Process Description

 

Introduction

 Maternal Child Health Bureau (MCHB) is a division of the Human Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services. MCHB awardees include all states, territories and freely associated states. The American Samoa MCH Title V Program is part of the American Samoa Department of Health. Each year, MCH awardees like American Samoa submit an Annual Report from the previous fiscal year and Application for the next fiscal year. In addition, MCHB awardees are mandated by law (Section 505a of the Title V Social Security Act) to submit a Comprehensive Needs Assessment every 5 years. The last MCH Title V Needs Assessment was submitted by awardees in 2015, and therefore the next MCH Title V Needs Assessment is due in 2020.

 

Goals

 The American Samoa MCH Title V Needs Assessment was based on the following goals: review MCH population needs, examine capacity to address needs, identify MCH priorities, develop strategies to address priorities, select measures to monitor progress and set targets. Each MCH Title V Program is divided into 5 main MCH population domains: Women/Maternal Health, Perinatal/Infant Health, Child Health, Adolescent Health, and Children with Special Healthcare Needs (CSHCN). Needs for each of the MCH population domains were

reviewed in the AS MCH Title V Needs Assessment. American Samoa’s island wide capacity was then examined if it will be able to fully address needs of the MCH population domains reviewed. Since each MCH Title V awardee were limited to 7-10 priorities, needs for the MCH population were identified and selected as priorities for the upcoming 5-year cycle. Once the MCH priorities were determined, strategies to address MCH priorities were developed. Measures from the National Performance Measure (NPM) Framework was selected to monitor the progress when addressing MCH priorities. Finally, targets were set and activities were identified to accomplish targets.

 

Framework

 The MCH Block Grant Needs Assessment Conceptual Framework in addition to the Association of Maternal and Child Health Program (AMCHP) MCH Needs Assessment Toolkit were utilized to conduct the AS Title V Needs Assessment. The MCH Title V Block Grant Conceptual Framework was a 9-step process which served as a checklist during the ongoing Needs Assessment process. Steps of the MCH Conceptual Framework in no particular order were as follows: engage stakeholders, assess needs and identify outcomes, examine strengths and capacity, select priorities, set performance objectives, develop action plan, seek and allocate resources, monitor progress and report back to stakeholders. The AMCHP MCH Needs Assessment Toolkit included ready, set and go resources. The Ready resources provided an overview of the MCH Title V Needs Assessment. The Set resources provided details for the MCH Title V Needs Assessment Conceptual Framework. The Go resources provided examples from states and jurisdictions for the need’s assessment.

 

Stakeholder involvement

Ideally, the MCH program planned to meet at least 4 times a year to discuss priority needs. But this past year was a little different due to the measles outbreak. Although meetings were canceled, we still worked together with our stakeholders to try and keep American Samoa measles free. We partnered up with DOE and LBJ to help get all the children and adults vaccinated. It was a coordinated effort that although we had 16 confirmed cases on island, we had no deaths. Our stakeholders met and worked together to come up with ways to help get everyone vaccinated. We did however manage to meet with them individually. We interviewed them and we put all the information we collected. Thankfully, we were able to host one meeting with everyone and presented our findings. We prioritized our needs for each population domain and everyone was excited to see what the MCH program will do for the next 5 years.                                                                                                                                            

 

Quantitative & Qualitative Methods

 The State System Development Initiative (SSDI) Jurisdiction Minimum Dataset was a method used by the AS MCH Title V program to provide quantitative data on selecting priorities for the AS MCH population domains. The SSDI dataset included the following indicators: teen pregnancy (15-19 years), low birth weights (<1500 grams and 2500 grams) , preterm births (<32 weeks and <37 weeks gestation), infant mortality (< 1 year), child mortality (1-9 years), adolescent mortality (10-19 years), adolescent suicide (15- 19 years), breastfeeding (ever breastfed and exclusive), risk behavior (female chlamydia 15-19 years), CSHCN with adequate insurance, immunization (full schedule for 19-35 months),  and WIC BMI (2-4 years overweight and obese).

Qualitative methods utilized for the MCH Title V Needs Assessment were key informant interviews, focus groups and a stakeholder meeting. Since the MCH Title V Program and the Maternal Infant Early Childhood Home Visiting (MIECHV) Program share most of the same stakeholders, key informant interviews and focus groups for both needs assessments were conducted together. For the key informant interviews, each stakeholder was interviewed individually so they would be confident in expressing needs and gaps in each of the MCH population domains to be addressed in the next 5-year cycle. Focus groups were conducted by MCH population domains: women/maternal health, perinatal/infant health, child health, adolescent health and CSHCN. Information collected from the key informant interviews were grouped together as talking points for the focus groups. The overall stakeholder’s meeting was the final part of the qualitative method for the MCH Title V Needs Assessment, where stakeholders came together and discussed as whole priorities to be set for the MCH population of American Samoa.

 

Data sources

 

SILAS: Share Integrate Link American Samoa

SILAS is a registry that Helping Hands, Part C and Helping Babies hear program use to store and share data with other partners within the Department of Health. It includes family demographics, where they live, contact information, program progress notes and so much more. MCH was able to partner up with the Helping Babies Hear (HBH) program to get a correct count of all the babies born every year. MCH used to go to the nursery to collect this data, but after learning we are collecting the same information, it was more ideal for HBH to collect this data to eliminate the duplication of work. Information such as hospital number, weight, height, mother of the baby, hearing test results etc. are collected and is given to the MCH epidemiologist to clean and analyze for program reports.

 

Postpartum & Newborn Kotelchuck cards

Postpartum & Newborn Kotelchuck cards are collected by the MCH health educators from the Nursery and the maternity clinic. These cards consist the newborns, spontaneous abortions and stillbirths outside and inside the hospital. All information regarding the newborn and mother are included. From demographics to gestational age to breastfeeding, all that information is on the cards. And just like the data from SILAS, all the information is downloaded and given to the MCH epidemiologist to analyze and cross check with the data from SILAS to see if there is any missing information. 

 

DHSS Women, Infants and Children WIC program

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC), is a federally funded program which provides American Samoa residents with nourishing supplemental foods, nutrition education, breastfeeding promotion and health and social service referrals. The participants of WIC are either pregnant, breastfeeding, or postpartum women, infants or children under age five who meet income guidelines and have a medical or nutritional risk. MCH mainly uses this data to check for breastfeeding data. Every year, we collaborate with the WIC program to promote breastfeeding and in return we share information that both programs have collected throughout the year regarding breastfeeding.

