Needs Assessment Activities

Since the submission of our Title V five-year needs assessment in 2020, Guam has been actively engaged in a series of crucial activities aimed at enhancing our understanding of the current issues affecting our MCH population. These activities, which include comprehensive analyses and information gathering from our partners, are instrumental in monitoring our progress and identifying barriers to achieving our performance objectives.

The Guam Department of Public Health and Social Services (DPHSS) conducted the Guam Title V Needs Assessment in 2020, assessing the needs and strengths of its MCH population and infrastructure. The purpose of the Needs Assessment was to 1) better understand the current health status of the island's MCH populations; 2) ascertain current MCH needs through qualitative and quantitative methods; and 3) utilize the findings and Title V National Performance Measure System to identify top priorities and determine the allocation of resources and strategies that would improve the health and well-being of each of the islands five MCH population health domains -women, infants, children, including children with special health care needs, and adolescents. Using a mixed methods approach (qualitative/quantitative), the capacity, accessibility, and quality of delivery of services for Guam’s MCH populations was assessed. Guam Title V received ongoing stakeholder feedback through both formal and informal channels. At the beginning of the needs assessment, the team engaged the MCH Advisory Council, comprised of representatives from government agencies, consumers and health care, and community-based organizations.

Our continual monitoring is not just about identifying priority health and quality of life issues. It's about being proactive and identifying emergent public health issues or those that require potential new direction. This approach ensures that we are always one step ahead, ready to address additional health issues perceived by residents and consumers.

 Lastly, continual monitoring and assessment determine forces that impact the way the MCH and 

The CYSHCN system operates in areas such as legislation, funding and funding shifts, and technology or other impending changes that may affect state residents, visitors, tourists, or the system itself. These changes provide opportunities for improvement and efficiency.

Operationalizing the Five-Year Needs Assessment Process and Findings

Guam's process for preparing the Five-Year Needs Assessment is a collaborative endeavor that follows a standard stepped process, building on the preceding stages. The process begins with brainstorming and planning meetings led by MCH leadership and staff. The early stages focus on clarifying partners and critical informants, outlining data collection procedures and constructing collection tools, assigning responsibilities, and formulating a tentative schedule of events. Routine meetings are scheduled to be spaced out over an 18- to 24-month period. As the submission deadline approaches, the frequency of meetings is escalated to ensure that milestones are met and to troubleshoot challenges. All members of MCH staff are directly or indirectly involved in the process, with the level of participation determined by the roles and responsibilities of staff.

Guam’s preparation for the 2026-2030 Title V Needs Assessment will begin in mid-2024 with planning meetings, development of a timeline, and identification of activities to be accomplished between then and the submission in July 2025. Initial efforts currently underway include:

• Reviewing materials implemented during the previous needs assessment, including public input surveys, critical informant surveys, and focus group scripts
• identifying community health assessments previously developed by community agencies and the hospital systems and reviewing for identified priorities about the MCH population

Another focus Title V wanted to gain a pulse on was Social Determinants of Health (SDOH) on Guam's MCH population. We aimed to see if the unmet needs of Guam's women, children, adolescents, and families have changed since the pandemic's beginning. We understand that poor health tied to unmet social needs is a widespread problem, and these factors impact a person's physical and mental well-being and ability to access quality health care. Title V is trying to ensure that Guam has it at the forefront of all our activities.

Emerging Issues

Guam Title V has identified the following emerging public health issues and Title V's capacity and resources to address them.

Infant and Maternal Mortality

There were 40 maternal deaths in the U.S. Territory of Guam from 1968 to 2021, resulting in a very high maternal mortality ratio (MMR) during the years when there were maternal deaths. The MMR during the past fifty years ranged from a low of 22.6 in 1996 to a high of 30.4 in2021; using a 10-year average MMR from the most recent ten-year period, 2008-2017, at 27.0 is still higher than the U.S. MMR of 20.7. Chamorro and Chuukese women in Guam have both disproportionately higher maternal mortality and meager birth weight (ELBW) infants. Approximately one-fourth of Guam women are at risk for unintentional pregnancy due to not using any contraception or any reliable methods of contraception. The percentage of pregnant women who receive prenatal care beginning in the 1st trimester in Guam remained relatively unchanged since 2015 at 60.9%, and the rate of women whose prenatal care initiation was late or received no prenatal care also remained unchanged at 13.4%. A study that examined reasons for the lack of prenatal care among women of reproductive age in Guam showed that lack of medical insurance (24.3%) and lack of transportation (22.6%) were the main reasons given by respondents. Risk factors for maternal death are also high in Guam and reflect disparities in access to health and coverage, whereby women with lower education and lower household income were less likely to either have health insurance coverage or have had a routine check-up in the past year. The estimated proportion of current smokers and the proportions of overweight or obese or with diabetes or gestational diabetes in Guam's female population all follow income and educational gradients.

From 2018 to 2023, there have been 198 infant deaths. The crude infant mortality rate for this period was 12.06 deaths per 1,000 live births.

In a recently published report by the Center for Disease Control and Prevention's National Center for Vital Statistics, researchers examined birth and infant deaths collected through the National Vital Statistics System (NVSS). Provisional U.S. data showed 5.6 infant deaths per 1,000 live births in 2022, 37% higher than the rate of 5.44 per 1,000 live births in 2021. The Guam infant death rate for 2022 was 10.7 per 1,000, double the U.S. rate. The Guam neonatal mortality rate rose 3% from 3.49 per 1,000 live births in 2021 to 3.58 in 2022, and the post-neonatal mortality rate grew 4% from 1.95 per 1,000 to 2.02 over the same period.

