It Takes a Village: how a culturally responsive public health program is improving birth outcomes for Utah Pacific Islanders

Story and news graphics by ALLISON OLIGSCHLAEGER

Before the Christian fervor to “multiply and replenish the earth” reached Hawaii, most women waited 18 to 24 months between pregnancies (the time period now recommended by medical professionals). Birth spacing was determined by a simple test: after bearing a child, a woman would wait to have sexual relations with her husband until that child could pick up a stone and throw it out of the house.

But according to Jacob Fitisemanu Jr. of the Utah Department of Health, in today’s Pacific Islander communities, the intervals between births are much shorter. According to a 2013 study by the department, 37.4 percent of Utah Pacific Islander mothers waited twelve months or less between pregnancies, compared to 15.9 percent of Non-Hispanic White mothers.

In addition to shorter pregnancy intervals, the health department’s first targeted study on ethnic disparities in birth outcomes found that Pacific Islander mothers had disproportionately high rates of obesity, hypertension and gestational diabetes, and were significantly less likely to access prenatal care in their first trimester of pregnancy.

“Less than half of Pacific Islander women even got screened or treated in their first trimester, which is horrific,” said Fitisemanu, who chairs the Utah Pacific Islander Health Coalition.

These factors lead to disproportionately poor birth outcomes for both mother and child. When compared to Utah’s state averages, Pacific Islander infants are significantly more likely to be born prematurely and about twice as likely to die within their first year.

In response to these findings, the health department reached out to The Queen Center and Moana Nui Utah, two local 501(c)(3) nonprofit organizations devoted to promoting health and wellness among Utah’s Pacific Islanders. Together, they ran focus groups and conducted surveys of about 60 Pacific Islander women and couples.

“We wanted to look at, if you’ve had a baby, did you have prenatal care or not? If so, where? If not, why?” Fitisemanu said in an interview at the University of Utah.

Alongside lack of insurance, researchers identified a lack of knowledge/understanding as the primary barrier to accessing prenatal care. In later focus group results published by the health department, no participants identified birth outcomes as an issue in the Pacific Islander community and most seemed unsure of what prenatal care was.

Looking for insight into this knowledge gap, Fitisemanu and Lita Sagato, who worked for The Queen Center at the time, began conducting individual interviews with Pacific Islander mothers.

“Our biggest concerns were making sure [the research] was an honest reflection of the community, meaning we actually went out to homes and met with different mothers and different women that had experienced losses,” Sagato said in a phone interview.

They found that for Pacific Islander women — even those who were born in Utah, spoke English as a first language, and/or had a college degree — the primary source of information about pregnancy and childbirth was older women in their families.

“So if you think about it, you ask your grandma … who delivered a baby in a village in a hut,” Fitisemanu said. “She doesn’t know what folic acid is, she doesn’t believe in ultrasounds — she had five healthy kids under a mango tree!”

Perhaps as a result of this, only 48 percent of Utah Pacific Islander mothers receive any sort of prenatal care within their first trimester, compared to the state average of 78 percent. Even among those who do receive professional care, the advice of family and community members is often valued above doctors’ recommendations.

“If no one in the family has experience with what you’re saying, they may go with what auntie said or what grandma said or what sister-in-law said over the advice of an MD or OBGYN,” Fitisemanu said.

Armed with insight and funding, the health department’s Office of Health Disparities established the MAHINA Task Force, a network of Pacific Islander public health professionals, educators and activists. MAHINA, a loose acronym for “maternal health and infant advocates,” is also the word for “moon” in Hawaiian and Tongan and the name of the moon goddess in many pre-colonial Polynesian religions.

“The health department said, ‘Hey, we want to help you with this. We see these statistics are really bad — one preventable death is too many — so what can we do?’” Fitisemanu said. “These women looked at the curricula and the different things the health department had and said, ‘Yeah, this stuff is not going to work in our community.’ It targets the mother, but if less than 50 percent of these mothers are even getting in in the first trimester, we’re missing all of those women.”

Working together with The Queen Center and the MAHINA network, Fitisemanu and Sagato set about adapting the health department’s approaches to maternal and prenatal health to better suit the needs of their community. This meant shifting the focus from the individual woman’s choices to the entire family’s lifestyle, in keeping with Pacific cultures’ emphasis on collective well-being.

“Everything important to us really is the family, the village,” Sagato said. “If everyone’s on board, it’s much easier for the women to take care of themselves.”

Fitisemanu also emphasized the practical necessity of involving the family.

“If we tell the mom, ‘You’ve got to take folic acid, you’ve got to eat this, you’ve got to exercise,’ but everybody in the house is eating a full pig for dinner, that doesn’t help,” Fitisemanu said.

beforeandafter

MAHINA’s community-oriented curriculum, titled “It Takes A Village,” was first debuted in a Salt Lake City focus group in 2015. The program spanned six weekly sessions, held in a Polynesian church building, and focused on teaching expectant mothers and their families what they can all do to promote healthy pregnancies and positive birth outcomes. Discussion topics included things like folic acid, diet and exercise, and birth spacing. The health department report on this pilot program notes that while participants were initially skeptical of advice on birth intervals, they were more receptive after learning that their ancestors practiced birth spacing.

“The pre-colonial constructs regarding that and customs regarding that are actually exactly the same,” Fitisemanu said. “We insert them into this curriculum to remind them, and these old ladies are like, ‘Oh yeah! That’s what my mom taught me.’”

Joyce Ah You, founder and director of The Queen Center, said the importance of culturally relevant resources cannot be overstated.

“It is everything,” Ah You said in a telephone conversation. “Having the program tailored to Pacific Islanders, making sure it’s culturally appropriate, we spoke to them. We didn’t speak about what was going on with Hispanics or African Americans, this is what’s happening in our homes.”

Even adjustments as simple as using photos of Pacific Islander women and families in slideshows make a difference, Sagato said.

“If they see Caucasian women on there or other ethnicities, they’re going to think, ‘Well, that’s not us,’” Sagato said. “When they see themselves on there, it kind of gives them a reminder that it affects all of us.”

confidence

The pilot program was “wildly successful,” Fitisemanu said, and is the only study in Utah’s health department history to have negative attrition, meaning it ended with more participants than it began with.

“That never happens when you do public health studies!” Fitisemanu said. “It’s a pretty neat program.”

Since its rollout in 2015, “It Takes a Village” has been through several rounds of testing and revision. About 200 Pacific Islander women and couples have completed the program to date, according to program manager Brittney Okada of the Office of Health Disparities.

“We are very proud of this curriculum,” Okada said in a phone interview. “To see the response — to see how they are taking pride in their culture and to see how it relates to maternal and child health, to see this light bulb go on when you mix in the cultural wisdom, it’s quite beautiful.”

Okada and her colleagues are in the final stages of preparing to release the curriculum to the public in April 2018. It will be available for free on the health department’s website, along with facilitator manuals and participant workbooks, for noncommercial public use. Okada hopes local Pacific Islander communities throughout the state will take advantage of the curriculum and implement it in ways that make sense for their populations.

“We are excited to see what might happen and to see how the community can take this program and make it theirs,” she said.

The health department has also been approached by public health organizations in Hawaii and California hoping to adapt the curriculum for their own Pacific Islander populations.

Ah You, who founded the Queen Center with her husband Sale Ah You “to help our people and give back to the community,” said her experience with the MAHINA Task Force was deeply fulfilling.

“I realized how much work needs to be done, but I realized also how much our community, my community, is like a sponge,” Ah You said. “They’re so willing. It just needs to be brought to their attention.”

 

This slideshow requires JavaScript.