The Palau MCH Title V Needs Assessment was conducted by the MCH Program, Family Health Unit within the Bureau of Public Health. The needs assessment provided the program with an opportunity to reassess its MCH services and provided a cornerstone for strategic planning and development of activities to improve the health status of Palau’s MCH population. The overall goal of this needs assessment was to identify the health needs of Palau’s MCH population to determine priorities for the next five years, set performance measures and establish measures to track progress, and develop strategies to address the identified priority needs.  This has been a process used in previous assessments and was again utilized with minor adjustments for this assessment.

 

A conceptual framework was developed to guide the needs assessment process to acquire a realistic view of the state’s MCH public health system in order to develop a five-year plan based on key MCH priorities.  The needs assessment process used a variety of data collection strategies to garner a better understanding of the current health related issues of women, infants, children, adolescents, and children with special health care needs. A state wide stakeholders’ engagement was a key element used in the needs assessment process. The input of Palau’s community members, health care providers, and quantitative data, provides a sound basis for MCH planning and future directions.

 

PreCOVID-19

The MCH Epi completed a five-year program report of the MCH population (2014-18) and this was shared with external and internal partners for initial reactions, comments and feedback in April 2019.  This report utilizes data that is collected by the program and other existing reports.  These are then shared through a variety of ways.  A workshop/meeting with partner public health programs to do an annual review of program activities and solicit comments for program improvement and alignment with similar partner program activities was completed in December 2019.  Community visits were done in collaboration with the public health outreach promotion team (to maximize available resources) and the health status report of the MCH population was shared - through ‘talks’ and distributed on paper.  At the end of these ‘visits’ an evaluation form was shared to collect their comments and feedback.  Specific topics relating to a particular community (village, age group, gender) is shared and comments/feedback is encouraged to address the issue, folks tend not to air their ‘dirty’ laundry in public.  We also attempted to utilize social media, and so the FHU social media page was created.  This is a subset of the Ministry’s social media page and provides additional health messaging regarding the MCH population.  There were ‘hits’ to the page, but no comments or feedback were received.  Mostly queries were received on where to go and who to contact for a particular issue.  The public health convention, has not been convened for the past several years and the last one was 2017-18.  The convention evaluation provides additional feedbacks to the data/information shared that the program reviews for relevance and action.  The program also conducts continuous surveillance and monitoring of its services through self-reported surveys and face to face surveys and these feed into the 2014-18 report that was shared.

 

COVID-19

Scheduled opportunities to meet with stakeholders to convene, review and develop measures for 2020-25 were unable to take place.  Alternatively, we opted to contact external stakeholders via email and phone calls to send in their comments/rankings of identified areas so that we could collect comments, evaluate rankings and prioritize to include in the needs assessment.  We were fortunate to be able to meet with providers to review our 2014-2018 data and hear back from them issues and challenges that are being encountered at the clinic during this pandemic.  The same ‘areas of need’ information that our stakeholders received was shared to get their input and to consider how we have been affected by this pandemic and other possible public health threats.

 

Three categories of data collection activities were conducted to obtain insights for the MCH populations.

 

Secondary Data Source Analysis - collection and analysis of the health status of women and children in Palau was conducted through a review of the most recent information by population domain. The programs gathered data source related to demographics of women, children, adolescents, and children and youth with special health care needs and other relevant data through existing reports. Information from the Palau Pregnancy Risk Assessment Surveillance System, Behavioral Risk Factor Surveillance System, Vital Statistics, School Health Screening Surveillance System, Youth Risk Behavioral Surveillance, SLAIT-Like CSHN Surveillance, Hospital Discharge Data, Family Planning Annual Report, Uniform Data System, Population Survey, Newborn Screening Programs, HIV/STD Surveillance, STEPS Survey, and Cancer Registry were utilized. Information gathered from these sources include data on well woman visit, immunization, injuries, low birth weight and preterm births, obesity, substance use, among others. Health indicators were compiled and presented to community members in a variety of settings.

 

Community Input - A model presentation called "Community Engagement" was developed, reviewed and approved by the collaborative members and presented to the various communities in the Republic of Palau. This presentation encompasses common health issues that are present in the six health domains. The MCH Program along with the state ECCS team (members of the health promotion outreach team) conducted community outreach to a variety of communities within Palau to conduct the presentations and solicit input from community members. The presentations were complimented by a tri-fold brochure which highlights data and findings from the secondary data source analysis.

 

Providers Input - MCH Providers and other public health partners were partners in the needs assessment process. The MCH program through the annual FHU, Division of Primary End of year Conference provided an opportunity for providers to meet and share and exchange ideas on areas of greatest needs.  This forum also provided an opportunity for staff to access and examine the program’s capacity to meet the needs of the MCH population.  Staff indicated top needs based on the data reports and then a consensus was developed across all members.  They were asked to primarily to consider whether the data indicated an area of need and whether the program had the capacity to address the need. A SWOT analysis was conducted to determine capacity issues that were common in all service areas of MCH.

