1. Adrian E. Dominguez, MS Spokane Regional Health District
“A Healthy Start: Spokane’s Future - Maternal and Infant Health”, Using a Community Health Assessment to Improve Health Equity and Social Justice in Spokane, Washington
Adrian E. Dominguez, MS
Spokane Regional Health District
Disease Prevention and Response
Community Health Assessment
APHA Annual Meeting and Exposition
November 10, 2010

2. Presenter Disclosures
Adrian E. Dominguez
The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:
No relationships to disclose

3. Spokane County Located in eastern Washington 1781 square miles
Population 459,000
90% of population is White NH
Average age is 35.4
Median HH income is $48,269
12.3% of population below poverty
Approximately 6,000 birth per year
City of Spokane is 20 miles from Idaho border
110 from the Canadian border
271 miles from Seattle

4. Spokane’s Future A Healthy Start: Maternal and Infant Health
This publication, A Healthy Start: Spokane’s Future, examines and explores the health and well-being of pregnant mothers and infants for Spokane County and compares findings to other counties that are similar demographically in Washington State (Clark County, and Snohomish County), and to state data.
Maternal and child health issues remain a focus of public health’s prevention and intervention efforts
An infant’s health begins well before a woman becomes pregnant
In Spokane County various risk factors during pregnancy affect the health of the mother, the unborn infant, and the newborn child

5. Conditions Requiring Medical Attention Family Support After Birth
Maternal Health
Birth Outcomes
Demographics
Age groups
Race/Ethnicity
Insurance status
Medicaid
WIC
Education
Marital status
Single parent
Medical Risks
Maternal mortality
STD’s
C-sections
Diabetes
Hypertension
Previous preterm births
Other previous poor pregnancy outcomes
Group B strep
Hepatitis B (mother and newborn)
Behavioral Risks
Smoking
Prenatal care
Folic acid
Pregnancy spacing
Intimate partner violence
Unintentional pregnancy
Child abuse
Immunization of infant
Prenatal
Preterm births-LBW/VLBW
Congenital anomalies
Postnatal
Infant mortality
Singleton vs. Multiple
SIDS
Conditions Requiring Medical Attention
Any/None
Assisted ventilation needed
NICU admission
Seizure or serious neurologic dysfunction
Significant birth injury
NICU
Preterm birth
LBW/VLBW
Anomalies
Family Support After Birth
CAPA, WIC, First Steps

6. Overall Births in Spokane County

7. Births in Spokane County
Year
Total Births (Count)
Percent by Age Group
Percent by Race
15-19
20-29
30-39
40-49
White NH
Black NH
AI/AN NH
API NH
Hispanic
2000
5666
11.0%
55.6%
31.1%
2.1%
86.2%
1.8%
2.6%
2.9%
3.8%
2001
5414
9.7%
57.4%
30.8%
84.9%
2.2%
2.3%
4.2%
2002
5543
9.5%
57.7%
30.1%
2.7%
85.7%
1.7%
2.4%
4.6%
2003
5455
57.2%
30.4%
86.7%
4.8%
2004
5480
8.8%
57.8%
31.0%
85.1%
2.5%
5.4%
2005
5593
8.5%
59.3%
29.9%
84.8%
2.0%
5.8%
2006
5986
8.7%
29.5%
86.0%
1.9%
2.8%
3.3%
2007
5983
59.9%
3.0%
5.5%
2008
6156
9.3%
59.6%
29.1%
3.6%
6.3%
NH=Non-Hispanic, AI/AN=American Indian/Alaska Native, API=Asian Pacific Islander

8. Overall Births by Education
Approximately 40% of all births in Spokane County are to mothers with <= a HS education/GED.

9. Service Utilization Medicaid and WIC
Medicaid and WIC are low income dependent programs and are used as a proxy for poverty.
½ of all births were to women with Medicaid as their primary insurance
Nearly ½ of all pregnant women in SC received WIC services 20

10. Maternal Smoking in Spokane County

11. Maternal Smoking
Smoking before and during pregnancy is the single most preventable cause of illness and death among mothers and infants.
Maternal smoking can result in complications during delivery for the mother and her newborn, and may result in adverse outcomes for the infant. Complications include LBW and premature births.
In 2006, Spokane County’s smoking rate among pregnant women was 20.1%, which was 2X greater than Washington State (10.3%)

12. Maternal Smoking by Age Group
So now let’s look at the effects of age on maternal smoking.
From , maternal smoking decreased as age increased for Spokane County
We also notice that for each age group, maternal smoking was significantly higher for Spokane County than Washington State’s rates.

