Abstract
Introduction
Tongan-Americans face severe disparities in health including diabetes, cardiovascular disease, and cancer. Educational disparities also affect health opportunities and well-being, influencing health status and community capacity to address disparities. Few resources have been identified within the Tongan-American community to address these concerns. The Tongan American Health Professionals Association (TAHPA) was conceived to identify and develop health and health career resources for the Tongan community. Through TAHPA, the Tongan-American community is utilizing a community-empowerment approach to address disparities and well-being.
Methods
TAHPA was formed in 2008 through the leadership of individuals with a vision of a healthier Tongan-American community. TAHPA’s purpose was to inspire and empower the Tongan-American community by developing an organization of Tongan-American health care professionals and pre-professionals, celebrating their accomplishments, and providing resources and support for educational and career development. Founders gathered in small work groups in community settings to discuss health concerns, well-being and solutions. Key community members facilitated the process to establish goals and objectives.
Next Steps
To date, 40 Tongan health professionals and pre-professionals have become members. TAHPA’s vision and outreach processes have been developed. TAHPA’s uniqueness and strength is that it is rooted in the community, created by the community to serve the community.
Keywords: Diversity in health professions, Mentoring, Community-based, Tongan
Introduction
The focus of this paper is to describe the development of a new network, The Tongan American Health Professionals Association (TAHPA). TAHPA’s purpose is to inspire and support Tongan individuals by celebrating the accomplishments of professionals and pre-professionals, and by providing resources and a support system for educational and career development. We believe this will lead to 1) community engagement and education around health, educational, and wealth disparities facing the Tongan community, 2) an increase in role models and resources for higher education, especially in health careers, to empower community members to achieve educational and economic success, and 3) improved community access to healthcare by training more Tongan health professionals.
Prior research has shown that there are severe shortages of minority health professionals. According to Libby et al. (1997), in order to eliminate racial and ethnic disparities in physician-population ratios, the number of first-year residents would need to double among Hispanics and African Americans, and triple among American Indians (Libby et al., 1997). This disparity in physician-population ratios may be particularly severe for Tongans; data from the U.S. Census 2000 indicate that there were only 41 Tongan physicians per 100,000 people, meaning that more than five times as many Tongans would need to be trained in order to eliminate the disparities they now face.
Training more Tongan to become health professionals would likely bring many benefits to Tongan communities. It has been well documented that, once trained, minority physicians are more likely to serve predominantly minority, low income, and medically underserved communities compared with white physicians (Rabinowitz et al., 2000; Komaromy et al., 1996; Moy & Bartman, 1995). Patients who can be treated by health care providers of their own ethnic and/or cultural background often report greater satisfaction with care and better communication with their physician (Morales et al., 1999), and more satisfaction with their ability to participate in their healthcare decisions (Cooper-Patrick et al., 1999; Kaplan et al., 1995). Furthermore, these individuals can serve as invaluable role models and sources of leadership and pride for the community.
Background: Tongans in the U.S
In order to provide background and context, we present a brief review of Tonga and Tongan-American social and economic issues.
History and geographic information
Tonga, population 101,991, is part of the sub-Oceanic region, Polynesia, which spans from the central to the southern Pacific. Tonga falls within the eastern wall of the Polynesian triangle, as it is sometimes referred to, with its corners in Hawaii, New Zealand and Easter Island. The Kingdom of Tonga was a former British protectorate that became fully independent in 1970. Tonga is the last remaining monarchy in the Pacific, is also known as the only island nation in the region to avoid formal colonization. The primary languages spoken in Tonga are Tongan and English, the predominant religion is Christianity.
