‘Tausi Feagaiga: A Project to Train Caregivers and Empower the American Samoan Community

Abstract

The ‘Tausi Feagaiga (Covenant Keeper) project was a partnership to support the traditional values of tausi matua (caring for one’s elders). The partners included a non-governmental organization (Pacific Youth and Community Development), a faith-based organization (Roman Catholic Diocese of Samoa-Pago Pago), and an institute of higher education (University of Hawai‘i John A. Burns School of Medicine). The project was created to address the lack of community-based health care such as home health or hospice, and families needing to work outside the home. A culturally based caregiving curriculum was developed to educate caregivers and improve their knowledge and skills. Using a train-the-trainer model, 125 caregivers were trained in family caregiving from 2016–2020. Training was conducted through an intensive workshop followed by practicum at Hope House, the Catholic Diocese home for the aged. Participants who expressed a willingness and competency were mentored to be trainers to continue the ‘Tausi Feagaiga project. The mean self-rated confidence in caregiving improved significantly from 3.17 ± 1.02 (mean SD) pre workshop to 3.53 ± 0.71 post workshop (P = .001). Competence in geriatric syndromes was improved from 18.04 ± 4.27 to 21.31 ± 4.30 after attending the workshop (P < .001) and the feedback was extremely positive. Technical assistance was provided to obtain funding through American Samoa Medicaid State Agency to improve the existing infrastructure of Hope House, obtain much needed supplies, and increase ability to hire the participants. ‘Tausi Feagaiga positively impacted the lives of the residents of Hope House, the course participants, the elders in the community, and those who care for them.

Introduction

American Samoa is an unincorporated territory of the US and Pago Pago is the territorial capital home to approximately 49 000 people.¹ Approximately 90% of the land is held in communal or village ownership and is administered by ‘matai, titled heads of ‘aiga or extended families, through a centuries-old family governance system. This system of rituals and practices is sustained by an intricate network of relationships that prize reciprocity and collective wellbeing. The ethnic majority of the population is Samoan (88%), and the remaining are classified as Tongan (3%), Asian (3%), and mixed and other (6%). Samoan and English are the primary spoken languages. The median age in American Samoa is 27 years old. The life expectancy at birth is 71.1 years for men and 77.8 years for women.² The population over 65 years of age and older has increased from 529 people in 1960 to 3216 in 2022.³

The foundation of the Samoan culture is Fa‘a Samoa, or the Samoan way. Fa‘a Samoa is collectivist in orientation and permeates every aspect of modern life. Fa‘a Samoa is reflected in how the land tenure and village governance systems, and family well-being is favored, as motivated by traditional values such as fa‘aaloalo (courtesy, respect, and politeness), alofa (compassion), agamalu (humility), osi aiga (proactive support of family), tausi matua (caring for elders), and loto fesoasoani (heartfelt outreach and support).

Lack of physical activity, proper nutrition, and tobacco use are among the major risk factors causing dramatically high rates of non-communicable diseases in American Samoa. Population surveys show that 93% of the adults are overweight or obese and 47% have diabetes.⁴ The leading causes of death include heart disease, diabetes, cancer and stroke.⁴ Many persons with disabilities live in isolation with limited access to proper health care resulting in premature death. With families having to work, there is an increased need for care of the disabled and elders. There is no welfare system in American Samoa, however, a federally funded food stamp program is available for elders and children with special needs. There are approximately 1300 American Samoa residents receiving Social Security Disability benefits from the Social Security Administration each month.⁵

There are no home health agencies, hospices, care homes, nursing homes or other forms of community-based health care. Services and programs for the seniors in American Samoa are provided by the Area Agency on Aging funded by the Older Americans Act. The American Samoa Government’s Territorial Administration on Aging (TAOA) is the lead agency responsible for programs and services for seniors and is one of the few resources available. TAOA administers federally funded programs to provide hot meals, nutrition education, disease prevention, caregiver support services, and part-time employment. Due to limited funding these programs are largely provided at the TAOA center, not directly offered at home.

Although fa‘a Samoa culture expects families to take care of their own, the demands of the current economy with limited job opportunities and low wages compels the majority of adults to go to work with no one in the home to serve as a full-time caregiver. However, committing the disabled or elderly to institutional care outside of the home is shameful and frowned upon within the Samoan community. Thus sometimes, the disabled or elderly loved ones are left at home, unsupervised, and without anyone to ensure their safety and help them with needs of daily living.

