Process Description
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. Three categories of data collection activities were conducted to obtain insights for the MCH populations.
Primary and Secondary Data Analysis - collection and analysis of the health status of women and children in Palau is conducted annually and every five years, including data related to demographics of women, children, adolescents, and children and youth with special health care needs and other relevant data through existing reports. Sources of data comes from medical records as well as annual surveys conducted with mothers, children and adolescents, patients, as well as the entire population (i.e., WEBIZ, UDS, Chronic Disease Electronic Health Management System, HIS, Cancer Registry, Palau Census Data, Palau Hybrid Survey). The data is compiled and organized and presented to internal and external partners, including community members through meetings, workshops/conferences, and outreach activities.
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. The program presents updated information to internal and external partners through various platforms and methods (emails, brochures, face to face events, social media, etc). Feedback is continuously collected and utilized for program planning.
Providers Input - MCH Providers and other public health partners are always involved in the needs assessment process. The MCH program through the annual FHU, Division of Primary End of year Conference provides an opportunity for providers to meet and share and exchange ideas on areas of greatest needs. This is an opportunity to look at the data, prioritize and redirect actions. This year, due to COVID-19, this conference was suspended; however, the entire Ministry conducted a Health Equity Summit which provided a similar avenue for discussions and feedback for improvement.
Palau MCH Program continues to identify every opportunity to share reports and findings and present in conferences, and during other public health programs and community meetings.
Findings
MCH Population Health Status
Women’s/Maternal Health
The consistent increase in the number of pregnant women who access prenatal services in the early (1st trimester) stages of pregnancy is encouraging for Palau. In 2022, 50% of females delivering a live birth received prenatal care beginning in the first trimester, and this is higher than previous years. Although data indicates that 37% received prenatal care in the second trimester, this could be attributed to the fact that other pregnant women access early prenatal care through private clinics. A lot of efforts go into education and awareness on the importance of early prenatal care through outreach and in clinics. Furthermore, providers are provided refresher trainings in documentation to ensure indication of first prenatal visits regardless of initial visit (MCH or private clinics).
During prenatal visits, women are provided HIV/STI screening, preventive dental cleaning and exams, prenatal education, counseling and referrals for cessation services if they are currently using tobacco, alcohol, or other drugs, physical exams including weight management, exercise, and safe diet, screening for hypertension and blood glucose and controlling existing conditions such as high blood pressure and diabetes. All these are services are facilitated by other public health programs and the Community Health Center in its efforts to provide comprehensive quality primary care services, which also translates into practice in expansions to other outlying states through this leveraging of resources.
Needs
Women in Palau comprise 43% of the reproductive age of 15-44 years. The Palau Hybrid Survey 2017 Report indicates that women 18 years and older are more likely to be overweight or obese than their male counterparts, and although it increase with age, we still get a signifigant number of women in their reproductive years with this poor health outcomes. The same can be said for elevated total cholesterol which was significantly highest among women, including those in their reproductive years.
In 2022, 30% of women who accessed family planning services were overweight (25.0-29.9) and 37% were obese (30.0 and above). Majority of the overweight and obese women are of reproductive age of 25 to 34.
Palau continues to see low fertility levels below replacement fertility in the past 5 years. The overall fertility rate for Palau in 2022 was 1.5 per 1,000 women. Fertility rates of women within the high-risk group of <20 years old was 15.7 and the rate for women ≥35 years old was at 25.0 in 2022.
Another alarming yet prevalent issue among pregnant women is gestational diabetes. In 2022, 12% of pregnant women were diagnosed with gestational diabetes. More than 60% are between 20-35 years old, 80% are Palauan, and 14% are Filipino. About 70% had a c-section, and 90% delivered big babies (≥2,500 grams).
In 2022, less than 40% of women who accessed our MCH, family planning, and breast and cervical cancer clinics were able to receive preventive medical services. Furthermore, the preventive medical services in these clinics are not necessarily comprehensive (i.e., limited to no SUD services).
It is apparent that our population as a whole, and including women who are pregnant and/or of reproductive age. Our 2022 survey also reveals that over half of pregnant women still use tobacco, over 10% report depression, high rates of infant mortality and c-sections while at the same time experiencing health disparities (low economic status, transportation barriers, low education), it is worthwhile to enhance strategies to provide more wellness/preventive services to these population groups.
