Palau Campaign Book

Credits Journalism 406 S.T.A.N.D Campaign

Instructor Jerry Bush

Agency Jeff Anderson Kaylyn Bergbower Nicholas Burke Jessica Carron Justin Cotrell Christine Emmons Michael Estes Rachel Fabian Mariana Gomez Ariel Hitchcock Andrew Hoggatt Savanna James Chris Johnston Wenqi Kong Jiaxu Liiu Jeremy Martin Jeremy Myer Jesse Morris Katie O’Riley Hayden Ohmes Lucas Olson Willie Porter Rudolph Scavuzzo Haley Shaw Taylor Wright

Graphic Designers Willie Porter

Logo Artwork & TV Storyboards Natalie Bartels

Photographers Jessica Carron, Rachel Fabian, Savanna James

Palau Photographers Genna Ord, Julia Rendleman

Risk Factors Baseball TV Advertisement Filming: Tyler Sullivan & Jingyi You Editing: Tyler Sullivan

Centers for Disease Control and Prevention Dr. Mark Keim

Palau Representative Dr. Stevenson Kuartei

Table of Contents Overview............................................. 7 Situation Analysis........................... 9 Modifiable Determinants............ 21 NCD Matrix........................................28 SWOT Analysis.................................30 Key Idea.............................................. 33 Target Audience Profile.............. 35 Objectives.......................................... 39 Creative Strategy.......................... 40 Media Strategy.............................. 78 Budget............................................... 82 Conclusion........................................ 85 References...................................... 87

Overview diet, community activities and events, as well as variety of other issues. These questions help in building a partnership with Palau in the construction, implementation and understanding of this campaign.

This campaign is intended to encourage positive engagement between parent (guardian) and child in addressing risk factors of non-communicable diseases (NCDs) in Palau. The campaign has been designed to seamlessly transition to other islands throughout the Pacific Island Region.

This campaign’s primary focus is to raise NCD awareness while creating behavioral changes among the three selected target audiences. The key idea of this campaign is create parent-child engagement among these three audiences in order to further awareness and create behavioral changes. Community engagement is also a key component of this campaign.

Secondary research was compiled in order to understand the severity of NCD’s in Palau and across the Pacific. The secondary research was obtained through a wide variety of resources from which it was determined to categorize and focus on five different NCDs to address. Diabetes, cardio vascular diseases, cancer, respiratory disease, and mental health issues were identified as priorities for this campaign. Modifiable determinants (risk factors) were then determined for each of the selected NCDs in order to confront behavioral change in lessening the risk factors.

Primary research was conducted by forming a community focus group in Palau to answer a series of questions concerning cultural traditions, school curriculum,

Stand Together Against Non-Communicable Diseases

7

Overview

Situation Analysis

NCDs in the Pacific Island Region The World Health Organization reports that each year more than 36 million deaths occur due to non-communicable diseases (WHO, 2013). NCDs are diseases that are not contagious or passed from person to person. NCDs usually last a long time and tend to increase in severity over time.

According to WHO some of the most commonly known NCDs are cardiovascular diseases (heart attacks and strokes), cancers, diabetes, respiratory diseases and mental illness. NCDs are the leading cause of all deaths in the world, causing roughly 63 percent of all deaths (WHO, 2013).

Although NCDs exist all over the world, smaller undeveloped countries tend to have higher rates. Our geographic area of focus is the Pacific Island region. “The rate of NCDs in the Pacific Islands is

alarming. NCDs cause 70-80 percent of all deaths, which is10-20 percent higher than the world average,” said The World Bank (2013, January 16). The rates are increasing so rapidly that the Pacific Islands Health Officers Association declared the rise of NCDs to be an epidemic in May of 2010 (PIHOA, 2010).

The rise of NCDs in the Pacific is directly related to the low income rate among the region.

According to Dr Lesley Russell, “Until recently, income level was not regarded as a significant problem in Pacific Island nations, many of which have high per capita incomes by developing country standards and relatively productive subsistence sectors” (Russell, 2009). “Over 40 percent of the population in the Pacific Islands (4 million people) live in low income housing within towns, cities, squatter settlements and rural villages” (2009, Habitat for Humanity International).

NCDs pose a substantial threat to children in the Pacific Islands. Many school systems in the Pacific Island Region have

Stand Together Against Non-Communicable Diseases

10

seen a major drop in the number of teachers to help give the children proper education. “Palau’s financial resources for education have been reduced over the past decade due to ineligibility for many of the U.S. Federal grants for education that it received in its early years of independence” (Republic of Palau, 2006).

Teachers do address the subject of nutrition as part of the school curriculum; however, Ateca Kama, senior nutritionist at Fiji’s National Food and Nutrition Centre said, “Pacific schools continue to sell junk food in the school canteen because they need to make a profit” (WHO, 2013).

A 2008 study by the World Health Organization found that the leading causes of NCD deaths in 2008 were cardiovascular diseases (17 million deaths, or 48% of all NCD deaths), cancers (7.6 million, or 21% of all NCD deaths), and respiratory diseases, including asthma and chronic obstructive pulmonary disease (4.2 million). Diabetes caused another 1.3 million deaths.

Situation Analysis

Type 2 diabetes is widespread in the pacific. The high amount of diabetes cases in the Pacific Islands is directly related to improper diet and physical inactivity.

World Bank data indicates that in the Pacific, 60% or more of the adult population is overweight, and in six regions more than 75% (The World Bank, 2012).

Replacing traditional foods with imported, processed food has contributed to the high prevalence of obesity and related health problems in the Pacific Islands (WHO, 2013).

fessionals, conflict and political instability, environmental crises, poor access to pharmaceuticals and increased use of drugs and alcohol” (Hughes, 2009).

Mental health is also a serious issue in the Pacific Islands. Pacific islanders struggle to recognize that mental health is a problem in their society. The World Health Organization states, “the low priority to mental health issues has led to understaffing, underfunding, and services that are difficult to access” (WPRO, 2007). Frances Hughes sums up the problems in the Pacific by saying, “Many of the difficulties that face the Pacific are basic and are shared by other developing nations. They include a lack of health pro-

Another prominent NCD in the Pacific is respiratory disease. Common respiratory diseases are chronic obstructive pulmonary disorder (COPD) and inflammatory lung disease. The high rate of tobacco use correlates with the rise in respiratory deaths. “Twenty-five percent of high school students in the Northern Mariana Islands are smokers. In the Marshall Islands, almost 90% of smokers start in adolescence, and two-thirds are daily consumers by 18 years of age (Wilson, 2013).” A study by the Palau Youth

Tobacco Survey conducted in 2009 revealed that “29.1% of students currently use any form of tobacco; 41.3% currently smoke cigarettes (Palau Youth Tobacco Survey Fact Sheet, 2009).”

The leading risk factors in the Pacific include improper diet, alcohol and drug abuse, tobacco and betel nut use and lack of proper exercise. The simplest way to reduce NCDs is to lessen the risk factors that are associated with each disease. By modifying behavior of the major risk factors, the amount of NCDs will dramatically drop over time.

Stand Together Against Non-Communicable Diseases

11

Situation Analysis

Diabetes Although is not the leading cause of death in the Pacific Island Region, diabetes is one of the most prevalent and widespread diseases. This campaign will address type 2 diabetes because it is highly preventable through education and behavioral change. It is one of the most challenging health problems that anyone can become faced with. Diabetes not only affects the individual but it can also change social and environmental factors.

According to, IDF Diabetes Atlas fourth edition, “Diabetes imposes a large economic burden on the national healthcare system; there is substantial evidence that it is epidemic in many low- and middleincome countries. Complications from diabetes, such as coronary artery and peripheral vascular disease, stroke, diabetic neuropathy, amputations, renal failure and blindness are resulting in increasing disability, reduced life expectancy and enormous health costs for virtually every

society.” It also states, “There is a large disparity in healthcare spending on diabetes between regions and countries. More than 80% of the global expenditures on diabetes are made in the world’s economically richest countries, not in the low- and middle-income countries where 80% of people with diabetes live.”

Diabetes is one of the most widespread global diseases. According to the Canadian Diabetes Association, An estimated 285 million worldwide are affected by it.

With a further 7 million people developing diabetes each year, this number is expected to hit 438 million by 2030” (Canadian Diabetes Association, 2013).

The number of cases of diabetes in the concerted western pacific region shows the need for intervention. According to the International Diabetes Federation, “More than 132.2 million people in the Western Pacific Region have diabetes; by 2030 this will rise to 187.9 million” (Diabetes at a Glance, 2012).

Diet is one of the biggest contributing

Stand Together Against Non-Communicable Diseases

12

factors to type 2 diabetes. According to The National Center for Biotechnology Information, “the top two reported chronic illnesses among residents age 15 years and older in Palau were, hypertension (24.1%), followed by Diabetes Mellitus (22.4%), (Ichiho,2013). Food is a common way to express social and cultural relevance in Palau. According to The Journal of Development and Social Transformation, “Pacific Islanders have strong ethnic identities that incorporate a mix of traditional native island heritage with western-influenced contemporary life-styles and beliefs” (Curtis, 2004).

Over the years, Palau has adopted unhealthy eating habits from exposure to western foods. What they fail to realize is that their health is suffering the consequences.

According to Dr. Temo Waqanivalu, poor diet is the blame for the region’s health problems. Dr. Waqanivalu states, “Promotion of traditional foods has fallen by the wayside. They are unable to

Situation Analysis

compete with the glamour and flashiness of imported foods” (Aitaoto, 2005).

The Journal of Development and Social Transformation also states, “The factors for this epidemic of obesity are a dramatic decrease in physical activity and a dependence on a western diet. Native Palauan’s food consists of taro, fish, tapioca, and sugar cane (Diabetes Mellitus in Palau, 2013). The traditional foods of the islands have been replaced by rice, sugar, flour, canned meats, canned fruits and vegetables, soft drinks and beer” (Curtis, 2004).

Knowledge about diet and the relationship it has to type 2 diabetes can help prevent the spread of this widespread NCD. Parent engagement and involvement in their child’s diet; both at home and at school, has proven to be an effective method of prevention. Center of Disease Control and Prevention (CDC) mentions, “A growing body of research shows that adolescents engage in fewer health risk behaviors and perform better

academically when their parents are actively involved in their children’s lives. Parent engagement in schools can promote health behaviors among children and adolescents” (CDC Feature, 2012).

Palau has an estimated population of only 21,400 (Indexmundi, 2012). Most recent estimates by Index Mundi show that diabetes in Palau affects 11% of the population (Indexmundi, 2012). Care for diabetes is not cheap. The International Diabetes Federation states, the mean healthcare expenditures per person with diabetes (USD) is $1,319 (Iapwesternpacific, 2012).

Exercising daily and eating healthy are two ways to reduce the risk of diabetes. Diabetes can be directly attributed to more than 1.7 millions death in the pacific region in 2012 (Iapwesternpacific, 2012).

Stand Together Against Non-Communicable Diseases

13

Cancer Cancer mortality is now the second most common cause of death in nearly all United States Association Pacific Islands (USAPI) jurisdictions. Socio-economic characteristics play an important role in determining the quality and accessibility to cancer services (Yano, 2006). High rates of unemployment, lack of medical insurance (cancer insurance), and living conditions in Palau have been shown to be predictive of the level of care a person receives. According to the 2005 census of Population and Housing, 52.6% (1,897 of 3,580 families) had an income below the poverty level. The median annual household income is $18,000 and the average household size is 5 individuals as indicated by census data. Of the total 10,203 in the labor force, 9,777 were employed and 426 were unemployed, with the overall unemployment rate is 4.4% (Palau Census, 2005).

Situation Analysis

Insurance coverage for cancer is very limited in Palau. Currently, there are only two insurance companies in Palau that provide very minimal coverage for cancer patients. The one-time coverage for Palauans is limited to $20,000 per person if and when they are diagnosed with cancer. During the coverage period of 20 years, if a person insured does not get cancer he/she will be reimbursed for all premiums paid. Palauan citizens are also not eligible for Medicare or Medicaid benefits (Yano, 2006).

From 1998-2002 there were 649 total deaths with 68 of these deaths caused by cancer (Wong, 2003). There were nine deaths attributed to lung cancer with one of the deaths being female while eight were male. These nine lung cancer deaths accounted for 21% of cancer deaths in that span of five years according to the Cancer Registry of Palau.

From 1997-2001 there were 122 cases of cancer reported for that five-year time span, sixty-eight being female and fiftyfour being male. Of the sixty-eight female cancer cases, six were lung cancer cases which accounted for 9% of total cancer cases. Out of the fifty-four male cancer cases, fifteen were lung cancer cases which was 28% of the total cancer cases reported (Wong, 2003).