 

WEBIZ: American Samoa Immunization Registry

WEBIZ is a web-based data system that stores information regarding every person’s immunizations records. MCH uses data from WebIz to see how many children are up to date with their immunizations and what percentage of kids that still need their immunizations shots updated. With the recent measles outbreak, having this web-based system made it easy for nurses and doctors to keep track of shots given and how many more shots needed. Our MCH epi was able to spearhead the measles outbreak surveillance and having this web-based system made it easy for everyone to dump this information. She then analyzed the disseminated information to our leader so they can make more informed decisions.

 

Youth Risk Behavior Surveillance System (YRBSS)

Youth the Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of health-related behaviors that contribute to the leading causes of death and disability among youth and adults. Behaviors that contribute to unintentional injuries and violence, STDs, unhealthy eating habits etc. This survey is self-reported and all information is recorded and shared with the MCH epi to analyze and report on its findings. It can be a national school-based or local survey conducted by state, territory and local education and health agencies and tribal governments.

 

NVSS: National Vital Statistics System

The NVSS provides the most complete data on births and deaths in the US and its territories.  Birth data helps track important demographics and health trends. Deaths data are helpful because it collects the most comprehensive information such as the causes of death. Fetal Deaths data can help identify pregnancy risks and improve the health of mothers and babies. This data is mandated by Federal law to be reported each year. The MCH epi analyzes this data and informs the leaders on what MCH should focus on the coming year and make that a priority.

 

 

 

 

MCH Population Health Status

 

Women/Maternal Health

 

a. Summary of strength

During 2015-2019, the percentage of pregnant women giving birth annually decreased by 25%. The number of females in the reproductive/child-bearing age group (ages 18-44) was 9496 representing 18.9% of the total population in 2019.

 

Another strength identified during the Needs Assessment are availability of preventive health services women can access. They include the following:

 

• DOH Women’s Clinic (Tafuna, Leone, Amouli)
• Breast and Cervical Cancer Screening
• HIV/STD Screening
• CHC Primary Care Clinics to screen for Non-Communiable Diseases
• WIC services
• LBJ Hospital OBGYN
• Title X Family Planning and CHC Family Planning
• American Samoa Alliance against Domestic & Sexual Violence
• Pae ma le Auli
• Catholic Social Services
• Women Faith-based Organizations
• Village Tinifu

b. Health Priority 1: Women should have access to and receive coordinated, comprehensive services before, during and after pregnancy.

According to the recent 2018 American Samoa Adult Hybrid Survey, 54.8% of adults self- reported that they received a medical check-up in the past year. Compared to the national rate of 70.4%, American Samoa’s adult population perspective of prioritizing annual wellness visits is very poor. Chronic conditions continue to be very high among the adult population despite reporting a decreased rate of smoking, alcohol use and eating more fruits and vegetables compared to the American Samoa STEPS NCD Survey back in 2004. Overweight and Obesity remains prevalent among adults, with 82.7% of women ages 18 and older are obese (Figure 5). 

 

In the 2019 ASMCH Jurisdictional Survey, 47% of women received a medical check-up in the last year. This percentage is even lower compared to the Hybrid Survey.

 

American Samoa’s Title V first health priority was generated based on the top three health priorities identified for Women/Maternal Health Population. They were:

 

1. Provider shortage & competencies

 

Clinic	Tafuna CHC	Leone CHC	Amouli CHC*	LBJ OBGYN	Manu’a Clinics
No. of Providers	1 Physician	1 MCH PN*	1 MCH PN*	7 Physicians	0 Prenatal Provider
Dates Clinic is done	Monday - Friday	Wednesdays Only	Thursdays Only	Monday - Friday	N/A

*  Same MCH PN serving both Leone and Amouli.

 

2. Utilization of medical and mental services are lacking 
   • NCD (include weight management) and STD Screening 
   • Preconception Health
   • Domestic violence (positive marriage counseling)
   • Healthy relationships (mental health)  

 

3. Decrease in accessing early prenatal care 

 

 

 

 

 

According to CHC UDS, there is an increase in women who begins prenatal care at first trimester from year 2017 to 2019. There are also more pregnant women coming in at first trimester compared to second and third.

 

This findings from ASCHC UDS contradicts data collected from Maternity Ward Postpartum Cards. There is an obvious decrease in the percentage of pregnant women beginning their prenatal care in their first trimester by 1.8%, from 37.7% in 2017 to 35.9% in 2019. Compared to the 77% at the national level, this is very low. Compared to other USAPI, it's still low, with Guam at 70% and CNMI at 45%.

 

Regardless of the differences in percentages it is still low in comparison to the national rates.

 

2.   Challenges and gaps

During focus groups and key-informant interviews, some of the challenges and gaps identified were:

• Lack of qualified, medical providers at women’s clinics that can do both Obstetrics and Gynecology at DOH. Both providers at DOH see low risk pregnant women. One does Gynecology only while the other does both. Current ultrasound machine is not working so all women are send to LBJ for this purpose and to determine Expected Due Date etc.
• Low rates of women receiving an annual medical check-up
• Lack of empathy and good communication skills between providers and patients
• Ultrasounds not available for pregnant women at women’s clinic at DOH
• Lack of committed provider for BCCP, STI and TB. Nurse can screen but cannot diagnose and consult.
• Only Tafuna Women’s Clinic provide routine STD screening at pregnancy. LBJ only screen for Chlamydia if under 21 and a pap smear at 21 and over.

 

3.    Current efforts to address health needs
   • The primary care provider for Women’s Clinic at Tafuna CHC has been stranded in Fiji. MCH Nurse Practitioner Tele Hill stepped in to serve these women but then is not consistent with seeing pregnant women at Leone. Amouli clinic has been closed for more than nine months. Pregnant women who reside in far East villages have to seek care at the LBJ Hospital OBGYN clinic.
   • Health promotions utilizing social media are ongoing. DOH programs utilizes community outreach education and health fairs (CHC Week, Breastfeeding Week, Immunization Outreach etc.) to promote available services for women.
   • Daily radio PSA are ongoing, informing the public of COVID-related preventive measures and clinics open to serve the community.
   • CHC continue to provide after-hour clinics on Tuesdays and Thursdays from 4pm to 8pm to boost STD, BCC and Non-Communicable Disease screening, monitoring, management and referrals.

