Feasibility of Healthy Beverages Policies in American Samoa and Federated States of Micronesia: Water and Coconut Water Only Community Interventions

American Samoa and the Federated States of Micronesia (FSM) are two small Pacific Island nations that have some of the highest noncommunicable disease (NCD) mortality rates in the world. Supported by church leaders to address obesity as an NCD risk factor, American Samoa, and Chuuk and Kosrae States of FSM selected the implementation of healthy beverages as a nutrition intervention through a water- and coconut water-only pledge in church events. The consumption of water and coconut water was tracked. Across 105 church events in the three jurisdictions, the count of water bottles before and after events decreased from 142.8 to 22.3, the number of coconuts before and after events decreased from 19.6 to 1.2, and cups of water before and after events decreased from 52.9 to 7.6. The promotion of healthy beverages in church settings holds promise in the Pacific as a feasible, accessible, and culturally responsive nutrition approach, given limited access to other nutritional alternatives, e.g., fresh fruits and vegetables. Supplemental health promotion messaging to maintain knowledge and attitudes about healthy is recommended for future scaling up.

Strengthening cancer control in the South Pacific through coalition-building: a co-design framework

Background

Cancer is a significant problem for the South Pacific region due to a range of complex health challenges. Currently gaps in diagnosis, treatment and palliative care are significant, and while governmental commitment is strong, economic constrains limit health system strengthening. Alliances have been successful in strengthening non-communicable disease and cancer control policy and services in resource constrained settings. A regional coalition approach has therefore been recommended as an effective solution to addressing many of the challenges for cancer control in the South Pacific. However, evidence regarding the effective mechanisms for development of alliances or coalitions is scarce. This study aimed to 1) create a Coalition Development Framework; 2) assess the use of the Framework in practice to co-design a South Pacific Coalition.

Methods

Creation of the Coalition Development Framework commenced with a scoping review and content analysis of existing literature. Synthesis of key elements formed an evidence-informed step-by-step guide for coalition-building. Application of the Framework comprised consultation and iterative discussions with key South Pacific cancer control stakeholders in Fiji, New Caledonia, Papua New Guinea, Samoa and Tonga. Concurrent evaluation of the Framework utilising Theory of Change (ToC) and qualitative analysis of stakeholder consultations was undertaken.

Findings

The finalised Coalition Development Framework comprised four phases with associated actions and deliverables: engagement, discovery, unification, action and monitoring. Application of the Framework in the South Pacific identified overwhelming support for a Cancer Control Coalition through 35 stakeholder consultations. Framework phases enabled stakeholders to confirm coalition design and purpose, strategic imperatives, structure, local foundations, barriers and facilitators, and priorities for action. ToC and thematic consultation analysis confirmed the Framework to be an effective mechanism to drive engagement, unification and action in alliance-building.

Interpretation

A Coalition to drive cancer control has significant support among key Pacific stakeholders, and establishment can now be commenced. Importantly results confirm the effective application of the Coalition Development Framework in an applied setting. If momentum is continued, and a regional South Pacific Coalition established, the benefits in reducing the burden of cancer within the region will be substantial.

Funding

This work was completed for a Masters of Public Health project. Cancer Council Australia provided project funding.

Abstract B007: Developing community-primary care-specialty care partnerships to address cancer disparities in Asian Americans, Native Hawaiians, and Pacific Islanders

Cancer continues to be the leading cause of death in Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPIs), with over one-third of the AANHPI population residing in California and Hawai’i. Due to linguistic, cultural, and sociodemographic differences, cancer prevention, control, and treatment remains a challenge. These compounded factors hinder AANHPIs from seeking care or following through with provider’s recommendations as they experience high level of dissatisfaction in care, risk of misdiagnosis or ineffective treatment plans, resulting in low levels of engagement with the healthcare system. This has called for a need to create partnerships and improve coordination between community, primary care, and specialty care. The Bristol-Myers Squibb Foundation’s Specialty Care for Vulnerable Populations initiative addresses inequities in access to and utilization of specialty care services by medically underserved and vulnerable populations in the US. The goal of this national initiative is to catalyze sustainable improvement and expansion of specialty care and health service delivery by safety net providers for people at high risk of cancer and cardiovascular disease. In response to the cancer disparities and inequities faced by AANHPI populations, the Bristol-Myers Squibb Foundation’s Specialty Care for Vulnerable Populations awarded 4 organizations $750,000 each to support 3 year health service delivery demonstration projects to improve access to quality cancer care, patient engagement, and supportive services to AANHPIs. Objectives for this session will be: • Describe the cancer disparities in Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPIs) • Explain current research and new partnerships to improve cancer outcomes and access for AANHPIs • Disseminate different models of care bolstering community, primary care, and specialty care in AANHPI cancer patients This session will delve into the cancer disparities apparent in AANHPIs and highlight the 4 AANHPI-dedicated projects to create better coordination between community, primary care, and specialty care: 1. University of California Davis Cancer Center/Health & Life Organization 2. University of California San Francisco 3. University of California Irvine Chao Family Comprehensive Cancer Center 4. University of Hawai’i John A. Burns School of Family Medicine These projects include forming new partnerships between a NCI comprehensive cancer center + FQHC-lookalike; testing an in-person and virtual patient navigation portal; utilizing a hub-and-spoke model between primary care, FQHCs, and specialty care; and bolstering telehealth capabilities to train workers in USAPI territories and Hawai’i on cancer topics and services.

