BEHAVIORAL HEALTH AMONG MICRONESIANS Behavioral Health TeleECHO Clinic
August 20, 2019
Davis Rehuher, BA1, Earl S. Hishinuma, PhD1, Keisha Willis, BS1, & Sidney Roberts, BS1
Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award number U54MD007601
1Department of Psychiatry, John A. Burns School of Medicine, University of Hawai‘i at Mānoa OBJECTIVES
BACKGROUND MENTAL CULTURAL AND CONTEXT HEALTH ASPECTS
Micronesia In the Micronesian Cultural Geography region considerations Political Status Among migrants in Resources the US Interests Implications and Indicators Recommendations Migration MICRONESIA, MELANESIA, POLYNESIA MICRONESIA FEDERATED STATES OF MICRONESIA UNITED STATES AFFILIATED PACIFIC ISLANDS - MICRONESIA
US Territories COFA Nations THE MICRONESIAN REGION Selected Selected Indigenous Indigenous Area Political Status Citizenship Populations Languages Guam Unincorporated Territory US Chamorro Chamorro
Commonwealth Chamorro Chamorro N. Mariana Islands US Territory Carolinian Carolinian
F. S. Micronesia Freely Associated State FSM
Chuukese Chuukese Chuuk State FSM State FSM Carolinian Carolinian
Kosrae State FSM State FSM Kosraen Kosraen
Pohnpeian Pohnpeian Pohnpei State FSM State FSM Nukuoro Nukuoro Kapingamarangi Kapingamarangi
Yapese Yapese Yap State FSM State FSM Ulithian Ulithian
Marshall Islands Freely Associated State Marshall Islands Marshallese Marshallese
Palau Freely Associated State Palauan Palauan Palauan GUAM NORTHERN MARIANA ISLANDS FEDERATED STATES OF MICRONESIA FEDERATED STATES OF MICRONESIA FEDERATED STATES OF MICRONESIA FEDERATED STATES OF MICRONESIA REPUBLIC OF THE MARSALL ISLANDS REPUBLIC OF PALAU RECENT HISTORY COLONIAL HISTORY
Country Period Spain 1886 - 1899 Germany 1899 - 1914 Japan 1914 - 1944 United States 1944 - 1995 Trust Territory of the Pacific Islands (TTPI) 1947 - 1994
TTPI was 1 of 13 Truk (Chuuk) Trust Territories of Ponape (Pohnpei) the United Nations Kusaie (Kosrae) post World War II Yap United States Marshall Islands mandated to Palau help develop Northern Mariana self-sufficiency Islands Nuclear Weapons Testing in the Marshall Islands “FOR THE GOOD OF MANKIND”
Between 1946 and Equivalent to 1958, 67 nuclear tests 7,200 were conducted Hiroshima bombs
Displacement from Health effects homes, evacuation (cancer, birth defects) to other islands linger to this day Nuclear Weapons Testing in the Marshall Islands
Largest ever American nuclear blast
The blast left a crater 2,200 yards across and 80 yards deep, shaking islands 120 miles away
Radioactive fallout reached Australia and Japan
42 coral species missing, with at least 28 locally extinct Destruction of Bikini Atoll, March 1, 1954 Nuclear Weapons Testing in the Marshall Islands
Effects of radiation Illness from acute radiation exposure
Illness from chronic radiation exposure
Loss of land
Cultural and social disruption Nuclear Weapons Testing in the Marshall Islands
Runit Dome, Enewetak Atoll Constructed in 1979 to temporarily store radioactive waste from nuclear testing
Concern of potential for waste to leak from underneath the dome and contaminate surrounding areas Nuclear Weapons Testing in the Marshall Islands Brewery named after Manhattan Project, first nuclear weapons developer, released in 2019: Bikini Atoll – no Bikinians live there today, except for 4-6 caretakers Half-Life – refers to length of time for 50% of nuclear decay Hoppenheimer – Hops (beer ingredient) + Oppenheimer (father of nuclear bomb) Plutonium -239 – extremely dangerous; stored in Runit Dome; half-life of 24,000 years Nuclear Weapons Testing in the Marshall Islands Not the first time Bikini Atoll has been appropriated in popular culture Bikini Atoll Beer
Bikini – two piece bathing suit. Named in the late 1940s to capitalize on “explosive” social reaction Compacts of Free Association (COFA)
United States with: “Compacts allow for citizens of the Freely Associated States Federated States of Micronesia (FAS) to enter the 1986 - Present USA to engage in occupations and Republic of the Marshall Islands establish residence 1986 - Present as non- immigrants” - US Department of Republic of Palau Commerce 1994 – Present Compacts of Free Association (COFA)
What does the US get in return?