 

4.   Opportunities for improvement

• Collaborate with all Prenatal Providers and supporting programs (BCCP, MEICHV, NCD, Intersections Inc., WIC, CHC Primary Care Providers) to promote early prenatal care services.
• Provide public service announcement videos and mass media campaign to promote pregnant women seeking early prenatal care.
• Ensure all health education materials and resources (Becoming a Mom curriculum) are translated appropriately and standardized across all prenatal clinics.
• Ensure all clients understand each session by having a pre and post-test to evaluate efficacy of the materials.
• Have appropriate handouts or reminders of each health education topic.
• Utilize peer groups, social media and social networks for women (village Tinifu and church groups) to promote and support, Breast and Cervical Cancer screening program.
• Formulate and disseminate a women check-up passport to improve tracking and monitoring of age appropriate visits and screening appointments.
• Implement Women’s Health week promotion in the month of May to promote preventive screenings.
• Partnering with promising fitness centers such as Slimmer Stronger You to promote behavioral change; polynerian diet (plant-based diet with or without lean meat); weight management; cholesterol, glucose and blood pressure monitoring.
• Maternal and postpartum depression can be done at Women’s Health, Well Child and Primary Care Clinics.

 

Perinatal/Infant Health 

 

a. Summary of strengths

Preterm births have gradually decreased in the past 6 years, from 9.14 per 1000 livebirths in 2014 to 5.92 per 1000 livebirths in 2019. Number of pregnant women have also been decreasing in the past five years. Approximately 80% of babies are born with normal weight and only 4% are born with low birth weight. Federal assistance has made it possible for pregnant women and infants to thrive, including nutritional assistance from WIC, free prenatal and well-baby check-ups. These strengths are mainly due to current collaborative efforts between DOH, LBJ Hospital, WIC and Medicaid to promote favorable birth outcomes and thriving babies in American Samoa.

 

b. Health Needs

Health Priority 3: Families are empowered to make educated choices about infant health and well-being.

 

Having families make appropriate healthy choices are critical to favorable birth outcomes and healthy babies. Empowering mothers to make informed decisions not only with improving health literacy but also promoting a healthy supportive environment is also important. Promoting proper nutrition, both during pregnancy and after pregnancy for both mom and baby are equally important. Providing and promoting educational resources for women and families to make informed decisions in taking care of their health and wellbeing are crucial.

 

Health Priority 4: Establish a Newborn Metabolic Screening Program in American Samoa

American Samoa is the only US Territory without a newborn metabolic screening. Babies born with congenital and metabolic disorders are not obvious most of the time until they are tested at birth and treated early. In American Samoa, routine newborn screening is not done at birth unless there is an obvious indication to do so. During stakeholders’ meeting, there was an unanimous consensus that it was time to focus our collaborative efforts in mandating and implementing a Newborn Metabolic Screening in American Samoa. Despite the odds in the past with lack of funding, manpower laboratory equipment, by forming a NMS Taskforce with is endorsed at the territorial level with legislature back-up, it can become a reality.

c. Challenges and gaps

 

During focus groups and key-informant interviews, some of the challenges and gaps identified were:

1. Support Infant Health and Wellbeing:

•      Baby-Friendly Initiative in the hospital is not enforced especially with allowing mommies to give formula to their babies.
•      Breastfeeding Coalition do not regularly meet to discuss annual goals and objectives
•      Not all work places promote favorable working environment to support breastfeeding
•      There is no legislation to mandate paid maternity leave for all working postpartum mothers

 

2. Newborn Metabolic Screening:

• No law to regulate the hospital to provide newborn metabolic screening
• No funding locally earmarked for metabolic screening
• No federal funding available for newborn screening
• Local laboratories are not equipped. Nearby Hawaii do not test their own blood samples, but mail their samples to a laboratory in Oregon. It will definitely be a challenge to identify a laboratory who is willing to test our samples outside of American Samoa.
• Environmental

 

4. Current efforts to address health needs
   •       Promote Infant Health and Wellbeing

• MCH Health Educators providing BF tips, reminders and support at Prenatal clinics and Maternity Ward
• Labor and Delivery nurses and providers support placing infants on mommy’s chest to initiate BF within one hour of life
• WIC peer counselors continue to provide counseling and assistance through the BF Warmline
• Breast pumps and other aiding tools are distributed at WIC offices
• WIC nutritional assistance package for postpartum moms are more than those for non-breastfeeding moms.
• Public service announcements on the radio and local tv talk-shows throughout and during breastfeeding week in the month of August.
• Women’s and Pediatric clinics Promote the BF Executive Order Policy for all government agencies by issuing BF certificates for moms to take the two hours off during working days up to 6 months to promote breastfeed.
• Hospital Labor and Delivery staff policy include initiate breastfeeding within one hour of birth unless unable to do so
• Hospital promote mommies rooming with babies

 

• Newborn Metabolic Screening

All MCH partners including Pediatricians and Laboratory mangers agree that this will be the new focus for the next five years, establishing Newborn Metabolic Screening in American Samoa.

 

5. Opportunities for improvement

 

•      Promote Infant Health and Wellbeing

• Revise Baby-Friendly Initiative policies in the hospital and enforce no Baby Formula unless medically indicated
• Breastfeeding Coalition regularly meet to discuss annual goals and objectives
• Promote favorable working environment in the workplaces to support breastfeeding
• Legislate paid maternity leave for all working postpartum mothers
  • Finesse all mass media campaign to promote uniformity, literacy and culture sensitivity.

 

• For the next five years, MCH Title V will initiate a Newborn Screening Taskforce to:

• Generate a strategic plan for implementing Newborn Screening
• Introduce to legislature a bill and budget for approval
• Engage buy-in of a qualified laboratory locally or off-island
• Train providers, local laboratory staff, care coordinators, Medicaid and billing staff
• Promote community awareness
• Advocate and enforce Implementation of newborn screening at birth
• Ensure policies in place also include referral for treatment in a timely manner once diagnosis is made.

