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Attitudes of Marshallese Women Toward and Barriers to Prenatal Care

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1 Attitudes of Marshallese Women Toward and Barriers to Prenatal Care
Emily Starr, BSN

2 What is Prenatal Care? Prenatal care: any health care given to a pregnant woman after conception and before birth. Usually commences during the first trimester of pregnancy and includes visits throughout the course of the pregnancy. Visits usually involve medical screening, physical exams, education and counseling, and help with social services for women.

3 Benefits of Prenatal Care
Can reduce the likelihood of a woman giving birth early or to a low-birth-weight baby, as well as detect various anomalies that can be treated in-utero. Can decrease the time a neonate spends in the hospital, thereby reducing overall costs which is especially important for low-income women. Improve the mother’s health by detection of conditions that the woman may develop during pregnancy (e.g. hypertension and diabetes) which could pose a potential threat to the fetus.

4 Republic of the Marshall Islands
Population:67,182 (July 2011 est.) Infant mortality:23.74 deaths/1,000 live births (2011 est.) Life expectancy:71.76 years (2011 est.) Fertility rate:3.44 children born/woman (2011 est.) Median age: 21.8 years (2011 est.) Net migration rate: migrant(s)/1,000 population (2011 est.) rm-map.gif

5 Health Status in the RMI
“Dual epidemic:” chronic health issues (e.g. heart problems and diabetes) and communicable diseases (e.g. Hansen’s disease, tuberculosis, etc.) Transition from marine foraging to more sedentary lifestyles plus American dietary principles has led to increases in obesity, cardiovascular disease, diabetes, etc. Malnutrition: diet poor in vitamins and minerals Radiation related issues: thyroid, some cancers, etc.

6 Marshallese Health Beliefs
Family “Untraditional” when compared to American notion of “normal” Multiple families living in same households; kids common “Clan raised” Circular migration

7 Health Beliefs Cont’d Time
Focus on the present, little regard for future Makes preventative care difficult Frustrates appointment schedules Illness Illness=pain. Therefore, if no pain, no illness. Will discontinue treatment when begin to feel better Sick are often shunned and feel ashamed so do not readily admit illness

8 Gender Roles Women: Raising children Home maintenance
Direct decision making Health issues related to women and children Men: Protect family Provide food and shelter Speak for the family Share in decision making

9 Compact of Free Association
Issued in 1986, outlines relationship between U.S. and RMI: U.S.: provides defense protection, financial aid, the ability to enter and exit the country without visa or time limit RMI: continues to serve as a nuclear testing site and provide exclusive military rights to the United States A Marshallese individual may enter the U.S. with only a passport, obtain a social security number, work, attend school, and serve in the U.S. military. The compact does not provide a pathway to citizenship and prohibits most state or federal funding.

10 Reasons for Leaving RMI
Better health care Better educational opportunities for children Family members living in U.S. Physical lack of land Population explosion Poor economy Employment opportunities in U.S.

11 Background The Marshallese population of NWA is estimated to be between 6,000 and 10,000 (the highest number outside of the Marshall Islands) The incidences of tuberculosis, Hansen’s disease, diabetes, HIV, syphilis (including congenital), and perinatal hepatitis B are all increased in the Marshallese population when compared to the general population

12 Health Profile 67% of congenital syphilis cases in NWA were of Marshallese ethnicity 54% of these cases were identified at birth (only 31% were identified during prenatal screening) The incidence of perinatal hepatitis B among Marshallese increased from 8.1 cases per live births in 2003 to 16.8 cases per 1000 live births in 2005

13 Trends in Prenatal Care
Less likely to seek prenatal care: 34% of Marshallese women do not seek prenatal care whereas only 2% of non-Marshallese women do not Less likely to be screened for HBsAG: 57% of Marshallese women were screened, as compared to 91% of non-Marshallese women More likely to test positive when screened for HBsAG: 10% of Marshallese women tested positive, as compared to 0% of non-Marshallese women

14 Purpose The purpose of this study is to investigate the attitudes toward and impediments to prenatal care among women of child- bearing age in the Marshallese population in Northwest Arkansas.

