Strategic Plan for Non-Communicable Diseases (NCDs) Prevention and Control 2025-2030

2025-2030 STRATEGIC PLAN FOR NCD PREVENTION & CONTROL Republic of Palau April 2024 2 Table of Contents MESSAGE FROM THE PRESIDENT OF THE REPUBLIC OF PALAU ............................................................... 3 MESSAGE FROM MECHESIL BELAU .......................................................................................................... 4 MESSAGE FROM THE MINISTER OF HEALTH AND HUMAN SERVICES ...................................................... 5 MESSAGE FROM COMMUNITY PARTNERS ............................................................................................... 6 ACKNOWLEDGEMENTS ............................................................................................................................. 7 EXECUTIVE SUMMARY .............................................................................................................................. 9 BACKGROUND ..................................................................................................................................... 10 METHODOLOGY AND WORKSHOP OBJECTIVES ..................................................................................... 13 RESULTS .................................................................................................................................................. 15 PROGRESS TOWARDS THE 2020 NCD RISK FACTOR TARGETS ............................................................... 15 PROGRESS TOWARDS THE 2020 OBJECTIVES ......................................................................................... 19 OVERALL VISION AND SUB-VISSIONS 2025-2030 ................................................................................... 23 AREA OF ACTION 2025-2030: TOBACCO CONTROL ............................................................................... 24 AREA OF ACTION 2025-2030: REDUCING HARMFUL ALCOHOL USE ..................................................... 28 AREA OF ACTION 2025-2030: IMPROVING NUTRITION ........................................................................ 32 AREA OF ACTION 2025-2030: INCREASING PHYSICAL ACTIVITY (PA) .................................................... 37 AREA OF ACTION 2025-2030: REDUCING METABOLIC RISK FACTORS .................................................. 42 AREA OF ACTION 2025-2030: MENTAL HEALTH .................................................................................... 45 CONCLUSIONS AND RECOMMENDATIONS ............................................................................................ 47 ANNEX 1: PARTICIPANT LIST .................................................................................................................. 48 ANNEX 2: EXECUTIVE ORDER NO. 484 .................................................................................................... 52 ANNEX 3: ANNUAL ACTION PLAN YEAR 1: JANUARY – DECEMBER 2025 ............................................... 56 file://phfs1/ncd$/NCD%20STRATEGIC%20PLANNING/2024-NCD-StrategicPlanning/2025-2030%20NCD%20Strat%20Draft%20Files/Palau%20NCD%20Strategic%20Plan%202025-2030 Final Draft.docx# Toc194657765 file://phfs1/ncd$/NCD%20STRATEGIC%20PLANNING/2024-NCD-StrategicPlanning/2025-2030%20NCD%20Strat%20Draft%20Files/Palau%20NCD%20Strategic%20Plan%202025-2030 Final Draft.docx# Toc194657766 3 MESSAGE FROM THE PRESIDENT OF THE REPUBLIC OF PALAU Alii! I am happy to endorse the Republic of Palau's Non-Communicable Diseases (NCDs) Strategic Plan 2025-30, a significant initiative dedicated to improving the health of the people of Palau. Non-communicable diseases remain among the leading causes of death of our population, and the strategic plan strengthens public health response to the crisis. The NCD program directly addresses pressing health challenges such as obesity, diabetes, and cardiovascular diseases. It embraces a comprehensive approach to prevention, early detection, and management of chronic conditions. Through awareness campaigns, promotion of healthy lifestyles, and accessible healthcare services, we aim to reduce the prevalence and severity of NCDs in Palau. Our healthcare professionals and staff are committed to providing high-quality care and support to individuals and families affected by NCDs. Their dedication to public service ensures the successful implementation of the strategic plan. The NCD program offers numerous benefits for Palau, including improved overall health and quality of life for citizens, reduced prevalence and severity of NCDs, increased awareness of healthy lifestyles, and accessible healthcare services. On behalf of the people of Palau, I extend our heartfelt gratitude and appreciation to the Ministry of Health and Human Services for leading the charge in addressing this critical health issue. Your unwavering efforts have undoubtedly contributed to a healthier and more vibrant Palau. With your support, the NCD program will continue to make a lasting difference in the lives of our people. Together, we can create a healthier, happier Palau. For more information or to get involved in the NCD program, please contact the Ministry of Health and Human Services. Sincerely, 4 MESSAGE FROM MECHESIL BELAU 5 MESSAGE FROM THE MINISTER OF HEALTH AND HUMAN SERVICES 6 MESSAGE FROM COMMUNITY PARTNERS 7 ACKNOWLEDGEMENTS The Republic of Palau’s Strategic Plan for Non-Communicable Disease (NCD) Prevention and Control 2025- 2030 emerged from the joint efforts of multiple stakeholders from the community, working together with the public and private sectors. The Ministry of Health and Human Services (MHHS) spearheaded the strategic planning process with support from a group of facilitators from the Association of State and Territorial Health Officials (ASTHO), the National Network of Public Health Institutes (NNPHI), the Hawai’i Public Health Institute (HPHI) and the Guam State Epidemiological Outcomes Workgroup (SEOW). The various agencies, institutions, and organizations that contributed to the creation of this plan include the following (Note: The participants list is provided as Annex 1): Institution/Agency/Organization Government Agencies Cheldebechel (Community Groups) Office of the President, ROP Palau National Olympic Committee Office of the Vice-President Palau Swimming Association/Palau Aquatics Federation Rubekul Belau/Council of Chiefs Palau Parents Empowered Mechesil Belau Peace Winds Palau The Senate, Olbiil Era Kelulau PW NCD Free Club Governors Association Sonsorol State Women’s Organization Ministry of Education The Angel Center Ministry of Human Resources, Culture, Tourism and Development The Filipino Community in Palau Ministry of Finance Various members of the public Ministry of Justice Youth with a Mission Ministry of Public Infrastructure and Industries Education Institutions Ministry of Agriculture, Fisheries and the Environment Meyuns Elementary School Ministry of State Palau Community College Ministry of Health and Human Services Palau Community Action Agency Office of Environmental Response and Coordination Palau Seventh Day Adventist School State Governments/Legislatures PEC Gospel Kindergarten Palau Climate Change Office Mindzenty High School Palau Community Health Centers Governing Board Faith-based Organization Palau Parole Board Apostolic Foundation Church Palau Visitors Authority Palau Evangelical School System Cheldebechel (Community Groups) Media Association of Maternal and Child Health Programs Palau Media Council Bangladesh Association Oceania TV News Belau Cancer Society Health service providers Belau Employers and Educators Alliance Belau National Hospital Belau Foreign Spouses Society Community Health Worker Trainees Belau Medical Center Wellness Palau Nurses Association Belau National Museum West Care Pacific Islands, Inc. Bungelkesol National, Regional, Bilateral and International Partners Coalition for a Tobacco Free Palau Association of State and Territorial Health Officials Eldebechel Ra Ngarablod Guam State Epidemiological Outcomes Workgroup Kotel A Deurreng Hawai’i Public Health Institute Johanna Ngiruchelbad Services Japan International Cooperation Agency Ngarachamayong National Network of Public Health Institutes 8 Omekesang Taiwan Technical Mission Palau Aging Council United Nations Office Palau Behavioral Health Advisory Council United Nations Economic and Social Commission for Asia and the Pacific Ngerbuns Club Palau Formosa Livestock Association Ngesechel a Sils rar Blechoel ngara Yolt Palau Taiwan Farmers Association 9 EXECUTIVE SUMMARY Palau’s battle against noncommunicable diseases (NCDs) is ongoing, as the threats to health and development are persistent and formidable. Palau is committed to sustainable development, but sustainable development requires healthy people. Today, the greatest threats to the health of Palau’s people, and therefore, to Palau’s sustainable development, are NCDs. The 2015-2020 NCD Prevention and Control Strategic Plan was extended to 2023 due to the COVID pandemic. Now that the implementation period has ended, the data demonstrate improvements in youth tobacco and alcohol use, and fruit and vegetable consumption. Conversely, mortality from NCDs, adult smoking prevalence, salt intake, fruit and vegetable consumption, and the prevalence of high blood pressure, high blood sugar and overweight/obesity among adults worsened over time, with the latest data trending further from the 2020 targets. In analyzing the reasons for these, the data indicate that where sound policies and strong programs have been implemented, risk factor prevalence rates have declined. In contrast, where policies and programs were weak or non-existent, risk factor prevalence worsened. Clearly, the data underscore the critical role of effective policies and programs in changing behavior patterns to reduce the risk of NCDs, highlighting the importance of investing in sound policy and program interventions for the new Plan. 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.” The priority areas of action have been augmented to include mental health, which is inextricably linked to NCD prevention and control. Multisectoral partnerships, political and cultural leadership and community mobilization are necessary to drive this plan into action for a healthier and richer Palau. The key lies in the strength of implementation, and the leadership of the National Coordinating Mechanism (NCM), established in 2015 to address the NCD epidemic, will be crucial in determining how effectively Palau is able to counter the greatest threat to its health and development. Participants at the Palau NCD Progress Dissemination and Strategic Planning Workshop, April 2024 (Photo credit: MHHS) 10 BACKGROUND Palau’s battle against noncommunicable diseases is ongoing, as the threats to health and development are persistent and formidable. Nearly 3 decades ago, in 1995, Palau joined the other Pacific Island Countries and Territories (PICTs) in articulating the “Healthy Islands” vision at the first meeting of the Pacific Ministers of Health in Yanuca, Fiji. 1 Over the years, this vision evolved towards a focus on health protection, health promotion, and creating healthy environments and lifestyles in response to the rapidly burgeoning NCD epidemic. The World Health Organization (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.2 In 2010, Palau and other United States-affiliated Pacific Islands (USAPIs) urged the Pacific Island Health Officers’ (PIHOA) Association to declare NCDs as an emergency in the USAPIs. 3 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.4 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.5 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.6 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, Palau joined other WHO Member States in adopting 9 global voluntary NCD targets and 9 Pacific NCD targets and endorsing the WHO Global Action Plan and the Regional NCD Roadmap. In September 2013, at the 68th Regular Session of the United Nations General Assembly (UNGA), the President of the Republic of Palau called on the UNGA to focus on NCDs and tobacco control as critical issues in the sustainable development goals.7 1 World Health Organization. Healthy Islands: The healthy islands story. Available at: https://www.who.int/westernpacific/about/how-we- work/pacific-support/healthy-islands 2 WHO FCTC Secretariat. WHO Framework Convention on Tobacco Control Parties. Available at: https://fctc.who.int/who- fctc/overview/parties 3 PIHOA. NCD regional health emergency. Available at: https://www.pihoa.org/ncd-regional-health-emergency/ 4 WHO Western Pacific Regional Office. Using emergency powers to mobilize improved and whole-of-society action on NCDs: The case of Palau. 2013. Available at: https://iris.who.int/bitstream/handle/10665/208139/9789290616436 eng.pdf?sequence=1&isAllowed=y 5 United Nations General Assembly. Political Declaration of the High-level Meeting of the General Assembly on the prevention and control of Non-communicable Diseases. 2011. Available at: https://documents.un.org/doc/undoc/ltd/n11/497/77/pdf/n1149777.pdf?token=nVQ5pXrlLfQZRwHsED&fe=true 6 Republic of Palau. Executive Order No. 295: Declaring a state of health emergency on noncommunicable diseases. 2011. Available e at: https://www.pihoa.org/wp-content/uploads/2019/08/Palau-NCD-Declaration-Ex-295.pdf 7 Republic of Palau. 2013 UNGA Remarks of President Tommy E. Remengesau, Jr. 2013. Available at: https://www.who.int/westernpacific/about/how-we-work/pacific-support/healthy-islands https://www.who.int/westernpacific/about/how-we-work/pacific-support/healthy-islands https://www.who.int/westernpacific/about/how-we-work/pacific-support/healthy-islands https://fctc.who.int/who-fctc/overview/parties https://fctc.who.int/who-fctc/overview/parties https://www.pihoa.org/ncd-regional-health-emergency/ https://iris.who.int/bitstream/handle/10665/208139/9789290616436 eng.pdf?sequence=1&isAllowed=y https://documents.un.org/doc/undoc/ltd/n11/497/77/pdf/n1149777.pdf?token=nVQ5pXrlLfQZRwHsED&fe=true https://www.pihoa.org/wp-content/uploads/2019/08/Palau-NCD-Declaration-Ex-295.pdf 11 We are all in it together The Honorable Gaafar Uherbelau Minister of Health and Human Services “Our multisectoral and multistakeholder task force on NCDs in Palau gives us an upstream perspective on NCDs and their risk factors. Yet, we also need to look upstream in our health system and continuously realign and reorganize ourselves to ensure we remain effective in our efforts to remain one step ahead of the NCD crisis” Remarks at the 2023 Multistakeholder Gathering on NCDs, 20 September 2023; available at: https://knowledge-action- portal.com/en/news and events/news/8132 In 2014, a multi-sectoral body of stakeholders convened to create the first Republic of Palau NCD Prevention and Control Strategic Plan of Action 2015-2020.8 The participants from the NCD prevention and control strategic action planning workshop recommended the establishment of a national NCD multi-sectoral coordinating body or mechanism to ensure oversight, mobilization of political commitment and resources, and coordination of implementation of the action plan. In May 2015, the NCD stakeholders witnessed the official launching of Palau’s NCD Plan and the creation of the National Coordinating Mechanism for NCDs (NCM), as established by Executive Order #379.9 Simultaneously, the Palau Legislature passed RPPL 9-57 (as amended by RPPL 10-9 & RPPL 11-8), allocating 10% of the alcohol and tobacco taxes for NCD prevention and health promotion activities in Palau.10 One of the tasks of the NCM is to administer the “Healthy Communities, Healthy Palau Initiatives”, where community organizations are supported to implement NCD prevention and control programs or projects, with funding from alcohol and tobacco tax revenues. The NCM subsequently established Working Groups (WGs) for each of the four major NCD risk factors (alcohol, tobacco, physical inactivity, poor diets); a fifth on metabolic risk factors (obesity, hypertension, raised blood glucose, and high lipids); a monitoring and evaluation workgroup; and a five-member Secretariat. These working groups provide the organizational infrastructure for implementing annual action plans and meet between the quarterly NCM meetings. Midway between the implementation period of Palau’s NCD Strategic Action Plan, in 2018, NCD stakeholders re-convened to review progress, using the results of the 2017 Palau Hybrid Survey and other data updates. The progress assessment guided the identification of priority actions for the remaining 2 years (2018- 2020). 