Pacific health dialog: a publication of the Pacific Basin Officers Training Program and the Fiji School of Medicine

Innovations in, and the use of emerging information and communications technology (ICT) has rapidly increased in all development contexts, including healthcare. It is believed that the use of appropriate technologies can increase the quality and reach of both information and communication. However, decisions on what ICT to adopt have often been made without evidence of their effectiveness; or information on implications; or extensive knowledge on how to maximise benefits from their use. While it has been stated that 'healthcare ICT innovation can only succeed if design is deeply informed by practice', the large number of 'failed' ICT projects within health indicates the limited application of such an approach. There is a large and growing body of work exploring health ICT issues in the developed world, and some specifically focusing on the developing country context emerging from Africa and India; but not for the Pacific Region. Health systems in the Pacific, while diverse in many ways, are also faced with many common problems including competing demands in the face of limited resources, staff numbers, staff capacity and infrastructure. Senior health managers in the region are commonly asked to commit money, effort and scarce manpower to supporting new technologies on proposals from donor agencies or commercial companies, as well as from senior staff within their system. The first decision they must make is if the investment is both plausible and reasonable; they must also secondly decide how the investment should be made. The objective of this article is three-fold: firstly, to provide a common 'language' for categorising and discussing health information systems, particularly those in developing countries; secondly, to summarise the potential benefits and opportunities offered by the use of ICT in health; and thirdly, to discuss the critical factors countries. Overall, this article aims to illuminate the potential role of information and communication technologies in health, specifically for Pacific Island Countries and Territories (PICTs).

Few studies have addressed Sociocultural factors underlying healthy lifestyles. The Sociocultural component of the Obesity Prevention in Communities (OPIC) project explores social and cultural factors that may promote or protect against obesity via adolescents' values, attitudes, beliefs and explanations for their patterns of eating and physical activity, as well as preferred body size. This paper reports on semi-structured interviews conducted with a sub-sample of indigenous Fijian females in terms of their descriptions of and explanations for their at-school eating patterns. While participants understood which foods and drinks were healthy, many skipped breakfast, and ate junk at recess and after school. The main reasons for these unhealthy eating patterns were poor time management in the mornings, and access to discretionary spending money for junk food. Participants cited family members and friends as key influences on their eating patterns. Findings were used to develop intervention strategies to encourage the regular consumption of healthy food at home and at school.

The Republic of the Marshall Islands has been recognised anecdotally to have high rates of major lower limb amputations secondary to diabetes. During 2001, a prosthetics service was introduced as part of the rehabilitation service at Majuro Hospital. 1. To determine the incidence of major lower limb amputations over a one year period from 2002 to 2003. 2. To evaluate the proportion of patients suitable for prosthetic fitting. 3. Determine survival rates and usage of prostheses six to eighteen months after prosthetic fitting. Amputation rates were established through review of the surgical logs at the two hospitals in the Marshall Islands. Prosthetic fitting rates were determined using records from Majuro hospital rehabilitation service. Follow up interviews were conducted with fifteen surviving patients who received prostheses during the study period, to investigate prosthetic use. The incidence of major lower limb amputation was found to be 79.5 per 100,000 population, with all forty-five amputations being associated with diabetes. Just over a third of these patients were discharged from rehabilitation with a prosthesis. Fifteen of the patients were followed up post discharge. All of the thirteen with transtibial amputations were found to be using their prosthesis at least some of the day. The two patients with transfemoral amputations had ceased to walk with their prosthesis. This study identified a very high rate of lower limb amputation in the Marshall Islands by world standards. Prosthetic fitting rates and follow up results were comparable to those reported by others, and indicate that small, geographically isolated island nations such as the Marshall Islands are able to provide a successful prosthetics and rehabilitation service locally.

Cancer is becoming an important cause of morbidity and mortality in Niue. Analysis of a cancer register showed an overall age adjusted rated of 11.3 and 9.9 per 10000 among males and females, respectively. A significant increase in the trend of cancer during 1952 to 1985 cannot be explained by improved registration alone. This study when compared with other data sources on Niue indicated a gross under-reporting of cancer (over 70%). The establishment of national registers for chronic diseases like cancer is the most accurate, economic and technically achievable way to provide population-based information for the small Pacific Island states.

