Assessing the Health Care System of Services for Non-Communicable Diseases in the US-affiliated Pacific Islands: A Pacific Regional Perspective

Abstract

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.

Introduction and Purpose

The purpose of this article is to summarize the findings of a capacity assessment to address NCDs conducted in ten USAPI sites: American Samoa, Guam, Commonwealth of the Northern Mariana Islands, Republic of the Marshall Islands (Majuro and Ebeye), Republic of Palau, and the four states that comprise the Federated States of Micronesia (Chuuk, Kosrae, Pohnpei, and Yap). This assessment evaluated the capacity of the administrative, clinical, support, and data systems to address the problems of NCD in the USAPI. Data and information were obtained through reviews of existing plans, reports, and documents, and data; interviews were conducted with selected key informants; issues and needs were identified and focus groups were used to define the priorities. This article examines and summarizes the data and the system assessments from all ten sites and provides a USAPI regional perspective.

Methodology

Methods, data sources, and references used for the data included in this publication are included in the introduction article and the individual site-specific publications contained in this supplemental issue.^2–12

Findings

Population, Mortality, Surveillance, Local Survey Data

Populations were compared using census data from 2000 and 2010² for the Pacific region (Tables 1, 2). In this 10-year period, there was no significant change in total population for the region (0.2% decrease), however, there were significant shifts in the population due to migration among specific jurisdictions. For example, between 2000 and 2010, the population in CNMI decreased by 23.2% and in RMI increased by 24.1%. There were noted shifts in age distribution of the population in that the number of children and young adults has decreased and the absolute number of adult residents (45+ years) has increased across the region.

Table 1.

Percent Change in US-affiliated Pacific Island Population by Jurisdiction, 2000 and 2010

Jurisdiction	2000	2010	Difference	Percent
Am Samoa	57,771	55,467	−2,304	−4.0
CNMIa	69,706	53,517	−16,189	−23.2
FSMb	107,724	107,154	−570	−0.5
Guam	155,324	159,434	4,110	2.6
RMIc	53,072	65,859	12,787	24.1
Palau	19,492	20,879	1,387	7.1
Total	465,089	464,320	−779	−0.2

^aCommonwealth of the Northern Mariana Islands.

^bFederated States of Micronesia.

^cRepublic of the Marshall Islands. Data source: US Census Bureau, International Database²

Table 2.

Percent Change in US-affiliated Pacific Island Population by Age Groups, 2000 and 2010

Age	2000	2010	Difference	Percent
<5	55,117	47,911	−7,206	−13.1
5–9	52,047	45,629	−6,418	−12.3
10–14	48,463	46,277	−2,186	−4.5
15–19	43,254	45,333	2,079	4.8
20–24	40,418	39,524	−894	−2.2
25–29	41,009	36,738	−4,271	−10.4
30–34	39,022	32,017	−7,005	−18.0
35–39	34,773	30,872	−3,901	−11.2
40–44	29,320	30,252	932	3.2
45–49	23,763	28,968	5,205	21.9
50–54	17,896	24,517	6,621	37.0
55–59	11,295	18,709	7,414	65.6
60–64	9,328	13,463	4,135	44.3
65–69	7,007	8,252	1,245	17.8
70–74	4,676	6,128	1,452	31.1
75+	5,701	7,720	2,019	35.4
Total	465,089	464,320	−779	−0.2

Data source: US Census Bureau, International Database²

Mortality

Non-communicable diseases and their complications have a significant impact on the residents of the Pacific jurisdictions. Mortality data were obtained in all sites from hospital death certificates between 2003 and 2010 (Tables 3,4). The data for each site were aggregated and crude mortality rates were calculated per 100,000 population based on 1999 or 2000 census data for each site. Each of the jurisdictions ranked their leading causes of death based on this information but due to the lack of common definitions the data can not be aggregated to obtain a regional ranking. Nevertheless, at least two NCD-related conditions (heart disease, hypertension, renal disease, or diabetes) were in the top five leading causes of death in each of the sites.

Table 3.

