1Paula Braveman, MD, MPH Reggie Caldwell, LCSW What We KnowPaula Braveman, MD, MPHReggie Caldwell, LCSW
2The Problem2-3 times higher rates of adverse birth outcomes among African American babies4 times higher ratio of maternal mortality among African American womenTraditional prenatal care has not improved birth outcomesbut some promising results from Centering Pregnancy
3The ScienceThe birth outcome patterns suggest that social factors are involved. Prime suspects include:Stress – especially chronic, e.g., due to discrimination &/or economic hardships ; plausible physiologic pathwaysSocial support may directly improve health; affects health behaviors; buffers stress effectsEmpowerment --Self-efficacy plays key role in health behaviors; key to escaping poverty; lack of control at work strongly linked with heart diseaseEmpowerment-focused group approaches may be more effective than 1:1 (based on theory and data)In other words: SSE WAS ON THE RIGHT TRACK!
4Rationale for Revising BIH Great work happening, but varied across sites so impossible to evaluate impactBring BIH up to date with scienceMore emphasis on systematically addressing social factors as key determinants of health and health behaviorsFocus efforts to maximize impact
5The Revised BIH ModelCombined the best of original BIH models with promising practices: Amplified SSE strength-based group intervention, supported by empowerment- & referral-oriented case mgmtGoal: Decrease disparities by improving African American infant and maternal healthMay not be able to see a difference in birth outcomes, especially short-termBut current science tells us that at the least, if we focus, we can strengthen maternal capacity, behaviors, & social support, which should improve maternal and infant health
6Intermediate Outcomes Conceptual FrameworkIntermediate OutcomesBIH ActivitiesINDIVIDUALIncreased health knowledgeIncreased healthy behaviorsIncreased empowerment through improved life skills and coping skillsIncreased receipt of quality medical, social & mental health servicesDecreased unplanned pregnancyIncreased social support both for & among the womenDecreased stress by mobilizing resources and servicesImproved parentingIncreased bonding between mother & infantImproved infants’ developmental milestonesCOMMUNITYIncreased community and provider knowledge & cultural competenceIncreased community partnerships & linkages among service agenciesDecreased stressors in the community through community & provider/agency actionImproved understanding among community and providers of influence of social inequities on healthINDIVIDUALServices provided to African-American women, infants, and their families & partners include:Referrals to medical, social & mental health servicesHealth educationSocial and group supportIdentifying resourcesSelf-advocacyCOMMUNITYPromote community and provider engagement and advocacyEducate community and providers about influence of social inequities on healthProblemPoor birth outcomesSocial isolationLack of health knowledgeLack of access to quality health carePovertyRacismEnvironmental stressorsMaximizing impact of the program (numbers served & effect size)Lack of cultural awareness and skills among providersUltimate GoalTo improve African American infant and maternal health in California anddecrease Black:White health disparities and social inequities for women and infantsGUIDING PRINCIPLES1. Comprehensive and integrated: Address multiple risk factors and use multiple strategies2. Multi-level: Address individual, community, service systems and societal levels, with empowerment focus3. Collaborative: Partner with community providers and agencies with similar activities4. Community-driven: Developed, implemented and evaluated by local communities5. Evidence-based: Developed from proven or promising strategies; impact is measurable6. Culturally competent: Designed & implemented in a culturally-competent manner7. Staff training and professional development: Conducted to ensure the BIH activities are provided effectivelyDRAFT
7To Impact Maternal & Infant Health, BIH Needed To: Decrease isolation/increase social supportBuild self-esteem and empower women to make better choices about their healthDecrease stress/improve coping skillsInvolve communities
8Program Tenets Promote and support healthy pregnancy and parenting. Build on client’s strengths to enrich them, their families and their community by empowering them to make healthy decisionsCulturally relevant and honor the unique history and traditions of people of African descentAddress issues important to African American womenReduce disparities by improving African American maternal and infant health.
9Black Infant Health Program - Revised Model RecruitmentMeets program requirements?YesProgram CompletionComplete ICPComplete Life PlanComplete Case ClosureNoIntakeProgram orientation and consentReferralsPrenatal Assessment 1Initiation of Individual Client Plan (ICP)Case ConferencingStandardized health promotion message&Refer out to appropriate agencyCaseManagementthat complimentsthe group sessionsGroup Sessions11-201-10BirthPostpartumPrenatalCore Intervention
10GroupsUse facilitative learning to access and enhance women’s knowledge and skillsGroup format means women draw strength from each otherSkill-building to achieve better physical and mental healthWeekly personal goal setting culminating in the creation of a Life PlanFocus on empowerment to:Make good choices to have a healthy pregnancyBe a good role model for one’s child.
11Challenges Identified StaffResistant to changeReluctant about the revised model’s successGreat facilitationFocused on “What If’s”ClientsRetaining them in groups (transportation and child care issues)Motivation for long-term participation/competing priorities
12Themes from the Progress Report SuccessesChallengesSome staff are having difficulty embracing the new modelNew data bookClient transportationTime for case conferences and other staff meetingsServing clients with multiple stressorsCollaborations with providers, community partners, and BoardReceived or applied for a grantPositive feedback from clients about new modelIn-kind donationsFlexibility by training all staff as group facilitators
13The “Magic” is Happening StaffClientsI learn about myself while I conduct the groupIt’s challenging and worth it!I used harm reduction strategies to help a pregnant client stop smokingA place where negative messages are countered with positive onesI now have a vision for my lifeThe group constantly reminds me that we ALL have talentHow to we keep the “magic” going?
14Implementation Timeline ActivityStart DateTransition begin for Group 17/1/10Official start for Group 111/1/10Feedback from Group 1 of the revised modelRevise intervention based on feedback7/1/11Transition begins for Group 2Official start date for Group 210/1/11Interim Report of Findings2/1/12Feedback from Group 1 and 2 of the revised modelFinal Report of Findings1/1/13Reconvene Expert Panel~2/1/133/1/13Transition begins for Group 34/1/13Official start for all sites7/1/13