Tongan immigration to the U.S. has remained constant since the 1960s, attributed in part to a search for better economic opportunities (Small, 1997). According to the 2000 Census, there were 36,840 Tongans in the U.S.; about 41% (15,252) lived in California (APALC, 2006). The vast majority of the Tongan American diaspora settled in the western United States: California, Hawaii, Washington, Arizona, Utah and Texas. In California, the Tongan population is found in Los Angeles, San Francisco Bay and Sacramento areas. Tongan Americans that live in Los Angeles County live in cities such as: Lennox, Inglewood, Hawthorne, Lawndale, Long Beach, Lakewood, Compton, Bell Flower, Norwalk, Hacienda Heights, and Pomona; in Orange County: Anaheim, Buena Park and Santa Ana; and in San Bernardino County: San Bernardino, Fontana, Ontario and Rancho Cucamonga. Tongan Americans are also found in Riverside and San Diego Counties. There were approximately 5,085 Tongan Americans in Southern California (APALC, 2005); 47% were foreign-born, and 33% reported having become naturalized citizens (US Census 2000). It is important to note that census data are thought to undercount minority and immigrant communities who are suspicious of government institutions (Nguyen, 1996; Williams, 1996).
Economic status
Socioeconomic status indicators paint a picture of a struggling Tongan immigrant population. Tongans have among Los Angeles County’s lowest per capita incomes, and more than one in four Tongan Americans (28.5%) in Los Angeles County live under the Federal Poverty Level (US Census 2000).
Health status
Tongans suffer from high rates of chronic diseases such as cardiovascular disease, diabetes, and cancer. High rates of poor health behaviors associated with westernization (such as tobacco and alcohol use, consumption of processed foods, and an increasingly sedentary lifestyle), barriers to healthcare access (such as low income, low rates of health insurance coverage and linguistic barriers) put Tongans at increased risk for a poor health status (Ulijaszek, 2005; Tanjasiri et al., 2002; Tanjasiri et al., in press;). Although specific data are not available for the undocumented Tongan immigrant population, community leaders believe that a significant proportion of Tongans face barriers to health care access, economic, and educational opportunities. Multiple families frequently live under one roof in order to minimize household expenses, and to encourage young adults to become income earners rather than to pursue educational goals to support the family.
Southern California Tongan communities live in densely populated urban environments. Some families lack access to the physical spaces conducive to physical exercise or activity, such as residential yard space, parks and other safe open spaces. Gang cultures prevalent in densely populated urban areas where most Southern California Tongans reside create public safety as another barrier to accessing open spaces. Low performing or underfunded schools in these areas also suffer and are unable to provide a competitive course of study fit for college preparation or extra-curricular activities like full athletic programs.
Occupation
Tongans, like many other Pacific Islanders in the US, are employed at high rates in service occupations, such as “healthcare support” (US Census 2000). Tongan Americans that work in the health care field are largely employed as caregiver’s provide health care support, especially in-home health and supportive care. The implications of this are twofold. First, many community members are employed in sectors with low rates of employer-sponsored health insurance coverage and face additional health insurance disparities associated with immigration status and limited-English proficiency (Ponce et al, 2008). Secondly, the high prevalence of employment as caregivers in the community may be leveraged to raise community awareness and interest in professional development opportunities in health careers.
Social structure
The Tongan community is a small, tightly-knit community held together by close, overlapping family, village, religious and high school ties in Tonga (Small, 1997). The Tongan community maintains these ties on a global scale. Some of the ways of maintaining these global ties are village and school reunions and church gatherings. Tongan churches in particular serve the role of the Tongan village in the U.S. Traditionally each village has a leader of noble blood who acquires the position as a birthright. All issues, communications and decisions within the village are filtered through an elected “town official,” who relays all communication to this noble leader through his talking chief. The hierarchy is well understood and respected within the village and maintains order in all village matters. In the absence of this, Tongans apply this structure to their churches. Tongans belong to a church the same way they identify and belong to a village. As such, churches have become the villages, with lay stewards as the talking chiefs, and pastors/bishops/priests as the leaders. To maintain Tongan identity, churches nurture Tongan culture through cultural celebrations and by maintaining the use of the Tongan language among the younger generation. Tongans view their church leaders as their champions and trust in their decisions. Churches serve as a community space for members to congregate for kava clubs, alumni and village meetings, youth groups, women’s groups and many other community functions beyond spirituality.