Citation Format: Priscilla Ko, Patricia Doykos, Moon Chen, Scarlett Lin Gomez, Neal Palafox, Sora Park Tanjasiri. Developing community-primary care-specialty care partnerships to address cancer disparities in Asian Americans, Native Hawaiians, and Pacific Islanders [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B007.

Cancer control in the Pacific: big challenges facing small island states

This Series paper describes the current state of cancer control in Pacific island countries and territories (PICTs). PICTs are diverse but face common challenges of having small, geographically dispersed, isolated populations, with restricted resources, fragile ecological and economic systems, and overburdened health services. PICTs face a triple burden of infection-related cancers, rapid transition to lifestyle-related diseases, and ageing populations; additionally, PICTs are increasingly having to respond to natural disasters associated with climate change. In the Pacific region, cancer surveillance systems are generally weaker than those in high-income countries, and patients often present at advanced cancer stage. Many PICTs are unable to provide comprehensive cancer services, with some patients receiving cancer care in other countries where resources allow. Many PICTs do not have, or have poorly developed, cancer screening, pathology, oncology, surgical, and palliative care services, although some examples of innovative cancer planning, prevention, and treatment approaches have been developed in the region. To improve cancer outcomes, we recommend prioritising regional collaborative approaches, enhancing cervical cancer prevention, improving cancer surveillance and palliative care services, and developing targeted treatment capacity in the region.

Cancer control in small island nations: from local challenges to global action

Cancer is a leading cause of death in small island nations and is forecast to increase substantially over the coming years. Governments, regional agencies, and health services of these nations face daunting challenges, including small and fragile economies, unequal distribution of resources, weak or fragmented health services, small population sizes that make sustainable workforce and service development problematic, and the unavailability of specialised cancer services to large parts of the population. Action is required to prevent large human and economic costs relating to cancer. This final Series paper highlights the challenges and opportunities for small island nations, and identifies ways in which the international community can support efforts to improve cancer control in these settings. Our recommendations focus on funding and investment opportunities to strengthen cancer-related health systems to improve sharing of technical assistance for research, surveillance, workforce, and service development, and to support small island nations with policy changes to reduce the consumption of commodities (eg, tobacco and unhealthy food products) that increase cancer risk.

Cancer management in the Pacific region: a report on innovation and good practice

Pacific island countries and territories (PICTs) face the challenge of a growing cancer burden. In response to these challenges, examples of innovative practice in cancer planning, prevention, and treatment in the region are emerging, including regionalisation and coalition building in the US-affiliated Pacific nations, a point-of-care test and treat programme for cervical cancer control in Papua New Guinea, improving the management of children with cancer in the Pacific, and surgical workforce development in the region. For each innovation, key factors leading to its success have been identified that could allow the implementation of these new developments in other PICTs or regions outside of the Pacific islands. These factors include the strengthening of partnerships within and between countries, regional collaboration within the Pacific islands (eg, the US-affiliated Pacific nations) and with other regional groupings of small island nations (eg, the Caribbean islands), a local commitment to the idea of change, and the development of PICT-specific programmes.