 

The public input process for the Palau MCH/Family Health Unit is a continuous process which allows us to analyze data, present them to the various communities of Palau and based on their input, we organize services to meet the community needs. From the community presentations and discussions, comments and recommendations relating to service improvements are collected, analyzed and strategies are developed to amend changes to reflect community needs. This engagement with our various communities has provided and improved our ability to capture, analyze and report health status information back to the public has greatly improved our relationship with various communities and stakeholders. The format of the "C ommunity Engagement" is similarly used in all communities that are visited.  Because of the program’s ability that has been built in the past, we are now able to feature "community‐specific" information in our presentation.  Program presented the findings from the data analysis and facilitated discussions on potential priority need. Input from other community members were also collected during the 2017/18 Public Health Convention where participants were asked to identify priority needs and potential strategies to address the needs. MCH program reviewed all data from the secondary data analysis and findings from the stakeholders input to select the priority needs for the population domains.

 

Linkages Between Priority Needs and National Performance Measures

Priority Need	Population Domain	National Performance Measure
Woman preventive visits	Maternal/Women’s Health	Well Woman care
Prevent Infant Mortality	Perinatal Health	safe sleep
Child and Adolescent Health Screening	Adolescent health	Adolescent Well Visit
Childhood screening (0-5)	Child	development screening
child/adolescent physical activity	Child/Adolescent	Physcial activity
Improve System of Care for CYSHCN	CYSHCN	Medical Home
Dental screening for pregnant women	Cross cutting	Preventive dental visit

 

Methodology

 

Birth registry data are collected from medical records or charts by a nurse from the Family Health Unit (FHU) and entered into the birth registry database. Data for this report were derived from matched files of 2014-2018 birth registry records and BNH HIS.

 

Pre and postnatal psychosocial needs assessment and pregnancy risk assessment surveillance surveys are administered and collected from women who access prenatal and postnatal services. PPRASS or Palau Pregnancy Risk Assessment Surveillance was modeled after the U.S. PRAMS but tailored to include questionnaires relevant to Palau and its population. Data are collected annually from mothers who delivered a live birth dating back to 2003. Data contains information on maternal behaviors and experiences that may influence pregnancy outcomes.

 

Descriptive calculations of data collected from the birth registry, surveys, and surveillance tools are cleaned and analyzed using excel and SPSS 21. Results are summarized throughout this report in graphs and tables with brief interpretations of key demographic and maternal and infant health indicators.

Projected Population

 

Palau’s projected population, based on the 2015 census is 18,089 for 2018. Gender difference indicates more male than female in all age groups except for ages 65 and above. Approximately 45% are within the reproductive age group (15-44) while children and infants 0 through 19 comprise about 27%.

 

Number of Births

 

The number of registered births in Palau for 2018 was 256. There were 250 singleton births and 6 multiple births. More than half of the births from 2014-2017 were male except for 2018 where 51% of the births were female.

 

Fertility Rate

 

The overall fertility rate for Palau in 2018 was 2.2 per 1,000 women. Fertility rates of women within the high risk group of < 20 years old has doubled in 2018 at 50.8 as compared to 2014 at 24.9 respectively.  This indicates a drastic increase of teen pregnancies in the past 5 years.

 

Palau’s total fertility rate (TFR) in 2014 was at 1.6 as compared to Guam at 2.4 and the US at 2.01 and has steadily increased to 2.2 in 2018. Overall, the 5-year average remains a little lower than the global average of 2.3 children per women.

 

Birth Rate

 

The annual crude birth rate for 2018 was 14.0 per 1,000 population.  The 3 years moving average is   at

12.7. In 2014, the birth rate for Palau was 11.1 per 1,000 persons in the population as compared to Guam at 17.0.

 

Live Birth by Maternal Age, Ethnicity, and Marital Status

 

Of all live births in Palau from 2014 to 2018, about 12% were women under the age of 20, 48% were women ages 20-29, 36% were to women ages  30-39, and 4% were to women ages 40 or older. Babies delivered to younger and older women are often at increased risk of poor birth outcomes, including prematurity, low birthweight, and infant mortality.

 

Among the women giving birth in Palau during 2014-2018, 78% were Palauans, 16% were Asians mainly from the Philippines, 5% were other Pacific Islanders, and only 1% were White.

 

The largest proportion of foreign residents are from the Philippines who are either employed or a dependent.

 

According to birth registry records from 2014-2018, about 56% of women indicated they were single during the time of delivery as opposed to 43% who were either married or with a partner.

 

Cesarean Delivery

 

Cesarean delivery (CS) rate in Palau has been slowly decreasing every year from 2014 to 2018, the rate declined in 2018 to 29% as compared to 2014  at 39%.

 

Of the total CS deliveries (n=395), about 28% had no indication of complications. 72% had the following complications: breech, transverse lie, incompetent cervix (CPD), fetal distress, twin pregnancy, chronic condition, or have had previous CS.

 

Preterm Birth

 

In 2018, there were 22 preterm births of

<37 weeks gestation in Palau representing 11.3% of live births. About 3% were less than 34 completed weeks gestation. Majority of the preterm births are due to complications in pregnancy.

 

Birth Interval

 

Among the 253 live births in 2018, 68% were multigravida deliveries. The average birth to pregnancy interval was 3.7 years. The shortest birth interval is at 7 months and the longest is 18 years.

 

Of the total births from 2014 to 2018, 44% had inter-birth interval of less than 1 year. The World Health Organization (WHO) recommends inter-birth interval of 33 months (24 months for not conceiving + 9 months period of pregnancy) between two consecutive live births. This reduces the risk of adverse maternal and child health outcomes.