Education
Few Tongan students pursue college education, contributing to the low numbers of Tongan American health and other professionals. Only 9% of Tongans across the U.S., and 6% of Tongans in Los Angeles County, report having attained a bachelor’s degree or higher, compared to the Los Angeles County average of 25% (US Census 2000). Dire disparities in socioeconomic indicators underscore the need for community-based efforts to promote health and healthcare professionalization for Tongans in the U.S. The remainder of this paper describes one such effort to increase the visibility and pipeline of Tongan health professionals in Southern California.
Meeting the Social Service Needs of Tongans in Los Angeles County
Only through understanding and respecting Tongan culture, beliefs, and practices are we able to affect change in our community. It is important to consider the role of social networks when determining how best to address issues of concern in the Tongan American community. Effective interventions can only be developed when recognizing the existing and dynamic social structure.
In response to the growing Tongan population in Los Angeles, the Tongan Community Service Center (TCSC) (a program of Special Services for Groups), was established in 1988 to provide much-needed social services to the Southern California Tongan community, particularly the poor, undocumented, those with limited English proficiency, the elderly, disabled, and children.
In addition to direct service, TCSC seeks to empower the community and spur active engagement in addressing the interrelated issues of health, poverty, education, and immigration. The Center is the single most experienced agency in providing a wide array of culturally and linguistically competent services to the Tongan community in Los Angeles County. TCSC addresses health and social service needs relevant to diverse age groups, health conditions and social issues. For example, as part of the Centers for Disease Control Racial and Ethnic Approaches to Community Health 2010-funded Promoting Access to Health for Pacific Islander and Southeast Asian Women program (PATH for Women), TCSC developed Tongan language breast and cervical cancer educational materials, some of the first of their kind in California. These materials were developed to reflect beliefs and practices of the community, interweaving health messages with community activities such as making tapa (traditional bark cloth), meeting with church members, learning about healthy eating, and creating healthy recipes from local island foods. The concept of TAHPA was based on a growing recognition that despite this experience and expertise, community capacity could be further enhanced and developed beyond what TCSC could do alone by leveraging existing resources in the community.
Methods
Promoting the Development of the Tongan American Health Professionals Association
In the remainder of this paper, we review the development and anticipated work of the TAHPA network as it will interact with the existing networks of Tongan American communities. We examine the potential for the network to create awareness and mobilize efforts to simultaneously address many Tongan American issues, including health disparities, educational disparities, and community empowerment. We believe this will be achieved through a multi-dimensional model in which the highly interrelated issues of health; educational and economic disparities are recognized and addressed equally within the socio-cultural fabric of Tongan American life.
Staff at TCSC, including a health outreach specialist, health educator, patient navigator and project coordinator began the process of conceptualizing TAHPA in 2008. It began by researching existing models of ethnic and professional organizations and by conducting internet searches and eliciting input from knowledgeable community informants. Several organizations were identified, such as the Tongan Nurses Associations of Tonga and New Zealand, Voices of Tonga in Texas, and the Tongan American National History Association in Utah. Although there are non-profit organizations that address health disparities among Pacific Islander communities including Tongans in Los Angeles, such as the Pacific Islander Health Partnership and the Tongan American Youth Foundation, none were specifically addressing the need for a Tongan American health professional’s network, and to nurture an educational pipeline for Tongan American students interested in the health professions. TCSC envisioned a new group, one in which community members are engaged from its inception, to facilitate the development of a network among Tongan health professionals and students interested in pursuing health-related careers. This organization would create such opportunities through role modeling, mentoring, and other supportive resources for students, and would showcase the resources and expertise present in the Los Angeles Tongan American community.
Through word-of-mouth among individuals connected through family ties and social networks, a small number of Tongan health professionals who worked in the Los Angeles Tongan community were identified and introduced to the concept of TAHPA. TAHPA was also promoted at community gatherings, health-related workshops, and events to engage the interest of additional health professionals and students. Together, a core team of two TCSC staff members and three health professionals (a mental health professional, a registered nurse, and a medical assistant) held two in-person meetings in late 2008 and early 2009, with follow-up meetings via email, to develop of a set of goals and objectives for TAHPA. They began with a small set of proposed objectives based on professional experience of the TCSC health educator, and elicited feedback and input from members of the group.