The Palau Cancer Registry stated that the oral cancer incidence rate from 1997-2002 per 100,000 was 18.0 which compared to the U.S. at 10.9 (Wong, 2003). Seventy-six percent of the Palau population chew betel nut while 80% of those chewers add a cigarette additive while chewing. As stated in the National cancer strategic plan for Palau, the Youth Tobacco Survey conducted showed 68% of high school students chew betel nut while 54% of middle school students chew betel nut, and more than 53.9% of students have started using tobacco with betel nut before the age of twelve. Also, more than two-thirds of high school students tried cigarettes while 34.8% rode in a car on one or more days of the week with someone who was smoking cigarettes, pipe, or cigars (Yano, 2006). The most common way to chew betel nut is

combined with slaked lime, pepper leaf, and/or various forms of tobacco. The addition of lime aggravates the gums and oral cavity and tobacco is a known carcinogen, so it could be a synergistic effect (Pobutsky, 2012). The repeated, long term chewing of the betel nut is known to have health effects, including oral lesions and oral cancer. Chewing betel nut with out tobacco may also be an independent risk factor for oral cancer without the addition of tobacco.

Cancer prevention and control is a concern for Palau. With Palau’s remote location, economic limitations, social and cultural traditions and environmental issues, cancer is a serious concern; presently, and for the future of the population and growth of the country.

Cardiovascular Disease The World Health Organization lists heart disease as the killer of seven million people in 2011. The disease accounts for around 7,000,000 of all mortalities in the world annually, placing heart disease as the leading cost of life (WHO, 2013).

Heart disease includes conditions affecting the heart, such as congenital heart disease, congestive heart failure, coronary heart disease, and heart attack.

Keys to prevention include: controlling high blood pressure, exercising, quitting smoking, lowering cholesterol, and maintaining a healthy weight (WebMd, 2013).

Today, conservative estimates place $8,104,044 of the Ministry of Health’s $14,659,570 annual budget allocated towards fighting NCD’s. If nothing is done by the year 2020, around 80% of the budget will constitute of NCD costs. Well over half the citizens have NCD’s in their family history, coupled with high risk factors such as hypertension, obesity, and tobacco usage (Ichiho, 2013). Amongst the problems are inconsistent policies on imports and locally produced alcohol and tobacco. Access to fruits, vegetables, and local produce continues to be difficult to sustain due to high costs and poor availability of fertile lands (MOH, 2013). Again, if nothing is done by 2015, 82% of men,

Stand Together Against Non-Communicable Diseases

14

and 87% of females will be overweight or obese (WHO, 2013). Heart disease is a serious, life threatening illness, but nearly 80%, or around 24 lives annually can be saved (Ichiho, 2013).

There are many different reasons why stroke can become an issue for the people of Palau. There is a huge risk for smokers because the carbon monoxide located in cigarette smoke decreses the level of oxygen that flows through the blood stream (CDC, 2010). CDC reports that secondhand smoke can increase a non-smokers risk for stroke. The use of alcohol can also be a factor; when consuming too much, it increases blood pressure levels which increases the chance for stroke (CDC, 2010). CDC also reports that physical inactivity increases chances of stroke because it can result in weight gain, which results in increased blood pressure, as well as cholesterol levels.

Having a stroke can leave you with many devastating effects, including memory loss, movement problems, language problems, emotional distress, and permanent brain damage (NSA, 2013). According to the World Health Organization, strokes totaled 16 percent of Palauans in 2011. The National Stoke Association reported that 3,639 Pacific Islanders died of stroke in 2009. Medical expenses for stroke have resulted in part of the $8,104,044 spent on NCDs in Palau (Kuartei, 2011).

Palauans face a greater threat for stroke because of lifestyle issues. Lack of activity, as well as social and cultural issues with food, result in weight gain and poor health conditions. Foods that are consumed by the community such as processed foods, salt, red meat, and fried foods all increase the risk of a stroke (Mercola, 2011).

Heat stroke is also a potential danger in Palau’s tropical climate. A heat stroke can take place when the body is exposed to high temperatures for too long (Mayo Clinic, 2013). Once the body temperature rises to at least 104 degrees it will overheat and become exhausted causing

Situation Analysis

a stroke (Mayo Clinic, 2013). The Mayo clinic has also reported that high humidity, health problems, some medications, and extensive physical work in high heat create a larger risk for stroke.

Respiratory Disease Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease that makes it difficult to breathe. This is due to the COPD causing coughing that produces large amounts of mucus, which causes shortness of breath, wheezing, and chest tightness. COPD is typically caused by long-term exposure to lung irritants that damage the airways. For example, cigarette smoke (first and secondhand), air pollution, chemical fumes or dust. According to the World Health Organization, COPD accounted for 21,000 deaths in the Western Pacific.

Another major cause of COPD is a problem with indoor air pollution, which occurs when people use biomass fuels such as

crop residues, dung, straw and wood for their cooking and heating needs (WHO, 2005). Women exposed to indoor smoke are three times as likely to suffer from COPD than women who cook with cleaner fuels such as electricity and gas (WHO, 2005). Indoor air pollution is responsible for 426,000 deaths in the Western Pacific Region (WHO, 2005).

Smoking is the biggest contributor to respiratory disease. The Palau Youth Tobacco Survey (YTS) was a schoolbased survey of students in Grades 6-12 conducted in 2001, 2005, and 2009.

From 2001 to 2009 the smoking rate of youth aged 13- 15 years old increased from 21.6% to 41.3% (Oseked, 2012).

The 2009 Youth Tobacco Survey reveals that 1 in 5 youth who have tried smoking had their first cigarette before the age of eleven and one in ten youth between the ages of 13 and 15 started chewing betel nut at 5 years old or younger. Almost fifty-four percent of the children surveyed reported that they lived in homes with a smoker, therefore being exposed to sec-

Stand Together Against Non-Communicable Diseases

15

ond hand smoke (Oseked, 2012).

Among the cigarette smoking youth, 1 in 5 reported buying their cigarettes in a store, which shows that these young children were not refused tobacco due to their age (Oseked, 2012). Furthermore, the youth who chew betel nut and tobacco (some reporting chewing as early as 5 years old) report getting the majority of their chew from friends or people they know, as well as from their family (Oseked, 2012).

Asthma is also a common illness. Coming in contact with some airborne allergens as well as exposure to some viral infections during infancy or childhood can cause asthma (National Heart Lung and Blood Institute). According to Dr. Kuartei, in 2006, asthma was ten percent of the illnesses reported in Palau.

Situation Analysis

Mental Health Major depression is considered a serious medical illness that affects one’s behavior, thoughts, feelings, physical health and mood. It is a mood state that goes beyond temporarily feeling down or sad. It is actually a life-long condition that reoccurs and can also be identified as clinical depression, major depressive illness, major affective disorder and unipolar mood disorder (Duckworth, 2009).

It is important to detect signs of depression at a young age to help prevent this ongoing sadness. A child starts to feel hopeless and worthless when suffering from depression. When this sadness becomes unending, it will interfere with the child’s everyday activities, relationships and schoolwork. The causes of childhood depression are unknown but can affect each family member’s life. Physical

health, life events, genetic vulnerability, environment, family history, and biochemical disturbance are factors that could relate to the cause of depression (Goldenberg, 2012).

Symptoms of childhood depression vary because it depends on the child’s mood disorder. Childhood depression often goes unnoticed because it is passed off as normal emotional and psychological change that occurs during growth.

“The signs and symptoms of childhood depression include: changes in appetite, changes in sleep, difficulty in concentrating, fatigue and low energy, feeling worthless, guilt, impaired thinking or concentration, increased sensitivity to rejection, anger, physical complaints such as stomachaches or headaches, reduced ability to function during activities, social withdrawal, thoughts of death or suicide, and vocal outbursts or crying” (Goldenberg 2012). Greater risks of childhood

Stand Together Against Non-Communicable Diseases

16

depression can also be affected by conflicted families and children abusing drugs and alcohol.

Neuropsychiatric disorders are said to be the cause of “12.4% of the global burden of disease” in the country of Palau (WHO, 2011). The finalization of mental health policy and implementation of the Human Resource Training Plan are currently being investigated.

Palau is now in the process of getting laws passed to protect the rights of people with these dangerous diseases.

Finally, the Palau Public Health Strategic Plan says there are eight priorities for their plan of action, three are related to mental health-depression and substance abuse (alcohol and tobacco).The budget allocation for mental health costs by the government health department are only 0.82% of the total health budget (WHO, 2011).

Situation Analysis

Prescription regulations do not allow regular doctors or nurses to prescribe psychotherapeutic medicines to patients when dealing with these disorders. Official policy does not let primary health care nurses diagnose and treat mental disorders on their own within the regular care system.

The majority of primary health care doctors and nurses have not received official in-service training on mental health within the last five years which is a major setback when dealing with these diseases according to World Health Organization.

They also do not have the materials to research more information on these diseases. The health care officials in Palau need to be more informed and more intelligent in the field in which these diseases are occurring (WHO, 2011).

To help with depression there are some simple criteria to follow. Eating smart will help lift the mind and body. A good diet will go a long way when trying to feel better about yourself, both mentally and physically. Even though there is not a specific exercise that works for depression, having a healthy diet can be a great part of an overall treatment plan.

sleep that you need is very important. Depression often will interfere with healthy sleep, some people sleep too much, others will have trouble falling asleep.

Finally, alcohol and drugs can slow or prevent recovery from depression. If you do not abuse substances, you’ll have a far better chance of overcoming depression (Goldenberg, 2012).

Exercise also changes the way you feel and can be a big factor when you’re trying to get over depression. As time goes on, increasing activity more and more until reaching almost a full week of exercise will better the outcome. Over time, it will improve your mood and make you physically feel better. Being active and exercising throughout the day will tire your body and help you sleep better at night. Giving support and exercising with a friend will lead to better results and help you stay focused. In addition, getting the healthy

Another mental disorder that affects many Palauans is schizophrenia. This is a brain disease that includes confusion, social withdrawals, loss of personality, delusions and bizarre behavior. Although schizophrenia can appear at any time in life, it often is found in late adolescence or early adulthood (Nordquist, 2009). A human’s brain has billions of nerve cells that send and receive messages from other nerve cells. The messaging system in the brain of the infected person with schizophrenia does not work correctly.

Stand Together Against Non-Communicable Diseases

17

Situation Analysis

This leads to individuals being convinced that others can read their mind or some may just hear voices, which often will lead to much anxiety (Nordquist, 2009).

There is no research that shows a single cause of schizophrenia, but evidence does show that environmental factors along with genetics can lead to this illness. Not only does schizophrenia affect the person with the disorder but also friends, family, and the society in which they live. It is hard for an individual to hold a job or take care of themselves, this forces them to rely on others. Major symptoms of this illness is experiencing delusions, hallucinations, and having thought disorder which will cause a person to skip from one subject to another for no reason (Nordquist, 2009).

One of the highest rates per capita of schizophrenia diagnoses in the world today comes from the Republic of Palau.

Rates for this disease is almost two times higher among males in this area.

“The 1998 cohort was not a random sample but nonetheless constituted more than 50% of Palauans with “strictly defined” schizophrenia known to be on-island at this time” (Sullivan, 2007).

The differentiation of the use of drugs between genders is a potential cause for higher rates in males. Betel nut, tobacco, cannabis, and alcohol are the preferred non-prescription psychoactive substances used by people with schizophrenia in Palau. When both sexes begin to enter into adult roles, usually is when signs of schizophrenia first appears in Palauans.

When a woman has this disorder, she often receives protection and support from her family. She is also given the chance to still live at her family’s house, if necessary. But for a man suffering from this disease, he has very few job offers and unable to repay his family for prior help. This leads to a young Palauan man becoming a cultural outcast and society’s expectations of him are not fulfilled. The reminders of failure along with stress and society rejecting him usually leads to the illness getting much worse (Bower, 2007).

Violence to oneself is the most common form of violence associated with someone suffering from this illness and sometimes results in suicide. Violence that involves other people is also not uncommon for people who are becoming delusional or hallucinating. Not all individuals are violent who suffer from this illness, most just want to be left alone. Substance abuse raises the rate of violence significantly. If someone with this illness starts to have suicidal talks, gestures, or threats, they should be monitored very seriously. Individuals are more likely to commit suicide during periods of depression, psychotic episodes, and during alcohol or drug abuse (Smith, 2013). Substance abuse can help trigger or aggravate psychotic symptoms which can lead to a more dangerous mood state. Suicide is a desperate attempt to escape suffering from hopelessness, isolation, and other forms of depression.