This paper provides an analysis of the Fiji Ministry of Health (MoH) budget for the last 46 years, its share of the national budget and annual percentage of GDP, its revenues, per-capita health expenditure, staff costs, and the performance on key population health indicators and Millennium Development Goals (MDGs). Despite annual increases in dollar terms, the proportion of GDP allocated to the national public health system has fallen from 4% to 2.6% over the last 15 years. Consequently the national performance on key health service indicators and MDGs is declining and health staff are migrating. We outline factors to retrieve the public health system in Fiji, such as the need for political commitment to the health of the people, public policy debate on the nature of the health system, the revision of hospital charges, the need to protect the poor by strengthening means testing, and propose compulsory health insurance for the employed.

The driving force of health research in the Pacific has been the expatriates. The common practice has been that health professionals from developed countries come and do research, without much involvement by local experts, take the data off shore to analyze and publish elsewhere, without benefiting the researched communities. this paper examines the participation of Fijians in health research publications on Fiji; identifies the most researched health areas; and discusses the implications for health priorities and research capacity development in Fiji. Medline published papers were used as database using "Fiji" as the search word. Two hundred and ninety-eight (298) health-related publications were retrieved from July 1965 to April 2002. Direct and indirect interviews were conducted for the identification of authors. Reviewing abstracts and full-textpapers were performed for the ascertainment of studied subjects of papers. The 298 papers identified include 275 (92.3%) descriptive studies (including community/population surveys, case series and cross-sectional studies); four (1.3%) case-control studies; eight (2.7%) cohort studies and 11 (3.7%) unknown-type studies. There were no randomized-controlled trials (RCT) or community intervention trials (CIT). Turning to authorship, there were more expatriates (82.3%) than local researchers (17.7%) out of a total 815 authors. There were fewer Fijians who had been sole and first authors (12.5% and 13.5%, respectively), and a significant difference between the proportion of non-Fijians to have contributed as sole and first author compared to that of Fijians (c2=6.4, df=1; p=0.01). Among the Fijian authors, males contributed five times more than females. Indo-Fijians (58%) participated more than indigenous Fijians (40%). Indigenous Fijian females contributed significantly more than Indo-Fijian females (c2=4.77; df=1; p=0.02). The majority of the authors (70.4%) were in the forties and fifties age groups. The staff from the Fiji School of Medicine (FSM) contributed only 12.9% to the total Fijian authorships. The remaining Fijian authors were affiliated with the Fiji Ministry of Health (MoH), the University of the South Pacific (USP) and other Fiji Government entities. The most researched areas were Non-communicable Diseases (13.4%), Infectious Diseases (11.4%), Health Services (10.4%), Nutrition and Dietetics (9.1%), and Mental Health (7.0%). The least researched areas were Cancer (2.3%), Gerontology (2.0%), Biochemistry (1.7%), Traumatology (1.7%) and Dermatology (1.3%). Only 31 (16.6%) out of 187 journals with papers about Fiji were available in the FSM Library. There was a significant increase of health publications over the studied period (r=0.502; 0.001<p<0.01), and, although the level of Fijian authorships was low, the proportion has been gradually increasing against declining non-Fijian authorships over time (r=0.32; 0.01<p<0.05). This study provides evidence of expatriate dominance in health research in Fiji using Medline publications as an approximation of research participation. Participatory discrepancies among local health professionals have been identified with possible contributing factors. The trend of papers published over the past 37 years; their availability, accessibility to local readers and their subjects relevance to country health priorities were documented. This study strongly suggests a need for participatory health research by the Fijians. It also emphasizes the ongoing demand for research capacity building and development among local health professionals. Among other discussions on the findings, attentions were drawn to considering for more rational research areas that are relevant to country health priorities.

Researches of and among Pacificans have been largely externally initiated, funded and controlled. It has become an imperialist tool to colonize, oppress and control the aspirations of Pacificans. This case study shows that research imperialism thrives in Tonga. Economic and social efficiency can be achieved through local initiatives by native researchers. Such an alternative approach must replace foreign data prospectors, "mosquito scientists" and "parachute consultants". This study provides a rapid assessment methods for monitoring research performance among Pacificans.

This paper shares 2000 data on Native Hawaiian health and compares the 2000 data with data from 1982 and 1990. The findings suggest that Native Hawaiians continue to die at younger ages than Hawai'i residents in other ethnic groups, have a higher prevalence of hypertension, diabetes, and asthma than other ethnic groups, and have higher rates of smoking, drinking, and being overweight. Compared to earlier years, however, smoking and drinking prevalence has decreased, and more Native Hawaiians are getting physical exams and other screening exams. These improvements may be related to increases in Native Hawaiian health professionals, supported by the Native Hawaiian Health Scholarship Program, and to increased access to health education and to care through outreach programs such as the Native Hawaiian Health Care Systems and the Breast and Cervical Cancer Control Program. If these programs are allowed to continue and to expand, we should see an improvement in overall health status of Native Hawaiians.

