Republic of Palau Non-communicable Disease Prevention and Control Strategic Plan of Action 2015-2020

Palau NCD Draft Plan Republic of Palau Non-communicable Disease Prevention and Control Strategic Plan of Action 2015-2020 HEALTHY COMMUNITIES HEALTHY PALAU 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page2 Table of Contents MESSAGES FROM THE LEADERSHIP AND PARTNERS ........................................................... 4 MESSAGE FROM THE PRESIDENT OF THE REPUBLIC OF PALAU .......................................................... 4 MESSAGE FROM RUBEKUL BELAU ....................................................................................... 5 MESSAGE FROM MINISTER OF HEALTH .................................................................................. 6 MESSAGE FROM COMMUNITY PARTNERS ................................................................................ 7 ......................................................................................................................... 7 ACKNOWLEDGEMENTS .............................................................................................. 8 EXECUTIVE SUMMARY ............................................................................................ 10 BACKGROUND ...................................................................................................... 11 FRAMEWORKS ...................................................................................................... 16 STRATEGIC PLANS OF ACTION .................................................................................. 17 OVERALL VISION, SUB-VISIONS, AND GOAL ........................................................................... 17 AREA OF ACTION: TOBACCO CONTROL ............................................................................... 18 SUB-VISION: “RICH, HEALTHY, AND TOBACCO-FREE ISLANDS” ......................................................... 18 GOAL: REDUCE TOBACCO CONSUMPTION BY 30% BY 2020 ............................................................ 18 SPECIFIC OBJECTIVES: ................................................................................................. 18 STRATEGIC ACTIONS: .................................................................................................. 19 AREA OF ACTION: REDUCING HARMFUL USE OF ALCOHOL ............................................................ 22 SUB-VISION: “BELAU IN CONTROL OF ALCOHOL” ....................................................................... 22 GOAL: REDUCE HARMFUL ALCOHOL USE BY 10% ....................................................................... 22 SPECIFIC OBJECTIVES: ................................................................................................. 22 STRATEGIC ACTIONS: .................................................................................................. 22 AREA OF ACTION: IMPROVING NUTRITION ............................................................................ 24 SUB-VISION: “A KELEL BELAU A DIDICHEL A KLUKUK (BREAST-FED AND WELL FED WITH LOCAL FOOD)” ................ 24 GOAL: IMPROVE OVERALL NUTRITION.................................................................................. 24 SPECIFIC OBJECTIVES: ................................................................................................. 24 STRATEGIC ACTIONS: .................................................................................................. 24 AREA OF ACTION: PHYSICAL ACTIVITY ............................................................................... 27 SUB-VISION: “A BEAUTIFUL & SAFE PALAU WHERE PHYSICAL & SOCIAL ENVIRONMENTS INVITE ACTIVE LIVING” .......... 27 GOAL: REDUCE PHYSICAL INACTIVITY AMONG CHILDREN, YOUTH, AND ADULTS ......................................... 27 SPECIFIC OBJECTIVES: ................................................................................................. 28 STRATEGIC ACTIONS: .................................................................................................. 28 AREA OF ACTION: REDUCING THE PREVALENCE OF NCDS ............................................................ 34 SUB-VISION: “NCD FREE PALAU” ...................................................................................... 34 GOAL: DECREASE THE PREVALENCE OF THE MAJOR NCDS BY 10% ..................................................... 34 SPECIFIC OBJECTIVES: ................................................................................................. 34 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page3 STRATEGIC ACTIONS: .................................................................................................. 34 IMPLEMENTATION OF THE PLAN/SUSTAINED COORDINATION ............................................. 36 COMMUNICATION AND INFORMATION DISSEMINATION ...................................................... 37 SURVEILLANCE AND EVALUATION .............................................................................. 38 CONTACT INFORMATION ......................................................................................... 40 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page4 Messages from the Leadership and Partners Message from the President of the Republic of Palau 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page5 Message from Rubekul Belau 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page6 Message from Minister of Health I am pleased to present the Republic of Palau’s Non-communicable Disease Prevention and Control Strategic Plan of Action 2015-2020. The launching of this five-year strategic plan, which builds upon previous activities in the last 10 years, could not have occurred at a more opportune time, as the general public, our leaders, and our community partners have come together to say enough is enough: We will not lose more loved ones prematurely to NCDs. The “Health of the Nation” is at a critical crossroads because of the persistent increase in non-communicable diseases such as heart disease and stroke, cancer, diabetes and chronic respiratory illnesses. NCDs are the leading causes of death and illnesses among adults in Palau, which have resulted in a heavy emotional as well as financial toll on all of us. We only have to look within our own families, where every one of us has lost somebody dear because of NCDs. The increasing medical cost to treat patients with NCDs is of serious concern to the government. Financially, NCDs account for 65% of hospital costs and almost 90% of our medical referral costs, not including the loss of productivity and opportunity. Even more alarming is the threat to future generations of Palauans, our children. Current data indicate high rates of obesity, tobacco and alcohol use in Palau’s school-aged children. If these trends continue, healthcare costs will not only be unsustainable, the human cost would be unimaginable. Our nation is one of only few countries that have universal healthcare coverage that is made affordable through a combination of government subsidies, the National Health Insurance scheme or federally funded Public Health Programs. However, the Ministry of Health and community partners recognize that the scope and impact of NCDs require a comprehensive response approach to transform our environment. We may have the best doctors, nurses, and hospitals, but unless we make the changes in our physical and socio-political environment—our laws, our churches, our workplaces, our schools, and our homes—to protect the health of our people, our efforts will prove fruitless. In addition to elevating the profile of NCDs at the national and regional levels, our policy makers and community have taken significant actions to address these lifestyle diseases through policy interventions. Examples include legislation passed in 2013 by the Olbiil Era Kelulau to raise tobacco taxes in order to reduce consumption of this deadly product, and the President’s Executive Order 372, creating a Task Force with members from the Ministries of Health and Education, mandated to implement school based strategies on healthy eating, active living, and tobacco and alcohol control. Other policies are in place, some of which are voluntary, initiated by parents, students and the schools. Community partners have also risen to address NCDs, with social marketing campaigns on healthy living targeting parents, families and the working age population. Although the challenges we face due to NCDs may seem overwhelming, I am confident that the momentum that has been initiated by these and other efforts will continue to build and spread throughout the whole of government and society as we come together to fight these diseases and ensure that our communities promote healthy lifestyles. This Plan is not only a “road map” but a “national movement” where each and every one of us has an important role to play in the prevention of disease and the promotion and protection of the health of all people living in Palau. Let us work together to implement the Palau NCD Plan, so that we can realize our vision of a truly healthy nation, where our elders continue to guide us, and our children live “long, happy