An Assessment of Non-Communicable Diseases, Diabetes, and Related Risk Factors in the Federated States of Micronesia, State of Pohnpei: 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 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.

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 Pohnpei during September 26–30, 2010. 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, National Institute on Minority Health and Health Disparities.

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

The Federated States of Micronesia (FSM) is an island nation consisting of a total of 607 high and low islands in the Northwestern Pacific Ocean. Although the area encompassing the FSM, including its Economic Exclusive Zone comprises 1,161,303 square miles of ocean area, the combined total land area is only 276 square miles with 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 Pohnpei consists of the main island of Pohnpei and eight outer atolls. The island of Pohnpei is roughly circular in shape, is approximately 13 miles long and has a land mass of 133.3 square miles, and is the largest island in the FSM. The island itself is a high volcanic island with a central rain forest and a mountainous interior. The elevated interior has eleven peaks of over 2,000 feet with the highest peak, Nahnalaud at 2,595 feet above sea level. Pohnpei proper is encircled by a series of inner-fringing reefs, deep lagoon waters and an outer barrier reef with a number of islets found immediately off shore. The island of Pohnpei is subdivided into six municipalities - the municipalities of Madolenihmw, U, Nett, Sokehs, Kitti, and the town of Kolonia where the majority of the state government buildings and offices are located. The Pohnpei State Hospital is located approximately one mile outside of Kolonia. Of the outer islands of Pohnpei, to the south lies Kapingamarangi (423 miles from Pohnpei proper), Nukuor (275 miles), Sapwuahfik (103 miles), Oroluk (190 miles), Pakin (28 miles), and Ant (21 miles). To the east are the islands of Mwoakilloa (104 miles) and Pingelap (163 miles).^3–6 Travel on the island of Pohnpei proper is increasingly easier with the development and improvement of paved roads to outlying communities from the central area. However, because of scattered housing along secondary unpaved dirt roads, there are still many residents who have a difficult time accessing health care. The outer islands are the most difficult to reach because of infrequent and undependable cargo ships which supply the islands. The regularly scheduled trip by ship takes place once a month to each of the outer islands bringing supplies and health personnel to deliver goods and services. These services are now augmented by a small plane that makes regularly scheduled flights to Pingelap, Mwoakilloa, and Sapwuahfik, carrying a maximum of six passengers and a small amount of cargo.

Population and Characteristics of the Population

Based on the 2000 Population Census and the 2010 Preliminary Census, there has been a slight increase in the total population by 1,495 residents (4.3%) in Pohnpei between the census enumerations.^7,8 The data by age groups reveal that there is a significant increase in the older population between 35–64 years of age, whereas the largest proportion of decline is among the youngest (under 10 years of age). Because of the increase in the population of residents 35–64 years of age, additional resources may be required as this population is at a higher risk for developing chronic diseases requiring on-going health and medical care.

In examining the distribution of the population of Pohnpei by geographic municipalities based on the 2010 Preliminary Census, the largest proportion of Pohnpei residents live in Sokehs with 6,640 (18.5%) persons followed by Nett with 18.2% (6,542) residents and Kitti with 6,470 (18.0%) residents. Table 2 also shows that 15.7% (5,662) people live in Madolenihmw, while 3,192 (8.9%) live in U, 16.9% (6,068) reside in Kolonia and 1,407 (3.9%) live on the outer islands the state.⁸

Table 2.

Population by Municipality, Pohnpei State, FSM, Preliminary Census, 2010

Municipality	Residents	Percent
Madolenihmw	5662	15.7
U	3192	8.9
Nett	6542	18.2
Sokehs	6640	18.5
Kitti	6470	18.0
Kolonia	6068	16.9
Outer Island	1407	3.9
Total	35981	100.0

Data source: Federated States of Micronesia, Office of Statistics, Budget and Economic Management, Preliminary Population Counts for FSM 2010 Census⁸

