Behavioral Healthcare through the Consumer Lens: Maternal Behavioral Health & Substance Use Service

Hawaii’s Medicaid program decided to focus its Medicaid Innovation Collaborative (MIC) participation on the issue of maternal behavioral health. The state faces numerous challenges to providing mental health and substance use services to pregnant people, including geographic barriers, lack of providers, and services that are oriented around Western norms rather than Native Hawaiian culture. To better understand the key challenges and opportunities in this space, MIC partnered with the Center to Advance Consumer Partnership (CAPC) to conduct a series of focus groups and interviews with beneficiaries, providers, and community-based organizations. Among other topics, the research explored disparities in maternal behavioral health care for Native Hawaiians, including the ways in which care needs to be culturally tailored to and focused on the inequities facing this group.

Six areas emerged over the course of these conversations as key aspects of Hawaiians’ maternal behavioral health experience that need to be improved:

• Care navigation
• Provider access
• Holistic family support
• Culturally competent care
• Care avoidance
• Opportunities for voice and choice

The report explores these areas in detail, highlighting both the challenges related to them and the opportunity for tech-enabled solutions to help address them. To read more, see full report here.

Maternal Behavioral Health & Substance Use in Hawaii

Access to treatment and screening for both behavioral health and substance use, particularly in rural settings and among Native Hawaiian populations is inconsistent and limited. There are significant gaps in access to outpatient treatment and residential or inpatient treatment for pregnant and newly parenting mothers, especially in rural areas. Furthermore, many women do not receive regular prenatal care, have significant financial barriers (housing & food insecurity), and services are often reflective of Western structures versus respecting traditional healing practices. To make matters worse, the geography presents logistical challenges to travel between islands to access care. Mistrust and fear of the health care providers and partners is also significant. Domestic abuse and violence in the home also prevent women from seeking behavioral health and substance use services.

Furthermore, Hawaii has experienced the highest overall growth in substance use disorder in the nation between 2018 and 2019. An estimated 8.45% of Hawaiian residents over the age of 18 experience substance use disorder, which is higher than the national average of 7.74%.

Hospitals and health centers report high anecdotal rates of substance use and postpartum depression among both native and non-native Hawaiian women. Significant disparities exist between native and non-native Hawaiian women across multiple maternal health measures.

Opportunities for Innovation in Hawaii

In Hawaii, there are five themes regarding barriers and challenges when it comes to seeking, accessing, and maintaining care for maternal behavioral health and substance use treatment. Solutions should address one or more of these obstacles:

1. Navigating Care in a Fragmented Ecosystem

There is not unified way to find out what is available to me

When it comes to Hawaiian mom’s, they face significant challenges initiating care and maintaining ongoing treatment. Providers and community-based organizations report that women face multiple entry points into the behavioral health system.

It is also clear that women do not have a central location to which they can turn for information and support about services that are available to them. The biggest problem is that they are left on their own to navigate the “system”, which can include traveling to other islands for treatment, resulting in leaving their families behind. This is a cultural taboo among Hawaiian families.

2. Access to Providers

Finding providers who take my insurance and can take me when I’m ready for help is difficult and complicated

There is an acute shortage of providers and resources that accept Medicaid in Hawaii including low availability of appointments and beds with recovery providers. This includes challenges access substance treatment for pregnant or newly postpartum women.

To make matters worse, when psychiatric providers are available, they are often not Native Hawaiian. Women in Hawaii want to talk to doctors who have a similar lived experience to them, which is causing a problem in a system that is already lacking a sufficient number of psychiatric providers. For this reason, other Hawaiian providers have called for increased funding to not only attract and train, but specialize Native Hawaiians for the workforce. Public funding for substance use treatment services is not credentialed for Medicaid and is not reimbursable. Providers are forced to choose which services they can offer to patients, because they have to absorb the costs, resulting in some clinics not treating Medicaid beneficiaries and decreasing access to services.

3. Holistic Family Support

I’m the primary caregiver for my family - getting treatment impacts my ability to provide for them

Mothers are usually the primary caregivers in Hawaiian families and are relied upon to be stable and put family above all else. If a woman experiences behavioral illness, it often affects the entire family. A mother cannot easily leave her family to get addiction treatment without a fear of Child Protective Services.

Native Hawaiian culture values family and community above anything else. What happens in the family usually stays in the family and it is imperative to avoid shame. Solutions should consider families are managed by one or more parents and/or multiple generations.

4. Cultural Responsiveness

We don’t trust people who don’t understand our culture, beliefs, and values

Cultural needs among Hawaiian women reflect the importance of trust, time, family, and ancestral or native practices. Cultural sensitivities and nuances within the native Hawaiian population undercut care-seeking behavior and impact treatment preferences. For this reason, community organizations incorporate traditional healing practices which are different than modern ones.

However, substance use and behavioral health is highly stigmatized in Hawaii. Native Hawaiians believe that substance use and addiction were brought to Hawaii by Westerners. This also contributes to bias felt toward Western people, practices, systems and care. In the Micronesian languages, there is no word for  “depression”, “sadness” and “anxiety” so providers often have to replace questions with discussion.

5. Effective Engagement

If you don’t engage with us in ways we feel respected and heard, finding solutions will be hard

Since families in Hawaii avoid care for a variety of reasons mentioned in previous sections, it is essential to build community trust in order to initiate change and provide care to women and families.

To successfully engage the Native Hawaiian community, it is important to honor and respect Hawaiian culture and traditions in order to build trust in the community before doing any project work. Having been colonized, many residents still live the trauma of having their way of life uprooted. They are often skeptical of the methods Westerners use and rightfully mistrust groups from the mainland. Success in Hawaii hinges on the ability to build trusting relationships with local individuals and/or organizations that work with Native Hawaiians.