PALAU MCH NEEDS ASSESSMENT UPDATE

 

Introduction

 

The Republic of Palau, an archipelago of over 300 islands in the western Pacific Ocean, is home to a diverse population of 17,614 individuals as of the 2020 census. The ongoing needs assessment aims to identify the health needs of Palau's Maternal and Child Health (MCH) population, determine priorities, set performance measures, and develop strategies to address the identified priority needs. By understanding the unique challenges faced by women, infants, children, adolescents, and children with special health care needs (CSHCN), Palau can build a more equitable and responsive system of care.

Methodology

This needs assessment utilized a mixed-methods approach to gather insights from diverse stakeholders. Secondary data analysis used existing reports on demographics, health status, and service utilization. Community input was solicited through presentations, report sharing, and outreach activities, engaging residents in dialogues about their experiences and priorities. Healthcare providers and public health partners shared their perspectives through the Family Health Unit's meetings and conferences, identifying priority needs and program capacity through consensus-building and SWOT analysis.

DEMOGRPAHIC PROFILE

Palau's population has slightly decreased in recent years to 17,614 in 2020 due to outmigration. This has implications for maternal and child health services, affecting resource demand and availability. The gender distribution skews slightly male, with 42% in the 15-44 age range. Children and infants make up 24% of the population, with 72% identifying as Pacific Islander and 26% as Asian.

Maternal Age Distribution:

The median age at first birth in Palau is 23.5 years, with 15% of births occurring to teenage mothers aged 15-19. Advanced maternal age (35+ years) accounts for 8% of births. Both adolescent pregnancy and advanced maternal age are associated with increased risks for maternal and infant health outcomes, underscoring the importance of tailored prenatal care and support services.

Fertility Rate:

The total fertility rate in Palau has declined from 2.6 children per woman in 2000 to 2.2 in 2020. This trend reflects changing social norms and increasing access to family planning services. However, the unmet need for family planning remains a concern, particularly among unmarried and adolescent women, highlighting the need for expanded access to reproductive health education and services.

 

Household characteristics:

The average household size in Palau is 3.7 people, with 27% of households headed by women. Multigenerational households are typical, with 35% of households including at least one grandparent. These extended family structures can provide critical support for mothers and children and increase caregiving responsibilities and stress, particularly for women. MCH programs should consider the role of family and household dynamics in shaping maternal and child well-being.

Racial and ethnic composition:

Palau's population is predominantly Palauan (73%), followed by Filipino (15%), Chinese (4%), and other Asian and Pacific Islander groups. This diversity requires culturally responsive approaches to MCH services, including language access, cultural competency training for providers, and engagement of community health workers and traditional healers.

Education:

Maternal education is a key determinant of child health outcomes. In Palau, 92% of women aged 25-34 have completed secondary education, and 28% have completed tertiary education. However, disparities persist, with lower educational attainment among women in rural areas and those from lower-income households. Strategies to promote girls' education and support women's health literacy are critical for MCH.

Employment:

The labor force participation rate for women in Palau is 59%, compared to 77% for men. Mothers, particularly those with young children, face challenges balancing work and caregiving responsibilities, which can affect their health and that of their children. Policies and programs to support working mothers, such as paid parental leave, flexible work arrangements, and quality childcare, are important for MCH.

Income and poverty:

Poverty and economic insecurity significantly impact MCH outcomes. In Palau, 24% of the population lives below the national poverty line, with higher rates among households headed by women and those in rural areas. Addressing health's social and economic determinants through programs such as conditional cash transfers, nutrition assistance, and housing support is critical for promoting MCH equity.

Child demographics:

Palau's population comprises 21% children under 15, with a male-to-female ratio of 1.05. The declining fertility rate is expected to decrease the child population, impacting resources for child health services. MCH prioritizes providing all children with access to quality healthcare, nutrition, early childhood development, and education services.