The Pohnpei 2000 Census Report on the socioeconomic status of the residents found 5,630 households with 34,486 persons for an average of 6.1 persons per household. About 13.4% of these households had ten or more people living in them. The census also reports that median household income in Pohnpei was $6,354 and the mean household income was $11,249. The regions of Pohnpei had large variations in their median household incomes with Pohnpei Proper having the highest at $6,617 while the Outer Islands had a median income of $1,762.⁷

Mortality Data

Leading Causes of Death

R. Salvador, Medical Records Supervisor provided the death certificate data (September 28, 2011) from Pohnpei State Hospital. Mortality data were aggregated for 2007–2009 and crude mortality rates per 100,000 population were calculated based on the Pohnpei 2000 census of 34,486 residents. The overall crude mortality rate for 2007–2009 was 1,266.3/100,000 population. The leading causes of death were heart disease (345.1), diabetes (116.0), hypertension (66.7), cancer (60.9), septicemia (42.5), and chronic obstructive pulmonary disease (42.5). When the proportions of the deaths due to chronic diseases or related conditions (heart disease, diabetes, cancer, stroke, and end stage renal disease) are aggregated for each year, the data show that 49.1% of the deaths in 2007, 52.1% of the deaths in 2008, and 43.1% of the deaths in 2009 were due to these conditions (data not shown).

Population-Based Surveillance Data

The Federated States of Micronesia (Pohnpei) NCD Risk Factors STEPS Report is based on data collected in November and December 2002 from a population-based cross-sectional survey conducted of key chronic diseases and their risk factors among 1,638 Pohnpeian adults aged 25–64 years (78% response rate). Of the 1,638 participants, 60.8% were women and 39.2% were men.⁹

The survey found that the overall prevalence of current tobacco users was 32.6% and the prevalence of daily use was 25.5% overall with 34.8% among men and 16.1% among women. The data for betel nut chewing showed that 29.9% reported currently chewing betel nut with more men (43.5%) reporting chewing than women (16.0%). Alcohol consumption in the past 12 months was 28.7% with a large gender difference with 47.5% of men and only 9.9% of the women reporting alcohol use.

The data for body mass index (BMI), diet, and physical activity showed that 73.1% of the population was overweight (30.5%) or obese (42.6%). Overall, 81.8% of the study population reported consuming fewer than the recommended five servings of fruits and vegetable per day. The mean number of servings of fruit eaten per day was 1.4 for men and 1.6 for women, while the number of servings of vegetables was slightly higher with 2.0 servings per day for both men and women. The prevalence of those physically inactive or with low levels of physical activity was 64.3% with 55.7% of the men and 73.5% of the women in this category.

Overall, based on venous blood samples, 32.1% of adults had diabetes with a higher rate among women (37.1%) compared to men (26.4%). The mean total cholesterol level among the participants was 199 mg/dl and 46.6% of the study population had hypercholesterolemia putting them at higher risk for coronary heart disease. The prevalence of high blood pressure was 21.2% with a higher proportion of men (26.8%) with hypertension compared to women (15.6%).

An important aspect of this report looked at combined risk factors and classified the study population into three NCD risk categories: high (3–5 risk factors), moderate (1–2 risk factors) and low (no risk factors). The five critical NCD risk factors included daily smoking, being overweight or obese, having high blood pressure, consuming fewer than 5 servings of fruits and vegetables, and a low level of physical activity. Using these risk factors, 56.7% of the study population was at high risk, 42.3% at moderate risk and only 1% at low risk for developing a chronic disease.

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 the entire FSM nation.

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%) report smoking in the past 30 days. 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% being 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

Diabetes Specific and Related Data

The staff of the DPCP maintains the NCD Diabetes database, enters data, and compiles patient visit summary data for patients who have diabetes and hypertension and who are seen at the Public Health clinics. The database is designed as an electronic medical record that documents all the data from a clinic encounter and summarizes the patient's visits.

