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Stand Together Against Non-Communicable Diseases

An Advertising Campaign Designed to Raise Awareness and Create Behavioral Change in Regard to NCD Risk Factors in Palau

Credits Jrnl 406 Advertising Campaigns

Instructor Jerry Bush

Agency Kaylyn Bergbower Nicholas Burke Christine Emmons Michael Estes Andrew Hoggatt Chris Johnston Jeremy Martin Jeremy Myer Jesse Morris Katie O’Riley Lucas Olson Willie Porter Rudolph Scavuzzo Taylor Wright

Graphic Designers Centers for Disease Control and Prevention Dr. Mark Keim Mollie Mahany

Palau Representatives Dr. Stevenson Kuartei Pearl Marumoto Sharon Sajuma

Table of Contents I. Overview II. Situation Analysis III. Modifiable Determinants IV. Key Idea V. Target Audience Profile VI. Objectives VII. Communication Strategy VIII. Creative Strategy IX. Media Strategy X. Budget XI. Evaluation XII. Conclusion XIII. References XIV. Appendix


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. 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, 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’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.

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


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.

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).

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. Pacificans 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 professionals,

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.


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


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 Journal of Development and Social Transformation, “Pacific Islanders have strong ethnic identities that incorporate a mix of traditional native island heritage with westerninfluenced 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 compete with the glamour and flashi-

ness 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 ac-

tively 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).


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).

Insurance coverage for cancer is very limited in Palau. Currently, there are only two insurance companies in Palau that provides 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. Skin cancrer is also a risk in the Pacific. The capital of Palau, Koror, sits just over 500 miles from the equator, giving the people of Palau exposure to large amounts of ultraviolent rays. Ultraviolent rays are harmful because the ozone layers closest to the Earth are deteriorating. Ozone serves as a filter to screen out and reduce the amount of UV light that humans are exposed. With less atmospheric ozone, a higher level of UV light reaches the earth’s surface (Ocean Health Index, 2004). Due to this reduction, the level of UV light today is higher than it was 50 or 100 years ago. Reduction of overhead ozone by one percent increases skin reddening or sunburn by about one percent, but increases the incidence of skin cancers by two to three percent (Duchêne, 1994). It is important for people to detect the symptoms of skin cancer early. The good news is that it is almost 100% curable is found quick enough. Early detection could save the lives of many people on the island. 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, 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 nonsmokers 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). Smoking also increases the risk of stroke (Mercola, 2011). Smoking in the community is a known activity which only adds to the chances of stroke. The National Stroke Association reported that smoking doubles a person’s risk of stroke. 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 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 second hand smoke (Oseked, 2012).

in 2006, asthma was ten percent of the illnesses reported in Palau.

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).

Major depression is considered a serious medical Illness that affect’s 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).

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,

Mental Health

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, relation-


ships, 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 varies, 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 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 depart-

ment are only 0.82% of the total health budget (WHO, 2011).

diseases are occurring (WHO, 2011).

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.

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.

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

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 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). Another mental disorder that affects many Palauan’s 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. This leads to individuals being convinced that others can read their mind or some may just hear voices, which leads 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 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 nonprescription 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).


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). 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 states, “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


states, Palau is the 7th obese country in the world. 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 II 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

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,). A 2009 CDC survey conducted by CDC indicates these following conclusions. Information shows that, “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). 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 worldwide 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,).

Tobacco and Betel Nut Use Tobacco and Betel Nut use directly contribute to the high rate of NCD’s 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 use was still increasing in 2009 from previous years (Oseked, 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 nonsmoking policies as 14.1% of students smoked a cigarette on school grounds before the age of 13 (Lippe, 2008). Considering 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 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 (2011, NCD Alliance). “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” (2011, NCAAD). 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


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


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).

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 NCD’s (CDC, 2013). A few examples of moderate-intensity exercises are walking briskly, mowing the lawn, dancing, swimming, or bicycling. Regular physical activity will increase 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).

Exposure to Sun It is important for Palauans to be aware of over-exposure to the sun. Precautions can be taken that will lessen the probability of skin cancer. According to the Chairman of Dermatology at the Baylor College of Medicine, John Wolf, there is

no such thing as perfect sunscreen. If you plan to be out in the sun for more than two hours, which most Palauan people are, it is best to choose a sunscreen with a Sunburn Protection Factor (SPF) of 30 or higher, (T.D. Wood, 2013). It would be more beneficial for people who do spend a quality amount of time outside during the day to use a sunscreen with a SPF of 50+. SPF 50 blocks approximately 98% of ultraviolet rays. Palau has a UV index of 10+ during the entire calendar year.

because of this false perception most cases aren’t diagnosed until they are in more advanced and difficult to treat stages,� (University of Cincinnati, 2006).

Many people are under the impression that non-Caucasians are less susceptible to get skin cancer than light skinned people. Darker skinned people are not the primary victims, however, they are not immune to the disease. Darkerskinned people are less likely to develop skin cancer, yet there is a higher mortality rate for them (Mona Gohara, 2013). This number is larger for dark skinned people because it is usually diagnosed late. According to University of Cincinnati dermatologist Hugh Gloster, “Darkskinned people do get skin cancer, and


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

Modifiable Determinants (Risk Factors)

1. Disability (physical) 2. Economic Burden 3. Low Output 4. Social 5. Culture 6. Behavioral

1. Diet (salt) (sugar) 2. Exercise 3. Alcohol

1. Disability (physical) 2. Economic Burden 3. Low Output 3. Climate Change

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


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 restaurant.

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 audience. 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.

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 campaign will take aim at increasing awareness and creating behavioral change through a year-long series of messages and events. 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. Community involvement and teamwork will be promoted throughout the campaign.

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 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 (7-14) 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 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 (0-6) 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 0-6 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 adolescent 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

Campaign Objectives

Communication Objectives 1. Encourage engagement between parent (guardian) and child when addressing the NCD risk factors throughout the campaign year. Rationale: To establish bonding and support systems for decreasing NCD risk factors. By creating family engagement, adults and adolescents will educate and reinforce positive behavior in the secondary (6 - 14) and tertiary audience (0-6). 2. Increase awareness of NCD risk factors among 85% of the primary and secondary target audiences within a series of broadcast, print, and digital messaging throughout the campaign year. Rationale: A high percentage of the primary audience (16+) can be reached in the higher populated areas. A high percentage of the secondary audience can be reached through the school system. 3. Inspire community involvement and engagement in the implemention and execution of the campaign. Rationale: The success of the campaign will elevated by the good community engagement in Palau.

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 protect themselves and their children. 2. Modify target audience behaviors toward NCD risk factors (diet, smoking, alcohol, exercise) 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.

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 (0-6) 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.

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 have 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 (7-14) 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. 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.


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