and purposeful” lives. Gregorio Ngirmang, Honorable Minister of Health 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page7 Message from Community Partners It gives us great pleasure to join with government leaders in endorsing this Strategic Action Plan for Prevention and Control of Non-Communicable Diseases. In Palau, government and civil society stand united in our collective agreement that NCDs constitute one of the most serious challenges to the sustainable development of our islands and that NCDs can only be redressed through the collaborative efforts of government and community working in close partnership. This Strategic Action Plan is aligned with global and regional NCDs targets and incorporates cost-effective intervention strategies as recommended by the World Health Organization, Centers for Disease Control, Secretariat of the Pacific Community, and Pacific Islands Health Officers Association. The plan is organized around the four main risk factors that fuel our NCD epidemic – poor diet, insufficient physical activity, tobacco use, and harmful use of alcohol. It recognizes that addressing these risk factors requires healthier choices by individuals and collective actions by government and communities to make healthier choices, easy choices through health promoting policies and places – in homes, schools, workplaces, stores, churches, and community facilities. Community partners have been fully engaged with the Ministry of Health in the development of this plan from the initial decision to move forward with a new plan, to the organization of the NCD Strategic Planning Workshop, and to the many hours of follow-up required to hone the recommendations into their final form. As community partners, we are committed to doing our part in seeing that the plan is fully implemented. It is only through our collective efforts that we can expect to achieve health for all in our lifetime. Belhaim Sakuma Valerie Whipps Chairperson, Ulkerreuil A Klengar Chairperson, Coalition for a Tobacco Free Palau Aholiba Albert Debbie Toribiong Chairperson, Omellemel ma Ulekerreuil a Bedenged Chairperson, Kotel A Deurreng 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page8 Acknowledgements The Palau Non-Communicable Disease (NCD) Prevention and Control Strategic Plan of Action 2015-2020 emerged from the joint efforts of multiple stakeholders from the community, and from the public and private sectors. The Ministry of Health, with support from the World Health Organization and the US Centers for Disease Control and Prevention, coordinated the strategic planning workshop, which initiated the planning process. The various individuals and/or agencies/institutions that contributed to the creation of this plan include the following: Institution/Agency Abbreviation Office of the President ROP PRES Council of Chiefs/Rubekul Belau COC Mechesil Belau None 9thOlbiil Era Kelulau OEK Governors Association GA Ministry of Education MOE Ministry of Natural Resources, Environment & Tourism MNRET Ministry of Finance MOF Ministry of Justice MOJ Ministry of Public Infrastructure, Industries and Commerce MPIIC Ministry of Community and Cultural Affairs MCCA Ministry of State MOS Ministry of Health MOH Office of Environmental Response and Coordination OERC State Governments/Legislatures Cheldebechel (Community Groups) Ulekerreuil a Klengar/NCD Coalition UAK Coalition for a Tobacco Free Palau CTFP Community Transformation Grant/Kotel a Deurreng CTG/KAD Omellemel ma Ulekerreuil a Bedenged/Cancer Coalition OMUB Community Health Centers Governing Board CHC Board Palau Behavioral Health Advisory Council PBHAC Palau Early Childhood Comprehensive System PECCS Parents and Teachers Association PTA Faith based Organizations/Churches Church of Latter Day Saints Palau Evangelical Church Catholic Mission Seventh Day Adventist Palau Evangelical Church Family Federation/FFPWU FBOs Food Industry Western Caroline Trading Company Penthouse Hotel Palau Community Action Agency/Head Start Program PCAA Palau National Olympics Commission PNOC Belau National Museum BNM United Nations Development Program UNDP Principals’ Association None Pacific Islands Health Officers’ Association PIHOA 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page9 US Centers for Disease Control and Prevention CDC World Health Organization WHO United Nations Development Program UNDP Pacific Resource for Education and Learning PREL Shin Kong Hospital SKH Taiwan 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page10 Executive Summary Sustainable development requires healthy people. Today, the greatest threats to the health of Palau’s people, and therefore, to Palau’s sustainable development, are non-communicable diseases (NCDs). Currently, NCDs cause over 70% of deaths, and have lowered Palauan’s life expectancy. Heart disease, stroke and cancer claim the most number of lives among working age people. Without action, premature death, productivity losses and the high cost of health care due to NCDs will erode gains in health and socio-economic progress. Evidence-based cost-effective interventions to counter NCDs exist. These interventions encompass policy and environmental changes, healthy lifestyle promotion, early detection and treatment of metabolic risk factors, advocacy and community outreach, and reliable data collection/surveillance (Figure 1). Palau intends to apply these interventions to the 4 behavioral risk factors – (1) tobacco use; (2) Harmful alcohol use (3) unhealthy diets (4) physical inactivity – and to the metabolic risk factors that lead to the (5) 4 major NCDs. Comprehensive action in these 5 areas of work is necessary to halt and reduce the NCD burden. This strategic plan of action, evolving from a diverse group of stakeholders, provides the vehicle to move Palau away from the current unhealthy situation brought on by NCDs, towards a vision of “healthy communities in a healthy Palau, with people living long, happy and purposeful lives.” Multisectoral partnerships, political and cultural leadership and community mobilization are necessary to drive this plan into action for a healthier and richer Palau. 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page11 Background Palau and the other Pacific Islands have long recognized NCDs as a major threat to health. The Pacific has outpaced the world in mortality and disease burden from NCDs, and Palau is no exception. Globally, NCDs cause 63% of the deaths, but today, NCDs already cause more than 70% of deaths in Palau, and indications are that NCD-related mortality and morbidity are rising. Common risk factors underlie NCDs. Globalization and urbanization bring with it unhealthy lifestyles and environmental changes that make communities susceptible to tobacco and alcohol use, unhealthy diets, and physical inactivity. These underlying behavioural risk factors give rise to metabolic risk factors such as high blood pressure, elevated blood glucose, abnormal lipid profiles and obesity. In turn, the metabolic risk factors predispose individuals to the “fatal four” – cardiovascular diseases, cancer, diabetes and chronic respiratory diseases (Figure 1). Figure 1. The Pacific framework for NCD prevention and control PROBLEMS ACTION AREAS Environmental determinants UNHEALTHY •Physical environment •Policy and legislation •Socio-cultural practices Behavioral Risk factors •Tobacco use •Harmful alcohol use, •Poor diet •Physical inactivity Metabolic risk factors: Overweight/ob esity, high blood pressure, raised blood sugar, elevated cholesterol Disease •Heart disease and stroke •Cancer •Diabetes •Chronic lung disease Premature death, chronic disability, economic losses Environmental interventions Built environment Policy and legislation Social norms change Lifestyle interventions Population behavior change Health promotion Clinical interventions Screening and early detection Early treatment Secondary prevention REDUCED NCD- related premature death DECREASED preventable disease and economic losses ADVOCACY and COMMUNITY OUTREACH DATA and SURVEILLANCE 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page12 Altogether, these chronic diseases account for majority of the deaths in Palau. Current epidemiologic data indicate that the life expectancy of Palauans is low when compared to the rest of the world; this is predominantly due to the heavy burden brought about by NCDs (Palau Health Status Report, 2013). The health care costs related to these diseases are formidable, accounting for as much as 55% of the health care budget (Palau NCD Declaration, 2011). In addition, NCDs contribute to the burden of poverty and retard national development by impeding workforce productivity; NCDs are a major cause of premature deaths among working age Palauans (Palau Health Status Report, 2013). Ironically, the behavioural risk factors for NCDs, singly or in combination, are preventable. Very cost- effective interventions and cost effective interventions exist (Tables 1 and 2). Yet, the prevalence of these risk factors, and consequently, NCDs themselves, in Palau remains unacceptably high (Table 3).One in four adult males smokes, 3 out of 5 adults chew tobacco with