Utah may be next to experience a physician crisis

Story and photos by Justin Trombetti

The concept of representation in modern society can often be a fickle thing. It’s also becoming a hard conversation to avoid; it was a massive focal point of the most recent midterm elections, it’s garnered both highly positive and staunchly negative critiques of our modern media landscape, and for better or worse, the political climate of 2019 America has thrust an unending array of opinions to the front of our social commentary.

Emotions aside, the reality is that minorities and historically marginalized groups are not represented visibly in proportion to the population percentages they make up.

While this issue is far from exclusive to them, it is especially relevant to Hispanic populations. In fact, it’s a large part of the reason why California is currently facing what has been termed a physician crisis. That is, while Hispanics make up over 40 percent of the state’s population, they account for only 12 percent of graduating physicians.

It’s been posited that this has resulted in disproportionately poor health and community-wide vulnerability that, at its current rate, would take over 500 years to equalize.

It would seem that, upon a deeper dive into the matter, the issue is far from specific to California. Further, while healthcare is an immediate concern, it may well be a problem that extends beyond just a single sector of the service economy.

Utah is experiencing its own tension in the local health sector, as its rapidly growing population has begun to feel the strain of underrepresentation. Yehemy Zavala Orozco, preventive health manager of Comunidades Unidas, has been on the front lines of this reality for eight years.

The West Valley City-based organization’s primary mission is to “keep families healthy and together,” and Zavala Orozco (whose preferred pronoun is they) believes that the odds are stacked against the communities it serves.

They believe the underlying issues of representation are just the beginning of a multifaceted dilemma facing the Hispanic community. “No one gives you a guide,” they said of first-generation immigrants who often struggle to find resources that not only speak their language, but also understand them on a cultural level.

Zavala Orozco recalled a story of a first-generation mother from Guatemala with whom they recently worked. “The doctors found a lump in her breast and she needed surgery. They thought she might have cancer.”

On top of the woman dealing with the gravity of her diagnosis, Zavala Orozco said she found little help with the hospitals and offices she dealt with. Language barriers alone created a back and forth with her care professionals that made treatment more stressful and time consuming. Instances where miscommunications led to hospitals completely missing information along the way were also prevalent.

Zavala Orozco believes that there’s an extreme lack of investment and effort from the government to shift these paradigms. They cited the backpedaling on the 2018 initiative Proposition 3, which dealt with Medicaid expansion that would have had a strong impact on the Hispanic population, as a primary example of this.

They strongly suggest that Utahns must begin bolstering the opportunities available to Hispanics that allow them to ultimately join the professional sectors where their communities are underrepresented.

“We need to ensure they know college is an option, they just don’t see options other than places like [Salt Lake Community College] or trade schools,” Zavala Orozco said. They also believes that access to higher education is often too expensive for minority groups, and helping to remove the financial barriers of access is essential to reversing these trends.

In Utah, physical health is not the only concern Hispanic populations are faced with. In a state where suicide rates among this group are close to double the national average, mental health treatment is just as important.

Brad Drown, a licensed clinical social worker in Murray, has seen some of the same problems in his field that Yehemy Zavala Orozco discussed. He stated that it’s common for Hispanics in Utah to go without mental healthcare. Drown added in his multiple decades as a social worker, he’d only ever treated a small handful of Hispanic patients, and that while this could be a geo-demographic reality, independent research and data from his colleagues show similar trends.

According to Drown, this is very much a cultural issue, and less so a linguistic one. He noted that Utah boasts a higher number of multilingual resources available in his line of work due to the growing population of Latinos and the large number of return missionaries who lived abroad in Spanish-speaking nations.

The issues lie partially in a pattern of cultural stigmas he’s noticed, but more prevalent is the problem of a shared cultural experience that can often make therapy more effective. While he believes it isn’t always a necessity for everyone, many people feel more comfortable seeking treatment when they believe there are providers who understand them on a deeper level.

Perhaps most important to note, however, is that a common experience does not always mean a common result. While it’s crucial to recognize the hardships that many Hispanics face, assigning victimhood to an entire population, especially one with so many positive victories, can be short-sighted.

Andres Rivera, who runs Myo Tensegrity Massage in Draper, provided some context on this. He said he’s been lucky to experience a different side of the matter.