There were a total of 243 patients registered in the database with the diagnosis of diabetes, diabetes with hypertension, and diabetes with obesity, representing only those patients with medical encounters at the public health clinics. As such, there is a major problem with identifying and tracking all patients in Pohnpei with the diagnosis of diabetes. If the patient is diagnosed with diabetes in another facility (Pohnpei State Hospital, Pohnpei Community Health Center, or one of the private clinics), that patient is not entered into the database unless the patient is referred to the public health clinic. Another major problem is that the patient is allowed to receive acute care and follow-up management services related to diabetes from any of the facilities in Pohnpei and that encounter data may not necessarily be captured by the staff entering the data into the NCD register database and encounter data may be lost. Furthermore, while the DPCP staff was able to view individual patient records, they were not able to produce reports that a diabetes register should be able to produce.

Diabetes and Tuberculosis

Data on the status of tuberculosis in Pohnpei was provided in a conversation by Dr. E. Johnson, the physician in charge of the Tuberculosis Program (September 30, 2010). There were a total of 38 patients with active tuberculosis receiving treatment and five patients with latent tuberculosis infection. Of the patients with active tuberculosis, two were also known to be diagnosed with diabetes. However, these data may not be accurate because there does not appear to be any consistent screening of patients with tuberculosis for diabetes, or screening of patients with diabetes for tuberculosis.

Because tuberculosis infection throughout the FSM has been a consistent problem, in 2000, the FSM established the nationwide BCG immunization program to be implemented by the state Immunization Program and included BCG as part of the newborn immunization schedule. In Pohnpei State, newborn immunizations were initiated in 2000 and in the first year, 62% of all newborns were immunized with BCG. Subsequently, the rate of newborns immunized has fluctuated, but has shown a steady general upward trend so that in 2007 and 2008, 96% and 94% of newborns respectively were immunized. The results of the BCG immunization program among newborns are promising in that the number of pulmonary tuberculosis infections among children under 5 years of age has been declining since the initiation of the program.

Description of the Administrative System

Legislation and Regulations

Currently, there is an existing tobacco law (FSM Code, Title 11, Chapter 13, Subsection 1302) that prohibits the sale of cigarettes or any tobacco products to minors (person under 18 years of age). There are no legislation or regulations that are specific to the public health responsibilities for the prevention and control of diabetes or other chronic diseases.

Planning Documents

There are no planning documents at the National or State levels for non-communicable diseases or for the prevention and control of diabetes. It is the intent of the Pohnpei State Division of Primary Care to initiate a planning process to develop a comprehensive strategic plan for the prevention and control of NCDs.

Policy and Procedure Manual

The Pohnpei State Department of Health Services, Division of Primary Health Care (DPHC) has developed and implemented several policy and procedure manuals. These manuals include: The Division of Primary Health Care Policy and Procedure Manual, The Immunization Program Policy and Procedure Manual, The TB and Hansen's Disease Program Policy and Procedure Manual, The NCD Program Policy and Procedure Manual, and The Community Health Center Policy and Procedure Manual. The Division of Primary Health Care Policy and Procedure Manual establishes that the mission of the DPHC is: To protect and promote health and well-being of Pohnpeians through culturally acceptable and appropriate public health approaches and preventative health services that are sustainable, equitable, affordable, and accessible to the people of Pohnpei State. Some of the components of the policy and procedure manual describe the quality assurance program based on the FSM Standards for Nursing Practice and the Code of Ethics as Applied to Nursing, the physician's role in public health clinics, management of public health programs and dispensaries. The TB and Hansen's Disease Policy and Procedure Manual describes the procedures for screening, treating, and managing tuberculosis; however, there are no procedures for the screening for diabetes of patients diagnosed with tuberculosis.

In addition to these policy and procedure manuals, there is a document, Guidelines for the Prevention and Management of Diabetes in the Federated States of Micronesia: A National Consensus Position, 2001, that 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.

Funding and Resources

R. Anson, Pohnpei State DPCP Coordinator, provided information in a conversation (September 28, 2010) on funding and resources. Funding for the DPCP in Pohnpei State is primarily dependent on US Federal funds that are distributed through the FSM National Government to the four states. The portion of the Centers for Disease Control and Prevention funds for Pohnpei State is $13,540 and provides funding for one staff, travel, and prevention/education materials. The Public Health Services Block Grant provides $11,000 for prevention and clinical activities that include funds for clinical and medical supplies, and educational materials. Other types of in-kind resources come from international organizations and include the Japan International Cooperative Association that provides volunteer staff and testing equipment; the WHO which provided the resources to plan and implement the STEPS survey, and the Secretariat of the Pacific Community (SPC) that funds prevention activities. Locally, the Island Food Community of Pohnpei, founded by the late Dr. Lois Englberger provides nutrition and food education, surveys, and research studies.