 

Birth Weight

 

The percentage of infants born at low birth weight (LBW) of <2,500 grams has slightly decreased in 2018 at 11% as compared with 15% in 2014. Birth weight distribution has moved toward more normal birth weight of 3,000 grams (6 lbs.) or more. Average birth weight of infants born in 2018 was 3,081 grams (6.79 lbs. or

7 lbs.).

 

Infant & Fetal Mortality Rate

 

Based on preliminary data for 2018, the infant mortality rate for Palau was 11.9 per 1,000 live births. The 5 year average of infant mortality is at 12.9 per 1, 000 live birth from 2009 to 2018. With Palau’s small population, the rate tends to fluctuate with small number of infant deaths.

 

2018 fetal mortality rate at 28 or more weeks’ gestation was 11.9 per 1,000 live births plus fetal deaths. The five year running average from 2009 – 2018 was 16.2. Fetal mortality is often under reported since data on spontaneous abortions are not collected.

 

Intended & Unintended Pregnancies

 

From 2014 to 2018, more than half of the pregnant women who participated in the Palau Prenatal Risk Assessment Surveillance System (PPRASS) survey said they wanted to be pregnant. On average, about 33% of women wanted to be pregnant later or they did not want to be pregnant.

 

Reasons for Unprotected Sex

 

As part of the PPRASS Survey, women who had an unintended pregnancy were asked why they did not use birth control. Overall, majority of pregnant women stated “they wanted to get pregnant.” Furthermore, 38% said “they didn’t think they could get pregnant.”

 

Access to Prenatal Care

 

While most women receive at least one antenatal care (ANC) checkup, the percentage of women who accessed prenatal care services varied by maternal education, where they live, parity, and by race/ethnicity.

 

Women with less education and who lived outside of Koror, whom have had babies before were less likely to access prenatal care early. Additionally, higher proportion of Palauan women accessed prenatal care late in their second or third trimester as compared to Non-Palauan women.

 

Tobacco Use

 

Tobacco use among pregnant women in Palau has remained the same in 2018 as compared to 2014. Tobacco is commonly used with betelnut.

 

On average, about half of pregnant women who used tobacco during pregnancy said they decreased use, about 34% said it remained the same, 6% increased tobacco use and only about 10% said they quit using tobacco.

Breastfeeding and Safe Sleep

 

Exclusive breastfeeding up to 3 months has remained the same from 55% in 2014 to 52% in 2018. About 40% of mothers’ said they stopped breastfeeding exclusively because they did not have enough breast milk. 35% said they had to go back to school or work. 19.4% said they had other reasons for not exclusively breastfeeding and about 6% said the baby was adopted.

 

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for up to the first 6 months. Even though solid foods are introduced at 6 months, it is recommended to continue breastfeeding to at least 12 months. Human milk can help lower risk of asthma, ear infections, and sudden infant death syndrome. Additionally, breastfeeding has equal health benefits for mothers, as it reduces the risk of ovarian and breast cancers.

 

In promoting safe sleep, women are provided counseling and educational materials as part of the discharge plan. In 2018, about 83% of women placed their infant to sleep on their backs. 13% said they either placed them on their back or side. And about 5% said they placed them on their stomach or chest.

 

In order to reduce the risk of sleep-related infant deaths, AAP recommends the following: 1. placing the infant on his or her back on a firm sleep surface such as a mattress in a safety-approved crib or bassinet, 2. having the infant and caregivers share a room, but not the same sleeping surface, and 3. avoiding the use of soft bedding (e.g., blankets, pillows, and soft objects) in the infant sleep environment. Additional recommendations to reduce the risk for sleep-related infant deaths include breastfeeding, providing routinely recommended immunizations, and avoiding prenatal and postnatal exposure to tobacco smoke, alcohol, and illicit drugs.

 

Methodology

 

The school health program provides comprehensive health screening services annually to all schools in the Republic of Palau, to include public and private schools. A team coordinated by the School Health Program consisting of pediatrician, nurses, hearing technicians, dentist, dental nurses, counselors and health educators work together to promote the effective and integrated provision of targeted services for children and adolescents. Students in odd grades of 1st, 3rd, 5th, 7th, 9th, and 11th are screened for common health problems and psychosocial experiences. The program screens students individually for any general and reproductive health, substance use, psychosocial, weight, physical activity, and behaviors that lead to unintentional injuries and diet issues to minimize the adverse impact of the selected health conditions.

Conditions such as:

 

• Cardiovascular conditions for obesity;
• Depression and suicide for psychosocial problems;
• Medical and social complications of substance abuse; and
• Health and social problems that go with teenage pregnancy and Sexually Transmitted Infections.
• Identifies those needing counseling or medical treatment.

 

Descriptive calculations of data collected from the school health screening database are cleaned and analyzed using Excel and SPSS 21. Results are summarized throughout this report in graphs and tables with brief interpretations of key demographic and children and adolescent health indicators.

 

Demographics

According to the Ministry of Education’s enrollment for school year 2018-2019 there were a total of 3,521 students enrolled in both public and private schools in Palau. Of the 3,521 students, about 1,568 or 44% fall within the school health screening criteria.

 

Approximately 74% (1158/1568) of the students in odd grades participated in the school health screening indicating an 8% increase

 

2014-2018 is 10 year old, the youngest is a 5 year old, and the oldest is a 19 year old. About 90% of the students are Palauans, followed by 7% Asians, leaving the remaining 3% other Pacific Islanders and Others.