Adolescent demographics:

Adolescents aged 15-19 comprise 7% of Palau's population, with a slightly higher proportion of males (52%) than females (48%). Adolescence is a critical period for physical, cognitive, and social-emotional development, with long-term implications for health and well-being. Addressing the unique needs of adolescents, including mental health, substance use prevention, sexual and reproductive health, and injury prevention, is essential for promoting healthy trajectories into adulthood.

Special populations:

Certain population groups in Palau, including people with disabilities (3% of the population), migrants and non-citizens facing language and cultural barriers, and LGBTQI+ individuals experiencing discrimination in healthcare, encounter difficulties in accessing MCH services. It is crucial to ensure that MCH programs are inclusive and responsive to the needs of these populations for health equity.

This demographic profile emphasizes the importance of a life-course approach to MCH, recognizing the distinct needs and challenges faced by women, children, and families at different stages of development. It also underscores the social and structural determinants of health, such as education, employment, income, and access to resources, that influence MCH outcomes and inequities.

By using this demographic lens to inform needs assessment, priority-setting, and program design, Palau can work towards a more equitable and responsive MCH system.

ACCESS TO CARE

Geographic barriers to care are substantial, with lengthy and costly trips required for residents of outlying states to reach Palau's main health facilities concentrated in Koror and Airai. One-third of women are uninsured pre-pregnancy, likely delaying or forgoing needed services. Workforce shortages, particularly in specialty and mental health care, limit access even when services are covered. Telehealth offers a promising avenue to expand reach and maximize scarce provider resources, especially for CYSHCN and behavioral health needs—cultural and linguistic factors influencing care-seeking warrant further exploration.

SOCIAL DETERMINANTS OF HEALTH

Health outcomes are intricately tied to underlying social and environmental conditions. Inadequate sanitation, hygiene, and safe water access persist in some areas of Palau. Food insecurity affects 26% of pregnant women, while the high cost and limited availability of nutritious foods constrain healthy eating. Lack of public transportation and high fuel costs impede access to services, particularly for low-income families. Overcrowding and substandard housing conditions elevate the risk of infectious diseases and injuries. While Palau boasts a high literacy rate of 96.6%, health literacy levels and their impact on MCH outcomes are unknown. The strong cultural traditions of family and clan support may bolster health, but data on their influence and ways to effectively engage these informal networks are needed.

SUMMARY OF STRENGTHS AND NEEDS BY DOMAIN

Women and Maternal Health (Strengths):

• High rates of health insurance coverage during pregnancy (66%)
• Most women receive some prenatal care, with 56% starting in the 1st trimester
• Widespread receipt of prenatal education on key topics like breastfeeding and safe sleep
• Decline in tobacco use during pregnancy for some women (36%)

Women and Maternal Health (Needs):

• Significant disparities in health care access and outcomes by socioeconomic status
• High rates of unintended pregnancy (57%) and lack of contraceptive use (81%) before pregnancy
• Prevalent mental health issues, including prenatal/postpartum depression and anxiety
• Ongoing tobacco and alcohol use during pregnancy for many women
• Gaps in preventive care, such as dental cleanings and screenings prior to pregnancy
• Socioeconomic barriers to care, including lack of paid leave, childcare, and transportation

Perinatal and Infant Health (Strengths):

• Near universal breastfeeding initiation (99%)
• Relatively low rates of very low birth weight (2%)
• Widespread newborn hearing and critical congenital heart defect screening
• High rates of infants placed on their back to sleep (80%)

Perinatal and Infant Health (Needs):

• The infant mortality rate (11.0 per 1,000 live births) is twice as high as the Healthy People 2030 goal
• About 1 in 11 infants are born preterm (9%) or low birth weight (9%)
• Suboptimal rates of exclusive breastfeeding (63%) and use of human milk at 6 months (64%) 
• Unsafe sleep practices are prevalent, including soft bedding and bed-sharing
• Late entry to prenatal care for some women, with 9% starting in 3rd trimester and 3% receiving no care
• Need for improved maternal health and preconception care to reduce preterm births and low birth weight