betel nut, and over 40% of adult males binge drink. Moreover, youth are smoking more than adults, and young females are binge drinking more than their adult counterparts. Three out of four Palauan adults are overweight or obese, nearly half have raised blood pressure and one in three have elevated blood glucose. Awareness of metabolic risk factors is low, and hypertension and diabetes appear to be under-diagnosed---the prevalence of measured high blood pressure was nearly double the rate of adults reporting a diagnosis of hypertension, while the prevalence of measured raised blood glucose was almost 3 times the rate of self-reported diabetes diagnosis (Palau STEPS data, preliminary results, 2011-13). Palau joined the other Pacific Island World Health Organization (WHO) Member States in articulating the “Healthy Islands” vision at the first meeting of the Pacific Ministers of Health in Yanuca, Fiji in 1995. Over the years, this vision evolved towards a focus on health protection and health promotion, and creating healthy environments and lifestyles, in response to the NCD epidemic. The WHO international Framework Convention on Tobacco Control (FCTC) came into force in 2005, with Palau as one of the first 40 signatories to the treaty. Palau and other United States affiliated Pacific Islands (USAPIs) highlighted the urgency for action against NCDs at the 2010 Pacific Island Health Officers’ (PIHOA) Association annual meeting, which declared NCDs as an emergency in the USAPIs. This declaration of the state of emergency was extended to the rest of the Pacific in 2011 at the Honiara, Solomon Islands WHO Pacific Ministers of Health meeting, and elevated to the highest political level at the Pacific Forum Leaders’ 2011 meeting. In September 2011, the United Nations (UN) convened a global summit on NCD prevention and control; Member States, including Palau, unanimously endorsed the UN High Level Political Commitment on NCDs. At the national level, Palau issued Executive Order No. 295 in May 2011, declaring a state of emergency on NCDs in Palau and calling for immediate action to reduce and eliminate the incidence of NCDs. From 2011 to 2013, Palau worked with several technical assistance providers, including the US Centers for Disease Control and Prevention (CDC), WHO, the Secretariat for the Pacific Community (SPC), and others, to initiate a planning process towards a national NCD strategic action plan. Meanwhile, following the 2011 UN High-level Political Commitment to NCD prevention and control, WHO Member States including Palau adopted 9 global voluntary NCD targets and 9 Pacific NCD targets (Table 4), and endorsed the WHO Global Action Plan and the Regional NCD Roadmap. September 2013, in his statement to the 68th Regular Session of the United Nations General Assembly, the President of the Republic of Palau declared NCDs and tobacco control as issues to be considered in the sustainable development goals. The Republic of Palau NCD Prevention and Control Strategic Plan of Action 2015-2020 represents the current multi-sectoral effort within Palau to articulate definitive actions within the country to halt and reverse the health and economic burden from NCDs. The Ministry of Health (MOH), diverse stakeholders from government agencies, traditional organizations, the private sector and community groups came together at a 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page13 strategic planning workshop from March 24-26, 2014 to initiate the multisectoral consultative process and define relevant strategic objectives and actions against NCDs. This document represents the input and insights from the planning workshop; its initial draft served as a springboard for further community consultations, culminating in a final strategic plan of action by the end of 2014. During the planning process, the voluntary global and Pacific targets and recommended very cost-effective and cost-effective NCD interventions were carefully considered in light of Palau’s current health and socio-political context, and the action plan was intentionally aligned, to the extent possible, with the global and Pacific targets (Table 4). Table 1. Very-cost effective interventions for NCD prevention and control Risk factor or disease Interventions Tobacco use Tax increases Smoke-free indoor workplaces and public places Health information and warnings Bans on tobacco advertising, promotion and sponsorship Harmful alcohol use Tax increases Restricted access to retailed alcohol Bans on alcohol advertising Unhealthy diet and physical inactivity Reduced salt intake in food Replacement of trans fat with polyunsaturated fat Public awareness through mass media on diet and physical activity Cardiovascular disease (CVD) and diabetes Counselling and multi-drug therapy for people with a high risk of developing heart attacks and strokes (including those with established CVD) (PEN) Treatment of heart attacks with aspirin Cancer Hepatitis B Immunization to prevent liver cancer Screening and treatment of pre-cancerous lesions to prevent cervical cancer Source: WHO Table 2. Cost-effective interventions for NCD prevention and control Cost-effective interventions Nicotine replacement therapy/tobacco cessation Promoting adequate breastfeeding and complementary feeding Enforcing drink-driving laws Restrictions on marketing of foods and beverages high in salt, fats and sugar, especially to children Food taxes and subsidies to promote healthy diets Source: WHO 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page14 Table 3. NCD Risk factor profile for Palau Indicator Overall prevalence Males Females Source NCD mortality 73% of all deaths in 2004 (WHO Estimates) WHO database Smoking, current, adults 17% 24% 8% STEPS Ex-daily smokers, adults 12% 15% 9% STEPS Smoking, current, youth 41% 58% 42% PYTS Betel nut + tobacco, adults 63% 60% 66% STEPS Smokeless tobacco use, youth 29% 31% 27% PYTs Exposed to SHS at home, adults 34% 34% 32% STEPS Exposed to SHS smoke at home, youth 44% 42% 44% PYTS Current alcohol consumption, adults 37% 50% 23% STEPS Current alcohol consumption, youth 43% 51% 38% YRBS Binge drinking, adults --- 44% 17% STEPS Binge drinking, youth 33% 40% 26% YRBS < 5 servings fruits and vegetables, adults 92% 94% 90% STEPS Salt/sodium intake NA NA NA --- Low levels of physical activity, adults 35% 28% 42% STEPS Hypertension, adults, diagnosed 25% 22% 28% STEPS Raised blood pressure (measured) 49% 53% 44% STEPS Diabetes, adults, diagnosed 13% 11% 16% STEPS Raised blood glucose (measured) 37% 39% 34% STEPS Overweight/obesity, adults 78% 78% 76% STEPS High cholesterol, adults 68% 65% 70% STEPS 3 or more NCD risk factors, adults 58% 61% 55% STEPS Coverage of multidrug therapy and counseling for CVD risk NA NA NA --- 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page15 Essential NCD medicines and basic technologies NA NA NA --- Note: Adults = 25-64 years old Youth = 13-15 years old Data Sources: Adult data: Palau 2011-13 STEPS data Note: The Palau 2011-13 STEPS data are preliminary data. The data are in the finalverification process; once that is complete a final report will be released. Youth data: Palau Youth Tobacco Survey (PYTS) 2009, Palau Youth Risk Behavior Survey (YRBS) 2011 Mortality data: WHO Global database; Palau Health Status Report 2013; National Cancer Strategic Plan for Palau2007-2012 Table 4. Palau NCD Strategic Plan targets and goals in comparison to Pacific Regional NCD targets and WHO Global Voluntary targets: WHO global voluntary targets Republic of Palau Goals/Targets Pacific regional NCD targets 2013-2020 2013-2018 2014-2020 Risk Factor/Lifestyle Reduce tobacco use 30% 30% Under 5% prevalence Reduce harmful alcohol use 10% 10% 10% Adolescent/adult obesity 0% increase from baseline Reduce childhood obesity by 10%; reduce adult obesity by 5% 0% increase from baseline Reduce physical inactivity 10% 30% for youth; 20% for adults 10% Reduce salt/sodium intake 30% 30% 30% Increase fruit and vegetable intake --- 50% --- Increase breastfeeding up to 6 months --- 50% --- Clinical Decrease premature mortality 25% --- 25% Decrease hypertension 25% 10% 25% Decrease diabetes prevalence 0% increase 10%% reduction 0% increase Coverage of multidrug therapy and counseling for CVD risk 50% --- 50% Essential NCD medicines and technologies 80% of countries --- 80% of countries 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page16 Frameworks The Republic of Palau’s strategic action plan for NCD prevention and control acknowledges and builds upon the Pacific NCD framework (WHO, 2008) that highlights effective types of action to prevent and control NCD throughout the course of NCD development and CDC’s Chronic Disease Prevention and Health Promotion Domains (Epidemiology and Surveillance, Environmental Approaches, Health Systems Strengthening, and Community-Clinical Linkages). These frameworks recognize that NCDs arise along a continuum. Policy, physical and socio-cultural environments that promote unhealthy lifestyles give rise to behavioral and metabolic risk factors, which, if left unchecked, result in established disease and, ultimately, cause premature death, chronic disability