“We moved to California when I was 8, and everyone spoke Spanish [where we lived],” he said. Even in Utah, he lived in areas with a dense Hispanic population, and he believes this made integration easier.

“My mom spoke OK English, but mostly Spanish. It made it a little difficult but going to certain places that were recommended [by other Spanish speakers] was a big thing,” he continued. “It helped to have connections where she felt comfortable as far as speaking Spanish, especially with finding places of employment, things like that.”

However, Rivera felt it important to acknowledge that he does not think that’s how it is for every immigrant family. “Older people that came here is where it’s more of a thing where it makes sense to befriend someone with a shared cultural experience. I can see why someone [that didn’t immigrate as a child] would really want people who understand where they’re coming from.”

The idea of representation is important to minorities and oft-marginalized groups, especially when it comes to health. While it doesn’t necessarily affect everyone equally, it’s a pressing concern that currently has no end in sight for a significant population of Hispanics in Utah and nationally.

Zavala Orozco said that beyond empowerment, investment in local organizations like Comunidades Unidas can have an enormous impact on the day-to-day lives of Utahns. It may not be a problem that can solve itself overnight, but awareness and grassroots effort can go a long way.

 

You are not crazy: Mental health stigma among Latinx community

Story and photos by SAYAKA KOCHI

One of the frequently discussed topics is that Latinx people are less likely to seek mental health treatment by themselves. Even when they are suffering from severe mental disorders, asking someone for help isn’t easy. There are several reasons why they cannot signal SOS.

“I didn’t want to admit that I was not OK,” Diana Aguilera said. Aguilera was born in Mexico and moved to Utah at age 10. She is a Peer Programs coordinator at the Latino Behavioral Health Services (LBHS) located at 3471 S. West Temple in Salt Lake City. LBHS is a nonprofit organization for unserved Latinx and Hispanic Utah citizens with mental illnesses, co-founded by Jacqueline Gomez-Arias and other contributors.

Before Aguilera became involved in LBHS, she had been suffering from depression, triggered by a harsh breakup. Because of her mental breakdown, she said she gave up school, her desire to be a social worker, and full-time work.

“I went to bed every day and like ‘please, don’t wake up anymore.’ I asked my body to give up because I couldn’t literally go on anymore,” Aguilera said. “I didn’t like to talk about it. I tried to hide it. Because I didn’t want my family to feel guilty.”

While she was ignoring her mental breakdown, she started volunteering at LBHS to help others in 2015. There, she said she met people with depression and those who have overcome their mental illnesses. Through being with them, she said she could finally acknowledge that she had to seek help.

“I met one of the founding members, Jacqueline [Gomez-Arias]. She was so open about her mental health issues. Through the conversation with her, she was like ‘you need help. You have depression. You have to seek help,’” Aguilera said. “Hearing from her, it was reassuring that it’s OK, I’ll be fine.”

With the help of Gomez-Arias and Aguilera’s sister, she was able to find a therapist and start fighting against her depression. At this point, health insurance is one of the main reasons that Latinx people cannot seek treatment. According to a report by the National Alliance on Mental Illness (NAMI), one-third of Latinx immigrants are uninsured.

“I was really lucky and privileged that I had health insurance. Not everyone has health insurance. Not everyone can afford a therapist,” Aguilera said.

After several years of taking multiple medications and attending therapy, she said her mental health slowly but steadily recovered.

“Right now, I’m doing very well,” Aguilera said. “I don’t think that is a magic thing. It’s just a huge combination of everything.”

Aguilera also explained the importance of belonging in the community. “I’ve gone through therapy but that wasn’t super enough. For my recovery, I needed my community. Latino Behavioral has been my community. That was the most important thing for me.”

Like Aguilera, Carla Astorga had also suffered from mental breakdown for a few decades. Astorga was born and raised in Lima, Peru, which was a “corrupted” place for her to live. Through a lot of traumatic events from her childhood, Astorga said that her mind was broken. To escape from such a harsh environment, she said she decided to move to Utah in 2005.

“I didn’t recognize my symptoms at first. I felt sadness for whole days. So I didn’t know that it became a depression,” Astorga said.

Ten years had passed since she escaped from her country, but she said her symptoms reached such a level that she couldn’t stand them anymore.