11 The COVID pandemic delayed the gathering of stakeholders to create a new Palau NCD Plan after 2020, and the 2018 update was extended until this strategic planning workshop from April 9-11, 2024. In the meantime, Palau’s President Surangel Whipps, Jr. issued Executive Order No. 484 (Annex 2), reconstituting the NCD National Coordinating Mechanism, and updating the operational goals, functions and responsibilities, membership and organization of the NCM, setting the foundation for a new action plan.12 8 Republic of Palau. Noncommunicable prevention and control strategic plan of action 2015-2020. 2015. Available at: https://www.palauhealth.org/files/FinalDraft-PalauNCDPlan complete%20pages- dc%20(Low%20Res).pdf 9 Republic of Palau. Executive Order No. 379: To create a National Coordinating Mechanism to facilitate and coordinate the Government of the Republic of Palau’s efforts to combat the occurrences and impacts of noncommunicable diseases in the Republic of Palau. 2015. Available at: https://www.pihoa.org/wp-content/uploads/2019/08/Palau-Executive-Order-No-379.pdf 10 Ninth Olbiil Era Kelulau. RPPL No. 9-57. 2015. Available at: https://assets.tobaccocontrollaws.org/uploads/legislation/Palau/Palau- RPPL-No.-9- 57-native.pdf 11 Palau Ministry of Health. NCD Action Plan progress assessment and update. 2018. Koror: MOH. Hard copy version available from Palau MHHS. 12 Republic of Palau, Office of the President. Executive Order No. 484: To reconstitute the National Coordinating Mechanism to facilitate and coordinate the Gov’t of the Republic of Palau’s efforts to combat the occurrences and impacts of NCDs in the Republic of Palau. July 2023. https://knowledge-action-portal.com/en/news and events/news/8132 https://knowledge-action-portal.com/en/news and events/news/8132 https://www.palauhealth.org/files/FinalDraft-PalauNCDPlan complete%20pages-dc%20(Low%20Res).pdf https://www.palauhealth.org/files/FinalDraft-PalauNCDPlan complete%20pages-dc%20(Low%20Res).pdf https://www.pihoa.org/wp-content/uploads/2019/08/Palau-Executive-Order-No-379.pdf https://assets.tobaccocontrollaws.org/uploads/legislation/Palau/Palau-RPPL-No.-9-57-native.pdf https://assets.tobaccocontrollaws.org/uploads/legislation/Palau/Palau-RPPL-No.-9-57-native.pdf https://assets.tobaccocontrollaws.org/uploads/legislation/Palau/Palau-RPPL-No.-9-57-native.pdf 12 Palau is committed to sustainable development, but sustainable development requires healthy people. Today, the greatest threats to the health of Palau’s people, and therefore, to Palau’s sustainable development, are NCDs. Currently, NCDs cause nearly 80% of deaths13, and have lowered Palauans’ life expectancy. The health burden is considerable, straining the health care system, and because of the chronic nature of NCDs, the health burden is expected to increase as the population ages. Heart disease, stroke and cancer claim the greatest 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. The economic burden of NCDs affects individuals, their families, and the national economy. Palauans and their families bear the burden of out-of-pocket NCD-related medical expenses, which can be significant. Persons afflicted with NCDs often have diminished work capacity, further aggravating the financial compromise by reducing their ability to earn money. Family members of NCD patients may also have to leave the workforce to care for their sick relatives, further diminishing the labor pool. At the societal level, the high prevalence of NCDs contributes significantly to already high and still rising public expenditure on health in Palau, raising questions about long-term financial sustainability. NCDs are a major driver of overseas medical referrals: presently, Palau’s health infrastructure does not have all the facilities and specialized personnel to treat more complicated cases of cancer, heart disease, diabetes or other NCDs. Overseas medical referrals for NCDs comprise a significant and often fast-growing component of the government’s health expenditure that benefits only a small fraction of the population while depleting funds for local health care. Projections by the World Bank indicate that if unabated, the economic burden of NCDs is projected to increase significantly by 2040, reducing Palau’s Gross Domestic Product (GDP) by 5- 6%.14 Palau’s health and economic future are inextricably linked to its ability to effectively counter the rising prevalence of NCDs. This is reaffirmed in the 2023 Bridgetown Declaration on NCDs and Mental Health, with Palau as an active participant, calling upon all Small Island Developing States (SIDS) to take bold action “to accelerate progress in SIDS to, by 2030, reduce by one-third premature mortality from noncommunicable diseases (NCDs) through prevention and treatment and promote mental health and well-being, in line with the 2030 Agenda for Sustainable Development.”15 Fortunately, NCDs can be prevented by reducing the prevalence of its risk factors. The challenge is in selecting those proven interventions to shape the policy, sociocultural, physical, and fiscal environment to influence community behavior. The WHO “Best Buys”16 and the Pacific NCD Roadmap17 outlined in the first Palau NCD Strategic Plan identify key strategic action areas for effective and feasible strategies to mitigate the NCD epidemic. Selecting the relevant priority actions for Palau and working collaboratively to implement them fully will be vital to ensuring the country can safeguard the health of its people and attain sustainable development. 13 Republic of Palau. Pathway to 2030: 1st Voluntary National Review of the SDGs. 2019. Available at: https://sustainabledevelopment.un.org/content/documents/23606VNR FINAL 21June2019 UN Version.pdf 14 World Bank. 2017. Pacific Possible: Long-term Economic Opportunities and Challenges for Pacific Island Countries. Washington, DC: World Bank. License: Creative Commons Attribution CC BY 3.0 IGO 15 WHO. 2023 Bridgetown Declaration on NCDs and Mental Health. Bridgetown, Barbados: WHO; 2023. Available from: https://www.who.int/publications/m/item/2023-bridgetown-declaration-on-ncds-and-mental-health 16 WHO. NCD “Best Buys” and other effective interventions. 2018. Geneva: World Health Organization. 17 World Bank. Non-communicable disease (NCD) roadmap report. Washington, DC: World Bank Group; 2014. Available from: http://documents.worldbank.org/curated/en/534551468332387599/pdf/893050WP0P13040PUBLIC00NCD0Roadmap.pdf WHY PALAU NEEDS HEIGHTENED ACTION TO COMBAT NCDS https://sustainabledevelopment.un.org/content/documents/23606VNR FINAL 21June2019 UN Version.pdf http://www.who.int/publications/m/item/2023-bridgetown-declaration-on-ncds-and-mental-health http://documents.worldbank.org/curated/en/534551468332387599/pdf/893050WP0P13040PUBLIC00NCD0Roadmap.pdf 13 METHODOLOGY AND WORKSHOP OBJECTIVES During the planning phase, members of the MHHS coordinated with facilitators from ASTHO, NNPHI, Hawai’i PHI and Guam SEOW to develop the workshop agenda. It was agreed to retain the current structure of the NCD Plan across the five action areas that encompass behavioral and metabolic risk factors: • Reducing tobacco consumption (smoking/chewing tobacco with betel nut) and e-cigarette use • Reducing harmful alcohol use • Reducing physical inactivity • Improving nutritional intake and, • Reducing the prevalence of metabolic risk factors that precede the major NCDs. The workshop objectives were: • Review the results of the hybrid survey data and other new data with key NCD stakeholders in relation to the NCD Strategic Plan 2015-2020 • Determine overall progress in implementing the NCD Strategic Plan 2015-2020 and, • Use the progress assessment to set future strategic actions and develop a new 5-year work plan (2025-2030) that builds on the previous plan to accelerate action against NCDs and its risk factors. The 2 ½ day workshop utilized a mix of plenary didactic sessions, and participatory group work to achieve the objectives. Current data, including results from the 2023 Palau Hybrid survey were reviewed, and participants were provided with individual copies of the survey report. An open forum permitted the audience to ask questions about the data, and stimulated a discussion of the advantages and disadvantages of the various data sources and surveillance mechanisms that are operational in Palau. On Day 1 of the workshop, participants self-selected based on their area of interest and expertise into one of five groups representing the five action areas in the 2015-2020 Plan. Facilitators guided the participants through an initial set of exercises that applied the current data to assess progress along the targets and outcome indicators of the NCD Plan. Participants also evaluated progress across the specific objectives under each of the five Palau NCD Plan action areas. Specific objectives, strategic actions and targets were gauged as to level of achievement. At the end of the session, participants reflected on possible factors to account for success or lack of progress in reducing NCD risks. The succeeding group activities were facilitated using a series of strategic planning exercises. A SWOT (Strengths, Weaknesses, Opportunities and Threats) assessment established the current situation for each of the NCD action areas. On Day 2, participants reviewed their progress assessment and SWOT analyses to revise or create new objectives, actions, and targets. This was followed by a prioritization exercise to select priority objectives for the next 5 years (2025-2030), ensuring alignment with the SMART (Specific, Measurable, Achievable, Relevant, Time-bound) model. The final group work for Day 2 consisted of developing a 5-year work plan for the selected priority objectives, identifying strategic actions/activities, timelines, and responsible persons/groups to achieve progress. On Day 3, groups reflected on potential risks and identified mitigation strategies, followed by brainstorming on key performance indicators to monitor progress and measure success. Groups presented their 14 work to the rest of the participants by reporting out during plenary sessions or through a “gallery walk” with written comments/feedback. The workshop ended with a summation and next steps. (Photo credit: Dr. Annette M. David) 15 PROGRESS TOWARDS THE 2020 NCD RISK FACTOR TARGETS RESULTS At the first NCD Strategic Planning Workshop in 2014, there were limited data on adult risk factor and NCD prevalence. A hybrid survey using elements from the US CDC BRFSS and the WHO STEPS was conducted in Palau in 2016. The preliminary results from the hybrid survey were released at a data dissemination workshop conducted in 201718, and the findings were used in the progress assessment conducted in 2018. A second iteration of the Hybrid Survey was completed in 2023.19 The final results of the survey are now available, together with results from the 2021 Youth Risk Behavior Survey (YRBS)20 and the 2022 Palau Youth Tobacco Survey (PYTS).21 The data provide an objective means to assess progress now that the Plan’s implementation period has ended. The following table summarizes the data for selected indicators for NCD behavioral and metabolic risk factors risk factors. Adult data in 2014 were derived from Palau STEPS (Stepwise Approach to NCD Risk factor Surveillance) Survey; subsequent data were taken from the 2016 and 2023 Palau Hybrid Survey. Youth data were based on 2011 and 2021 YRBS surveys and 2022 PYTS, with baseline data on chewing and smokeless tobacco use taken from the Palau Youth Tobacco Survey (YTS) 2009. The “Status” column is color coded: red if the data worsened from baseline and the target was unmet, yellow if it was unchanged or if it improved over time but not sufficiently to meet the target and green if it improved from baseline and met the target. Table 1. Selected NCD indicators, change over time and comparison to targets set in the 2015-2020 Plan Indicator Baseline (2014/2015) Mid- term (2018) Target (2020) Today Status Mortality Mortality attributed to cardiovascular diseases, cancer, diabetes, and COPD* 70% 80% 25% reduction by 2025 ? Tobacco Use Overall smoking prevalence, adults 17% 20.6% 12% 20.8% Overall chewing betel nut with tobacco, adults 54.2% 46.2% 28% 41.2% E-cigarette use, adults** --- 1.7% --- 1.7% Overall smoking prevalence, youth 41% 46.8% 29% 23.6% (2021 YRBS HS) 19.5% (PYTS 2022, HS) 18 Palau Ministry of Health. Palau Hybrid Report 2017. 2017. Available at: https://www.palauhealth.org/MOHpages/MOHReports1.aspx 19 Palau Ministry of Health and Human Services. Palau Hybrid Report 2024. 2024. Hard copy version available from MHHS. https://www.palauhealth.org/MOHpages/MOHReports1.aspx 20 Palau Ministry of Education. Palau Youth Risk Behavior Survey 2021. 2021. Available at: https://nccd.cdc.gov/Youthonline/App/Results.aspx?TT=A&OUT=0&SID=HS&QID=QQ&LID=XX&YID=2021&LID2=&YID2=&COL=S&ROW 1=N&ROW2=N&HT=QQ&LCT=LL&FS=S1&FR=R1&FG=G1&FA=A1&FI=I1&FP=P1&FSL=S1&FRL=R1&FGL=G1&FAL=A1&FIL=I1&FPL=P1&P V=&TST=False&C1=&C2=&QP=G&DP=1&VA=CI&CS=Y&SYID=&EYID=&SC=DEFAULT&SO=ASC 21 Palau Ministry of Health and Human Services. Palau Youth Tobacco Survey 2022. Results for youth from 6th to 12th grades https://www.palauhealth.org/MOHpages/MOHReports1.aspx http://www.palauhealth.org/MOHpages/MOHReports1.aspx https://nccd.cdc.gov/Youthonline/App/Results.aspx?TT=A&OUT=0&SID=HS&QID=QQ&LID=XX&YID=2021&LID2&YID2&COL=S&ROW1=N&ROW2=N&HT=QQ&LCT=LL&FS=S1&FR=R1&FG=G1&FA=A1&FI=I1&FP=P1&FSL=S1&FRL=R1&FGL=G1&FAL=A1&FIL=I1&FPL=P1&PV&TST=False&C1&C2&QP=G&DP=1&VA=CI&CS=Y&SYID&EYID&SC=DEFAULT&SO=ASC https://nccd.cdc.gov/Youthonline/App/Results.aspx?TT=A&OUT=0&SID=HS&QID=QQ&LID=XX&YID=2021&LID2&YID2&COL=S&ROW1=N&ROW2=N&HT=QQ&LCT=LL&FS=S1&FR=R1&FG=G1&FA=A1&FI=I1&FP=P1&FSL=S1&FRL=R1&FGL=G1&FAL=A1&FIL=I1&FPL=P1&PV&TST=False&C1&C2&QP=G&DP=1&VA=CI&CS=Y&SYID&EYID&SC=DEFAULT&SO=ASC https://nccd.cdc.gov/Youthonline/App/Results.aspx?TT=A&OUT=0&SID=HS&QID=QQ&LID=XX&YID=2021&LID2&YID2&COL=S&ROW1=N&ROW2=N&HT=QQ&LCT=LL&FS=S1&FR=R1&FG=G1&FA=A1&FI=I1&FP=P1&FSL=S1&FRL=R1&FGL=G1&FAL=A1&FIL=I1&FPL=P1&PV&TST=False&C1&C2&QP=G&DP=1&VA=CI&CS=Y&SYID&EYID&SC=DEFAULT&SO=ASC 16 Indicator Baseline (2014/2015) Mid- term (2018) Target (2020) Today Status Overall smokeless tobacco use, youth** 35% 27.7% --- 24%* E-cigarette use, youth** 20.8 --- --- 49.2% (2021 YRBS HS) 53.4% (PYTS 2022, HS) Alcohol Use Current alcohol consumption, adults 36.7% 35.6% Binge drinking, adults 27.2% 28.0% Current alcohol use, youth 43% 37.4% 39% 30% Binge drinking, youth 33% 24.1% 30% 15.9% Nutrition Adults watching their salt intake --- 69% 75% 64.7% Adults with 5 or more servings of fruits and vegetables per day 8% 9.9% 12% 7.8% Mothers who breastfeed infants up to 6 months*** --- 47% 50% increase from baseline 63% Youth with no fruit consumption in the past 24 hours --- 36.7% 30% decrease from baseline 16.6% Youth with no vegetable consumption in the past 24 hours --- 24.8% 6.7% Physical activity Adults who are physically active at least 30 minutes a day on all or most days 65% 53.1% 81% 77.3% Adults participating in any PA or exercise in past 30 days**** Percent of school age children participating regularly in sports 60.4% 52.7% 75% 79% walked, biked, hiked or swam in the past 7 days (School Health Screening 2023) **** Metabolic risk factors Raised blood pressure, adults 49% 30.1% 44% 47.7% Raised blood glucose, adults 20.4% 21.1% 18% 36% School aged children who are overweight or obese 33% 32% 30% 30.6% Adults who are overweight or obese* 77.6% 71.7% --- 75.6% Mental health indicators^ Adults with signs of depression 5.2% Adults with signs of anxiety 4.3% Adults, suicidal ideation, past 12 months 2.3% 17 Indicator Baseline (2014/2015) Mid- term (2018) Target (2020) Today Status Youth who felt sad or hopeless in the past 12 months 44.4% Youth who seriously considered suicide, past 12 months 29.8% Youth who attempted suicide in the past 12 months 25.2% Notes: *Smokeless tobacco use among youth (High School, Grades 9-12) taken from PYTS 2022 ** The e-cigarette and youth smokeless tobacco use indicators were added in 2018, but targets were not set for these