13. Maternal Smoking by Race
Maternal smoking rate for Spokane County was higher for each racial group than Washington State’s rates

14. Maternal Smoking by Education
As education increase maternal smoking decreases
Approximately ½ of pregnant women with <HS education smoked during their pregnancy
28% of pregnant women with a HS diploma/GED smoked during their pregnancy
Data Source: Birth Certificate Data, Washington State Department of Health, Center for Health Statistics

15. Maternal Smoking by Education
Smoking among pregnant women with < a HS education was 40 times higher than women with an advanced degree
23 times higher for women w/a HS diploma/GED
13 times higher for women with some college
8 times higher for women with a 2 year degree
2 times higher for women with a BS/BA
Data Source: Birth Certificate Data, Washington State Department of Health, Center for Health Statistics

16. Where Maternal Smoking Occurs in Spokane County
East Central
Chief Garry
Park
Hillyard
Riverside
Browne’s Addition
West Central
Logan
Whitman
Primarily in areas surrounding downtown in low income areas.

17. Significant Findings For Pregnant Women Who Smoke in Spokane County
Pregnant women with a lower education are 4.3x more likely to smoke than pregnant women with a higher education
40% are unmarried
Unmarried pregnant women are 5.8x more likely to smoke
Pregnant women on WIC are 4.3x more likely to smoke
Pregnant women on Medicaid are 4.3x more likely to smoke

18. Significant Findings For Pregnant Women Who Smoke in Spokane County3
26% of pregnant women with an unintended pregnancy smoked
13% of pregnant women who smoked had a preterm infant
10% of pregnant women who smoke have a LBW infant
34% of infant deaths identified that the mother smoked while pregnant

19. An Innovative Approach to Addressing Maternal/Child/Family Health
Neighborhoods Matter
An Innovative Approach to Addressing Maternal/Child/Family Health

20. Neighborhoods Matter
A targeted, community-driven, community-based approach to reduce the health disparities impacting maternal, child and family health
Intra-divisional, interdisciplinary program
Being funded with current funding streams
18% state consolidated contract dollars
82% local dollars
Changed from individual approach to community approach
Step back and look at root causes
3 year program

21. Neighborhood Selection
Maternal and Infant Health Factors
Neighborhood and Health Factors
Desired Neighborhood Assets
Maternal and infant indicators from “A Healthy Start: Spokane’s Future”
Neighborhoods below county average
Community center
Organizations
Engaged citizens
Health data
Population data
Application (Request for Information and Intent)
East Central
Greater Hillyard
West Central
Selection process needed to be transparent.

22. Neighborhood Selection
Key Indicators
Teen mothers
Maternal smoking
Unmarried mothers
Births paid by Medicaid
Late or no prenatal care
Low birth weight
Preterm births
Short inter-pregnancy
Interval (IPI)
Key indicators were selected:
Good indicators to determine future health of neighborhood
Risk factors greatly affect the health and well-being of mothers, infants, and unborn child
Data available by block group and could organize by neighborhood
* Data Source: Birth Certificates

23. 38 down to 17 neighborhoods
Review of neighborhood assets narrowed it down to 3

24. Demographics/Health Factors (Quantitative)
Neighborhood/Application Factors
(Qualitative)
40% of Overall Score
Demographic Factors – 5%
Poverty Factors – 10%
Health Factors – 10%
Maternal/Infant Factors - 15%
60% of Overall Score
Protective Factors – 15%
Stabilizing Factors – 10%
Willingness to Partner Factor – 25%
Resident Involvement Factor – 10%

25. Indicators For Demographics/Health Factors -40%
(x1)
Poverty – 10%
(x2)
Health – 10%
(x3)
Maternal/Infant – 15%
(x4)
Age 0-4
Age 15-34
Race/Ethnicity
Single parents
Each indicator weighed at 25% of total demographic score
Data Sources: OFM Washington State population statistics, City-Data.com Zip Code Profiles
Education
Food stamps
Free/Reduced lunches
Each indicator weighed at 33.3% of total poverty score
Data Sources: Behavioral Risk Factor Surveillance System (BRFSS), Washington State Department of Social and Health Services (DSHS), Washington State Office of Superintendent of Public Instruction (OSPI)
Life expectancy
Mortality rate
STDs
Chronic diseases
Asthma
Diabetes
Obesity
Life expectancy and mortality weighed at 15%, STD’s and chronic diseases weighed at 35% of total health score. Diseases weighed at 33.3% of chronic disease score
Data Sources: Center for Health Statistics, Death Certificates, SRHD CD Epidemiology, BRFSS
Teen mothers
Maternal smoking
Unmarried mothers
Medicaid
Late/No prenatal
Short IPI
Low birth weight
Pre-term birth
Each indicator weighed at 12.5% of total maternal/infant health score
Data Source: Birth Certificates

26. Indicators For Neighborhood/Application Factors – 60%
Protective – 15%
(x5)
Stabilizing – 10%
(x6)
Willingness to Partner - 25%
(x7)
Resident Involvement – 10%
(x8)
Resources that promote
Nurturing/
Attachment
Child development
Parent resilience
Social connections
Concrete support
Each indicator weighed at 20% of total protective score
Agencies that support families and children
Current major activities that support the health of families and young children
Each indicator weighed at 50% of total stabilizing score
Interested in partnering with Neighborhoods Matter
Resources committed (letters of commitment) and past work with neighborhood
Each indicator weighed at 50% of total willingness to partner score
How are residents involved in creating change in their neighborhood
Indicator is weighed at 100% of total resident involvement score