Ranking of Leading Causes of Death, US-affiliated Pacific Jurisdictions

Cause of Death	ASa	CNMIb	Chkc	Pnid	Yap	Guam	Maje	Ebef	ROPg
Cancer	1	2		4	1	2	2	5	1
Heart Disease	3	1	2	1	5	1		3	2
Diabetes	2		1	2	3	5	3
Accident					2	4			3
Sepsis		5	3	5			1	1	4
Cerebrovascular	4	3	5			3
Flu/Pneumonia	5		4		4		4	2	5
Hypertension				3			5
Renal Failure		4						4

^aAmerican Samoa.

^bCommonwealth of the Northern Marianna Islands.

^cChuuk (FSM).

^dPohnpei (FSM).

^eMajuro (RMI).

^fEbeye (RMI).

^gRepublic of Palau. Data source: See individual site articles in this supplemental issue

Table 4.

Deaths Due to Non-Communicable Disease (NCD)-Related Conditions, US-affiliated Pacific Islands, 2003–2010

NCD	ASa	CNMIb	FSMc	RMId	Guam	ROPe	Total
	n	n	n	n	n	n
Heart Disease	92	82	465	19	661	118	1,437
Hypertension	28	0	86	28	0	0	142
Cerebrovascular	81	55	52	10	158	30	386
Cancer	109	62	131	72	324	93	791
Renal Disease	0	41	23	23	40	27	154
Diabetes	99	0	259	64	79	0	501
Total NCD deaths	409	240	1,016	216	1,262	268	3,411
Total Deaths all causes	758	491	2,391	914	2,088	485	7,127
	%	%	%	%	%	%
Percent NCD deaths	54.0	48.9	42.5	23.6	60.4	55.3	47.9

^aAmerican Samoa.

^bCommonwealth of the Northern Mariana Islands.

^cFederated States of Micronesia.

^dRepublic of the Marshall Islands.

^eRepublic of Palau. Data source: See individual site articles in this supplemental issue

Based on these calculations, Heart disease and cancer were among the top two leading causes of death in 5 jurisdictions, followed by diabetes, accidents, sepsis, and cerebrovascular accident. The deaths due to NCD-related conditions (heart disease, hypertension, cardiovascular disease, cancer, renal disease, and diabetes) were aggregated for each jurisdiction and the proportion of NCD-related deaths were also calculated. Overall, 47.9% of all deaths in the Pacific region were related to NCDs and related conditions. The percent of NCD-related deaths in individual jurisdictions ranged from 23.6% in the RMI to 60.4% in Guam.

Surveillance

There are two primary sources of population-based surveillance data for NCDs and their risk factors in the USAPI for adults over the age of eighteen, the Behavioral Risk Factor Surveillance System (BRFSS) and the World Health Organization (WHO) STEPwise approach to Surveillance of Risk Factors for NCDs (STEPS). The BRFSS, a Center for Disease Control and Prevention population based survey of adults 18+ years old, was conducted in Guam annually in 2007–2009 and in the CNMI in 2009 to identify behavioral risk factors that contribute to the 10 leading causes of death. The STEPS is a standardized population health survey of adults aged 25 to 64 years that measures chronic disease and associated risk factors through a questionnaire, physical measurements, and biochemical tests. The STEPS was conducted in Pohnpei (2002), RMI (2002), and American Samoa (2004).

Local Survey Data

Some of the jurisdictions have conducted local surveys and studies to obtain data related to NCD nutrition, physical activity, and measurements of BMI, blood pressure, and blood lipids. For example, American Samoa conducted studies on the prevalence of obesity among students in the public schools; Palau conducted a comprehensive, country-wide household survey of risk factors for NCD (2003), and an adapted NCD mini-STEPS survey of employees of the Ministry of Health (2009); Yap conducted the Wa'ab Community Health Center Household Survey (2006–2007) and the Outer Island Household Survey (2008–2009), and the Maternal and Child Health School Health Survey (2006–2007 and 2009–2010); and, Kosrae conducted a survey with participants of the Community Health Clubs (2011) and the Kosrae State Worksite Wellness Program (2011).