Child Health 

 

a. Summary of Strengths

High immunization coverage of routine vaccinations like the measles, mumps and rubella (MMR) is a strength for the child health MCH population domain in American Samoa. This was evident during the recent measles outbreak in American Samoa from November 2019 to March 2020. The 1st MMR dose for school age children (both public and private schools) and children in childcare services at 12 months and older, was estimated to be at 99.5%. In addition, 2nd MMR dose coverage for the same group was estimated to be at 99.5%. For the measles outbreak situation in American Samoa, a total of 16 laboratory confirmed measles cases and 0 deaths were recorded. However, the measles outbreak situation in neighboring Samoa was unfortunate. A total of 5,707 measles cases and 83 deaths (~80% among children less than age 5 years) was documented. WHO and UNICEF estimated MMR coverage in Samoa among young children to dramatically decrease from 74% in 2017 to 34% in 2018. The low MMR vaccination coverage in 2018 is largely attributed to the deaths of 2 infants who were mistakenly injected with the wrong MMR vaccine mixture.

 

b. Health Priority Needs

 

Developmental Screening

Ages and stages questionnaire (ASQ) is a developmental screening tool that will be utilized for the child MCH population domain. Specifically, ASQs for the following child ages: 14 months, 16 months, 18 months, 20 months, 22 months, 24 months, 27 months, 30 months, 33 months, 36 months, 42 months, 48 months and 54 months will be utilized. Most of the above ASQs for child health are conducted around the time a child is due for a vaccine. ASQs are easy to use and have a parent centered approach. Studies have shown consistently that when development of a child is assessed is early on, there is an increase chance of the child to reach his or her full potential.

 

Oral Health

Data from the 2019 ASDOH Basic Oral Screening for school children (Grade 1-3) in public schools, strongly suggest oral health to be a priority for the child MCH population domain. When compared to US National data, American Samoa school children had a much higher number of decay and a significantly lower number of dental sealants. About 80% of AS school children had a decay experience compared to about 50% of US school children. For untreated decay, about 75% of AS school children had evidence of it compared to about 15% of US school children. The high occurrence of decay, mostly untreated may be due to the low number of AS school children with dental sealants at about 5% compared to about 40% in US school children.

 

Obesity

The high prevalence of obesity in American Samoa has been well documented. The recent population based, Adult Hybrid Survey (2018) has noted a significantly high prevalence of obesity (BMI of 30 or higher) of about 80% among adults in American Samoa. Furthermore, BMI data from the local WIC program have strongly suggest a continued increase of obesity in children (2 to 4 years) of American Samoa (~17% in 2014 to ~19% in 2016).

 

c. Challenges and gaps

 

Developmental Screening

The wide implementation of developmental screening tools like the ASQ-3 questionnaires to children of the MCH child health population domain (>1 year to 9 years) is fairly new in American Samoa. Early Intervention Programs like Part C is one of the few programs locally who are able to perform ASQ tools consistently and at appropriate ages. However, the Part C Early Intervention Program is limited to perform appropriate ASQs on children up to age 3 years and are eligible for their program, children with a developmental delay.

 

Oral Health

The MCH Title V Program does not have a full-time dentist. A full-time dentist of the Community Health Center currently leads the one team to conduct Basic Oral Screening for schoolchildren. In addition, there have been several competing public health campaigns like elimination of neglected tropical diseases like the lymphatic filariasis and immunization campaigns like the MCV, HPV, Tdap and MMR vaccines.

 

Obesity

Nutrient deficient processed foods and drinks are easily accessed by children. Processed foods and drinks are cheap and are also conveniently accessed by children and their families. Most grocery stores locally have a much larger inventory of processed foods and drinks compared to nutrient dense whole foods.

 

d. Current efforts to address health needs

 

Developmental Screening

ASQ-3 questionnaires were first introduced to MCH Zika Client Navigators in mid-2019. Therefore, most children part of the MCH Zika Program have passed the age to conduct most of the ASQ-3 questionnaires. In addition, some Community Health Center providers for children have begun to use the ASQ-3 developmental screening tools in early 2020. However, the use of ASQ-3 questionnaires by both MCH Zika Client Navigators and CHC children providers has been inconsistent.

 

Oral Health

There is only one dental team which consists of a dentist and dental assistant performing Basic Screening Survey in school children. Due to the limited staff, BSS is limited to school children grade 1 to 3 in public schools.

 

Obesity

There are very few programs in American Samoa who are addressing the obesity problem in the territory. School sports are not available to school children until they reach the age of 10 years. Private leagues for sports like baseball and soccer are only available at least once a year.  A set physical education (PE) and proper nutrition curriculum is not part of the public-school system in American Samoa.

 

e. Opportunities for improvement

 

Developmental Screening

Early developmental screening is important to the growth of a child. It is pertinent that we are able to identify a developmental delay of a child early on so the appropriate interventions are implemented in a timely manner. Therefore, developmental screening at appropriate ages based on the ASQ-3 screening tool should be mandate by law in American Samoa. High immunization coverage for routine vaccines like MMR is a result of the immunization mandate before a child is enrolled in school both public and private schools.

 

Oral Health

In addition, to developmental screening and immunization, oral health screening should also be a requirement before school enrollment. Oral health is a strong indicator of a child’s overall health. Tooth decay shows a diet high in sugar sweetened foods and beverages, and would suggest the increase likelihood of childhood obesity.

 

Obesity

A standardized and locally relevant PE and nutrition curriculum should be implemented from kindergarten to grade 4. Early intervention for obesity at childhood has been shown in studies to be successful. Standardized PE and nutrition curriculum should follow guidelines from the American Academy of Pediatrics and Center for Disease Control and Prevention.

 

 

Adolescent Health 

 

a. Summary of Strengths

For adolescent health, there have been past and existing infrastructures. The Pacific Island Center for Education Development (PICED) was one of the first programs to address adolescent health specifically through education in the early 2000s. PICED services included college bound courses like standardized testing preparation and college applications. PICED has paved the way for existing adolescent infrastructures like Intersections Inc. However, Intersections Inc. offer a range of services from college preparation courses to addressing behavioral health of adolescents.

 

b. Health Priority Needs

 

Weight management: Obesity

As mentioned previously, obesity is a well-documented problem in American Samoa. According to the Youth Risk Behavior Surveillance System (YRBSS) survey, obesity among adolescent age 14 to 17 years has increased significantly from 35% in 2007 to 45% in 2015. In addition, MCH stakeholders including providers and educators have affirmed this significant change in the weight of adolescents in American Samoa.

