Although chronic disease has long concerned high-income countries, 80% of chronic disease deaths occur in low- to middle-income countries (1). A complex interplay of socioeconomic, demographic, technologic, cultural, environmental, and biological factors explains this epidemiologic transition from communicable disease to noncommunicable disease (NCD) (1,2). The burden of chronic disease is substantial in the US Associated Pacific Islands (USAPI) jurisdictions (American Samoa, Guam, Commonwealth of the Northern Mariana Islands [CNMI], Federated States of Micronesia [FSM] [Chuuk, Kosrae, Pohnpei, and Yap], Republic of Palau, and Republic of the Marshall Islands [RMI]). For example, although differences in age-standardizations hinder comparison (3,4), age-standardized cardiovascular disease (CVD) mortality estimates among the USAPI jurisdictions are generally higher than similar US age-standardized CVD mortality estimates (5,6) (Table 1).

The USAPI jurisdictions' population spreads across 104 inhabited islands in more than 3 million square miles of ocean, crossing the International Date Line. Despite the challenges of geographic isolation, dependence on US and international aid, and lack of health care funding (7), the USAPI jurisdictions are targeting chronic disease prevention by developing partnerships and approaches that reflect the interface between Pacific cultures and Western science (2,8,9). In addition, a May 2010 Pacific Island Health Officers Association resolution declaring a state of health emergency due to the epidemic of chronic disease encourages stronger coordination of partnerships across multiple sectors to mobilize policy, investments, and technical resources to reduce the prevalence and costs of chronic disease within the region (10). Effective chronic disease surveillance systems can support this effort and help the USAPI leadership monitor disease trends, evaluate public policy, prioritize resource allocations, and guide program planning, evaluation, and research.

Surveillance is defined as the ongoing, systematic collection, analysis, interpretation, and dissemination of data essential for health promotion and disease prevention (11). Chronic disease surveillance data sources supported by the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and USAPI health care systems can be divided into 2 main categories: population-based (ie, household surveys) and institution-based (ie, disease registries) (Figure). The objective of this study was to assess the quality of existing USAPI chronic disease data sources and identify the capacity for chronic disease surveillance by individual jurisdiction, following WHO's Health Metric Network Framework (HMNF). We also offer recommendations for continued capacity building to strengthen surveillance within the region.

After reviewing the literature and documents available on the web or through individual jurisdictions, we established an inventory of data sources for monitoring standard chronic disease indicators (11). Using this list, USAPI chronic disease representatives identified their jurisdictions' existing data sources, frequency of data collection, and availability of analysis and reporting. For each identified data source, the frequency of data collection, analysis, and reporting was confirmed by the respective USAPI Ministry of Health or Department of Health administration. CDC verified USAPI participation in the CDC-supported data sources. The US Renal Data System (USRDS) Western Pacific Renal Network verified the Medicare certification dates for jurisdictions participating in the USRDS data network (S. Tanner, oral communication, April 2011).

We completed a literature search concerning USAPI capacity for chronic disease surveillance through the National Library of Medicine’s and National Institutes of Health’s PubMed (www.ncbi.nlm.nih.gov/pubmed/) and EBSCO’s Cumulative Index to Nursing and Allied Health Literature (CINAHL). Publications included meet the following criteria: 1) they assessed chronic disease surveillance capacity for the USAPI region overall or by individual jurisdiction and 2) were published in English within the last 10 years (ie, 1999 through October 2010). We excluded publications that presented only results of USAPI chronic disease-related research (ie, epidemiologic, clinical, and qualitative) or program evaluation without inclusion of an assessment related to chronic disease surveillance in the region overall or by individual jurisdiction. Search terms were “chronic disease,” “population surveillance,” “disease surveillance,” “American Samoa,” “Guam/epidemiology,” “Micronesia/epidemiology,” and “Marshall Islands.” To select the publications, the titles and abstracts were reviewed by 1 author (G.H.) for relevance; those that met the inclusion criteria were selected. Subsequently, the entire text of selected publications was read and publications that did not meet the inclusion criteria were excluded.

We used the WHO HMNF as the foundation for assessing the quality of USAPI chronic disease surveillance data sources and identifying jurisdiction capacity (Table 2). The HMNF is a global health partnership formed in 2005 that supports assessment and capacity building for health information systems in low- to middle-income countries (12). Two authors (G.H., H.I.) completed independent assessments for each data source by using supporting documentation retrieved from web-based archives, literature review, or from surveillance documentation provided by individual jurisdictions. Aggregate scores for each assessment criterion ranged from 3 (highly adequate) to zero (not adequate). We did not score data sources without complete documentation.

