ANDREA: Welcome to More Than Half. I’m Andrea Smardon. Today on the program - we’re thinking about what it takes to improve the health of mothers and babies. If you see an alarmingly high infant mortality rate in a group of people - how do you go about changing it? As we’ll learn today - it takes more than access to information and healthcare. And it isn’t just about focusing on the problem. To make an impact in this case, it takes cultural knowledge, intergenerational wisdom, storytelling, and a strong community. It takes… a village.

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TIMAIMA CLAWSON: In the Pacific culture, we have kalioa in Tongan and or aliloa in Samoan. And they're used as pillows. Kaliloa or alioa is also the word used for the mother's forearm.  Kaliloa or aliloa is how Pacific Islanders pass on the wisdom, share the wisdom in the home.   It continues to support the child during the child's life.

ANDREA: In 2016, a friend told Timaima Clawson about a program called It Takes a Village.  It was designed for Native Hawiian and Pacific Islanders to raise awareness about maternal and infant health.  Timaima is Fijian, one of hundreds of groups considered Pacific Islander, so she signed up.  Before attending the program, she hadn’t really thought about the kaliloa.  But afterwards, she called her mother… and the memories flooded back.

TIMAIMA:  I remember at a very young age that it was my mother's forearm that I gained knowledge and wisdom. I laid there on my mother's forearm as she shared stories of her young self, of her family, of her tribe, of her community and ancestors. Then my mother left to the United States seeking for a better future for our family. And my grandmother took my mother's place and I laid on her forearm as she passed on cultural knowledge and wisdom to me.

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ANDREA:When It Takes a Village started, it’s main mission was awareness.  The program helped families learn about the importance of things like prenatal care, family planning, and ways to prevent miscarriage. But along the way, it sparked something else-- a connection to community and culture. 

TIMAIMA: We are storytellers, and that's how we connect with one another.  The storytelling reminds us of our identity and so when you bring something like It Takes a Village who introduces not only the health issues, but culture, it's beautiful.

ANDREA: But it wasn’t an immediate success. It was only through the partnership of a public  health worker and a Tongan organizer that It Takes a Village realized its potential.

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BRITTNEY OKADA: A lot of times when public health or whoever is trying to work to solve a problem, they focus on the problem and the barriers.

ANDREA: Brittney Okada works with the Utah Department of Health’s Office of Health Disparities. These days she’s mostly focused on COVID-19, but It Takes A Village opened up new possibilities in her work.

BRITTNEY: With this project, we just had this most amazing opportunity to focus on the strengths of this community and work with the community to go back to culture in practices that were practiced by ancestors and passed on from mothers to daughters.

ANDREA:  It Takes a Village was started 10 years ago.  Participants from different generations and backgrounds came together in workshops that merged cultural practices and wisdom with health information.  Utah has the highest population of Native Hawiian and Pacific Islanders in the Continental US. In fact, one in 4 Tongan Americans live in Utah.  But before 2010, very little was known about their health status.   Most data included both Pacific Island and Asian communities together.

BRITTNEY: When we were able to separate out Asians and Native Hawaiians and Pacific Islanders, we saw large disparities.  So what was happening was the healthier status of our Asian population was overshadowing the challenges and struggles in our native Hawaiian Pacific Islander communities.

ANDREA: They found that the infant mortality rates for Native Hawaiians and Pacific Islanders was much higher than other populations.  In Pacific island families, for every 1000 children born, 9 will pass away.  That rate is double other Utah communities. 

BRITTNEY: That is one of the most important public health indicators because that shows us intergenerational health and how that is passed on.  So that was the impetus for It Takes a Village.

ANDREA:  But, an early pilot of the program didn’t seem to connect with participants.  They decided to create a new position - a Pacific Island health specialist, someone who knew the community. They hired Lavinia Taumoepeau Latu, though everyone knows her as Nia.

LAVINA TAUMOEPEAU LATU: Taumoepeau actually means fighting with the waves. 

ANDREA: Nia could see the program wasn’t working.

LAVINA TAUMOEPEAU LATU: I think with the focus groups, they took a very Western approach, but it was difficult for some of the community members to understand how significant the data was in addressing the health of Pacific Islander babies. 

ANDREA: She thought she knew a way in. Like many of the Native Hawiian and Pacific Island people she knew, she was born and raised in Utah.  But, she still had a special connection to her heritage, something she shared with other pacific islanders in the community.