The person feels like there is no alternative other than ending their own life when they are trying to escape from a mental illness. This is most common in teens and is becoming a serious growing problem. Suicide warning signs in teens can include; changes in eating or sleeping habits, withdrawal from family, violent behavior, not tolerating rewards, running away, and unusual neglect of personal appearance (Smith, 2013).

Stand Together Against Non-Communicable Diseases

18

Situation Analysis

Stand Together Against Non-Communicable Diseases

19

Situation Analysis

Modifiable Determinants

Diet Type 2 diabetes typically occurs in adults, but is increasingly affecting all ages, including children. Type 2 diabetes accounts for approximately eighty-five to ninety-five percent of all diabetes cases in the region. The highest prevalence is noted in Pacific Island countries and areasd. This is due to rapid changes from traditional to more affluent lifestyles.”

(WHO, 2013). The most difficult factor in reducing Type 2 diabetes in Palau will be modifying unhealthy eating habits and increasing physical activity. Obesity is a problem for twenty-four percent of children in Palau and results from poor eating habits, lack of dietary awareness, as well as physical inactivity. Today many are consuming diets rich in carbohydrates

and starches. According to the Journal of Health in Palau and Micronesia, “Many are planting less taro and tapioca in their gardens. The availability of taro and tapioca in the markets depends on weather and farm output” (Heath in Palau and Micronesia, 2005). Elderly Palauans who are the most invested in planting traditional foods are also adopting westernized habits. It is difficult for the elderly to dig out taro and tapioca without another persons help (Health in Palau and Micronesia, 2005). The Journal also suggests that nutrition education should be implemented and targeted to the elderly, who in turn influence younger generations. For instance, “Food preparation, balanced meals, and selecting healthier food choices”. Many non-communicable diseases are caused by poor care of the body. Palau’s former Minister of Health

Stand Together Against Non-Communicable Diseases

22

states, Palau is the 7th obese country in the world per capita. Eight out of every ten deaths are related to NCDs. Thirty three percent of our school children are [overweight or] obese” (Health in Palau and Micronesia, 2005).

According to American Heart Association, “The older you are, the higher your risk. Generally, type 2 diabetes occurs in middle-aged adults, most frequently after age forty-five. However, health care providers are diagnosing more and more children and adolescents with type 2 diabetes” (American Heart Association, 2013). The changes in daily intake can have a dramatic effect on type 2 diabetes risks. By maintaining a healthier diet it can reduce blood sugar and salt hypertension, which is prevalent in type 2 diabetes patients. Type 2 diabetes

Modifiable Determinants

can also lead to other conditions such as cardiovascular damage. “Untreated high blood pressure has been linked to the development of diabetes.” (American Heart Association, 2013). According to the World Health Organization, “Type 2 diabetes is strongly associated with modifiable behavioral risk factors such as overweight and obesity, abdominal obesity, physical inactivity, maternal diabetes, total fat intake, some saturated and trans fats intakes, and intrauterine growth retardation. Obesity doubles the risk of Type 2 diabetes.” (WHO, 2013).

A 2009 CDC survey indicates these following conclusions: “twenty percent of the population did not participate in at least 60 minutes of physical activity on any day during the 7 days before the survey. Seventy-seven percent were physically active at least 60 minutes per day or less during the 7 days before the survey. Sixty-seven percent did not attend physical education (PE) classes in an average week when they were in school.

Seventy-nine percent did not attend PE classes daily when they were in school.

Twenty-eight percent watched television 3 or more hours per day on an average school day. Fourteen percent used computers 3 or more hours per day on an average school day” (CDC, 2009).

According to the World Health Organization, “In 2007, it was estimated that nearly 113 million people in the region, or about five percent of the adult population, had diabetes. Estimates in 2000 showed that there were 2.9 million deaths world-

wide directly due to diabetes, of which fifty-one percent, or 1.5 million deaths were in the Asia Pacific Region. Worldwide, there were an additional 4.6 million people with diabetes who died from other causes such as cardio vascular disease.

(WHO, 2013).

Tobacco and Betel Nut Use Tobacco and Betel Nut use directly contribute to the high rate of NCDs in Palau, specifically COPD, lung cancer, oral cancer, stroke and asthma. The Palau Youth Tobacco Survey of 2009 gathered that among the youth ages 13-15, nearly 3 out of 10 currently use smokeless tobacco. In addition, 4 out of 10 currently smoke and 5 out of 10 chew betel nut.

Secondhand smoke is also adding to this problem with 53.8% of students living in places where others smoke.

In Palau, addiction to tobacco starts very early in life. One in five youths stated that they smoked their first cigarette before the age of eleven. A major issue is how they are obtaining tobacco products as one in five youths reported getting their cigarettes from a store and not being refused cigarettes due to their age (Oseked, 2012).

According to the 2009 Youth Tobacco Survey, Palau is doing a good job educating their youth about the harmfulness of tobacco use, however youth tobacco

Stand Together Against Non-Communicable Diseases

23

use was still increasing in 2009 from previous years (YTS, 2012). This may be due to tobacco and betel nut being easily accessible through stores, friends and family, as well as seeing the adults that they admire using tobacco.

The schools should consider enforcing stricter non-smoking policies as 14.1% of students smoked a cigarette on school grounds before the age of 13 (Lippe, 2008). Considering that these 13-15 year olds understand the harmful effects of tobacco use and still choose to start smoking or chewing, sends the message that a change needs to start with the elders setting a smoke-free example.

Betel nut is chewed for its stimulation.

There are approximately 200 million people in the Western Pacific Basin and South Asia that chew betel on a regular basis. Only three drugs; nicotine, ehtanol, and caffenine are used more widely (Norton, 1998). The use of betel nut is linked with oral leukoplakia, submucous fibrosis, and squamos cell carcinoma (Norton, 1998).

In 2009, the Palau Youth Tobacco Survey reported 74.8% of high school students and 62.9% of middle school students have tried betel nut. These numbers are down significantly from the 2005 survey which indicated that 82% of middle school and 74.8% of high school students had tried it (Kennedy, 2012). High school students are more likely to chew while mixing tobacco at a

Modifiable Determinants

reported rate of 52.2% and the majority of students would use cigarettes as the source of tobacco (Kennedy, 2012).

Over one-third of students chewing betel nut with tobacco experience cravings within three hours after their last chew.

One encouraging statistic is that the use of piper leaf was less common among young people. The interaction of the piper leaf with other ingredients is what causes the red discoloration of the mouth. In the 2009 Palau Youth Tobacco Survey, the use of smokeless tobacco has risen to nearly five times the amount since 2001, increasing from 6.3% to 29.1% (Oseked, 2012).

Alcohol Abuse Alcohol is a worldwide problem in regards to NCDs. With alcohol being legal and socially accepted, many people do not see it as a risk factor.

“Alcohol is causally linked (to varying degrees) to eight different cancers, with the risk increasing with the volume consumed. Similarly, alcohol use is related detrimentally to many cardiovascular outcomes, including hypertension, hemorrhagic stroke and atrial fibrillation.

Alcohol is furthermore linked to various forms of liver disease (particularly with fatty liver, alcoholic hepatitis and cirrhosis and pancreatitis” (Parry, 2011).

Alcohol has also been clearly linked to mental disorders and in some systems mental health is seen as an NCD (NCD Alliance, 2011).

“Harmful use of alcohol results in the death of 2.5 million people annually, causes illness and injury to millions more, and increasingly affects younger generations and drinkers in developing countries” (NCAAD, 2011). While this only accounts for a small fraction of the 36 million NCD related deaths, alcohol consumption, when combined with other unhealthy habits, can lead to poor health.

Excessive alcohol consumption increases your risk of having a hemorrhagic stroke.

This oftentimes occurs because of the effects of alcohol on the liver. The liver

Stand Together Against Non-Communicable Diseases

24

Modifiable Determinants

generates proteins that are necessary to prevent spontaneous bleeding, which is a common symptom associated with stroke (Vega, 2008).

A study done at the Diabetes Obesity and Metabolism Institute at the Icahn School of Medicine at Mount Sinai found that binge drinking causes insulin resistance, which increases the risk of type 2 diabetes (Thiele, 2013). Insulin resistance occurs when insulin becomes less effective, which in return causes an increase in blood glucose.

Alcohol in a household can be very easy for children to gain access. If a parent drinks alcohol, it is more likely to be placed in a cabinet or refrigerator that can be easily accessed. A study done by the World Health Organization indicated that in Palau, 14% of females and 29% of males consumed alcohol before the age of 13 (COSAP, 2006). The study also

states that 20% of females and 35% of males consume 5 or more alcoholic beverages in a short period of time (binge drinking) (COSAP, 2006).

Parry summarizes the difficulties of alcohol prevention by stating: “Preventing alcohol use is difficult because it is such a common component in daily life. The advertisements are everywhere and presented in a sense that the common man can relate. Finally, the alcohol industry interests operate effectively in political spheres to minimize the efforts of public health proponents to address the impact of alcohol use on NCDs, among other harms� (Room, Rehm, Parry, 2011).

In terms of per capita consumption for adults 15+ Paluans consume 9.1 liters of pure alcohol. That compares to the western pacific average of 6.3. (WHO, 2011).

Palau has few restrictions when it comes to alcohol sales. Alcohol purchases can be made at any time of day with little restrictions. The only restriction in terms of alcohol are age (21and over), where it can be sold (petroleum stations are not allowed to sell), and where it can be consumed. The legal BAC to operate a vehicle in Palau is 0.10 percent (WHO 2011).

In terms of consumption Paluans consume beer more than any other spirit. Seventy-seven percent of all spirits consumed in Palau are the various beers served on the island. Compared to 18 percent of all spirits consumed being hard liquor and five percent being wine.

Stand Together Against Non-Communicable Diseases

25

Modifiable Determinants

Physical Activity The current levels of overall health are partially due to insufficient participation in physical activity during leisure time, followed by an increase in sedentary behavior during domestic and workplace activities (WHO, 2013). The process of modernization has led to the access of technologies that provide a more sedentary lifestyle. Such technologies likewise enhance one’s ability to access high calorie foods, alcohol, and tobacco. This further promotes the movement away from traditional lifestyles that require more movement and physical activity (Kuartei, 2013). In fact, only 9% of all secondary schools participate in community-sponsored physical activities in their indoor athletic facilities (CDC, 2013).

According to Dr. Kuartei, “genetic studies show Paulan genes evolved to allow them to survive in areas with small amounts of food.” Kuartei goes on to say, “those

same genes can mutate back, but with the current epidemic, that time period is simply too extensive.” The augmention of urbanization has led to factors that may discourage physical activity such as: highdensity traffic, lack of parks or recreation facilities, low air quality and pollution, and violence (WHO, 2013). Three of the leading outcomes of physical inactivity are coronary heart disease, mental health issues, and type 2 diabetes; all of which are major burdens on the economy (WHO, 2013).

It is estimated that approximately 35% of coronary heart disease mortality in the world is due to physical inactivity (PICD, 2013). Adding to the intensity of your physical activity, if done correctly, can reduce your risk of NCDs (CDC, 2013).

A few examples of moderate-intensity exercises are walking briskly, mowing the lawn, dancing, swimming, or bicycling.

Regular physical activity will increase

Stand Together Against Non-Communicable Diseases

26

learning, judgment, and thinking (CDC, 2013). It was also reported that muscle strengthening exercises and an increased mix of aerobic activities 3 to 5 times a week, for 30 to 60 minutes, would increase your mental health benefits (CDC, 2013).

Part of the crisis is lack of education regarding physical activity, and how to safely exercise. Looking toward the future, additional education is essential as only 55% of secondary schools in Palau teach two key physical activity topics in a required course. The more physical activity safely conducted, the greater the benefit to overall health (CDC, 2013).

Climate Change Climatic events that have posed public health risks in Palau and other small

Modifiable Determinants

island developing states in the south pacific are extreme heat, sea level rise, and El Niño.

such as obesity diabetes and heart disease“ (Barnett, 2007).

The Intergovernmental Panel on Climate Change (IPCC) reported, “the sea level is estimated to rise 50-90 mm within the next 50-100 years” (Republic of Palau, 2002). Sea level rise is considered to be one of the greatest threats to the country, as it is responsible for crop damage and vector borne infections.

Dengue fever, malaria, and encephalitis are water borne and vector borne diseases that have become increasingly common in areas that are susceptible to flooding. With the high temperatures in Palau, vector-borne diseases are projected to increase, as warmer temperatures facilitate the expansion and replication of the virus.