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 and other agencies' employees, and also allowed employees 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 providing medical coverage options for the entire workforce of the FSM, both public and private sectors.¹¹ In January 2006, the President of FSM signed into law an amendment extending eligibility to students attending post secondary institutions in the FSM. The MiCare Health Insurance Plan consists of three options: Basic Option (BA), Supplemental Resident Option (SR), and Supplemental Non-Resident Option (SNR) and Table 7 shows the premiums required for each of the plans.¹⁰ According to the MiCare Health Insurance Plan office, as of September 2010, there were a total of 3,120 subscribers and 9,819 dependents (36% of the population based on the 2010 census) in Pohnpei State who are covered by the health insurance plan.

Table 7.

MiCare Health Insurance Biweekly Premiums, FSM, 2010

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

Data source: MiCare, Federated States of Micronesia¹¹

Partnerships and Collaborations

The Pohnpei DPCP partners with several local agencies to implement activities in the community. The agencies include: the Tobacco-Diabetes Coalition which provides prevention activities in the community and lobbies for legislation and policies, and promotes advocacy efforts; the Pohnpei Women's Association Council (PWAC) which represents women from all the communities and carries out community activities such as gardening, clean-up campaigns, and training and education opportunities for women; the Land Grant Extension Program which provides community nutrition education, cooking and gardening demonstrations; the Pohnpei Department of Agriculture which works with farmers on issues of food security and provides education and materials for community-based farming and gardening, and promotes local farming to reduce the importation of foods and increase the exportation of products; and the Pohnpei State Department of Education, which implements a WHO-funded project, Health Promoting Schools Project and provides physical activity, sports activities, and gardening projects for students.

Research

The most recent research in Pohnpei was conducted by the late Lois Englberger, PhD, and was part of a multi-site study on documenting traditional food systems in different parts of the world to provide evidence that local resources are critical for food security, nutrition and health. The findings of the research project, Pohnpei, FSM Case Study in a Global Health Project Documents its Local Food Resources and Successfully Promotes Local Food for Health, were published in the Pacific Health Dialog.¹²

The Micronesian Seminar (www.micsem.org) is a private non-profit organization whose purpose is to assist the people of Micronesia, through public education, in reflecting on life in their islands under the impact of change in recent years. It was established as a research-pastoral institute by the Catholic Church and turned over to the Jesuit Order in 1992 under the direction of Fr. Fran Hezel, SJ. As part of its mission, the Micronesian Seminar has produced hundreds of articles and books, videos on social issues, and historical photo albums on Micronesia. The library contains about 23,500 titles and is one of the best collections on Micronesia anywhere in the world. Aside from its published materials on the area, the library also contains locally produced reports, maps, and microfilms.

Description of the Clinical Services System

Medical and Health Services

Medical and health personnel are available to provide services to patients in several settings. In Pohnpei, these professionals may be found in the Pohnpei State Hospital, public health clinics, community-based dispensaries, the Community Health Center, and private offices in the community.¹³ There are nine dispensaries with four on the island of Pohnpei and five on the outer islands. In addition to these state provided services, there are several private health care providers in the community. These providers include: Genesis Family Clinic (Inpatient and Outpatient), Pohnpei Family Health Clinic, MedPharm Clinic and Pharmacy/Optical, Berysin Community Health Center, Kolonia Dental Clinic, and the Kaselehlia Dental Clinic.

Outreach and Prevention

The DPCP staff provide a variety of outreach and prevention services that include distributing educational brochures and materials in the community, usually accompanying community presentations on diabetes risk factors, nutrition and physical activity. Also there are radio spots, posters and announcements, school presentations and activities that involve the students around nutrition and physical activity, and health fairs and community events. There are four staff in the program that devote part of their time to outreach and prevention activities. The Health Educator provides a 50% FTE to these activities, along with a Nutritionist (20% FTE), one Health Assistant at 20% FTE and an additional Health Assistant at 5% FTE.