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NIA:  Every time we go to school or anywhere, we would all kind of gravitate towards each other and then kind of hang out with each other all the time.

ANDREA: She said there was a connection even when their ancestors came from different islands or spoke different languages. There was something unique to their experience.  But there was also a longing to know more.

NIA:  I mean, we could identify with Pacific Islander ways, but there was a disconnect in the culture.

ANDREA: Nia and Brittney could see if they wanted to have an impact, they were going to have to take a different approach.

NIA:  I said to Brittany, I know this is very Western, but what do you think about us trying to use cultural concepts?

ANDREA: Nia knew it would help participants relate to the otherwise impersonal data.

NIA:  And so it was kind of trying to bring out all the things that are beautiful about being Pacific Islander, to really help the community understand how important it is that we are taking care of ourselves.

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ANDREA: For Brittney, it highlighted the need to make programs that met communities where they were at.

BRITTNEY: People, we try and put them in boxes, we try and make patterns and we want to do that to create systems for them.  But people just don't fit in that. People, their lives are so diverse and varied and so I love the idea of trying to create something for people. 

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ANDREA: But, they also found there was a lot of silence surrounding the issues. Nia says topics like the death of a child are often considered taboo in Pacific Island families.  

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NIA:  Sometimes that kind of stigma surrounding a topic makes it really difficult for you to face each other. Especially if you spend quite a bit of each other. And I think that just goes back to how close and interconnected the culture is.

ANDREA: So Brittney and Nia set out to find a way to build in a space for discussion that could authentically connect with the community.

NIA:  I kind of told her like, okay, well, what do you think about this? Instead of trying to call it a workshop in the islands, they call it fono.  Fono is like village meetings. And if we're talking about It Takes a Village and this is the name, that's how, how about we look at it as like a village, you know?

ANDREA: At their heart, the program fonos looked to nourish the Togan concept vā. Vā literally means space, but has a deeper meaning that touches all aspects of Pacific Islander life.  Brittney says it took her a while to understand.

BRITTNEY: But it’s really, It has to do with time and space and proximity and this relationship between people which we focused on the communication around infant mortality and that we are communicating openly with our family members about these issues.

ANDREA: Nia says starting with vā helped set a strong foundation for the fonos.  She included an old Tongan metaphor in the curriculum.

NIA:  Fofola e fala (kae talanoa e kāinga)- which basically just means to roll out the mat so that they can have a deep discussion. And normally when you use a metaphor, it is really to try and address something that is a deep issue.

ANDREA: They structured the program to provide participants a space to reflect on their lives and their families in a new way.

NIA:  There are many times when participants were really emotional about the curriculum and it kind of spoke to home how much people have really not had the opportunity to speak about something like that, or even really sat down to really think about it, right?. It was almost like connecting the dots in some ways.

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ANDREA:  For the participants that were younger and further removed from their Pacific culture, it gave them a chance to reconnect to their roots.  Brittney remembers this was especially true for one group of younger participants.

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BRITTNEY:  What was  really cool as they would go back and talk to their mom and dad or auntie and uncle, and be like, do you have a hope? Is this true? You know, and they'd be like, Oh my gosh it is.  Which is so cool that our program was prompting them to talk with their parents or their grandparents, or about their culture.

ANDREA: They included a communication activity to help facilitate more of that dialogue.  It starts with two participants asking questions as they face each other.  The activity sets participants up for deeper conversation.  Brittney remembers a mother and son that did the activity together.

BRITTNEY: At first they're just laughing, you know, like I like you because you're my mom, you know what I mean?  And then it goes deeper into like, when you're hurting, this is what I want you to do. And they answer it. And we had people say, I've never said that to my mom before. And  people would end up in tears because they've never been able to express those things to each other.

ANDREA: Britney says the experience felt sacred.

BRITTNEY: We had some really beautiful experiences in our group where it was the first time women had ever shared that they lost a baby. And we had that happen between siblings.  And it was hard, there were a lot of tears shed, you know.  But to see people talk about things that they never talked about before, felt like they have never been given space to talk about before was so beautiful.

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ANDREA: And it wasn’t just mothers who were affected.

NIA:   We had one participant say like, dang, I let my wife go through all of these things. And I didn't even really think about it. And now I see that I should have done more.