Advancing Cancer Health Equity in Pacific Islanders: A 15-Year Investment in Cancer Research, Training and Outreach in Guam, Hawaii and the U.S. Associated Pacific Islands

Background: Pacific Islanders (PI) in Guam (GU), Hawaii (HI), and the U.S. associated Pacific Islands (USAPI) experience greater cancer health disparities compared with majority populations in GU, HI, and the U.S. continent. Social determinants including geographic, socio-cultural, and economic factors are barriers to health and health care, leading to late stage diagnosis and poor survival outcomes. PIs are also highly underrepresented among cancer researchers. Aim: The University of Guam (UOG)/University of Hawaii Cancer Center (UHCC) partnership aims to grow cancer research capacity at UOG, develop cancer health disparities research at UHCC focusing on Pacific Islanders (PI), raise awareness of cancer and cancer prevention in GU, HI and the USAPI, and increase the number of cancer and biomedical scientists of PI ancestry in the U.S. Methods: An infrastructure comprised of five principal investigators and approximately 30 participating faculty, administrative staff, and community and scientific advisory members, supported by funds from the National Cancer Institute and the partnering institutions, has provided 15 years of support for cancer research, training, and outreach designed to reduce cancer health disparities and advance health equity among Pacific Islanders in GU, HI and the USAPI. Results: Fifteen collaborative research projects have been funded through the partnership. Many of these projects have focused on the prevention of unhealthy lifestyle behaviors that lead to increased cancer risk. Prepilot, pilot and full research projects address cancer health disparities of regional relevance and global importance, notably breast, cervical and oral cancers as well as tobacco and betel nut use. A betel nut cessation intervention, the first of its kind, shows promising quit rates. This research has resulted in over 80 publications, 100+ abstracts, and 9 grant awards. The partnership has recruited and trained 26 underrepresented graduate scholars in cancer health disparities, including two scholars who have since joined UOG's faculty and are now independently conducting research, participating in the partnership as investigators, and mentoring tomorrow's scientists. UOG faculty and early stage investigators continue to receive mentorship and career development support. Outreach activities have contributed to the introduction and passage of significant cancer prevention and control legislation in Guam and Saipan. Outcomes are communicated through the partnership's Website, social media, and community reports and seminars. Conclusion: The partnership has significantly increased research capacity at UOG and cultivated interest in cancer research among underrepresented minority students at the partnering institutions. A regional research infrastructure has been established, and research findings are informing public health policy and planning. Resources have been leveraged to address PI cancer health disparities in GU, HI, and the USAPI.

An assessment of the Pacific Regional Cancer Coalition: outcomes and implications of a regional coalition internal and external assessment

SIGNIFICANCE

The Pacific Regional Cancer Coalition (PRCC) provides regional leadership in the U.S. Affiliated Pacific Islands (USAPI) to implement the Regional Comprehensive Control Plan: 2007-2012, and to evaluate its coalition and partnerships. The Pacific Center of Excellence in the Elimination of Disparities (CEED), aims to reduce cancer disparities and conducts evaluation activities relevant to cancer prevention and control in the USAPI.

PURPOSE

The PRCC Self (internal) and Partner (external) Assessments were conducted to assess coalition functioning, regional and national partnerships, sustainability, and the role of regionalism for integrating all chronic disease prevention and control in the Pacific.

METHODS

Self-administered questionnaires and key informant telephone interviews with PRCC members (N=20), and representatives from regional and national partner organizations were administered (N=26). Validated multi item measures using 5-point scales on coalition and partnership characteristics were used. Chronbach's alphas and averages for the measures were computed.

RESULTS

Internal coalition measures: satisfaction (4.2, SD=0.48) communication (4.0, SD=0.56), respect (4.0, SD=0.60) were rated more highly than external partnership measures: resource sharing (3.5, SD=0.74), regionalism (3.9, SD=0.47), use of findings (3.9, SD=0.50). The PRCC specifically identified its level of "collaboration" with external partners including Pacific CEED. External partners identified its partnership with the PRCC in the "coalition" stage.

PRINCIPAL CONCLUSIONS

PRCC members and external partners are satisfied with their partnerships. All groups should continue to focus on building collaboration with partners to reflect a truly regional approach to sustain the commitment, the coalitions and the programming to reduce cancer in the USAPI. PRCC and partners should also work together to integrate all chronic disease prevention and control efforts in the Pacific.

Viral hepatitis in Hawai'i--differing perspectives

This publication contains information from a conference titled "Individual Perspectives on the Silent Epidemic of Viral Hepatitis in Hawai'i" held in October of 2007 with updates and additional contributions from annual conferences in 2008 and 2009. These conferences were sponsored by the Hepatitis Support Network of Hawai'i and held in Honolulu, Hawai'i at the Queen's Conference Center. The primary objectives of the conferences have been to heighten awareness of viral hepatitis in Hawai'i and to bring together health care professionals to learn about these infections and to help them respond to the challenges they bring to the people of Hawai'i. The initial conference was oriented to present the unique and individual perspectives of patients, physicians, and other healthcare providers specific to the complex issues of hepatitis in an effort to help them understand their role in the context of others and to develop a team approach in responding to this epidemic.