and economic losses (Figure 1). Comprehensive action is needed across the continuum; for each level of action, very cost-effective and cost-effective interventions for NCD prevention and control exist. The actions at each stage of the continuum consist of the following: 1. At the environmental level, through multisectoral policy and regulatory interventions, restructuring the built environment and social norms change; 2. At the level of behavioral risk factors through promotion of healthy lifestyle interventions (population-level behavior change); and 3. At the level of metabolic risk factors and established disease through clinical interventions targeting the entire population (screening), high-risk individuals (risk factor modification) and persons with established disease (clinical management), requiring strengthening of the health system for effective service delivery. A core set of evidence-based clinical interventions for reducing morbidity and mortality from NCD that are feasible for implementation through primary care in low resource settings have been identified and are collective known as the WHO package of essential NCD interventions (PEN) (WHO, 2010). Advocacy and community outreach will be required across the continuum to engage community stakeholders; mobilize partnerships and generate champions and leaders. Data will be needed to guide the selection of specific interventions and to monitor progress; hence, data and surveillance will also be critical throughout the entire continuum. Palau’s NCD stakeholders have elected to concentrate action across 5 areas that encompass behavioral and metabolic risk factors. This was based on the NCD profile of the population, with data indicating high prevalence rates of tobacco and harmful alcohol use, physical inactivity, poor nutrition, overweight/obesity, high blood pressure and high blood glucose. Thus, the action plan is organized along a 5-pronged approach that identifies goals, specific objectives and strategic actions in the following areas of action: 1. Reducing tobacco consumption, both smoking and chewing tobacco with betel nut; 2. Reducing harmful alcohol use; 3. Reducing physical inactivity; 4. Improving nutritional intake; and, 5. Reducing prevalence of metabolic risk factors that precede the major NCDs. This document serves to reflect Republic of Palau’s strategic action plans for NCD prevention and control in the next five years. It is a living document, to be continually edited and updated based on identified annual activities and performance measures. 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page17 Strategic Plans of Action Overall Vision, Sub-visions, and Goal Over-all Goal: Reduce the preventable burden of NCDs in Palau Vision: Healthy communities in a healthy Palau, with people living long, happy and purposeful lives 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page18 Area of Action: Tobacco Control Sub-vision: “Rich, Healthy, and Tobacco-free islands” Goal: Reduce tobacco consumption by 30% by 2020 Baseline Target Overall smoking prevalence, adults1 Smoking prevalence, adult males1 Smoking prevalence, adult females1 Overall chewing prevalence2 17% 24% 8% 40% 12% 17% 6% 28% Overall smoking prevalence, youth3 Smoking prevalence, youth males3 Smoking prevalence, youth females3 41% 58% 42% 29% 41% 29% 1STEPS, 2014 2BRFSS, 2010 3PYTS, 2009 Specific Objectives: 1. By March 31, 2015, a national high level multi-sectoral coordinating body or mechanism to address (among other issues), demand and supply reduction strategies for tobacco products as required by FCTC Article 5.2(a), is convening regularly. 2. By 2020, have procedures in place to protect all public health policies from interests of the tobacco industry. 3. By January 1, 2016, as required by WHO FCTC Article 14, the infrastructure and capacity for tobacco dependence treatment and cessation services is established per Article 14 guidelines. 4. By April, 2016, at least 15% of tobacco tax revenue is dedicated to MOJ, MOF, MOH, and MOE to implement their tobacco control (FCTC) obligations 5. By July, 2016 action plans for the implementation of education, communication and training activities regarding tobacco control are established based on WHO FCTC Article 12 guidelines. 6. By January 1, 2016, a system is in place to monitor, evaluate and report on enforcement of Palau’s tobacco control ACT (RPPL 8-27, RPPL 9-6) and tobacco tax legislation (RPPL 9-15). 7. By 2020, 100% compliance with provisions of the Framework Convention on Tobacco Control (FCTC) that address demand reduction is achieved. 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page19 Strategic Actions: Specific Objective 1: By 2020, have procedures in place to protect all public health policies from interests of the tobacco industry. (FCTC Article 5.3) Baseline 2020 Targets No procedures in place Procedures in place Strategic Actions Who can lead Convene stakeholder group to become familiar with FCTC Article 5.3 and reasons why we treat tobacco industry differently from other industries MSCB (CTFP, MOH) Carry out a formal assessment of the country’s compliance with Article 5.3 of the FCTC MSCB (CTFP, MOH) Raise awareness about tobacco industry interference with countries’ tobacco control policies (local, regional, international) MSCB (CTFP, MOH) Establish guidelines for meetings and other interactions with the tobacco industry deemed necessary, including a requirement that they be made public MSCB (MOH, MOF-BPSS) Develop and seek endorsement of a formal national policy and enforcement mechanism for public agencies’ engagement with the tobacco industry, conduct of officials in dealings with industry, and management of conflicts of interest MSCB (CTFP, MOH) Establish a formal mechanism for monitoring and responding to the tobacco industry’s activities MSCB (CTFP, MOH) MSCB – Multi-sectoral coordinating body Specific Objective 2: By January 1, 2016, as required by WHO FCTC Article 14, the infrastructure and capacity for tobacco dependence treatment and cessation services is established per Article 14 guidelines. Data Baseline 2020 Targets (# of people who received cessation services in past X years and # stayed quit after 1 year) what data is currently collected – what are current indicators used? ? Strategic Actions Who can lead Conduct national situational analysis MOH Develop and disseminate national treatment guidelines MOH Develop training capacity MOH Create environment that prompts quit attempts MOH Monitor and evaluate cessation and dependence treatment strategies/programs MOH Specific Objective 3: By April, 2016, at least 15% of tobacco tax revenue is dedicated to MOJ, MOF, MOH, and MOE to implement their tobacco control (FCTC) obligations. 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page20 (FCTC Article 6) Data Baseline 2020 Targets No set asides exist At least 15% of tax revenue dedicated to meet national health objectives (via MOH, MOE, MOJ, MOF) Strategic Actions Who can lead Research legality of set-asides in ROP MOH Conduct cost analysis for each Ministry to implement their responsibilities of the WHO FCTC MOH Civil society engage in active advocacy with support from MOH Coalitions, Community Leaders and Partners Draft and submit proposed legislation Attorney/CTFP/MOH Specific Objective 4: By July, 2016 action plans for the implementation of education, communication and training activities regarding tobacco control are established based on WHO FCTC Article 12 guidelines. Data Baseline 2020 Targets Activities take place but not systematically documented or evaluated as a whole of government approach. Strategic Actions Who can lead Convene work group to review FCTC Article 12 guidelines regarding education, communication and training activities MOH Convene planning workshops to develop action plans MOH Specific Objective 5: By January 1, 2016, a system is in place to monitor, evaluate and report on enforcement of Palau’s tobacco control ACT (RPPL 8-27, RPPL 9-6) and tobacco tax legislation (RPPL 9-15). Data Baseline 2020 Targets Strategic Actions Who can lead Gather all needed materials (e.g. recommendations from workshop of May 2013, baseline data, regulations, etc.). MOH Hold tobacco enforcement planning meeting to present recommendations of the 2013 workshop and solicit input on Palau’s enforcement system. MOH Develop and implement monitoring, evaluation and reporting framework based on agreed upon enforcement structure/regulatory body. MOH & regulatory body Specific Objective 6: By 2020, 100% compliance with provisions of the Framework Convention on Tobacco Control (FCTC) that address demand reduction is achieved (Articles 8,9,10,11,13). Baseline 2020 Targets 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page21 (see attachment for detail on baseline) Demand reduction No compliance: tobacco products packaging & labeling (Art. 11) regulation of content of tobacco products (Art. 9) regulation of tobacco product disclosures (Art. 10) Partial compliance: smoke-free places (Art. 8) Tobacco advertising, promotion and sponsorship (Art. 13) tax and price measures (Art. 6a) see objective 2 education, communication, training and public awareness (Art. 12) see objective 4 cessation (Art. 14) – see objective 3 None: 3/8 Partial: 5/8 Full compliance Strategic Actions Who can lead Identify legal assistance to draft proposed legislation MOH Research issues specific to Articles 8,9,10,11,13 MOH/CTFP Draft proposed legislation or amendments of existing legislation attorney Submit proposed legislation/amendments to OEK CTFP/MOH 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page22 Area of Action: Reducing harmful use of alcohol Sub-vision: “Belau in control of alcohol” Goal: Reduce harmful alcohol use by 10% Specific Objectives: 1. By 2020, formalize a community coalition for alcohol use and abuse prevention and control. 