Hope House operated by the Catholic Diocese is the only facility in American Samoa that provides 24/7 care for the elders and disabled, and it has a continuous wait list. It was originally founded by the Sisters of the Nazareth in 1987 as a home for the poor and needy. At that time, individuals who did not have a next of kin or ‘aiga were admitted to Hope House. The only exceptions were severely disabled children who needed care that was above and beyond the capability of their own family. Hope House was staffed by 1 registered nurse, 1 certified nurse assistant, 3 nurse aides who receive nominal stipends as compensation for their work and 20+ volunteers. Almost 30 years later, the community need for assistance at Hope House has grown exponentially because of the increasing number of elders and adults with special medical needs who require advanced care. Thus the ‘Tausi Feagaiga (Covenant Keeper) project was born.

The ‘Tausi Feagaiga project was a partnership developed in 2016 between a non-governmental organization (Pacific Youth and Community Development), a faith-based organization (the Roman Catholic Diocese of Samoa-Pago Pago), and the University of Hawai‘i John A. Burns School of Medicine. The purpose of ‘Tausi Feagaiga project was to create a sustainable caregiver program to improve the lives of American Samoan elders. The goal was to train participants to perform caregiving skills and for them to teach these skills to family caregivers. Secondary goals were to increase the sustainability of Hope House to improve the access to long-term care for elders and adults with disabilities.

Methods

‘Tausi Feagaiga was developed based on an existing Family Caregiver Certificate that had been created by Pacific Islands Geriatric Education Center (PIGEC) and successfully piloted in the Republic of Palau, as well as neighboring US Affiliated Pacific Islands. PIGEC’s mission is to promote training in geriatric education in the Pacific Islands to improve health care for older adults and persons with disabilities. The core curriculum of the Family Caregiving Certificate was divided into 4 main competencies: caregiver health literacy, mental health, hands-on skills training, and a field practicum.⁶ The training covered topics such as activities of daily living, common medical problems, wound care, proper use of durable medical equipment, managing difficult behaviors, and caregiver burnout. Table 1 describes the modules and learning objectives. The participants underwent didactics in various caregiving topics and geriatric syndromes. Geriatric syndromes include a number of conditions typical of aging such as pressure ulcers, incontinence, falls, functional decline, dementia and delirium.

Table 1.

Core Curriculum of the Family Caregiving Certificate Modules and Learning Objectives

Session	Module	Learning Objectives
1	Normal Aging Cultural Aspects of Caregiving	Understand the general principles in caring for the elderly. Strengthen the cultural aspects of caregiving in Samoa. Increase knowledge on the physical changes associated with aging.
2	Gait and Transfer Training Fall Prevention	Learn strategies to prevent falls at home. Training on gait and transfers techniques. Proper use of durable medical equipment such as canes, walkers, and wheelchairs.
3	Pain and Symptom Management Managing Difficult Behaviors	Understand the World Health Organization (WHO) approach to pain management. Learn non-pharmacological approaches to managing difficult behaviors. Improve communication with persons who have dementia.
4	Activities of Daily Living - Part 1	Learn the importance of proper hygiene. Increase confidence in performing activities of daily living. Competence in giving a bed bath.
5	Activities of Daily Living – Part 2	Understand the importance of oral care and dental hygiene. Learn dietary recommendations for chronic diseases. Describe strategies to improve appetite.
6	Wound care and Bedsore Prevention Common Medical Problems	Increase knowledge on prevention of bed sores. Learn signs and symptoms of a heart attack and stroke. Understand common medical problems affecting the elderly.
7	Relieving Family and Caregiver Stress	Describe stress management strategies. Recognize signs of caregiver burnout. Increase knowledge of community resources available for the elderly and disabled in Samoa.
8	Practicum	Practicum at Hope House to provide trainees a real-world experience. Hands-on skills check and assessment. Opportunity to work with an interdisciplinary team.