indicators. Also, no indicator was set for adult e-cigarette use. ***The breastfeeding data comes from MOH/MHHS data. ****The physical activity indicators changed in the 2023 Hybrid Survey. ^ Mental health was not included in the past NCD Action Plan 18 The data indicate improvements in youth tobacco and alcohol use, with declines in smoking and smokeless tobacco consumption and current and binge drinking. Fruit and vegetable consumption increased among school children, surpassing the 2020 targets. Conversely, mortality from NCDs, adult smoking prevalence, salt intake, fruit and vegetable consumption, and the prevalence of high blood pressure, high blood sugar and overweight/obesity among adults worsened over time, with the latest data trending further from the 2020 targets. In addition, the use of e-cigarettes among youth has risen significantly. Notably, Palau’s obligations to the WHO FCTC have resulted in sustained community advocacy and outreach about tobacco’s harmful effects. The minimum age for cigarette sales was increased to 21 years and Palau’s tobacco tax now comprises at least 70% of the pack price. Alcohol taxes have also been raised in the past, with alcohol prevention education incorporated into the schools’ curricula. Global evidence confirms that youth are particularly price-sensitive, so that tax increases on harmful products can result in immediate and measurable declines in youth consumption. These demonstrate the efficacy of sound demand reduction policies on youth tobacco and alcohol consumption. With regards to the improvement in fruit and vegetable intake, the Ministry of Education has embarked on a program where school meals include healthy fruit and vegetable options, and school cafeteria personnel are supported with training and tools to create healthier menus for school children. Taken altogether, the data appear to indicate that where sound policies and strong programs have been implemented, risk factor prevalence rates have declined. In contrast, where policies and programs were weak or non-existent, risk factor prevalence worsened. The planned strategy to tax unhealthy foods and beverages did not occur, and the price increases from tobacco and alcohol taxation may not have been sufficient to impact purchasing behavior of adults. (Note: Members of the Coalition for a Tobacco Free Palau highlighted the need to reduce the affordability of tobacco through periodic tax increases that keep up with inflation.) No healthy menu planning programs were implemented for adults as were done for schoolchildren. Not surprisingly, adult smoking, unhealthy food consumption, and the prevalence of high blood pressure, high blood sugar and overweight/obesity got worse over time. These likely contributed to the worsening proportion of NCD-attributable mortality. Clearly, the data underscore the critical role of effective policies and programs in changing behavior patterns to reduce the risk of NCDs. The other key takeaway from the review of data is the importance of having consistent measures over time. When how indicators are defined and/or measured shift within the period of implementation, it is methodologically challenging to track progress. This was evident with the physical activity indicators. Because the indicators changed during the measurement period, it was not possible to gauge progress. In the future, aligning indicators with existing data collection instruments and ensuring consistency over time will enhance progress assessment. 19 The five working groups representing the five action areas of the Plan reviewed progress in detail, examining each of their specific objectives to determine the extent of attainment of these objectives. Specific objectives that have been achieved were color tagged green, those that are partially achieved or in progress were tagged yellow, and those which have not been achieved were tagged red. The teams then assessed if any new specific objectives need to be added for the next Plan, based on current data and developments in the policy and program environment. The results of these sessions are highlighted in the following tables Tobacco Control Specific Objective Status 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) 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. 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. 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. 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). Specific Objective 6: By 2020, 100% compliance with provisions of the FCTC that address demand reduction is achieved (Articles 8,9,10,11,13). Add-on: Integrate regular tax increase into the existing tobacco tax regulation. Add-on: Address e-cigarettes in tobacco tax law. Add-on: Improve youth data on chewing betel nut with tobacco. Add-on: Include affordability of tobacco products as an indicator, together with prevalence targets. PROGRESS TOWARDS THE 2020 OBJECTIVES 20 Reducing harmful use of alcohol Specific Objective Status Specific Objective 1: By 2020, formalize a community coalition for alcohol use and abuse prevention and control with TORs and that convenes on a regular basis. Specific Objective 2: By 2020, reduce underage drinking by 10% by: 1) Raising alcohol taxes and earmark a portion of the tax revenues for health. 2) Legislating a total ban on alcohol advertising, including at point of sale. 3) Enhancing/strengthening enforcement of laws prohibiting sales to minors by requiring ID verification of age of all buyers. Specific Objective 3: By 2020, reduce binge drinking in adults by 10% by: 1) Minimizing alcohol use at cultural & social functions (customary events). 2) Strengthening enforcement of alcohol laws (i.e. DUI Laws, hours of sale). 3) Legislating total bans on alcohol advertising, including at point of sale. 4) Training and authorizing bartenders, salespersons, bouncers to refuse sales and ban intoxicated persons from purchasing more alcohol. Improving nutrition Specific Objective Status Specific Objective 1: By 2015, a national multi-sectoral working group to address overall nutrition improvement activities in Palau, is convening regularly. Specific Objective 2: By 2020, reduce salt intake in Palau by 30% by: 1) Legislating taxes on imported food products high in sodium, fat and sugar. 2) Increasing the number of food vendors (stores, restaurants) that sell healthier meals/food items. 3) Supporting legislation for English language nutrition labels on imported foods and English or Palauan language ingredients list for locally produced food products. Specific Objective 3: By 2020, increase fruits & vegetables intake by 50% by: 1) Securing earmarked funds to support local agricultural projects and subsidize local production of fruits and vegetables. Specific Objective 4: By 2020, increase breastfeeding by mothers of infants up to 6 months of age by 50% by establishing policies in birthing centers and all workplaces to promote and ensure breastfeeding. 21 Increasing physical activity Specific Objective Status Specific Objective 1: By 2015, a formal physical activity working group to address physical inactivity among youth and adults in Palau, is convening regularly. 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. Specific Objective 3: By 2020, change social norms and behaviors resulting in a community-wide increase in activity levels and reduction in inactivity by building on the existing Kotel A Deurreng campaign and further developing and implementing a sustained nationwide social marketing campaign to promote regular, moderate physical activity. 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 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. Specific Objective 6: By 2020, 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 through the following: By 2017, every community will have designated green spaces appropriate for physical activity. By 2017, all state master plans will designate areas for parks and green spaces appropriate for physical activity. 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). By 2017, the Palau Government will enact pedestrian and cycling legislation. Reducing NCD prevalence Specific Objective Status Specific Objective 1: By 2015, an MOH multi-disciplinary team to address the prevalence of NCDs in Palau is convening regularly, with community-clinical linkages in place. Specific Objective 2: By 2020, reduce prevalence of raised blood pressure among adults by 10% by: Promoting healthy eating through community outreach and information dissemination. Promoting widespread screening and monitoring of blood pressure among adults. Ensuring counseling 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. Specific Objective 3: By 2020, reduce prevalence of raised blood glucose among adults by 10% by: Developing and implementing 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. Developing and implementing self-management programs for people with diabetes and other chronic diseases/conditions. Specific Objective 4: By 2020, reduce overall prevalence of overweight or obese school-aged children by 10% by: Develop and implement weight screening and counseling programs in the clinics. Training community partners on weight management for children. 22 During the plenary discussion, participants noted that those areas that had more accomplishments towards their specific objectives – tobacco control and harmful alcohol prevention – were also the areas that showed greater progress in demonstrating improvements in prevalence, particularly among youth. An exception was noted for the action area on controlling metabolic risk factors – this area demonstrated successes particularly in implementing screening programs for blood pressure, diabetes, and overweight/obesity, yet the prevalence rates of these conditions increased over time. However, upon further reflection, the participants pointed out that enhanced screening would have uncovered more cases of elevated blood pressure, blood sugar and overweight/obesity. Thus, the seemingly paradoxical increase in metabolic risk factors may have been the direct effect of better screening. Therefore, additional indicators that measure how good the control of these factors are, are needed to supplement the information provided by the current indicators. The plenary discussion also addressed what may be missing from the current plan. Participants pointed out the profound impact of mental health on these NCD risk factors and the frequent co-existence of mental health issues with NCDs and poor compliance with treatment. Thus, they recommended the addition of a sixth action area to address mental health and its central role in the NCD epidemic. Former Minister of Health, Palau https://www.kuam.com/story/17086588/2012/03/Monday/regional-officials-get-master- training https://www.kuam.com/story/17086588/2012/03/Monday/regional-officials-get-master-training https://www.kuam.com/story/17086588/2012/03/Monday/regional-officials-get-master-training 23 To guide the way: 6 sub-visions Overall goal: Reduce the preventable burden of NCDs in Palau (25% reduction in NCD-attributable mortality by 2030) [80% of deaths due to NCDs today  60% of deaths due to NCDs in 2030] OVERALL VISION AND SUB-VISSIONS 2025-2030 24 AREA OF ACTION 2025-2030: TOBACCO CONTROL Sub-vision: Thriving people and a vibrant island nation free from the harms of tobacco and nicotine Goal: Reduce overall tobacco consumption by 30% by 2030 Indicator Baseline % (Current) Target % (2030) Adults (Source: 2023 Hybrid survey) Overall current smoking 20.8 14.6 Current smoking, males 31.9 22.3 Current smoking, females 8.3 5.8 Current smokeless tobacco use 9.6 6.7 Current betel nut chewing 46.7 32.7 % of current betel nut chewers who add tobacco to their chew 88.3 61.8 Current e-cigarette use 1.7 1.2 Youth (Source: 2022 PYTS) * Current smoking, high school 19.5 13.6 Current smoking, middle school 13.6 9.5 Current smoking (middle & high school) 16.9 8.0 Current smokeless tobacco use, high school 24.0 16.8 Current smokeless tobacco use, middle school 12.5 5.3 Current smokeless tobacco use, (middle & high school) 10.4 5.0 Current betel nut chewing, high school 18.7 8.8 Current betel nut chewing, middle school 15.2 10.6 Current betel nut chewing (middle & high school) 17.1 10.0 Current e-cigarette use, high school 53.5 4.0 Current e-cigarette use, middle school 30.9 2.0 Current e-cigarette use, (middle & high school) 43.5 3.0 Note: * Data from the Palau Youth Tobacco Survey (PYTS) were recalculated for with grade levels 6-8 (middle school) and grade levels 9- 12 (high school) to align with the YRBS; the PYTS data will be uses for future monitoring of youth tobacco use. Specific Objectives: 1. By 2025, achieve full compliance with the other demand reduction provisions of the WHO FCTC Articles 8 -protection from exposure to tobacco smoke, 11- packaging and labelling of tobacco products, and 13 - tobacco advertising, promotion and sponsorship). 2. By 2026, establish the infrastructure and capacity for tobacco dependence treatment/cessation services (per WHO FCTC Article 14 tobacco dependence and cessation). 3. By 2026, Palau will adopt measures to protect public health policies from commercial and other vested interests of the tobacco industry. 4. By 2026, amend tax legislation to ensure periodic increases in tobacco taxes adjusted to inflation thereby reducing the affordability of tobacco products. 25 Strategic Actions: Specific objective 1: By 2025, achieve full compliance with the other demand reduction provisions of the WHO FCTC; Article 8: Protection from exposure to tobacco smoke Article 11: Packaging & labeling of tobacco products Article 13: Tobacco advertising, promotion and sponsorship Indicators Baseline Target Comprehensive tobacco legislation is updated and signed into law. Current Tobacco Control Act Amendments signed into law Strategic actions Who will lead? By when? Review drafted amendments CTFP/MHHS 2025 Develop and implement a comprehensive communications strategy and plan to effectively identify and engage targeted stakeholders (e.g. champions in the OEK) and raise awareness about the specific demand reduction provisions being targeted. CTFP 2025 Meet and present proposed amendments to relevant committees in OEK. CTFP 2025 Specific objective 2: By 2027, establish the infrastructure and capacity for tobacco dependence treatment/cessation services (per WHO FCTC Article 14 tobacco dependence and cessation) Indicators Baseline % Target % Want to stop using tobacco in past 12 months, adults 69.8 75 Stopped using tobacco for 1 day or longer in the past 12 months, adults 46.3 51 Advised to stop using tobacco during any visit to a doctor in the past 12 months, adults 41.3 46 Current youth tobacco smokers who tried to stop smoking in the past 12 months (grades 6-12) 79.5 85 Current youth tobacco smokers who wanted to stop smoking now 68.2 73 Current youth tobacco smokers who thought they would be able to stop smoking if they wanted to 71.9 77 Current youth tobacco smokers who have ever received help/advice from a program or professional to stop smoking 28.0 33 Current youth who chew betelnut with ANY tobacco who tried to stop chewing betelnut with tobacco in the past 12 months 8.3 15 Current youth who chew betelnut with tobacco who wanted to stop chewing betelnut with tobacco now 6.4 15 Current youth who chew betelnut with tobacco who thought they would be able to stop if they wanted to 11.5 15 Current youth who chew betelnut with tobacco who have ever received help/advice from a program or professional to stop chewing betelnut with tobacco 3.8 8 Number of cessation services that are operational No baseline available TBD 26 Number of cessation trainings conducted per year No baseline available TBD Notes: Adult data source – Palau Hybrid Survey, Youth data source –PYTS, “TBD” – to be decided Strategic actions Who will lead? By when? Identify and recruit a national cessation coordinator (Focal Person) MHHS 2025 Finalize and present landscape analysis that outlines cessation services currently available and service gaps that need to be addressed. Coalition for Tobacco Free Palau (CTFP) Feb 2025 Develop and adopt a national cessation strategy based on the landscape analysis. MHHS May, 2025 Finalize tobacco, nicotine, betel nut use policy for MHHS MHHS May 2025 Adopt and disseminate national cessation treatment guidelines to community-based clinics and other primary care service providers. MHHS with community partners 2025 Establish clear national referral and treatment pathways for cessation. MHHS 2026 Develop tobacco, nicotine, betelnut use policy for Ministry of Education MHHS/MOE May 2026 Build capacity for tobacco cessation services among community partners. MHHS, CTFP with community partners 2026 Establish tobacco cessation pilot programs for priority populations, including pregnant women and staff at MHHS. Maternal and child health providers, MHHS 2026 Raise community awareness about available tobacco cessation resources, services, and pathways. CTFP, MHHS 2026 Specific objective 3: By 2026, Palau will adopt measures to protect public health policies from commercial and other vested interests of the tobacco industry. Indicators Baseline Target Global tobacco index score 39 35 Strategic actions Who will lead? By when? Explore options through legislation or amendments to government Civil Service Rules and Regulations/Code of Ethics, to prevent TI interference with public health policy MHRCTD and CTFP 2025 Amend Palau’s tobacco control legislation to prohibit tobacco industry corporate social responsibility (CSR) activities. CTFP, OEK 2025 Develop & implement a comprehensive communications strategy and plan to effectively engage stakeholders, raise awareness about the issue of industry interference and the importance of rejecting tobacco industry interference in Palau’s public health policies and ensure timely dissemination of information CTFP, REACH, NCM, Prevention Unit MHHS 2025-2030 27 Specific objective 4: By 2026, amend tax legislation to ensure periodic increases in tobacco taxes adjusted to inflation thereby reducing the affordability of tobacco products. Indicators Baseline Target Tobacco products do not become affordable overtime. 