Child and Adolescent Health (Strengths):

• Routine child health screenings and immunizations widely available
• Robust data collected on youth health behaviors and experiences through YRBSS and Annual School Health Screening
• Some infrastructure in place for school-based health services
• Engaged network of youth-serving community organizations and programs

Child and Adolescent Health (Needs):

• High rates of overweight (29%) and obesity (36%) among children and adolescents
• Prevalent mental health concerns, including persistent sadness (42%) and suicidal ideation (23%)
• Widespread substance use, including alcohol (61%), e-cigarettes (54%), and marijuana (42%)
• Exposure to violence, with 32% experiencing sexual violence and 14% dating violence 
• Barriers to accessing confidential reproductive health services for adolescents
• Physical inactivity and excessive screen time are common among youth
• High rates of dental caries (55%)

CYSHCN (Strengths):

• Most families report being able to access needed health services (73%) and care coordination (78%)
• Effective partnerships with Early Intervention and special education programs
• Active family organizations advocating for CYSHCN, like Palau Parents Empowered
• Palau Disability Fund and National Health Insurance support for specialty services

CYSHCN (Needs):

• 1 in 4 families face challenges accessing specialty and mental health services for their child
• Lack of on-island access to certain therapies and medical supplies/equipment
• Socioeconomic strain, with 50% of families earning below $15,000 annually yet facing high out-of-pocket costs
• Significant school absenteeism due to chronic conditions or acute illness
• Difficulties with self-care and behavior for many children 
• Respite care and other family supports limited

WOMEN/MATERNAL HEALTH UPDATE

The data from the 2023 Palau Pregnancy Risk Assessment Survey and 2023 Palau Hybrid Survey paint a picture of the complex challenges women in Palau face on their journey to motherhood. Even before conception, many women lack the foundation of health insurance, family planning services, and preventive care that can help them prepare for a healthy pregnancy. Over a third are uninsured, leaving them without access to vital preconception counseling and screenings. A staggering 81% aren't using contraception when they conceive, suggesting an unmet need for quality family planning education and services that the hybrid survey confirms affects 35% of reproductive-age women.

As women embark on pregnancy, mental health concerns like anxiety and depression emerge for a significant proportion, compounded by physical complications like gestational diabetes and hypertension. Postpartum, the struggle continues as nearly a third of new mothers grapple with frequent feelings of depression and hopelessness.

The challenges extend beyond medical issues. Nearly half of households earn less than $10,000 a year, and many struggle with food and utility bills. Pregnant women face job-related challenges, and affordable childcare is scarce. Health issues like high blood pressure and diabetes add to the risks women face. Preventive measures, such as cervical cancer screening and HPV vaccination, are underutilized. The data underscores the need for a comprehensive maternal health approach in Palau, including access to health coverage, contraception, and mental health support and addressing socioeconomic barriers through paid leave, affordable childcare, and food and housing security programs.

MEN’S HEALTH: A CALL TO ACTION

The state of men's health in Palau has a significant impact on the well-being of men and also affects maternal and child health. By addressing men's health issues and encouraging their involvement in family health, Palau can create a positive ripple effect that enhances the health outcomes of women and children.

 

Health Issues

 

• Limited knowledge about family planning and reproductive health among men can lead to unintended pregnancies and inadequate support for their partners during pregnancy and childrearing.
• Poor mental health and substance abuse among fathers can create an unstable home environment, negatively impacting the emotional and developmental well-being of their children.
• Lack of male involvement in prenatal care and child health appointments can result in missed opportunities for education and shared decision-making.

 

 

Implications

 

Maternal health: When men are not actively involved in family planning and prenatal care, it can lead to increased stress and reduced emotional support for expectant mothers, potentially affecting maternal mental health and pregnancy outcomes.

 

Child development: Children who grow up in households where fathers have untreated mental health issues or substance abuse problems are at higher risk for developmental delays, behavioral problems, and adverse childhood experiences (ACEs).