Data on the prevalence of residents who are overweight or obese and those who are diagnosed with diabetes are two important indicators of interest. The STEPS surveillance data for the prevalence of overweight and obesity among adults ranged from a high of 93.5% in American Samoa to 73.1% in Pohnpei, and 62.5% in the RMI (Table 5). Other local surveys reported a range of 92% (Kosrae, Community Health Clubs) to 63% (Yap, Wa'ab CHC Household Survey) among adults and 55.6% (American Samoa, Public School Survey) to 24 % (Yap, MCH School Survey) among children and youth. The data for prevalence of diabetes among adults showed that the highest rate is among American Samoan residents (47.3%) and the lowest rate may be as low as 7.9% in Guam, depending on the survey year.

Table 5.

Prevalence of Overweight/Obese (O/O) and Diabetes, USAPI, 2002–2011

Site	Data Source (Year)	Age	% O/O	% Diabetes
American Samoa	NCD STEPS (2004)	25–64 Years	93.5	47.3
	Public School Survey (2008–2009)	K-11 Grade	55.6	-
	WIC Survey (2009)	2–5 Years	33.7	-
CNMIa	BRFSS (2009)	18+ Years	-	9.8
	Pacific Wellness Center (2009)	Adults	86.8	-
	YRBS High School (2003)	Youth	76.8	-
	YRBS High School (2007)	Youth	64.2	-
Chuuk, FSMb	None	-	-	-
Kosrae, FSM	Kosrae Wellness Programs (2011)	Adults	82	13
	Community Health Clubs (2011)	Adults	92	14
Pohnpei, FSM	NCD STEPS (2002)	25–64 Years	73.1	32.1
Yap, FSM	Wa'ab CHC HH Survey (2006)	Adults	63	23
	Wa'ab CHC HH Survey (2006)	Children	32	-
	Outer Island HH Survey (2009)	Adults	74.1	12.7–23.9
	Outer Island HH Survey (2009)	2–14 Years	33.8	-
	MCH School Survey (2006–07)	Elementary	24	-
Guam	BRFSS (2007)	18+ Years	-	9.1
	BRFSS (2008)	18+ Years	-	7.9
	BRFSS (2009)	18+ Years	-	9.1
	YRBS - High School (2001)	Youth	29.7	-
	YRBS - High School (2007)	Youth	31.2	-
RMIc	NCD STEPS (2002)	15–64 Years	62.5	19.6
	YRBS High School (2003)	Youth	42.6	-
	YRBS High School (2007)	Youth	40.6	-
Palau	Palau Community Assessment (2003)	15+ Years	-	22.4
	Health Ministry, Mini-STEPS (2009)	Adults	90	12.6
	YRBS High School (2001)	Youth	30.1	-
	YRBS High School (2003)	Youth	30.4	-
	YRBS High School (2005)	Youth	21.7	-
	YRBS High School (2007)	Youth	26.7	-
	YRBS High School (2009)	Youth	28.6	-

^aCommonwealth of the Northern Mariana Islands.

^bFederated States of Micronesia.

^cRepublic of the Marshall Islands. Data source: See individual site articles in this supplemental issue

Administrative System of Services

Components of Administrative System of Services include policies (such as legislation and regulations); planning and evaluation protocols; and research that inform policies are important to set and maintain country goals and standards in health and health systems. Resources and community partnerships were also assessed. To assess the administrative system of services, information was obtained through review of documents and key informant interviews.

