Lessons from the Field

Abstract

Almost a quarter of Pohnpei's population is overweight or obese, a major factor influencing a 2010 non-communicable diseases (NCD) emergency declaration. The Racial and Ethnic Approaches to Community Health (REACH) project in Pohnpei is implementing a culturally tailored policy, systems, and environmental (PSE) intervention to reduce NCDs through healthy nutrition projects. Through collaboration with traditional leaders and using traditional protocols, REACH succeeded in soliciting formal approval from a Traditional Monarch to serve only healthy beverages during events at all traditional houses in the municipality. The Governor, in turn, also supported this initiative. This project cultivated relationships with traditional and government leaders to implement a culturally appropriate healthy nutrition PSE change intervention.

Issue

The Federated States of Micronesia (FSM), a low-middle income country, has over 600 islands across more than a million square miles of the Western Pacific Ocean. The FSM consists of the following four states: Chuuk, Kosrae, Pohnpei, and Yap. Pohnpei Island, which has a population of approximately 36,000, is the largest island in the FSM and is home to the nation's capital.¹ There are six municipalities in Pohnpei Island, which are Kitti, Kolonia, Madolenihmw, Nett, Sokehs, and U.

After World War II, the FSM states were part of the United Nations Trust Territory under the United States (US) before entering an agreement named the Compact of Free Association. Currently, under the Compact of Free Association, the US provides grant and program assistance to the FSM and allows FSM citizens to live and work in the US without a green card or visa.

Since World War II, the FSM has been influenced by the Western diet of high-fat processed foods and sugary drinks and has adopted widespread tobacco use. In Pohnpei, 32.1% of the adult population had diabetes.² Data also showed that 73.1% of the adult population was overweight or obese, 25.0% of adults smoked tobacco daily, and 42.1% chewed betel nut with tobacco daily.^2,3 Whereas, 17.4% of youth were overweight and 4.5% were obese.⁴ According to a youth survey, 22.3% of Pohnpeian high school students used cigarettes daily and 50.1% used smokeless tobacco.³ These unhealthy lifestyle practices have led to high non-communicable disease (NCD) morbidity and mortality rates. In fact, the life expectancy in the FSM is ten years less than in the US.⁵

The 2010 US Affiliated Pacific Islands health emergency declaration called for regional, national, and local agencies to mobilize and respond to reduce the incidences of NCDs in the region.⁶ Due to the state of emergency, the Pohnpei State Department of Health Services (DHS) has worked on health interventions that impact the Pohnpeian population. Previously, Pohnpei State DHS implemented public health and behavior change programs, such as health education campaigns and exercise programs, which targeted individual change and were non-sustaining. Whereas, the new approach focused on policy, system, and environmental strategies that affect population health and is a long-term approach.⁷

Description

To help in the efforts, in 2014, the Pohnpei State DHS became a sub-grantee of the University of Hawai‘i John A. Burns School of Medicine Department of Family Medicine and Community Health's Racial and Ethnic Approaches to Community Health (REACH) project, a Centers for Disease Control and Prevention funded grant that implements culturally-tailored policy, systems, and environmental (PSE) interventions to improve health in the US Affiliated Pacific Islands. Community PSE strategies are designed to reduce exposure to adverse health risks and to promote healthy behaviors by ensuring healthy choices are practical and accessible in the community.^8–10 The REACH PSE interventions aligned with existing objectives within the Pohnpei State DHS and the 2010 Non-Communicable Diseases State of Emergency declaration. The REACH project was designed to develop a local health policy to promote healthy behaviors and improve community health knowledge. Due to the accessibility of water and coconut water in Pohnpei, the REACH nutrition objective focused on increasing access to healthy beverages at events held at the traditional houses in Pohnpei. Water is a crucial nutrient for normal body functioning along with physical and cognitive performance.¹¹ Also, research has demonstrated comprehensive approaches that includes both promoting an environment in support of water-only consumption and community education can decrease the risk of being overweight for children by 31%.¹²