 

Family dynamics: Poor male health can strain family relationships, lead to financial instability, and create an unhealthy family environment that hinders the growth and development of children.

 

Recommendations

 

Integrate men's health into maternal and child health programs: Incorporate men's health education and services into existing maternal and child health initiatives to promote a holistic approach to family well-being.

 

Encourage active fatherhood: Develop programs that encourage and support active fatherhood, such as parenting classes, father-child bonding activities, and peer support groups for fathers.

 

Provide couples' education: Offer educational sessions for couples on topics such as family planning, reproductive health, and effective communication to foster shared responsibility and decision-making.

 

Screen for paternal mental health and substance abuse: Implement screening protocols for mental health and substance abuse among fathers during prenatal and pediatric visits to identify and address potential risks to family well-being.

 

Promote work-life balance: Advocate for policies and workplace cultures that support work-life balance, allowing fathers to be more involved in their children's lives and share caregiving responsibilities.

Recognizing the connection between men's health and maternal and child health, Palau can create a comprehensive approach to strengthen families and promote community well-being. Involving men in family health improves outcomes and creates a positive environment for women and children to thrive. Integrated services and support can foster healthier families and build a stronger foundation for future generations.

PERINATAL AND INFANT HEALTH UPDATE:

The 2023 Maternal and Infant Health data provides insights into the challenges facing Palau's youngest citizens. While there were 181 live births, 2 infant deaths occurred, resulting in an infant mortality rate of 11.0 per 1,000 live births. This rate is higher than the Healthy People 2030 target of 5.0 infant deaths per 1,000 live births, indicating a need for enhanced efforts to protect infants' lives.

Preterm births and low birth weight are key risk factors for infant health complications. In Palau, 9% of infants were born preterm, and 9% had low birth weight (under 2,500 grams). These rates suggest a need for interventions to improve maternal health and access to high-quality prenatal care to prevent these adverse birth outcomes.

Breastfeeding is known to provide numerous health benefits for infants. While breastfeeding initiation was nearly universal at 99%, only 63% of infants were exclusively breastfed at the time of the survey. This points to a need for strategies to support mothers in continuing exclusive breastfeeding, particularly as they return to work or school.

Creating a safe sleep environment is critical for preventing sudden, unexpected infant deaths (SUIDs). While 80% of parents placed their infants to sleep on their backs as recommended, many used potentially hazardous items such as blankets (50%), comforters or quilts (30%), pillows or cushions (10%), or crib bumper pads (14%). Ongoing education on safe sleep practices is needed to ensure all infants have a safe sleeping space. 

Prenatal care is crucial for monitoring maternal and fetal health. Efforts are needed to encourage early access to care and address barriers. High rates of primary cesareans need to be reduced to lower risks for future pregnancies. Screening and timely treatment of STIs during pregnancy are critical for preventing congenital infections.

CHILD & ADOLESCENT HEALTH UPDATE

The data from the 2023 school health screenings and the 2021 Youth Risk Behavior Survey in Palau reveals significant concerns regarding obesity, mental health, and substance use among children and adolescents. High rates of excess weight pose risks for chronic diseases, while mental health issues such as persistent feelings of sadness and suicide ideation are prevalent. Substance use, including alcohol, e-cigarettes, and marijuana, is also widespread among high school students. Additionally, potential unmet needs for vision and hearing services have been identified. It is crucial to address these issues through accessible mental health services, comprehensive prevention strategies, and timely diagnosis and treatment for vision and hearing abnormalities to ensure the well-being and educational success of young people in Palau.

 

School Health Screening data from 2023 in Palau showed a high incidence of dental caries among school-aged children. In the screening, 55% of the students screened in 2023 had dental caries, a significant increase from 48% in 2021. On average, each child had between three and four caries, with as few as one and as many as nineteen cavities.

