A previous column presented the Association of State and Territorial Health Officials' (ASTHO's) overarching health equity technical package, which is a resource describing priority interventions for implementation within state health departments and by extension territorial, rural, and local health departments.1 This column furthers the specification of a technical package developed for ASTHO's engagement with island jurisdictions, necessitated by important cultural and contextual nuances and differences, including both strengths and challenges. This technical package, along with other frameworks and logic models ASTHO is developing, will help ensure our engagement with island jurisdictions is of the highest quality and relevance, aimed at successfully impacting health outcomes. Island Representation Within ASTHO's Membership ASTHO is the only national nonprofit organization representing the nation's 59 chief health officials, the agencies they lead, and the more than 100 000 public health professionals these agencies employ.2 ASTHO members formulate and influence sound public health policy and ensure excellence in state- and island-based public health practice. ASTHO's mission is to support, equip, and advocate for state and territorial health officials in their work of advancing the public's health and well-being. ASTHO's primary functions are to develop strong and effective public health leaders; improve public health through capacity building, technical assistance, and thought leadership; and advocate for resources and policies that improve the public's health and well-being. The organization envisions state and territorial health agencies advancing health equity and optimal health for all.2 ASTHO's membership includes a total of 8 island jurisdictions. There are 5 US territories and 3 freely associated states (FAS).2 Two US territories are located in the Atlantic (Puerto Rico and the US Virgin Islands [USVI]) and 3 in the Pacific (American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands or CNMI). The US Affiliated Pacific Islands (USAPIs) in ASTHO's membership also include 3 sovereign nations holding Compacts of Free Association (COFA) with the United States. These are the Republic of the Marshall Islands (RMI), the Federated States of Micronesia (FSM), and the Republic of Palau, collectively known as Compact nations or the FAS.3 Island Jurisdictions' Unique History and Context: Challenges, Strengths, and Resiliency The legacy of colonialism and racism overshadows and complicates relationships between the federal government and island jurisdictions and sets the foundation for significant health disparities. Island jurisdictions experience a disproportionate burden of both communicable and noncommunicable diseases.4 The USAPIs' infectious disease profile includes pathogens uncommon in the Continental United States (CONUS), including dengue and tuberculosis. The region's limited health care access and public health infrastructure compound these challenges. In fact, every Pacific jurisdiction is recognized as a medically underserved and health care professional shortage area.4,5 In terms of noncommunicable disease, in 2022, the Pacific Islands Health Officers Association (PIHOA) renewed its public health emergency,6 as the Pacific region hosts some of the world's highest rates of obesity and related illnesses including diabetes, heart disease, and increased risk for severe COVID-19.4 Many factors are contextually important when undertaking efforts to address communicable and noncommunicable diseases and public health interventions aimed at reducing health disparities. These include the following: Historical impact of colonization. Colonization brought not only hostilities and armed conflict to island jurisdictions but also influenza, smallpox, enteric illnesses, and measles. Today, this history contributes to jurisdictions' heightened vigilance and quick response to infectious disease, as evidenced by jurisdictions' responses to COVID-19.4 Remoteness and geographic dispersion. Especially in the Pacific, island jurisdictions are extremely remote, with 2500 to 4600 miles separating them from Honolulu. Settlement patterns within jurisdictions create additional barriers, as populations are widely distributed on remote, isolated atolls with little access to public health and health care services.3 Strained public health and underdeveloped health care systems. Public health infrastructure is typically strained in island jurisdictions, and acute care systems are underdeveloped and overburdened.3 Reliance on external health resources and laboratory testing. Limited on-island care resources, especially acute care in the FAS, means that residents must travel to neighboring territories, states, or countries at significant cost to receive needed care. Similarly, reliance on off-island public health laboratories leads to lengthy turnaround times for diagnostic testing.3 US military influence and the legacy of nuclear testing. The US government detonated 67 thermonuclear devices near inhabited atolls as part of its testing program from 1946 to 1958. Because radiation-induced cancers have a long latency, the true population health impact is still being discovered.7 The United States also conducted bombing exercises in Vieques, Puerto Rico, and used the island to test everything from Agent Orange to depleted uranium from the 1940s until 2003. Studies have shown higher cancer rates in Vieques than in the rest of Puerto Rico.8,9 While there is a tendency to focus on challenges within island jurisdictions, it is important to realize there are strengths to build upon as well. Current efforts to improve population health outcomes are aided by the strength and resiliency of island communities, committed local workforces, and national and international organizations committed to the Pacific and Atlantic regions.3 Recently, these contributed to a successful initial COVID-19 response among island jurisdictions characterized by “strong political will to address infectious disease threats through immediate and severe action, and regional collaboration both across jurisdictions and with multilateral, nongovernmental, and governmental partners.”4(p12) Remarkably, half of the island jurisdictions (American