 

Reproductive Health

The American Samoa teen birth rate has decreased from 45 births per 1000 population in 2013 to 31 births per 1000 population in 2019. However, US Pacific Island territory like CNMI have a low birth rate of 15 births per 1000 population. The US national average teen birth rate is also much lower at 24 births per 1000 population.

 

Behavioral Health

Bullying and suicide have been shown to be significant behavioral health among adolescents in American Samoa according to the YRBBS data. Adolescents reported bullying on school property has increased from 25% in 2011 to 30% in 2015. Furthermore, there is an increasing number of adolescents who reported to have attempted suicide from 20% in 2007 to 25% in 2015.

 

 

c. Challenges and gaps

 

Weight management: Obesity

Like child health, a standardized and locally relevant PE and Nutrition curriculum is not in place. Therefore, addressing weight management has not been fully addressed.

 

Reproductive Health

Sex or reproductive health education is a taboo subject in communities like American Samoa. There is a common misconception in the community that reproductive health education promotes sexual behaviors among adolescents. Furthermore, American Samoa is a community with significant Christianity influence.

 

Behavioral Health

Mental health is undermined in American Samoa. Emotions and feelings are encouraged to be limited to the individual. Adolescents are not seen at the Well Child Clinic by the Pediatrician for an annual check-up but get their check-up at the Primary Care Clinic which also caters to all age-groups. It is recommended for all age-groups to have a depression/behavioral screening and immediately gets counseling at Tafuna CHC. Unfortunately, not all clients get a mandatory depression screening.

 

d. Current efforts to address health needs

 

Weight management: Obesity

A range of sports like volleyball, soccer, and football are offered from middle school to high school (Grade 5-12). However, spots to play each sport are limited and therefore, not all adolescents are able to participate in sports activities.

 

Reproductive Health

Reproductive health education through Family Planning is only limited to adults and married couple. Young and single individuals like adolescents are discouraged to explore family planning options.

 

Behavioral Health

Current programs for adolescents like Intersections Inc, Boys and Girls Club and Teen Challenge are addressing behavioral health.

 

e. Opportunities for improvement

 

Weight management: Obesity

The standardized and locally relevant PE and Nutrition curriculum should be implemented from child health years up to adolescent years. This implementation must involve the adolescent, family and their communities either church or village. When all parties work together, implementation of the standardized and locally relevant PE and Nutrition curriculum.

Reproductive Health

 

With existing infrastructures of adolescent health, safe and open conversations about sex education can occur. The approach is to not promote sex but raising awareness so that adolescents can have more informed decisions.

 

Behavioral Health

 

Through the same infrastructures for adolescent health, a safe haven and open space to address mental health. Furthermore, trained individuals to maintain the confidentiality in small communities like American Samoa.

 

Children with Special Health Care Needs

 

a. Summary of Strengths

• CSHCN Client Navigator worked alongside with the Zika Client Navigators to share information, ideas and resources to improve services.
• CSHCN Client Navigator schedules appointments and coordinates primary care and dental visits for CSHCN clients at the district health centers.
• Transportation is available to assist clients who may need a ride to and from the clinic.
• The CSHCN Program is benefiting from screening opportunities through the Zika Program. These screenings are for vision and hearing. These screenings are accessible at no cost to the families with free transportation to access these clinics during weekends or after hours.
• The CSHCN continues to partner with the Parents Network of children with Special Needs during the summer months to support a one-week summer camp catered for the specific population.
• CSHCN continues to work closely with Medicaid and the LBJ Hospital to determine what can be sponsored by funding that is available towards durable medical equipment that is much needed by many of the children with special needs, but are too expensive to be purchased by individual families. CSHCN Navigator is the key in this process, to assure that specific health needs are met and supported, and resources are identified with payment guaranteed.
• Client Navigators work closely with Helping Hands Early Intervention Program to refer children for EI if child is eligible, and vice versa.

 

b. Health Priority Needs

• Very low rate of Early Diagnosis and Treatment/Management
• Lack of mandatory Newborn Metabolic Screening in American Samoa
• Lack of specialists in American Samoa

 

c. Challenges and gaps

• Limited resources and specialty care for CSHCN (PT, OT, Speech Therapy, Neurology, etc.)
• There is no current count of CSHCN island wide, so it is still a challenge to develop plans that can service and support this group. The count for children in the school system with an Individualized Education Plan (IEP) includes children who are identified to have a learning disability and not necessarily a developmental disability. Therefore, this number could be an overestimate of the CSHCN population.
• Limited advocacy from families of CSHCN due to lack of understanding pertaining to rights and service that are beneficial to this population.
• Providers may not be comfortable with serving the CSHCN population due to lack of training on specialty care.
• Interagency on disabilities need to be restored and strengthened, to be advocate for people with disabilities, including children.

 

d. Current efforts to address health needs

• Due to the Measles Outbreak and COVID-19, the client navigator can only manage to provide care coordination by conducting daily phone calls to follow up on the client and schedule appointments when needed by the clients.
• The CSHCN Program is collaborating with the newly established Family to Family Health Information Center to increase parent and family participation with the center and to determine advocacy activities that would best fit the needs of families and their CSHCN.
• Currently working with the Leo o Aiga, Family to Family Center to recruit clients to the Dial a Ride program to assist with transportation to and from clinic, WIC, Food Stamp and so forth.

 

e. Opportunities for improvement

• Transition Zika Navigators to work as Care Coordinators for CSHCN to help manage cases and provide care coordination to this population
• Incorporate health care plan (HCP) for family-provider (parent/guardian, primary provider, care coordinator, nurse practitioner)
• Create Standard Operating Procedures (SOPs) on how to implement HCPs and engage families/parents to promote Family/Patient centered care models and preparation for adult transition.
• Offer training for providers on Family/Patient Centered Care.
• Engage LBJ Pediatricians and other specialists with WBC providers in collaborative coordination for CSHCN. Also, a clarification will be needed to improve communications and referral protocols for CSHCN Care Coordinators (Client Navigators) and providers.
• Telehealth options

 

The American Samoa Maternal and Child Health (ASMCH) Program under the Department of Health supports existing health care services in American Samoa that caters to improving the health and wellbeing of women and children, including children and youth with special health care needs. The MCH Title V is currently under the leadership of the Nursing Director, who reports directly to the Director of Public Health as shown in Figure 1. Director of Public Health (ASDOH), Director of Human and Social Services (runs WIC and SNAP) and the Chief Executive Officer of the LBJ Tropical Medical Center Authority all report directly to the Governor of American Samoa.