PRIORITIES: Our priority will be changed to give more focus on the well woman, instead of workforce capacity, which can be incorporated as a strategy or activity under this priority, and to align ESM and strategies in order to increase the percentage of women 18-44 who receive preventive medical visits through the health center program (FQHCs).
Perinatal/Infant Health
The average number of births annually in Palau has been 215 in the past five years. In 2022, there were 157 deliveries of which 155 were live births, the lowest recorded number of births in a decade. There were more male than female births except for 2018 and 2021 where more than half of the deliveries were female. Palau provides newborn hearing screening through its Universal Newborn Hearing Screening Program. In 2022, 100% of infants passed their newborn hearing screening. Other developmental screening is done manually.
Strengths
Needs
Palau has seen an increase in infant and fetal mortality rates in the past ten years. Although in 2022, there were no infant deaths reported, the five-year average remains high at 15.1 per 1,000 live births. For the combined years of 2018 to 2022, the Palau fetal deaths at 24 or more weeks gestation were 15.1 per 1,000 live births and fetal deaths.
The percentage of infants born at low birth weight (LBW) of <2,500 grams in 2022 is 9%. The average birth weight is 3,096 grams (6.83 lbs.). In 2022, Palau had 18 preterm births of <37 weeks gestation, representing 12% of live births. About 4% were less than 34 completed weeks gestation. Most preterm births are due to complications in pregnancy.
Additionally, only 41% of infants and children received a developmental screening using the parent completed screening tool (ASQ). Diagnoses capability is also limited in Palau and an audiologist, for example, has to be flown in to provide diagnoses to children who fail their hearing tests. At times, they have to wait up to a year.
PRIORITIES: Palau rewords its priority (to simplify) from “promote activities to improve the health of infants, children, and adolescents” to “improved birth outcomes/child health”. Due to poor birth outcomes, grantee feels that an improvement on the health of the mother as well as early intervention such as prenatal care will contribute to better birth outcomes, and incorporates such strategy under this domain. Developmental screening is also critical in this domain but will be placed under the child domain. Although there is strong support for breastfeeding within the health department, the percentage of women who breastfeed exclusively for 6 months doesn’t appear to increase. The program will incorporate an ESM that incorporates evaluation as part of the strategy to promote breastfeeding. Finally, since safe sleep doesn’t appear to be an outright issue at this time, grantee is taking it out but maintains it as part of the system of care.
Child Health
The school health program provides comprehensive health screening services annually to all schools in the Republic of Palau, including public and private schools. A team coordinated by the School Health Program consisting of doctors, nurses, hearing technicians, dentists, 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.
Strengths
Needs
Overall, 40% of the students screened between the ages of 5 to 10 years old were overweight or obese (≥ 85th %ile) and 28% were obese (≥ 95th %ile) in 2022. Furthermore, male students were more likely to be overweight and or obese than female students. High levels of overweight and obesity for both male and female indicate a need for collaborated efforts to continue to improve diet and physical activities in the community and at schools.
Twelve out of twenty schools have increased physical activity days to three. The program continues to advocate for an increase in the number of physical activity days to five days. About 29% of children were physically inactive in 2022, more than 50% only participated in one day of physical activity.
School health screening data also indicates that dental caries continue to be a health issue among children, and although a number or a significant percent of children were indicated for needed dental services, only 4% reported that they see a dentist on a regular basis. We need to strengthen interventions through the school health program, and/or ensure that children obtain these preventive services in the dental clinics.
Bullying and violence also continue to plague children in schools, with 57% reporting being made fun of due to the way they look, 30% reported being hit, kicked, or shoved around, and 11% reported being bullied some other way.
Priority: Most priorities for this domain remain the same including childhood immunization, mental health, obesity, and oral health. However, one of the priorities was re-labeled to “improved birth outcomes/infant health placed under appropriate domain. Palau maintains same strategies in order to move closer to objectives.