BRITTNEY:  I think that if anything that came out of this project, those discussions were the best part.

ANDREA: Through creating an open and safe space, the facilitators could then more easily introduce educational topics to participants.  One example is birth spacing.

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BRITTNEY:  We saw a really  high percentage of women who were not having adequate birth spacing, which is the time that after you have your last baby, until you conceive the next to give women time to heal.

ANDREA: When the program introduced the idea of birth spacing in the pilot group, it was not received well. 

BRITTNEY:  It was like, they're trying to control how many kids we have cause they don't want our families to be big and they don't want us to take over.

ANDREA: But introducing it in a culturally relevant way made a difference. 

BRITTNEY: We were able to link the two to say, you know, if we practice birth spacing the child has more time on the kaliloa and aliloa which gives time for the mother to heal and it benefits the child and the culture is actually more intact because of that.

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BRITTNEY:  We had a complete opposite reaction when we included the kaliloa and aliloa they're like, yeah, we get it, we accept this.

ANDREA: The program taught participants that historically, Native Hawaiian and Pacific Island families would wait until a child could throw a stone before having another, which matches with the recommended 18 months.

BRITTNEY: And it was great to say that it's, yes, medical science supports this, but actually their ancestors knew this before medical science, you know?  And so  I love this project for that reason that we're able to marry culture and science and it's just reminding them of how beautiful, smart, you know, helpful, I can't even find the words to describe it that their culture is, if we're able to hold on to it.

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ANDREA: The program had some clear successes.

BRITTNEY: We saw increases in the participants being able to talk to their family members about pregnancy. We also saw increases and then being able to coach family members and community members.

ANDREA:  Awareness of maternal and infant health increased across all topics.

BRITTNEY: Birth spacing was actually the one where only 25% of people knew what birth spacing was. But by the end, almost 100% knew exactly the recommendation for birth spacing,

ANDREA: But one of the happiest outcomes was that 100% of participants felt it was culturally relevant to them.

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ANDREA: As a Tongan American, Nia loved to see the program connecting people with their culture in new ways.

NIA:  I feel proud that we actually came up with something like that because it was really meaningful.  We had people that said, Oh, this is the first time I was able to even talk about something so important, but still so very Pacific. And it really helped them to really understand the urgency. And it made them understand also different things about their own identity and culture that they were never able to really vocalize before.

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NIA: I think that was one of the coolest things for the It Takes a Village program.

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BRITTNEY: I think it's so important for us to take into account the home and different people's experiences and their, and their families. But also we have to change the systems and infrastructures around that as well.

ANDREA:  While providing education is a big part of Brittney’s job, she says working to create equitable systems is another important part.

BRITTNEY: So that when families  go to make those changes, but it's, there's an environment, there's a system, there's infrastructure that supports that.  It has to be both. One without the other is going to fail.

ANDREA: She says that it’s important to understand the different needs of communities.  What works well for the majority might not work for everyone. 

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BRITTNEY: And so I just, that’s where my passion is, that’s where I want to work, is making sure their voices are heard.  Or someone thinks about them, or is designing for them, or is interested in them and understands their challenges.  Or is at least willing to learn about their challenges.

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BRITTNEY: We make things for people because that’s what matters. 

ANDREA: As for Timaima, participating in It Takes a Village taught  her a lot about maternal and infant health. So much so she was actually hired on by the project as a facilitator.  But the biggest thing she got out of the program - was the connection to her community and her culture.

TIMAIMA:  Family is the heart of our society. We protect each other, we respect each other and we fight with each other. We sacrifice together. We cry together. We celebrate together. Our ancestors valued and practice cultural wisdom and the sharing of it. My parents, my aunts, my uncles, the elders, they shared their wisdom with me since I was a baby. And now I have my own family. I'm carrying on the legacy to my children and hoping that they will one day pass on the legacy as well.

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TIMAIMA: So I’m so grateful for this cultural practice that was shared from my grandmother to my mother, to me.

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ANDREA: To Learn more about It Takes a Village and the Office of Health Disparities, visit www.pbsutah.org/morethanhalf

This is a PBS Utah production. Subscribe wherever you get your podcasts and please rate and review. Research, interviews and production conducted by Alicia Rice and Ashley Swansong. Audio mixing by Will Montoya.

I'm Andrea Smardon, and I hope you'll join us next time on More Than Half.

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