This paper examines the oral health status of older adults in Fiji to determine the risks of dental disabilities. Using cross-sectional data collected in 1985 and 1999, logistic regression models are used to measure the effect of select demographic, socioeconomic and health variables on difficulty with chewing. While the general picture for the older persons is quite positive, the largest concern is the striking increase in poverty as a predictor for our dependent variable.

Cesarean section rates and outcomes in Fiji have not been previously reported in the literature. Between 1986 and 1996, Fiji's cesarean section rates rose 2.5%, from 9.4% to 11.9%. Labor dystocia (33%), repeat cesarean (18%), and "fetal distress" (17%) were the most common indications for performing c-sections. A retrospective case-control study covering the period 1986-1996 in Fiji's three referral hospitals found that cesarean deliveries were three times more likely to involve child mortality (O.R. = 3.01, 95% c.l. = 1.19 < OR < 8.08), 26 times more likely to involve maternal morbidity (O.R. = 26.53, 95% c.l. = 8.10 < OR < 105.38), and 13 times more likely to require blood transfusion (OR = 13.17, 95% c.l. = 7.09 < OR < 25.05). Cesarean deliveries also required an average of 6 days spent in the hospital, compared to two days for vaginal deliveries. Children delivered by cesarean in the study population were 6 times more likely to have a 5-minute Apgar score below 7 and 4 times more likely to have an Apgar score below 5. Fourteen percent (14%) of cesareans followed an attempted induction of labor, while 1 in 11 women delivering vaginally underwent an attempted induction of labor for "Social reasons". The study found scope to potentially reduce the number of first and repeat cesareans through active labor monitoring, development of uniform clinical guidelines and indications for cesarean intervention and labor induction, and increased trial of labor for women with a history of a previous cesarean.

Utilizing a standardized oral health assessment tool, public school children ages 5 through 9 were evaluated Statewide in 1989 and 1999. In both samples, it was demonstrated that Asian & Pacific Islander children (as a group), by contrast with Caucasian, African Amercan or Hispanic children, suffered from disproportionately high rates of dental caries, were more likely to have unmet treatment needs and less likely to utilize dental sealants. Significant variance among oral health/ oral disease indicators was found among ethnic and regional groups and all Hawaii cohorts were found to have poorer oral health indicators by contrast with U.S. national findings. Data was not found to follow any particular pattern with regards to urban vs. rural settings. This report shows the value of considering a variety of oral health indicators in evaluating the health of a community. More research needs to be done in evaluating the influence of socioeconomic status and cultural beliefs and practices on the oral health of young children in Hawai'i.

This paper discusses the result of a mortality analysis carried out in the Federated States of Micronesia in 2005. The result shows that the population crude mortality rate decreased slightly between the years 1990-1992. Disease-specific mortality was highest among the chronic, or non-communicable diseases (i.e., diabetes, stroke, cancer, heart disease combined) compared to communicable diseases and injury combined. In addition, the study suggests that mortality due to NCD is occurring among people as young as 40 years old. In order to curb this trend, the authors recommend drastic change to the current health care delivery system.

In an area of the world not previously studied for the presence of nutritional deficiencies, this study conducted in 1994, examined the prevalence of Vitamin A deficiency on a representative atoll of the Marshall Islands. All children ages three through ten living on Mili atoll were surveyed. The study was conducted house-to-house with all 38 subjects on the atoll voluntarily enrolling in the study. Vitamin A status was assessed by conjunctival impression cytology with transfer ([CT), clinical ophthalmic signs, and nutritional survey in all children ages three through ten living on Mili atoll, Republic of the Marshall Islands. Forty-seven percent had xerophthannia (5% with XN, 39% with XN + XIA, and 3% with XN + XIB). More than three-quarters (78%) were ICT abnormal, indicating 31% of the population had mild sub-clinical vitamin A deficiency. Eighty-six percent of the children had not received the U.S. recommended daily allowance of vitamin A in the previous week. Oiven the World Health Organization's published guidelines that anything greater than a 1% prevalence, Vitamin A deficiency on Mili atoll may be classified as a significant public health problem.