15 Aim 1 Aim 1: Explore the attitudes of Marshallese women towards prenatal care. Research question 1: How does the Marshallese culture view prenatal care? Research question 2: How do Marshallese women describe their experience with prenatal care in northwest Arkansas?

16 Aim 2 Aim 2: Explore barriers to prenatal care as viewed by Marshallese women. Research question 1: How knowledgeable are Marshallese women of child-bearing age about opportunities for prenatal care in northwest Arkansas? Research question 2: What environmental factors impact noncompliance (e.g. money, transportation, etc)?

17 Aim 3 Aim 3: Identify ways to improve Marshallese women’s experience with prenatal care. Research question 1: What suggestions to improve prenatal compliance do Marshallese women have? Research question 2: What measures by health care professionals and institutions do Marshallese women identify would promote a better prenatal experience?

18 Sample Qualifications for participation in the study: Female
Marshallese ethnicity Between the ages of (child-bearing age) 15 participants ranging in age from 19 to 45 Mean age = years; Standard deviation: years

19 Design An interview was developed based on the health belief model
Accompanied nurse from the Washington County Health Department on Marshallese home visits to interview participants Accompanied member of the Marshallese community associated with the Marshallese consulate to conduct interviews

20 Interview Details Qualitative exploratory interview process
Each interview occurred face-to-face and an interpreter was present for each interview Each interview took about 30 minutes Each participant had her own copy of the interview on which responses were recorded Informed consent was acquired at the beginning of each interview

21 Health Belief Model Individuals will not take action to treat, control, or prevent a health problem unless they perceive that the problem is serious in nature and consequences, that taking action will produce a desired outcome beneficial to them, and that few obstacles exist in taking said action Perceived severity (i.e. the degree to which an individual perceives a condition to be serious) Perceived benefits (i.e. the degree to which an individual believes that an action will have an outcome that is personally beneficial) Perceived barriers (i.e. the degree to which negative features of an action deter an individual from compliance) Components: Perceived susceptibility (i.e. the degree to which an individual feels personally susceptible to developing a particular condition) Other variables and cues to action (e.g. demographic, socio- psychological, and structural variables)

22 Interview Breakdown 43 questions
13 questions involved demographic inquiries (e.g. age, time lived in United States, number of children, etc.) 10 questions were related to potential barriers to receiving prenatal care (e.g. transportation, money, etc.) 12 questions were related to prenatal health beliefs: 2 questions addressed perceived susceptibility, 4 questions addressed perceived severity, 4 questions addressed perceived benefits, and 2 questions addressed perceived barriers 6 questions involved evaluation of reasons to seek prenatal care 2 questions inviting participants to share other thoughts, experiences, etc. related to prenatal care

23 Approval and Funding Interview approved by Department of Health nurse as well as member of the Marshallese community University of Arkansas Institutional Review Board (IRB) approval Experimental Program to Stimulate Competitive Research (EPSCoR) grant funding

24 Data Analysis Mean, median, standard deviation, and frequencies were performed on all of the data to assess for initial patterns and trends Non-parametric correlation test utilizing Spearman rho was done to identify significant relationships between data Some items asked the same question in different ways, so variables were combined. Reliability analysis was run for each combination

25 Time Spent in the U.S. Ranged from one month to 360 months (30 years)(M=91.27, SD= ) The longer one spends in the country, the less likely it is that the pregnancy was planned (p<0.023) The more time spent in the U.S., the less likely it is to be afraid to talk to strangers, especially male doctors (p<0.004) Many participants said that they would be willing to go to a foreign male doctor, but not a Marshallese male doctor