“Anxiety, depression, panic attack, paranoid, fear — everything was starting to growing up and growing up,” Astorga said. “I started to see things that were not there. One day, I was driving to send my kids to school. After that, I went to the police station, because I smelled a bomb in my car. Police checked my car, but there was no bomb.”

At this moment, Astorga said she realized for the first time that she had a mental illness. She then decided to take treatment. As a first step, she came to visit LBHS to pull herself out of the darkness. She said she also took psychiatric medication, therapy, and some training provided by NAMI, which is the nation’s largest mental health organization. Over a couple of years going through hard times, she could finally overcome her mental disorder.

“The most successful part of my recovery was to be able to find one place with my own culture and language that I could feel like I was at home,” Astorga said.

Ever since her symptoms improved, she has been helping people at LBHS as a peer supporter and at NAMI as a Wasatch/Summit affiliate leader.

“I didn’t see enough sources with my own language in my area. Latino people need more sources for mental health,” Astorga said. “When I was getting recovered, I started to be aware that I had confidence and trusted myself. So I started thinking that I wanted to help other people.”

Astorga said a lack of knowledge is the main issue for Latinx people when they develop mental illnesses.

“In my culture, if you go to a psychologist or a doctor to take medicines, you are crazy,” Astorga said.

As Astorga pointed out, finding a peer mentor who has the same cultural background is really hard for underrepresented minorities.

Laiyan Bawadeen, a counseling intern for international students at the University of Utah, addressed this cultural difference issue from a counselor’s perspective.

“To address cultural differences in general, it is important that a counselor uses a multicultural viewpoint where they approach counseling through the context of the student’s world and culture while their own values or bias is not more important than that of the student,” Bawadeen said in an email interview.

Bawadeen is half Taiwanese and half Sri Lankan, and she is pursuing her master’s degree in clinical and mental health counseling at the U. As a member of the minority group, Bawadeen also suggested the importance of correct knowledge about mental treatment.

“I think demystifying what mental health [is], understanding what a counseling session looks like and what to expect can help demystify the counseling process, remove the stigma around mental health and make it easier for individuals to seek help,” Bawadeen said.

Seeking help is not easy for Latinx and other minority people. This might be because of the language barrier, not having health insurance, stigma, or caring so much about families or those who are closest to them. However, at some point, they need help.

Astorga said, “Latino[x] people are very strong. They were fighters or warriors. So they say they can do this alone, but they can’t.”

 

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Kids need more Latinx role models in Utah, and here’s why

Story and photo by KRISTEN LAW

Kids pursue what they see. This is what former Utah State House Representative Rebecca Chavez-Houck said in an interview. She said that kids are inspired by the role models in their lives.

The most impactful thing from a study released in January 2018 by Education and Employers reveals that over 36 percent of kids place their career hopes based on people they know. Lack of diversity and lack of authentic and encouraging mentorships were two major issues that stunt a child’s dreams for their future, the report said.

Jennifer Mayer-Glenn, director of Family and School Collaboration in the Salt Lake City School District, creates opportunities to help build the capacity of school staff and create welcoming environments for culture in the Salt Lake schools. 

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East High is one of the five high schools in the Salt Lake City School District.

Mayer-Glenn says that although there are a few Latino teachers, diversity could be better in the Salt Lake City School District. “Even if a student of color has one teacher of color through their entire career, that makes a huge difference in them feeling connected to the institution,” Mayer-Glenn said. Additionally, she said it can be hard for students who don’t see themselves in their history books. “If they can’t see themselves, it is hard for them to relate.”

Mayer-Glenn said it’s important that Latino kids see other Latino doctors, lawyers, leaders, business owners, and politicians because then they see themselves and say, “I see me and I can be that person.” The hope behind this is to encourage all kinds of kids to pursue all kinds of careers to help all kinds of people.

Recently, Mayer-Glenn said she took a trip to the doctor’s office. Upon arriving she was delighted to see that the medical assistant there was Latina. “We need more Latina doctors,” Mayer-Glenn said. Excited about this, she decided to encourage the assistant by stopping to talk with her about her career goals and aspirations. 

Cecilia Rollett is a wife and mother, originally from Veracruz, Mexico. “It was hard at first to adjust to living in America because of the language.” She recalled a difficult moment with this when she was first pregnant, only a year after being in Utah and still not knowing the language. She had to work through her doctor appointments during her pregnancy sometimes without her English-speaking husband or an interpreter.