 

Furthermore, nearly 80% of the students are elementary students in the 1st, 3rd, 5th, and 7th grade. The least proportion of students who participate in the screening are high school students in the 9th and 11th grade.

 

Chronic Health Conditions and Common Ailments

 

The School Health program screens for chronic health conditions and or ailments such as diabetes, obesity, high blood pressure/hypertension, eye sight, and hearing that might affect the students’ physical and emotional well-being, school attendance, and academic performance. Students who are identified with any of the health conditions, are referred to specific clinics for further evaluation and/or treatment.

 

Blood pressure in children and adolescents are based on age, sex, and height. The majority of students who were identified with prehypertension, HTN 1 and 2 were male students who were either overweight and or obese. Prehypertension is defined as blood pressure in at least the 90th percentile, but less than the 95th percentile, for age, sex, and height, or a measurement of 120/80 mm Hg or greater. Hypertension is defined as blood pressure in the 95th percentile or greater. A secondary etiology of hypertension is much more likely in children than in adults, with renal parenchymal disease and renovascular disease being the most common. Children with hypertension should also be screened for other risk factors for cardiovascular disease, including diabetes mellitus and hyperlipidemia. Hypertension in children is treated with lifestyle changes, including weight loss for those who are overweight or obese; a healthy, low-sodium diet; regular physical activity; and avoidance of tobacco and alcohol.

 

Additionally, students who fail the vision screening are also referred for further evaluation to see if the child requires eye glasses. About 15% of the students failed the vision screening in 2018. Students are also screened for hearing problems such as the collection of fluid in the ear (otitis media), wax, or foreign bodies blocking the ear canal. Students in the 1st or 3rd grades are screened with an Otoacoustic Emissions (OAE) equipment to test their inner ear for signs of hearing loss. In 2018, about 30% of the 1st and 3rd grades failed the OAE screening in their left ear and 36% failed in their right ear. Students who failed the OAE are referred for further re-testing and evaluation.

 

Further blood test are administered to identify students who are positive for glucose and protein spill as well as occult blood in the stool. In 2018, less than 1% of the students had elevated blood glucose, and about 22% of the students were positive for protein spill (excess protein in urine). Early stages of proteinuria have no symptoms but the child may experience the following signs or symptoms: difficulty breathing, fatigue, high blood pressure, and swelling (especially around the eyes and in the hands, feet, and belly), or urine may appear foamy or bubbly.

 

The Body Mass Index (BMI) is used to assess the weight status of children and adolescents to determine the cut points that define obesity and overweight. BMI is calculated using the child’s age or date of birth, sex, weight, and height and varies in growing children. A BMI of < 5th percentile indicates an eating disorder or poor nutrition. Overweight and obese children with the BMI between ≥85th percentiles can face chronic health conditions and diseases, such as asthma, sleep apnea, bone and joint problems, and type 2 diabetes.  Furthermore, children who are obese are more at risk for heart diseases.

 

In the past 5 years, there is a noticeable increase by 1 to 2 percent in BMI of ≥85th percentile for both male and female students. Male students were more likely to be overweight and or obese than female students. Early intervention is necessary to address problems of overweight and obesity by recommending changes to diet, more physical activity, and less sedentary activities, such as watching TV, playing video games, and etc.

 

Physical Activity

 

During school year 2015-2016, new physical activity questionnaires were introduced to adequately capture data on physical activity. The following questions replaced screening for physical activity level of light, moderate, vigorous:

 

1. During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day?
2. During the past 5 days, on how many days did you walk or ride a bicycle to or from school?
3. During this school year, on how many days did you go to physical education (PE) class each week?
4. How much time do you spend during a typical or usual day sitting and watching television, playing computer games, talking with friends, or doing other sitting activities?

 

During the screening, students are often encouraged to participate in PE classes as well as be physically active for at least 60 minutes per day. Additionally, students are advised to participate in vigorous physical activities, muscle and bone strengthening for at least three days per week as well as the importance of physical activity in their growth and overall health.

 

From 2015 to 2018, an average of 52% of the students said they did not participate in any physical activity for at least 60 minutes in the past 7 days. About 90% spent less than 5 days in any physical activity and only 8 to 11% said they were physically active in all 7 days. Many of the students said they spent at least 1 day being physically active for at least 60 minutes.

 

Additionally, students are asked if they walk or ride a bicycle to or from school. Nearly 20% of the students said they walked or rode a bike to school every day. About 10% said they either walked or rode a bike one or two times out of the week.

 

Moreover, majority of the students participated in at least 1 day of PE class. Less than 5% participated in PE class in all 5 days. And an average of 14% of the students did not participate in PE class at all.

 

It is recommended by the American Academy of Pediatrics (AAP), that in order to prevent childhood obesity, children should be active daily and to spend less time in  sedentary  pursuits

such as watching TV, playing video and computer games, etc. And that children should be limited to less than two hours of screen time daily. According to the 2018 school health screening, 43% of the students said they spend 3 or more hours per day watching TV, playing video or computer games, and/or doing other sedentary activities such as browsing the internet or on social media. Overall, from 2015 to 2018, an average of 55% of the students spend 3 or more hours engaged in sedentary activities.

 

Dietary Behaviors

 

Like physical activity questionnaires, diet questions were also revised to ask the following questions listed below instead of diet recall where students were asked what they ate in the past 24hrs in order for the providers to determine contents of the food they ate.