26 Atoll Distribution The majority of participants were from Majuro

27 Health Insurance 46.7% (n=7) of participants do not have any form of health insurance. Of the 53.3% (n=8) who do have health insurance, 50%(n=4) identified themselves as possessing public insurance (e.g. Medicaid) whereas the other 50% (n=4) possess private insurance (e.g. through job or spouse’s job). The more children one has, the more likely that the individual will have some sort of health insurance (p<0.009)

28 Number of Children The number of children per participant ranged from 1 to 7 (M=4.07, SD=1.831). The incidence of adoption among participants can be seen in Table 2. Only one participant had any children die. The more children one has, the less likely to be afraid of seeing a male doctor (p<0.043)

29 Number of Prenatal Visits
100% (n=3) of participants who did not receive any prenatal care had a problem during delivery (p<0.009) In 2005, 34% of Marshallese women received no prenatal care

30 Prenatal Care Locations
More research needs to be done to determine why participants chose the location that they did.

31 Problems During Pregnancy
20% (n=3) of participants admitted to having a problem during pregnancy. Complications identified: urinary tract infection, renal issues, diabetes mellitus, and baby in breech position (Caesarean-section necessitated upon delivery)

32 Complications During Delivery
26.7%(n=4) of participants conceded to having complications during delivery. Problems during delivery included: Caesarean-section (n=2, 13.3%), cord wrapping around baby’s head (n=1, 6.7%), and baby being born prematurely (n=1, 6.7%). 100%(n=4) of participants who had a problem during delivery strongly agreed (rated as 5) that they were afraid of the medical exam in the barrier portion of the interview

33 Incidence of Regular Health Care Providers
80%(n=12) of participants do not see a doctor or health care provider for regular check ups This correlates to two Marshallese health beliefs: the absence of pain indicates that they are healthy, and the focus on the present with little notion of preventative health care

34 Incidence of Planned Pregnancy
20%(n=3) of participants’ most recent pregnancy was planned. This could be attributed to a cultural/religious belief or a lack of awareness about family planning. More research could be done to ascertain the reason why women do not plan pregnancies

35 Methods of Confirming Pregnancy
80%(n=12) confirmed themselves as pregnant 20%(n=3) of participants confirmed their most recent pregnancy by going to a doctor or health clinic, 20%(n=3) by experiencing nausea/morning sickness, 33.3%(n=5) by missing a menstrual cycle, and 26.7%(n=4) claimed they “knew” they were pregnant. Potentially dangerous for mother and fetus

36 Evaluation of Barriers to Prenatal Care
Statement 1 2 3 4 5 I couldn’t get an appointment when I wanted one. 11/73.3% 0/0% 4/26.7% I didn’t have enough money or insurance to pay for my visits. 2/13.3% I had no way to get to the clinic or doctor’s office. I couldn’t take time off from work. (n=14) 13/92.9% 1/7.1% I had no one to take care of my children. (n=14) 12/85.7% I have to talk to people I don’t know. 12/80% 1/6.7% I had no problems with previous pregnancies. 3/20% I was afraid of the medical exam. 10/66.7% 5/33.3% I was afraid to see a male doctor. I had a bad experience with prior care. (n=14)

37 Most Common Barriers Top four deterrents to prenatal care were:
No problems with previous pregnancies Fear of the medical exam Difficulty getting an appointment Transportation

38 Health Belief Responses
Questions 1 2 3 4 5 My baby could develop serious health problems if I don’t come for prenatal care. 2/13.3% 0/0% 1/6.7% 11/73.3% I could develop serious health problems if I don’t come for prenatal care. 13/86.7% Prenatal care is important to the health of my baby. 14/93.3% Prenatal care is important to my health during pregnancy. My baby is going to be born without complications whether or not I go to the doctor. 6/40% 3/20% 5/33.3% Going to the doctor improves my baby’s likelihood of survival. 9/60% Going to the doctor has no effect on my baby. 8/53.3% 1.6.7% Certain illnesses can be prevented by seeking prenatal care. It will be easy for me to keep my prenatal appointments. 3/13.3% It will not be easy for me to go to the doctor for prenatal care. Whenever I’m ill, no matter how mild the symptoms, I take it seriously. 7/46.7% 4/26.7% Whenever my baby is ill, no matter how mild the symptoms, I take it seriously. 10/66.7%

