Lessons Learned from Palau's Journey to Develop Health Equity Indicators

February 05, 2024 | Julia Von Alexander, Heidi Westermann

Traditional meeting house in Palau, called a baiTracking improvements in health equity poses a challenge to public health, and even with many measurement frameworks available, developing meaningful indicators can be challenging. Palau’s Ministry of Health and Human Services’ (MHHS) took on this challenge successfully, in part due to its attention to Palau’s unique settings and needs. MHHS’ work provides a model for other public health agencies as they develop their own health equity indicators.

Understanding the Context

Palau, a country of over 300 islands in the western Pacific Ocean, holds a distinct cultural and historical context, shaped by its indigenous heritage and strategic location. Cultural traditions are an important community tie, which MHHS balances with its efforts to achieve health equity. For example, in most of Micronesia—including Palau—chewing betel nut is a part of the social fabric, connecting generations through this shared ritual. However, this tradition poses some health risks, research linking it to oral cancer and other health issues that become more likely when used in combination with tobacco. This example illustrates how health agencies in Micronesia must navigate a delicate balance between honoring cultural practices, addressing the introduction and marketing of harmful substances via globalization, and maintaining the well-being of the population.

As MHHS developed health equity indicators, it was essential to customize health measures that resonated with the unique dynamics of the community. Such indicators enable MHHS to design interventions that address issues facing the Palauan population while fostering inclusiveness, transparency, and more sustainable outcomes.

Developing the Indicators

In June 2021, Palau received funding for its health equity efforts and work to reduce COVID-19 disparities through a CDC grant dedicated to addressing health disparities for high-risk and underserved communities. This allowed MHHS to further engage the community and improve data collection and reporting. As they developed a community-led health equity council, the MHHS team recognized the importance of measuring their progress. To do so, they needed to identify indicators relevant to their context, which they did in collaboration with ASTHO and the Center for Wellness and Nutrition (CWN).

The first step was reviewing existing resources and potentially relevant indicators. CWN completed an environmental scan and shared a comprehensive list of possible health equity indicators. Following this, the Palau team collectively imagined an ideal state from which to work backwards and identify key outcomes, outputs, activities, and the resources necessary to create that ideal state. The process concluded in developing the indicators in collaboration with community and ministry stakeholders.

ASTHO and MHHS drafted a list of meaningful and available indicators based on the Palau team’s shared vision and outcomes, objectives outlined in the Healthy People 2030 initiative, and available data in Palau. The Palau team shared these draft indicators with their community through two workshops at the 2023 Palau Health Summit. Then, with the community, they identified the most important indicators and specified the populations to focus on within these measures. Once analyzed, MHHS plans to share the baseline data and any updated data with their community.

Lesson 1: Importance of Community Engagement

Health agencies must commit to community engagement and collaboration when developing indicators because these practices are people-centered, bringing diverse perspectives and lived experiences to the table. Not only does this ensure the indicators are relevant and reflective of what is going on in their communities, but it also brings buy-in and empowers the community to address health disparities.

Working closely with the Palauan community and partners led to the successful development of indicators. In February 2023, during the Palau Health Summit open to all Palauans, ASTHO’s Performance Improvement and Island Support teams facilitated workshops where participants shared their expertise of existing strategies and provided context for potential indicators. MHHS staff and community partners worked to refine draft indicators and agreed to subpopulations of interest.

“It was important for us to collaborate with our community to identify the indicators that mattered most to them.”

Sydney Ngiraidong, Health Equity Coordinator, Palau MHHS.

After the summit, the MHHS team identified gaps and updated their list of health disparities indicators. The team also began formulating ways to bring the indicator project to the community. They then plan to travel throughout the communities to share findings from the Palau Health Summit along with data on the health disparities indicators. When asking for community input, it is essential to share back findings and continue to seek feedback. This promotes transparency, shows value and respect for the input of others, builds trust, and fosters a sense of inclusivity, making community members feel heard and valued.