All ten sites had legislation on tobacco control although they reported problems with monitoring and enforcement. None had legislation or regulations in place specific to nutrition and physical activity. The assessment team identified two sites (Guam and Kosrae) with policies on nutrition and physical activity, however, they were limited to government employees and facilities. All the sites (with the exception of Pohnpei) had at least one plan on diabetes prevention and control. Five sites (Kosrae, Guam, Majuro, Ebeye, and Palau) had NCD plans and only one site (Palau) had a public health strategic plan. These plans did not seem to be connected and moreover, no budgets were attached to most of plans (except for the isolated workplans, ie, the CDC funding for the Diabetes Prevention and Control Program). Chuuk, Kosrae, Pohnpei, Yap, Ebeye, and Palau had policy and procedure manuals for both diabetes/NCD programs and clinical services. The FSM manual is dated 2001 and needs to be updated and revised. The other sites had a manual for clinical services only. The majority of funds come from external sources such as the US Federal Government, WHO, Secretariat of the Pacific Communities (SPC), and Taiwan Government. Local funding was very limited and non-existent in many sites. Specific information on the amount of NCD funding in the region by each funder was not available. The diabetes/NCD programs collaborate with many community partners including churches, diabetes/NCD coalitions, women's groups and village organizations, which is indicative of the necessity of sharing resources. Half of the sites (Chuuk, CNMI, Yap, Majuro, and Palau) have no known research within the past ten years related to NCD and its risk factors. The others have recently participated in research on obesity (American Samoa and Guam), food security/systems (Kosrae, Pohnpei), cancer (Kosrae), and diabetes care and treatment (American Samoa, Guam, and Ebeye). A multi-site collaborative research project to prevent childhood obesity has recently been funded (American Samoa, CNMI, Guam, FSM, Hawai‘i, and Palau).

Clinical System of Services

To assess the clinical system of services, the assessment team reviewed records and obtained information from key informants on prevention and risk reduction, screening and diagnosis, and treatment and management. In all sites, the Diabetes Prevention and Control Program (DPCP) provides prevention services in collaboration with other public health programs, schools, and community organizations. These services include efforts to increase awareness of and education on diabetes risk factors, nutrition, and physical activity through presentations and workshops in churches and schools, hosting and participating in health fairs and community events, creating radio and television public service announcements, and distributing posters and flyers. The Majuro DPCP provides specialized train-the-trainer workshops to teachers, and health policy education and information sessions to legislators. All ten sites provide screening for diabetes through public health clinics, hospital outpatient clinics, community events, and special outreach activities to worksites, churches, and villages. Services provided include random or fasting blood glucose and blood pressure measurements.

Treatment and management services varied among jurisdictions; two sites (Palau and Ebeye) had services based on the Disparities Collaborative Model and used the team approach to serve patients. The majority of the sites (American Samoa, CNMI, Kosrae, Chuuk, Pohnpei, and Majuro) reported no mechanisms for linkage or communication between the physicians at the medical clinic and the staff in community health clinics, which resulted in fragmentation and loss of continuity of care for patients with diabetes and other chronic diseases. Moreover, these sites had no common sets of policies and procedures or standards to provide guidance to assure that the services that the patients are receiving are consistent, comprehensive, and meet quality of care standards. In regards to specialty care, Guam had the most services (retinopathy, neuropathy, diabetic foot, cardiovascular). The CNMI, Majuro, and Ebeye conducted foot care clinics for the prevention of lower limb amputation, and both Ebeye and American Samoa had an eye clinic. Only half of the sites had renal dialysis services (American Samoa, CNMI, Pohnpei, Guam, and Palau).

Support System of Services

Support system of services refers to quality assurance, continuing education, equipment and supplies, educational materials, laboratory services, and pharmacy services. To assess the support system of services in each site, the assessment team reviewed documents and conducted key informant interviews (Tables 6–8).

Table 6.

NCD Policies and Research by Jurisdiction

NCD Policies & Research	FSMa				RMIb		ROPc	ASd	GUAM	CNMIe
	PNIf	KOSg	CHKh	YAP	MAJi	EBYj
Tobacco Control Legislation	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Legislation addressing Nutrition and Physical Activity
Policies addressing Nutrition and Physical Activity		Y							Y
Diabetes Prevention & Control Plan		Y	Y	Y	Y	Y	Y	Y	Y	Y
NCD Plan		Y			Y	Y	Y		Y
Public Health Strategic Plan							Y
Policy and Procedure Manual for DM/NCD Programs and Clinical Services	Y	Y	Y	Y		Y	Y
Recent Research on Obesity								Y	Y
Recent Research on Food Security/Systems	Y	Y
Recent Research on Cancer		Y
Recent Research on Diabetes Care and Tx						Y		Y	Y
Current Research on Childhood Obesity	Y	Y	Y	Y			Y	Y	Y	Y

^aFederated States of Micronesia.

