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Attitudes of Marshallese Women Toward and Barriers to Prenatal Care

Attitudes of Marshallese Women Toward and Barriers to Prenatal Care. Emily Starr, BSN . What is Prenatal Care?. Prenatal care: any health care given to a pregnant woman after conception and before birth.

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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 10-14 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:-5.19 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; 8-12 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 • Physical lack of land • Population explosion • Poor economy • Employment opportunities in U.S. • Better health care • Better educational opportunities for children • Family members living 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 1000 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 18-45 (child-bearing age) • 15 participants ranging in age from 19 to 45 • Mean age = 33.13 years; Standard deviation: 7.298 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 • Components: • Perceived susceptibility (i.e. the degree to which an individual feels personally susceptible to developing a particular condition) • 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) • 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=101.321) • 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

  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

  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

  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), 250-259. • 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), 377-396. doi:10.1080/13557858.2010.481329 • Chakrabarti, R. (2010). Therapeutic networks of pregnancy care: Bengali immigrant women in new york city. Social Science & Medicine, 71(2), 362-369. • Choi, J. Y. (2008). Seeking health care: Marshallese migrants in hawai'i. Ethnicity & Health, 13(1), 73-92. • Choi, J. Y. (2009). Contextual effects on health care access among immigrants: Lessons from three ethnic communities in hawaii. Social Science & Medicine, 69(8), 1261-1271. • CIA - The World Factbook. (2011). Central Intelligence Agency. Retrieved March 15, 2011, from https://www.cia.gov/library/publications/the-world-factbook/

  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), 2185-2192. • 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), 7-11. 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), 290-300. • Human capital, resources, and healthy childbearing for mexican women in a new destination immigrant community. (2010). Journal of Transcultural Nursing, 21(4), 332-341 • 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, 1447-1458

  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), 97-107. 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, 2007. MMWR Surveillance Summaries, 57(-12), 28-56. • 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), 37-44. • 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), 638-640. • Mikhail, B. I. (1999). Perceived impediments to prenatal care among low-income women. Western journal of nursing research, 21(3), 335-350. 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), 1629-1636.

  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), 25-33. • 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), 101-111. • RMI Homepage. (2005). Retrieved February 28, 2011, from http://www.rmiembassyus.org/index.htm • 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, 2003-2005. American Journal of Public Health, 100(5), 877-887. doi:10.2105/AJPH.2009.177345 • 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), 169-180. • 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), 138-144 • 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), 15-24.

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