2. By 2020, reduce underage drinking by 10%. 3. By 2020, reduce binge drinking in adults (males and females) by 10%. Strategic Actions: Specific Objective 1: Formalize a community coalition for alcohol use and abuse prevention and control. Data Baseline 2020 Targets Alcohol Working Group Formal Alcohol Control Coalition exists and convenes on a regular basis Strategic Actions Who can lead Convene a meeting of the UAK alcohol working group for initial planning (identify members, determine operating procedures, and develop action plan for establishing coalition) UAK Alcohol Working Group Engage other partners/potential members UAK Alcohol Working Group Determine operating procedures/Develop action plan for establishing coalition UAK Alcohol Working Group Formalize Alcohol Control Group UAK Alcohol Working Group Specific Objective 2: By 2020, reduce underage drinking by 10%. Data (YRBS, 2011) Baseline 2020 Targets Overall current alcohol consumption, youth Current alcohol consumption, boys Current alcohol consumption, girls Binge drinking, youth Binge drinking, boys Binge drinking, girls 43% 51% 38% 33% 40% 26% 39% 46% 34% 30% 36% 23% Strategic Actions Who can lead 1. Establish/enhance a regulatory and enforcement mechanism for alcohol and tobacco control. Multi-sectoral coordinating body (MOJ, Office of the President, MCCA, MOF, Traditional Leaders) 2. Raise alcohol taxes and earmark a portion of the tax revenues for health Multi-sectoral 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page23 promotion and alcohol control (Law enforcement & monitoring) activities. coordinating body (MOH, Alcohol Working Group/ Coalition, MOF, Office of the President, Traditional Leadership ) 3. Advocate for and ensure that health (focusing on NCDs) becomes a core subject in schools. MOH-MOE Taskforce (Ex. Order 372) 4. Legislate total bans on alcohol advertising, including at point of sale. MSCB (MOH, Alcohol Working Group/Coalition, Traditional Leadership, ABC/Regulatory Board) 5. Enhance/strengthen enforcement of laws prohibiting sales to minors (i.e., retailer compliance checks/sting operations) MSCB (MOJ, ABC/Regulatory Board, Traditional leadership, State Governments, MOH) Specific Objective 3: By 2020, reduce binge drinking in adults by 10%. Data (STEPS, 2011-2013, preliminary data) Baseline 2020 Targets Current alcohol consumption, adult males Binge drinking, adult males Current alcohol consumption, adult females Binge drinking, adult women 50% 44% 23% 17% 45% 40% 21% 15% Strategic Actions Who can lead 1. Minimize alcohol use at cultural & social functions (customary events). Council of Chiefs, Mechesil Belau, Cheldebechel 2. Raise awareness about the harms of binge drinking. Develop and implement a social marketing campaign to counter binge drinking Build capacity within existing social structures (i.e. men’s and women’s organizations, sports federations) to counter binge drinking and other harmful uses of alcohol MOH, Alcohol Working Group/Coalition, Kotel a Deurreng 3. Strengthen enforcement of alcohol laws ( i.e. DUI Laws, hours of sale) MSCB (MOJ, ABC/Regulatory Board, Traditional Leadership, State Governments, MOH 4. Legislate total bans on alcohol advertising, including at point of sale. MSCB (MOH, Alcohol Working Group/Coalition, Traditional Leadership) 5. Identify and implement other best practices to address alcohol use and abuse prevention and control (i.e., limit hours/days of sale, SBI - screening & brief intervention) MOH, Alcohol Working Group/Coalition 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page24 Area of Action: Improving nutrition Sub-vision: “A Kelel Belau a Didichel a Klukuk (Breast-fed and well fed with local food)” Goal: Improve overall nutrition Specific Objectives: 1. By 2015, establish a multi-sectoral working group to address overall nutrition improvement activities in Palau. 2. By 2020, reduce salt intake by 30%. 3. By 2020, increase fruits & vegetables intake by 50%. 4. By 2020, increase breastfeeding by mothers of infants up to 6 months of age by 50%. Strategic Actions: Specific Objective 1: By 2015, a national multi-sectoral working group to address overall nutrition improvement activities in Palau, is convening regularly. Data Baseline 2020 Targets Nutrition Working Group – initiated as part of UAK (NCD coalition) called Tabesul Blengur but not as active as other coalitions Formal Working Group convening regularly Strategic Actions Who can lead Convene a meeting of the UAK nutrition working group/Tabesul Blengur for initial planning Nutrition Working Group, MOH Engage other partners/potential members Nutrition Working Group, MOH Determine operating procedures/Develop action plan for establishing coalition Nutrition Working Group, MOH Formalize Nutrition Working Group Nutrition Working Group, MOH Note: This nutrition working group might be formed after National Multi-sectoral Coordinating Body is formalized and convened in 2015. Specific Objective 2: By 2020, reduce salt intake in Palau by 30%. Data (STEPS, 2014) Baseline 2020 Targets Salt intake No data 30% reduction from baseline Strategic Actions Who can lead 1. Establish credible baseline data on current sodium intake in Palau. Ensure salt intake indicators are included in surveillance instruments for risk factor surveys. Surveys of the salt content in foods; population based surveys for intake; stakeholder views, current practices MOH, MOF 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page25 2. Educate the public to reinforce awareness on the dangers of high sodium consumption, and healthy alternatives to reduce consumption. Establish and disseminate Palau Food Guidelines; use “nutrition facts” format; education outreach; social marketing on local foods, health curriculum. MOH, UAK, Kotel a Deurreng, Traditional Leadership, Community Partners 3. Pursue a nationwide school policy that mandates the provision of healthy meals in all public and private schools Advocacy and education; ensure “passable bill”; training and capacity building MOH-MOE Task Force (Ex. Order 372) 4. Legislate taxes on imported food products high in sodium, fat and sugar. Strong advocacy and education; ensure “passable bill” Offer alternatives – more healthy options in stores, restaurants; subsidies on health food UAK, MOH, MOF, Traditional Leadership, Office of the President 5. Increase the number of food vendors (stores, restaurants) that sell healthier meals/food items. MOH, UAK, Kotel a Deureng 6. Support legislation for English language nutrition labels on imported foods and English or Palauan language ingredients list for locally produced food products. UAK, MOH, Traditional Leadership, Office of the President Specific Objective 3: By 2020, increase fruits & vegetables intake by 50%. Data (STEPS, 2014) Baseline 2020 Targets % of population consuming 5 or more servings of fruits and vegetables per day 8% 12% Strategic Actions Who can lead 1. Designate public land for local agricultural projects. MNRET (BOA), State Governments, Traditional Leadership, Office of the President 2. Secure earmarked funds to support local agricultural projects and subsidize local production of fruits and vegetables. MNRET (BOA), State Governments 3. Pursue a nationwide school policy that mandates the provision of healthy meals in all public and private schools, with fruit and vegetable options at every meal. MOH-MOE Task Force (Ex. Order 372) 4. Raise public awareness on the importance of fruit and vegetable consumption, and strategies to increase fruit and vegetable consumption in families. Establish and disseminate Palau Food Guidelines. Use the “Nutrition Facts” format for community outreach and education Targeted social marketing techniques Advocate (through state level media campaigns) for local gardens MOH, UAK, Kotel a Deureng, Mechesil Belau 5. Support the expansion of school gardening initiatives (i.e., social marketing techniques using children as champions; encourage use of produce exclusively for school meals MOH-MOE Task Force, PCAA, UAK, Kotel a Deureng 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page26 Specific Objective 4: By 2020, increase breastfeeding by mothers of infants up to 6 months of age by 50%. Data Baseline 2020 Targets % of mothers who breastfeed their infants up to 6 months of age No data(get from MOH) 50% increase from baseline (determine new target based on baseline and trend) Strategic Actions Who can lead 1. Surveillance Data