USAPI data sources are listed by category and data availability by year (Table 3). A summary description of each data source follows.

Our review showed that the USAPI jurisdictions are using both population-based and institution-based data sources to build capacity for chronic disease surveillance. The USAPI chronic disease data sources are aligned with widely accepted indicators for chronic disease surveillance (11) that use standardized measures and methodology to collect, analyze, and report data related to chronic disease behavioral risk, preventive practices, illness, and death. Consistent use of these data sources allows the USAPI to establish population benchmarks, compare chronic disease trends regionally and among other population groups within the United States and internationally, set priorities for resource allocations, and guide evidence-based policy and population health interventions needed for chronic disease prevention.

However, the review also illustrated the need to strengthen USAPI chronic disease surveillance through expanded support for valid and reliable data collection, analysis, and reporting among population-based data sources. For example, 5 jurisdictions began monitoring and tracking health risk behaviors among youth and young adults (YRBSS, YTS) in the early 1990s. Although these surveys are administered at standard intervals, statistical analysis and reports are generated by CDC for participating jurisdictions that obtain an overall response rate of 60% or more and submit appropriate survey documentation. With the exception of Palau's YRBSS, timely and reliable data collection representative of the target YRBSS youth and young adult population across survey years varies among participating jurisdictions. Similar challenges exist with obtaining representative samples every 4 to 5 years for the YTS and GYTS.

Additionally, Guam, through participation in BRFSS, is the sole jurisdiction with sustained capacity for monitoring and tracking adult (≥18 y) health risk behavior and preventive practices. Other jurisdictions (eg, Palau) are building capacity for participation in BRFSS or STEPS (American Samoa, CNMI, FSM, and RMI), but financial resources and organizational capacity are limited. These constraints were particularly evident for STEPS, resulting in challenges with timeliness and consistency of survey administration (>5 y in American Samoa and RMI), data analysis (ie, standardized weighting and disaggregation by age, sex, and socioeconomic status), and reporting. USAPI jurisdictions' chronic disease surveillance infrastructure does not adequately support the standard and complex analysis of STEPS and other available surveillance data.

Although jurisdictional institution-based chronic disease data sources use nationally accepted standards and methodology, data quality concerns remain. These concerns are

Finally, this review did not assess biases within population-based data sources. For instance, the YRBSS and YTS exclude youths not attending or registered within jurisdictional school systems. The BRFSS includes only households with an available landline telephone and uses self-reported data. Additionally, sample size in some survey modules may limit data analysis. Lastly, responders to population health surveys might not be representative of the total target population.

Chronic disease surveillance can provide a foundation for population health efforts designed to address health disparities within USAPI communities. Using the HMNF, this assessment provides an initial platform to understand the quality of existing USAPI data sources and identify jurisdictional capacity for chronic disease surveillance. The need to strengthen USAPI chronic disease surveillance through continued assessment and expanded support for valid and reliable data collection, analysis and reporting, dissemination, and integration among population-based and institution-based data sources is common across jurisdictions. Continued engagement of USAPI leadership across multiple sectors (eg, public health, business, education, faith- and community-based groups) to empower innovative systems and linkages for chronic disease surveillance is essential for understanding and improving health within Pacific communities.

Our recommendations are aligned with the White House Initiative on Asian Americans and Pacific Islanders (www.whitehouse.gov/administration/eop/aapi) and the Department of Health and Human Services (HHS) National Partnership for Action to End Health Disparities (www.minorityhealth.hhs.gov/npa/) designed to mobilize a comprehensive, community-driven, and sustained approach to reducing health disparities among racial and ethnic minorities. Recommendations include continued assessment, investment, and technical assistance in support of a chronic disease surveillance system that integrates USAPI population-based and institution-based data sources. Innovative strategies that link and expand these data sources could advance evidence-based policy and environmental transformations that target chronic disease prevention. Related recommendations include 1) collaboration among USAPI governance, local and regional partnerships, and US and international agencies to integrate surveillance; 2) investments to strengthen USAPI infrastructure that support an expanded surveillance system; 3) workforce development, through education and training, to promote quality surveillance; and 4) translation of data to inform policy, research, and program planning and evaluation at local, national, and international levels.