 

The MCH Program Director, Mrs. Margaret Sesepasara also oversee other programs within ASDOH (Figure 3). This includes MIECHV, Immunization Program, and Nursing Home Visit. Other related programs include Helping Babies Hear (EDHI) and Helping Hands (EI). All these programs meet regularly to discuss referred patients from LBJ and other agencies, streamline goals and objectives to prevent duplication of services and plan annual activities together in collaborative projects. Most Title V direct and enabling services are carried out within the Community Health Centers (Figure 2). MCH Staff consists of a Nurse Practitioner, Registered Nurse, CNA/Health Educators, Dental Assistant, Client Navigators, and Administrators. MCH Title V collaborates with ASCHC to identify gaps in available services and assist in filling those gaps. Majority of these gaps are enabling services such as health education and care coordination. In return, program staff is promoting MCH health priorities and services identified annually through regular Needs Assessments and DOH priorities as a whole.

 

Low risk pregnant women are encouraged to utilize the nearest prenatal clinic within their districts. Low risk pregnancies are women who have no existing chronic condition, Gestational Diabetes, previous cesarean births and other complication in previous pregnancies. Those who live in the central villages (closest to the Hospital), together with all high-risk pregnant women, receive prenatal care at the LBJ Hospital. At 37 weeks, all pregnant women who were served at CHCs are also transferred to the Hospital. MCH provides health education during these visits, appointment reminders and care coordination. All women’s postpartum information is collected and linked to their newborns and their birth information. Pediatrics Department at LBJ Hospital refer all premature babies and newborns with birth defects and syndromes to MCH for care coordination, and continued monitoring.

 

MCH Title V pick up newborn cards from nursery and deliver them to each community health center where each will receive wellness visits and routine immunization. This is also where children should be receiving developmental screening and referral to EI. All preventive, primary care services are provided for the MCH population at the Community Health Center unless they need acute care, then they are referred to LBJ Hospital. All US citizens, permanent residents and foreign pregnant women and children are covered under Medicaid and hence CHC and LBJ Hospital will receive Medicaid reimbursement. All other population who are not US citizens or US Nationals (born in American Samoa) will not be reimbursed by Medicaid. All DOH services are free for all women and children at the Community Health Centers.

 

Family Planning is currently being addressed at LBJ Hospital who is the grantee for Title X, and the Tafuna CHC Women’s Clinic who is funded by the CMS-Zika Supplemental grant. All women are referred to either clinic depending on preference and convenience. Types of contraceptives also determine where to refer women to. LBJ Hospital has a variety of resources and Tafuna only supplies pill contraceptives and condoms.

 

MCH Title V administer and coordinates all funded activities earmarked to accomplish annual State Action Plan. All activities are preapproved by the Program Director and then the Director of Health. MCH Title V also supports public health essential services including monitoring and tracking of all MCH health status across all programs within ASDOH, provides health trends, morbidty and mortality rates. MCH Title V Epidemiologist and SSDI funded Epi Tech are responsible for such Public Health Surveillance. They both work closely with the Territorial Epidemiologist to ensure weekly, monthly and annual reports are send out across ASDOH programs and ASG agencies and any other community organizations that may request for MCH Health Indicators or Measures. Refer to the supporting documents for the various Organizational Charts.

 

Figure 2: American Samoa Community Health Center Organizational Chart

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Public Health Services Systems Model for MCH Populations defines the core functions of Public Health as Assessment, Policy Development and Assurance. 

 

Direct Services:  The Essential Services of Public Health Standard is to Provide Access for Care.  Direct services are preventative, primary or specialty clinical services to MCH populations.  Mrs. Tele Hill(NP) and Dr. Mirella Chipongian are the two Providers for pregnant women, Dr. Faiese Talafu provides the care for children including children with special health care needs, Dr. Raymond Almeda serves children with RHD and Dentist Inoke Siasau provides dental care for children at all ages.  The services are not limited to preventive, primary or specialty care visits, urgent care visits, outpatient care for mental and behavioral health services, and prescription drugs. All direct services are offered through the Tafuna Family Health Centers and its satellite clinics across the island.

 

Enabling Services:  Enabling services are non-clinical services (not included as direct or public services) that enable individuals to access health care and improve health outcomes.  The funding provided by MCH Block Grant is used to finance these services for  MCH populations.  The Essential services of Public Health Standard is to investigate health problems, inform and educate the public and engage community partners.  In addition, promoting and implementing evidence based practices with access and monitoring MCH Health Status are also enabling services.  The MCH Program funds for an epidemiologist who helps to interpret data to guide decisions to improve health for women and children.  Also, MCH affords for health educators to provide education on nutrition and healthcare for women who come to the clinic, as well as case managers and navigators who help guide families and consumers in accessing pertinent care for their health needs.  These MCH staff engage in community capacity building to deliver enabling services, such as transportation, nutrition counseling, and care coordination. 

 

Public Health Services and Systems:  Public Health Services and systems are to support and maintain Public Health Workforce and develop public policies and plans for the benefit of the society.  Enforcing Public Health laws and ensuring quality improvement are essential services for the Public Health standard.  These services include the Epinet and surveillance to monitor changes in the health status of the population, as well as providing necessary training for the work force and staff.  Another MCH initiative to support public health services is the success in pushing for an executive order to allot two hours of breastfeeding time for all working mothers in the government.  This order was signed by the Governor and is currently being implemented in American Samoa.

 

 

MCH Title V Bureau at the National level provides ongoing Technical Assistance in collaboration with AMCHP, Public Health Schools and other federal entities to improve and promote MCH Workforce Capacity at the state and territorial level. American Samoa is very much grateful to Dr. Warren and his excellent staff, especially Mrs. Michelle Lawler, for the programmatic support and enabling the USAPIs to have its own Spring TA in Hawaii for the past five years. Having the opportunity to get trained, network and share best practices among Pacific Island Jurisdictions with similar cultures, geographical locations, population sizes, enabled a friendly, familiar environment conducive to learning definitely improved confidence, programmatic competencies and workforce capacity.