MILITARY STRATEGIC MILITARY RIGHTS DENIAL INFRASTRUCTURE Strategic rights US can deny US has the to the region any other right to over water, country military establish land and use of the military bases airspace Micronesia any time and region anywhere in the region ECONOMIC AND HEALTH INDICATORS SELECTED INDICATORS
Life Average Underage Expect. Per Capita Household Unempl. Area Population (%) (Years) GDP (US$) Size Rate (%) Guam 159,358 36 79 30,000 3.8 8.4
N. Marianas Islands 53,883 36 76 15,359 3.3 16.8
Federated States of 102,843 43 69 2,341 6.1 16.2 Micronesia Chuuk State 48,654 44 n/a 1,411 6.9 24.6
Kosrae State 6,616 44 n/a 2,323 5.8 23.0
Pohnpei State 36,196 43 n/a 3,138 5.8 9.0
Yap State 11,377 39 n/a 3,532 4.9 6.0
Marshall Islands 53,158 46 72 2,918 6.8 34.0
Palau 17,501 28 72 11,145 4.0 4.2 HEALTH ISSUES
Cancer Heart disease
Diabetes Stroke
Sepsis Lung disease
Malnutrition Obesity OTHER CONCERNS
Unemployment Climate change
Education Food security
Infrastructure Natural disasters
Political status MIGRATION REASONS FOR MIGRATION
Employment
Education
Health care MICRONESIAN POPULATION HAWAI‘I 2010
Ethnic group 2000 2010 Growth Guamanian or Chamorro 4,221 6,647 57% Micronesian 6,492 11,645 79% Marshallese n/r 6,316 n/r Chuukese n/r 2,563 n/r Palauan n/r 1,216 n/r Pohnpeian n/r 775 n/r Kosraen n/r 494 n/r Yapese n/r 281 n/r MICRONESIAN POPULATION UNITED STATES 2010
Guamanian or Chamorro 147,798 Marshallese 22,434
Palauan 7,450
Chuukese 4,211
Pohnpeian 2,060
Saipanese 1,031
Yapese 1,018
Kosraen 906
Carolinian 521
Mariana Islander 391 Thousands MICRONESIAN POPULATION GROWTH UNITED STATES 2000 - 2010
Chuukese 544
Kosraen 301
Marshallese 237
Carolinian 201
Pohnpeian 194
Yapese 177
Mariana Islander 177
Saipanese 117
Palauan 115 Guamanian or 60 Chamorro
Percentage MENTAL HEALTH IN THE MICRONESIAN REGION SUICIDE
Most studied mental health problem
Hezel and Rubinstein published several studies
Most studies from 1970s through 1980s, a few in the 1990s Most recent are from Guam (Booth, 2010; Twaddle et al, 2011; Ran, 2015) Since peaking in the late 1980s, suicide trends since the 1990s are unclear due to lack of research data (Ran, 2007) SUICIDE RATES
Area Deaths/100,000 Guam 21.0 Chuukese 52.9 Chamorro 30.0 Other Micronesian 12.4 Palau 21.7 Federated States of Micronesia 13.0 Marshall Islands 24.5 SCHIZOPHRENIA
Most schizophrenia studies in Micronesia are on Palau
Palau has one of the highest lifetime prevalence in the world: 2.77% for males and 1.24% for females (Myles-Worsley et al 1999) Higher prevalence in western Micronesian (Palau and Yap) than eastern Micronesia (Chuuk, Pohnpei, Kosrae, Marshall Islands) (Dale, 1986; Hezel & Wylie, 1992)
Males have more than twice the rate as females (Hezel & Wyle, 1992; Myles-Worsley et al 1999) SUBSTANCE ABUSE
Alcohol Tobacco abuse is a serious use is widespread – smoking issue across the region and with betel nut Marijuana Methamphetamine high prevalence use in Guam, Northern throughout the region Mariana Islands, and Palau Inhalants Heroin (sniffing glue and gas) in serious outbreak Chuuk and Palau in Palau in the 1980s Sakau Betel nut (kava) in Pohnpei a traditional tradition in Yap, Palau, Guam practice and N. Mariana Islands INTIMATE PARTNER VIOLENCE
Federated States of Marshall Micronesia Palau Islands Percentage ever-partnered women reporting having 32.8 25.2 48.0 experienced physical violence in their lifetime
Of above, percentage with experiences in the past 12 34.7 8.0 16.0 months MENTAL HEALTH CARE RESOURCES Workforce Development
Marshall Islands (WHO, 2015) • 0 appropriately trained mental health professions Federated States of Micronesia (WHO, 2015) • 1 rotating psychiatrist based in Chuuk (may have left by 2018) • Trained mental health counselors and outreach workers Palau • 1 psychiatrist (Palauan) Pacific Behavioral Health Collaborating Council • Provides substance abuse counseling across the region MENTAL HEALTH CARE RESOURCES Availability of Mental Health Facilities