At the end of Pohnpei's centralized government system of the Saudeleur Dynasty in the 1600s, the Pohnpeian government was decentralized into municipalities. Each of the municipalities is lead by a Traditional Monarch called the Nahnmwarki, who is assisted by a Nahnken (second in command), and supported by many village chiefs. The Nahnmwarki is the paramount chief of the municipality and the Nahnken serves as the liaison or bridge between the people and the Traditional Monarch.^13–16 The Traditional Monarchs inherit the title and are highly respected in the community as they oversee all affairs in their municipality. Traditional Monarchs can make formal resolutions or rules, which are verbal directives carried out by the village chiefs, who are appointed by the Traditional Monarch.^15,16

Currently, in the Municipality of Kitti, the leadership council is comprised of the Traditional Monarch and other non-elected traditional leaders, the elected Chief Magistrate (mayor) and the elected officials of the Municipal Council, who represent the village and districts in Kitti Municipality. The Chief Magistrate and Municipal Councils have no role in the traditional system but must interface with the traditional leaders because government services are provided to the people of the municipality. Meetings with the Traditional Monarch of Kitti on government-related services or affairs are handled by the Chief Magistrate, who would then relay the information to the Traditional Monarch.

To reach 75% of the population in Pohnpei, traditional houses or nahs were strategically chosen for the PSE interventions due to their high frequency of utilization by many Pohnpeians and for their cultural and traditional value as places of gathering and community events. These events, including meetings, social gatherings, and funerals, constantly have food and beverages available for the attendees. The traditional houses are managed by the traditional chiefs who oversee the matters of the village and help preserve their cultural heritage.

Methods

During a family gathering at a traditional house, the Pohnpei REACH Local Project Assistant (LPA) learned that the Traditional Monarch of Kitti supported banning unhealthy foods and beverages during events at traditional houses. Since the initiative was administered by the Pohnpei State DHS, the communication protocol started within the government organizational structure, beginning with the Pohnpei State DHS Director, who then contacted the Governor. As a courtesy and by way of protocol, the Governor communicated with the Chief Magistrate's office, who would usually work within the traditional protocol system. In this case, the Chief Magistrate worked directly with the Traditional Monarch of Kitti Municipality.

Due to the REACH LPA's working relationships within the traditional system, it was appropriate to communicate directly to the traditional leaders of Kitti to avoid the lengthy communication process and any delays. The LPA was versed in the communication and traditional protocols, as well as the organizational structure of the Traditional Monarch system, to ensure rules were being followed. Per the instructions of the Traditional Monarch of Kitti, the LPA worked closely with the Chief Magistrate and the Traditional Monarch's appointed a Council Member on the REACH project. While it is common for resolutions to only be verbalized by the Traditional Monarch, the LPA asked the Chief Magistrate and Council Member for a formal written commitment showing support of serving only healthy beverages at traditional houses.

Initially, the LPA created a healthy beverage commitment template that documented support for the REACH initiative. However, advisors to the Traditional Monarch asked if the written commitment could be changed to an official resolution. To create this resolution, the LPA worked with a Pohnpei State Cancer Coalition member who had experience with legal language and terminology for the Pohnpei government. The advisors to the Traditional Monarch and the LPA met a few times to edit and review the resolution. A draft of the resolution was shared with the Government of Kitti Municipality for review and approval before it was given to the Traditional Monarch of Kitti Municipality.

Results

The Chief Magistrate worked with the Council Member to secure a meeting between the REACH LPA and the Traditional Monarch of Kitti. When meeting with the Traditional Monarch, the guest must bring sakau (or kava or ava as known throughout Polynesia), which is a Pohnpeian cultural beverage that is used for all ceremonial practices. The Chief Magistrate volunteered to provide the sakau to the Traditional Monarch in support of the efforts of the REACH project. After the ceremonial sakau session, the Traditional Monarch of Kitti signed a resolution proclaiming that only healthy beverages will be served during events at all traditional houses in the municipality. The municipality includes 41 villages and this resolution impacted approximately 6,500 Kitti residents.