The family caregiver training curriculum was modified and tailored to meet the needs of the volunteers at Hope House and family caregivers in American Samoa. Caregiving handouts were translated into Samoan. The workshop integrated local culture and included role play, the teach-back method, and hands-on demonstrations. ‘Tausi Feagaiga revised and adapted the curriculum to ensure cultural sensitivity and linguistic competence for its intended audience. The ‘Tausi Feagaiga planning team met weekly to address the participant training needs and involvement of guest speakers. Physical therapists from Lyndon B. Johnson Hospital and nurse faculty at the American Samoa Community College were recruited to provide additional training. In year 2, an advanced caregiver training was conducted for the year 1 cohort. This included topics such as stroke, depression, Alzheimer’s disease, delirium, polypharmacy, and substance abuse. Higher level skills such as peg tube care, Foley catheter care, and proper use of a Hoyer lift were taught. The advanced level training only occurred in year 2 and not in subsequent years due to lack of interest among future cohorts for an advanced level training and inability to offer a longer time commitment.

The week-long intensive in-person workshop was followed by monthly webinars distance learning with PIGEC and a practicum at Hope House. The long-distance learning was well attended and further instilled the principles of the culturally based curriculum. Hope House facility was used as the primary training site as well as the venue for providing the 10-months of experiential learning practicum. Participants were matched with severely disabled residents whom they visited weekly and practiced skills including transfers and gait training, medication management, and personal care services. They were given the opportunity to provide families with health education to improve health literacy. Nurses working at Hope House served as mentors for the trainees.

Participants self-evaluated their competence and confidence to teach specific geriatric skills before and after attending the workshop using a Likert scale of 1 to 5, with 1 representing a low rating and 5 representing a high rating. Each year approximately 20 volunteers obtained the necessary knowledge and skills to deliver proper and appropriate care for Hope House residents through formal training and certification.

In years 4 and 5, a caregiver creativity workshop was added to address unmet emotional needs and caregiver burden. Former participants were not invited as the numbers for the workshop would be too large to permit smooth facilitation. The goal of the creativity workshop was to facilitate creativity and self-expression where participants wrote and performed short prose and poetry pieces. Caregivers were encouraged to imagine, read, dance, and speak in a safe nurturing environment. The facilitator encouraged them to speak and write using all their senses, visualize deeply, and become aware of sensations arising in their body. Some of the exercises included: What does fear smell like? What does inspiration taste like? Gather a poem using objects from nature.

Data was collected on all participants to the fullest extent possible. Descriptive statistics with means and percentages were used to characterize participants. A pre-post test containing 28 multiple-choice questions was administered to assess knowledge of core geriatric topics. A score of 1 point was awarded for every correct answer. There were 4 questions for each geriatric syndrome, summed scores range 0–4 for each category. These questions were developed by PIGEC and used in past training conducted in Palau and Yap.^6,7 The post-test was administered on the final day of the week long intensive in-person workshop. To assess changes in knowledge and confidence to train and teach specific geriatric skills, values from the pre- and post-questionnaires were compared using paired t-tests. Data was analyzed using SAS version 9.1.3 (SAS Institute, Cary, NC).

Hope House and the Catholic Diocese did not have an ethics committee or institutional review board. The board of directors of Hope House and Pacific Youth and Community Development gave approval for the project. The caregiver training was considered usual care for Hope House volunteers and exempt from research. While no written informed consent was obtained from the participants, oral consent was provided by the participants to share lessons learned.

Results

The year 1 cohort of 19 trainees went on to further train 106 family caregivers. The trainers were supported in their teaching through an advanced course in year 2 and ongoing monthly webinar didactics. ‘Tausi Feagaiga trained 125 participants as caregivers over 5 years. These included community health workers, nurses, and family caregivers. The majority were Samoan, followed by Tongan. Participant demographic information was missing for 7 participants while years of caregiving experience was missing for 75 participants because they did not understand the interpreter or were in a hurry to return home to their families. Eighty-seven participants were female, 30 were male. Sixty participants were high school graduates, 13 had less than high school education, 27 had some college, and 14 had a college degree. The majority were in the age range of 40–49 years with less than 5 years of experience. Demographic characteristics of the participants are described in Table 2.

Table 2.