Screening and Diagnosis

Screening services are provided upon patient request and in a variety of settings including regular clinic visits and outreach activities at the workplace, health fairs, special community events, and church events. The strategy to reduce morbidity and premature mortality associated with Type 2 diabetes is to assure early detection through active screening and case finding. The 2001 Guidelines for the Prevention and Management of Diabetes in the Federated States of Micronesia lists the following risk factors for undiagnosed Type 2 diabetes that should be used for screening: Age over 30, obesity (BMI ≥30), hypertension, family history of diabetes, women with a previous history of gestational diabetes, past history of impaired glucose intolerance, and clinical cardiovascular disease.

Treatment and Management

The treatment and management of patients with diabetes in the Public Health NCD Clinic is described in the NCD Program Policy and Program Manual — Medical Consultation and Treatment. However, patients diagnosed with diabetes are able to receive treatment and management services from any health care provider of their choice, and do not necessarily receive all of their services at the NCD Clinic. Patients are able to obtain services from multiple sites including the clinics, at dispensaries, at the Community Health Center, at the Pohnpei State Hospital by appointment with a specific provider (there are no diabetes clinics at the hospital), or private healthcare provider. The major problem is that there are no linkages among these sites and when the patients move from site to site, their care is fragmented and continuity of care is lost.

Renal Dialysis

The Renal Dialysis unit is located in the Pohnpei State Hospital. There are three dialysis units that are operational and are managed by two nurses. The unit is able to serve six patients per day — three patients in the morning and three patients in the afternoon. In 2009, a total of five patients were provided hemodialysis services and six patients were treated during the first nine months of 2010. With the capacity to provide services to six patients per day and the number of patients receiving services, it appears that hemodialysis services are sufficient.

Medical Referrals

R. Anson, Diabetes Prevention and Control Program (DPCP) Coordinator obtained data (September 27, 2010) on medical referrals for 2007–2009. Complete medical referral data was only available for 2007. In 2007, there were a total of 166 off-island medical referrals approved for care that could not be provided on Pohnpei. Of these referrals, 25 (15.1%) were NCD-related and included 18 for heart disease, four for eye problems, two were referred with gestational diabetes, and one patient for amputation. Of these 166 patients that were referred off-island, 33 (19.9%) patients did not have medical insurance while 133 (80.1%) were enrolled in the MiCare insurance program.

Description of the Support Services System

Quality Assurance and Continuing Education Program

The Pohnpei State Division of Primary Health Care, Policy and Procedure Manual describes the policies for both the quality assurance (QA) program and the continuing education (CE) program. All units in the Division of Primary Health Care are involved in the QA program and require the setting of standards, implementing the standards, performing QA audits by the QA Coordinator, and holding post-audit meetings to correct any deficiencies. The policy and procedure manual provides detailed procedures for implementing the QA program. The CE program assures that all public health staff have the opportunity to grow professionally and to increase their knowledge and improve their practical skills. The policy and procedure manual provides the details on the required CE hours for nurses and CE opportunities for health professionals.

Diabetes Health Education Materials

The DPCP is currently using culturally appropriate diabetes and other NCD educational materials and brochures in Pohnpei. Examples of some of these materials include: Small Steps Big Rewards; Walk 10,000 Steps Every Day; If You Are Pacific Islander, You May Be at Risk for Diabetes; You Can Prevent Diabetes: Advice for Pacific Islander Young Adults; Benefits of Physical Activity (Kamwahupen Mwekimwekid); Love Local, Live Local, Stay Local (Poakoahng, Momourki, Kolokol Pein Sakatail) (Papa Ola Lokahi, Pacific Diabetes Education Program);¹³ Types of Foods for Diabetes and Nutritional Tips, Basic Food Groups, Healthy Lifestyles, and Diabetes Prevention and Management in the Pacific Islands (SPC).¹⁴