27. Scoring

28. East Central Spokane WA State
Indicator
East Central
Spokane
WA State
Factor 1 – Demographic Factor
Age 0-4
9.7% * ^
6.4%
6.6%
Age 15-34
35.0% * ^
28.0%
27.9%
Race-Ethnicity
24.3% * ^
9.7%
22.0%
Single Parent
10.6% * ^
9.8%
9.1%
Factor 2 – Poverty Factor
Education £ HS/GED
35.8%
30.1%
33.1%
Food Stamps
32.5% * ^
15.7%
12.1%
Free/Reduced Lunch
71.4% * ^
43.3%
42.2%
Factor 3 – Health Factor
Life Expectancy
74.3 Years * ^
78.7 Years
79.3 Years
STD Rate
642.2/100,000
270.1/100,000
Not Available
Mortality Rate
1,055.1/100,000 * ^
774.0/100,000
743.6/100,000
Asthma
18.6% ^
14.3%
13.8%
Diabetes
13.2% ^
9.3%
Obesity/OW
65.9%
61.6%
61.9%
Factor 4 – Maternal/Infant Factor
Teen Mothers
15.8% * ^
9.0%
8.4%
Maternal Smoking
30.2% * ^
18.7%
10.3%
Unmarried Mothers
52.3% * ^
34.3%
31.5%
Medicaid
65.4% *
42.8%
(06-08 Data Only)
Late/No Prenatal Care
6.02% *
3.0%
5.1%
Short IPI
40.3%
44.5%
LBW
7.9% ^
6.5%
6.3%
Pre-Term
12.4% ^
10.7%

29. Neighborhoods Matter Structure
Neighborhood Governance Council
SRHD Staff
Neighborhoods Matter Advisory Board
Neighborhood Governance Council - Comprised of neighborhood residents reflecting neighborhood makeup. Identified neighborhood problems/concerns that contribute to poor maternal, child and family health, and prioritize.
At top because neighborhood based project. The neighborhood is responsible for identifying problems and prioritizing. Also responsible for building capacity within neighborhood.
Neighborhoods Matter Advisory Board – Comprised of influential community leaders, neighborhood representatives, policy makers from various sectors including government, non-profits, academia, Department of Social and Health Services, education, mental health, media, medical society, etc. Advises NM team on assessing feasibility of proposed policies and offering options and expertise in the area of policy development and implementation.
Neighborhoods Matter Staff – Comprised of a public health nurse, community organizer, health program specialist from Health Promotions, environmental public health staff, and program manager. Program under Community and Family Services and program is supervised by Division Director. Collaborates with community partners and neighborhood members to address root causes of child and family health.
Steering Committee – Comprised of SRHD Health Officer and Division Directors of contributing staff. Oversee program activities and direction. Assist with creating sustainability and provide input to evaluation plan. Able to provide insight and trouble shoot problems.
SRHD Steering Committee

30. Focus on needs and deficits
Comparison of Models
Service Delivery
Focus on needs and deficits
Problem orientation
Pathologies
Problem response
Charity orientation
More services
High emphasis on agencies as experts and a specialized approach to problem solving
Focus on individuals as target of problem solving efforts
Community Building
Focus on Assets
Skill orientation
Resources
Identify opportunities
Investment orientation
Fewer services
Low emphasis on agencies as experts, more emphasis on resident helpers
Focus on community and community members working together to build capacity for the whole
We are using an asset based model which is reflected in our operating structure.
Service Delivery – (One on one) The structure is “there is a problem, were here to fix it, you need us.” You needed more money, more programs to operate this type of service. Relying largely on a program.
Community Model – Focus on assets. “Everything you need is in the neighborhood – the knowledge about the neighborhood, expertise.” The idea is to build capacity to address community problems. If there is a problem, then let’s figure out how to fix it.
Build capacity – identify leaders and educate/train them regarding leadership skills, grant writing, etc. so that they they can advocate on behalf of the neighborhood.

31. Community Information Gathering
Key Leader
Interviews
Focus Groups
Community Luncheon
Asset
Interviews
Identify Neighborhood Assets & Concerns
Governance Council
Key Leader interviews – Done throughout the county
Asset Interviews – Done in neighborhood. Identified leaders in community from agencies/businesses in the community, churches in the community, and residents from the community
Three areas of prioritization: 1) Maternal Health (focusing on maternal smoking and parenting); 2) Physical activity and nutrition; 3) Housing/Transportation/Neighborhood Safety
For example in Maternal Health we have started “Community Cafes” which are informal peer groups that meet in public places or at someone’s home in the neighborhood with trained counselors who discuss the concerns about maternal smoking and parenting. In addition, they discuss how to address and resolve these problems specific to the neighborhood.
Prioritize
Work Team
Action

32. Next Steps Share best practice interventions
Create action plans with short and long term goals
Conduct community training for implementation
Identify and address policy issues impacting neighborhood/county (ongoing)
Develop Communication Plan

33. It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environment conspire against such change. Institute of Medicine