The survey in Palau revealed significant oral health issues among children. Many require dental sealants, extractions, and fillings due to cavities. Additionally, a Youth Risk Behavior Survey showed that 11.7% of high school students did not receive dental check-ups in the past year. There are also potential gender disparities in oral health service use among teenagers.

Only 12% of high school students met the daily recommended 60 minutes of exercise, highlighting the need to promote physical activity for healthy development.

The YRBS also showed high rates of violence victimization, with 32% experiencing sexual violence and 14% experiencing physical dating violence. Prevention and trauma-informed support services are essential.

A study on adolescent SRH service utilization identified confidentiality concerns as a major barrier to access in Palau. Strategies to increase utilization included using digital education and communication tools, offering youth-specific clinic hours, and equipping parents to discuss SRH with their children. 

 

 

CHILDREN & YOUTH WITH SPECIAL HEATLH CARE NEEDS UPDATE

The 2023 survey of 143 families of children and youth with special health care needs in Palau provides valuable insights into the unique challenges these children and their caregivers face in accessing services and support.

The survey revealed that the most common causes of disability among CYSHCN were neurodevelopmental disorders (43%), congenital anomalies (18%), neurological disorders (15%), and multiple disabilities (15%). These conditions necessitate a well-coordinated care system that addresses each child's unique needs.

While 73% of families reported being able to access necessary services for their children, significant gaps in care persist. Notably, only 79% received specialized services, such as specialty care, and only 68% received physical, occupational, or speech therapy. Additionally, 29% of children who needed counseling were unable to access mental health services.

Although 78% of families expressed satisfaction with coordinating their child's care across multiple providers and systems, there is still room for improvement to ensure that all families receive the support needed to navigate complex care systems.

Access to assistive devices is crucial for many CYSHCNs. For instance, 83% of children had no difficulty seeing, while 16% had some vision difficulties and 10% experienced hearing difficulties. Ensuring timely access to vision and hearing services and equipment is essential for optimal development and learning.

The survey also highlighted the extensive caregiving needs of many CYSHCNs. Nearly half (47%) had difficulties with self-care tasks, emphasizing the importance of parent education and respite services.  Behavioral health needs were also noted, with 45% of children exhibiting problems like acting out, fighting, or bullying. Integrating behavioral health supports into the care plan for CYSHCN can help address these challenges.

Educational outcomes were also impacted, with over three-quarters (77%) of CYSHCN having missed at least one day of school due to illness, with 16% missing a month of classes. Collaboration between health services and schools is essential to support attendance and academic success for these students.

Finally, the financial impact of caring for CYSHCN must be considered. Half of the families surveyed had annual incomes under $15,000, yet 16% paid over $300 monthly in out-of-pocket medical costs. While the Palau Disability Stipend Program provided vital assistance to 64% of families, more support is needed to alleviate the financial strain of accessing necessary services. 

 

CROSS-CUTTING

The needs assessment data reveals several cross-cutting issues and opportunities for strengthening systems of care for the MCH population in Palau.

 

Health Equity: Significant disparities emerge across the MCH population based on factors like income, education, and geographic location. For example, 43% of households with a pregnant woman earned under $10,000 annually, and 26% experienced food insecurity. Half of families of CSHCN had incomes below $15,000. Comprehensive strategies are needed to address the root causes of inequities and ensure all families have access to the resources and services they need to thrive.

 

Male Health: The needs assessment highlights the importance of integrating men's health into maternal and child health (MCH) services. Addressing male health within the MCH framework can involve fathers in care, develop male-friendly health services, and promote policies supporting paternal engagement. This holistic approach aligns with themes like health equity and family engagement, improving MCH outcomes in Palau.

 

Family and Community Engagement: The data highlights the importance of involving families and communities as partners in promoting Maternal and Child Health (MCH). Focus group participants emphasized the role of parents in promoting adolescent sexual and reproductive health. Providing education and support to families and leveraging the strengths of tight-knit communities can enhance the reach and impact of MCH services.