Demographic Characteristics of ‘Tausi Feagaiga Participants (N = 118)^a

No.	Variable	Frequency (%)
1	Sex (n = 117)
	Male	30 (26%)
	Female	87 (74%)
2	Ethnicity
	Samoan	89 (75%)
	Tongan	12 (10%)
	Caucasian	2 (2%)
	Other Pacific Islander	5 (4%)
	Other	10 (9%)
3	Primary Language
	Samoan	90 (76%)
	Tongan	7 (6%)
	English	17 (14%)
	Other	4 (4%)
4	Age
	10–19	6 (5%)
	20–29	28 (24%)
	30–39	20 (17%)
	40–49	33 (28%)
	50–59	22 (18%)
	60 or older	9 (8%)
5	Education (n = 114)
	Elementary School	13 (11%)
	High School	60 (53%)
	Some college	27 (24%)
	College degree	14 (12%)
6	Years of Caregiving Experience (n = 50)
	<5	27 (54%)
	5 to <10	9 (18%)
	10 to <15	8 (16%)
	15 to <20	3 (6%)
	20 to <30	3 (6%)

^aParticipant information was missing from 7 participants.

Self-rated competency of the participants with regards to skills on common geriatric syndromes before and after participating in the workshop is shown in Table 3. Data on 113 participants who completed both the pre and post-tests are shown in the table, paired data are missing for 12 participants who completed only one assessment. Competency in geriatric syndromes was significantly improved after attending the workshop. Topics such as gait and fall prevention, pain and symptom management, activities of daily living, oral care, and nutrition had statistically significant improvements (P < .001) in scores.

Table 3.

Participant Caregiving Knowledge (N = 113)^a

Knowledge Question Categories	Pre-Training (Mean ± SD)	Post-Training (Mean ± SD)	Change (Mean ± SD)	P-valueb
Normal Aging	2.96 ± 0.80	3.02 ± 0.90	0.06 ± 0.80	.415
Gait and Fall Prevention	2.01 ± 0.94	2.87 ± 1.04	0.86 ± 1.08	<.001
Pain & Symptom Management	2.07 ± 0.89	2.97 ± 0.99	0.90 ± 0.98	<.001
Activities of Daily Living	2.37 ± 0.95	2.51 ± 1.14	0.14 ± 1.13	.186
Oral Care and Nutrition	2.26 ± 1.04	2.97 ± 0.95	0.71 ± 1.02	<.001
Common Medical Problems	3.22 ± 0.90	3.53 ± 0.74	0.31 ± 0.94	.007
Relieving Caregiver Stress	3.17 ± 0.99	3.46 ± 0.77	0.29 ± 1.05	.004
Overall Summary Scores	18.04 ± 4.27	21.31 ± 4.30	2.56 ± 3.01	<.001

^aParticipant information was missing from 12 participants who completed only one assessment.

^bP-value based on paired t-tests.

The self-rated confidence to teach geriatric topics pre workshop was 3.17 ± 1.02 and post workshop was 3.53 ± 0.71 showing significantly improved scores (P = .001) after attending the workshop (not shown in table). Participants were very pleased with the overall quality of the workshop, mean score 4.68 based on a 1–5 Likert scale. Mean satisfaction with the handouts translated into Samoan were 4.40 while content of the modules was 4.69. See Table 4 for satisfaction survey variables. Some of the comments were: “I learned so much, this will help me in caring for my family,” and “Teachers were encouraging and motivating.”

Table 4.

Participant Satisfaction Survey after attending the ‘Tausi Feagaiga Family Caregiving Certificate Train-the Trainer workshop (N = 113)^a

No.	Training Evaluation	Mean ± SDb
1	Handouts	4.66 ± 0.56
2	Translations	4.40 ± 0.88
3	Demonstrations	4.64 ± 0.55
4	Audiovisuals	4.48 ± 0.66
5	Content of the modules	4.69 ± 0.55
6	Educational materials	4.62 ± 0.60
7	Trainer’s knowledge of content	4.63 ± 0.82
8	Trainer’s teaching skills	4.65 ± 0.70
9	Activities such as role plays	4.63 ± 0.61
10	Overall quality of the training	4.68 ± 0.56

^aParticipant information was missing from 12 participants.

^bLikert Scale of 1–5, where 1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent

Monthly webinar didactics conducted with PIGEC had an overall attendance of 70%. Poor internet in American Samoa contributed to technical difficulties. The practicum at Hope House was a welcomed field training with 95% of caregivers availing of this opportunity weekly to hone their skills.

The product of the caregiver creativity workshop, short story poems and songs, were developed into a booklet in year 4 and a video in year 5.⁸ O Ai Ea A’u in Figure 1 is a collage poem, a compilation of literary composition from the participants. It was an invitation to explore what it means to be a caregiver. These products were shared with participants and grantors.