Adolescent Health
Strengths
One of the program’s greatest strength is its School Health Program, which implements an annual school health screening to all the elementary and high schools in Palau, and as mentioned elsewhere in this document, screens only odd grades due to limited resources. The rationale is to screen this population every other year, with the intention of delivering needed interventions and re-screening them after two years. This platform is a great opportunity (and in some cases, the only opportunity) to encounter children and adolescents, assess their health, provide brief interventions, and make necessary referrals, therefore connecting them to much needed primary/preventive care, including medical, dental, and behavioral health. Adolescent well visits are provided through the annual school health screening. 53% of adolescents between the ages of 11 to 19 participated in the screening. In 2022, the program identified and referred 63% of the participating students for further assessment, counseling and treatment.
Collaborations and partnerships are also the program’s strengths, and they also allow the program to provide guidance in strategies that promote the health of children and adolescents. And because of this, the Ministry of Education, over the years, have implemented more and effective strategies to increase physical activity and nutrition in the schools. Our non-federal partners (i.e., Coalition for a Tobacco Free Palau and SAFE Committee) advocate for us and in the past year alone, legislation was passed to implement the Seat Belt Safety Act and a ban on the sale and use of vapes or electronic cigarettes.
Needs
Sexual Behaviors and STIs
The prevalence of sexually transmitted infections is relatively high among adolescents in Palau. Data from Palau Communicable Disease Unit (CDU) from 2018 to 2022 showed a significant increase in chlamydia among adolescents aged 15-19 at 4,976 per 100,000 population in 2022. Furthermore, females had a higher infection rate at 7,283 per 100,000 compared to males in the same age group at 2,793 in 2022.
According to the 2022 school health screening results, about 7% of adolescents ages 10-19 indicated currently or ever been sexually active, with the mean age of first sexual intercourse at 11 years old. Additional risks include 1.3% reporting having multiple partners, 17% not using contraceptives, and 78% not using condoms during the last sexual intercourse. Males were more likely than females to initiate sexual intercourse. Although it is evident that adolescents in Palau get exposed to sexual activities at a very young age, many have little understanding of sexual and reproductive health and contraception. In addition, Palau’s complex social and cultural dynamics about sexual and reproductive health discourage discussing sex with families. Like many other Pacific Islands countries, cultural taboos around sex hinder the provision of sexual and reproductive health services. The 2022 family planning report shows that 14% of females and 0% of males ages 19 and under accessed family planning services. Many young female clients prefer using three months of hormonal injections vs. pills, 13% use condoms, and 0% choose abstinence as a form of contraception.
Teen pregnancy is still a significant problem in Palau. In 2022, the teen pregnancy rate in Palau was 15.8, higher than the current U.S. national average of 15.4 per 1,000 females ages 15-19. A review of birth records in the past ten years (2013-2022) indicated that, of the teen births, 16% had a cesarean delivery, 7% had late or no ANC, 19% had anemia, 18% had a low birth weight (<2,500 grams), and 11% had a preterm birth (Table 3). Furthermore, 4% had an inter-birth interval of less than one year, and about 9% tested positive for sexually transmitted infections during pregnancy. According to the 2022 Prenatal Risk Assessment Survey, 100% of teen pregnancies in Palau are unplanned.
Alcohol Use
Palau school health screening from 2013 to 2022 indicates increased alcohol consumption among adolescents ages 11 and older, from 10% to 22% among males and 9% to 11% among females. The average age of initiation was ten years old, with the youngest to try alcohol at 9. Many report consumption of beer as opposed to spirits. About 10% said they consumed over six cans of beer once in the past month.
There may be many factors that contribute to alcohol consumption, and we would be remiss to not consider the fear and stress of the pandemic as one of them. Other cultural factors may have also shaped Palau’s more tolerant atmosphere to alcohol consumption, especially with males, as it is not uncommon to see drinking in most social and cultural events in the community, including after sports celebrations, first birth ceremonies, funeral preparations, and other events. Children and adolescents are constantly exposed to this type of behavior and it is inevitable that they follow the footsteps of the adults around them.
Similarly, a study (Durand, Cash, & Durand, 2022) to assess the effectiveness of regional initiatives to reduce the burden of non-communicable diseases in the nine US-affiliated Pacific Island Jurisdictions indicates a much higher rate of alcohol use among youths in Palau (37.4%) as compared to Guam (18.2%) and four other jurisdictions.
