Summary Findings of USAPI NCD Capacity Assessments and Ways Forward Stacy De Jesus Islands Coordinator National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention August 31, 2016

How It All Began NCCDPHP has provided funding, guidance, and technical assistance to PIJs for at least two decades A more coordinated approach was needed to change the tide of chronic disease Jurisdictions were asked for input on “how CDC can help change the tide” at an August 2013 meeting on strengthening NCD capacity Priorities: Communication Surveillance Capacity Building Partnerships A workgroup was formed in 2012 with CDC representatives from tobacco, diabetes, heart disease, cancer, population health, and global health promotion to brainstorm ideas on how to better serve the Island Jurisdictions Coordinated and strategic action plan that responds to the needs of each Jurisdiction A new approach is the only way forward. CDC has supported both regions for at least 2 decades, rates of chronic diseases have soared, the burden is higher and the funds continue to shrink or stay the same. In 2013 we began our fact finding mission and we asked you “how we could help change the tide. Results from the fact finding and meetings, we need coordination, strategic plans and you made your priorities communication, surveillance, capacity building and partnerships.

Cooperative Agreement DP14-1406 Public Health Actions to Prevent and Control Diabetes, Tobacco Use, Heart Disease, and Associated Chronic Disease Risk Factors and Improve Health in the US Affiliated Pacific Islands, Virgin Islands, and Puerto Rico We began improving coordination through a funding opportunity announcement- DP14-1406, of which we will discuss futher later this morning.

DP14-1406 Aims Support implementation of cross-cutting, unified approaches that: promote health prevent and control tobacco use, diabetes, heart disease promote healthy pregnancy and infancy through primary and secondary prevention of NCDs Coordinate activities that increase capacity and address common risk factors reduce administrative and reporting requirements Develop NCD plans and establish organizational structure to collect and use surveillance data and develop evaluation plans

Two Prong Approach Capacity Building Phase – Years 1-2 Develop NCD plans Establish organizational structure Develop monitoring and surveillance plans and identify surveillance needs Develop evaluation plans Implementation Phase – Years 3-5 Increase cross-cutting approaches epidemiology surveillance environmental approaches clinical-community linkages Still focusing on communication, surveillance, capacity building, and partnerships

NCD Capacity Assessments Conducted in 2014 – 2015 Tool developed by CDC to evaluate the following: Demographics and NCD burden Health system infrastructure and primary care services Workforce capacity building Surveillance and health information Planning, policy, and program management Partnerships

NCD Country Capacity Tool Description Objective overview of a country’s capacity to address NCDs Composed of two parts: Online questionnaire which is sent to the primary contact within health department who works with NCDs Interview to discuss more in-depth questions Objective measures (figures, surveillance reports, close-ended questions) and qualitative data (interviews and briefings) – provides a comprehensive perspective on how NCDs are structured in the jurisdictions Interviews were usually held over 2 days

NCD Capacity Assessment Topics Type of healthcare system, organization of NCD control departments, specific budget and resource allocation for NCDs Available data: vital statistics, civil registration, surveillance systems related to NCDs and its risk factors and how the data are processed and managed Workforce: availability of trained individuals working with NCDs, availability with training links with other academic institutions for training MOH staff Planning, policy, programs: national NCD strategic plan, availability of national guidelines for prevention and treatment and associated risk factors

Summary Results NCD burden high Accounts for a significant percentage of mortality and morbidity and health budgets Heart disease, cancer, and diabetes are in the top 5 causes of death for most of the jurisdictions Life expectancy similar across the USAPIs and ranged from Youth smoking ranges from 8% - 47% Adult smoking ranges from 13% - 32% Youth (high school students) overweight/obesity ranges from 24% - 60% Adult overweight/obesity ranges from 63% - 94%

Health system, Prevention, Primary Care System structure and coverage Delivery of healthcare is often mixed, with predominantly public with some private providers Usually one hospital and federally funded community health centers (CHCs) NCD Unit All jurisdictions have some form of an NCD Unit, where the tobacco and diabetes programs supported by 1406 are housed. NCD plans available in most jurisdictions, some still need to be finalized. Plans are a deliverable for 1406. Some behavioral health related programs may sit in a different section of the department/ministry of health. NCD Coalition Status of NCD Coalition varies across the USAPIs. Some were already established prior to 1406 and have since been enhanced. Some have created new coalitions. An NCD Coalitions are a deliverable for 1406 Budget Majority of the budget for NCDs come from U.S. federal funds

Workforce Capacity Number of core NCD staff members can vary in size, often because organizational structure Education levels of staff can vary NCD staff may not have specific training and/or education in public health, so there is a need for on-the-job training Most have a Territorial epidemiologist, but no epidemiologist dedicated to NCDs Training needs identified include: Leadership training for managers Financial and grant management training Program management training Policy/advocacy Program evaluation Data/epidemiology training

Health Information Systems All have Vital Statistics, but sometimes incomplete (challenges with outer islands) Coding challenges Medical records vary from paper-based to EHRs Behavioral Risk Factor Surveillance System – self-reported Not all USAPIs are funded and those that are, often have challenges and data may not be usable. In jurisdictions that have reliable and usable BRFSS data, the need for physical measurements would be useful All have Cancer Registries Almost all have YRBS (every 2 years) Some have GYTS (every 4 y ears) STEPS – sporadic and delays with reporting All jurisdictions usually have some sort of local assessment/efforts (community health surveys)

Planning, Policy, and Programs All have NCD Strategic plans, but some need to be finalized Most have developed monitoring and surveillance plans NCD programs usually include: Tobacco Diabetes Comprehensive Cancer Breast and Cervical Cancer Cancer registry Racial and Ethnic Approaches to Community Health (REACH) All have endoresed The Policy Commitment Package from PIHOA – made up of 15 essential policies

Resources, Partnerships, and Collaborations Collaborate with other local government agencies Often collaborate with local community colleges, University of Guam, Fiji National University, University of Hawaii, and other outside universities All have strong partnerships with local NGOs Partnerships with international agencies, such as WHO, PIHOA, SPC

Opportunities and Priority Areas for CDC Data/epidemiology training Data for Decision Making Operational Research Training Working to strengthen vital statistics data and underlying causes of death NCD Dashboards/reports Surveillance and data Support Regional Epidemiologist (Dr. Haley Cash) NCD Hybrid Survey Pilot test #1 in CNMI – data collection complete, over 1000 surveys completed, dissemination workshop planned for late October Pilot test #2 in Palau – ongoing, data collection about 40% complete, will have over 2000 completed surveys

Opportunities, Priority Areas for CDC, con’t Health education and programs Chronic Disease Self-Management Program (CDSMP) – will train 24 people from the USAPIs to become Master Trainers from September 12-16, 2016 in Honolulu CDSMP is for community members with ANY chronic disease and teaches them how to better manage their conditions Master trainers are expected to complete at least 2 workshops per year and at least 1 Leader training Peer exchanges  NCD Hybrid survey Ongoing technical assistance Training opportunities through National meetings, other identified opportunities Grants management training Stronger coordination and integration within CDC to reduce burden Identifying what is working and what is NOT working, so CDC can better tailor our cooperative agreements Support for regional approaches to address the burden of NCDs in the USAPIs