Some of the reasons stated were maternity care deserts – where's there a lack or absence of maternity care – which limits the ability to care for infants properly. The second reason is the limited access to abortion, particularly following the Supreme Court decision of Dobbs vs Jackson in June 2022, which overturned Roe vs Wade.

It is important to note that ethnic/racial breakdown in analyses is used to analyze how the experience of living as a person who identifies with an ethnic/racial group affects their health outcomes. This includes cultural practices, prejudice they experience that could affect their quality of life, and so on. Thus, race is not a biological metric but a sociological one. Chamorro's comprised 37% of births in 2018-2023. For every 1,000 births from mothers who identified as Chamorro from 2018 to 2023, 10.7 Chamorro infants would pass away before reaching 12 months of age, making up 35% of all infants.

There have been 440 fetal deaths in Guam between the years 2013 and 2023, an average of 44 deaths per year. The fetal death rate for the ten years combined was 13.33 per 1,000 live births. Guam experienced a 6.7% increase in the stillbirth rate from 2013-2023.

Infection, congenital disabilities, and pregnancy complications such as placental abruption or pre-eclampsia have been associated with stillbirths. Identifying these conditions can be challenging and requires adequate prenatal care. Social determinants of health (low income, housing insecurity, low education, etc.) are also associated with stillbirths. Stillbirths are a significant public health concern – approximately one-fourth of these deaths in the U.S. are preventable. Source: DPHSS OVS

Stillbirth occurs in families of all races and income levels and women of all ages. However, it disproportionally affects women of Micronesian and Asian ethnicity. The fetal mortality rate for Chuukese women for the years 2013-2023 was 45.36 fetal deaths of 20 weeks or more per 1,000 live births. Chamorro women have a fetal mortality rate of 24.74, and Filipino mothers have a fetal mortality rate of 11.34 per 1,000 live births.

Workforce Challenges

Guam Title V Guam's healthcare delivery system, with its unique challenges, such as limited resources and high demand, and its proximity to the U.S., which offers more competitive job opportunities, are disadvantages regarding staff retention. Although every effort is made to fill vacancies quickly, the government's hiring processes can be an impediment.

Workforce challenges are also experienced at Guam DPHSS, where many staff have left the Department over the past few years, leading to a loss of institutional knowledge and necessitating additional staff time and resources to fill vacancies.

Inflation and Cost of Living

Rising inflation and the 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 critical basic needs, like housing, food, medicine, technology, and childcare. Title V programs will help families access concrete support to meet these needs and assess the impact of public benefits and programs that promote economic stability, including paid family and medical leave and the earned income tax credit.

The 2020 Guam Census data were available, allowing for the calculation of Guam's poverty rate. According to recently released data, 1 in 5 people living in Guam lived below the poverty line. The poverty rate for those whose poverty status was determined was 20.2%. The poverty rate for Native Hawaiian and Other Pacific Islander populations was 28.5%, and the poverty rate for Asian households was 12.3%.

Methamphetamine

Methamphetamine, specifically high-purity crystal methamphetamine, poses a severe illicit drug threat to Guam. Authorities report that crystal methamphetamine abuse has increased in Guam during the past decade. The increase in abuse of the drug is attributed to multiple factors, including its ready availability, low cost (less than heroin or cocaine), and the duration of its euphoric effects, which can last 12 hours or more--considerably longer than the effects associated with many other illicit drugs. Crystal methamphetamine is often called poor man's cocaine due to its relatively low cost and similar effects.

The Department of Mental Health and Substance Abuse (DMHSA) and law enforcement officials report that crystal methamphetamine abuse is evident throughout Guam's population. Methamphetamine abuse spans all ethnic, cultural, and age groups--some abusers are as young as 12. Of the students in grades 7 through 12 who completed a 1999 drug use survey conducted by DMHSA, more than 7 percent reported having used methamphetamine at least once in their lifetime.

Crystal methamphetamine is readily available in Guam in gram-to-kilogram quantities because of a steady supply of the drug from the Philippines as well as from Hong Kong, China, Taiwan, and South Korea. The Drug Enforcement Administration (DEA) reports that the price of crystal methamphetamine at the retail level--while still high by mainland standards--decreased during the past few years. The cost of 1 gram of crystal methamphetamine decreased from a range of $600 to $1,000 in fiscal year (FY) 1999 to $250 to $500 in FY2000 and FY2001, according to DEA. Ounce prices for crystal methamphetamine remained stable at around $8,000 from FY1999 through FY2001, and kilogram prices ranged from $180,000 to $200,000 during that period. Purity ranged from 97 to 100 percent.

In 2023, Methamphetamine deaths (directly caused) and methamphetamine-related deaths are now the third cause of death.

Source: DPHSS OVS

Title V Partnerships and Collaborations

Guam Title V programs have many internal and external relationships that enable or facilitate achieving goals and objectives. These partnerships and collaborations have resumed since the coronavirus pandemic, given the ability to meet in person. Virtual meetings are still available, allowing more individuals to attend and participate. MCH and CSHCN personnel and their many partners thrive on the interaction gained by working closely on collaborative projects. With the pandemic abating and the relaxation of guidelines, there are opportunities to resume meetings with existing partners and to build new connections meaningful to building the data capacity necessary for comprehensive needs assessments of the MCH populations.