Rollett has now been in Utah for five years and speaks English fluently as her second language. Those interactions she had with doctors during a very vulnerable time in her life encouraged her to be a translator and counselor working with Spanish-speaking clients at the Pregnancy Resource Center.

Thinking of her own experiences, Rollett said, “Whether or not they know English, these women need these resources. I had [my husband] who is American, but some of these women, it’s just them.”

Mayer-Glenn said, “It’s about developing relationships with people.” Trusting in those authentic relationships and then encouraging other people to invest in those same kinds of impactful relationships. Mayer-Glenn calls this her “heart work.” “Having those individual relationships where people trust you and push you and encourage you I think is really important [in a child’s life],” she said.

Teachers and mentors play a large role. Mayer-Glenn recalls an impactful moment in her own life where a mentor, Archie Archuleta, an icon of activism in Utah, encouraged her to push herself toward her potential. “I’ll never forget Archie [telling] me ‘it’s your turn, you’ve earned it,’ like go forward and do this work because you’re ready.”

The most impact Mayer-Glenn has felt being on the other end of this was when she was an assistant principal at Glendale Middle School. This is where she felt she had more of a direct influence because she interacted with the kids every day.

“They would come to my office and sometimes they would just need a pat on the back and be told ‘you’re going to be OK.’ And also challenging them and really pushing them saying ‘you have the right and you can be who you want to be’ and show them ‘these are the things you are going to have to do in order to get there.’” It was those individual relationships that she believes really had an impact.

Hispanic belief system that the family is the heart and focus of life

Story and photo by EMMA JOHNSON

The family is the heart of the Hispanic culture. Children taking care of their parents as their parents took care of them in their childhood is a “circle of life” concept the Latinix communities value. Birth and death are interesting life experiences. Latinx people are viewed as family-centered with divine importance placed on caring for the young and elderly. Learning from family members’ wisdom that will benefit future generations is an honorable life adventure Hispanic families respect.

A 2014 poll conducted by the Associated Press-NORC Center for Public Affairs Research found that Hispanics have a higher likelihood of caring for their elderly relatives and having it be a positive experience. The poll concluded that Hispanic families have reported a greater percentage of their caregiving being less financially stressful.

Alex Guzman, president and CEO of the Utah Hispanic Chamber of Commerce, feels the opportunity to take care of his elders enhances his family centered beliefs. “In the Hispanic culture, they will take care of their parents because their parents took care of them.” For him and his family, the statement is as simple as it sounds. Guzman says assisted-living homes are a rarity in his home county of Guatemala. The family is the center. Whatever sacrifices need to be made to ensure fulfillment of the circle of life will be made.

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The Livas family represents the circle of life. Standing from left: Norma, Manny, and Ed. Sam is seated

Latinx communities are loyal to their heritage.  They are proud of who they are and willing to share their rich culture with others. Sam Livas is a Mexican-American who prides himself on his family-oriented lifestyle. Livas’ mother grew up in Cananera Sonora, Mexico, and his father in Tucson, Arizona. His mother migrated to the United States to marry his father. Livas was born in California but said he would not trade his Hispanic upbringing up for the world.

Growing up, Livas said he watched as his mother cared for her elderly parents. “Seeing my mother and her siblings take care of their mother is where I feel or saw the need to take care of my own parents.” The firsthand experience helped him to realize the cultural importance and value of caring for those he loved.

According to a study conducted by the University Of Austin, Texas, despite high levels of need, Hispanics shun nursing homes and remain where they are even with compromised health conditions. It isn’t uncommon for children caretakers to fail meeting the needs of their elderly relatives. Most family members aren’t medical professionals. The looming pressure of where family members with health complications will live daunts and alters cultural customs.

Livas said in an email interview that his Mexican-American values have given him a clearer understanding of why many Americans put their parents into nursing centers. “I don’t fault those that CAN provide better care for their loved ones.” He said he feels assisted and rehabilitation homes should not be a substitute for family, but used as a resource that benefits all. “Don’t forget to call and visit,” Livas added, there is no better emotional love than a family can provide.