Excess water and salt –water intrusion have significantly affected the taro, sugarcane, and tapioca crops-all main staple food in Palau. As a result of the decrease in availability of traditional crops, there has been an increase in the consumption of processed foods. “Penetration of local markets by cheap, poor quality imported foods with little nutritional value has brought health problems with increased rates of non-communicable diseases,

Extreme heat in the islands has led to excessive dry land and droughts not only affecting the crop growth rate, but also putting the community at risk due to little water supply and low moisture that can lead to wildfires. As a result of the heat, many crops lack a lot of their nutritional value, low rates of crops are being harvested, and once again Palauans must turn to imported processed foods.

With extreme heat, the population, es-

Stand Together Against Non-Communicable Diseases

27

pecially the elderly and those in isolated populations, are also at greater risk of developing a respiratory disease or other heat-related illnesses.

El Niño is a weather event that alters the weather conditions in many regions of the Pacific. An increase in the water temperature can contribute to unpredictable weather conditions such as rainfall that can cause flooding while trade winds are responsible for droughts and wildfires. El Niño affected the coral reefs in Paulau, the increase in water temperature has the potential to bleach and kill many species of the coral. Coral reefs are important to the islands as they protect the shores from the impact of wave s and storms, supply food and medicine, and are economically beneficial to local communities as their beauty attracts tourists.

Modifiable Determinants

NCD Matrix

NCD Diabetes a. Type 2

CardioVascular a. Heart Attack b. Stroke

Cancer a. Lung Cancer b. Skin Cancer c. Thyroid/colon/renal/etc d. Oral Cancer

Respiratory Disease

a. COPD b. Asthma Mental Health a. Despression b. Schizophrenia

Social/Environmental Factors 1. Disability (physical) 2. Economic Burden 3. Low Output 4. Social 5. Culture 6. Behavioral 7. Morbidity and Mortality Rate

Modifiable Determinants (Risk Factors) 1. Diet (salt) (sugar) 2. Exercise 3. Alcohol

1. Disability (physical) 2. Economic Burden 3. Low Output 4. Climate Change 5. Morbidity and Mortality Rate

1. Diet (salt) 2. Smoking/Tobacco 3. Lack of Exercise 4. Alcohol Abuse

1. Disability (physical) 2. Economic burden and Output 3. Climate Change (skin) 4. Behavioral (betelnut) 5. Diet (color) 6. Culture (holistic Medicine) 7. Morbidity and Mortality Rate

1. Betel nut/Tobacco 2. Exposure to Sun 3. Poor Nutrition/diet 4. Smoking

1. Disability (physical) 2. Economic Burden and Output 3. Climate Change/ Pollen 4. Morbidity and Mortality Rate

1. Smoking 2. Second-hand Smoke

1. Disability (mental) 2. Economic Burden and Output 3. Culture (island isolation) 4. Violence

1. Alcohol 2. Lack of Exercise 3. Nutrition

Stand Together Against Non-Communicable Diseases

29

NCD Matrix

S.W.O.T Analysis

Strengths: 1. Strong NCD advocacy in Palau.

2. Good community engagement.

3. Social cohesiveness of family and church systems.

4. Able to work together, pooling labor and talent, to achieve projects that are important to the community. When citizens work together on a community project it gains a powerful element of support.

5. New healthier food alternatives now available locally in Koror restaurants.

Weaknesses: 1. Low income.

2. Lack of insurance.

3. Isolated populations.

4. Cultural obstacles with betel nut.

5. Cultural obstacles with diet.

6. Limited hospital services and space.

7. Increased disability rate due to high morbidity rate.

8. Decreasing productivity rate due to high morbidity rate.

Opportunities: 1. Use social cohesiveness and good community engagement to implement a parent – child engagement initiative.

2. Community appreciation of their own resources and capabilities compared to the desire for western goodies inspired by the media and by overseas travel.

3. Opportunity to reach a large portion of the secondary target audience through Palau school systems.

Threats: 1. The glamour of imported foods seems more exciting than traditional diet for younger audiences.

2. Island isolation leads to depression among younger audience.

3. Lack of support systems for alcohol, drug and tobacco abuse.

4. Mental Illness becoming more prominent and more difficult to detect.

5. Increasing violence due to mental illness. (Schizophrenia) 6. Health problems from poor nutrition caused by improper diets of “convenience foods.� Specifically heart disease, diabetes, and cancer.

Stand Together Against Non-Communicable Diseases

31

S.W.O.T Analysis

Key Idea Following examination of our primary and secondary research, two major topics stand out: (1) the acknowledged need for parent - child engagement on health issues, such as NCDs, and (2) the strong community engagement in Palau. Family and community engagement greatly increases the chances for success in educating and protecting the island’s population against NCDs. The key idea will be to utilize the messaging and events to encourage parents to engage and participate in positive health choices with their children. Parent - child relationships are vital for our campaign because the parents or guardians (our primary age group, ages 16+) can relay the messages on to the children that they look after. Children in the tertiary audience (1-6) cannot absorb this knowledge themselves without the assiatance of the adult.

Community involvement and teamwork will also be promoted throughout the campaign.

Stand Together Against Non-Communicable Diseases

33

Key Idea

Target Audience

Primary Audience (16+) Sixteen years of age and up has been selected as our primary target audience. This audience includes parents and caregivers that will engage and exchange information with our secondary and tertiary audiences.

Seventy-nine percent (16,748) of Palau’s total population (21,108) falls within the primary audience of 16 years old and up. The demographic makeup of the 16+ audience is fifty-three percent male (8,852) and forty-seven percent female (7,896) (CIA World Fact Book, 2013).

Literacy is high with ninety-two percent of the total population able to read and write.

The average life expectancy of Palauans is 72.33 years of age with males living on average to 69.17 years old, while females live on average to 75.68 years old. The median age in Palau is 32.9 years. Palauan’s life expectancy compared to the rest of the world ranks 133 out of 223 nations (CIA World Factbook, 2013).

According to the 2005 census 5,982 males and 3,795 females were employed in Palau (Office of Planning and Statistics, 2006). In 2005, there were 4,707 households in Palau with a median household income of $15,119 (Pacificweb.Org, 2013). The average individual income for males in Palau was $7,225, and women earned about $1,000 less. Koror had the highest family income at $22,600.

Ngchesar and Ngardmau had the least falling below $8,000 (Office of Planning and Statistics, 2006).

Income is earned primarily through tourism, fishing, agriculture, and construction. In Palau, the main forms of transportation are cars, bicycles, boats, and foot. Our primary target audience also engages in many informal activities. The most common activities include farming, food preparation, fishing, and woodcarving. While farming contributes to a significant amount of the food supply for this

Stand Together Against Non-Communicable Diseases

35

Target Audience

audience, many continue to shop at local stores. For regular grocery needs, many in this audience visit WCTC Shopping Center and Surangels, both located in Koror. Individuals also shop at Yano, a market that supplies locally grown foods.

The primary audience utilizes radio, newspapers, and television to receive their information. Although very few radio stations exist in Palau, this audience uses radio frequently, most listen to Diaz Broadcasting, 89.5 FM. Our primary audience also obtains their information from the three local newspapers; Island Times, Palau Horizon, and Tia Belau. Of the 11,000 televisions in Palau, 5,000 households subscribe to the digital cable network, Palau National Communication Corporation (PNCC). Our primary audience mostly accesses the four local channels broadcasted through PNCC, specifically Channel 23, Oceania Television Network, and Channel 26, Diaz Broadcasting.

Secondary Audience (7-15) According to 2005 Palau census data, approximately 17.2% (3,435) of the population account for the secondary audience (Office of Planning and Statistics, 2006). This audience consists of 51% (1,769) males and 49% (1,666) females.

It is very important to reach the secondary audience through the school system.

According to Humanium Help the Children, “School is mandatory for children between the ages of 6 and 17� (CeCe, 2013). Palau schools include 20 elementary schools (two of which are private) and 6 high schools (five of which are private). Enrollment numbers sway drastically. The smallest schools average less than 10, whereas Palau High School has 700 students. Anguar, JFK (Kayangel), Pulo Anna and Sonsorol Elementaries are located on isolated islands.

The school year lasts from August to May. The secondary audience also uses radio to receive information and listens to 88.9 KRFM most often. This radio station

Stand Together Against Non-Communicable Diseases

36

Target Audience

is among the most popular based on its broadcast of current music, playing both American and Palauan songs. Cable television is popular among the secondary audience, allowing for a wider range of television programs, when this audience is not in school they may be playing, participating in after-school sports activities (baseball, soccer and tennis), boating, fishing, watching television and spending time with friends and family.

Tertiary Audience (1-6) The early years are the most critical times in human development, our investment here establishes the foundations of all learning in the future (Kolucki, 2011).

The behavioral characteristic for this targeted age is focused on the concept of, “learning by doing and playing by presenting information to children 1-6 through repetition and routine” (Kolucki, 2011). Lemish and Koluki also state that “Although Unicef and its partners have many years of experience developing communication for school-aged and ado-

lescent children, communication for this youngest group has, for the most part, been targeted at their caregivers; such as family members, early childhood educators, and health practitioners.”

It’s noted that poor dietary habits during childhood and adolescence increase the risk of disease and lack of healthy eating and physical exercise affect emotional and cognitive development of this age group (Wilson, 2011).

According to The NCD Alliance, “NCDs are major cause of highly preventable mortality, morbidity and disability amongst young children in middle and low income countries.” It’s imperative to future generations that parents and guardians act as a primary enforcer of NCD prevention. The NCD Alliance also states, “Children and young people are often targeted by companies advertising fast food, tobacco or alcohol, and many grow up today in environments that are not conducive to them adopting healthy lifestyles.” ( NCD Alliance, 2011) .

Stand Together Against Non-Communicable Diseases

37

Target Audience

Campaign Objectives

Advertising Objectives: 1. Establish top-of-mind awareness among 85% of the primary target audience of parent 窶田hild engagement activities through a series of broadcast, print and digital media and events.

Rationale: By establishing top-of-mind awareness of the dangers and unhealthy effects of the NCD risk factors, parents will become more educated about proper ways to protect themselves and their children.

2. Create behavioral change toward NCD risk factors (diet, smoking, alcohol, exercise) among 50% of the target audience with a series of broadcast, print, digital media and events throughout the campaign year.

Rationale: Frequently addressing each risk factor (bad habits) through a variety of media and events will eventually create healthier behavior among all target audiences.

3. Inspire community involvement to 75% of the target audience.

Rationale: Increasing community involvement will encourage a healthier lifestyle among the majority of the population. This involvement will eventually create healthier behaviors among all target audiences.

Media Objectives: 1. Reach 85% of the primary target audience (16+) at least 25 times during the campaign year.

Rationale: A high amount of message frequency is required to change behavior and raise awareness. Strategic media mix and placement will allow us to reach a large amount of the population.

2. Reach 80% of the secondary target audience (7-15) at least 50 times during the campaign year.

Rationale: Frequent messaging within the school systems as well as media exposure and events will create high reach and frequency of adolescents.

3. Reach 50% of the tertiary target audience (1-6) at least 15 times during the campaign year.

Rationale: Awareness rises and behavior of the tertiary audience toward NCD risk factors will become more positive due to adults and adolescents engagement with children.

Stand Together Against Non-Communicable Diseases

39

Objectives

Creative Strategy

Logo and Slogan Strategy S.T.A.N.D. is an acronym for “Stand Together Against Non-communicable Diseases.” The phrase, “Stand Together” promotes community engagement in working together and taking the necessary steps to decrease the number of NCDs in Palau. We want to promote healthier lifestyle behavior such as: eating healthy, staying active, decreasing tobacco and alcohol use and address depression and mental health. Since the community has a history of working together, being sociable, and has an appreciation of its own resources, it was important for our slogan to deliver that message.

The logo was created to represent a family that contains members of all three target groups; two parents or guardians (16+), an adolescent (7-15) and a small child (0-6). The logo depicts the family standing together demonstrating engagement between the parents (guardians) and their children. The colors of the logo are white and blue. The blue swatch in the background represents the pacific ocean. The figures of the people were designed to match modern pacific style art form.

Stand Together Against Non-Communicable Diseases

Parents serve as gatekeepers and provide support as children assume more responsibility for themselves and regulate their own lives. We encourage the school system to teach awareness of NCDs among children, but they need to hear about the risk factors outside the confinements of school as well. That is why our primary target audience is adults. Guardians not only influence children’s in-school achievement, but they also make decisions about children’s out of school activities.