39 Health Belief Trends Results in the context of the health belief model: 83.4%(n=12.5) perceived susceptibility for themselves and their baby 90%(n=13.5) perceived the benefits of prenatal care 56.7%(n=8.5) perceived severity 73.2% perceived no barriers Based on these numbers, it is important to focus on: Increasing awareness of severity by specifying consequences of the risk and the condition Removing identified barriers

40 Evaluation of Reasons for Seeking Prenatal Care
Reason for Seeking Prenatal Care 1 2 3 4 5 I get to meet other pregnant women. 6/46.2% 2/15.4% 1/7.7% I learn about changes in my body. 0/0% 12/92.3% I learn how my baby is doing. 13/100% I get to talk with someone about my pregnancy. 7/53.8% 4/30.8% I learn better health habits, such as better eating and exercise. I learn about the labor and delivery process. 5/38.5%

41 Most and Least Important Reasons for Seeking Prenatal Care
Top reasons for seeking prenatal care: Learning how the fetus is doing, learning better health habits, and learning about changes in the mother’s body Less important reasons for seeking prenatal care: Being able to talk about pregnancy Learning about labor and delivery process (if multipara)

42 Future Prenatal Care All participants said that they would seek prenatal care in the future The reasons given were as follows: 26.7%(n=4) gave no reason, 40%(n=6), claimed that it was best for the baby’s health, and 33.3%(n=5) stated that it was necessary for both mother and baby’s health

43 Comments on Prenatal Care
“Prenatal care is too expensive in the United States.” “Nurses can be rude and racist. I felt very judged and uncomfortable.” “Put God first because He can take care of all of your health needs.” “Someone made an error when they were closing up my belly after my C-section.”

44 Limitations Small sample size
Interviews conducted by members of the health care community Use of translators

45 Implications for Further Research
Expand to larger sample size Compare health beliefs with other immigrants in northwest Arkansas Compare results with other Marshallese populations Reason behind choice of prenatal care location Reason why do not have a regular health care provider

46 Acknowledgments Sandy Hainline and the Washington County Health Department Melisa Laelan Dr. Marianne Neighbors and the Eleanor Mann School of Nursing Ling Ting from the University of Arkansas Marshallese community

47 References Bronstein, J., Lomatsch, C., Fletcher, D., Wooten, T., Lin, T. M., Nugent, R., & Lowery, C. (2009). Issues and biases in matching medicaid pregnancy episodes to vital records data: The arkansas experience. Maternal & Child Health Journal, 13(2), Ceballos, M., & Palloni, A. (2010). Maternal and infant health of mexican immigrants in the USA: The effects of acculturation, duration, and selective return migration. Ethnicity & Health, 15(4), doi: / Chakrabarti, R. (2010). Therapeutic networks of pregnancy care: Bengali immigrant women in new york city. Social Science & Medicine, 71(2), Choi, J. Y. (2008). Seeking health care: Marshallese migrants in hawai'i. Ethnicity & Health, 13(1), Choi, J. Y. (2009). Contextual effects on health care access among immigrants: Lessons from three ethnic communities in hawaii. Social Science & Medicine, 69(8), CIA - The World Factbook. (2011). Central Intelligence Agency. Retrieved March 15, 2011, from