Tobacco Use
School Screening Data from 2013-2022 indicates a decreasing trend in tobacco use among adolescents ages 10-19, from 31% to 19% for males and 28% to 18% for females. Smoking a cigarette and chewing betelnut with tobacco also indicates a decreasing trend. The tobacco age of initiation was twelve years old, with the youngest to try at 4. Subsequently, the use of e-cigarettes and vapes increased drastically from 1% in 2019 to 11% in 2022. Over half of the respondents said they used an e-cigarette or vaping product daily.
Overweight/Obesity
Childhood obesity is a growing Public Health concern in Palau. Males are at a higher risk of obesity at 29% compared to females at 27%. There was a 42% increase in obesity in the last ten years among adolescents 11 years and older. In addition, participation in sedentary activities (watching tv, on social media, etc.) both in and out of school has increased from 43% in 2018 to 67% in 2022. Despite modifications to the public-school lunch program, the percentage of students who eat healthy meals hasn’t changed over time. Furthermore, participation in physical activity indicates a more than 200% increase from 2018 to 2022. There is a need for intervention programs that target social norms and beliefs, and strong policies that protect children from unhealthy food marketing as well as overall health among young people in Palau.
Self-Harm
Self-harming behavior in the 11 and older age group is an alarming public health concern in Palau. The increase was observed from late 2019 to 2022 for both male and female adolescents. However, self-harming behaviors were more common among female students and may be related to higher rates of depression. Cutting is the most common form of self-injury among females, mainly on the wrist or thighs. The school health screening program provides brief intervention consisting of education regarding risk and problem-solving for young persons before a referral to a psychiatrist.
Immunization
Although Palau serves as a role model for high immunization coverage in the Pacific, we continue to face challenges in low coverage of the HPV vaccine. In 2022, the HPV coverage was 46% for the eligible population (WEBIZ).
Priority: Priorities for this population group will include sexual and reproductive health, substance use disorder particularly on alcohol, obesity, mental health, and immunization. Strategies will include school-based interventions on alcohol and drug use, HIV, STI, pregnancy reduction intervention, efforts to increase HPV vaccine demand targeting parents, increase of physical activity among youth through partnerships with youth organizations to implement community wide campaigns, and to continue to provide mental health support to adolescents in schools as well as provide linkage back to primary/preventive services.
Children with Special Health Care Needs
The 2020 survey for children with special health care needs identified about 4% of Palau’s children and adolescent population require special health care needs. During the legislative compliance review for disability, some identified challenges were a lack of family and social support, transition services and programs, community-based rehabilitation services for the outlying states, and better coordination amongst NGOs, government agencies, development partners, and stakeholders.
The survey for children with special health care needs (SLAIT-LIKE Survey) surveyed 228 parents, guardians, and caregivers of children and adolescents ages 0-18 with special health care needs.
Strength
The program works with interagency partners to strengthen collaborations and refine the referral process for children diagnosed with conditions. The program will continue to work with the state ECCS team to provide awareness of services and the medical home concept. Training is provided on case management, follow-up, and early intervention services. Work with other community NGOs such as Palau Parent Empowered and Omekesang in developing health education materials that are culturally appropriate for Palau’s CSHCN and families. Furthermore, additional trainings on case management and care coordination for CSHCN for parents and service providers are also provided.
Additionally, the Palau UNHSI program recently established an Advisory Board to support the development of statewide programs and systems of care by increasing the knowledge of pediatric care professionals, family members of deaf or hard-of-hearing children, and other relevant agencies in providing recommendations to improve care coordination, information sharing to contribute to the improvement of the program.
Moreover, the Division of Human Services under the Bureau of Public Health coordinates efforts in addressing the welfare of the community, including CSHCN, with a vision for the vulnerable population “life with dignity,” supporting two goals: To ensure the basic needs of all residents is met, and to reduce vulnerability by preserving and strengthening safety nets. Furthermore, the Palau National Disability Policy provides the framework for addressing disability issues in Palau by promoting more equality and inclusiveness and promoting greater independence for awareness of the needs and rights of persons with disabilities. This division oversees the equal distribution of the disability funds appropriated annually by congress to families of children with special health care needs. The additional funding assistance helps support families with the basic needs of the child as well as medications.
Needs
One out of five children with special health care needs in Palau have ongoing physical/medical conditions lasting more than 12 months. Approximately 46% are reported with moderate to severe conditions, and about 54% have needs that usually remain the same. About 42% live in families with less than $10,000 annual household income, and 30% spend more than $100 on monthly medical care. Additionally, 78% of parents of children with special health care needs utilize their medical savings account to cover for prescription cost. In 2020, 15% of families of CSHCN said they did not have enough money to pay for care.