Establish credible baseline data on breastfeeding in Palau. Ensure breastfeeding indicators are included in surveillance instruments for risk factor surveys. MOH, Breastfeeding Working Group (MOH and UAK) 2. Raise public awareness, particularly among new mothers, on the benefits of breastfeeding. MOH and Breastfeeding Working Group (MOH and UAK), Community Breastfeeding Support Group, Mechesil Belau 3. Establish an incentive scheme to reward mothers who breastfeed for at least 6 months. MOH and Breastfeeding Working Group (MOH and UAK), Community Breastfeeding Support Group 4. Pursue a national policy to extend maternal leave to 6 months and other policies that support breastfeeding mothers. MOH and Breastfeeding Working Group (MOH and UAK), Community Breastfeeding Support Group, Mechesil Belau 5. Establish policies in birthing centers to promote and ensure breastfeeding. MOH and Breastfeeding Working Group (MOH and UAK), Community Breastfeeding Support Group 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page27 Area of Action: Physical activity Sub-vision: “A beautiful & safe Palau where physical & social environments invite active living” Goal: Reduce physical inactivity among children, youth, and adults Data Baseline 2020 Target Sources for physical activity data are: Children’s Healthy Living Survey (Head Start students); Youth Risk Behavior Survey (high school students), school health assessments (grades 1-12), Behavioral Risk Factor Surveillance System (adults 25-64 years of age), and STEPS (adults 25-64 years of age). Except for the Children’s Healthy Living Survey which is based on pedometer data, data sets use self-reports which may over-estimate actual levels of activity achieved. High school students who meet the physical activity standard for youth (physically active at least 60 minutes/day on 5 or more days a week) 36.6% (YRBS, 2011) 25% increase to 46% or higher High school students who participate in physical education classes weekly 41.6% (YRBS, 2011) Increase to 100% High school students who watch more than 3 hours of TV on an average school day 24.2% (YRBS, 2011) 25% reduction to no more than 18% Data from Children’s Healthy Living Survey (Head Start students) to be integrated when available to support targets for children 3-5 years of age Not yet available To be determined Adults (18 years of age and over) who are physically active at least 30 minutes a day on all or most days of the week 72% (men), 58% (women), 65% (all persons) were classified as moderately or vigorously active (STEPS 2011-13) Increase 25% over baseline meaning 90% (men), 72% (women), 81% (all persons) will be classified as moderately or vigorously active (STEPS 2016) 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page28 Specific Objectives: 1. By 2015, establish a formal physical activity working group to address physical inactivity among children, youth, and adults in Palau. 2. By 2020, the reliability of data and data collection, analysis and dissemination relative to physical activity in Palau has improved through the effective implementation of a strong and collaborative monitoring and evaluation system. 3. By 2020, social norms around physical activity and sedentarianism will be changed thereby resulting in a community-wide increase in activity levels and reduction in inactivity. 4. By 2020, all schools will have facilities, human resources, curricula, and policies to ensure that students achieve the recommended 60 minutes per day of moderate or vigorous physical activity on 5 or more days of the week 5. By 2020, at least 50% of government offices and private sector enterprises will establish policies, programs, and infrastructure to support regular physical activity by staff and management. 6. Enhance the physical activity “enabling environment” of communities through establishment of policies, programs, and effective communications, as well as the development of infrastructure to Strategic Actions: Specific Objective 1: By 2015, a formal physical activity working group to address physical inactivity among youth and adults in Palau, is convening regularly. Data Baseline 2020 Targets Physical Activity Working Group out of the UAK, not formalized Formalized PA Working Group regularly convening Strategic Actions Who can lead Convene a meeting of the UAK nutrition working group/Tabesul Blengur for initial planning Physical Activity Working Group, Kotel a Deureng, UAK Engage other partners/potential members Physical Activity Working Group, Kotel a Deureng, UAK Determine operating procedures/Develop action plan for establishing coalition Physical Activity Working Group, Kotel a Deurreng, UAK Formalize Nutrition Working Group Physical Activity Working Group, Kotel A Deureng, UAK Note: This working group might be formed through the National Mulit-sectoral Coordinating Body (To be formalized). 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page29 Specific Objective 2: By 2020, the reliability of data and data collection, analysis and dissemination relative to physical activity in Palau has improved through the effective implementation of a strong and collaborative monitoring and evaluation system. Data Baseline 2020 Targets Strategic Actions Who will lead By the end of 2015, develop tools that will compile reliable objective data to assess population-wide physical activity levels that do not rely exclusively on self-reports and that can be disaggregated for specific populations (e.g. gender, age groups, rural-urban) Physical Activity Working Group (Lead) in cooperation with, NCD Unit, UAK, MOH Epidemiologist Using small population groups, by mid 2015, to have tested multiple approaches to collecting physical activity data (e.g. questionnaires, activity diaries, objective measures, and sentinel data) in order to determine the best combination of approaches for monitoring physical activity levels in Palau. Physical Activity Working Group (lead) with NCD Unit, UAK, MOH Epidemiologist & other partners Integrate improved data collection tools into the 2016 STEPS survey. NCD Unit (lead) with Physical Activity Working Group, MOH Epidemiologist, and other partners By the end of 2015 to have conducted community assets audits across the various states and hamlets. Physical Activity Working Group (Lead) with State Governments, PNOC, MCCA By the end of 2015 to have conducted a community perceptions study to identify perceived determinants (environmental and social) of physical activity. Physical Activity Working Group (Lead) with NCD Unit, UAK, MOH Epidemiologist, PNOC, and other partners Specific Objective 3: To change social norms and behaviors community-wide around physical activity and sedentariness resulting in a community-wide increase in activity levels and reduction in inactivity. Data Baseline 2020 Targets Strategic Actions Who will lead Building on the existing Kotel A Deurreng campaign, further develop and implement a sustained nationwide social marketing campaign to promote regular, moderate physical activity. Kotel A Deurreng with partners (MOH, UAK, CTFP, OMUB, PNOC) Activities During 2015 conduct formative research to support an expanded social marketing initiative by determining for different age, gender, and ethnic groups: o Knowledge (what people know about the benefits of active living and the risks of inactivity and sedentarianism) Kotel A Deurreng with partners (MOH, UAK, CTFP, OMUB, PNOC) 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page30 o Attitudes (what attitudes people hold regarding physical activity that encourage or discourage active living) o Readiness to adopt more active lifestyles o Barriers and constraints (what challenges people face in becoming more active). By the end of 2015 to define a group of “ready” participants for a regular moderate physical activity campaign and including a control group, which would address the contribution of secular trends Kotel A Deurreng with partners (MOH, UAK, CTFP, OMUB, PNOC) By the end of 2015 to have monitored, evaluated and refined a social marketing campaign promoting moderate physical activity and identified funding sources to support a sustained campaign. Kotel A Deurreng with partners (MOH, UAK, CTFP, OMUB, PNOC) During the period 2016-2020 to implement and monitor the progress of the campaign. (Refer to Objective 1 relating to monitoring and evaluation of physical activity targets). Kotel A Deurreng with partners (MOH, UAK, CTFP, OMUB, PNOC) Specific Objective 4: By 2020, all schools will have facilities, human resources, curricula, and policies to ensure that students achieve the recommended 60 minutes per day of moderate or vigorous physical activity on 5 or more days of the week Data Baseline 2020 Targets Policy on physical education o High School o Elementary PE to become a graded core subject at all levels of education One semester One session per week (Koror); Two sessions per week (rural) Core but not graded Four semesters Five sessions per week (all) Core and graded Strategic Actions Who can lead Adopt school policies nationwide that increase the opportunities for physical activity for students. MOE 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page31 