Marshall Islands (WHO, 2011) • 2 mental health outpatient facilities • 0 day treatment facilities • 0 psychiatric beds in hospitals Federated States of Micronesia (WHO, 2011) • 4 mental health outpatient facilities • 0 day treatment facilities • 0 psychiatric beds in hospitals Palau (WHO, 2011) • 4 mental health outpatient facilities • 8 day treatment facilities • 8 beds psychiatric beds in hospitals TREATMENT GAP
World Health Organization estimates of treatment gaps in Micronesia Federated States of Micronesia 92% Marshall Islands 90% Northern Mariana Islands 90%
On Guam, of almost 15% of adults reporting a serious mental illness, only 5% reported receiving treatment (David & Rosadino, 2015) MENTAL HEALTH AND BEHAVIORAL WELLNESS AMONG MICRONESIAN MIGRANTS IN THE UNITED STATES NEED FOR MENTAL HEALTH SERVICES IN HAWAI‘I FOR MICRONESIAN MIGRANTS
Needs assessments found need to provide mental health services to Micronesian migrants:
Statewide (Healthcare Association of Hawai‘i, 2015)
Micronesian community members (University of Hawai‘i Department of Public Health Services, 2009)
Homeless shelter (Lee, et al., 2007) HOSPITALIZATIONS IN HAWAI‘I
Micronesians hospitalized at younger ages and often sicker than comparison groups, including for mental health (Hagiwara et al., 2015)
Micronesians had higher unadjusted inpatient hospital costs, $58.1m over three years, 75% covered by Medicaid (Hagiwara et al., 2016)
Micronesians had the lowest average age (35.0 years vs. 48.7 years overall), the highest percentage paid by Medicaid for all emergency room visits, and one of the highest percentages paid by Medicaid for emergency room visits with a primary psychiatric diagnosis (with only American Indians/Alaska Natives & Portuguese having higher rates) (Schultz, Solimine, Smith, Hishinuma, Elliott, and Lee (2019, in preparation) DEPRESSION AND PSYCHOLOGICAL DISTRESS
Marshallese adolescents in Arkansas scored above the cutoff point on self-administered surveys on depression to warrant clinical evaluation (Fitzpatrick & Willis, 2018; Gavin, 2017)
On Guam, Micronesian adolescents reported increasingly higher percentages of depression compared to Chamorro and Filipino youth (David, 2011; David & Lapid-Rosadino, 2015; David, Lapid- Rosadino & Tydingco, 2016)
In Hawai'i, Micronesian adults admitted to the ER and diagnosed with a psychiatric disorder had the lowest rates of depression (Schultz, Solimine, Smith, Hishinuma, Elliott & Lee, 2019, in preparation)
On Guam, Pinhey (2004) study on empty nests and parental wellbeing found that Micronesian adults reported greater distress scores and lower happiness scores compared to European Americans, Filipinos, Chamorros and Asians.
On Guam, Micronesian adults reported distress scores lower than Chamorros but higher than Other, Filipinos, and European Americans (Bosqui, Kouvonen & Kawabata, 2018) SCHIZOPHRENIA
Palauan migrants on Guam have had the highest rates of schizophrenia among all ethnic groups (Sharma-Gopinath, 2010)
In Hawai‘i, Micronesians lower rates of schizophrenia than Asians and Native Hawaiians but higher than European Americans (Schultz et al., 2019). SUBSTANCE ABUSE
Micronesian youth migrants on Guam have high rates of smoking tobacco and use of chewing tobacco (David, 2016)
Among adults in Guam, Micronesians have the highest rates of heavy drinking and binge drinking (David, 2016; Saleh, 2004) SUBSTANCE ABUSE
Alcohol abuse/dependence, Hawai‘i
Alaska Native 50.0 Other Micronesian 48.5 Guamanian or Chamorro 42.9 Marshallese 37.9 American Indian Mexican Other Pacific Unknown Tongan White Overall Micronesian = 46.0% Data not collected Vietnamese Thai Arab/Arabian Other Hispanic Other Samoan Other Asian Korean Black Asian Indian 2001-2010 % of alcohol abuse/dependence as Part Native Hawaiian primary ER mental health diagnosis, by ethnicity Hawaiian Japanese Not Applicable Portuguese Either no occurrence or 0% rate: Fijian, Laotian, Chinese Malaysian, Maori, Other Melanesian, Tahitian, Native Hawaiian Filipino Tokelauan Puerto Rican SUICIDE
Between 2000 and 2011, with the exception of 2012 (second highest), Micronesians (particularly Chuukese) had the highest rates of suicide mortality on Guam (David 2009; David 2010; David 2011; David 2013).