Among the most important aspects of the relationship between parents and children that contribute to children’s moral development are parental discipline, the quality of the relationship, and conversational dialogue.

Parent-child relationships teach children the mutual obligations of close relationships. Many children learn by observation; they watch and adapt to their parent’s behavior.

41

Creative Strategy

Broadcast Media Strategy Television Advertising Strategy Television advertisements have been developed as public service announcements. They will include powerful facts and statistics that relate directly to the key idea.

Each commercial will display images linked to the facts being provided. The harsh images and statistics will capture the attention and establish top-of-mind awareness with the viewer. The advertisements are designed to create behavioral change amongst the target audiences.

The first television ad will be one minute. A narrator will state information about NCD risk factors in relation to the children of Palau while images are shown.

The touching images of Palauan children will demonstrate the reality of how these beautiful children can be harmed by NCDs if preventive measures aren’t taken.

Important statistics will tie the images together. The campaign logo and slogan will appear at the end of the commercial as well as the campaign website address.

The second television broadcast is a forty-five-second spot demonstrating symptoms of depression and other mental illness. This ad will provide facts and information where more help can be found for individuals coping with mental health disorders.

Typeface for this text will be consistent with other ads used to create continuity between ads. Background music in the ads will provide a serious tone, which connects with the reality of the message. After presenting the information and images, the S.T.A.N.D logo will fade in to encourage all viewers to STAND together against non-communicable diseases.

The last television ad will focus on the risk factors for the non-communicable diseases that are common in

Stand Together Against Non-Communicable Diseases

Palau and in the Pacific Islands. Keeping the target audiences in mind and with its high popularity among these age groups, a baseball themed commercial was developed. Because baseball is an increasingly popular sport in the pacific islands, viewing a commercial referencing baseball will captivate the viewers’ attention and effectively inform them about the dangers and effects of smoking, consuming alcohol, having a bad diet, and physical inactivity.

The spot will run for about thirty seconds, capturing the NCD risk factors as baseball players. Each risk factor player will engage in their respective behavior, in turn being unsuccessful in the game and in their stats. The commercial will end by displaying baseball trading cards for each risk factor player with statistics for their negative effects. Including the trading cards at the end of the commercial will allow for viewers to be able to later recognize them as poster advertisements in schools. The spot closes with the S.T.A.N.D logo, reminding viewers to stand together against non-communicable diseases.

Radio Advertising Strategy The radio ads will follow the same concept as the television ads as public service announcements. The first ad will run for one minute and will focus on NCD statistics in Palau as well as the entire Pacific Island region. The opening announcer will brand the radio ad as a public service announcement sponsored by CDC and the STAND campaign. The second announcer will discuss the NCD crisis in Palau and the Pacific and particular risk factors that contribute to the diseases.

The message will localize the NCD crisis by utilizing statistics related specifically to Palau and will end by encouraging everyone to STAND together against

42

Creative Strategy

NCDs and to visit the campaign website. The message is designed to target the primary and secondary audiences and raise awareness levels of the severity of the NCD problem.

The second radio ad will be one minute in length and will focus on WHO facts and statistics affecting the Pacific Island region. The opening announcer will brand the radio ad as a public service announcement sponsored by CDC and the STAND campaign. The second announcer will discuss the NCD crisis in the Pacific and how awareness and behavioral change will help eliminate the diseases. The PSA will be followed by encouragement to Stand Together Against Non Communicable Diseases as well as the website address. The purpose of stating facts about the South Pacific region, including Palau, demonstrates the devastating effects that NCDs are having on their people.

The third radio ad will be roughly thirty seconds in length and will focus on the healthy lifestyles of Palauans. This will be a poem which is spoken which will easily grab the attention of anyone hearing it. Poetry is a big part of the Palauan culture and this advertisement will not only be easily recited by all those hearing it, thus spreading awareness through word-of-mouth, but also sending the message that a healtier lifestyle is necessary.

Stand Together Against Non-Communicable Diseases

43

Creative Strategy

Print Media Strategy The print messages for the campaign are designed to: a) deliver information regarding NCDs; b) raise awareness of the NCD crisis; and c) modify behavior regarding NCD risk factors. Messages will focus on each of the NCD risk factors that are jeopardizing health in Palau. Each risk factor will be addressed in its own series of print advertisements. Each of the advertisements will address a problem and solution, or prevention and instruction. Print advertising will be formatted for for a variety of newspaper sizes, billboards, and posters. The print messages will impact the audience through a combination of shock advertising and through the delivery of critical information.

Advertising will include use of dramatic, graphic, and real life visuals to help appeal to the target audience’s emotions in some manner. Several messages will deliver the concept of parent-child engagement (as well as community engagement) in regard to addressing the NCD crisis.

The headlines and content of each ad will embrace a powerful message. All messages are focused on addressing the campaign’s objectives, which are creating parent-child engagement, modifying behavior, and raising NCD awareness. The campaign’s website address will be displayed in each print message. The advertising copy in the messages was derived from our research. The brand identity of S.T.A.N.D will become a staple in the mind of our audience, which will help empower and spread our message. The S.T.A.N.D logo and concept will be placed on every medium we use to advertise.

Newspaper will be the primary carrier of our print ads.

The newspaper ads are created in a variety of sizes.

Full-page, half-page, and quarter page ads will be placed in the tabloid newspapers circulated in Palau. All ads are available in full-color (4-color) and black and white.

The print messages will also be produced as full-color posters. Posters will be made available in both 8 1/2”

Stand Together Against Non-Communicable Diseases

44

X 11” and 11” X 16” formats. Posters will be displayed in schools, businesses, clinics, gyms, events, etc. Utilizing posters will help in the delivery of the messages to adolescents (secondary audience). Posters have a longer shelf-life than fleeting newspaper ads and can be regularly changed to avoid burnout.

Print messaging will also be adapted to fit roadside billboards and signs. Billboard ads will be full-color and the advertising message will be shorter and straight to the point opposed to the content heavy versions designed for the newspaper and posters.

A full-page, full-color newspaper ad showing a child and parent hand-in-hand will launch the campaign. This message connects with our key idea showing parent-child engagement, along with the body copy that explains our mission. We will only be running this ad in Palau newspapers the first week of our campaign to raise awareness of the campaign and brand the logo and slogan within the community. Target audience reaction to this ad should be increased communication and engagement with their children as well as setting a positive example for them.

The next ad displays several different photos of Palauan’s in their community. This ad will also be full-page, full-color and placed in all three Palau newspapers. This is the beginning of a series of ads designed to raise awareness of NCDs with body copy emphasizing various statistics.

These ads will begin during the second week of the campaign. The message of these ads will help encourage a positive change in their behaviors.

The next series of ads are directed at creating positive behavioral change toward NCD risk factors such as: diet, smoking, alcohol and physical inactivity. We will place these ads as full-page, full-color and half-page, full color in newspapers and also utilize them as full-color posters to hang up in schools and in the community. Some of these

Creative Strategy

ads will also be made into roadside billboards.

The next ad is the start of a series of ads to address depression. These ads will raise awareness about the dangers of depression and how to seek help if you encounter anyone in the community that might be suffering from this disease. These ads will be also running in the Palau newspapers and formatted for posters around the schools. The reaction to these ads should encourage the teenage and adult audiences to communicate and engage with others and seek the proper help.

The final set of advertisements are a series of four baseball cards which display each risk factor player engaging in their respective behaviors. The back side of the advertsiements will feature a stats chart displaying the negative effects of each NCD risk factor. The baseball card theme was chosen because of the popularity of baseball among the majority of Palauans. These characters are also displayed in other aspects of our campaign.

The subject matter and strategy used in creating these ads was developed through extensive research and the necessity to achieve our objectives. The visual stimuli (photographs and artwork) that is used along with the informational subject matter in the advertisements should gain attention and further awareness on the NCD crisis.

Our billboards, newspaper ads, posters, and t-shirts will be a constant reminder to STAND together against noncommunicable diseases.

Stand Together Against Non-Communicable Diseases

45

Creative Strategy

Digital Media Strategy The digital media strategy for the Palau NCD Campaign is to develop a website that will provide to both in-depth information about the progression of NCDs in the Pacific as well as providing an educational tool for similar projects. The web address that was chosen for this campaign is www.Palauncd.com. This web address was selected based on availability, memorability and Google search positioning.

The design layout for the webpage contains pictures of people in Palau that are members of our target audience and who are at risk of NCDs. The campaign logo and slogan are positioned in the top left corner of the home page. The navigation bar displays tab menus for home, about, campaign book, creative work, presentation, gallery, and contributors. Each tab links to the appropriate area of interest.

When you click the campaign book tab it will take you to a page with plug-in software that creates an adobe pdf version of the campaign plan book. You can also follow, share, add to, or like the book to social media.

Clicking the creative tab will provide users with a drop down menu that displays two different categories of the campaign’s creative work which are print and broadcast media. By selecting print or broadcast you

Stand Together Against Non-Communicable Diseases

can view the advertisements and products from each category (newspaper, billboards, posters, radio, television).

Below the navigation bar we have an automated revolving gallery of photos that can also be manually moved if preferred. On the homepage we provide a mission statement that reads, “An advertising campaign designed to raise awareness and create behavioral change in regard to the NCD crisis in Palau.�

We also incorporated key video from Palau that is located at the bottom of the homepage. Above the video is a picture description that gives an abstract about our project and the geographic location of Palau, a second link to the NCD campaign book, a link to a list of prominent NCD research, and lastly, an NCD news feed.

46

Creative Strategy

Event Strategy Street Teams As a way to get the people of Palau engaged in helping battle NCDs, street teams will be organized in every city that has 100 or more people in population.

These street teams will consist of eight Palauans from each respective city. They will organize various events to engage the Palauan people in our objective to enhance parent child engagement. These street teams will be in charge of delegating responsibilities to volunteers. Volunteers will take on various roles in our street events. They may be assigned to perform as costumed actors (risk factors), puppeteers, teachers (gardening and cooking), judges, and/or any other various duties that may be assigned.

NCD Risk Factor Mascots (Costumed actors) The mascots will be members of the street team that will rehearse and perform skits that target the secondary and tertiary audiences. The skits will take place at various awareness week events, the weekly market in Koror, and in the school system. The NCD risk factor mascots will consist of four different people dressed in faceless morph suits. The four suited individuals will all represent the NCD risk factors (diet, smoking, alcohol and physical inactivity). The characters will be the same as the ones featured in our NCD baseball advertisements, which describe the dangers of each of the risk factors to increase their recognition throughout the community and the consequences that can come from ignoring the dangers of each risk factor.

Puppet Shows The puppet shows will also target the secondary and tertiary audiences. Puppets are a great education tool that catch the attention of children easily. The puppet shows will consist of four puppets. The four puppets being the four NCD risk factor mascots. The puppe-

Stand Together Against Non-Communicable Diseases

47

teers will be members of the street teams and they will travel to all the various schools in their area for performances.

Family Garden The key idea of the campaign is to create parent-child engagement. So some events need to include the parents. The act of growing food should be a family activity from the planting, growing, harvesting, preparing, sharing and eating. It will help to foster a deeper appreciation for everything that’s involved in getting it to our dinner tables while having some fun family time.

The various street teams will hold a family garden challenge to all the families in that street team’s area.

A family garden is a fun way to bring awareness to healthy eating. The street teams will provide families with seeds from various fruits and vegetables. Families will be encouraged to plant these seeds and grow a garden with the entire family. People are more likely to eat healthy foods if they grow it themselves. So, by encouraging families to grow healthy foods together, they will in return be proud of what they have accomplished and proceed to eat these fruits and vegetables.

The family garden also transfers well into a school activity. Each school could start it’s own garden and use the products in school lunches.

Some tips on creating parent-child engagement through gardening: • Start small. Window boxes or containers, because of their small size, can actually turn out to be rather luxurious gardens. Recycle clean bleach and milk containers. Cut off the tops and use them as planters.

Creative Strategy

• Be willing to put up with a less-thanperfect looking garden: crooked rows and weeds are okay.

• Leave an area where kids can dig, even after planting. This is often their favorite part of gardening. Look for earthworms together!

• Get some child-sized tools from a local nursery or garden center. Try to find tools that look genuine so the kids will feel like real gardeners. Can’t afford it? Plastic spoons and shovels work well in window boxes.

• Make a secret place in the garden for your kids. Leave a space between the stalks of easy-to-grow sunflowers or bean poles so they can crawl “inside.” Make a chicken wire animal and train ivy around: instant topiary!