 

In the past five years, ASMCH Title V has improved in building and implementing some of the core public health functions including assessment, policy development and assurance. American Samoa Title V has improved in terms of increased accountability through ongoing performance measurement and monitoring required to have an adequately sized and skilled workforce.

 

Example of programmatic skills, resources and tools learned and applied are listed below:

• Systems mapping
• Work flow charting
• Formulating Policies and implementation
• Fostering Partnerships and Collaboration skills
• Implementing Focus groups
• Improved epidemiological skills, data collection and surveillance
• Finance, expenditures tracking and reporting
• SMART objectives and MCH Evidence (ESMs)
• Annual reporting and applications
• MCH leadership skills and competencies
• Return on Investments
• Public Health essential services
• Needs Assessment Framework and Implementation

 

(i) Number, location and full-time equivalents of state and local staff who work on behalf of the state Title V programs

 

ASMCH Title V had only 8 full time funded staff 8 years ago. Fast forward, we are expecting 17 staff to be fully paid or in-kind to run Title V efficiently.

Staff Position Description	Quantity	Location	FTE
Title V Program Director Margaret Sesepasara, NP	1	Nursing Office MIECHV MCH Clinics	.50 0.25 0.25
Title V Program Coordinator Dr. Anaise Uso	1	Title V Office	1.00
CYSHCN/RHD Program Coordinator Ipuniuesea Eliapo-Unutoa	1	Title V Office	0.75
CSHCN/RHD Case Manager Emmalaine	1	Title V Office	1.0
CSHCN/Zika Client Navigator Fetina’i Taitai	1	Title V Office	1.0
RHD Client Navigator Lotu Tupuola	1	Tafuna CHC Title V Office	.75 .25
MCH Epidemiology Tech. Ruta Ropeti	1	Title V Office	1.0
MCH Epidemiology Mata’uitafa Faiai	1	Title V Office	1.0
Nurse Practitioner Tele Frost Hill	1	CYSHCN/Fagaalu Well Child Clinic Prenatal Clinic	0.75 0.25
Registered Nurse Sweetheart Nua	1	Leone Well Child Clinic/CSHCN	1.00
Health Educator/Certified Nurse Aids Conference Alailefaleula Manulelei Silva-Aitaoto	2	CHC Women’s Clinic LBJ Hospital OBGYN Fagaalu Primary Care Clinic	1.00 .05 .05
Certified Dental Assistant/Administrator Matauaina Ifopo	1	Dental Clinic Well Child Clinic	.05 .05
Certified Nurse Aid Faafetai Meleisea	1	Leone Well Child Clinic	1.0
Zika Client Navigator/CSHCN Driver Sa Savaii	1	MCH Title V Office	1.0
Cardio-Pulmonary Tech Hiring in Progress	1	CHC and Schools	1.0
Finance Officer (Local funded salary) Paul Peko	1	DOH Main Office	0.10

 

(ii) Names and qualifications of senior level management employees who serve in lead MCH-related positions and program staff who contribute to the state’s planning, evaluation, and data analysis capabilities

Staff Position Description	Types of State Level Management Roles
Title V Program Director Margaret Sesepasara, NP	Departmental planning and evaluation for all programs and policies at ASDOH. Oversee all training and quality improvement projects for nurses. Mrs. Sesepasara is a Nurse Practitioner by profession and has been serving women and children for more than twenty years.
Title V Program Coordinator Dr. Anaise Uso	Departmental planning for all MCH related activities within ASDOH. Departmental planning and media relations for all public health emergencies and outbreaks in American Samoa. Dr. Uso is a general dental practitioner and has been working in the administration capacity for the past six years.
CYSHCN/RHD Program Coordinator Ipuniuesea Eliapo-Unutoa	Departmental planning for all MCH related policies and activities within ASDOH. Departmental planning and media relations for all public health emergencies and outbreaks in American Samoa. Mrs. Eliapo-Unutoa has a Masters in Occupational Therapy from Loma Linda University. She has been working for ASDOH for the last 19 years under Title V and CSHCN.
MCH Epidemiologist	Planning, Monitoring and Reporting of all Public Health Epidemiological Surveillance in American Samoa

 

(iii) Number of parent and family members, including CSHCN and their families, who are on the state’s Title V program staff.

 

Family Members	Title V Role
F2F Office Administrative Assistant Mocha Mua	Paid by F2F Leo o Aiga. Not only does she work as an administrative assistant but she is also instrumental in recruiting CSHCN families, point of contact for families during Needs Assessment and provides resources for families when they call Title V office. Mrs. Mua is also a parent of a child with special health care needs. She has an AA degree from the American Samoa Community College.
CYSHCN/RHD Program Coordinator Ipuniuesea Eliapo-Unutoa	Mrs. Eliapo-Unutoa is a parent of a child with special health care needs. She is extremely passionate about the work that she administers not only because of her educational background but she is also advocating for her loved ones.

 

(iv) Additional MCH workforce information, such as the tenure of the state MCH workforce and projected shifts in the MCH and CSHCN workforce over the five-year reporting period, that aligns workforce capacity with the achievement of Title V program goals.

 

ASMCH Title V has come a long way not only in increasing staffing, funding but also service capacity. Shifting the needle from direct care to more public health and enabling services are not easy especially for a low-resource island territory such as American Samoa. ASDOH still depends on MCH Title V to assist with the Nursing department and its initiatives. Direct services are not just for CYSHCN but also includes women and children as long as Title V is being administered by the Nursing Department. Title V administration will continue to promote its priority needs and state action plan in order for ASDOH to understand why its federal dollars are being maximized in such a way.

 

As we await the new Governor and his new administration to be elected come October 2020, ASMCH Title will continue to promote and implement its new state action plan to achieve its goals and objectives for the next five years. Title V Program will continue to collaborate with key stakeholders, utilizing current legislation and policies, to promote MCH health priorities. Program staff will continue to request for Technical Assistance annually to improve workforce development and competencies.

Title V Program Partnerships, Collaborations and Coordination

The American Samoa Maternal & Child Health Program works closely with many organizations around the country and here at home

Partners on the federal level and off-island private teams  include Health Resources and Services Administration (HRSA), Centers for Disease Control (CDC), World Health Organization (WHO), Secretariat of the Pacific Communityl (SPC), US based academic institutions, and cardiology teams from off-island hospitals.