^bRepublic of the Marshall Islands.

^cRepublic of Palau.

^dAmerican Samoa.

^eCommonwealth of the Northern Marianna Islands.

^fPohnpei.

^gKosrae.

^hChuuk.

ⁱMajuro.

^jEbeye. Data source: See individual site articles in this supplemental issue

Table 8.

Support System of Services by Jurisdiction

Support Services	FSMa				RMIb		ROPc	ASd	GUAM	CNMIe
	PNIf	KOSg	CHKh	YAP	MAJi	EBYj
Public Health Quality Assurance Protocols	Y			Y		Y				Y
Hospital Services Quality Assurance Protocols	Y			Y		Y		Y		Y
Continuing Education Program for physicians/nurses	Y			Y		Y		Y		Y
Culturally and Linguistically NCD educational materials	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Pharmacy Services	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Major Problem with ordering medications	Y	Y	Y		Y			Y	Y

^aFederated States of Micronesia.

^bRepublic of the Marshall Islands.

^cRepublic of Palau.

^dAmerican Samoa.

^eCommonwealth of the Northern Marianna Islands.

^fPohnpei.

^gKosrae.

^hChuuk.

ⁱMajuro.

^jEbeye. Data source: See individual site articles in this supplemental issue

Four sites (CNMI, Pohnpei, Yap, and Ebeye) reported formal quality assurance protocols for public health and hospital services and continuing education programs for physicians and nurses. American Samoa has a quality assurance protocol for the Lyndon Baines Johnson Tropical Medical Center, but not for public health programs. All 10 sites are currently using culturally and linguistically appropriate diabetes/NCD educational materials developed with the support of the Papa Ola Lokahi, Pacific Diabetes Education Program. In addition, some sites are using educational materials developed by the WHO, SPC, and the CDC National Diabetes Education Program; and some sites are developing their own materials using local funds. All ten sites provide pharmacy services and medications necessary to treat and manage diabetes, its co-morbidities and complications. Four sites (CNMI, Yap, Ebeye, and Palau) reported no major problems with ordering medication and there is a consistent supply of medications. The other sites cited consistent shortages of medications due to insufficient funds to purchase medication, lack of coordination between the pharmacy and the department that orders the medications, and complex procurement procedures that require comparison pricing and multiple approvals. All ten sites are able to perform the laboratory tests necessary to manage diabetes and its co-morbidities (glucose, HemoglobinA_1C, cholesterol and lipids, urinalysis, and renal function). However, laboratory staff in most sites reported the shortage of reagents or test kits as a major problem. Issues around laboratory supplies are similar to pharmacy services, as they have to follow the same procurement process. One of the sites (Palau) has a successful system for purchasing medication and supplies where commonly used are automatically ordered on a quarterly basis.

Data Systems

Data collection, management, and analysis are important functions for administrative decision-making. Two sites (Ebeye and Palau) were implementing the Patient Electronic Care System (PECS) diabetes registry as part of the Health Disparities Collaborative with plans to convert to the Chronic Disease Electronic System (CDEMS), a more current diabetes/NCD registry. The Community Health Center in Guam also implemented the PECS, however, the database was not updated and was not able to provide information or reports. Other sites had a variety of data systems. Nevertheless, numerous problems were reported including lack of policies and procedures for data collection, lack of variable definitions, and no collaboration between clinicians (where data are generated) and data staff. Moreover, although most sites entered data into a data system, the information was not studied and used to make clinical or program decisions. Another major concern was that staff responsible for these data systems did not have the skills, education, or training support to manage or maintain a data system. There was no evidence of data analysis, interpretation of data, or reporting of data (publications or reports) from the diabetes data.