 

1. During the past 24 hours, how many times did you eat fruit?
2. During the past 24 hours, how many times did you eat vegetables?
3. During the past 24 hours, how many times did you drink carbonated soft drinks?
4. During the past 7 days, how many times did you eat from a fast food restaurant (prepackaged food i.e. bento?

 

Children and adolescents require food rich in nutrients that may have lasting effects on growth potential and developmental achievement. Food such as fruits and vegetables, home cooked meals, more water intake and less carbonated drinks have nutritional values that are essential for children and adolescent growth and development.

 

From 2015 to 2018, there were more students who reported eating at least 1 or more fruit or vegetables in the past 24 hours. More than half of the students from 2015-2018 said they drank carbonated soft drink in the past 24 hours except for 2018 where 52% of the students said they did not drink any carbonated soft drink in the past 24 hours. About half of the students said they ate pre-packed food i.e. bento (store bought food) 1 or more times in the past 7 days. Majority of the students who reported eating pre-packed food attended private schools.

 

Students are often advised on choosing healthful foods, food safety, and behaviors that contribute to maintaining healthy weight.

 

Oral Health

Dental caries (tooth decay) is still a major oral health problem among children and adolescent in Palau, affecting more than half of the students screened in 2018. The prevention of dental caries can be approached in three ways: the use of fluorides, reduce frequent consumption of sugars, and the application of pit and fissure sealants. Furthermore, children and adolescents should brush twice a day, in the morning and at night just before bedtime with toothpaste that contain fluorides.

 

Moreover, 82% of the students screened in 2018 needed sealant, and 70% needed restoration to repair missing parts of the tooth structure caused by tooth decay.

 

Psychosocial Issues and Concerns

Psychosocial issues and concerns often develop when a child reaches adolescent age at a stage when they start experiencing rapid physical and emotional changes. Students are screened for various psychosocial issues and concerns and are provided counseling or are referred for further evaluation. Majority of the psychosocial issues experienced by the students are largely due to issues with family, a friend, and being bullied in school or at home.

 

From 2014 to 2018, there was a noticeable increase in the number of students who experienced depression as well as the thought of harming oneself. Additionally, there is an increase in the number of students who are bullied in school or at home or have experienced strong fears. Many of the students that experienced strong fears attribute them to insects, dogs, ghost, darkness, and heights. Moreover, 15% of the students in 2018 said they needed help with their psychosocial issues or concerns. In 2018, about 3.7% of the students screened said they been told to have special learning problems and 15.2% had problems with their grades.

 

Further to assessing psychosocial issues and concerns, students are asked if they have had any problems with the law, school, family or relationships and whether the problem was associated with drugs or alcohol use.

 

In 2018, 5% (n=61) of the students said they recently had problems with the law, school, family or relationships and about 20% (n=12) said it was associated with drugs or alcohol use. There is a slight increase from 2014 to 2018 in the number of students who have experienced problems with the law, school, family or relationships.

 

In 2018, about 4% of the students screened said they were hurt or abused. Of the students that reported abuse, majority of them said they were either neglected or physically abused. 9 of the students did not indicate the type of abuse. About 12% said they were sexually abused and 12% said they were verbally abused (harsh scolding by family member). 15% said they were emotionally abused by being associated with their biological parents.

 

Violence and Unintentional Injury

In addition to bullying, students are asked how they were often bullied in the past 30 days. In 2018, about 46% said they were bullied some other way (food or items taken away by others). 23% said they were made fun of because of how their body or face looks, 18% said they were hit, kicked, pushed, shoved around, or locked indoors, and about 13% said they were made fun of because of their race, nationality, or color.

 

Alcohol, Tobacco, and Other Drug Use

The school health program screens students for alcohol, tobacco, marijuana, and other drug use to identify students who have tried or are current users of any ATOD to reduce the prevalence and intensity of ATOD use among children and adolescents. Additionally, students are educated on the short-term and long-term negative consequences of any ATOD use to include social influences and refusal skills.

 

Students who are current users, and are willing to quit any ATOD use, are often referred for further evaluation and cessation services.  Screening for ATOD use is conducted in a face to face interview with a nurse asking the students about their recent ATOD use. Results are often biased or under reported as responses from the students are not always truthful. The screening section of the ATOD use is currently been enhanced to allow the student to respond to the questions anonymously.

 

Among the students, the average age of initiation for alcohol use was 13 years old, the youngest to try alcohol was 11 years old and the oldest was 17. Some of the students said they tried a sip of alcohol out of curiosity, while others said they had a glass of liquor or 1 can of beer. The maximum number of alcohol consumed in a month was 6 cans of beer. In 2018, about 43% (n=15) of the students who said they tried alcohol were 13 years old or were elementary students.

 

Additionally, there was an increase in smoking cigarette among the students from 43% in 2014 to 58% in 2018.  There were more female students who smoked cigarette as opposed to male students.

 

Overall, there was a 6% increase in tobacco use among the students in 2018 as compared to 2014 at 7%. About 72% said they use less than a stick of cigarette per day and 28% use more than a stick to close to a pack a day.

 

In addition to smoking cigarettes, 6% of the students said they tried marijuana in 2018. The youngest to try marijuana was 12 years old. Majority of the students who tried marijuana said they had a single puff. About 10% (n=7) use more than 2 joints of marijuana per day. There is also an increasing use of marijuana use among the students from 1% in 2014 to 6% in 2018.