This process led to the development of the name “Tongan American Health Professionals Association,” which was intended to reflect the multi-disciplinary focus of the organization, involving physicians from different specialties, mental health professionals, other clinicians such as nurses and caregivers, and students interested in related fields. The name TAHPA also echoes the Tongan tapa or bark cloth, traditionally used for clothing, blankets, and ceremonial purposes. Tapa is of great social importance among Tongans, and gifts of tapa play a significant role in events such as weddings, funerals, and events involving royalty. The name TAHPA speaks to the mother’s traditional role of collecting and distributing tapa as an expression of caring for the family and community. This process also led to a set of initially proposed objectives. These were designed to address TAHPA’s three overarching goals: 1) to engage and educate community around health, educational, and wealth disparities facing the Tongan community; 2) to increase role models and resources for higher education, especially in health careers, to empower community members to achieve educational and economic success; and 3) to improve community access to healthcare by training more Tongan health professionals. The final set of objectives and their associated goals are presented in Table 1.
Table 1.
TAHPA Goals and Objectives
Goal 1
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Goal 2
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Goal 3
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In late 2009, TCSC staff began to promote TAHPA at meetings such as bi-monthly TCSC community health education trainings, addressing topics such as preventive health, cancer screening, HIV, nutrition, diabetes, stress, and risky health behaviors such as alcohol and tobacco use. Information was disseminated to attendees about the development and objectives of TAHPA, and professionals and students who might want to get involved were recruited from the community. Information was further disseminated about the new network by word of mouth. A database was built of interested health professionals, including nurses, caregivers, mental health professionals, as well as students. To date, 40 individuals have registered as TAHPA members.
In addition, a needs assessment of members has been initiated. A TCSC staff member developed questionnaire items based on demographic information thought to be useful for promoting future networking and mentoring opportunities, as well as capturing factors that determine success in their educational and career pathways. The questionnaire covered significant Tongan social factors such as family name, home village in Tonga, religious affiliation, Tongan high school attended; best mode of contact including social networking websites (e.g. Facebook, alumni websites), educational background information, professional history; health topics the individual would be most interested in promoting; medical field in which the individual currently works or studies; reasons for entering health field and choosing career path, what the individual enjoys most about their current job or classes. Additional challenges respondents may have faced and overcomed in pursuing their career and educational goals, advice respondents would give to a young Tongans considering a health career or college degree, and recommendations for how TAHPA can best benefit the Tongan community.
Data collection is currently underway. Once complete, the information from these surveys, such as barriers and facilitators of career success, and advice for young people interested in health careers, will be summarized and used to inform and shape TAHPA’s focus. Members’ profiles and personal success stories will be disseminated through TCSC’s website and an in-print community newsletter to highlight the career paths of Tongan health professionals. This would ideally raise awareness of different health professions among Tongan youth, how challenges and obstacles were overcomed, and most importantly celebrate these individuals and their families as role models in the community. Three such profiles have been collected to date, and one TAHPA member’s profile has been published, along with her health advice to community members through the aforementioned TCSC website and newsletter.
Lastly, to further meet the needs of students, TAHPA has participated in a successful partnership with other Pacific Islander community groups to form the Pacific Islander Health Careers PIPELINE Program (Tran et al., 2010). In 2007, Orange County Asian and Pacific Islander Community Alliance (OCAPICA) spearheaded a needs assessment of health and educational disparities among Southern California Pacific Islander communities [funded by The California Endowment]. OCAPICA’s 2008 Pacific Islander Health Careers PIPELINE Program Report (PIHCPP) put forth findings and key policy recommendations to state policy makers such as college and high school administrators, community stakeholders, health administrators, funding organizations and community-based organizations. These policy recommendations advocate for actions that foster community coalitions and networks, community education and strengthen individual knowledge and skills. The goals developed by TAHPA’s initial meetings are consistent with goals of the Pacific Islander Health Careers PIPELINE program and reinforce increase focus on developing future Pacific Islander health professionals. In future rounds of PIPELINE we hope to leverage the growing TAHPA network to provide to Tongan students additional mentoring opportunities with Tongan health professionals.