Pharmacy Services

The medications that are available for the control of diabetes include: Glucophage, Metformin, Micronase, and Insulin. Some of the administrative problems described by the pharmacy staff include insufficient funding for purchasing adequate supplies of medications, and a cumbersome and complicated process for ordering medications — requiring comparison pricing, multiple approvals, and complex procurement procedures. Glucometers or glucometer testing strips are not available through the Pohnpei State Hospital pharmacy or the public health programs. They can be purchased by private pharmacies, but the cost is high with a bottle of 50 test strips priced at $50. Consequently only about 5% of the patients with diabetes have glucometers.

Laboratory Services

The laboratory is able to perform all of the routine laboratory tests for diabetes patients including: blood sugar, total cholesterol, HDL, LDL, triglycerides, urinalysis, and renal function tests. The Community Health Center and the public health clinics are able to perform the HbA_1c test; however, the testing reagents cost $16/test and therefore these tests are often not performed due to shortage of supplies.

Description of the Data System

The data system for the DPCP is a Microsoft Access-based software program that was locally developed and implemented by Dr. Rally Jim and captures data for all NCD programs from encounters in the public health clinics. At the time of the assessment, there was no written documentation of the specific components of the database program or how the program functions; there also was no policy and procedure manual, and the diabetes program staff were not able to demonstrate all of the functions of the software program; therefore it is difficult to determine whether the data system is useful for patient management.

Conclusion: Prioritized Issues and Needs

Non-communicable diseases, including diabetes, have been identified as an emergency in the USAPI. 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.

Although the total population between 2000 and 2010 has remained stable, there has been a shift in the age distribution of the population. There is a significant increase in the 35–64 year old age group - a population with increased risk for chronic illnesses that may require additional resources for health and medical care. The mortality data reveal that heart disease, diabetes, cancer, and hypertension were the leading causes of death among the residents of Pohnpei. Other findings show that high rates of overweight and obesity, low physical activity, and inadequate consumption of fruits and vegetables are risk factors associated with chronic diseases.

The description of the system of services reveals that there are no overall planning documents for the prevention and control of NCDs or diabetes. Other findings of the clinical system show that although services for diabetes are being provided, these services are provided in multiple sites with little linkages, communication, or coordination, leading to fragmentation and loss of continuity of care. A data system to identify and track patients with diabetes and other chronic diseases exists; however, it does not generate useful information because of lack of trained staff. Although surveillance for chronic disease data, local population survey data, vital statistics, and program data exist,¹⁶ 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.

Based on some of the findings of this report, the top three administrative issues include: (1) Need to develop and implement an NCD/Diabetes data registry; (2) Need to continue population-based surveillance surveys; and (3) Need for a policy and procedure manual for data entry. The top three clinical issues include: (1) Need for a team approach to NCD/Diabetes care; (2) Need for staff training on Stages of Change, Self-Management Skills, and Lifestyle Behaviors; and (3) Need to shift the health education paradigm to behavior change and personal accountability. The following tables list all the administrative and clinical issues and needs identified during the priority ranking.

Table 1.

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

Age	2000	2010	Difference	Percent
<5	5037	4096	−941	−18.7
5–9	4549	4202	−347	−7.6
10–14	4428	4467	39	0.9
15–19	4163	4067	−96	−2.3
20–24	3089	3315	226	7.3
25–34	4575	4980	405	8.9
35–44	3836	4255	419	10.9
45–54	2452	3470	1018	41.5
55–64	1179	1983	804	68.2
65–74	777	735	−42	−5.4
75+	401	411	10	2.5
Total	34486	35981	1495	4.3

Data source: Pohnpei Branch Statistics Office, 2000 FSM Census of Population and Housing⁷ and Federated States of Micronesia, Office of Statistics, Budget and Economic Management, Preliminary Population Counts for FSM 2010 Census⁸

Table 3.