Local partners include the American Samoa Government, specifically Department of Human and Social Services (DHSS), Women, Infant, and Children (WIC) Breastfeeding Program, Department of Education Special Education Division (SPED)/Secondary Division/Early Childhood Education (DOE), Department of Office of Protection and Advocacy (OPAD), Department of Public Works (DPW) Dial A Ride Division, Department of Vocational Rehabilitation (VR), and Medicaid.

Department of Health internal programs such as Home visiting, Helping Hands Part C, Helping Babies Hear, HIV/TB/STD, Breast and Cervical Cancer Prevention (BCCP), Immunization Program, and Community Health Centers (CHC).  Additionally, other non governmental entities include LBJ Tropical Medical Center (Family Planning, Maternity Clinic, Nursery, OBGYN, Pediatrics), University Centers for Excellence in Developmental Disabilities (UCEDD) under the local Community College, and the Telecommunication Companies such as American Samoa Telecommunications Authority (ASTCA) and BlueSky Communications.

Local Health Based Businesses: South Pacific Watersports (SPW), Slimmer Stronger You (SSY) focus on nutrition and physical activity.

Non-profit organizations: American Samoa Alliance against Domestic and Sexual Violence, Parents of Children with Special Healthcare Needs Network (PCSN), Intersections Inc. on teenage pregnancy prevention and teen counseling.

Church groups:  (Pastors, Youth groups, etc.).

Media outlets: South Seas Broadcasting, KSBS 92.1, KVZK TV (local TV) and private media businesses.  

The methodologies utilized to help us identified the final list of priorities for each of the population domains under MCH services was detailed by the Title V Grant Guidance.  We were able to produce a list of priorities that can drive the next five-year cycle in MCH work by combining qualitative information with quantitative data available from reliable sources. These priorities were presented to MCH stakeholders under specific population domains, so to gather their feedback, recommendations, support, as well as their endorsement as our partners in serving women, pregnant women, and all children including children with special needs for the next five years.

 

Priorities that were identified in the list but were not ranked as one of the top three from each of the population domain, were categorized as emerging needs. Emerging means priorities that are becoming apparent or prominent in the population but are not necessarily top priorities based on the data collected. There emerging priorities are still important and must be considered as it may be influential in the wellbeing of our women and children.  The following emerging issues were identified under each specific domain.

Women/Maternal Health-

• Domestic Violence
• Positive marriage counseling /healthy relationships 
• Reproductive Health Education in schools (13-14 years old) 
• Transportation Needs for Pregnant women to access care

 

Perinatal/Infant Health- 

• Postpartum Depression
• Immunizations.

 

Child Health

• Developmental Screenings for children
• Parent/Child Activities including family physical activities and their involvement with their children
• The availability of Telehealth for any public health emergencies that may occur at any time in the territory.

 

Adolescent Health

• Substance abuse amongst adolescents
• Child abuse
• Preventive care through recommended immunizations and annual physical assessments. 

 

Children with Special Needs

• Resource center (support groups for families) 

• Medical home (Health Follow up)
• Transportation services 
• Special equipment

 

PRIORITIZATION:

DOMAINS	Women and Maternal Health	Perinatal/Infant Health	Child Health	Adolescent Health	CSHCN
PRIORITY 1	PROVIDER COMPETENCY/PROVIDER SHORTAGE	BREASTFEEDING	IMMUNIZATION	WEIGHT MANAGEMENT	CERTIFIED PROFESSIONALS (PROVIDERS & EDUCATORS)
PRIORITY 2	PRENATAL CARE (Accessible/Affordable)	HEALTH & NUTRITION (Both Mother & Baby)	OBESITY	RHEUMATIC HEART DISEASE AND RHEUMATIC FEVER	TRANSITIONING PROCESS
PRIORITY 3	WOMEN'S HEALTH (NCDs/STDs Screening & Pre-Pregnancy	SCREENING (Developmental, Metabolic and Oral)	ORAL HEALTH	SUICIDE & BULLYING	EARLY SCREENING & DIAGNOSIS OF CSHCN

 

*Emerging Needs*

DOMAINS	Perinatal/Infant Health	Child Health	Adolescent Health	CSHCN	Women and Maternal Health
EMERGING NEEDS	Immunization	- Developmental Screening, Parent/Child Activities, Public Health Emergencies (Telehealth as alternative)	- Substance Abuse (Smoking & Alcohol); Child Abuse (Physical), Preventive Care (Immunization)	- Resource Center (Support Groups for families); Medical Home (Health Follow Up), Transportaion Services; Special Equipments	- Domestic Violence/Positive Marriage Counseling/ Health Relationships; Sex education in schools; Transprotations, Postpartum Depression

 

The following are some contributing factors to the change in priorities from the last reporting cycle, which were identified during stakeholder meetings. 

• Growth of MCH Staff: In the past 5 years, MCH only employed a staff of 7 which includes 1 Program Director, 2 Program Coordinators, 2 clinical staff and 2 health educators. This past year it has increased to a total staff of 21 under different programs within MCH.
• Drop and rise in the economy: Due to natural disasters, outbreaks, and the most current COVID situation, the change in economy directly effects MCH priorities.  In the past, outbreaks such as Zika prioritized accessibility of care for pregnant women, then with the measles outbreak, more emphasis was placed on immunizations for all children population as well as adults. With the influx of federal assistance after natural disasters, families were more able to afford necessary nutritional food items than before.
• New federal funding:  New financial opportunities from the Federal Government enabled programs such as the “Leo o Aiga Health Information Center” to be in existent to assist families of children with disabilities within the community.

 

In conclusion, MCH was tasked to take the selected priorities from each of the population domains and strategically look at evidence-based programs or approaches that will best fit the needs of our women and children.  From there, strategies that are culturally appropriate, evidence-based, accessible, family centered, coordinated and comprehensive would be selected to achieve specific objectives assigned under each population domain priority.  These will be included in the next five-year MCH plan to guide the work that our local MCH workforce will be implementing together its partners and the DOH as a whole.  There will be internal and external evaluation methods conducted throughout this process annually to communicate the level of progress made and if such progress is affecting improvement in services and overall quality of life for all women and children in AS.