Also on Guam, report that Micronesian migrants had the highest rates of deaths by suicide in 2015 (David, Lapid Rosadino & Tydingco, 2016) SUICIDE
Hawai‘i:
Galanis, D. (2017). DoH personal communication HUMAN RIGHTS VIOLATIONS
Sex Trafficking Micronesian women have been recruited under false pretenses and forced into prostitution in the US (Posmanick-Cooper, 2015) Federated States of Micronesia and the Republic of the Marshall Islands have been identified as source countries for other countries, including the US, for recruitment and transportation of women and children for sex trafficking and sexual abuse (US Department of State, 2017)
Labor Trafficking Micronesians fraudulently recruited to work in the US, but upon arrival are subjected to forced labor conditions, including passport confiscations and excessive work hours (US Department of State, 2017)
International Adoptions Abuses Pregnant Marshallese women trafficked to US to give birth and give baby up for adoption without being clearly informed they will not see their child again (Roby and Matsumoto, 2002) CRIMINAL JUSTICE SYSTEM
Juvenile Justice In Guam, From 1987 to 2000 in Guam's juvenile justice system, Chuukese youth were disproportionately overrepresented. In comparison, Chamorro youth were overrepresented and Filipino, European American and Palauan youth were underrepresented (Rapadas, 2001).
In Hawai‘i, a program intended to reduce Disproportionate Minority Contact (DMC) in the Hawai'i juvenile justice system by diverting youth from the usual juvenile justice route to more supportive pathways was implemented in an urban, diverse area (Miao, Umemoto, Hishinuma, & Smith, 2017). Results show of that the top five groups cited for diversion, Chuukese youth (31.5%) were overrepresented, compared to Filipino (18.9%), Hawaiian (16.0%), Samoan (11.2%) and European American (4.9%) youth.
Criminal Justice In Hawai'i, Micronesians were found to be among the youngest at median age of first arrest (fourth youngest among all ethnicities for both men and women), were less likely to be arrested (second among all ethnic groups compared to Hawaiians), were more likely to receive shorter probation sentences, and were more likely to be sentenced to shorter days in prison (Office of Hawaiian Affairs, 2010)). CHILD ABUSE AND NEGLECT
In Hawai'i, the number of unique (unduplicated) reported cases of Micronesian children being abused or neglected has risen in recent years. In 2016 and 2017, the most recent data available, Micronesian cases were the fourth highest reported, behind Hawaiian, European American, Mixed Race, and Filipino cases (State of Hawai'i Department of Human Services, 2012 - 2017) HOMELESSNESS
In Guam from 2015 - 2017, Chuukese have the highest rates among Micronesians, but Yapese, Pohnpeians and Palauans are represented. Combined, the total Micronesian homeless population rivals that of the native Chamorros (Guam Homeless Coalition, 2017). All Micronesian groups were overrepresented compared to their respective population rates.
In Hawai'i, Micronesians use homeless services at rates disproportionately overrepresentative of their population; however, studies show that European Americans and Native Hawaiians utilize homeless services more than Micronesians (Gleason, Barile & Baker, 2017; Yuan & Garcia, 2018)
Micronesians identify overcrowded housing and not being able to afford rent as the biggest reasons for being homeless in Honolulu (Omori, Kleinschmidt, Lee, Lindshield, Kuribayashi, & Lee, 2007).