Access to care remains a challenge with limited specialty services on the island. The program works with the medical referral office to prioritize required specialty services for CSHCN when a request is made through Tripler Medical Center and Shriners Hospital in Hawaii.
The Palau MCH program is yet to conduct a state-wide survey this year to identify/update the needs of children and youths with special health care needs, which will ultimately provide critical information that will guide the program in providing services to the CSHCN and their families.
Priority: The priority remains to improve systems of care for children with special health care needs. The program will continue improving care coordination services for children and their families and will work with providers to establish and enhance medical home programs. Training and workshops are also necessary to increase the knowledge and understanding of educators, parents or caretakers, special education services, family health unit, and the community of the transition services requirements for CSHCN. In addition, improving transition services by building school capacity to address the needs of the CSNCN population. Furthermore, the program will work with others to mobilize resources outside of Palau to provide diagnosis and interventions to this population, and to develop a telehealth program that supports much needed services not available in Palau.
Capacity, systems of care and partnerships
Palau has taken steps to address issues of care, especially in light of the delayed and pronounced health needs of the community due to the pandemic and our local capacity for primary, secondary and tertiary care. We are a geographically isolated island where the closed places to where residents can access four-year post-secondary education, advanced secondary and tertiary medical care, and other opportunities (well-paying jobs) are about 500 to 2000 miles away (Guam, Taiwan, Philippines, Hawaii). And even within the island, travel is challenging considering the price of fuel is over $5.00/gallon and over half of the population makes less than 10k/year.
Primary and preventive health services must be the priority for Palau, as it is the least expensive and achievable for us. A notable change in the past year has been the passage of a legislation to separate the Belau National Hospital from the Public Health department, to allow more investment of resources where is it much needed, in disease prevention and health promotion. This was especially pronounced during the pandemic and in early 2022 when Palau experienced its first and highest surge of COVID-19, all resources were redirected to the response. Lessons learned from the response include the leveraging of resources to ensure successful achievement of objectives. The MCH program currently funds an overall MCH coordinator, a school health/adolescent health coordinator, a counselor, an administrative specialist, and a pediatrician. However, partnerships with other programs and departments who share similar cross cutting objectives allows for leadership support, providers (physicians, nurses, dentists, dental assistance, lab and radiology technicians, pharmacy) to ensure delivery of services, and integration of much needed services and resources (family planning, newborn hearing screening, cancer screening, HIV/STI screening, GYN).
Local and external partners also lend expertise and resources to advance maternal and child health including children and youth with special healthcare needs. Health coalitions and advisories in areas of tobacco, alcohol, nutrition, physical activity, mental health, people living with disabilities, education, early childhood, and many more, advocate as well as contribute to the planning and implementation of programmatic goals and activities. AS mentioned elsewhere in the document, our partners were responsible for the passage of the seat belt law and vape ban. The schools have been instrumental in implementing policies to increase physical activity and healthy eating in the schools.
At this time, the Family Health Unit (FHU) doesn’t have a program manager, but the Chief of the Division fulfills this role, while training an identified staff member to take on the role in the next 6-8 months. The Division epidemiologist/evaluator also supports the entire program in its data and surveillance activities, and facilitates training for staff to take on the roles of data management specialists. Three additional staff within the FHU have been identified to obtain the Data for Decision Making program facilitated by the Pacific Islands Health Officers Association (PIHOA) and will add on to the resources to move our objectives forward. During the pandemic, Ministry of Health and Human Services was able to recruit additional staff to not only respond to COVID, but to also meet the pent up demands due to delayed and suspended services. Because of this and Palau’s priority in the MCH populations, there was less than 10% decrease in the number of patients accessing MCH services. Plans were implemented to ensure that our MCH clinics were protected (through rigorous screening) so that our clients were reassured that they were somewhat protected when they came in for their appointments.
Finally, Palau learned the value of telehealth and its potential in not only allowing for workforce education and training, but for provider – provider consultations and delivery of much needed services to patients in remote areas, or who cannot come into the clinics for other reasons. At this time, the Ministry of Health is working with regional partners to establish a formal telehealth program in Palau.
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