4.92% affordability Strategic actions Who will lead? By when? Review existing tobacco tax legislation and prepare an updated draft CTFP & Partners 2025 Collect supporting information and data MHHS/CTFP 2025 Meet with and present proposed amendments to champions in the OEK CTFP 2026 Develop and implement a comprehensive communications strategy and plan to effectively engage stakeholders, raise awareness about the issue of taxation policy as a tool to control tobacco use and also raise revenue and ensure timely dissemination of information CTFP/REACH 2026 *Affordably (defined and calculated by WHO) is the percentage of GDP per capita required to purchase 100 packs of 20 cigarettes (2,000 cigarettes) of the most sold brand in a country Risks and mitigation strategies: Risk factor/Threat Mitigation strategies Lack of stakeholder and community commitment and collaboration • Leverage leaders who have “bought in” to tobacco control policies • Build community awareness about tobacco industry interference through social marketing • Build community awareness about tobacco cessation resources and support through: o Tobacco free sports and tournaments o Radio, social media o Targeting youth groups, religious groups, etc. • Disseminate reports to the public Tobacco industry (TI) interference • Raise awareness about TI interference and the need for legislative efforts to counter this • Leverage legislative and executive champions to support policies that counter TI interference Affordability of tobacco products • Educate policy makers on the “win- win” (raise revenue, reduce MM rates) concept of tobacco tax policy. • Leverage leaders who have “bought in” to the tobacco tax policy • Ensure that tobacco tax increases make tobacco products less affordable 28 AREA OF ACTION 2025-2030: REDUCING HARMFUL ALCOHOL USE Sub-vision: Belau in Control of alcohol. Goal: Reduce binge drinking among adults by 50% by 2030. Reduce underage drinking to 0% by 2030. Indicator Baseline % (Current) Target % (2030) Adults (Source: 2023 Hybrid survey) Overall binge drinking 28.0 14.0 Binge drinking, males 36.1 18.0 Binge drinking, females 19.0 9.5 Youth (Source: 2021 YRBS) Overall current alcohol use 30.0 0 Current alcohol use, males 28.3 0 Current alcohol use, females 31.3 0 Overall binge drinking 15.9 0 Binge drinking, males 13.0 0 Binge drinking, females 18.6 0 Specific Objectives: • By 2026, formalize an interagency coalition for alcohol use and abuse prevention and control with terms of reference that convenes on a regular basis. • By 2026, enhance/strengthen enforcement of laws prohibiting sales of alcohol to minors by requiting mandatory ID verification of age of all buyers. • By 2030, increase alcohol-free cultural and social functions (customary events). • By 2028, earmark alcohol tax revenues for regulatory enforcement and other relevant authorities. Strategic Actions: Specific objective 1: By 2026, formalize an interagency coalition for alcohol use and abuse prevention and control with terms of reference that convenes on a regular basis. Indicators Baseline Target List of coalition members and attendance sheets of meetings Currently non- existent Terms of reference for coalition adopted Meeting minutes Official declaration/order establishing the coalition Number of signed Memoranda of Understanding (MOUs) for agencies that are members of the coalition Official Standard Operating Procedures (SOP) adopted Workplan developed Quarterly reports submitted Strategic actions Who will lead? By when? Identify potential community champions to lead the coalition. National Youth and Cheldebechel Council (NYCC) Jan 2025 Identify potential stakeholders and partners. MHHS, NYCC, TFCP, BFSS June 2025 29 Convene the local interagency multisectoral coalition to develop their TORs and SOPs. NYCC June 2025-March 2026 Create MOUs between agencies to formalize their membership in the coalition. MOJ April 2026 Draft the coalition’s workplan to address the goals above. Incorporate the previous Plan’s alcohol control objectives into the workplan. NYCC, MHHS, TFCP, BFSS, MOJ October 2026 Regularly report on progress to the NCM Alcohol control interagency coalition 2025-2030 Specific objective 2: By 2026, enhance/strengthen enforcement of laws prohibiting sales of alcohol to minors by requiring mandatory ID verification of age of all buyers. Indicators Baseline Target List of members of Steering Committee to tighten enforcement of mandatory ID checks. Currently non- existent Meeting minutes of Steering Committee Report on analysis of gaps in current legislation Updated legislation requiring mandatory ID check approved and adopted Increase in number of trained enforcers Increased budget to support enhanced enforcement Survey tracking compliance rate of alcohol vendors Survey tracking public awareness of mandatory requirement Strategic actions Who will lead? By when? Identify and convene the agencies and partners involved in implementing the existing law into a Steering Committee. MOJ, MOE, MHRCTD, MHHS, MOF Dec 2024 Review the existing regulation to identify the gaps. June 2025 Draft an updated regulation that address the gaps and mandates universal ID checks for all buyers of alcohol and ensure its approval through the APA process. June 2025 Allocate sufficient resources and manpower for enforcement. National Congress October 2025 Conduct mandatory training for officers and enforcers, with refreshers as needed. MOJ As soon as new regulation is officially implemented Educate the public and alcohol retailers and vendors about the mandatory ID check requirement. Interagency coalition During the grace period prior to implementation 30 Specific objective 3: By 2030, increase alcohol free cultural and social functions (customary events). Indicators Baseline Target Meetings with Mechesil Belau and Rubekul Belau accomplished, with meeting minutes Currently non- existent Agenda for convention on alcohol-free events created Consistent messaging for alcohol-free events disseminated widely Number of outreach visits to States Number of alcohol-free events per year per State Koror Night market Annual report on number of alcohol-free events across the country Currently non- existent Strategic actions Who will lead? By when? Collaborate with Mechesil Belau and Rubekul Belau in implementing alcohol-free social and cultural events. Interagency coalition After coalition is established Engage and work with community cultural partners to promote alcohol-free events. Advocate and educate the public about alcohol-free events. Interagency coalition, Mechesil Belau, Rubekul Belau April 2025-2030 Promote the alcohol-free Night Market as a good practice example across the different States. Palau Visitors’ Authority (PVA) and Interagency coalition Encourage each State/country to create local alcohol-free events laws. Traditional leaders, State Gov’ts. Assign an agency to collect and evaluate data on alcohol-free community events. MHRCTD, PVA, MHHS Every 2 years until 2030 Specific objective 4: By 2028, earmark a portion of the alcohol tax revenues for regulatory enforcement and other relevant authorities. Indicators Baseline Target Amount of money earmarked for alcohol enforcement Currently no earmarking for enforcement Increase in number of enforcement staff Number of people attending public hearings to support alcohol tax earmarking for enforcement Number of news events covering the earmarking proposal in mass media Strategic actions Who will lead? By when? Identify a champion in Congress to propose earmarking a portion of alcohol tax revenues for enforcement. Interagency coalition, MOJ June 2025 Advocate to Congress to earmark a portion of alcohol tax revenues for regulatory enforcement. June 2026 Mobilize community support for earmarking alcohol tax revenues for enforcement. Interagency coalition Until earmarking is enacted 31 Risks and mitigation strategies: Risk/Threat Mitigation strategies Time constraints • Provide incentives for attending coalition meetings (e.g. food, transportation allowance, etc.) • Ensure close communication and follow-up. • Schedule meetings in advance and provide agendas ahead of time. • Select the right people as coalition members; ensure agencies designate the right members who can serve as influencers. • Obtain coalition members’ commitment to the goals and objectives of the coalition. • Provide multiple options for meeting, both virtual and in- person. • Ensure meetings are brief and focused. Lack of manpower and resources • Tap community volunteers who are interested in alcohol abuse prevention. • Provide incentives for partners (e.g. public recognition, stipends, transportation allowances, etc.). • Leverage NGOs to expand manpower pool. • Prepare detailed budgets and have back-up budgets for contingencies. • Manage resources efficiently and encourage sharing of resources. • Build capacity of volunteers through technical assistance and trainings and use the train the trainer’s model to create a local pool of trainers. Competing funding priorities in Congress • Draft regulations/laws/amendments strategically to address funding priorities. • Create multiple options for budgets. • Provide compelling data with impactful narratives to persuade lawmakers to support proposed amendments and regulations. Create “win-win” arguments. • Ensure the right champions can speak up for alcohol control. • Time requests for legislative action appropriately. • Hold leadership accountable. Changing priorities of the NCM • Showcase success of alcohol prevention and control. Show the relevance of alcohol control in preventing accidents, reducing cancer, decreasing medical expenditures, improving nutrition. • Highlight the costs of alcohol abuse to the community. • Attend NCM meetings and act as a “salesperson” for alcohol prevention and control. • Engage the community and harness their support to advocate to the NCM. • Explore the economic arguments and “Return on investment” scenarios to make the case for alcohol abuse prevention. • Leverage the influence of interagency coalition champions to persuade the NCM to keep alcohol control as a priority. 32 AREA OF ACTION 2025-2030: IMPROVING NUTRITION Sub-vision: “A Kelel Belau a Didichel a Klukuk” - Breast-fed and well fed with local food Goals: Improve overall nutrition Indicator Baseline % (Current) Target % (2030) Adults (Source: 2023 Hybrid survey) % watching their salt intake 64 83 (30% increase) % consuming at least 5 servings of fruits and vegetables per day 7.8 12 (50% increase) % consuming processed meat at least once a day 51.1 46.0 (10% decrease) % consuming at least one sugar sweetened beverage (SSB) each day 70.7 46.0 (35% decrease) % mothers who breastfeed their infants up to 6 months 63 94.5 (50% increase) Youth (Source: 2021 YRBS) Did not eat fruit or drink fruit juice 16.6 8.3 (50% decrease) Did not eat vegetables 6.7 3.4 (50% decrease) Specific Objectives: • By 2030, convene a multisectoral workgroup to address overall nutrition improvement activities in Palau quarterly. • From 2025 to 2030, enhance nutrition education in schools, workplaces, and communities by adding 5 sites per year. • By 2030, reduce salt, sugar, and fat intake according to the targets above. • By 2030, increase the percentage of adults and youth consuming fruits and vegetables by 50%. • By 2030, increase breastfeeding by mothers of infants up to 6 months of age by 10% by establishing policies in birthing centers and all workplaces to promote and ensure breastfeeding. • By 2030, improve access to farming resources, materials, and education to increase the number of people growing their own food. 33 Strategic Actions: Specific objective 1: By 2030, convene a multisectoral workgroup to address overall nutrition improvement activities in Palau quarterly. Indicators Baseline Target Working group convenes; initial meeting minutes Currently nonexistent/not operational Number of new members recruited Roles and responsibilities defined and documented Charter, organizational and operational structure formalized Strategic actions Who will lead? By when? Convene existing members. MHHS and existing members February 2025 Engage potential new members. MHHS and existing members April 2025 Formalize roles and responsibilities/membership. Coalition members June 2025 Develop and formalize a charter and an organizational and operational structure. Coalition members June 2025 Specific objective 2: From 2025 to 2030, enhance nutrition education in schools, workplaces, and communities by adding 5 sites per year. Indicators Baseline Target Nutrition curricula include traditional practices and healthy eating guidelines Curriculum/guidelines exists in schools and hospital, but not for workplaces/community Widely available in all settings Dissemination and communication plan finalized and implemented. Currently nonexistent Number of partners involved in activities Currently unknown Monitoring and evaluation plan finalized Currently nonexistent Strategic actions Who will lead? By when? Review and revise existing curriculum to include traditional practices and healthy eating guidelines. Ministry of Education (MOE)/ Ministry of Health (MOH) December 2025 Develop and implement a dissemination and communication plan. Nutrition Working Group December 2026 and ongoing Engage partners, including Mechesil Belau, for mobilization of resources, coordination of activities and communication. Nutrition Working Group December 2026 Develop a monitoring and evaluation plan to track progress. Ministry of Education (MOE)/ Ministry of Health (MOH) December 2025 34 Specific objective 3: By 2030, reduce salt, sugar, and fat intake according to the targets above. Indicators Baseline Target Salt content of school meals (interim measure) TBD Salt content of hospital meals (interim measure) TBD Purchasing data for processed meat NA Average Body Mass Index over time 2023 School Health Screening: average BMI = 22 TBD Enactment of an SSB tax Currently non- existent Number of food vendors offering healthy food options over time TBD Increase by at least 1 per year Nutrition labels on local and imported foods Currently non- existent Strategic actions Who will lead? By when? Build relationships with grocery stores and gather purchasing data for processed meats. Nutrition Working Group December 2030 Legislate a tax on sugar-sweetened beverages. Nutrition Working Group with legislative nutrition champions December 2026 Increase the number of food vendors and organizations that sell or offer healthy food options by at least one per year Annually starting December 2026 Mandate nutrition labels on imported and local foods. List ingredients on local foods. Translate English nutrition labels on imported foods into Palauan. December 2030 Specific objective 4: By 2030, increase the percentage of adults and youth consuming fruits and vegetables by 50%. Indicators Baseline Target Number of vendors with healthier options. TBD 20% Social marketing plan by 2027. 