Homeless Micronesians in Hawai‘i were more likely to have better health status than other ethnic groups, were more likely to have less number of physically sick days compared to European Americans, and were more likely to have less number of mentally sick days compared to European Americans (Perumal, 2018). RESILIENCE AND STRENGTHS
Micronesian youth in middle and high schools In Hawai‘i, strong family cohesion, attending church, participating in cultural activities (Kaneshiro & Black, 2012; Okamoto et al., 2008)
Church as source of resilience Marshallese in Arkansas (McElfish, 2016; McElfish, 2017) and Oklahoma (Allen, 2001) RISK FACTORS
Racism/discrimination Chuukese in Hawai‘i (Hagiwara 2016) Micronesians in Hawai‘i (Appleseed Center 2011; Levinson 2015) Among UH students towards Micronesians (Caparoso & Collins 2015) Among health service providers towards Micronesian patients in Hawai‘i (Yamada 2011), Arkansas (Duke 2014), and Guam (Smith 2015) Among teachers towards Marshallese students in Oklahoma (Atiles 2017) Incarceration In Guam, Micronesians make up 25% of prison population but only 8.5% of total population (Hezel 2013) In Hawai‘i, Micronesian men (first) and women (fourth) among youngest at first arrest (Office of Hawaiian Affairs 2014) Micronesian youth overrepresented at Hawai‘i Youth Correctional Facility (Department of Education School Status and Improvement Reports) RISK FACTORS
Economic stability Food insecurity – Micronesians highest in Hawai‘i (Buchthal 2012) Poverty – Micronesians (Hezel & Levin 2012) and Marshallese (Fogleman 2018) in Hawai‘i Housing instability – Micronesians in Hawai‘i (Okamoto et al 2008) and Guam (Bautista 2010; Hezel 2010) Homelessness – Micronesians in Hawai‘i (Gleason 2018) Crime and violence – Hawai‘i (Palafox et al 2010) and Guam (Hezel & Levin 2012) Access to care Micronesian health access in Hawai‘i (Appel 2017) Micronesian migrants not eligible for federal benefits (Appleseed Center 2011) Issues with health access among Chuukese in Guam (Hattori-Uchima 2017) and Arkansas (McElfish 2015) IMPLICATIONS AND RECOMMENDATIONS
Research Across the lifespan and on the regions with concentrated Micronesian populations Beyond prevalence studies, expand into culturally relevant measures, risk/protective factors and causes, and prevention/intervention and policy evaluations Protective factors, Resilience, and Strengths Although knowing the risk factors regarding mental health and behavioral wellness is important, the focus should also be on the protective factors, resilience, and strengths of Micronesian communities Prevention and Intervention Much more prevention and intervention programs and services are warranted given the overall finding of Micronesians in the U.S. being at greater risk for problems regarding mental health and behavioral wellness Legislation and Policy Policies that do not advance the mental health and behavioral wellness of Micronesians in the U.S. must be revisited. Restoring Medicaid, rescinded only for Micronesian migrants under the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, would provide federal relief of states’ costs of providing care CULTURAL CONSIDERATIONS CULTURAL CONSIDERATIONS Riklon, 2015
Over 20 languages, Different cultures, have to speak English customs, and protocols
Family comes Religion (Christianity) first An important part of life
Group needs are Preference for peer and important group interaction
Go with the flow/ Speak softly and Easy going attitude slowly CULTURAL CONSIDERATIONS Riklon, 2015 Micronesian Western Present, today, now Future, tomorrow, later Deference, distance Openness, intimacy Group Self-individual Blending in Standing out Extended family Nuclear family Obedience Argument Consensus Confrontation Family development Self development Elderly Youth CULTURAL CONSIDERATIONS Riklon, 2015
Parenting Parents are authority Patterns and Roles figures to be obeyed
Children expected to Mothers frequently refer learn by observation discipline to fathers
Parenting is a shared Grandparents are extended family cultural educators obligation CULTURAL CONSIDERATIONS Riklon, 2015
Taboo Topic
Discussion of sex, sex Inappropriate in the organs is highly presence of opposite restricted sex
Inappropriate in the If possible, interpreter presence of family and provider should be members the same sex CULTURAL CONSIDERATIONS Riklon, 2015 YES
Yes may mean: A way to avoid Yes confrontation, getting No out of uncomfortable Maybe situations
Reiterate that No is an Okay to bring along a acceptable response supportive person CULTURAL CONSIDERATIONS
Attitudes towards Expect language mental health as “black barriers – be prepared magic” to use an interpreter
Discrimination/stigma Leaders/bosses are may cause mistrust authority figures to be and disengagement respected and obeyed
Patients may not follow Engage pastors and up with questions other community during encounter leaders for assistance RESOURCES RESOURCES
We Are Oceania http://www.weareoceania.org/
Compact of Free Association Community Advocacy Network (COFACAN) https://www.facebook.com/cofacan THANK YOU!
Contact information: Dave Rehuher, Program Manager Department of Psychiatry 677 Ala Moana Blvd, Suite 301 Honolulu, HI 96813 T. 808.692.1915 F. 808.528.2907 E. rehuherd@dop.hawaii.edu