Although chronic disease surveillance system data, local population survey data, vital statistics, and program data exist,³ there continues to be limited availability of and accessibility to these data and a paucity of published data reports. Comparisons of mortality, morbidity, and behavior risk factor data across the Pacific jurisdictions are severely limited because of differences in defining the data elements, data collection methods, and timeliness of reporting. Another concern is that the population-based surveillance surveys (BRFSS and STEPS) are neither uniformly nor periodically conducted so it is not possible to determine trends in risk behaviors or changing prevalence rates of diabetes and NCDs.

Priority Issues and Needs

The assessment team assisted in the review of all the information from documents, records, and key informants interviews and identified the strengths, problems and needs. A group of Pacific administrators and a group of clinicians were convened separately in all 10 sites to vet the list of problems and define the priorities and needs. Ranked priorities were determined by the number of jurisdictions that identified a specific need (Tables 9, 10).

Table 9.

Prioritized Administrative Issues and Needs Identified by Site, US-affiliated Pacific Islands

Priority Issue and Needs	Site	Number of Sites
1. Need to develop and implement a health plan for diabetes/NCD	American Samoa, CNMI, Chuuk, Pohnpei, Yap, Guam, Majuro, Ebeye	8
2. Need a data system/registry and staff training in working with the data system	CNMI, Chuuk, Kosrae, Pohnpei, Yap, Guam, Ebeye	7
3. Need Policy and Procedure Manual for diabetes/NCD clinics	American Samoa, CNMI, Chuuk, Kosrae, Yap, Majuro	6
4. Need staff training on data analysis, interpretation, and reporting	CNMI, Kosrae, Pohnpei, Yap, Majuro, Ebeye	6
5. Need more community partners to provide prevention services in communities	American Samoa, Yap, Guam, Ebeye	4

Data source: See individual site articles in this supplemental issue

Table 10.

Prioritized Clinical Issues and Needs Identified by Site, US-affiliated Pacific Islands

Priority Issue and Needs	Site	Number of Sites
1. Need standards of care and definitions for diagnosing patients with diabetes/NCD	American Samoa, CNMI, Chuuk, Kosrae, Pohnpei, Yap, Guam, Palau	8
2. Need to address fragmentation of care and assure continuity of care in diabetes/NCD clinics	CNMI, Chuuk, Kosrae, Pohnpei, Majuro	5
3. Need standard and guidelines for patient care for diabetes/NCD	Chuuk, Kosrae, Guam, Majuro, Palau	5
4. Need a team approach to providing care for patients with diabetes/NCD	American Samoa, Kosrae, Pohnpei, Guam	4
5. Need continuing education on diabetes/NCD for physician and nurses	American Samoa, Majuro, Palau	3

Data source: See individual site articles in this supplemental issue

The 5 top identified administrative needs were: (1) to develop and implement a health plan, supported with resources and technical assistance to draft and implement the plan; (2) develop a data registry/system and training on data collection and management; (3) develop policy and procedure manuals for public health and clinical practices in diabetes/NCD clinics; (4) provide staff training on data analysis, interpretation, and reporting, and (5) engage more community partners to assist with planning and implementation of chronic disease prevention and control in the community was identified in four sites.

The 5 leading clinical needs identified by the convened clinical groups in each site were: (1) need for a common standard of care and standard definitions for the diagnosis of patients with diabetes/NCD; (2) need to address the fragmentation of care and loss of continuity of care; (3) need for standards and guidelines for treatment and management of patients with diabetes/NCD, an issue closely related to the first priority; (4) need for a team approach for providing care to patients with diabetes/NCD, and (5) need for continuing education for physicians and nurses on diabetes/NCDs.

Discussion

The members of the Pacific Chronic Disease Council (PCDC) recognized the need for a comprehensive assessment of the existing data and the system of services for diabetes and other NCDs. To assure wide participation, PCDC members served as the designated team leaders in their respective jurisdiction or state and participated in the planning of the assessment, identified assessment team members, gathered documents and records, identified key informants, and assisted in reviewing the information and identifying the issues and needs. In addition, groups of health care stakeholders including administrators and clinicians from each of ten sites participated in prioritizing the issues and needs based on the conditions surrounding their system of services and work environment.