The concept of TAHPA has been met with great enthusiasm in the community. Nonetheless, as is frequently the case when developing new programs, the formation and development of TAHPA has involved some challenges. The primary challenge faced by TCSC staff has been the time necessary to engage potential TAHPA members and supporters. Coordinating the already hectic schedules of members, community leaders, and TCSC staff has made arranging culturally critical face-to-face meetings a challenge to organize. In the current landscape of limited agency resources and competing priorities, it can prove difficult to dedicate staff time for this type of time and effort-intensive work. Fortunately, efforts invested in laying the groundwork for TAHPA are paying off and interest and membership continue to grow.
Future Directions
As recognized by TCSC staff and recommended by TAHPA members as an essential approach to working within existing, culturally significant Tongan social structures, TAHPA is seeking to open a dialogue within and among Tongan churches. Many Tongan faith-based institutions are successful in the spiritual needs and cultural networks within independent congregations, but have not traditionally community health issues. However, some community members and religious leaders are beginning to recognize that they may have an impactful role in addressing health needs of the Tongan community. In the absence of the village leaders that traditionally addressed health issues in Tongan communities, some Tongan church leaders in the U.S. are beginning to examine ways to address health issues and social needs. Some church leaders address the congregation members’ temporal needs through internal church social support services, but are seeking ways to go further develop these approaches, particularly in light of the needs resulting from the current economic recession. For example, Tongan alumni associations closely affiliated with church institutions are raising scholarships funds for Tongan American students. TAHPA will work to encourage community conversations about the ways in which Tongan churches, community-based agencies, and Tongan community health professionals can work together and support missions.
Some of TAHPA’s long-terms goals are to encourage the establishment of similar networks statewide and nationwide. Communication between smaller localized networks can be facilitated through an annual conference and a well developed website. Another long-term goal is to explore possible collaborations with the Ministry of Health in Tonga and its Health Promotion Unit as well as the Tongan Nurses Association which already exists in New Zealand. TAHPA’s long term educational goal is to increase opportunities for college education in health career tracks by developing a sustainable scholarship fund. This will help increase and promote research on the relationship between Tongan health and social disparities as more Tongan American scholars obtain higher education degrees. Another long-term goal is to connect TAHPA with mainstream health professional organizations and promote advocacy in priority issues. Eventually as this newer model of community network becomes more established, other networks can be fashioned to support professionals currently employed and/or sought after in the Tongan community.
Some next steps in TAHPA’s development include the following. First, we plan to develop mechanisms through which the community can find out about TAHPA professionals, such as through the TCSC website. We also plan to harness online social networks, such as Planet-Tonga and Facebook, to spotlight the successes of TAHPA health professionals. TAHPA also plans to eventually serve as a clearing house for resources on health career opportunities, related degrees and certifications, program entry requirements, costs and resources for financial assistance, and appropriate professional certifications (e.g., for caregivers). We hope to build and maintain relationships with institutions providing such training, as well as raise awareness among interested students, pre-professionals and professionals regarding national health professional networks, associations, and societies. It is our belief that more Tongan health professional will not only increase access to quality healthcare for Tongan Americans, but also serve as a catalyst to increase the development, implementation, and dissemination of health-related research relevant to the Tongan community.
In summary, TAHPA is a vehicle for community empowerment. TAHPA is a network formed by community members in response to the call from leaders and young people in the community for a means to provide opportunities for Tongans to break the cycle of low education, lack of professional job attainment and poverty and replace it with a cycle of success.
Acknowledgments
We would like to acknowledge support from WINCART: Weaving an Islander Network for Cancer Awareness, Research and Training, through funds from the National Cancer Institute’s Center to Reduce Cancer Health Disparities (Number U01CA114591). Diana Tisnado received support from The University of California Los Angeles Resource Center for Minority Aging Research/Center for Health Improvement of Minority Elderly (RCMAR/CHIME) NIH/NIA Grant #P30-AG021684, and from a UCLA Older American Independence Center Career Development Award, Grant #5P30 AG128748. The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the funders.
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