Samoa, FSM, RMI, and the Republic of Palau) sealed their borders for years to allow the development of local response infrastructure, including the distribution of test kits, vaccines, and therapeutics. These measures came at a significant cost to local economies and the emotional toll of separated families, but past experience with deadly infectious disease outbreaks and the knowledge that local infrastructure was limited provided leadership with the necessary political will and backing. Strong political will and bold public health measures allowed island communities to prepare for and respond to COVID-19 spread effectively. When the repatriation of stranded citizens began, the Pacific jurisdictions collaborated on an innovative system of double quarantine: flights were controlled, and repatriated citizens were subjected to strict facility quarantine in Hawaii or Guam before boarding and upon arrival on their home island. Once COVID-19 was detected, both Pacific and Atlantic islands' response tended to be relatively quick and effective, with aggressive contact tracing on the part of a motivated workforce. Regional partnerships were also strengthened and played an essential role throughout the pandemic.4 In the Atlantic, Puerto Rico has the leading vaccination rates across the country, with 83.9% of its total population having received the primary COVID-19 vaccination series.10 Building upon these strengths can provide a foundation for the effective implementation of efforts to address health disparities. ASTHO's Island Support Technical Package Across its program and policy areas, ASTHO currently has 8 technical packages aimed at improving both the focus and proactive nature of ASTHO's technical assistance roles. They are based on literature reviews and subject matter assessments of evidence-based interventions, expert recommendations, overviews of current activities, and a review of the Centers for Disease Control and Prevention's and other federal funding guidelines.1 Based on this assessment process, specific areas of work are prioritized in the Table. The table highlights the following 5 objectives along with potential indicators to measure their implementation success; strategies for achieving these objectives; and partners, policy makers, funders, and stakeholders to be considered and included. Improve data collection within island health agencies and at the national level. Like their counterparts in state and local health public health agencies, island leadership strives to improve the utilization of data for informed decision-making. Various organizations are leading in this area. Since 2010, PIHOA's Regional Health Information Management Systems and Surveillance (HIMS) initiative provides hands-on training to assist member jurisdictions' efforts to improve the collection and use of vital statistics, community-based surveys, medical records, disease registries, administrative data, and other data resources.11 Fiji National University offers a postgraduate certificate in field epidemiology and has trained 101 island public health staff since 2015.12 To support the National Initiative to Address COVID-19 Health Disparities among island jurisdictions (OT21-2103) grant efforts,13 ASTHO joins these organizations, providing a learning series to Puerto Rico and USVI to help define how a planned data dashboard will be used and by whom, along with assistance in determining needed staff capacity and resources. ASTHO is also working to improve the inclusion of island jurisdictions' data in national public health databases through the Island Areas Workgroup established in 2021.14 The work group brings together representatives from island jurisdictions, federal agencies, and trusted partners to address key administrative challenges impacting island health outcomes including those related to health financing, data capacity, and workforce development. Increase community partnerships and community health programs. Given the contextual concerns noted earlier, there is a pronounced need to develop comprehensive and vibrant systems of health care on island to lessen reliance on off-island care and develop less centralized care models within communities. Island health systems need meaningful community partnerships and increased utilization of community health workers (CHWs). Through their OT21-2103 grant, USVI has hired its first 5 CHWs and Guam is also developing a CHW training program. ASTHO has provided assistance with community partner mapping and connected USVI with peer support from Kentucky Department of Public Health, which has deployed CHWs in underresourced areas of the state. Improve policy capacity and expertise. It is widely recognized that public health policy can have a “profound impact on health status”15; yet, island jurisdictions report they have few public health agency staff resources devoted to this purpose, if any.16,17 Recognizing the need to build capacity in this area, ASTHO hosted 2 regional policy academies for OT21-2103—one for Pacific jurisdictions and one for Atlantic jurisdictions. The goal was to provide tools and resources in this area and a framework for island jurisdictions to set their policy priorities and next steps. Dedicated staffing, health equity offices, and sustained funding to achieve health equity. Through a review of available island jurisdictions' OT21-2103 workplans and initial discussions, it was reinforced that the term “health equity” has not been traditionally used in island settings. Terms such as “social justice” and “human rights” held greater relevance. Therefore, it was not surprising to learn that needed infrastructure to support and maintain nascent but important health equity efforts is frequently missing in island jurisdictions. ASTHO is working across many channels to build sustainability, including convening e-learning modules and creating a Web site dedicated to innovative financing strategies that can support crosscutting public health programming.18 ASTHO staff recently submitted an article coauthored by CNMI staff describing the jurisdictions' successful efforts to braid and layer funding to better meet population health needs.19 Defining health equity within an island context. The foundation on which this technical package ultimately rests