0 1 Implementation of social marketing plan initiated after six (6) months of completion. Strategic actions Who will lead? By when? Work with food vendors to offer healthier options (fruits and vegetables). BNH Kitchen and NCD Unit 2030 Social marketing campaign on fruits and vegetables assessment (i.e.: consumer research). PNYCC 2030 35 Specific objective 5: By 2030, increase breastfeeding by mothers of infants up to 6 months of age by 10% by establishing policies in birthing centers and all workplaces to promote and ensure breastfeeding. Indicators Baseline Target Revise and endorse policy for birthing center. 0 1 Government Workplace Policy on breastfeeding. 0 1 Policy brief (parental leave). 0 1 Strategic actions Who will lead? By when? Establish policies in birthing center. FHU 2026 Establish policies in government workplaces to promote and ensure breastfeeding. Kotel a Deurreng/Nutrition Group 2030 Advocate for longer parental leave. Kotel a Deurreng/Nutrition Group 2027 Specific objective 6: By 2030, improve access to farming resources, materials, and education to increase the number of people growing their own food. Indicators Baseline Target Number of people engaged about growing their own food. TBD 20% Number of campaigns TBD 4 per year Strategic actions Who will lead? By when? To improve access to farming resources, materials, and education. Palau Community Action Agency (PCAA) 2030 Develop campaign on growing own food. Nutrition Working Group 2027 36 Risks and mitigation strategies: Risk factor/Threat Mitigation strategies Change of leadership • Support a candidate who is a champion for health, with a platform for “Healthy Palau” • Continue to inform policymakers to ensure continuity • Establish structure Lack of trust/engagement and burnout • Setting milestones/celebrating success • Show value and connection across initiatives (leverage support) • Clear roles and responsibilities of committee members Funding sustainability • Establish financial plan • Leverage non-governmental partners to help advocate Climate change • Utilize Climate Outlook Weather Connections Palau (application in collaboration with NOAA) • Translate NOAA app and ensure accessibility offline (for those without internet/data plans) Messaging on “why” • Host focus group to test messages • Positive campaign messages • Incorporate messaging into communication plan Lack of support/buy in • Focus group to support the development (ensure participation of community groups • Celebrating/building on success • Social marketing – “make nutrition sexy” Threat on individual choice/rights • Related to buy-in • Pay for choice-making healthy options more affordable Trust in local foods vs. imported foods • Transparency – how it’s made, who made it, etc. • “Stamp of approval” system (example: certified organic) Capacity for implementation • Assess partner capacity, activities, etc. • Utilize a train-the-trainer approach • Consider utilizing CHWs • Engage retired community members Local food taste rival imported food • Educate parents • Use positive social messages (marketing) • Strengthen school-parent partnerships • Make baby food with local food (use grinder/blender to make own locally sourced baby food) Champions and role models of program (“practice what you preach”) • Identify champions and role models • Ensure community representation (local/state champions) • Create a champion support group (consider utilizing social media) 37 AREA OF ACTION 2025-2030: INCREASING PHYSICAL ACTIVITY (PA) Sub-vision: A beautiful and safe Palau where physical and social environments invite active living Goals: Reduce physical inactivity among children, youth, and adults by at least 10% by 2030 Indicator Baseline % (Current) Target % (2030) Adults (Source: 2023 Hybrid survey) % Participating in any physical activity or exercises in the past 30 days 77.4 85.1 % who have access to places to exercise 78.9 86.8 % who are sedentary 8 or more hours a day 13.7 12.3 Youth (Source: 2021 YRBS) Physically active for at least 60 minutes on at least 1 day in the past 7 days 77.1 84.8 Physically active for at least 60 minutes per day on 5 or more days in the past 7 days 28.5 31.4 Attended physical education (PE) classes on 1 or more days in an average week in school 31.6 34.8 Played on at least 1 sports team in the past 12 months 42.5 46.8 Specific Objectives: • By 2025, develop standardized indicators, methods, data collection, analysis, and dissemination for active living in Palau. • By 2030, 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. • By 2030, at least 50% of government offices and private sector enterprises will have adopted a Worksite Wellness program that incorporates a holistic approach that includes tobacco free policies and programs, good nutrition, alcohol control, and regular physical activity. • By 2025, a formal physical activity and sports working group to address and prioritize active living among youth and adults in Palau is convening regularly. • By 2025, change social norms and behaviors resulting in a nationwide increase in activity levels by strengthening community-specific activities. • By 2030, enhance physical and social environments in Palau’s communities through policies, communication strategies and infrastructure development to invite active living. This includes: o By 2027, every community will have designated spaces suitable for physical activity. o By 2027, each state will have incorporated active transportation and designated spaces suitable for physical activity into their state master plan. o By 2028, the national and state governments will enact inclusive pedestrian and cycling legislation. 38 Strategic Actions: Specific objective 1: By 2025, develop standardized indicators, methods, data collection, analysis, and dissemination for active living in Palau. Indicators Baseline Target Indicator list and data sources identified Currently nonexistent/not operational Data collection and analysis SOPs developed Data dissemination training modules created Monitoring and evaluation framework developed Strategic actions Who will lead? By when? Identify specific indicators for active living, starting with physical activity indicators that are already included in existing surveillance instruments (e.g. Hybrid survey, YRBS). If additional data is needed, develop monitoring and evaluation tools (e.g. questionnaires, surveys) to capture data. PAWG, MHHS, PNOC, MOE, NGOs 2025 PAWG will develop standard operation procedures (SOPs) on data collection and analysis. PAWG End of 2025 PAWG will develop trainings and capacity-building programs that will empower stakeholders for data dissemination. NCD funded programs, NCM, Youth groups, CHWs, Office of Planning and Statistics, MOF End of 2026 Identify and secure resources to develop data collection, analysis, and dissemination. PAWG End of 2025 Develop a monitoring and evaluation framework to assess and measure progress. PAWG End of 2025 Specific objective 2: By 2030, 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. Indicators Baseline Target Number of PA programs in schools TBD Updated school PA curriculum Number of schools with adequate, well-maintained, operational PA facilities Number of certified PE instructors per school Strategic actions Who will lead? By when? Introduce events (once per quarter) in all schools that integrate physical activity for all students. Include access and resources for students with disabilities. MOE, PTA Student body association By 2025 Strengthen collaboration between all schools and external partners to achieve the recommended 60 minutes per day of moderate or vigorous physical activity on 5 or more days per week. MOE, PNOC, Sports Federation, Sports Education Commission, State government offices, CBO, PTA By 2026 Support MOE to update and localize the physical education curriculum. MOE, PNOC, MHHS By 2027 39 Ensure schools have adequate, well-maintained, and operational physical facilities and adopted maintenance policies. MOE, Public works, COFA, CIP, CAT By 2027 Strengthen human resources in the schools for support of school-based activity through a national policy requiring all schools to have adequate staffing and at least one certified Physical Education instructor. MOE, PAWG By end of 2030 Specific objective 3: By 2030, at least 50% of government offices and private sector enterprises will have adopted a Worksite Wellness program that incorporates a holistic approach - tobacco free, nutrition, and alcohol control. Indicators Baseline Target Number of gov’t offices with a Worksite Wellness program TBD Number of private sector enterprises with a Worksite Wellness program Strategic actions Who will lead? By when? Identify key business leaders for the private sector. PAWG, Key private business leaders End of 2025 Develop a standard model of a holistic Worksite Wellness program. PAWG, MHHS End of 2026 Pilot the Worksite Wellness program in government offices and promote its widespread adoption. PAWG, Palau Entrepreneurs for Growth, Chamber of Commerce, Other ministries End of 2028 Develop and launch a pilot Worksite Wellness program for the private sector and promote its widespread adoption. MHSS, PAWG, Palau Entrepreneurs for Growth End of 2028 Specific objective 4: By 2030, a formal physical activity & sports working group to address prioritize active living among youth& adults in Palau is convening regularly. Indicators Baseline Target All identified stakeholders/partners confirmed membership. TBD Calendar of meetings and activities has been established. Strategic actions Who will lead? By when? Identify key partners such as Ministry of Education, youth groups, community groups, PNOC. MHHS December 2024 Minimum of 9 members in the Physical Activity Working Group. 40 Specific objective 5: By 2030, change social norms & behaviors resulting in a nation-wide increase in activity levels by strengthening community specific activities. Indicators Baseline Target Meetings, workshops. TBD Formal recognition of specific community activities. 50% of 16 state 10% within state Strategic actions Who will lead? By when? Education & awareness campaigns for healthy lifestyle specifically active living. MHHS, State Government, Community Leaders 2030 Formalize community activity and existing practices. Community Leaders, MHHS 2030 Engage and empower community physical activity leaders. MHHS, State Government, Community Leaders 2030 Specific objective 6: By 2030, enhance physical and social environments in Palau’s communities through policies, communication strategies and infrastructure development to invite active living. This includes: Indicators Baseline Target Community announces identified the designated space through newspaper ads, social media, radio announcements, and TV ads. TBD TBD Each State has a plan for improvement of the infrastructure. TBD TBD Each State has introduced policies for PA spaces and inclusive active transportation. TBD TBD Strategic actions Who will lead? By when? Every community will have a designated space suitable for physical activity. MOS, MHHS, Palau Walks, State Governments, PA Working Group By 2027 Each state will improve infrastructures to allow safe space for walking, biking, running, etc. State Governments, MOE, MHHS, Palau Walks, PA Working Group By 2027 The national and state governments will enact inclusive pedestrian and cycling legislation. Palau Walks, MOS, MHHS, State Governments, PA Working Group By 2028 41 Risks and mitigation strategies: Risk factor/Threat Mitigation strategies Personnel losses/turnover; Lack of adequate staff to support physical fitness activities • Partner with PNOC, police academy, sports programs, CAT • Salary raises for staff who stay behind (legislate COLA $$ to address high cost of living). • Use CHWs. • Tap into Peace Corps, JICA, Interns, Taiwan Tech. • Partner with the Ministry of Justice (tap into staff working with juveniles). • PCAA. • Utilize online tech resources like YouTube, Tik Tok, etc. create PA “challenges” that students want to engage with. • Partner with parents, elders in the aging program. • Model KES cultural programs that encourage cultural practices that promote physical activity. • Use physical therapists/ allot their internship hours to involve schools. Budget loss; inadequate funding • Include “non-lapsing” funding within legislation. • Provide advocacy training for community members to talk to legislators and allocate funds to physical fitness activities that reduce NCDs re: COFA funding. In particular, tap into the Veterans Association for support. • Partner with countries that have embassies in Palau. • Increase lobbying capacity for PA. • Develop fundraising opportunities. • Recruit parents & CAT to volunteer at schools. • Incorporate Employer insurance for wellness check and physical activity. Poor facilities, lack of proper maintenance • Establish school-wide initiatives, such as a general clean-up of PA facilities once per quarter • Develop a Standard Maintenance Plan that is consistent across schools. Tap into MOE, MHHS & CIP for support. • Increase lobbying & advocacy efforts to maintain PA facilities in schools and communities. • Partner with PCC to develop trade programs that create education, training, and jobs for maintenance purposes like landscaping, construction, air-conditioning, and electrical. • Create physical education certification program through PCC & CAT. 42 AREA OF ACTION 2025-2030: REDUCING METABOLIC RISK FACTORS Sub-vision: Palau free from NCDs Goals: Decrease the prevalence of the major NCDs – heart disease, cancer, diabetes, and chronic obstructive pulmonary disease - by at least 10% by 2030 through a reduction in the prevalence of the major metabolic risk factors preceding these NCDs. Indicator Baseline % (Current) Target % (2030) Adults (Source: 2023 Hybrid survey) % with high blood pressure (BP) 47.7 40.5 % with high BP who are not diagnosed with hypertension 50.5 42.9 % with uncontrolled blood pressure who are diagnosed and on BP medication 56.7 48.2 % estimated to have diabetes 30.5 25.9 % estimated to have pre-diabetes 36.0 30.6 % with diabetes who are undiagnosed and not on medication 60.2 51.2 % with diabetes who are diagnosed and on medication with A1c<7% 30.9 35.5 % who are overweight or obese 75.6 64.3 Youth (Source: 2021 YRBS) Are obese 15.8 13.4 Are overweight 14.8 12.6 Specific Objectives: • By 2030, maintain a multi-disciplinary team with community-clinical linkages in place to address the prevalence of NCDs in Palau, with quarterly meetings. • By 2030, reduce the prevalence of raised blood pressure among adults by 15%. • By 2030, reduce the prevalence of raised HbA1c among adults by 15%. • By 2030, reduce the overall prevalence of overweight/obesity among youth and adults by 10%. Strategic Actions: Specific objective 1: By 2030, maintain a multi-disciplinary team with community-clinical linkages in place to address the prevalence of NCDs in Palau, with quarterly meetings. Indicators Baseline % Target % List of key partners Currently non-existence 1 list Number of meetings Currently non-existence 4 Finalized annual workplan Currently non-existence 1 finalized plan Strategic actions Who will lead? By when? Identify key partners/stakeholders for the multi-disciplinary team. NCD Collaborative June 2025 Convene meeting with identified team members to discuss goals and objectives. NCD Collaborative December 2024 Develop and finalize annual workplan Multi-disciplinary team December 2024 Implementation of workplan Multi-disciplinary team December 2024 43 Specific objective 2: By 2030, reduce the prevalence of raised blood pressure among adults by 15%. Indicators Baseline Target Palau hypertension guidelines developed and utilized Currently non-existent 1 finalized guideline Standard data collection process for blood pressure (BP) screening adopted 1 standard BP process Communications plan for healthy BP messaging created 1 plan