Latinx communities rely on family units as human bodies rely on their heart. Family belonging and involvement is the foundation of their lives. Guzman, with the Utah Hispanic Chamber of Commerce, said, “If you have to work three jobs with the intention to provide for your children, you do.”

 

University of Utah Pacific Islander Medical Student Association

Story by ALEXANDRA OGILVIE

Julius Ulugia is a Samoan American in his second year at the University of Utah School of Medicine. He helps to operate the University of Utah Pacific Islander Medical Student Association (PIMSA). According to their currently cached University of Utah club website, the mission is, “To provide students and mentors with a venue to network, increase awareness, promote and advocate, serve our Pacific Islander communities, and prepare for careers in medicine, healthcare, and administration. PIMSA provides peer mentors and role models for students seeking to enter academic and clinical healthcare fields.”

PIMSA was started in 2008 by Jake Fitisemanu Jr. and Kawehi Au. But, “it essentially became dormant when those who started either sought other careers or graduated and went off to residency,” Ulugia said. Currently, Ulugia is the only Pacific Islander in his medical school class of around 130, according to the school.

“Many people, Pacific Islanders and non-Pacific Islanders alike, see us as great athletes. That is literally what I got from my own family and non-Pacific Islanders. Many of us don’t see ourselves as intellectually equal to other people. This is magnified in health care, where we are unable to sufficiently care for our own,” Ulugia said in an email interview.

Fitisemanu wears many hats in the Utah Pacific Islander community. Among other things, he works at the Utah Health Department, he chairs the Utah Pacific Islander Health Coalition, and he is an elected representative for West Valley City. “PIMSA was a great opportunity for medical students to get involved in our own ethnic communities and expose other youth to possibilities in health science careers,” he said in an email interview.

“PIMSA has helped at least eight Pacific Islander pre-meds who have been accepted to med schools, and at least that many who have prepped for the MCAT and applied to medical school,” Fitisemanu said. Although it started off for MD students, it has branched to include other health sciences fields like nursing, physician assisting, dental, and pharmacy. Since there is only one Pacific Islander MD student in the state (Ulugia), the focus has shifted to undergrads rather than graduate students.”

Vainu’upo Jessop, a Samoan American anesthesiologist attendant, helped to found PIMSA when he was an undergraduate student at the University of Utah. He went on to complete medical school at the University of Utah. He was only one of four Pacific Islanders in his class and the first Samoan American to graduate.

PIMSA’s current focus is on Pacific Islander high school and undergraduate students. One way they excite high school students is to bring them to health conferences held at the University of Utah and Salt Lake Community College, to show them cow heart dissections and other exciting demonstrations. PIMSA also works on a one on one basis to help students navigate the college process.

“A lot of the [Pacific Islander] college students are first-generation students, and we would help them with the logistics of how to set up their schedule in order to optimize their chances for success at the undergraduate level.  We would also get these people more involved in increasing awareness in the [Pacific Islander] community by having them run booths at health fairs, participating in after-school programs to promote healthy lifestyles, etc,” Jessop said in an email interview.

Jessop left town to do his residency at the University of Massachusetts in Worcester, Massachusetts, from 2012-2016 and completed a fellowship in critical care from 2016-2017. He returned home to Utah soon thereafter.

“Since I’ve moved back, I’ve had many [Pacific Islander] patients who are shocked to find out I’m a doctor. They ask me if I’m Polynesian, and when they find out I am, they usually say, ‘Wow! I didn’t know that there were any Polynesian doctors!’ I hope to be an example to other [Pacific Islanders] and show them, that we can make it,” he said.

Jessop believes that getting more Pacific Islanders into medical professions would increase the health of Pacific Islanders in the state. Currently, Pacific Islanders lead the state in incidents of diabetes, cardiovascular disease, and obesity, according to the Utah Department of Health.

“A lot of the older [Pacific Islanders] either don’t feel the need to see a medical provider, they don’t understand what a provider is telling them, or they flat out don’t trust people in the medical establishment. I think the more [Pacific Islander] providers there are in the community, the easier it will be to increase health awareness in the community,” he said.