48 References Cont’d Elo, I. T., & Culhane, J. F. (2010). Variations in health and health behaviors by nativity among pregnant black women in philadelphia. American Journal of Public Health, 100(11), Dawkins, C., Ervin, N., Weissfel, L., & Yan, A. (1988). Health orientation, beliefs, and use of health services among minority, high-risk expectant mothers. Public Health Nursing, 5(1), Retrieved April 19, 2009, from CINAHL. Fischer, Gayle (2007). Investigation of Perinatal Hepatitis B Virus Infections among Marshall Islanders Living in Washington County, Arkansas. (pp. 1-16, Rep.). Grewal, S. K., Bhagat, R., & Balneaves, L. G. (2008). Perinatal beliefs and practices of immigrant punjabi women living in canada. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 37(3), Human capital, resources, and healthy childbearing for mexican women in a new destination immigrant community. (2010). Journal of Transcultural Nursing, 21(4), Kartal, A., & Ozsoy, S. A. (2007). Validity and reliability study of the Turkish version of Health Belief Model Scale in diabetic patients. International Journal of Nursing Studies, 44,

49 References Cont’d Lin, M., Shieh, C., & Wang, H. (2008). Comparison between pregnant southeast Asian immigrant and Taiwanese women in terms of pregnancy knowledge, attitude toward pregnancy, medical service experiences and prenatal care behaviors. Journal of nursing research, 16(2), Retrieved April 22, 2009, from CINAHL. Lippe, J., Brener, N., Kann, L., Kinchen, S., Harris, W. A., McManus, T., & Speicher, N. (2008). Youth risk behavior surveillance -- pacific island united states territories, MMWR Surveillance Summaries, 57(-12), Loue, S., Cooper, M., & Lloyd, L. S. (2005). Welfare and immigration reform and use of prenatal care among women of mexican ethnicity in san diego, california. Journal of Immigrant Health, 7(1), McLafferty, S., & Grady, S. (2005). Immigration and geographic access to prenatal clinics in brooklyn, NY: A geographic information systems analysis. American Journal of Public Health, 95(4), Mikhail, B. I. (1999). Perceived impediments to prenatal care among low-income women. Western journal of nursing research, 21(3), Retrieved April 20, 2009, from CINAHL. Perreira, K. M., & Cortes, K. E. (2006). Race/ethnicity and nativity differences in alcohol and tobacco use during pregnancy. American Journal of Public Health, 96(9),

50 References Cont’d Raube, K., Handler, A., & Rosenberg, D. (1998). Measuring satisfaction among low-income women: a prenatal care questionnaire. Maternal and child health journal, 2(1), Reitmanova, S., & Gustafson, D. L. (2008). " They can't understand it": Maternity health and care needs of immigrant muslim women in st. john's, newfoundland. Maternal & Child Health Journal, 12(1), RMI Homepage. (2005). Retrieved February 28, 2011, from Schempf, A. H., Mendola, P., Hamilton, B. E., Hayes, D. K., & Makuc, D. M. (2010). Perinatal outcomes for asian, native hawaiian, and other pacific islander mothers of single and multiple race/ethnicity: California and hawaii, American Journal of Public Health, 100(5), doi: /AJPH Stout, A. E. (1997). Prenatal Care for Low-Income Women and the Health Belief Model: A New Beginning. Journal of Community Health Nursing, 14(3), Suzuki, K., Motohashi, Y., & Kaneko, Y. (2006). Factors associated with the reproductive health risk behavior of high school students in the republic of the marshall islands. Journal of School Health, 76(4), Teagle, S. E., & Brindis, C. D. (1998). Perceptions of motivators and barriers to public prenatal care among first-time and follow-up adolescent patients and their providers. Maternal & Child Health Journal, 2(1),

51 References Cont’d Voetsch, D., & Chideya, S. (2006). Epi-Aid # Final Trip Report: Investigation of the public health burden of certain reportable diseases (tuberculosis, Hansen's disease, syphilis, perinatal hepatitis B, and HIV) among Marshall Islanders-Northwest Arkansas (pp. 1-38, Rep.). Weeks, S. (2007). Summary of CDC Epi-Aid Findings & Recommendations, plus Attachments (pp. 1-6, Rep.). Williams, D., & Hampton, A. (2005). Barriers to health services perceived by Marshallese immigrants. Journal of Immigrant Health, 7(4), Retrieved March 22, 2009, from CINAHL.

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