Community outreach calendar disseminated Annual Calendar Strategic actions Who will lead? By when? Develop, finalize, and implement hypertension guidelines specific to the population. Integrate WHO “Best Buys” for hypertension into the guidelines. Therapeutic Committee, Medical Director June 2025 Ensure all health service providers use the hypertension guidelines for screening, diagnosis, treatment, and follow-up of high blood pressure. MHHS, Clinic Directors 2025-2030 Develop standardized data collecting, recording, sharing and dissemination process for all partners who conduct blood pressure screenings. NCD Collaborative Screening Team Sept 2025 Create a communications plan to determine the health messaging for promoting healthy lifestyles and maintaining normal blood pressure levels. NCD Collaborative Screening Team June 2025 Coordinate community outreach and education/information dissemination using an outreach calendar. NCD Collaborative Screening Team 2025-2030 Specific objective 3: By 2030, reduce the prevalence of raised HbA1c among adults by 15%. Indicators Baseline Target Updated patient education materials with holistic messaging on blood glucose and other NCD risk factors Currently non-existent 1 Diabetes self-management education in all relevant clinic encounters 1 Strategic actions Who will lead? By when? Review current social marketing and awareness campaigns focusing on risk factors causing raised blood glucose and update them to address all the relevant NCD risk factors that affect blood sugar levels. In particular, include the role of tobacco use in diabetes causation, and the impact of mental health on diabetes treatment compliance. NCD Collaborative Screening Team June 2025 Incorporate diabetes self-management education in all primary care, NCD clinic, and wellness clinic encounters. Clinic directors, health educators 2025-2030 Identify the pre-diabetic population and refer them to self- management programs. NCD Collaborative Screening Team June 2025- 2030 Address barriers to compliance with blood sugar lowering regimens through chart reviews and surveys and address the barriers to good blood glucose control. NCD Collaborative Screening Team Sept 2025- 2030 44 Specific objective 4: By 2030, reduce the prevalence of overweight/obesity among youth and adults by 15%. Indicators Baseline % Target % % adults who are overweight or obese 75.6 64.3 % youth who are obese 15.8 13.4 % youth who are overweight 14.8 12.6 Strategic actions Who will lead? By when? Coordinate with existing programs, such as school-based health programs, to promote healthy weight strategies among youth. NCD Collaborative Screening Team, Family Health Unit, MOE June 2025- 2030 Include weight monitoring in clinic encounters for school children and adult patients. Clinic directors, clinicians 2025-2030 Work with schools, the MOE, and parent-teacher associations (PTA) to educate students’ parents and legal guardians about healthy eating and maintaining a healthy weight for their children. NCD Collaborative Screening Team, MOE, PTA June 2025- 2030 Incorporate dietary counselling and other healthy lifestyle interventions into clinical care for overweight/obese children and adults. NCD Collaborative Screening Team, clinicians, health educators June 2025- 2030 Risks and mitigation strategies: Risk factor/Threat Mitigation strategies Lack of standardized data collection and sharing; reluctance of medical field to adhere to standardized data protocols. • Prioritize the standardization of clinical data collection • Identify key data points that all clinicians should be using • Advocate to the medical society to adopt standard screening of specific NCDs and to use uniform measures so data is standardized. Lack of knowledge among parents and legal guardians about ways to prevent overweight and obesity among school children. • Develop public education modules and messages to increase the understanding and capacity of parents and caregivers to implement healthy lifestyle interventions for their children • Mobilize the maternal and child health programs (MCH) to include parent education and public messaging on NCD prevention and control in the clinical setting Poor patient compliance with NCD risk management interventions. • Create case management teams for challenging patients. • Track and assess the “no-shows” at follow-up clinic encounters and determine the factors for noncompliance. 45 AREA OF ACTION 2025-2030: MENTAL HEALTH Sub-vision: An island community where mental health is valued, and mental wellness exists for all Goal: Promote mental well-being and decrease the prevalence of symptoms of mental disorders by 30% by 2030 Indicator Baseline % (Current) Target % (2030) Adults (Source: 2023 Hybrid survey) With signs of depression 5.2 3.6 With signs of anxiety 4.3 3.0 Suicidal ideation, past 12 months 2.3 1.6 Youth (Source: 2021 YRBS) Felt sad or hopeless in the past 12 months 44.4 31.1 Seriously considered suicide, past 12 months 29.8 20.9 Attempted suicide in the past 12 months 25.2 17.6 Specific Objectives: • By 2025, mental health is incorporated into NCD education, outreach, social marketing, and communications campaigns. • By 2026, all clinical encounters for NCD-related conditions include a mental health assessment at the initial clinic visit and periodically during follow-up visits. • By 2026, a referral pathway utilizing existing mental health resources and programs is in place to provide diagnostic and therapeutic support, and counseling, for persons at risk for mental disorders. Strategic Actions: Specific objective 1: By 2025, mental health is incorporated into NCD education, outreach, social marketing, and communications campaigns. Indicators Baseline Target NCD outreach materials include mental health promotion Currently non-existent Strategic actions Who will lead? By when? Coordinate with Behavioral Health to develop educational and outreach materials that address the link between mental health and NCDs. NCM, Behavioral Health June 2025- 2030 Include mental health messaging when doing community campaigns to raise awareness about the interconnectedness of mental health and NCD prevention and control. NCM working groups, NCD coalitions 2025-2030 46 Specific objective 2: By 2026, all clinical encounters for NCD-related conditions include a mental health assessment at the initial clinic visits and periodically during follow-up visits. Indicators Baseline Target Clinical protocol for mental health screening developed and adopted Currently non-existent Strategic actions Who will lead? By when? Work with Behavioral Health to develop clinical protocols for mental health screening in the clinical setting. NCD Collaborative Screening Team, Behavioral Health Dec 2025 Advocate to all clinical service providers to include mental health screening at the initial clinic visit and periodically in subsequent follow-up visits, according to the clinical protocol. NCM, Behavioral Health 2026-2030 Train primary care providers to do rapid mental health assessment. Behavioral Health. Medical Society 2026-2030 Specific objective 3: By 2026, a referral pathway utilizing existing mental health resources and programs is in place to provide diagnostic and therapeutic support, and counseling, for persons at risk for mental disorders. Indicators Baseline Target Inventory of mental health resources readily available to clinicians and NCD partners Currently not available Referral pathway for mental health disorders established in primary care clinics Currently non-existent Strategic actions Who will lead? By when? Work with Behavioral Health to identify existing mental health resources and programs and create a resource inventory or directory to serve as a reference for clinical service providers and NCD community partners. NCD Collaborative Screening Team, Behavioral Health Dec 2025 Establish a referral pathway so that all persons who are found to have mental health risks on screening can be referred to the appropriate mental health services and providers. NCM, Behavioral Health 2026-2030 Disseminate the resource inventory and referral pathway to all clinical service providers and NCD community partners. NCM, MHHS, NCD coalitions 2026-2030 Risks and mitigation strategies: Risk factor/Threat Mitigation strategies Lack of awareness of the relationship between mental health and NCDs • Raise awareness through community campaigns, social marketing, and advocacy • Find community champions to speak up about the important role of mental health in NCD prevention and control. Lack of knowledge among clinicians to perform rapid mental health screening • Ensure provider trainings in rapid mental health assessments. • Obtain TA from external partners if needed. • Link these trainings to licensure renewals to incentivize clinicians who undergo the training. Poor patient compliance with NCD risk management interventions • Create case management teams for challenging patients. • Track and assess the “no shows” at follow-up clinic encounters and determine the factors for noncompliance. 47 CONCLUSIONS AND RECOMMENDATIONS This NCD Prevention and Control Strategic Plan for 2025-2030 builds upon and updates the previous plan that was originally set for 2015-2020 and extended to 2023 during the COVID pandemic. A committed multisectoral group of NCD stakeholders in both the public and private sectors convened for a 2-½ day strategic planning workshop to assess the progress in implementing the earlier Plan, identify the areas where greater action is needed, and determine the baseline and target indicators and key strategic actions that comprise the new Plan. The group decided to retain the five action areas representing the key NCD behavioral and metabolic risk factors and recommended the addition of a sixth action area to address mental health. Because of the limited time, the workshop participants selected 3-4 priority objectives for each action area to develop into strategic actions with responsible lead agencies/organizations and a timeline. However, the group agreed that the remaining objectives would need to be addressed at a future time. The National Coordinating Mechanism (NCM) for responding to the NCD epidemic in Palau was created by Executive Order 379 in 2015 and continues to play a pivotal role in overseeing action to counter the NCD threat. This committee will continue to be responsible for providing oversight, facilitating mobilization of political commitment and resources, and coordinating the implementation of this new Plan. This body will also coordinate regular monitoring, evaluation, and reporting of those actions identified in the Plan. For efficiency, prevalence indicators have been aligned with existing surveillance instruments, specifically the Hybrid Survey for adults and the Youth Risk Behavior Survey (YRBS) for youth. In the action area of tobacco control, the Palau Youth Tobacco Survey (PYTS) can also yield valuable information; the data from the full report is consistent with the grade levels used in the YRBS. Policy implementation progress can be guided by the Monitoring Alliance for NCD Action (MANA) Dashboard data maintained by the Pacific Islands Health Officers Association (PIHOA). With regards to goals and objectives, whenever possible, these have been aligned with the Global Voluntary NCD Targets and the Pacific Roadmap targets. The key recommendations emerging from this workshop include the following: 1. Include an action area that addresses the interplay between mental health and NCDs and build upon the initial objectives and proposed strategic actions in this Plan. 2. Align indicators to the extent possible with existing surveillance systems to ensure efficiency in data availability. The Hybrid Survey, YRBS and PYTS are conducted regularly, and already have the data collection infrastructure in place. Using measures that are part of these surveys increases the likelihood that the NCM, MHHS and NCD stakeholders are able to track progress systematically over time. 3. Affirm the responsibility of the Working Groups within the NCM of delineating workplans based on the broad strategic directions set out in this Plan to warrant the successful implementation of these interventions so that NCD risks are reduced across the population, and the overall vision of a healthier nation and sub-visions are achieved. 4. Midway between 2025 and 2030, reconvene the NCD stakeholders to conduct a progress assessment, and use the results of this assessment to revise the Plan for the remainder of the implementation period. 5. Sustain the engagement and participation of the various NCD stakeholders and partners through close coordination and periodic communication, spearheaded by the NCM Secretariat. 48 ANNEX 1: PARTICIPANT LIST Name Organization 1 Kalistus Rexid The Angel Center 2 Sylvester Francis Alonz Ministry of Human Resources, Culture, Tourism, and Development- Bureau of Human Resources 3 Nancy Wong Amayong 4 Yoko K. Woodcock Amayong 5 RB Alvarado Angaur State Government 6 Klebokel Moses Angaur State Government 7 Johaina Eledui Apostolic Foundation Church 8 Herman Decherong Apostolic Foundation Church 9 Helgah Sharp Apostolic Foundation Church 10 Neyling Fajardo ASTHO 11 Sara Bell ASTHO 12 Brian Levites ASTHO 13 Alex Wheatley ASTHO 14 Alauddin Alazad Bangladesh Association 15 Mohamad Momen Ullah Bangladesh Association 16 Lucas Salii, Jr. BEEA 17 Lue Cee Kotaro Belau Cancer Society/ Division of Behavioral Health 18 Ma. Lourdes Jack Belau Foreign Spouse Society 19 Salve Sugiyama Belau Foreign Spouse Society 20 Lourdes Funa Belau Foreign Spouse Society 21 Joseph Tiobech Belau Medical Clinic- Wellness Program 22 Nancy Renguul Belau Modekngei School 23 Melina Oiterong Belau Modekngei School 24 Olympia Morei-Remengesau Belau National Museum 25 Pearl Marumoto BMC-Wellness Program 26 Mesiwal Madlutk Bungelkesol-non-government organization 27 David K. Madlutk Bungelkesol-non-government organization 28 Wilfred Williams Cancer Survivors 29 Johanes Thing Cancer Survivors 30 Hana Ngiruchelbad CFTP/JN Services 31 Annabel Lyman Coalition for a Tobacco Free Palau 32 Valerie Whipps Coalition for a Tobacco Free Palau 33 Thelma R. Ngirameketii Coalition for a Tobacco Free Palau 34 Elchesel Wilfred Community Health Center 35 Salustia Mira Community Health Center 36 Loretta Shmull Eldebechel ra NgaraBlod 37 Shirley Tirso Family Health Unit 38 Annette David Guam SEOW 39 Jessica Yamauchi Hawaii Public Health Institute 40 Makamae Namahoe Hawaii Public Health Institute 41 Fumitoshi Yano JICA Palau 42 Lorraine Rivera Kotel a Deurreng 43 Philomena Temengil Kotel a Deurreng 44 Rosalynne Florendo MCH State Family Leader 45 Bilung Gloria Salii Mechesil Belau 49 46 Margarette Williams Mechesil Belau 47 Carol Emaurois Mechesil Belau 48 Sara Sugiyama Meyuns Elementary School 49 Obechou K. Mereb Mindzenty High School 50 Dean Terry Ministry of Education 51 Hilda Kenzio Ministry of Education- Health 52 Sharnnel D. Sumang Ministry of Finance 53 Dr. Isau Mekoll Ministry of Health & Human Services 54 Dr. Vijayananda Sundara Ministry of Health & Human Services 55 Edolem Ikerdeu Ministry of Health & Human Services 56 Justice Taima Ministry of Health & Human Services 57 Sheliza Ngirturong Ministry of Health & Human Services 58 Dr. Glenda Santos Ministry of Health & Human Services 59 Bisau Ngiraidong Ministry of Health & Human Services - Policy Research Development 60 Leona Teblak Ministry of Health & Human Services- Community Health Worker 61 Calvin Johanes Ministry of Health & Human Services- Division of Environmental Health 62 Ribka Kintaro Ministry of Health & Human Services- Division of Human Services 63 Imee Pedro Ministry of Health & Human Services- Division of Human Services 64 Loretta Philip Ministry of Health & Human Services- Family Health Unit 65 Tino Faatuuala Ministry of Health & Human Services- Kitchen Department 66 Dr. Nihla Reddin Ministry of Health & Human Services- Oral Health 67 Antonnette Merur Ministry of Health & Human Services- Palau Nurse Association 68 Sherilyn Madraisau Ministry of Health & Human Services- Public Health 69 Jason Nolan Ministry of Health & Human Services- Rehab Department 70 Ulang Ngirchemat Ministry of Health & Human Services-Bureau of Health System Administration 71 Arnice Yuji Ministry of Health & Human Services-Bureau of Health System Administration 72 Litang Kelmal Ministry