will be a common understanding of health equity within the unique context of island jurisdictions. Efforts supporting this include this column and other resources and activities, including an island jurisdiction health equity framework to complement existing state and local frameworks. For OT21-2103, ASTHO undertook 2 health equity regional action institutes—one in the Pacific and one in the Atlantic—to provide ASTHO staff and capacity-building partners the opportunity to meet with island jurisdictions and federal funders and discuss plans and vision. The action institutes featured presentations from subject matter experts on topics such as using data for decision-making and building community public health workforce cadres. Jurisdictions were also allotted time to meet as a team to discuss their priorities and focus and to share across jurisdictions. The overarching goal was to begin the dialogue necessary for reaching a common understanding of health equity within an island context and the best ways to address health disparities within island jurisdictions based on needs, existing efforts, and island community strengths. This technical package will help inform efforts to achieve these goals now and in the future. TABLE - ASTHO Island Support Technical Package of Health Equity Interventions Objective Potential Indicators of Successful Implementationa Strategies for Achieving Objectives Partners, Policy Makers, and Stakeholders Improve data collection within island health agencies and at the national level Number of active island public health dashboards Completeness of island data reports to federal agencies Number of federal agency databases that include island data Use of data within island jurisdictions for decision-making Number of islands that establish jurisdiction-specific health equity indicators Federal and island disease reporting practices and requirements Data collection and reporting capacity within island health agencies Analysis of federal data set inclusion Public health staff education about data collection and analysis at the island health agency and federal levels Clarify race and ethnicity definitions and standards for disaggregating by race and ethnicity Electronic transmission capabilities Federal data collectors (CDC NCHS, HRSA, ONC, OASH, Census Bureau) Island FQHC associations, eg, Pacific Islands Primary Care Association (PIPCA) Pacific Islands Health Officers Association (PIHOA) Island policy makers National Public Health Associations (CSTE, APHL) Increase community partnerships and community health programs Number of island advisory groups formed for health equity Number of community health and outreach worker programs Meaningful partnerships Contracts with CBOs, NGOs, faith-based organizations, etc Map community partners and level of engagement Health advisory groups that are representative of underserved communities and incorporate community partners in decision-making Evidence-based practice recommendations Streamlining contracts with partners and increasing partners' capacity to subcontract on federal grants New funding lines and resources, braiding and layering funding Island contract policies Island policy makers Island financial and health agencies National Public Health Associations (NACHW) Partners In Health CDC Office of Minority Health and Health Equity Pacific Islands Health Officers Association (PIHOA) Academic partners Improve policy capacity and expertise Island legislative policies related to island priorities and advancing health equity Tailor federal big “P” and little “p” policies to the island context Data collection tools that inform policy development Improve knowledge and expertise in policy development within island health departments Map existing capacity and legislative authority ASTHO's Health Equity Policy Toolkit ASTHO's Policy Academies ASTHO Federal policy makers Island policy makers Pacific Islands Health Officers Association (PIHOA) Asian and Pacific Islander American Health Forum Dedicated staffing, health equity offices, and sustained funding to achieve health equity Up-to-date workforce surveys Key positions identified in the workforce survey filled Increased number of islands with consistent utilization of an indirect rate to support health equity funding CHW job descriptions, salary ranges, supervision structures in HR system Increased knowledge and capacity among all staff members for health equity implementation Career pipelines, staff retention methods, workplace resiliency, and career ladders Workforce reorganization/decentralization of health department structure to center community needs within available funding sources New funding lines and resources, braiding and layering funding Redirection of existing funding Attrition planning Health equity trainings Agency-wide health equity plans Island HR systems Island policy makers Island executive branch Island administrative partners and agencies Academic partners Defining health equity Definition of health equity in each island Application of ASTHO Islands' Health Equity Framework by federal partners and agencies Amplify island conceptions of health equity and implementation approaches Health equity convenings with community and partners Health equity advisory groups Review of international and Indigenous health equity frameworks Island health agencies CDC Office of Minority Health and Health Equity Pacific Islands Health Officers Association (PIHOA) National Indian Health Board Reclaiming Native Truth Abbreviations: APHL, Association of Public Health Laboratories; ASTHO, Association of State and Territorial Health Officials; CBO, community-based organization; CDC, Centers for Disease Control and Prevention; CHW, community health worker; CSTE, Council of State and Territorial Epidemiologists; FQHC, Federally Qualified Health Center; HR, human resources; HRSA, Health Resources and Services Administration; NACHW, National Association of Community Health Workers; NCHS, National Center for Health Statistics; NGO, nongovernmental organization; OASH, Office of the Assistant Secretary for Health; ONC, National Coordinator for Health Information Technology.aUS Department of Health and Human Services indicators used as a reference.20
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