Population, Mortality, Surveillance Data

The population in the USAPI region did not significantly change between 2000 and 2010, however, there are observed shifts in specific age groups. The increase in the number of residents 45 years of age and older is important because at this age there is the higher risk of developing NCDs and this increase may intensify the need to plan for more resources, manpower, and medical and health care services for individuals with NCDs.

In examining crude mortality rates across the USAPI, cancer and heart disease were the leading causes of death, followed by diabetes. When aggregating all of the deaths, almost half (47.9%) of the deaths in the region are due to NCD-related conditions. However, care must be taken when interpreting these data because, although mortality data do exist, there is a lack of common definitions and differences in completing death certificates, data collecting procedures, assurances of the quality of the data, levels of training of personnel, and the timely reporting of these data across the sites. Due to these limitations, comparing mortality statistics across all sites is difficult to perform.

In examining the data from population-based surveillance and local survey, the data show that the rates of overweight and obese residents ranged from a high of 93% among residents in American Samoa to a low of 62.4% in the RMI. The data for prevalence of diabetes ranged from a high of 47% in American Samoa to a low of 9.1% in Guam depending on surveillance year. However, care must be taken when examining these data because of the differences in the way each jurisdiction collects data and surveys populations. The BRFSS is a telephone survey with self-reported responses; whereas the NCD STEPS is a community-based survey with face-to-face interviews and physical and biochemical measurements are obtained. Other local surveys are limited to specific segments of the population (ie, government workforce, health care sector, and K-12 students), which may introduce bias in the results and these data may not be generalizable to the population. Because of the differences in methodology and surveyed populations, point in time survey data from different jurisdictions cannot be compared with each other.

Administrative System of Services

All sites (with the exception of Pohnpei) had a plan for the prevention and control of diabetes/NCDs, and some had multiple plans (eg, nutrition, physical activity, and tobacco control) however, these plans did not appear to be connected, and in some cases there was no evidence of implementation. Stakeholders identified the following problems with planning documents: Plans are often funding-driven and are time limited with no sustainability to continue programs and services; furthermore, budgets are not attached to plans for implementation with the exception of specific and focused work plans. The majority of funds for health programs is from external sources with specified targeted activities and is short-term and time limited. Funding for health programs and services is a problem with minimal to no funds committed or matched from the jurisdiction governments, resulting in the lack of opportunities and resources for infrastructure development, maintenance, and sustainability of programs and services. The lack of funding for diabetes/NCD programs and services necessitates the need to partner with other organizations. The Diabetes Prevention and Control Programs (DCPC) in all sites partnered and collaborated with various community groups, church groups, schools, and other public health programs. Policy and procedure manuals were missing in most of the sites and though a few had manuals for NCD/Diabetes programs, they were not being implemented and some needed to be updated and revised. There is a need for training to assure the implementation of the policy and procedure manuals and monitoring to assure that the standards and protocols described in the policy and procedure manuals are being implemented.

Clinical System of Service

DPCP staff provided outreach and prevention services in collaboration and public health programs, community organizations, and schools. Several issues were identified related to outreach and prevention activities including insufficient targeting of prevention to high risk populations and little to no coordination with and among medical care providers, clinics, and hospitals. Criteria needs to be developed to target screening for at-risk patients; and referral mechanisms need to be created to collaborate with medical care providers.

Most sites (except Ebeye) provide screening to all individuals upon request and some programs reported repeated screening of same individuals due to lack of screening records. Ebeye has banned mass screening and uses criteria to define risk and eligibility for screening. Due to the lack of a common standard among clinicians for the diagnosis of diabetes, different criteria are being used. All DPCP/NCD programs need to develop standard criteria to target screening for high-risk populations and for diagnosing diabetes.

Treatment and management for patients with diabetes and NCDs varied among sites. For most sites there was little to no communication or collaboration between providers and public health staff, resulting in fragmented services and no continuity of care. Other issues identified included the need for common standards of care and policy/procedure manuals with training on implementation of the standards and procedures. Two sites (Palau and Ebeye) had diabetes/NCD services based on the Health Disparities Collaborative model and had teams to treat, manage, and follow-up with patients. All DPCP/NCD programs need to examine the feasibility of developing and implementing the team approach to care for patients with diabetes and NCDs.