MOE policy to increase physical activity sessions in the elementary schools from one (current) to five (target) MOE MOE policy to increase physical activity requirement at high school level from the current 1 semester (freshman year) to four semesters (all years) MOE Schools to introduce innovative ways to increase activity levels and reduce sedentarianism (such as energizer breaks between classes, increasing activity at lunch and recess, etc) MOE Physical education to become a graded subject; this will help to ensure that it is taken more seriously by all stakeholders – students, parents, and educators. MOE Strengthen human resources in the schools for support of school-based physical activity MOE (Lead) with PCC and PNOC Education policy to require all schools to have on staff at least one certified Physical Education instructor MOE Enhance the capacity of classroom teachers to integrate physical activity into their teaching activities MOE (Lead) with PCC and PNOC Develop a local data base that demonstrates the link between physical activity and student academic performance MOE (Lead), MOH (NCD unit), Physical Activity Working Group Harness the potential of social modeling by developing programs to create “youth” champions of active living PNYC (Lead), Kotel A Deurreng Specific Objective 5: By 2020, at least 50% of government offices and private sector enterprises will establish policies, programs, and infrastructure to support regular physical activity by staff and management. Data Baseline 2020 Targets Number of government offices/enterprises with sustained comprehensive workplace physical activity policies and programs Number of private sector enterprises with sustained comprehensive workplace physical activity policies and programs (Note: many workplaces have implemented physical activity promotions often in conjunction with “Biggest Loser” contests. Few of these programs, however, are comprehensive (combining both physical activity and other related lifestyle changes) or sustained over the long-term) 1 (MOH) Data unavailable 6 12 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page32 Strategic Actions Who can lead 4.1. The Physical Activity Working Group will approach the Chamber of Commerce and through the Chamber, the Tri-Org to request that the Chamber take a lead on this objective. Physical Activity Working Group to ask Chamber of Commerce to lead 4.2. The Working Group will assist the Chamber and develop a system of incentives to encourage business action. Chamber of Commerce (lead) supported by the Working Group 4.3. The Working Group will work through the Public Service System to develop supportive policies for public sector offices/enterprises. Physical Activity Working Group with Public Service System (Lead) Specific Objective 6. Enhance the physical activity “enabling environment” of communities through establishment of policies, programs, and effective communications, as well as the development of infrastructure to support active living. DATA Baseline 2020 Targets Percent of school age children participating regularly in sports 60.4% (high school YRBS, 2011) Increase to 75% Number of states/hamlets that offer sustained community programs encouraging physical activity for all residents No baseline available 100% of states Number of residents within walking distance of a green space, park, or recreational facility appropriate for physical activity No baseline available Roadways (residential miles) that support multiple uses by walkers, bikers, and motorists and by all age-ability groups No baseline available Number of state master plans that make specific provisions for physical activity and complete streets No baseline available Strategic Actions Who can lead Enhance and support sports programs and other after-school programs that provide youth with resources, facilities, opportunities and encouragement to be physically active. PNOC, PNYC, MOE, MOH and sports federations Create, support and sustain community-based programs that support active living for all residents PNOC, PNYC, Sports Federations, State governments Enhance recreational areas and the built environment in communities to encourage and support activity living By 2017, every community will have designated green spaces appropriate for physical activity State Governments By 2017, Palau will have developed sub-division legislation that requires complete streets and designation of green space appropriate for physical activity OEK 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page33 By 2017, all state master plans will make provisions for complete streets State Governments; State Planning Commissions By 2017, all state master plans will designate areas for parks and green spaces appropriate for physical activity State Governments; State Planning Commissions By 2017, all state budgets will earmark funds for operations and maintenance of sidewalks, parks, green spaces, and other areas designated for physical activity. State Governments Further develop the “share the road” initiative in order to enhance “walkability” of Palau’s streets and roads. By 2015, voluntary guidelines will be developed to inform pedestrians, cyclists, and motorists of desired behaviors for “sharing” the road Palau Women and Sports Commission (Lead) with Public Safety, Physical Activity Working Group, UAK, and CTFP By 2017, the Palau Government will adopt National Road Design Standards that prioritize the needs of multiple uses (walking, cycling, and driving) and all users (young, old, able-bodied, and disabled) Palau Women and Sports Commission with Public Safety, Capital Improvement Office, Physical Activity Working Group, Sustainable Development and Climate Change Working Groups, UAK, and CTFP By 2017, the Palau Government will enact pedestrian and cycling legislation Palau Women and Sports Commission (Lead), Physical Activity Working Group, Public Safety, Sustainable Development and Climate Change Working Groups, Belau Tourism Association, UAK, CTFP. By 2016, the OEK will increase the allocation to the MCCA Parks and Recreation and/or PNOC to maintain, improve, and further develop spaces for physical activity. OEK (Lead) with MCCA, PNOC, MOH,UAK, and State Governments Promote collaboration between environment, tourism and health sectors to develop facilities and improve the ‘built environment’ to encourage more physical activity by visitors and locals alike (e.g., develop hiking/biking trails, etc.). Physical Activity Working Group; Belau Tourism Association; Palau Conservation Society; State Governments; Protected Area Networks 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page34 Area of Action: Reducing the prevalence of NCDs Sub-vision: “NCD free Palau” Goal: Decrease the prevalence of the major NCDs by 10% Specific Objectives: 1. By 2015, establish/strengthen an MOH multi-disciplinary team to address the prevalence of NCDs in Palau. 2. By 2020, reduce prevalence of raised blood pressure among adults by 10%. 3. By 2020, decrease prevalence of raised blood glucose among adults by 10%. 4. By 2020, decrease prevalence of overweight/obesity among school-aged children by 10%. Strategic Actions: Specific Objective 1: By 2015, an MOH multi-disciplinary team to address the prevalence of NCDs in Palau is convening regularly. Data Baseline 2020 Targets NCD Collaborative Team (formerly known as Diabetes Collaborative) revitalized 2014 NCD Collaborative Team with clear roles and function convening regularly Strategic Actions Who can lead Gain consensus from MOH stakeholders on vision for a multi-disciplinary team NCD Unit, MOH Secure support and agreement from management and members of MDT NCD Unit, MOH Develop TOR and convene group regularly NCD Unit, MOH Annual work plans developed and implemented NCD Collaborative Team, MOH Specific Objective 2: By 2020, reduce prevalence of raised blood pressure among adults by 10%. Data (STEPS, 2014) Baseline 2020 Targets Raised blood pressure, adults (25 – 64 years) 49% 44% Strategic Actions Who can lead 1. Promote healthy eating through community outreach and information dissemination (benefits of less sodium, less fat; advocate for consumption of health foods). MOH, Nutrition Working Group 2. Promote widespread screening and monitoring of blood pressure among adults. MOH and partner coalitions 3. Ensure counselling and multi-drug therapy for people with a high risk of developing heart attacks and strokes, by incorporating the package of essential NCD interventions (PEN) into primary care. (*Suggested addition) MOH, health providers and partner coalitions 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page35 Specific Objective 3: By 2020, reduce prevalence of raised blood glucose among adults by 10%. Data (STEPS, 2014) Baseline 2020 Targets Raised blood glucose, adults (25 – 64 years) 37% 33% Strategic Actions Who can lead 1. Develop and implement social marketing and awareness campaigns focusing on risk factors causing raised blood glucose, and recommended levels of blood glucose, healthy eating (nutritional values, recommended portion sizes) and active living. MOH and community partners 2. Increase monitoring and