• Kids like extremes, so plant huge flowers, like sunflowers, and small vegetable plants, like cherry tomatoes. Plant fragrant flowers or herbs like peonies, lavender, and chocolate or pineapple mint. Show your kids how to rub the herbs between their fingers to get a really good whiff.

youngsters about specific plants. Kids Garden! by Avery Hart and Paul Mantell includes information on “sowing and growing” as well as activities for kids ages 4 and up (Klemmer, 2006).

Anti-Smoking School Activites • Smoking Kills ~ Have a class poster contest for creating the best poster against smoking. Tell the students the title for the poster is “Smoking Kills,” and instruct them to make their posters bright and colorful with large, eye-catching lettering.

Give students plenty of time to make the posters, and supply markers, colored pencils and crayons for adding colors. Let the students vote for the best poster and display the posters all around the school.

• Teach your kids how to compost.

Find a place behind a tree, or dig a hole in the ground. Don’t add anything that ever swam, walked, or flew. Toss in rinds and peels from fruit, coffee grounds, tea bags, eggshells. When it turns black and crumbly (this will take several months) you can mix it with soil and use this for fertilizer for your garden. Don’t forget to put your gloves on first.

• Healthy Lungs Versus Cancer Lung ~ Let students research the effects of smoking on the lungs. Have students draw a picture of a set of healthy lungs, and another picture of a set of lungs after years of smoking. Students place a piece of poster board in front of themselves so one of the long sides is directly across from them. Each student draws a vertical line down the center of the poster board. Have them paste their healthy lung pictures on the left, the unhealthy lung drawings on the right.

Students then write a paper about each type of lung and display the posters. Remind students that lungs rejuvenate, so some damage from smoking is repairable.

• Look in the children’s section of your library or bookstore for both gardening how-to books and storybooks.

Ready, Set, Grow! A Guide to Gardening, by Suzanne Frutig Bales, teaches

• Smoking Effects Others ~ Give students an assignment to draw a picture of a person smoking in the center of a 12-by-18-inch sheet, then surround that picture with drawings

Stand Together Against Non-Communicable Diseases

48

of how people around the smoker feel about the smoke. Assign students a location for the smoker in their drawing, such as a restaurant, baseball game, park, carnival, store or the beach. Students also should add a caption on the picture. Put the drawings up during drug awareness week and let everyone see how smoking affects others.

• Smoking Isn’t Cool, It Kills You ~ Have students make a poster about the truth behind smoking. The students title their posters “Smoking Isn’t Cool, It Kills You,” and draw what they think goes with the title. Have students make a list of questions about smoking for their parents. This poster activity not only gets the students involved in anti-smoking activities, but it also involves the parents.

Let the students discuss the results of their questionnaires with the class, along with how they feel about smoking.

• How Much Can You Save? ~ Teach anti-smoking math. Give each student a budget of $700. Tell the students that $700 is what an average person spends on cigarettes each year and ask them to make a list of what a person might buy with the money instead of cigarettes. Give the students a list of different items with prices. Include items like video games, pizzas, movies and other items and activities your students like.

Have each student figure out how he would use the $700 (Stepp, 2012).

Creative Strategy

T-Shirt Strategy

T-shirts will be an important supplement to the S.T.A.N.D campaign. T-shirts will serve as a promotional tool that literally when people wear it they serve as walking billboards.

The S.T.A.N.D campaign t-shirt will be a white t-shirt (based on the hot climate in the Pacific Island Region) that features the STAND logo and slogan “Stand Together Against Non-communicable Diseases� placed on the chest area. The t-shirt will be available in most sizes ranging from children to adult.

The t-shirts will help to further awareness and create a strong brand identity for the S.T.A.N.D. campaign. The t-shirts will provide an advertising medium that will not only welcome people to join our cause but also create the opportunity for the campaign’s brand identity to outlast the duration of the campaign. The t-shirts will help emphasize the goal of a unified community engagement.

The campaign t-shirts will be distributed throughout the duration of the campaign at various events, presentations, and planned promotional efforts.

Stand Together Against Non-Communicable Diseases

49

Creative Strategy

Newspaper Advertisements

Stand Together Against Non-Communicable Diseases

50

Creative Strategy

Newspaper Series 1: Logo Ads

Stand Together Against Non-Communicable Diseases

51

Creative Strategy

Stand Together Against Non-Communicable Diseases

52

Creative Strategy

Newspaper Series 2: NCD Awareness Ads

Stand Together Against Non-Communicable Diseases

53

Creative Strategy

Newspaper Series 3: Parent-Child Engagement Ads

Stand Together Against Non-Communicable Diseases

54

Creative Strategy

Stand Together Against Non-Communicable Diseases

55

Creative Strategy

Stand Together Against Non-Communicable Diseases

56

Creative Strategy

Newspaper Series 4: Fact Ads

Stand Together Against Non-Communicable Diseases

57

Creative Strategy

Stand Together Against Non-Communicable Diseases

58

Creative Strategy

Newspaper Series 5: Public Figure Ads

Stand Together Against Non-Communicable Diseases

59

Creative Strategy

Stand Together Against Non-Communicable Diseases

60

Creative Strategy

Newspaper Series 6: Baseball Card Ads

Stand Together Against Non-Communicable Diseases

61

Creative Strategy

Stand Together Against Non-Communicable Diseases

62

Creative Strategy

Billboard Advertisements

Billboard Spot: S.T.A.N.D Campaign

Stand Together Against Non-Communicable Diseases

64

Creative Strategy

Billboard Spot: Smoking (Fact)

Stand Together Against Non-Communicable Diseases

65

Creative Strategy

Billboard Spot: Poor Diet

Stand Together Against Non-Communicable Diseases

66

Creative Strategy

Billboard Spot: Alcohol (Parent-Child)

Stand Together Against Non-Communicable Diseases

67

Creative Strategy

Billboard Spot: Smoking (Parent-Child)

Stand Together Against Non-Communicable Diseases

68

Creative Strategy

Television Advertisements

Televison Spot: Children of Palau

:60 Seconds Various images of Palauan children will appear for 4 seconds each while the announcement is being made.

Announcer:

“Non-communicable diseases pose a substantial threat to children in the Pacific Islands. Obesity is a problem for twenty-four percent of children in Palau and results from poor eating habits, lack of dietary awareness, as well as physical inactivity. The early years are the most critical times in human development. Ranging from infancy to six years, children learn by observation. Adolescents engage in fewer health risk behaviors and perform better academically when their parents are actively involved in their children’s lives. Poor dietary Stand Together Against Non-Communicable Diseases

habits during childhood and adolescence increase the risk of disease. A lack of healthy eating and physical exercise affect emotional and cognitive development of this age group. This is why it is important for parents to be engaged with their children by setting examples of healthy lifestyle choices and promoting positive behavior.”

Guest Announcer:

“Brought to you by the S.T.A.N.D campaign. Stand Together Against Non-Communicable Diseases.”

70

Creative Strategy

Televison Spot: Mental Health

:45 Seconds Audio 1: You don’t understand me.

Guest Announcer:

Audio 2: There are no good days.

“Brought to you by the S.T.A.N.D. campaign.

“Stand Together Against Non-Communicable Diseases”.”

Audio 3: I am not happy.

Audio 4: I feel so alone.

Announcer:

“The World Health Organization reports, about half of mental disorders begin before the age of 14. Around 20% of the world’s children and adolescents are estimated to have mental disorders or problems, with similar types of disorders being reported across cultures.”

Stand Together Against Non-Communicable Diseases

71

Creative Strategy

Televison Spot: Baseball

:60 Seconds Clips of the NCD Risk Factor characters partaking in the respective bad habits.

Announcer:

“Ladies and Gentleman! Introducing the 20142015 NCD Risk Factors.

Starting at center field for the Risk Factors is Smoking. Smoking coughed up a meager .02 batting average last year. With zero stolen bases and (Smoking starts coughing and leaves the screen).

Starting at catcher for the Risk Factors is Unhealthy Diet. Unhealthy Diet batted a heafty .003 last season but on base, his percentage was team leading at .05% due to his inability to get out of the way of inside pitches.

Starting at third base for the Risk Factors is AlcoStand Together Against Non-Communicable Diseases

hol. Alcohol recieved last year’s LVP...Least Valuable Player due to his league leading 500 strikeouts at the plate.

And last but not least...

Starting at first base is Physical Inactivity. Physical Inactivity spent all last season on the disabled list due to a nagging Lazy Butt Injury.”

“NCDs are responsible for nearly 80% of dealths in the Pacific. Join Palau’s effort to become NCD free and Change your unhealthy habits today!”

Voiceover:

“Brought to you by the S.T.A.N.D campaign. Stand Together Against Non-Communicable Diseases.”

72

Creative Strategy

Radio Advertisements

Radio Spot: Pacific Specific

:60 Seconds Announcer:

“According to the World Health Organization, this year nearly 63 percent of all deaths were caused by non communicable diseases. NCDs are the leading cause of death in the world. Diabetes, Cancer, Cardiovascular Disease, Respiratory Disease and Mental Health are only a portion of the non communicable diseases that are drastically affecting the South Pacific regions. By modifying a series of determinants and creating beneficial behavioral changes that are directly linked with these diseases, the amount of NCDs will dramatically drop over time. We must “Stand Together Against Non-Communicable Diseases”. For more information visit www.palauncd.com.”

Stand Together Against Non-Communicable Diseases

74

Creative Strategy

Radio Spot: Palau Specific

:60 Seconds Announcer:

“The country of Palau located in the South Pacific Islands is currently undergoing a major crisis. Non communicable diseases cause 70 to 80 percent of all deaths in this specific region. Although NCDs exist throughout the world, smaller, undeveloped countries tend to have higher rates. Obesity in particular is a problem for twenty-four percent of children in Palau. Factors contributing to this particular NCD include poor eating habits, lack of dietary awareness, as well as physical inactivity. By increasing education in schools and homes, awareness will rise. Be conscious of what you and your children are consuming and “Stand Together Against Non Communicable Diseases”. For more information visit www.palauncd.com”

Stand Together Against Non-Communicable Diseases

75

Creative Strategy

Radio Spot: Palau Specific

:30 Seconds Announcer: Hey! Wake up and follow me We’ll stay away from NCDs No More Drinking, smoking, wheezing, choking Being lazy, acting crazy Eating poor like chips and more There’s habits to cut like beetle nut So, Pick up a ball Pick up a mask Pick up a glove Pick up a bat Run to a base Run in a race Run at a pace

Stand Together Against Non-Communicable Diseases

Or, just run in place Go to the gym or Go for a swim Go fishing with Tim He’s healthy and trim We’ll cook up a feast Without using grease Ice water for drinks It allows us to think So, if you want to be strong And live extra long Then eat, drink, and play better As we all S.T.A.N.D together

76

Creative Strategy

Media Strategy

Print Media Newspaper There are three major newspapers that serve Palau; The Island Times, Palau Horizon, and Tia Belau (This is Palau). Each newspaper has a circulation of about 1,200 copies each with the Island Times and Palau Horizon publishing twice a week, while Tia Belau has only one issue per week. The Tia Belau is published every Monday while the Palau Horizon and Island Times are both published every Tuesday and Friday. Newspaper readership is high throughout all of Palau due to the limited access to media. All three Newspapers are tabloid-sized format and sixteen pages in length. Each newspaper has 5 columns on each page; color is also available on back pages and the doubletruck pages (pages 8-9). Spot colors are available on certain pages (2,7,10, and 15) for an additional fee.

During the first month of the campaign (August 2014) we will be running the first series of ads, which are the ads that introduce the campaign in all three papers per week. During the months of September and October we will be running the second series of ads that address smoking, cancer, and mental health. These also happen to be the awareness months for Smoking, Cancer, and Mental Health. Finally the third stage of our campaign will be released in December through February.

These ads will be the alcohol, physical inactivity, and chicken nugget (processed foods) ads.

Posters There will be two sizes of posters for this campaign 8.5” X 11” and 11” X 17”. By implementing posters into the campaign, both primary and secondary audiences can be reached. Our secondary and tertiary audiences are adolescents and children who may not be as exposed to billboards as the adult population, however strategically placed posters stand a higher probability of exposure. We will print 10,000 copies of the small posters and 5,000 of the large posters. We will run 10 different versions of the posters. The posters will be placed both indoors and outdoors in every state in the country to ensure reaching isolated populations such as Kayangel and Peleliu.

Indoor areas such as the schools, hospital, dispensaries, clinics, health and fitness facilities, grocery and retail outlets, meeting locations, and outdoor events will be utilized.

