	1	Outreach workers (Diabetes)	4
Division of Preventive Health Services	1	Health Educator	1
Health Planner	0	DOT workers	4
Epidemiologist	0	Dental Health Clinics
Hospital Support Services		Dentists (DD, DO)	3
Laboratory	6	Dental Nurse	1
Radiology	2	Dental Assistant/Aids and Technician	3
Pharmacy Tech	2	Other Divisions
Physical therapy	1	Substance Abuse/Mental Health	15
Clinical Nutritionist	1	Environmental Health/Sanitation	5
Vital and Health Statistics	4

Data source: Data source: Department of Health and Social Affairs, 2008 Health Digest for the Federated States of Micronesia¹³

Disclosure Statement

The authors report no conflict of interest.