A pilot food store intervention in the Republic of the Marshall Islands

To improve diet and reduce risk for obesity and chronic disease, we developed, implemented and evaluated a pilot intervention trial with 23 large and small food stores in the Republic of the Marshall Islands (12 intervention, 11 control). The intervention included both mass media (radio announcements, newspaper ads, video) and in-store (cooking demonstrations, taste tests, shelf labeling) components. Consumer exposure to the mass media components was high (65% had heard half or more of the radio announcements, 74% had seen at least one of the newspaper ads). Consumer exposure to the in-store components of the intervention was moderate (61% attended at least one cooking demonstrations, 59% received at least one recipe card). After adjustment for age, sex and education level, increased exposure to the intervention was associated with higher diabetes knowledge (p<0.05) and label reading knowledge (p<0.05), but not with increased self-efficacy for performing promoted healthy behaviors. The intervention was associated with increased purchasing of certain promoted foods (p<0.005), including oatmeal, turkey chili, fish, canned fruit and local vegetables. It was also associated with improvements in healthiness of cooking methods (p<0.05). Food store centered interventions have great potential for changing cognitive and behavioral factors relating to food choice and preparation, and may contribute to lessening the burden of diet-related chronic disease worldwide.

Indigenous health in Australia, New Zealand, and the Pacific

We survey Indigenous health issues across the Pacific with a case study approach that focuses on Australia, New Zealand, Hawai'i, and US Associated Micronesia. For each case study, we provide an overview of the Indigenous population, its colonial history, and current health and social outcomes. In the discussion that follows, we flag some of the key policy initiatives that have been developed to address Indigenous health disadvantage, albeit within the context of continuing debates about Indigenous rights and policy.

Micronesian Migrants in Hawaii

More than 20,000 Micronesians have migrated to Guam, Hawaii, or the Commonwealth of the Northern Mariana Islands. Of these migrants, more than 8,000 now live in Hawaii. Factors in their home islands driving the recent emigration include the limited economic resources and struggling health care systems. Education systems in Micronesia are inadequate, and there are few job opportunities. The rates of infectious diseases remain high while at the same time, the epidemiologic transition in health has led to an explosion of non-communicable diseases. In Hawaii, the impact of the Micronesians emigration has been significant with most health and education expenses un-reimbursed. The health care costs alone are substantial as many Micronesians travel to Guam or Hawaii for medical treatment unavailable in their home islands. At the same time, Micronesians have difficulty accessing and navigating the health care system. While governmental, private, and academic programs already provide innovative and communitybased services to the Micronesian population, more work remains to be done. Not only are additional services, tailored to the culture and needs of Micronesian migrants, needed but a keener awareness and understanding of the issues surrounding Hawaii’s migrant population must be promoted among all public health stakeholders to ensure that the priority necessary to successfully address these challenges is recognized.

In-country and community-based postgraduate family practice training for Micronesian physicians--the Palau AHEC: a collaborative effort

The U.S. Institute of Medicine in its 1998 review of the health care systems among the U.S.-Associated Pacific Islands (USAPI) identified promotion of primary health care (PHC) and training of the regional health workforce including postgraduate training for physicians as priorities. With the support of the health leadership of the USAPI and the Republic of Palau, the John A. Burns School of Medicine (JABSOM) of the University of Hawaii captured U.S. federal Area Health Education Center (AHEC) funds to implement a postgraduate program to train Family Practitioners - physician specialists in primary care for the region. The Palau AHEC has evolved into ajoint activity of JABSOM, the University of Auckland Faculty of Medicine and Health Sciences (UAFMHS), the School of Public Health & Primary Care--Fiji School of Medicine, and Palau Community College to provide Diploma-level training in Family Practice and Community Health for Micronesian physicians.

On the biopsychosocial model: the example of political economic causes of diabetes in the Marshall Islands

Biomedical reductionism, the unwritten theory underlying the practice of medicine, is being supplanted by the biopsychosocial model. The explanatory power of the biopsychosocial model, however, is hampered by an inadequate mechanism to account for the social production of disease. We examine diabetes in the Marshall Islands to explore a conceptual approach that incorporates ecology, history, and political economy into the biopsychosocial model. The use of the Marshall Islands by the United States as testing grounds for nuclear war has led to ecological destruction, population displacement, and economic dependency. The consequence at the biological level has been an epidemic of weight gain, altered metabolism, and diabetes. A political economic perspective reveals that such outcomes are the result of decisions made by those who do not live with these decisions. Such a perspective points the way for social engagement and political work toward justice and health.