Changes in the Health Status and Needs of the MCH Population

The Guam Title V Program conceives of needs assessment as a continuous process in which valuable data, both quantitative and qualitative, relevant to the broad mission of the Program are continuously being gathered and analyzed with an eye to adjusting the Program priorities and activities as appropriate Key findings resulting from the needs assessment highlighted the following priority areas: well-woman visits, breastfeeding; reducing perinatal disparities; mental health including grief and trauma-informed care; implicit bias/discrimination; positive youth development; early childhood developmental screening; medical home identification/place-based care; and addressing social and economic needs. The findings point to persistent health disparities by race/ethnicity, immigration documentation status, and socio-economic status. Furthermore, these findings emphasize the need to address social determinants of health, such as housing, education, violence, and discrimination/implicit bias, among the top factors identified by community members as the most significant unmet needs of Guam women, children, and families.

In addition to reviewing primary and secondary data sources, Needs Assessment efforts involved collecting input from staff/programs, engaging external stakeholders in discussions of ever-evolving conditions and emerging needs, and changing priorities. The information supports and informs Guam’s Title V planning, decision-making, and resource allocation. The Title V Federally Available Data (FAD) and the MCH Jurisdictional Survey continued to serve as the primary data source for ongoing needs assessment. Because the FAD utilizes the federal race/ethnicity classifications, state vital statistics data may be used to report data for Guam’s detailed ethnicity groups.

The following section provides an overview of population-level data updates available during the reporting period.

Women’s/Maternal Health:

Prenatal Care: Although Guam women are engaging in some preventive care services, rates of women accessing prenatal care are significantly lower. For 2022, slightly over half (52.2%) of the live births were to women who initiated prenatal care during the first trimester of their pregnancy; 14.8% of the live births received no prenatal care. Twenty percent of Chamorro women, 12.7% of Filipino, 5.5% of White, and 4.6% of Chuukese women initiated prenatal care during their first trimester.

Breastfeeding: Data from the 2022 Guam Birth Certificates indicated that 82.6% of mothers initiated breastfeeding at hospital discharge. Chamorro women had the highest breastfeeding initiation rate at 36.6%, followed by Chuukese (18.7%) and Filipino (18.2%) women. Carolinian (0.02%), Kosraean (0.7%), and Japanese (1.5%) women had the lowest breastfeeding initiation rates among mothers that delivered in 2022.

Smoking in Pregnancy: According to 2022 Birth Certificate data, 4.3% of women reported that they smoked during the three months before pregnancy (down from 4.4 in 2021), 2.7% of women said that they smoked during the last three months of pregnancy (up 3.8% from 2021), and 5.4% reported that they smoked postpartum. All smoking rates were highest among women under the age of 25. Prenatal smoking rates in Guam are slightly higher than the Healthy People 2030 objective for smoking during pregnancy.

Perinatal/Infant Health:

Infant Mortality: From 2018 to 2022, there were 160 infant deaths. The crude infant mortality rate for this time period was 11.1 deaths per 1,000 births, which was twice the crude infant mortality rate for the United States.

Chamorro's made up 37% of births in the time period 2018 to 2022. For every 1,000 births from mothers who identified as Chamorro from 2018 to 2022, 10.7 Chamorro infants would pass away before reaching 12 months of age, making up 35% of all infant deaths.

Child Health:

Developmental Screening: The annual objective for reporting year 2022 was 23%. The yearly objective still needs to be met, as stated in the MCH Jurisdictional Survey. An important caveat is that the data for this measure has a wide confidence interval due to the small sample size (CI – 0.3-14.7) of 1,250 children.

Immunizations: The Vaccination Coverage of Selected Vaccines among kindergarten children school year 2021-22 shows vaccination coverage with two doses of measles, mumps, and rubella (MMR) was 91.5%, diphtheria, tetanus, and pertussis vaccine (DTaP) was 89.8%, and poliovirus vaccine was 90.9%.

Adolescent Health:

Mental Health and Suicide: According to the 2022 Maternal and Child Health Jurisdictional Survey in Guam, only 22.1% of children aged 3 through 17 years with a mental or behavioral condition received treatment or counseling. Among children identified with special health care needs, only 8.6% report receiving care in a well-functioning system, and among children and adolescents, 2.8% of those were not able to obtain the care they needed. A factor contributing to the gap between identifying and treating children's behavioral health disorders is the need for more services or treatment options in Guam.

Adolescents in Guam experience various health issues. Poor mental health has become a significant concern in recent years. As a result of the Covid 19 pandemic, mental health among adolescents has further declined due to uncertainty, social isolation, stress, disruption to daily life and loss of routine, and loss of family members or loved ones.