Lung cancer is the leading cause of death from cancer among persons of Native Hawaiian ancestry. Because a large number of Native Hawaiian patients with cancer are treated at this hospital, a single-institution review was conducted to compare recent non-small cell lung cancer (NSCLC) survival and treatment patterns in Native Hawaiian and non-Native Hawaiian patients. A total of 1,394 cases of NSCLC registered between January 1995 and December 2001 were reviewed; of those, 229 patients self-reported Native Hawaiian ancestry. Independent predictors of survival were determined by proportional hazards regression modeling. The median age at diagnosis for all cases of NSCLC, and for males and females separately, was significantly lower for Native Hawaiian vs. non-Native Hawaiian patients. Although there were no significant differences in the distribution of cancer stage, the median age at diagnosis at each stage was also significantly lower for Native Hawaiian vs. non-Native Hawaiian patients. A higher proportion of patients were women in the Native Hawaiian group. Differences in the time to receiving primary treatment, or the proportions receiving surgery, radiation therapy, or chemotherapy, for each stage of disease, were not significant. Controlling for age, gender, stage and Native Hawaiian ancestry was associated with an increased mortality risk. An observed higher mortality risk from NSCLC for Native Hawaiians was not associated with differences in treatment as appropriate for stage, nor with delays in treatment; this suggests other factors, including environmental or biological influences, as contributors to unfavorable lung cancer outcomes among Native Hawaiians.

The Surveillance System for many Notifiable Diseases in Fiji is described by many as inadequate. This system includes the reporting and recording of Acute Rheumatic Fever (ARF) and Rheumatic Heart Disease (RHD). Prominent amongst the inadequacies of this system is the under reporting and the diagnostic dilemma and classification of he cases. Under-reporting was estimated at about 40% in Viti Levu, 44% in Vanua Levu, and 66% in the outer islands. This paper reviews the Surveillance System pertaining to ARF and RHD and describes the trends and demographic distribution of ARF and RHD in Fiji during the period 1996-2000 while highlighting the problem of the system A retrospective review of admission records of the Pediatric Ward, Colonial War Memorial Hospital (PW/CWMH), Suva, Fiji, from 1996 to 2000 was undertaken. Admission books were cross-checked with patient folders, when required, to avoid inaccurate counting of cases. Data obtained were analyzed and compared with those obtained from the Ministry of Health (MoH) during the same period. Under-reporting of ARF was documented with fewer ARF cases reported less than the actual number of ARF cases admitted to PW/CWMH in 1998 to 2000. On average, 18 ARF cases were reported each year for a cumulative incidence of 2.3 per 100,000 population; 173 RHD cases were reported each year for a cumulative incidence of about 21 per 100,000 population during this 5-year period. The problems seemed to be more prevalent among the Fijians compared to Indians; children in the 5-9 age group were more affected by ARF and those in the 10-14 age group were more affected by RHD. There was no statistically significant difference in the mean age between Fijian and Indian cases for both ARF and RHD. Under-reporting was apparent in the surveillance of ARF and RHD in Fiji. The cumulative incidence of ARF in Fiji appeared much lower than that reported from other Pacific countries. There is a definite need to improve the Disease Surveillance System and to sustain an effective ARF/RHD prevention programme are needed in Fiji.

Information on the oral health of institutionalized elderly populations in a number of countries is available but, no data is available nor published on the elderly population of Fiji. A pilot survey was carried out at the nursing homes in the Suva area. The aim of this study was to investigate the dental status and treatment needs of institutionalized elderly people. Examiner was calibrated and consent approved from the relevant institutions. This study found that residents were institutionalized, because family members could not care for them; did not receive any form of financial assistance and therefore totally relied on the institution; generally had medical problems such as neurological disorders, cardiovascular disease and diabetes. Generally had poor oral health status such as root stumps, many missing teeth, calculus and shallow pockets were common, oral hygiene practices were poor, high demand for dentures/or the dentures were not clean, some cases of leukoplakia were found and there was an urgent need for the dental profession to deliver dental care. Recommendations include issues in developing a supporting environment, provision of adequate and appropriate access, community education and skill development, workforce development and research in geriatric dentistry in Fiji.

An outbreak of Measles in Koro Island occurred during the spring of 1997 of which 245 suspected Cases of Measles were identified. Measles was most virulent among pre-adolescent and adolescent age groups that resulted in absenteeism during the epidemic. Crowded housing and transport encouraged spread of the virus. Measles IgM was confirmed in 88% of specimens tested. The Outbreak is attributed to primary vaccine failure and accumulation of susceptible cases caused by frequent breaks in the cold chain and subsequent reduction in population immunity to Measles. A recommended two-dose Measles Immunisation schedule will achieve and sustain a high population of immunity to Measles. Also essential is strengthening Laboratory & Epidemiological Surveillance, maintaining a high Immunisation coverage and integrity of a cold chain system to achieve the WHO target OF Measles Elimination by 2005.