 

Furthermore, less than 1% of the students said they tried other drugs such as tramadol, Tylenol 3, and methamphetamine (ice).

 

Sexual History

In 2018, about 2% (n=26) of the students ages 12 to 19 said they were sexually active. Nearly all of them (85%; n=22) reported contraceptive use during their recent sexual intercourse. Similar to ATOD use, screening for sexual history is often biased or under reported. Enhancement to this section is also been modified to allow the student to respond anonymously. From 2014-2018 there were more male than female students who reported been sexually active. The average age of the students was 15 years old, the youngest was 12 years old.

The Title V MCH Block Grant implemented by the Family Health Unit.  The direction of the Program is under Sherilynn Madraisau who is the Director of the Bureau of Public Health and Edolem Ikerdeu, Chief of the Division of Primary & Preventive Health.  This is seen as a practical administrative structure for the Project as it crosses public health into the hospital. Kliu Basilius, Acting Program Manager for the Family Health Unit works with Sherilynn Madraisau and Edolem Ikerdeu to assure that the project attains what it was set out to do, but also to assure that activities are integrated as routine services in the on-going neonatal and well-baby services and women and maternal services that are available in Palau.  Other Divisions under the direction of the Public Health are the Division of Behavioral Health, Division of Environmental Health and the Division of Oral Health.  These divisions work collaboratively to ensure that general public health initiatives work together to improve the lives of those that live in Palau.

 

At present, the Family Health Unit is a service component of the Division of Primary Health Care, one of four divisions within the Bureau of Public Health.  This division also oversees the services of the Communicable Disease Unit, the Non-Communicable Disease Unit and the Immunization Program.  The Family Health Unit Acting Program Manager oversees all managerial activities of the Unit including grant writing, data analysis and reporting of important factors influencing the health of the MCH population.  Within the Unit, a Clinic Nurse Supervisor oversees all clinic activities.  An OB/GYN and a Pediatrician are on schedule to the Unit to provide services to the Unit’s clients.  Other specialists also provide services to clients through referral process.  From time to time, specialty clinics are sought out to provide services for that are outside of the capacity of the Belau National Hospital and Public Health.  The FHU Acting Program Manager works closely with the FHU Clinic Nurse Supervisor and the Primary Health Care Division to ensure that activities undertaken are in conjunction with the planned Goals and Objectives set forth by the Maternal & Child Health Program and the Primary Health Care Division.

 

The MCH program complements and works with other public health programs to respond to the needs of the MCH population through partnerships with the following:

 

State System Development Initiative- The purpose of the SSDI projects is to assure that the Title V agencies have access to policy and program relevant information and data. SSDI assists State Agency Maternal and Child Health and Children with Special Health Care Needs programs in the building of State and community infrastructure

 

Family Planning improves the health of women and men of reproductive age group and infants by enabling families to plan and space pregnancies and prevents unplanned pregnancy.

 

Universal Newborn Hearing Screening and Intervention (UNHSI) screens for hearing loss in newborn babies and links infants to appropriate intervention.

 

Emergency Medical Services for Children-- supports the entire spectrum of emergency services, including primary prevention of illness and injury, acute care, and rehabilitation, is provided to children and adolescents as well as adults, no matter where they live, attend school or travel.

 

MCH Data/Epi- supports data collection and analysis for all MCH programs and Family Health Unit Programs.

MCH currently has the capacity (structural resources, data systems, partnerships and competencies) to provide Title V services to the following domains: maternal/women’s health, perinatal health, child health, and CYSHCN . The MCH program also oversees the Adolescent Health Program that oversees services relating to adolescent needs. In each domain, MCH initiates partnerships with external organizations to ensure a statewide system of services that are comprehensive, community‐based, coordinated and family centered.

 

Maternal/Women’s Health

 

MCH uses Title V funds to provide services for women of reproductive age. Family planning clinics supported by Title X funding also provide preventive services for all women and men of reproductive age group. MCH has an epidemiology staff that support programmatic efforts. Data sources used are PRAMS, Vital Records, BRFSS and Family Planning program data. MCH has active partnerships with the hospital, private practice physicians, academic institutions, Cancer and HIV screening programs, Behavioral Health, Oral Health, Environmental Health and the Public Health Emergency Preparedness Program to ensure a comprehensive system of services for women and men of reproductive age in Palau. The program also have strong partnership with external partners and various community organizations such as UAK, PPE, and Omekesang Associations among others.

 

Perinatal Health

Title V staff supports newborn screening, breastfeeding initiatives, preterm birth initiatives, perinatal regionalization and the Safe to Sleep campaign to promote perinatal health. MCH also participates in the. MCH also provides financial support towards the Breastfeeding Community Work Group Initiatives and other projects that target high‐risk pregnancies. Title V supports epidemiology staff to collect and analyze data on perinatal health. The primary data sources used are Vital Records and PRAMS.

 

Child Health

MCH promotes child health through promoting developmental screenings among children, prevent injury and promoting physical activity. MCH also supports the “Dewill to Live “ Initiative that supports activities targeting childhood injuries specifically underage drinking. Program also supports UAK which promotes and supports physical activity.

Title V supports the work of these programs, however they rely on additional funding sources as well. MCH has an epidemiologist specialist to support data collection efforts . To ensure a comprehensive system of services among children, MCH has active partnerships with Head Start , Ministry of Education, private day care facilities and faith base schools that provide early care and education services.