of Health & Human Services-Community Health Worker 73 Leilanin Otiwii Ministry of Health & Human Services-Community Health Worker 74 Aileen Kingya Ministry of Health & Human Services-Community Health Worker 75 Chelsea Ngirchokebai Ministry of Health & Human Services-Community Health Worker 76 Keryan Roman Ministry of Health & Human Services-Community Health Worker 77 Jenalyn Jesse Ministry of Health & Human Services-Community Health Worker 78 Mayva Masters Ministry of Health & Human Services-Community Health Worker 79 Germaine Beltau Ministry of Health & Human Services-Community Health Worker 80 Dr. Irene Naito Ministry of Health & Human Services-Community Health Worker 81 Leah Moses Ministry of Health & Human Services-Community Health Worker 82 Wickliff Ingais Ministry of Health & Human Services-Community Health Worker 83 Athena Stephanus Ministry of Health & Human Services-Community Health Worker 84 Gandercia Tarkong Ministry of Health & Human Services-Community Health Worker 85 Danjela Sikong Ministry of Health & Human Services-Community Health Worker 86 Didbed Ulechong Ministry of Health & Human Services-Community Health Worker 87 Leila Joseph Ministry of Health & Human Services-Community Health Worker 88 Missy Remurang Maximo Ministry of Health & Human Services-Community Health Worker 89 Laeticia Sekool Ministry of Health & Human Services-Community Health Worker 90 Avis Otei Ministry of Health & Human Services-Community Health Worker 91 Erur Francisco Ministry of Health & Human Services-Community Health Worker 50 92 Bailechesel OJ Tumechub Ministry of Health & Human Services-Division of Behavioral Health 93 Stephanie Tmodrang Ministry of Health & Human Services-Division of Environmental Health 94 James Remengesau Ministry of Health & Human Services-Division of Human Services 95 Hera Subediang Ministry of Health & Human Services-Division of Human Services 96 Mindy Sugiyama Ministry of Health & Human Services-DPPHS 97 Minister Gaafar Uherbelau Ministry of Health & Human Services-Minister 98 Darla Rengulbai Ministry of Health & Human Services-NCD Unit 99 Bonnie Rengiil Ministry of Health & Human Services-NCD Unit 100 John Sadao Ministry of Health & Human Services-NCD Unit 101 Adeline Santos Ministry of Health & Human Services-NCD Unit 102 Verna Kyota Ministry of Health & Human Services-NCD Unit 103 Joyce Antonio Ministry of Health & Human Services-NCD Unit 104 Selma August Ministry of Health & Human Services-NCD Unit 105 Norie Funaki Ministry of Health & Human Services-NCD Unit 106 Carla Ngirailemesang Ministry of Health & Human Services-NCD Unit 107 Geggy Baiei Ministry of Health & Human Services-NCD Unit 108 Janice Mathew Ministry of Health & Human Services-Oral Health 109 Violet Rengulbai Ministry of Health & Human Services-Prevention Unit 110 Candance Koshiba Ministry of Health & Human Services-Prevention Unit 111 Israella Y. Reklai Ministry of Health & Human Services-Prevention Unit 112 Dilsiich D. Maui Ministry of Health & Human Services-Prevention Unit 113 Sergio Ngiraingas Ministry of Health & Human Services-Prevention Unit 114 Athena Mengloi Ministry of Health & Human Services-Prevention Unit 115 Sanya Olkeriil Ministry of Justice 116 M. Nabeyama Ministry of Justice 117 Kenny Sengebau Ministry of Justice 118 Benedict Kintaro Ministry of Justice 119 Ariel Dirkedil Siang Ministry of Agriculture, Fisheries and the Environment 120 Akira Samsel Ngerbuns Club 121 Valerie Stephanus NSBY 122 Joe Aitaro Office of Climate Change 123 Omdasu T. Ueki Office of the President 124 Asterio Takashi Office of Vice-President 125 Lynn Kailang OMEKESANG 126 John Takisang OMEKESANG 127 Elenita Brel Palau Behavioral Health Advisory Council 128 Harline Haruo Palau Community College 129 Juliet Ngotel Palau Evangelical Church 130 Kenneth Mereb Palau Formosa Livestock Association 131 Rose Ongalibang Palau Formosa Livestock Association 132 Jill Senior Palau Media Council/OTV 133 Todd Ngiramengior Palau National Baseball League 134 Stephanie Ngirchoimei Palau National Olympic Committee 135 Jerry Nabeyama Palau NCD Free Club 136 Jocelyne Tonyokwe Palau Nurse Association 137 Sayuri Okada Palau Parent Empowered 138 Elilai Ngirmang Palau Parent Empowered 139 Francesca Morei Misch Palau Parents Empowered 140 Germaine Yaoch Palau SDA School 51 141 Judy Otto Palau Swimming Association/ Palau Animal Welfare Society 142 Kenji Dengokl Palau-NCD Free Club 143 Balkuu Sandario Parole Board 144 Wridon Ngiralmau PCHC 145 Hirono Sasaki Peace Wind 146 Griselda Gates PEC Gospel Kindergarten 147 Dodger Kumangai PECSS 148 Dr. Sylvia Osarch Physician 149 Maria Rehuher PTFA 150 Karya Lustig Public Health Institute 151 Laura I. Miles Sonsorol State Women Organization 152 Benjamin Tsai Taiwan Technical Mission 153 Kelvin Chen Taiwan Technical Mission 154 Charito I. Ililau TFCP 155 Divina Caldern TFCP 156 Danka Ledgerwood The Angel Center 157 Elizabeth Harong The Angel Center 158 Leonard Basilius UAK/PCAA 159 Uong Yalap UN ESCAP 160 Sharon Sakuma United Nations Office 161 Chelsea Pedro West Care Pacific Is. Inc. 162 Shanetty Masang West Care Pacific Is. Inc. 163 Tublai Ililau West Care Pacific Is. Inc. 164 Jacqui Alexander YWAM 165 Violet Fernando Community member 52 ANNEX 2: EXECUTIVE ORDER NO. 484 53 54 55 56 AREA OF ACTION 2025-2030: TOBACCO CONTROL ANNEX 3: ANNUAL ACTION PLAN YEAR 1: JANUARY – DECEMBER 2025 Objective 1: By 2025, achieve full compliance with the other demand reduction provisions of the WHO FCTC Articles 8 -protection from exposure to tobacco smoke, 11- packaging and labelling of tobacco products, and 13 - tobacco advertising, promotion and sponsorship). Strategic Action Tasks Start Date End Date Deliverables Status Review drafted amendments Reach out for legal consultant to review amendments (previously drafted) Jan. 2025 March 2025 Input from legal expertise Develop and implement a comprehensive communications strategy and plan to effectively identify and engage targeted stakeholders (e.g. champions in the OEK) and raise awareness about the specific demand reduction provisions being targeted. Identify and engage/contract person(s) to develop the strategy July 2025 Dec. 2025 Communications strategy is developed Meet and present proposed amendments to relevant committees in OEK. Identify and contact champions in the OEK March 2025 May 2025 Resources needed $5,000 Responsible party CTFP/tobacco working group 57 Objective 2: By 2026, establish the infrastructure and capacity for tobacco dependence treatment/cessation services (per WHO FCTC Article 14 tobacco dependence and cessation). Strategic Action Tasks Start Date End Date Deliverables Status Identify and recruit a national cessation coordinator (focal person) • CTFP, PH Director/NCM Co-Chair meet to discuss job requirements and strategic steps to recruit • Secure NCM commitment & funding • Post vacancy • Interviews/recruitment Jan 2025 May 2025 • Meeting notes • Job description drafted • NCM budget allocation • Vacancy announcement Finalize and present landscape analysis that outlines cessation services currently available and service gaps that need to be addressed. • Review previous reports by consultants and summarize findings and recommendations • Present to MHHS Jan 2025 Feb 2025 Final report Develop and adopt the National Cessation Policy based on landscape analysis. CTFP, REACH, Prevention Unit meet to develop a draft policy Meet with Minister of MHHS to gain input and support for such a policy Minister presents draft policy to the President for endorsement as national policy Share & promote policy with stakeholders Feb. 2025 May 2025 Policy formally endorsed & adopted by the President Finalize tobacco, nicotine, betel nut use policy for MHHS • Solicit input/comment from CTFP (tobacco working group) on draft policy • Present policy to Director of Public health to gain input and support • Director to present final draft to Minister of HHS for endorsement • Develop and implement a communication plan to promote the policy to MHHS, patients and visitors to all MHHS facilities and properties Jan 2025 May 2025 Policy endorsed and adopted by Minister of MHHS. Adopt and disseminate national cessation treatment guidelines to primary health care, public health, hospital and community settings. Convene stakeholders to finalize and adopt work accomplished to date on the draft set of guidelines for primary health care, public health, hospital and community settings March 2025 May 2025 Finalized guidelines Resources needed $50,000 (includes recruitment, development and implementation of guidelines, promotions, etc.) Responsible parties NCM, MHHS, CTFP 58 Objective 3: By 2026, Palau will adopt measures to protect public health policies from commercial and other vested interests of the tobacco industry. Strategic Action Tasks Start Date End Date Deliverables Status Explore options through legislation or amendments to government Civil Service Rules and Regulations/Code of Ethics to prevent TI interference with public health policy • Consult with TI interference working group (MHRTCD and offices of the Ethics Commission, of the President and the Attorney General) • Reach out for legal consultant to draft amendment language regarding tobacco industry for tobacco control & present to OEK. Jan. 2025 June 2025 Review of options to take and a decision is made Amend Palau’s tobacco control legislation to prohibit TI corporate social responsibility (CSR) activities. Reach out for legal consultant to review amendments (previously drafted) Jan. 2025 March 2025 Amendments drafted Meet and present proposed amendments regarding CSR, to relevant committees in OEK. March 2025 May 2025 Draft amendments proposed Develop & implement a comprehensive communications strategy and plan to effectively engage stakeholders, raise awareness about the issue of industry interference and the importance of rejecting tobacco industry interference in Palau’s public health policies and ensure timely dissemination of information. Identify person to develop communication strategy for TI Interference (flyers, infographics, media/social media plan, etc.) Implement communication plan Jan. 2025 March March 2025 ongoing Communications strategy developed Resources needed $5,000 Responsible party CTFP, MHHS (for information dissemination) 59 Objective 4: By 2026, amend tax legislation to ensure periodic increases in tobacco taxes adjusted to inflation thereby reducing the affordability of tobacco products Strategic Action Tasks Start Date End Date Deliverables Status Review existing tobacco tax legislation and prepare an updated draft Reach out for legal consultant to draft amendment language for tobacco control & present to OEK. Jan. 2025 March 2025 Draft legislation developed Collect supporting information and data Collect accurate evidenced based reports/GDP affordability. July 2025 Dec. 2025 Develop and implement a comprehensive communications strategy and plan to effectively engage stakeholders, raise awareness about our initiatives, and ensure transparent, timely dissemination of information Identify person to develop communication strategy for TI Interference (flyers, infographics, media/social media plan, etc.) Implement communication plan June 2025 Dec 2025 Resources needed $5,000 Responsible party MHHS, CTFP/tobacco working group 60 Associated Objective 1: By 2026, formalize an interagency coalition for alcohol use and abuse prevention and control with terms of reference that convenes on a regular basis. Strategic Action Tasks Start Date End Date Deliverables Status Identify potential community champions to lead the coalition and identify potential stakeholders and partners. • Draft initial letter; send letter to potential stakeholders, partners and community champions. • Meet with partners and stakeholders to get buy-ins. • Schedule meeting; draft Calendar of Events. Jan 2025 Dec 2025 1. Finalized/a pp roved TOR Finalized/appr oved MOUs/SOPs Convene the local interagency multisectoral coalition to develop their TORS and SOPs. • Convene meeting with interagency coalition members; develop TOR & SOP. • Finalize TOR & SOP Jan 2025 Dec 2025 Create MOUs between agencies to formalize their membership in the coalition. • Draft/review MOUs. • Finalize MOUs. Jan 2025 Dec 2025 Draft the coalitions workplan to address the goals above. Incorporate the previous plans alcohol control objectives into the work plan. Convene workshop to develop workplan; finalize/endorse workplan. Jan 2025 Dec 2025 Regularly report on progress to the NCM Send progress report to NCM. Jan 2025 Dec 2030 Resources needed Meeting expenses, TA-Workplan, TOR, MOU, and SOP. Responsible party AREA OF ACTION 2025-2030: REDUCING HARMFUL USE OF ALCOHOL 61 Associated Objective 2: By 2026, enhance/strengthen enforcement of laws prohibiting sales of alcohol to minors by requiring mandatory ID verification of age of all buyers. Strategic Action Tasks Start Date End Date Deliverables Status Identify and convene the agencies and partners involved in implementing the existing law into Steering Committee • Draft sending invitation letters to partners and agencies into the Steering Committee. Jan 2025 Dec 2025 Invitation letters drafted Review the existing law/regulations to identify the gaps. • Convene meeting with partners to review existing Jan 2025 Dec 2025 • Law/regulation and identify gaps. • Seek Legal Adviser to support on reviewing documents. Meeting conducted. Allocate sufficient resources and manpower for enforcement. • Advocate for resources (amongst Interagency Coalition) to support Enforcement Agencies. Jan 2025 Dec 2025 Resources needed Meeting expenses, TA-Workplan, TOR, MOU, and SOP. Responsible party Associated Objective 3: By 2030, increase alcohol free cultural and social functions (customary events). Strategic Action Tasks Start Date End Date Deliverables Status Advocate and educate the public about alcohol-free events. Develop Public Service Announcements to promote, educate and encourage Community to create alcohol- free events. Jan 2025 Dec 2025 Developed PSAs; Meeting conducted; Report shared to public Promote the alcohol-free Night Market as a good practice example across the different States. Meet and collaborate with Palau visitors Authority to promote Night market as “alcohol-free event”. Encourage each State/country to create local alcohol-free events laws. Create banners with message “alcohol-free event”. Assign an agency to collect and evaluate data on alcohol-free community events. Assign agency to collect, evaluate and report data on alcohol-fee events in the community. Resources needed Meeting Expenses, materials to develop PSAs, banner, and other educational materials. Responsible party 62 Associated Objective 4: By 2030, earmark a portion of the alcohol tax revenues for regulatory enforcement and other relevant authorities. Strategic Action Tasks Start Date End Date Deliverables Status Identify champion in congress to propose earmarking a portion of alcohol tax revenues for enforcement. • Draft a letter requesting to meet with Senate Committees on Health & Social Welfare/ Community, culture, Youth & Sprots, and House Committees on Health, Social & Cultural Affairs and Education & Youth Affairs. • Meet with OEK Committee members to discuss plan. • Identify Champions, meet at least 1 or 2 from Senate and House. Jan. 2025 Dec 2025 Drafted/Deliver ed Letters; Meeting conducted; Champions identified Resources needed Meeting expense Responsible party Description Results Working Group Name Alcohol Prevention & Control Working Group Meetings Coordinating Meeting Lead Chief Sylvester Alonz Reporting Lourdes Funa Resources Needed Meeting expense, training/TA on workplans, TOR, Etc., educational materials. 63 AREA OF ACTION 2025-2030: IMPROVING NUTRITION Associated Objective 1: By 2030, convene a multisectoral workgroup to address overall nutrition improvement activities in Palau quarterly. Strategic Action Tasks Start Date End Date Deliverables Status Identify potential existing and new members. 1. Identify existing members. 2. Identify and engage. potential new members. 