Alyssa Lolofie, a Samoan American PIMSA member who is about to start medical school at Rocky Vista University College of Osteopathic Medicine, agrees. “It’s important to get more [Pacific Islanders] interested in medicine (medical school, physician’s assistant programs, nursing, etc.) to increase representation and education on Western or mainland medicine for these [Pacific Islander] communities. Many patients with diverse backgrounds or from underserved communities are less likely to see a medical provider because of an assumed lack of understanding of the traditions and ways of life of these communities,” she said in an email interview.

Jessop added, “Overall, as more [Pacific Islanders] we can get into college and get professional degrees, there will be an overall increase in awareness in the community. I believe the benefits are twofold: the overall health of the [Pacific Islander] community will improve, and the younger PIs will see this and want to contribute.”

Two other organizations could potentially be helpful: the Asian Pacific American Medical Students Association and the Health Sciences Multicultural Student Association of Utah.

Nā HALE: A home for Pacific Islander well-being

Story and slideshow by MARISSA SITTLER

In Hawaiian, nā hale means “the houses,” a word that embodies the sense of traditional Hawaiian community. This word is the driving force behind the newly formed umbrella organization for Pacific Islander wellness and resources. HALE is an acronym for Health, Advocacy, Leadership and Education.

Some of the strongest leaders of Utah’s Pacific Islander community came together to hatch the idea of Nā HALE. The idea was devised by members of the Utah Pacific Islander Health Coalition, the University of Utah Pacific Islander Studies Initiative, Margarita Satini from Utah Pacific Islander Civic Engagement Coalition and Charlene Lui from Hui Hawai’i O Utah Hawaiian Civic Club.

The first formal meeting took place in January 2016. During that meeting, an exploratory committee was formed “to research different collaboration models, bylaws and articles of incorporation, and membership structures of existing organizations in other states,” said Jake Fitisemanu Jr. in an email interview. He is the acting chair of the steering committee that is tasked with preparing Nā HALE to become a more formal entity. He is also the council member for District 4 in West Valley City, Utah. 

In April 2016, the Utah Pacific Islander Health Coalition unanimously supported the proposal to create a statewide umbrella group. It was one month later that the name Nā HALE was chosen.

Pacific Islanders have a strong sense of family and community, so it is only natural that many of the already formed Pacific Islander resource groups are some of the main collaborators for this project. In addition to the founding organizations, Fitisemanu said local groups including Queen Center, National Tongan American Society, Beyond Culture, Utah Pacific Islander Behavioral Health Association, Samoana Integrated Language Initiative, Southern Utah Pacific Islander Coalition, Pacific Island Knowledge 2 Action Resource and PEAU Artists Collective are all main members of Nā HALE.

Charlene Lui, director of educational equity for Granite School Districts, is native Hawaiian and has lived in Utah since the 1970s. She and her husband, who is Tongan, have been very involved in the Pacific Islander community in Utah through various groups, such as Hui Hawaiʻi O Utah and the National Tongan American Society.

Lui said in a phone interview that collectively, they have always wanted to strengthen the Pacific Islander community by organizing a group somehow. She sees Nā HALE as “trying to bring everybody together under one umbrella and to strengthen and maximize what every group group does, to collectively share our resources.”

Dr. Kalani Raphael, who is a kidney, electrolytes and high blood pressure specialist at the University of Utah School of Medicine and one of the key members of Nā HALE’s formation, said in a phone interview that the importance of Nā HALE “boils down to recognizing that there’s a lot of disparities in health, economics and incarceration in the Pacific Islander community.” He adds, “We can and should be doing better.”

Fitisemanu sees Nā HALE as a way to strengthen each individual organization’s capacity and reach. “This kind of network can facilitate resource pooling as well as information sharing; for example, a program that has been successful in the Samoan community might be more readily adopted as a best practice among the Tongan community. It also creates opportunity for more impactful civic engagement, when communities can band together and promote policies that are in the best interest of underrepresented communities,” he said.

While Nā HALE is a solidified concept, it is still just that — a concept. The individuals who are working on this project also have full-time careers, which can make it difficult to dedicate extra time to Nā HALE’s formal creation. Despite this, the umbrella organization already has a strong presence in the Pacific Islander community. It was featured as a community-based initiative during the American Public Health Association conference in October 2016 in Denver and was introduced to national partners across the United States and the Pacific territories in May 2017 during a webinar hosted by the Native Hawaiian & Pacific Islander National Network in Los Angeles.

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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.”

 

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