Healthy beverages to be served during gatherings and events held at the traditional houses included water, coconut water, and local tea (madeu). The Traditional Monarch also incorporated in the resolution a mandate that only healthy foods would be served and a prohibition of tobacco use and betel nut chewing. Upon signing the resolution, the Traditional Monarch called on the Chief Magistrate and the Speaker of the Municipal Council to oversee and ensure that the people were educated about this new policy and that appropriate enforcement protocols and measures were to be established. For the first time a resolution made by the Pohnpeian traditional leader in modern-day Kitti Municipality was written and documented.

The Pohnpei REACH nutrition objective demonstrated that there was support from the traditional leaders to improve the health of their people. When the Pohnpei State Governor was notified that a nutrition resolution was being discussed with the Chief Magistrate and Traditional Monarch of Kitti, the Governor wanted to provide his administration's support and commitment to this community-based initiative. As a result, the Governor stated that the resolution would be shared with relevant departments and agencies. The resolution signing by the Traditional Monarch of Kitti and the Pohnpei State Governor was publicized in the community. An article of the resolution signing was written and disseminated in the local newspaper the Kaselehlie Press, as well as posted on the Pohnpei State Government website and shared on the REACH Facebook webpage.

Conclusions

This REACH initiative established a culturally appropriate intervention to increase access to environments with healthy options. Since there are many traditional houses throughout Kitti Municipality, the intervention in this setting impacted many families. This community-based policy may decrease NCD-related health disparities in this municipality.

The REACH project cultivated relationships with traditional leaders along with government leaders to implement this intervention. The Traditional Monarch of Kitti Municipality's support of serving healthy beverages during community events at traditional houses was instrumental in establishing the necessary connections and partnerships with the village leaders. The support by the Pohnpeian leaders and the signing of the resolution may ensure sustainability of the REACH goals.

Traditional leaders have a vital role and influence modern governance in the Pacific Islands, including in the FSM and other countries. Thus, the lessons presented in this paper can likely resonate with other Pacific Islands whose traditional chiefs have significant political, positional, and cultural influence. The traditional leaders are the gatekeepers in Pohnpei. As it is in other communities, the buy-in and approval of gatekeepers or community leaders are essential for the successful implementation of an effort in the community.

Lessons Learned

This healthy beverage initiative had its challenges and lessons were learned.

Due to social and cultural events, including funerals, the resolution signing ceremony was rescheduled twice. Project flexibility was necessary in order to accommodate social and cultural practices to maintain support from the traditional leaders while upholding deadlines for grant requirements. There was a delay in the scheduling of the signing ceremony with the Traditional Monarch related to the cultural sakau purchase. Sakau, which is used for Pohnpeian ceremonial practices, is essential, so there was a need to consider other options to acquiring gifts to show respect to cultural practices. Flexibility was also needed to accommodate the schedule and priorities of those within the traditional system who had a role in the signing of the resolution.

There is still a need to educate the traditional leaders and the public about this new local health policy at the traditional houses. The LPA plans to work with the Chief Magistrate and Speaker of the Kitti Municipal Council to provide education to the community about the resolution and importance of drinking water and coconut water through educational workshops and local media, including local radio, newspaper, social media, and partner websites. Continuous awareness in the community regarding the policy at the traditional houses in Kitti is needed to ensure adherence.

An evaluation would have been helpful to monitor compliance and assess the changes of knowledge, attitudes, and behavior to demonstrate effectiveness. The LPA created evaluation assessments; however, the evaluation was not implemented due to limitation of time and resources. Metrics should include actual use of water and other beverages at the event (number of bottles before and after), the number of events adhering to the policy, and the average daily consumption of different beverages.

Conflict of Interest

None of the authors identify any conflict of interest.