Figure 1.

O Ai Ea A’u (Who I Am)

Discussion

For most Samoans, an underlying philosophy in the family structure is that children will serve their parents forever. This is the concept of tautua, or service. Until recently, it was almost unheard of for Samoan elderly to go to rest or retirement homes. It is more likely they would live out their lives with one of their children, usually their eldest daughter, whose siblings would help with the financial cost of their parents’ care. The basic tenet is that a loving obedient child who takes good care of their parents will be blessed by the service of their own children.

A train-the-trainer model was incorporated, where graduates from previous cohorts co-taught the curriculum with the PIGEC faculty for subsequent cohorts. This allowed the training to be conducted in Samoan and Tongan without much need for interpretation. Short skits, live demonstrations, poster boards, crafts, song and dance were some of the innovative methods of instruction used by the graduates. The new teaching role boosted the self-confidence and self-esteem of the graduates. Some even expressed a desire to study further and pursue a career in health care. A partnership was created with the American Samoa Community College to establish a pathway for the participants to obtain certification as a nursing aide and a nursing degree if desired.

The creativity workshop was extremely popular with the participants as it tied into the local culture of song, dance, poems, drawing, and drama. There is a certain kind of alchemy in writing poetry. Metaphors bring healing by helping people to listen to their inner voice that guides them to share stories only they can tell. The workshop facilitator and faculty found it incredibly moving to see what the participants created. Creativity rose quickly to the surface finding its form in word, song, or dance. It brought a sense of joy and liberation to the participants who were creating.

Care for residents at Hope House over the years has been sustained by the community fundraising efforts and subsidization by the Catholic Diocese. The American Samoa Medicaid State Agency only covers hospitalizations and outpatient provider visits. Long-term support services are not included. In 2020, Hope House was granted a designation of a Medicaid Assisted Living Facility Provider. This additional funding has improved the lives of the residents by providing salaries for trainees and staff, monies for much needed improvements of the facility, and purchase of supplies. The primary source of referrals to Assisted Living would be from Lyndon B. Johnson Hospital and the Department of Health.

Lessons learned from this partnership were that community buy-in is key to recruitment and sustainability of the project. American Samoa has a fairly large Tongan population who migrated for employment at the Starkist tuna cannery. Handouts were only translated into Samoan, Tongan translations should be provided at future trainings. There were many positive outcomes as a result of the 5-year ‘Tausi Feagaiga project that impacted the lives of many in American Samoa. The strengths of the project were the changed lives of the Hope House volunteers who demonstrated the ability to continue the program with new participants. They now have increased opportunity for education and income with the potential of being hired at Hope House. ‘Tausi Feagaiga empowered them with additional skills and knowledge to either obtain employment in the home health care field or start up their own microenterprise as a sole proprietor and independently contract their services to families or partner agencies including TAOA and the hospital.

Some of the limitations of the project were unforeseen natural disasters that affected participant’s learning. In Year 3, tropical cyclone Gita led to cancellation of the final day of the workshop. In Year 5, COVID-19 pandemic led to the inability to continue the practicum at Hope House due to social distancing requirements. Follow up with the graduates to evaluate long term outcomes on caregiving were also limited due to the pandemic.

Future research is needed to determine the sustainability of home care. The number of jobs created, satisfaction of families, unmet needs, cost, utilization of hospital and emergency room could also be evaluated. The formal relationship concluded with the ending of the grant and with the shutdown of the island from COVID-19 pandemic.

Conclusion

‘Tausi Feagaiga increased the capacity of family caregivers to properly care for their loved ones in the home. This project transformed the lives of the participants empowering family caregiving and strengthening the existing culture of tausi matua. An important related outcome is that Hope House which depended on charitable fundraising is now reimbursed as a Medicaid Assisted Living Facility. This far reaching project impacted the current residents, future residents and caregivers of Hope House by improving their living environment, nutrition, equipment and the quality of care they receive.

Glossary

Abbreviations

CMS

Centers for Medicare and Medicaid Services

COVID

Coronavirus Disease

PIGEC

Pacific Islands Geriatric Education Center

TAOA

American Samoa Government’s Territorial Administration on Aging

Conflict of Interest

None of the authors identify a conflict of interest.