Lesson 2: Collaborative Approach

To begin the iterative indicator development process, the team used innovative strategies that encouraged active participation and input as the project evolved. To support brainstorming and consensus building, the project team used MURAL, an interactive web-based collaboration tool that can be used to promote creativity and systems thinking. It mitigated the limitations of virtual planning and made collaboration more accessible. Additionally, the Palau team connected with stakeholders in other parts of the ministry to ensure they included priorities from multiple programs. Involving other ministry staff also allowed the team to better identify existing data and data that other program teams could collect easily.

Lesson 3: Embrace an Iterative Process and Imperfect Data

There is no perfect indicator list. Health equity indicators attempt to capture elements of complex, unique, and changing communities. Public health agencies often collect data for these purposes but are also reliant on healthcare, social, demographic, and other data to describe and reflect the health status and disparities of a community.

All data has limitations and the MHHS team consistently reviewed and discussed the strengths and limitations of available data. For example, Healthy People 2030 encourages public health agencies to measure access to care; in Palau, physical distance to the largest city and main hospital can be a potential barrier to timely and affordable care. With several potential data sources, the MHHS staff discussed whether the non-communicable disease hybrid survey or the hospital record would allow for a more accurate and meaningful measure of access. Both data sources have advantages and disadvantages, so the team also considered whether to collect new data through a Community Health Worker program. Ultimately, the group decided to review data from the hybrid survey before finalizing the indicator.

When new research or community strategies becomes available, public health agencies may have access to better data or need to change what they measure to ensure it is representative. Public health agencies must hone communication skills to explain the value of imperfect data and acknowledge when it is time to adapt. In Palau, MHHS continues to move forward to collect the baseline data for their indicators, knowing that they may need to shift based on new data and community input.

Empowering the Community

Palau MHHS has worked to create model practice for including the community in developing health equity indicators. Communities know what they are facing best, so gathering information and ideas from them gives a more meaningful picture of health status and equity. By working with community, staying adaptable, and listening to feedback, health agencies can ensure their indicators truly reflect what matters.

Moving forward, MHHS plans to display the indicators on a dashboard and share the information with the community. They are continuing to work with their health equity advisory council and are looking to use the data to support policy decisions in a process that also involves community. Ultimately, well-designed health equity indicators can help health agencies track their progress, identify areas for improvement, and correct course, if needed.

Table 1. Sample of Palau’s Health Equity Indicators (as of October 2023)

This table provides samples of health equity indicators used as metrics by the Palau Ministry of Health and Human Services. Examples include age, location, and nationality.

Subpopulations Indicators
People who are non-Palauan/Palauan
  • % of Palauans age 18 and older who visited the dentist in the past 12 months
  • % of non-Palauans age 18 and older who visited the dentist in the past 12 months
People who live/do not live in Koror (Palau’s largest city and commercial center)
  • Average time in days to primary care providers for people who live in Koror
  • Average time in days to primary care providers for people who do not live in Koror
Youth: People age 0 to 24 years old
  • % of children age 9 to 20 using betel nut
Youth: People ages 9 to 20 years old
  • % of residents ages 9 – 20 who are engaged in their community
Older Adults: People ages 55 and older
  • % of residents ages 55 and older working to improve their neighborhood/community
LGBTQ+ youth (9 – 20 years old)
  • % of LGBTQ+ people ages 9 – 20 who report feeling down, depressed in the last two weeks
  • % of non-LGBTQ+ people ages 9 – 20 who report feeling down, depressed in the last two weeks

This product was supported by funds made available from the Centers for Disease Control and Prevention, National Center for STLT Public Health Infrastructure and Workforce, through cooperative agreement OT18-1802, Strengthening Public Health Systems and Services Through National Partnerships to Improve and Protect the Nation’s Health award # 6 NU38OT000317-04-01 CFDA 93.421. Its contents are solely the responsibility of ASTHO and do not necessarily represent the official views of the U.S. Department of Health and Human Services/Centers for Disease Control and Prevention.