According to the 2019 YRBSS, 60% of LGBTQ high schools in Guam seriously considered suicide (survey participants were only asked about their sexual orientation). Compared with the percentages for heterosexual peers, these numbers are exceptionally high. The survey showed that 16.5% of straight teens had seriously considered suicide.

Bullying: In 2019, 11.1% of Guam students in grades 9 through 12 reported feeling unsafe at school. This was an increase from 2017's 10.9%. Both female (10.7%) and male (11.2%) students reported feeling unsafe on school grounds. Feeling unsafe at school decreased as grade level increased from grade 9 (9.8%) to grade 12 (7.5%).

Children and Youth with Special Health Care Needs:

Medical Home: The percentage of Children with Special Health care Needs, ages 0-17, who have a medical home was 62% in 2022. The annual objective for reporting year 2022 was 62%, and the annual objective still needs to be met.

COVID 19 Status

* As of May 11, 2023, the CDC has ended the pandemic emergency and no longer requires reporting negative COVID-19 test results; therefore, the positivity rate will no longer be reported.

Changes in MCH/Title V Program Capacity

Over the past 2-1/2 years, Guam DPHSS/MCH has experienced numerous events that have had a serious impact on staff and services, many of which remain unresolved: the impact of COVID-19, including critical staffing shortages; a government-wide reassessment and realignment of job classifications; and a continuing drain of skilled public health professionals. These events have made recruiting and maintaining knowledgeable and skilled Title V staff challenging. To recruit and retain qualified MCH staff, MCH works closely with Human Resources to increase hiring efficiency. Standardized hiring procedures are now in place, and additional technical assistance has been provided throughout the hiring process. Proactive strategies have also been employed to publicize vacant positions. MCH works with colleges throughout the state to initiate critical conversations to draw student talent.

Inflation and Cost of Living The rising inflation and cost of gas, food, and other goods in Guam and across the country are adversely affecting families served by Title V. As a result of the COVID-19 pandemic, many people in Guam were already struggling with important basic needs, like housing, food, medicine, technology, and childcare. The recent infant formula shortage has added additional stress and hardship for families. Title V programs will support families in accessing concrete support to meet these needs and assess the impact of public benefits and programs that promote economic stability.

Title V Partnerships/Collaborations

Partnerships ensure coordination within the MCH healthcare delivery system. The MCH team provides expertise, gathers feedback, facilitates conversations and relationships, and makes connections to assure access to services and maximize the effectiveness of the health system. Title V is heavily focused on collaborative partnerships and demonstrates a solid commitment to coordinating with others to address the emerging and ongoing needs of MCH populations. Both formal and informal collaborative relationships exist that support Title V work.

Guam's Title V program aims to ensure access to quality health care and needed services for maternal and child health (MCH) populations across the island. We have successfully leveraged partnerships and resources to maximize the benefits available to the MCH population. Guam's Title V program is responsible for grants and cooperative agreements from numerous federal funders.

Social determinants of health

Access to affordable, accessible, and safe housing, transportation, and employment are pressing needs in Guam, and many families and youth are experiencing negative social and economic consequences due to COVID-19. To address this priority, Title V will support and advise external coalitions and agencies to promote equitable access to childcare and educational opportunities for all children, support families in accessing concrete supports such as housing, job training, and public benefits, and promote best practices for access to virtual health and social services to help bridge the digital and economic divide.

Health Equity

The U.S. Department of Health and Human Services defines health equity as attaining the highest level of health for all people. This means people have fair access to resources needed to achieve their BEST physical, emotional, and social well-being. Adversely, health inequities "are the preventable differences in health outcomes closely linked to social, economic, and environmental conditions." Achieving health equity requires valuing everyone equally, focusing on addressing avoidable inequalities, historical and contemporary injustices, and eliminating health and healthcare disparities. According to the Centers for Disease Control and Prevention, addressing social determinants of health is a primary approach to achieving health equity.

The Health Equity Framework (HEF) is promoted by the Maternal and Child Health Bureau (MCHB) as a science- and justice-based framework specifically designed for researchers and practitioners working across public health and social science fields. The HEF recognizes that inequities result from experiences across one's life and the generations before and that the following four factors are interconnected: relationships and networks, systems of power, individualized factors, and physiological pathways. 1. Relationships and networks: family, friends, partners, community, schools, workplaces 2. Systems of power: policies, processes, practices 3. Individualized factors: response (e.g., attitudes, skills, behaviors) to social, economic, and environmental conditions 4. Physiological pathways: biological, physical, cognitive, and psychological abilities

The HEF is centered on outcomes at the population level, explicitly targeting factors that affect access to resources and opportunity. Instead of focusing only on the individual's ability to act on those opportunities, framing it this way can allow systems to think in new ways, identify gaps, and address how the above factors provide risk and protective factors for health outcomes.