Billboards

We will be running five different billboards. The first billboard will be running from August all the way through February. We will then run two smoking billboards from September to November so we touch on tobacco awareness month. Finally from December to February we will be running alcohol and diet ads.

Stand Together Against Non-Communicable Diseases

Billboards are small in size but one of our most important mediums in Palau, especially because there is only one main road, Compact road. All along this road is where most of the billboards will be located. The standard size for all Palau billboards is 8 feet by 4 feet. There are also some smaller secondary roads that also have billboards and we will utilize these as well.

There are approximately 50 to 75 billboards in Palau. Strategic placement of signs will yield a high amount of impressions by vehicular traffic as well as by pedestrian traffic. The largest number of billboards will be placed in and around the Koror area due to a denser population and high amount of traffic traveling to and from work on a daily basis. Billboard messages will be changed monthly to prevent viewer wear-out.

T-Shirts The campaign t-shirt was designed to act as a promotional tool that will allow t-shirt recipients to serve as walking billboards.

S.T.A.N.D. will distribute 10,000 t-shirts throughout the course of the campaign. The t-shirts will be distributed to our audience (both children and adults) at the various campaign events and presentations. The t-shirts will be white in color due to the very warm climate in Palau. The t-shirt will work to increase and spread brand recognition of the S.T.A.N.D logo.

Broadcast Media Television Television advertisements have been developed as public service announcements. They will include powerful facts and statistics that relate directly to the key idea. Each commercial will display images linked to the facts being provided. The harsh images and statistics will capture the attention and establish top-of-mind awareness with the viewer. The advertisements are designed to create behavioral change amongst the target audiences.

The first television ad will be one minute. A narrator will state information about NCD risk factors in relation to the children of Palau while images are shown. The touching images of Palauan children will demonstrate the reality of how these beautiful children can be harmed by NCDs if preventive measures aren’t taken. Important statistics will tie the images together. The campaign logo and slogan will appear at the end of the commercial as well as the campaign website address.

The second television broadcast is a forty-five-second spot demonstrating symptoms of depression and other mental illness.

This ad will provide facts and information where more help can be found for individuals coping with mental health disorders.

Typeface for this text will be consistent with other ads used to

79

Media Strategy

Digital Media

create continuity between ads. Background music in the ads will provide a serious tone, which connects with the reality of the message. After presenting the information and images, the S.T.A.N.D logo will fade in to encourage all viewers to STAND together against non-communicable diseases.

The Website

The last television ad will focus on the risk factors for the noncommunicable diseases that are common in Palau and in the Pacific Islands. Keeping the target audiences in mind and with its high popularity among these age groups, a baseball themed commercial was developed. Because baseball is an increasingly popular sport in the pacific islands, viewing a commercial referencing baseball will captivate the viewers’ attention and effectively inform them about the dangers and effects of smoking, consuming alcohol, having a bad diet, and an unhealthy lifestyle.

The spot will run for about thirty seconds, capturing the NCD risk factors as baseball players. Each risk factor player will engage in their respective behavior, in turn being unsuccessful in the game and in their stats. The commercial will end by displaying baseball trading cards for each risk factor player with statistics for their negative effects. Including the trading cards at the end of the commercial will allow for viewers to be able to later recognize them as poster advertisements in schools. The spot closes with the S.T.A.N.D logo, reminding viewers to stand together against non-communicable diseases.

Radio Radio is a good way to reach the people of Palau because it is a frequently used medium. There are four local radio stations, but this campaign will only make use of three of them. Diaz Broadcasting, WWFM 89.5 MHZ, and KRFM 88.9 MHZ and the government owned station, Eco- Paradise Fm/Voice of Palau that broadcasts simultaneously on 87.9 MHZ and 1584 AM. Each station reaches a variety of listeners and placing advertisements on each station will help expand on reach and frequency goals. Given the large number of people driving to and from work every day, both morning (6-10 a.m) and evening (3-7 p.m.) drive times are utilized to reach the primary and secondary audience.

Stand Together Against Non-Communicable Diseases

PalauNCD.com will be the URL for the S.T.A.N.D campaign website. Currently, Palau has very limited web access. However, the website was developed for dual purposes: (1) expectations for better future Internet connectivity in Palua and (2) to function as an educational model for other “cause marketing� campaigns.

Community Awareness Events Events are a crucial medium in Palau for reaching large numbers of people. Events are a way to get the people of Palau involved in community efforts. The goal of the events is achieve our highest reach of any of the mediums.

The events being put on by the campaign will be organized by the appointed street teams in Palau. The street teams will consist of eight hand picked individuals to represent the campaign in every city with a population over 100, making 17 street teams. The activities the street teams will present include the skit with the four risk factor mascots, risk factor puppet shows, family gardening, and poster competitions in the schools. The mascot skits will be performing at every major festival, awareness event, school function, fair, carnival, or major community activity. The ideal reach for all these events would be 85% of the population. The puppet shows will be preforming at all the elementary schools in Palau to reach the younger target market, and further familiarize them with the risk factor characters.

The family garden will be in the hands of the street teams. The street teams will be distributing seeds, tools, and all other gardening needs to all the families in their specific area. Finally the poster competitions in the schools will reach every school Palau so no child is left out of the competition.

80

Media Strategy

Budget

Stand Together Against Non-Communicable Diseases

83

Budget

Conclusion In conclusion, this campaign was designed to further awareness of NCDs, as well as create behavioral change in regard to the NCD risk factors. Creating parent-child engagement through promotion and activities will lead to a more interactive, educational, and fun experience for both parent and child. The campaign encourages parents to engage and participate in positive health choices with their children. The campaign is designed for the people of Palau to embrace as their own and utilize the strong community engagement in Palau.

While this particular campaign is designed for Palau, it was created to be easily adaptable to other islands in the Pacific Island Region.

Stand Together Against Non-Communicable Diseases

85

Conclusion

References

AHC Public Relations, (2006). Skin Cancer Rare-but More Deadly- in People with Darker Skin. University of Cincinnati Academic Health Center. http://healthnews.uc.edu/news/?/2878/ Aitaoto, N. (2005). Diabetes today in the pacific: Reports from the field. Retrieved from http://www.pacifichealthdialog.org.fj/ Volume 12/V12No1/Pacific Health Institution/Diabetes Today in the Pacific.pdf American Heart Association. (2013, 01 31). Understand your risk for diabetes: Non-modifiable risk factors for type 2 diabetes.

Retrieved from http://www.heart.org/HEARTORG/Conditions/Diabetes/UnderstandYourRiskforDiabetes/Understand-YourRisk-for-Diabetes_UCM_002034_Article.jsp Bower, Bruce. (2007). Science News. Trouble in Paradise: High Schizophrenia Rates Among Pacific Islanders Raise Cultural Questions. Retrieved September 15, 2013, from http://www.thefreelibrary.com/Trouble+in+paradise%3A+high+schizophrenia+rate s+among+Pacific+islanders...-a0166537943 The prevalence and costs of diabetes. (n.d.). Canadian Diabetes Association | Home. Retrieved September 19, 2013, from http:// www.diabetes.ca/diabetes-and-you/what/prevalence/ iew=true CDC Features - Engaged Parents Have Healthier Adolescents. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 29 Nov. 2012. Web. 19 Sept. 2013. http://www.cdc.gov/features/parentengagement/index.html?prev CDC. (n.d.). The obesity epidemic and Palau students. Retrieved from http://www.cdc.gov/healthyyouth/yrbs/pdf/obesity/ pw_obesity_combo.pdf CDC. (2010, 01 14). Stroke Behavior . Retrieved from http://www.cdc.gov/stroke/behavior.html Cece, I. (2013, 04 17). Humanium help the children: Children of Palau. Retrieved from http://www.humanium.org/en/palau/ Cece, I. (2013, 04 17). Humanium help the children. Children of Palau: Realizing children’s rights in Palau. Retrieved September 16, 2013 from http://www.humanium.org/en/palau/ “Physical Activity and Health.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 16 Feb. 2011. Web. 11 Sept. 2013.

Center for Disease Control and Prevention (2011, February 16). Physical Activity for Everyone. Retrieved September, 11, 2013, from http://www.cdc.gov/physicalactivity/everyone/health/ Central Intelligence Agency. (2013, August 13). The World Factbook Palau.

Retrieved September 26, 2013, from https://www.cia.gov/library/publications/the-world-factbook/geos/ps.html Children and NCDs | The NCD Alliance Website. September, 2011.The NCD Alliance Website.

Retrieved September 16, 2013, from http://www.ncdalliance.org/children CIA World Factbook. (2011, 01 1). index mundi. Retrieved from http://www.indexmundi.com/g/g.aspx?v=26&c=ps&l= CIA World Factbook. (2013, 02 21). Palau death rate. Retrieved from http://www.indexmundi.com/palau/death_rate.html CIA World Factbook, “Palau Demographics Profile 2013.” Index Mundi. n.p., (2013, February 21,). Retrieved from September 16, 2013, from http://www.indexmundi.com/palau/demographics_profile.html COSAP (2006). Substance Abuse Prevention Strategic Plan, 2007-2011 Republic of Palau. Retrieved from http://www.who.int/ fctc/reporting/Palau_annex4_national_strategic_plan.pdf Countries ranked by Diabetes prevalence (% of population ages 20 to 79). (n.d.). Index Mundi - Country Facts. Retrieved September 19, 2013, from http://www.indexmundi.com/facts/indicators/SH.STA.DIAB.ZS/rankings

Stand Together Against Non-Communicable Diseases

88

References

Curtis, M. (n.d.). The obesity epidemic in the pacific islands. Retrieved from http://www.maxwell.syr.edu/uploadedFiles/moynihan/dst/curtis5.pdf Diabetes at a glance. (n.d.). International Diabetes Federation Western Pacific . Retrieved September 19, 2013, from iapbwesternpacific.org/download/countries/palau/IDF_Palau_2012.pdf Diabetes Mellitus in Palau. World Life Expectancy. N.p., n.d. Web. 19 Sept. 2013. http://www.worldlifeexpectancy.com/palaudiabetes-mellitus Duchêne, AS, Lakey, JRA, Repacholi. (1994). Protection Against Exposure to Ultraviolet Radiation. World Heath Organizaiton.

Retrieved From http://www.who.int/uv/publications/proUVrad.pdf Duckworth, Ken. (2009). National Alliance on Mental Illness. What is depression? Retrieved September 8, 2013, from http:// www.nami.org/Template.cfm?Section=depression Durand, M. (2011, 08). Ict decisions: In an imperfect world. Retrieved September 16, 2013 from http://www.phinnetwork.org/ Portals/0/Durand- PHIN-ICT Decisions (8-11).pdf “Exercise and Depression: Endorphins, Reducing Stress, and More.” WebMD.WebMD, 2013. Web. 11 Sept. 2013. <http://www. webmd.com/depression/guide/exercise-depression>.

Fixed broadband Internet subscribers, http://www.indexmundi.com/facts/palau/fixed-broadband-internet-subscribers#IT.NET. BBND. Retrieved September 30, 2013 Gohara, M., & Perez, M. (2013). Skin Cancer and Skin of Color. Skin Cancer Foundation. http://www.skincancer.org/skin-cancerinformation/skin-cancer-facts/myths-vs-facts Goldenberg, Joseph. (2012) WebMD. Depression Health Center. Childhood depression. Retrieved September 16, 2013, from http://www.webmd.com/depression/childhood-depression Habitat for Humanity International (2009). Poverty Housing in the Developing Nations of the Pacific Islands. Retrieved September 18, 2013, from http://reliefweb.int/sites/reliefweb.int/files/resources/A683A2AF32E84694492575BB000B34F7-Full_Report.pdf Healthy Pacific Lifestyle Section Public Health Division Secretariat of the Pacific Community (2010). NCD Statistics for the Pacific Islands Countries and Territories.

Hughes, F. (2009). Mental Health in the Pacific: the role of the Pacific Island Mental Health Network. Pacific Health Dialog, 15(1).

Retrieved from http://www.who.int/mental_health/policy/pimhnet/PacificHealthDialogFeb09_MHinPacificArticle.pdf Humanium. (2013, April 17). Children of Palau . Retrieved from http://www.humanium.org/en/palau/ Ichiho, Henry M., MD,MPH, Yorah Demei, Stevenson Kuartei, MD, and Nia Aitaoto, MPH, MS. “National Center for Biotechnology Information.” National Center for Biotechnology Information. U.S. National Library of Medicine, May 2013. Web. 09 Sept. 2013.