Support System of Services

The pharmacy and laboratory continue to have numerous issues including lack of funding to order and purchase supplies (ie, reagents and medications) and cumbersome procedures for purchasing. Methods for purchasing medications and supplies need to improve. Palau has a unique automated system for purchasing medications and supplies that is based on level of usage, incorporating an automated standing order for medications, and supplies that are commonly used to assure a continuing supply. Other sites may benefit implementing a similar purchasing system.

Data System

Data systems in the DPCP/NCD programs varied from four sites having no data system (American Samoa, CNMI, Chuuk, Majuro), four sites that had a data system that included incomplete data and did not produce reports (Kosrae, Pohnpei, Yap, Guam), and the two that were using the PECS diabetes registry and were planning conversion to CDEMS. Several barriers to a functional data system were identified including: lack of standard definitions, no written procedures for collecting data, lack of collaboration and coordination between clinicians and data staff, no written procedures for data entry, no procedures for database back-up and retrieval, no quality assurance of the data, and limited resources to support hardware for the data system. Also, data in all sites were entered into a data system, but information extraction from the system was not performed. There was no evidence of data analysis, interpretation, or publication of data reports from any of the diabetes data. As a result, data are not being used to make clinical or program decision, the main purpose of diabetes registries. Another issue is that the majority of the staff who are in charge of data do not have adequate skills, education, or training to be able manage a data system. All sites need technical assistance to further develop the infrastructure and staff training to improve the data systems and to be able to analyze, interpret, and report the data and information extracted from the system.

Conclusion

When these priorities are examined in the aggregate, the primary issues facing NCD identification and treatment in USAPI are the need to: (1) Develop a comprehensive health plan for diabetes and NCDs; (2) Select, develop, and integrate standards of care, definitions, policy, and procedures for the diagnosis, treatment, and management of patients with diabetes and NCDs; (3) Develop data systems with training for staff on working with data systems, analysis, interpretation, and reporting of data; (4) Develop a team approach to providing care to patients with diabetes and NCDs to mitigate fragmentation and improve continuity of care; and (5) Develop continuing education programs on the latest developments in the prevention, treatment, and management of diabetes and NCDs for physicians, nurses, and public health staff.

The PCDC, as the lead group for addressing diabetes and other NCDs in all the USAPI jurisdictions are in the process of examining and addressing these issues in collaboration with partners (community, local, faith-based, government agencies, and non-government organizations). In 2009, PCDC submitted a document with prioritized recommendations to a US Federal Agency Steering Committee consisting of representatives from the Health Resources and Services Administration, National Institute of Health, Office of Global Health Affairs, Office of Public Health and Science, Office of Women's Health, and the Centers for Disease Control and Prevention. This document included recommendations to address some of the issues that were found in the assessment. As of this publication, PCDC is piloting the Health Disparity Collaborative/Chronic Care Model training in the FSM that will address some of the clinical and data issues.

Table 7.

Clinical Services by Jurisdiction

Services	FSMa				RMIb		ROPc	ASd	GUAM	CNMIe
	PNIf	KOSg	CHKh	YAP	MAJi	EBYj
Diabetes prevention and risk reduction education and services	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Diabetes Screening	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Treatment and management services based on the Disparities Collaborative Model						Y	Y
Linkage/Communication Mechanism between medical clinic and other clinics (including community and public health)				Y		Y	Y		Y
Foot care clinic					Y	Y			Y	Y
Eye clinic						Y		Y	Y
Renal Dialysis Services	Y						Y	Y	Y	Y
Recent Research on Obesity								Y	Y

^aFederated States of Micronesia.

^bRepublic of the Marshall Islands.

^cRepublic of Palau.

^dAmerican Samoa.

^eCommonwealth of the Northern Marianna Islands.

^fPohnpei.

^gKosrae.

^hChuuk.

ⁱMajuro.

^jEbeye. Data source: See individual site articles in this supplemental issue

Disclosure Statement

The authors report no conflict of interest.