 

Adolescent Health

The Adolescent health program is located in Adolescent and School Health Clinic which is managed by the MCH program. MCH works in collaboration with the Division of Behavioral Health and Bureau of Nursing and hospital physicians to provide primary and preventive health services for the adolescent health population.

 

CYSHCN

MCH supports several programs to provide services to Palau’s CYSHCN. The Interagency/CYSHN initiative acts as the point of entry for children with an identified special need. The program provides services for children from birth to twenty one years of age. MCH through the Inter agency initiative continues to provide on‐going, comprehensive medical care for CYSHCN. Since Palau does not have SCHIP and Medicaid, MCH program is the lead agency and provider of services for CYSHN. Epidemiologists support data collections for CYSHN. MCH has a data system that captures all children and youth with special health care needs.

 

Oral Health

MCH has Title and state provides funding support for oral health initiatives targeting children, adolescents and pregnant mothers. MCH also support the school oral health screening initiative that provides preventive oral health services to all school age children.

Recently we have had a number of staff and service providers that have retired.  Almost half of the workforce that provides Title V services have been with in MCH for less than five years.  this is a double edged sword as staff/providers are learning on the job but also, it provides a great opportunity for program innovation and improvement.  Although the workforce of the Family Health Unit (FHU) is at an equilibrium of staff tenure of greater than or less than five years, we also have the support of the Director of Public Health who has been with the program for many years.  Staff are actively looking for opportunities of growth, and are enrolled in the substance abuse counseling and enrolling in Community and Public Health courses at the local college to further enrich the outreach efforts that the program provides.

 

Title V program staff along with providers in the clinic and nursery have received refresher trainings on first embrace, nursery care and education, these trainings included safe sleep and breastfeeding.  These are annual refresher trainings for providers and educators.  In response to providing and promoting our services to clients that are not accessing our services and in providing information to those that have not heard of our program, all the programs under the Division of Primary and Preventive Health (Title V included) have established a collaborative outreach team that provides health education, screening, recruitment and counseling to individuals that are unable to access services at the various health centers.  This arrangement provides services and activities, eliminate duplication of efforts and ensures that those seeking information receive them effectively and efficiently. Recognizing limitations in funding, staff, expertise and reach, this arrangement aims to reduce the gap in the areas of service utilization, education, recruitment and community engagement participation.

 

The program currently faces the challenge of filling roles as three staff have since retired and they provided essential clinic services.  The program was also able to hire a health counselor to join the school health team, however, we are still in need staff to cover the areas of prenatal nutrition/education, home visitation and case coordination.  These are key roles in the delivery of service and coordination of efforts.  For a quick fix to the current situation while we look at possible avenues to respond to this, current staff are being tasked to undertake these roles while a long term solution is sought.  The program has been actively looking for possible replacements but have been largely unsuccessful.

 

Family partnerships are essential to the success of the MCH program for insights and issues raised that are not reiterated to the program directly.  Family partnership participation is recruited through a variety of methods, including those who use the services, pediatricians, schools, workshops, health fairs, word of mouth, non‐profit organizations and committees.  Several parents of special needs children are members of the ECCS state team and the Inter agency initiatives.  MCH also partners with the Palau Parents Empowered, a non-profit organization that supports parents of children with disabilities.  Information and education are being developed for families of CYSHCN to empower them to provide input on policies and program activities and to assist in disseminating program information to families in their network.  It is through this partnership that the program develops and strengthens the interagency committee so that services and care coordination can be fully utilized by those that need it.  The program also partners with Ulekereuil a Klengar for continued growth of the breastfeeding initiative in the private sectors.  The Title V program works with OMUB (community advisory council for cancer in Palau) to promote cancer prevention efforts through education and behavioral change strategies.

 

The Title V program is a member of various organizations that promote family centered services, community based and coordinated care for all of our clients.  These are essential ‘family health’ partnerships that have been developed through the years.

 