Ichiho, H. (2013, 05). An assessment of non-communicable diseases, diabetes, and related risk factors in the republic of Palau: A systems perspective. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3689453/ Kennedy, D. (2012). Review of Areca (Betel) Nut and Tobacco Use in the Pacific. , 68.

Kuartei, S. (2011). Declaration of the state of health emergency on non communicable diseases in palau. , 8. Retrieved , from http://www.palau-health.net/images/Palau_Declaration.pdf Kuartei, S. (n.d.). Declaration of State of Emergency on NCDs. Retrieved from http://www.palau-health.net/images/Palau_Declaration.pdf

Stand Together Against Non-Communicable Diseases

89

References

Kuartei, M. Stevenson (n.d.). Retrieved from http://www.palau-health.net/images/Palau_Declaration.pdf Kuartei, M. Stevenson, (2011). Responding to NCD crisis in Palau . Retrieved from http://www.palau-health.net/images/Palau_ Declaration.pdf Lemish, D., & Kolucki. B.(2011) Communicating with Children. UNICEF. Lippe J, Brener ND, McManus T, Kann L, Speicher N. Youth Risk Behavior Survey 2005: Commonwealth of the Northern Mariana Islands, Republic of Palau, Commonwealth of Puerto Rico. Atlanta, GA: Centers for Disease Control and Prevention, 2008.

Mahady, Matthew. (2010, June 25). Fast Facts: Skin Cancer and Melanoma. Once Live. Retrieved from http://ww.onclive.com/ publications/obtn/2008/january2008/fastacts_jan2008 Mannino, D., Kin, Victor. (2006, Septmeber). Changing the burden of COPD mortality. International Journal of Obstructive Pulmonary Disease. Vol. 3. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2707151/.

Mayo Clinic (2011, 08 02). Heat stroke . Retrieved from http://www.mayoclinic.com/health/heat-stroke/DS01025 Dr. Mercola. (2011, 10 10). Avoid these common stroke risk factors . Retrieved from http://articles.mercola.com/sites/articles/archive/2011/10/10/3-foods-that-can-trigger-a-stroke.aspx “Ministry of Health, ROP.” Ministry of Health, ROP. N.p., 2011. Web. 09 Sept. 2013.

National Heart, Blood, and Lung Institute. What is Asthma? Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/printallindex.html.

National Stroke Association (2013). Retrieved from http://www.stroke.org New York State Department of Health. (1999, Auguest). Physical Inactivity and Cardiovascular Disease. Retrieved September, 11, 2013, from http://www.health.ny.gov/diseases/chronic/cvd.htm NCAAD (2011). 2.5 Million Alcohol-Related Deaths Worldwide- Annually. Retrieved September 18, 2013, from http://www. ncadd.org/index.php/in-the-news/155-25-million-alcohol-related-deaths-worldwide-annually The NCD Alliance (n.d.). The Global Epidemic. Retrieved September 18, 2013, from http://www.ncdalliance.org/globalepidemic Nordquist, Christian. (2009). Medical News Today. What is Schizophrenia? Retrieved September 16, 2013, from http://www. medicalnewstoday.com/articles/36942.php Norton, S. (1998). Betel: Consumption and Consequences. Journal of the American Academy of Dermatology, 38(1), 81-88.

Ocean Health Index. (2012, August 15). UV Radiation. Woods Hole Oceanographic Institution [WHO]: Oceanus. Retrieved from http://www.oceanhealthindex.org/Components/UV_Radiation Oceania Television Network, Palau Television Marketing Guide n.p., http://www.oceaniatv.net/palau.html Retrieved September 29, 2013.

Office of Planning and Statistics, “Republic of Palau 2005 Census Volume II: Census Monograph Population and Housing Profile” n.p. (2006, May). Retrieved from September 16, 2013, from http://www.pacificweb.org/categories/Statistical%20Activities/ Census/ROPCensus.html Oral Health in Palau. Retrieved September 2013, from http://www.docstoc.com/doc/44771544/Oral-Health-in-Palau Oseked, R., & Recheungel, K. (2012). Tobacco Use & Chewing among Youth in Palau. , 5. Retrieved , from http://www.guamhealthpartners.com/photo_albums/pdfs/Palau_expanded%20Fact%20sheet.pdf

Stand Together Against Non-Communicable Diseases

90

References

PacificWeb.Org Insular Areas Matrix of Basic Social and Economic Indicators n.p., http://www.pacificweb.org/categories/Summary_Statistics/Indicators_Matrix.html. Retrieved September 29, 2013.

Palau National Communication Corporation. (2007). Our Company History. http://www.palaunet.com/company_history.aspSeptember 26, 2013.

Palau Travel Guide, 2013, http://www.iexplore.com/travel-guides/australia-and-south-pacific/palau/things-to-do Retrieved September 30,2013 Palau Demographics Profile 2013. (n.d.). Index Mundi - Country Facts. Retrieved September 19, 2013, from http://www.indexmundi.com/palau/demographics_profile.html (2006).

Palau Youth Tobacco Survey Fact Sheet (2001). Retrieved September 18, 2013, from http://www.hawaii.edu/hivandaids/Report%20on%20the%20Results%20of%20the%20Global%20Youth%20Tobacco%20Survey%20in%20Palau.pdf Parry,C.D.; Patra,J.; Rehm,J.; (2011). Alcohol consumption and non-communicable diseases: epidemiology and policy implications.

Addiction, 106(9). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21819471 “Physical inactivity: A global public health problem.” Physical Inactivity and Cardiovascular Disease. N.p., 1999. Web. 11 Sept.

2013. (n.d.). Retrieved from http://www.who.int/dietphysicalactivity/factsheet_inactivity/en/index.html PIHOA (n.d.). NCD Regional Health Emergency. Retrieved September 18, 2013, from http://www.pihoa.org/initiatives/policy/ ncds.php Pobutsky, A., & Neri, E. (2012). Betel Nut Chewing in Hawai‘i: Is it Becoming a Public Health Problem? Historical and Socio-Cultural Considerations. Hawai’i Journal of Medicine & Public Health, , 8. Retrieved , from http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3298432/ Public Health Division Secretariat of the Pacific Community (n.d.). NCD Statistics for the Pacific Islands Countries and Territories.

Retrieved from http://www.spc.int/hpl/index.php?option=com_docman&task=doc_download&gid=67 Republic of Palau (2006). “Plus 5” Review of the 2002 Special Session on Children and World Fit for Children Plan of Action.

Retrieved from http://http://www.unicef.org/worldfitforchildren/files/Palau_WFFC5_Report.pdf Russell, Dr. Leslie. (2009, April). Poverty, Climate Change and Health in Pacific Island Countries. Retrieved September 18, 2013, from http://ussc.edu.au/s/media/docs/publications/0904_pacificislandspaper_russell.pdf Smith, Melinda. Segal, Jeanne. Robinson, Lawrence. (2013) Helpguide. Suicide Prevention. How to Help Someone who is Suicidal.

Retrieved September 8, 2013, fromhttp://www.helpguide.org/mental/suicide_prevention.htm Thiele, T. (2013). Insulin Resistance from Binge Drinking: It’s All in Your Head. Science Translational Medicine, 5(170). Retrieved from http://http://stm.sciencemag.org/content/5/170.toc Tobacco use & chewing among youth in Palau: Results from the Palau youth tobacco survey 2009. (2012, MARCH). Retrieved from http://www.guamhealthpartners.com/photo_albums/pdfs/Palau_expanded%20Fact%20sheet.pdf Vega, J. (2008, May 26). Causes of Stroke - Drugs and Alcohol - Risk of Stroke. Retrieved September 18, 2013, from http:// stroke.about.com/od/strokeprevention/a/drugs_stroke.htm WebMD (2012, July 23). Exercise and Depression. Retrieved September, 11, 2013, from http://www.webmd.com/depression/guide/exercise-depression Wilson, C. (2013, August 19). Killer Smoke Blows Through Pacific Islands. Retrieved September 18, 2013, from http://www. ipsnews.net/2013/08/killer-smoke-blows-through-pacific-islands/

Stand Together Against Non-Communicable Diseases

91

References

Wilson, M., Linke, L., Bellhouse-King, M., & Singh, M. (2011). Nutrition and physical education policy and practice in Pacific Region secondary schools. Issues&Answers REL Pacific, 2012(117). Retrieved September 16, 2013, from http://files.eric.ed.gov/ fulltext/ED526430.pdf Wolf, John E., (2013). Sunscreen: How to Choose. Department of Dermatology at the Baylor College of Medicine in Huston. http://www.rei.com/learn/expert-advice/sunscreen.html Wong, V., Taoka, S., Kuartei, S., & Demei, Y. (2003). Cancer in the Republic of Palau. Pacific Health Dialog, , 6. Retrieved , from http://www.pacifichealthdialog.org.fj/Volume%2011/no2/PHD11%202%20p064%20069%20Wong%20orig.pdf WPRO (2007, March 12). WPRO | New network seeks to improve mental health care in Pacific island countries. Retrieved September 18, 2013, from http://www.wpro.who.int/mediacentre/releases/2007/20070312_1/en/index.html The World Bank (2013, January 16). The Economic Costs of Non Communicable Diseases In the Pacific Islands. Retrieved September 18, 2013, from http://www.worldbank.org/en/news/feature/2013/01/16/the-economic-costs-of-noncommunicable-diseases-in-the-pacific-islands The World Factbook, “Communications: Palau“ Internet hosts, n.p.

(2005). Retrieved from September 16, 2013, from https://www.cia.gov/library/publications/the-world-factbook/geos/ ps.html World Health Organization. (2013). Chronic Respiratory Diseases: Causes of COPD. Retrieved From http://www.who.int/respiratory/copd/causes/en/index.html.

WHO (2008). Deaths from NCDs. Retrieved September 18, 2013, from http://www.who.int/gho/ncd/mortality_morbidity/ ncd_total_text/en/index.html WHO (2009, July 8). WHO | New network to combat non communicable diseases. Retrieved September 18, 2013, from http:// www.who.int/mediacentre/news/releases/2009/noncommunicable_diseases_20090708/en/index.html WHO (2013, March). WHO | Noncommunicable diseases. Retrieved September 18, 2013, from http://www.who.int/mediacentre/factsheets/fs355/en/ WHO (2013, July). WHO | Pacific islanders pay heavy price for abandoning traditional diet. Retrieved September 18, 2013, from http://www.who.int/bulletin/volumes/88/7/10-010710/en/ World Health Organization. (2005). Indoor Air Pollution, Health and the Burden of Disease: Indoor Air Thematic Briefing 2. Retrieved from http://www.who.int/indoorair/info/briefing2.pdf.

World Health Organization. (2011). Palau: Socioeconomic context. Retrieved from http://www.who.int/substance_abuse/publications/global_alcohol_report/profiles/plw.pdf World Health Organization, (2013). Physical Inactivity: A Global Health Problem Retrieved September, 11, 2013, from http:// www.who.int/dietphysicalactivity/factsheet_inactivity/en/index.html World Health Oragnization. (2010, 07). Pacific islanders pay heavy price for abandoning traditional diet. Retrieved from http:// www.who.int/bulletin/volumes/88/7/10-010710/en/ World Health Organization. (n.d.). The impact of chronic disease in Palau. Retrieved from http://www.who.int/entity/chp/chronic_disease_report/Palau.pdf “The Top 10 Causes of Death.” WHO. N.p., n.d. Web. 09 Sept. 2013.

WHO. (2011) World Health Organization. Department of Mental Health and Substance Abuse. Mental Health Atlas.` CDC. (2010, 01 14). Stroke Behavior . Retrieved from http://www.cdc.gov/stroke/behavior.htm

Stand Together Against Non-Communicable Diseases

92

References

World Health Organization (2013, 05). Palau: Health Profile . Retrieved from http://www.who.int/gho/countries/plw.pdf (2011). World Life Expectancy. Lung Cancers in Palau. Retrieved September 2013, from http://www.worldlifeexpectancy.com/ palau-lung-cancers World Life Expectancy (2011). Stroke in Palau . Retrieved from http://www.worldlifeexpectancy.com/palau-stroke Yano, V., Kuartei, S., & Aitaro, J. (2006). National cancer strategic plan for Palau 2007-2012. , 67. Retrieved , from http://cancercontrolplanet.cancer.gov/state_plans/Republic_of_Palau_Cancer_Control_Plan.pdf Zhang, P. (n.d.). Economic impact of diabetes. Retrieved from http://www.idf.org/sites/default/files/Economic_impact_of_Diabetes.

Stand Together Against Non-Communicable Diseases

93

References