3. Convene members. Feb 2025 Feb 2025 List of members Letter of invites Schedule meeting Develop a Term of Reference 1. Formalize roles, responsibilities, and membership *Develop and an organization & operation structure Mar 2025 Mar 2025 Endorse TOR Develop and an organizational & operation structure 1. Draft organizational & operation structure 2. Review and finalize 3. Endorse SOP Mar & Apr 2025 Apr 2025 SOP Resources needed Meeting spaces and expenses, TOR and SOP Templates Responsible party Associated Objective 2: From 2025 to 2030, enhance nutrition education in schools, workplaces, and communities by adding 5 sites per year. Strategic Action Tasks Start Date End Date Deliverables Status Create a working group • Identify and create a working group • Invite members • Convene working group meeting Jan 2025 Feb 2025 List of members Schedule meeting (Include Traditional Members) Review existing curriculum and guidelines Identify/locate existing curriculum and guidelines. Feb 2025 May 2025 Review and revise • Review & revise • Adopt curriculum May 2025 Dec 2025 Resources needed Meeting spaces and expenses Responsible party Description Results Working Group Name Nutrition Working Group: Edolem Ikerdeu, Heather Ketebengang, Mia Kuartei, Charlene Mersai, Tino Faatuuala, Hera Subediang, Kelvin Chin, Norie Funaki, Joyce Antonio, and Adeline Santos. Meetings Coordinating Meeting Lead Verna Kyota Reporting Resources Needed 64 Associated Objective 1: By 2025, develop standardized indicators & methods & data collection, analysis, and dissemination for active living in Palau. Strategic Action Tasks Start Date End Date Deliverables Status Identify specific indicators for active living starting with physical activity indicators that already included in existing surveillance instruments (e.g. Hybrid Survey, YRBS). If additional data is needed develop monitoring and evaluation tools (e.g. questionnaires, surveys) to capture data. The Physical Activity working group have developed monitoring and evaluation tool for Physical activity based on the indicators for active living. March 2025 May 2025 Surveys, questionnaires PAWG will develop standard operation procedures (SOPs) on data collection and analysis. The Physical Activity working group establishes SOPs on developed on monitoring and evaluation tool. March 2025 May 2025 SOP PAWG will develop trainings and capacity building programs that will empower stakeholders for data dissemination. • To assess stakeholders’ capacity of disseminating data. • Set the dates and venue for training and capacity building. June 2 025 July 2025 Assessment results Sign-up sheet Evaluation workshop Identify and secure resources to develop data collection analysis and dissemination. Develop monitoring and evaluation framework to assess and measure progress Resources needed Responsible party Associated Objective 2: By 2030, 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. Strategic Action Tasks Start Date End Date Deliverables Status Introduce events (once per quarter) in all schools that integrate physical activity for all students. Include Work in collaboration with partners to identify percentage of children with special needs. Aug 2025 Dec 2025 Access and resources for student with disabilities. To identify the number of students with special needs at risk of obesity. Percentage of children with special needs Resources needed Responsible party AREA OF ACTION 2025-2030: INCREASING PHYSICAL ACTIVITY (PA) 65 Associated Objective 3: By 2030, at least 50% of government offices and private sector enterprises will have adopted a Worksite Wellness Program that incorporates a holistic approach that includes tobacco free policies and programs, good nutrition, alcohol control, and regular physical activity. Strategic Action Tasks Start Date End Date Deliverables Status Identify key business leaders for the private sector. Write an invitation letter and disseminate to private sector to identify business leaders. Jan. 2025 Jan. 2025 Letters List of Members Sign-up Sheet Meeting minutes Confirm members and convene first meeting. Jan. 2025 Jan. 2025 The PAWG will initiate work on the model. July 2026 2026 Resources needed Responsible party Associated Objective 4: By 2025, a formal physical activity & sports working group to address prioritize active living among youth & adults in Palau is convening regularly. Strategic Action Tasks Start Date End Date Deliverables Status Identify key partners. Invitation to key partners to confirm membership is distributed. Dec 2024 Jan 2025 Letters of invitation and confirmation Minimum 9 members in the working group. Convene first meeting with working group. Jan 2025 Jan 2025 Sign-up sheet, meeting minutes, calendar Resources needed Logistic administrative support, meeting venue, funding for supporting the meeting. Responsible party Description Results Working Group Name Physical Activity Working Group Meetings Coordinating Meeting Lead Dean Terry Reporting Resources Needed 66 Associated Objective 1: By 2030, maintain a multi-disciplinary team with community clinical linkages in place to address the prevalence of NCD’s in Palau, with quarterly meeting Strategic Action Tasks Start Date End Date Deliverables Status Establish and formalize a multi- disciplinary team. Identify new key partners/stakeholders. Jan. 2025 Jan 2025 Multi- Disciplinary Team Convene meeting with key partners and discuss goals and objectives. Feb 2025 Feb 2025 Develop and finalize annual workplan with roles and responsibilities. Mar 2025 Mar 2025 Develop quarterly calendar meeting. April 2025 Apr 2025 Implement plan May 2025 May 2026 Resources needed Meeting expenses and compensation Responsible party Associated Objective 2: By 2025, reduce the prevalence of raised blood pressure among adults by 15%. Strategic Action Tasks Start Date End Date Deliverables Status Develop, finalize, and implement hypertension guidelines specific to the population. Integrate WHO “Best Buys” for hypertension into the guidelines. Identify new key partners/stakeholders. Jan. 2025 Jan 2025 Multi- disciplinary Team Convene meeting with key partners and discuss goals and objective. Feb 2025 Feb 2025 Develop and finalize annual workplan with roles and responsibilities. Mar 2025 Mar 2025 Develop quarterly calendar meeting. April 2025 Apr 2025 Implement plan May 2025 May 2026 Ensure all health service providers use the hypertension guidelines for screening, diagnosis, treatment, and follow up high blood pressure. Implement HTN guideline at all points of entry. July 2025 Ongoing Develop standardized data collection, recording, sharing and dissemination process for all partners who conduct blood pressure screenings. Compile and review any existing SOPs for data management. Jan 2025 Feb 2025 Develop and finalize data management tool that allows for interoperability between existing data system Mar 2025 Apr 2025 AREA OF ACTION 2025-2030: METABOLIC RISK FACTOR 67 Pilot data management tool. May 2025 Jun 2025 Adopt and implement the data management tool. July 2025 Ongoing Assess utilization of data management tool. Dec 2025 Dec 2025 Create a communications plan to determine the health messaging for promoting healthy lifestyles and maintaining normal blood pressure levels. Develop a communication plan with key messages & implement according to plan Jan 2025 Jun 2025 Coordinate community outreach and education/information dissemination using an outreach calendar. Convene meeting with NCD screening team and develop outreach calendar. Jan 2026 Jan 2026 Resources needed Meeting expenses and TA from outside partners Responsible party Associated Objective 3: By 2030, reduce the prevalence of raised Hba1c among adults by 15%. Strategic Action Tasks Start Date End Date Deliverables Status Review current social marketing and awareness campaigns focusing on risk factors causing raised blood glucose and update them to address all the relevant NCD risk factors that affect blood sugar levels. In particular, include the role of tobacco use in diabetes causation, and the impact of mental health on diabetes treatment compliance. Review existing social marketing and revise if necessary. Jan. 2026 Jan 2026 Multi- disciplinary Team Incorporate diabetes self- management education in all primary care, NCD and wellness clinic encounters. Implemented in clinic. Started Ongoing Identify the pre-diabetic population and refer them to self-management programs Identifying pre-diabetic population through community screenings and referring to self-Management program (i.e. DPP program) Started Ongoing Number of pre- diabetic individuals referred Address barriers to compliance with blood sugar lowering regimens through chart reviews and surveys and address the barriers to good blood glucose control. Identify assessment tool used to address barriers to compliance (i.e. PDSA tool) Sept 2023 Ongoing Number of patients surveyed and assessed Resources needed Meeting expenses and TA from outside partners Responsible party 68 Associated Objective 4: By 2030, reduce the prevalence of overweight/obesity. Strategic Action Tasks Start Date End Date Deliverables Status Coordinate with existing programs, such as school-based health programs, to promote healthy weight strategies among youth. Objective 3 will begin Fall 2025. Description Results Working Group Name Working Group Members Metabolic Risk Factor Working Group Dr. Myra Adelbai, Verna Kyota, Salustia Mira, Elchesel Wilfred, Violet Rengolbai, Laura Miles, and Kendal Titiml. Meetings Coordinating Meeting Lead Dr. Myra Adelbai and Selma August Reporting Resources Needed AREA OF ACTION 2025-2030: MENTAL HEALTH Associated Objective 1: By 2025, mental health is incorporated into NCD education, outreach, social marketing, and communications campaigns. Strategic Action Tasks Start Date End Date Deliverables Status Coordinate with Behavioral Health to develop educational and outreach materials that address the link between mental health and NCDs. Form educational and outreach materials working group. Apr 2025 Apr 2025 Working Group Educate working groups on the link between mental health and NCDs. May 2025 May 2025 Concept of the link between mental health and NCDs. Develop educational and outreach materials. Jun 2025 Jun 2025 Educational and outreach materials Resources needed Training & Technical Assistance Responsible party 69 Associated Objective 2: By 2025, mental health is incorporated into NCD education, outreach, social marketing, and communications campaigns. Strategic Action Tasks Start Date End Date Deliverables Status Work with Behavioral Health to develop clinical protocols for mental health screening in the clinical setting and NCD clinics. Assess existing protocol for mental health screening. Jun 2025 Jun 2025 Protocols in place Update protocols. Jul 2025 Jul 2025 Updated protocols Train Trained personnel Resources needed Training & Technical Assistance Responsible party Associated Objective 3: By 2026, a referral pathway utilizing existing mental health resources and programs is in place in to provide diagnostic and therapeutic support, and counseling, for persons at risk for mental disorders. Strategic Action Tasks Start Date End Date Deliverables Status Work with Behavioral Health Identify existing programs and Jan 2025 Mar 2025 Registry list of to identify existing mental services that are active. resources health resources and programs and create a resource inventory or directory to serve as a reference for clinical service Review and update resources and programs Apr 2025 May 2025 Updated resources providers and NCD community partners. Resources needed Responsible party Description Results Working Group Name (Members) Elenita Brel; Francesca Morei-Misech; Dilsils Kanai; Cecilia Olikong; Lue Cee Kotaro; Godfrey Sandario; Israella Y. Reklai; Glenda Mechadelchutem; Germaine Beltau; Mayva Masters; OJ Tumechub; Jayvee Grapa, Chelsea Pedro Meetings 1st Meeting on December 05, 2024 Coordinating Meeting Lead Lue Cee Kotaro Reporting Resources Needed MESSAGE FROM THE PRESIDENT OF THE REPUBLIC OF PALAU Alii! I am happy to endorse the Republic of Palau's Non-Communicable Diseases (NCDs) Strategic Plan 2025-30, a significant initiative dedicated to improving the health of the people of Palau. Non-communicable diseases remain among the leading causes of death of our population, and the strategic plan strengthens public health response to the crisis. The NCD program directly addresses pressing health challenges such as obesity, diabetes, and cardiovascular diseases. It embraces a comprehensive approach to prevention, early detection, and management of chronic conditions. Through awareness campaign... Our healthcare professionals and staff are committed to providing high-quality care and support to individuals and families affected by NCDs. Their dedication to public service ensures the successful implementation of the strategic plan. The NCD program offers numerous benefits for Palau, including improved overall health and quality of life for citizens, reduced prevalence and severity of NCDs, increased awareness of healthy lifestyles, and accessible healthcare services. On behalf of the people of Palau, I extend our heartfelt gratitude and appreciation to the Ministry of Health and Human Services for leading the charge in addressing this critical health issue. Your unwavering efforts have undoubtedly contributed to a... With your support, the NCD program will continue to make a lasting difference in the lives of our people. Together, we can create a healthier, happier Palau. For more information or to get involved in the NCD program, please contact the Ministry of Health and Human Services. Sincerely, MESSAGE FROM MECHESIL BELAU MESSAGE FROM THE MINISTER OF HEALTH AND HUMAN SERVICES MESSAGE FROM COMMUNITY PARTNERS ACKNOWLEDGEMENTS EXECUTIVE SUMMARY Participants at the Palau NCD Progress Dissemination and Strategic Planning Workshop, April 2024 BACKGROUND METHODOLOGY AND WORKSHOP OBJECTIVES RESULTS The five working groups representing the five action areas of the Plan reviewed progress in detail, examining each of their specific objectives to determine the extent of attainment of these objectives. Specific objectives that have been achieved were... The teams then assessed if any new specific objectives need to be added for the next Plan, based on current data and developments in the policy and program environment. The results of these sessions are highlighted in the following tables PROGRESS TOWARDS THE 2020 NCD RISK FACTOR TARGETS PROGRESS TOWARDS THE 2020 OBJECTIVES OVERALL VISION AND SUB-VISSIONS 2025-2030 AREA OF ACTION 2025-2030: TOBACCO CONTROL Sub-vision: Thriving people and a vibrant island nation free from the harms of tobacco and nicotine Specific Objectives: Strategic Actions: Risks and mitigation strategies: AREA OF ACTION 2025-2030: REDUCING HARMFUL ALCOHOL USE Sub-vision: Rich, healthy, tobacco and nicotine-free islands Goal: Reduce overall tobacco consumption by 30% by 2030 Specific Objectives: Strategic Actions: Risks and mitigation strategies: AREA OF ACTION 2025-2030: IMPROVING NUTRITION Sub-vision: “A Kelel Belau a Didichel a Klukuk” - Breast-fed and well fed with local food Specific Objectives: Strategic Actions: Risks and mitigation strategies: AREA OF ACTION 2025-2030: INCREASING PHYSICAL ACTIVITY (PA) Sub-vision: A beautiful and safe Palau where physical and social environments invite active living Goals: Reduce physical inactivity among children, youth, and adults by at least 10% by 2030 Specific Objectives: communication strategies and infrastructure development to invite active living. This includes: Strategic Actions: Risks and mitigation strategies: AREA OF ACTION 2025-2030: REDUCING METABOLIC RISK FACTORS Goals: Decrease the prevalence of the major NCDs – heart disease, cancer, diabetes, and chronic obstructive pulmonary disease - by at least 10% by 2030 through a reduction in the prevalence of the major metabolic risk factors preceding these NCDs. Specific Objectives: Strategic Actions: Risks and mitigation strategies: AREA OF ACTION 2025-2030: MENTAL HEALTH Sub-vision: An island community where mental health is valued, and mental wellness exists for all Goal: Promote mental well-being and decrease the prevalence of symptoms of mental disorders by 30% by 2030 Specific Objectives: Strategic Actions: Risks and mitigation strategies: CONCLUSIONS AND RECOMMENDATIONS ANNEX 1: PARTICIPANT LIST ANNEX 2: EXECUTIVE ORDER NO. 484 ANNEX 3: ANNUAL ACTION PLAN YEAR 1: JANUARY – DECEMBER 2025 AREA OF ACTION 2025-2030: IMPROVING NUTRITION AREA OF ACTION 2025-2030: MENTAL HEALTH AREA OF ACTION 2025-2030: INCREASING PHYSICAL ACTIVITY (PA)