surveillance of blood glucose among adults. MOH, health providers 3. Ensure counseling (for healthy lifestyle interventions) and early treatment for adults diagnosed with raised blood glucose. (*Suggested addition) MOH, health providers 4. Develop and implement self-management programs for people with diabetes and other chronic diseases/conditions. MOH, health providers, coalition Specific Objective 4: By 2020, reduce overall prevalence of overweight or obese school-aged children by 10%. Data (School Health Screening Survey, 2011) Baseline 2020 Targets School-aged children who are overweight or obese 33% 30% Strategic Actions Who can lead 1. Implement/support student mentoring programs (LEEP, Boy/Girl Scouts, Pathfinders) on healthy eating and active living MOH-CAP/MOE/Head Start/Community Partners 2. Conduct parent training on nutritional food preparation and needs. MOH and community partners 3. Mandate measurement and documentation of Body-mass Index for all school children during clinic visits. MOH, health providers, school nurses 4. Incorporate counseling or other healthy lifestyle interventions into clinical care for overweight/obese children. MOH, health providers, school nurses 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page36 Implementation of the Plan/Sustained Coordination The participants from the NCD prevention and control strategic action planning workshop, held from March 24- 26, 2014 at the Palasia Hotel and a subsequent planning/brainstorming session among multi-sectoral partners October 7-8, 2014 at the Palau International Coral Reef Center in Koror, Palau recommended the establishment of a national NCD multi-sectoral coordinating body or mechanism, responsible for providing oversight, facilitate mobilization of political commitment, resources, coordination and implementation of this Plan. This body will also coordinate regular monitoring, evaluation, and reporting of the national response to addressing NCDs including those actions identified in the Plan. Members of this multi-sectoral coordinating body include high level or designated representation from the eight ministries (education, environment, resources, health, state, justice, finance, customs, agriculture, etc.), schools, various non-governmental organizations/civil society, state governments, traditional leadership, and the attorney general. The body is headed by a chairperson on a rotational basis of 2-3 years; Ministry of Health will serve as temporary chairperson during the first meeting until the permanent chair is elected. Members will serve a term of two years (three years for NGOs for staggering purposes), responsible in attending meetings, incorporating plans into their respective agencies, and ensuring programs are implemented. The secretariat, a committee of five individuals from different agencies/organizations, will be appointed by the coordinating body and should not include any of its original members; two permanent members will be from Ministry of Health. The secretariat serves to document the progress of the work plan and report back to the entire group. Working groups or ad hoc committees may be formed by the coordinating body to lead or implement annual activities reflected in the work plans. Members of these groups include volunteers from the March 2014 strategic planning workshop. This coordinating body meets bi-monthly for the first year, and then quarterly thereafter. Special meetings maybe called upon as needed. The Palau NCD Plan only outlines strategies and lead agencies. This coordinating body will develop annual work plans with activities, outputs, responsible agencies/organizations, timelines, and evaluation measures. There will be semi-annual written reports and other types of communication (using the media) to show progress to stakeholders. (See attached Executive Order for Coordinating Body) 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page37 Communication and information dissemination Within the operational body comprised of Ministry of Health, traditional community partners, and volunteers from the working groups established during the strategic planning workshop, communication will be facilitated through emails, face to face meetings, and teleconferencing to finalize the Plan and get it endorsed and launched before the end of 2014 or early 2015. Dissemination of the draft plan to the broader community will be conducted through a variety of media, including: o Traditional media – via television, radio talk shows and print media o Community town hall meetings, face-to-face meetings and public hearings at various settings o New media – including social media After the Plan has been endorsed and the coordinating body convened, an ad hoc committee will be formed to develop and implement a communications plan to ensure smooth and effective communication amongst partners, stakeholders, and the general public. 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page38 Surveillance and Evaluation Palau, like the rest of the Pacific region, acknowledges the need to enhance its surveillance capacities in order to adequately inform decisions in response to the NCD crisis. NCD surveillance has persistently posed challenges due to various reasons including limited resources and capacity to collect, analyze, interpret and disseminate important health data for better and timely decision making. The Palau Ministry of Health (MOH) will be the lead agency in developing and implementing NCD surveillance plans in the country while engaging other partners in these efforts to ensure effective and sustainable surveillance of NCDs. Palau has relatively good data for youth risk factors in the last 10 years from the local School Health Screening Survey, the Youth Tobacco Survey and the Youth Risk Behavior Survey. For adults, however, it was only in 2010 and 2011 that Palau started to again collect risk behavior data with the Behavioral Risk Factor Surveillance System (BRFSS) and the WHO STEPS Survey, respectively. The last community health assessment that included adult data prior to these surveys was done in 2003. Youth Risks: Youth (ages 5-17) indicators include 30 day tobacco use, 30 day alcohol use including heavy episodic drinking, overweight/obesity, < 60 minutes daily physical activity, < 5 serves fruits and vegetable daily intake. Early childhood indicators include underweight, overweight, breastfeeding, and gestational substance use. Palau will use both the School Health Screening Survey (annually) and Youth Risk Behavior Survey (biennially) for the former and data from P-PRASS and Well Baby clinics for the latter on an annual basis. Adult Risks: Adult (ages 18 and over) indicators include30 day tobacco use, 30 day alcohol use including heavy episodic drinking, < 150 minutes weekly of moderate physical activity, salt intake per day, <5 serves F/V, overweight/obesity, HTN, High Cholesterol, Cancer, and DM. Surveys and other surveillance systems to be used include the BRFSS every 1-2 years, the WHO STEPS or face to face BRFSS (or a hybrid survey/combination of both) every five years, and the Palau Cancer Registry. Adult Mortality: Premature mortality (ages 30-69) include all-cause mortality and specific (cardio-vascular, cancer, diabetes, chronic respiratory diseases) and will be taken from MOH medical records/HIS reported annually and every 5-10 years (yet to be determined). Policy uptake monitoring: Policies include regional and best buys as reflected in this Plan and will be reported on an annual basis through progress reports or other templates to be developed. Clinical Services monitoring: Clinical services indicators include essential medicines and technologies to treat major NCDs including heart disease and strokes, cancer, diabetes, and chronic respiratory illnesses. (MOH needs to determine specific indicators, data sources, and other elements). 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page39 Evaluation: There will be annual evaluation plans developed every year based on the work plans developed; this evaluation will include not only the surveillance data mentioned above to monitor progress of behavioral outcomes, it will also include measures on performance. This evaluation will help inform all partners and stakeholders on aspect of the response, including the effectiveness of implementation and the activities or interventions. Distribution of Reports: Periodic reports (annual, 5 year periods) will be distributed to the following: • MOH Management • Muti-sectoral Coordinating Body • Other partners and the public Evaluation reports or updates might include detailed reports, executive summaries, slide presentations, briefings, brochures, newspaper articles, or radio or TV spots. 2015-2020 HEALTHY COMMUNITIES IN A HEALTHY PALAU page40 Contact Information To join the Ministry of Health and community partners in efforts in response to the NCD crisis, or for more information, please contact the: NON-COMMUNICABLE DISEASE UNIT DIVISION OF PRIMARY AND PREVENTIVE HEALTH SERVICES BUREAU OF PUBLIC HEALTH MINISTRY OF HEALTH PO BOX 6027 KOROR, PALAU 96940 PHONE: (680) 488-4612 FAX: (680) 488-4800 WEBSITE: www.palauhealth.org