 

Behavioral Health Integration: Mental health and substance use are significant concerns across the life course, with high rates of depression, anxiety, and substance use among pregnant women and adolescents. Integrating behavioral health screening and treatment into MCH services can help address these challenges.

 

Care Coordination and Transition: Ensuring seamless care for CSHCN is critical. While 73% of families accessed needed services, gaps remained in specialty care, therapy, and mental health. Improving care coordination systems and transitioning from pediatric to adult care can enhance outcomes. Implementing Title V Maternal and Child Health Services Block Grant program components can strengthen care coordination infrastructure.

 

Data and Quality Improvement: The needs assessment process has identified opportunities to strengthen MCH data systems and use data for continuous quality improvement. Regularly collecting and analyzing population health and program data can help identify emerging needs, target interventions, and monitor progress. Initiatives like the State Systems Development Initiative (SSDI) support ongoing needs assessment and quality improvement efforts.

 

Workforce Development: Building a skilled and diverse MCH workforce is foundational to meeting the needs of Palau's mothers, children, and families. A range of disciplines is needed, from obstetric and pediatric providers to mental health professionals, community health workers, and interpreters. Ongoing training, support, and efforts to recruit and retain providers from the communities served can help build a robust workforce.

 

Emergency Preparedness: The COVID-19 pandemic underscored the importance of emergency planning and response systems that address the unique needs of the MCH population. Incorporating MCH considerations into emergency operations plans, training providers, and strengthening surveillance systems can improve readiness for future public health threats.

EMERGING NEEDS:

1. Mental Health: High rates of depression, anxiety, and suicidal thoughts are reported among pregnant women, new mothers, and adolescents. Maternal mental health issues can adversely affect birth outcomes, bonding, and child development. Youth mental health challenges are linked to risky behaviors and poorer educational and health outcomes. Palau will need to expand its behavioral health workforce and integrate mental health care into primary care, prenatal, and postpartum services to adequately address this issue.

 

2. Chronic Diseases: Gestational diabetes, hypertension, and obesity are prevalent among pregnant women, which increases risks for adverse birth outcomes and future chronic disease for both mothers and children. High rates of overweight and obesity are also seen in children and adolescents, setting the stage for lifelong health problems. Palau will need to strengthen its health system's capacity for chronic disease prevention, early detection, and ongoing management through provider training, care coordination, and community-based interventions.

 

3. Substance Use: Tobacco, alcohol, and marijuana use are common among adolescents and women of reproductive age in Palau. Prenatal substance exposure can lead to birth defects, developmental delays, and behavioral problems in children. Substance use also contributes to unintentional injuries, violence, and chronic disease risk. Palau will need to invest in comprehensive prevention programs, early intervention services, and accessible treatment options to reduce the impact of substance use on the MCH population.

 

4. Socioeconomic Disparities: Palauan families face challenges like poverty, food insecurity, housing instability, and lack of transportation, which can limit access to essential resources. Cross-sector collaboration and policy implementation are needed to strengthen economic support, improve living conditions, and connect families to resources. The healthcare system must also adapt to address social needs as part of providing comprehensive maternal and child health care.

 

5. Reproductive Health Access: Many women in Palau do not use contraception, leading to high rates of unplanned pregnancies and concerns about delayed prenatal care and STIs. Limited access to reproductive health services hinders women's ability to plan pregnancies and prevent infections. To address this, Palau will need to improve the availability of family planning services, sexual health education, and prenatal care, especially for hard-to-reach populations.

 

6. Fathers and Fathers-to-Be: The maternal and child health field in Palau needs to focus on involving fathers more actively. Our data shows alarming trends in male health that significantly impact family welfare, including high rates of substance use, prevalent chronic diseases, low engagement in preventive care, potential underreporting of mental health issues, and poor nutrition habits. It is important to increase paternal involvement in maternal and child health services and prioritize male health within our framework to improve outcomes for families and communities.

 

SEE FULL NEEDS ASSESSMENT REPORT ATTACHED IN OTHER SUPPORTING DOCUMENTS.