1. Family Planning, Information & Education Committee.  This committee advises the family planning program on appropriate information and education materials for the various ethnic backgrounds on the island.  This group also discusses key issues that are happening/impacting users and potential users right now.  Topics range from teen pregnancy, contraception, religion, finances and culture to name a few.  This committee assists plays an important role to the program office as they provide an entry point into their community and peers. 
2. Community Advocacy Program and Early Childhood & Comprehensive Committee.  This program develops radio talk shows, community engagements and outreach to schools to deal with issues around areas of sexual and reproductive health.
3. Adolescent Health Program & School Principals:  Each year this team meets to discuss issues and ideas on how to equip teachers with the necessary tools to enable our children to be more active and lead healthier lives.
4.  Health Advisory Committee.  This committee discusses health and safety in the head start centers.  The program participates in parent trainings, stakeholder meetings and also participation of inspections before school starts to ensure they follow guidelines.  Parent trainings are provided based on the head start needs assessment that is completed every year as well as specific requests made by individual schools.
5. Nutrition Committee:  This committee adopted breastfeeding as one of its goals to further promote the effectiveness and benefits or breastfeeding, especially exclusive breastfeeding through six months.  This committee as part of the NCD Mechanism provides education and community awareness on the benefits of breastfeeding.
6. Chronic Disease Self-Management program: this program provides CE sessions for identified people with chronic disease on how to improve their current health status and promote healthy lifestyle choices.  As some of our clients are children who are obese or have pre-hypertension, through this course, parents are invited to attend these sessions to learn attitudinal and behavioral techniques to help assist their children to improve their calorie intake whether at school or home.  Program encourages clients to attend these self-management courses to obtain educational information and awareness of chronic health problems as well as hear success stories from their peers.
7. Head Start Policy Council– to ensure that all centers follow policies that cover hiring, personnel receive appropriate training and centers follow safety protocols for all children that are enrolled in the centers.
8.  CSN Committee, review CSN cases (home visits, transportation services) – this committee meet to discuss current children with special health care needs that have been identified by a Pediatrician or Psychiatrist. Every month, clinical providers, head start, special education, partner family NGO meet to discuss progress of children and update on specialty clinics that will be available.
9. UNHSI Advisory Committee – strategic and program planning.  This committee advises the program on how to improve service coordination for children that have been identified with a hearing loss or is suspected of a hearing loss.
10. Health Promotion and Outreach Team – program outreach and awareness.  This is a team that comprises of clinicians, educators and program staff from programs under the division of primary and preventive health.  These programs include immunization, NCD, CDU as well as the health centers to enable access to care to those that would normally not be able to travel to the clinics to access services.
11. Health & PE Planning Committee – this committee works with the Ministry of Education in upskilling the current workforce (teachers/curriculum development personnel) in the areas of health and physical education.  It also provides an annual venue for all schools to convene and share/discuss good practices that have been implemented and delve further on how to improve on current ones. 
12.  Division of Primary & Preventive Health Conference Committee – this conference brings all the programs under the division to look at how we can improve on services that are offered back to the community.  Each program share their goals, report on accomplishments and provide continuing education opportunities for clinical and non-clinical staff.
13.  Public Health Convention Committee – this conference brings all the programs under the Bureau of Public Health to report out to the community.  Through this forum we gather feedback from the community on we can best serve them through the provision of our current services and how to improve/bring in new services.  Each program share their goals, report on accomplishments.
14. Health Care Coalition – this is a coalition of various agencies that assist the National Emergency Management Office and Public Health Emergency Health in response to disasters and emergencies.  The Unit is a partner in this coalition in ensuring that the MCH population, including children and youth with special health care needs, are protected in times of emergencies.

 

Palau does not have and is not eligible for Medicaid and SCHIP. Family/Consumer Partnerships

A conceptual framework was developed to guide the needs assessment process to acquire a realistic view of the state’s MCH public health system in order to develop a five-year plan based on key MCH priorities.  The needs assessment process used a variety of data collection strategies to garner a better understanding of the current health related issues of women, infants, children, adolescents, and children with special health care needs. A state wide stakeholders’ engagement was a key element used in the needs assessment process. The input of Palau’s community members, health care providers, and quantitative data, provides a sound basis for MCH planning and future directions.

 

PreCOVID-19

The MCH Epi completed a five-year program report of the MCH population (2014-18) and this was shared with external and internal partners for initial reactions, comments and feedback in April 2019.  This report utilizes data that is collected by the program and other existing reports.  These are then shared through a variety of ways.  A workshop/meeting with partner public health programs to do an annual review of program activities and solicit comments for program improvement and alignment with similar partner program activities was completed in December 2019.  Community visits were done in collaboration with the public health outreach promotion team (to maximize available resources) and the health status report of the MCH population was shared - through ‘talks’ and distributed on paper.  At the end of these ‘visits’ an evaluation form was shared to collect their comments and feedback.  Specific topics relating to a particular community (village, age group, gender) is shared and comments/feedback is encouraged to address the issue, folks tend not to air their ‘dirty’ laundry in public.  We also attempted to utilize social media, and so the FHU social media page was created.  This is a subset of the Ministry’s social media page and provides additional health messaging regarding the MCH population.  There were ‘hits’ to the page, but no comments or feedback were received.  Mostly queries were received on where to go and who to contact for a particular issue.  The public health convention, has not been convened for the past several years and the last one was 2017-18.  The convention evaluation provides additional feedbacks to the data/information shared that the program reviews for relevance and action.  The program also conducts continuous surveillance and monitoring of its services through self-reported surveys and face to face surveys and these feed into the 2014-18 report that was shared.

 

COVID-19

Scheduled opportunities to meet with stakeholders to convene, review and develop measures for 2020-25 were unable to take place.  Alternatively, we opted to contact external stakeholders via email and phone calls to send in their comments/rankings of identified areas so that we could collect comments, evaluate rankings and prioritize to include in the needs assessment.  

 

We were fortunate to be able to meet with providers to review our 2014-2018 data and hear back from them issues and challenges that are being encountered at the clinic during this pandemic.  The same ‘areas of need’ information that our stakeholders received was shared to get their input and to consider how we have been affected by this pandemic and other possible public health threats.

 

A scoring matrix of issues through ranking of importance, feasibility and impact of the issues was developed to gather further feedback from our partners and providers and these responses were ranked and categorized to assist the program in developing the state action plan.  Program also looked at its own internal capacities and partnerships on how we can strengthen existing partnerships and explore innovative options to implement to address issues and achieve objectives.  Considerations on technological capacity at its current stage, available infrastructure at the Belau National Hospital, School Health office, Community Health Centers, existing partnerships and expertise available to the program were considered for program’s ability to reach identified objectives.  This guided the program in the selection of the performance measures and strategies.