Leading Causes of Death, Pohnpei, 2007–2009

Cause of Death	2007	2008	2009	2007–2009	Ratea
Heart disease	139	121	97	357	345.1
Diabetes	41	38	41	120	116.0
Hypertension	28	19	22	69	66.7
Cancer	17	23	23	63	60.9
Septicemia	20	13	11	44	42.5
COPDb	13	12	19	44	42.5
Senility	5	7	13	25	24.2
ESRDc	5	7	8	20	19.3
Pneumonia	5	6	8	19	18.4
Unknown	17	34	29	80	77.3
Other	178	119	172	469	453.3
Total	468	399	443	1310	1266.2

^aCrude mortality rate/100,000 population.

^bCOPD — Chronic obstructive pulmonary disease.

^cESRD — End stage renal disease. Data source: Personal communication, R. Salvador (September 28, 2011)

Table 4.

Prevalence of Selected NCD Risk Factors by Gender, Pohnpei State, FSM, 2002

NCD Risk Factor	% Total	% Male	% Female
Daily smoker	25.5	34.8	16.1
Betel nut chewing	29.9	43.5	16.0
Current alcohol use	28.7	47.5	9.9
Diabetes	32.1	26.4	37.1
High BP	21.2	26.8	15.6
Overweight/Obese	73.1	63.9	82.7
Low physical activity	64.3	55.7	73.5
Eat <5 servings fruit/veg	81.8	81.3	82.4

Data source: World Health Organization and the Government of the Federated States of Micronesia, NCD Risk Factors STEPS Report⁹

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.

BCG Immunization, Pohnpei State, FSM, 2000–2008

Year	BCGa	TB casesb
2000	62	1
2001	91	2
2002	72	6
2003	46	1
2004	74	1
2005	93	1
2006	84	0
2007	96	0
2008	94	1

^aPercent newborns immunized.

^bDiagnosed TB Cases < 5-years-old. Data source: Personal communication, Dr. E. Johnson (September 30, 2011)

Table 8.

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

Personnel	PH	Hospital	CHC
Physician, Medical Officers	3	17	1
Dentist		3
Health Assistants			2
Clinical Nurse		51
Public Health Nurse	18
Nutritionist, Dietitian	1
Social Worker	None
Physical Therapist		2
Health Educator (General)	1
Certified Diabetes Educator	None
Epidemiologist	None

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

Table 9.

Administrative Issues Priority Ranking

Priority Rank	Administrative Issue/Need	Average Scorea
1	Need to develop and implement an NCD/Diabetes Registry	16.0
2	Need to continue population-based surveillance surveys	24.3
3	Need for a policy and procedure manual for data entry	24.7
4	Need for linkage of medical records across facilities to track service encounters	25.0
5	Need for computer training on how to extract data from database systems	26.3
6	Need to develop an NCD/Diabetes State Plan	29.7
7	Need for training for analyzing and interpreting data into information	34.0
8	Need to secure State funding to support NCD/Diabetes prevention and control activities	36.0

^aLower the score, higher the priority

Table 10.

Clinical Issues Priority Ranking

Priority Rank	Clinical Issue/Need	Average Scorea
1	Need to shift the health education paradigm from signs and symptoms of diabetes, nutrition, physical activity to lifestyle behavior changes, self management skills, and personal accountability	22.8
2	Need for training on: (a) Stages of Change, (b) Self Management Skills, (c) Lifestyle behaviors	27.2
	Need for a “Team Approach” to NCD/Diabetes care	27.2
3	Need to address the fragmented care for patients with NCD/Diabetes	31.2
4	Need to update the 2001 Guidelines for the Prevention and Management of Diabetes based on the ADA (US) or the IDF (WHO) standards	31.3
5	Need for a centralized clinic for NCD/Diabetes patients	32.3
6	Need to address the insufficient supply of medications and laboratory supplies	32.8
7	Need to support and assure the consistent supply of HgbA1C testing reagent	35.7
8	Need for NCD/Diabetes specialty training for: (a) Physicians, (b) Hospital Nurses, (c) Health Assistants, and (d) Public Health Nurses	39.0
9	Need for on-island ophthalmology and podiatry specialists	49.2

^aLower the score, higher the priority

Disclosure Statement

The authors report no conflict of interest.