By Melliza Young, MD, MSGH, CDCES, CHCQM, FABQAURP
November is an exciting time of the year for all diabetes advocates across the country and worldwide. It marks National Diabetes Awareness Month, 1 emphasizing the assembly of the diabetes health care team in the provision of person-centered care, and World Diabetes Day, 2 which focuses on facilitating access to quality diabetes education for both the health care team and people living with diabetes. This month is also a great time to acknowledge a decade of monumental efforts by the Pacific Island communities, particularly among the United States (US)-affiliated Pacific Islands (USAPI), in addressing the burden of the diabetes epidemic and overcoming health disparities.
The healthcare challenges facing USAPI communities
The USAPI communities are comprised of jurisdictions from the flag territories of American Samoa, Commonwealth of the Northern Mariana Islands and Guam, and the freely associated states of Federated States of Micronesia, Republic of Marshall Islands and Republic of Palau. Collectively, the USAPI has a population of about half a million people. However, with the perpetual challenges to its health care systems due to its “geographic isolation, shortages of health care professionals, dependence on U.S. and international aid, and persistent health care funding constraints”, 3 it has some of the highest rates of non-communicable diseases (NCD) in the world.
Among the NCDs, the prevalence of diabetes in USAPI jurisdictions was noted to be persistently higher compared to the U.S. population. Even in the most recent 2019 data from the Institute for Health Metrics and Evaluation, 4 the prevalence of type 2 diabetes in the US is 11.64% compared to 19.44% in American Samoa, 13.98% in CNMI, 16.14% in the RMI, and 17.99% in the Republic of Palau. Although the 2019 data from Guam and FSM revealed a lower prevalence of type 2 diabetes at 9.15% and 10.45% respectively, from 2010 to 2019, diabetes rose to the third rank in both Guam and FSM in terms of cause for years lived with disability compared to a stable fifth ranking in the U.S. 5
Despite emerging evidence that diabetes self-management education and support (DSMES) improves outcomes among persons with diabetes and cardiometabolic conditions, the culturally diverse USAPI jurisdictions have limited access to such programs. For example, in 2019 data from the Centers for Disease Control and Prevention (CDC), the proportion of adults in Guam with diagnosed type 2 diabetes who have taken a diabetes self-management course was only at 46.6%, compared to 54.6% in the U.S. 6
The development of the Pacific Care Model
Despite these challenges, the USAPI communities have proven their resilience, collaborative skills and innovative thinking to overcome systemic health disparities through the adaptation of the evidence-based Pacific Care Model. This model serves as a framework that consists of: (1) the outrigger canoe which represents prepared and proactive health care teams, community and health systems, as well as an informed, empowered patient and family connected via effective communication and patient-centered services; and (2) six navigating stars that provide expert knowledge and guidance such as decision support, delivery system design, community resources and partnerships, clinical information systems, health care organizations and self-management support. 7 The Pacific Care Model also steered the creation of a multidisciplinary NCD Collaborative Team between community health centers and hospital-based systems comprised of physicians, clinical support staff, community health outreach workers, data clerks and an administrator.
Through the NCD Collaborative Team’s concerted efforts, diabetes management and prevention programs were initiated and sustained in the USAPI jurisdiction’s target population. From a pilot study in 2016, the collaboration led to median improvements in A1c by 1.4%, 14% improvement in blood pressure control, 72% for annual foot exams and 76% for self-management goal setting. 8 Regular learning sessions enabled the multidisciplinary NCD Collaborative Team members to freely share and learn from each other’s experiences, challenges and accomplishments. More importantly, the learning sessions provided a platform for NCD Collaborative Team members to incorporate their cultural identity and feel empowered to build sustainable solutions for health care system change.
The NCD Collaborative Team’s continued engagement using the Pacific Care Model framework led to significant progress in strengthening the USAPI regional health care system. 9 Partnerships expanded to include training of health care workers in addressing lower extremity amputation prevention and management of regional diabetes patient registries. Because of the high co-existence of tobacco use and tuberculosis among persons with diabetes in the USAPI, loco-regional practice guidelines were also established in their screening and treatment. Furthermore, the participatory process embraced by the NCD Collaborative Team led to the development of a culturally relevant DSMES curriculum for the USAPI population–Navigating the Course of Diabetes Self-Care.
Because of the impact of the COVID-19 pandemic in health care systems, the NCD Collaborative Team’s monumental progress over the last decade may have temporarily stalled. But despite competing priorities from COVID-related activities and shifting to virtual learning sessions, the engagement of USAPI leadership and the NCD Collaborative Team remained solid. As long as the integrity of the collaborative learning approach and participatory process endures through the Pacific Care Model, the NCD Collaborative Team will keep their paddles strong in the water no matter where the tide takes them.
- National Institute of Diabetes and Digestive and Kidney Diseases, 2022. National Diabetes Month 2022 [online]. Available at https://www.niddk.nih.gov/health-information/community-health-outreach/national-diabetes-month. [Accessed on November 7, 2022]
- International Diabetes Federation, 2022. About World Diabetes Day [online]. Available at https://worlddiabetesday.org/about/theme/. [Accessed on November 7, 2022]
- Hosey G, Aitaoto N, Satterfield D, Kelly J, Apaisam CJ, Belyeu-Camacho T, et al. The culture, community, and science of type 2 diabetes prevention in the US Associated Pacific Islands. Prev Chronic Dis 2009;6(3). http://www.cdc.gov/pcd/issues/2009/ jul/08_0129.htm.
- Institute for Health Metrics and Evaluation, 2022. GBD Compare [online]. Available at https://vizhub.healthdata.org/gbd-compare/. [Accessed on November 11, 2022]
- Institute for Health Metrics and Evaluation, 2022. GBD Compare [online]. Available at https://vizhub.healthdata.org/gbd-compare/#0. [Accessed on November 11, 2022]
- Centers for Disease Control and Prevention, 2022. Chronic Disease Indicators, Category: Diabetes, overall, age-adjusted prevalence 2019 [online]. Available at https://nccd.cdc.gov/cdi/rdPage.aspx?rdReport=DPH_CDI.ExploreByTopic&islTopic=DIA&islYear=9999&go=GO. [Accessed on November 11, 2022].
- National Association of Chronic Disease Directors. Pacific Chronic Disease Council [online]. Available at https://chronicdisease.org/page/pcdc/. [Accessed on November 7, 2022]
- Hosey, G. M., Rengiil, A., Maddison, R., Agapito, A. U., Lippwe, K., Wally, O. D., Agapito, D. D., Seremai, J., Primo, S., Luther, X., Ikerdeu, E., Satterfield, D. (2016). U.S. Associated Pacific Islands Health Care Teams Chart a Course for Improved Health Systems: Implementation and Evaluation of a Non-communicable Disease Collaborative Model. Journal of Health Care for the Poor and Underserved, 27(4A), 19-38.
- Rural Health Information Hub, 2021. The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management [online]. Rural Health Information Hub. Available at: https://www.ruralhealthinfo.org/project-examples/952 [Accessed 31 October 2022]