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Addressing Racial Disparities in Maternal and Child Health

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... in infant mortality rates, low birth weight, and adequacy of prenatal care. Infant deaths attributable to poor health of women prior to conception ... – PowerPoint PPT presentation

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Title: Addressing Racial Disparities in Maternal and Child Health


1
Addressing Racial Disparities in Maternal and
Child Health
  • JudyAnn Bigby
  • Barbara Ferrer
  • Dianna Christmas

2
Session Objectives
  • Describe racial and ethnic disparities in
    maternal and child health indicators in Boston
  • Discuss factors that may contribute to health
    disparities
  • Discuss challenges in identifying and using race
    and ethnicity data for maternal child health
    assessment
  • Describe one project in Boston to address
    disparities in infant mortality and low birth
    weight births

3
Health Disparities in Boston
4
Infant Mortality in Boston by Race and Ethnicity
Data source Mass Dept of Public Health Data
analysis Boston Public Health Commission
5
Boston Fetal and Infant Mortality 1992-96 (Data
and analysis Boston Public Health Commission)
Maternal Health 6.2
Maternal Care 3.2
Newborn Care 1.0
Infant Care 1.8
6
Excess Fetal and Infant Mortality Rate 1992-96
Data and analysis Boston Public Health Commission
7
LBW in Boston,1991-1999
DATA SOURCE Boston resident live births,
Massachusetts Department of Public Health DATA
ANALYSIS Boston Public Health Commission,
Research and Technology Services
8
(No Transcript)
9
(No Transcript)
10
What accounts for racial and ethnic disparities?
11
What accounts for racial disparities?
  • Biology
  • Social factors
  • Racism
  • Personal beliefs
  • Provider behavior
  • Institutional polices and procedures

12
Definitions of Race
  • A vague, unscientific term referring to a group
    of genetically related individuals who share
    certain physical characteristics
  • Biologic distinctiveness does not determine race
  • Race is a social construct
  • Racial designations are most often important in
    societies with a history of oppressing some
    racial/ethnic groups
  • Race has no meaning to many groups

13
Definition of Ethnicity
A subgroup that shares a common ancestry,
history, or culture
  • Geographic origins
  • Family patterns
  • Language
  • Values
  • Cultural norms
  • Religion
  • Literature
  • Music
  • Dietary patterns
  • Gender roles
  • Employment patterns

14
Biology Genetics not the answer
  • Increasing evidence that the gene pool is the
    same across racial and ethnic groups
  • Paradoxical observations of apparent biologic
    difference
  • Response to antihypertensives by race
  • Antidepressants
  • Metabolism of nicotine, alcohol

15
Social Factors
  • Poverty
  • Blacks, Latinos, American Indians and some Asians
    are 3 times more likely to be poor than are
    whites
  • Education
  • Immigration status
  • Employment
  • Housing
  • Geographic location

16
Racisms impact on health status
  • Social outcomes
  • Racial bias in medical care
  • Stress of experience of discrimination (micro
    aggressions, MEES)
  • e.g. hypertension, prematurity, depression
  • Acceptance of social stigmata of inferiority
    (internalized racism)

17
Personal Beliefs
  • Reject certain treatment or preventive
    interventions
  • Health seeking behavior
  • Interpersonal interactions with physicians
  • Withholding information
  • Belief about control of health status
  • Use of non-traditional or non-Western medicine

18
Provider Behavior
  • Provider perceptions of symptoms and presenting
    complaints
  • Provider perception of worthiness of patient
  • Provider misunderstanding of racial and ethnic
    differences

19
Institutional Policies and Procedures
  • Policies dictating insurance coverage
  • Implications for formularies, assessment of
    compliance, public health education
  • Hours of operation, location of services
  • Provider profiles
  • Resources to support care of non-majority
    populations
  • Content of medical education

20
Contributions to Health Outcomes
gender
RACISM
BIOLOGY/GENETICS
sexuality
ethnicity
ENVIRONMENT
HEALTH OUTCOMES
R A C E
CULTURE
POLICIES
SOCIAL RESOURCES
SOCIOECONOMICS
HEALTH CARE RESOURCES
PERSONAL PRACTICE
E.G. INSURANCE PHYSICIANS HOSPITAL
SYSTEMS RELATIONSHIPS W/PROVIDERS QUALITY OF CARE
21
Factors Influencing Health Status
22
Challenges in Identifying and Using Race and
Ethnicity Data for Maternal and Child Health
Assessment
23
Public Health Perspective
  • Within public health, the classification of
    groups of people into racial groups is meaningful
    only if this classification leads to a better
    understanding of the factors that have led to
    disparity in disease treatment and health outcome
  • Identification and monitoring of racial and
    ethnic disparities in maternal and child health
    outcomes requires the ability to measure race and
    ethnicity
  • Design of effective, targeted interventions and
    strategies to address poor birth outcomes varies
    by race and ethnicity

24
Underlying Assumptions
  • Race and ethnicity categories and specific racial
    and ethnic group designations are consistently
    defined and determined
  • The categories and designations are understood by
    the populations questioned
  • Survey enumeration, participation, and response
    rates are high and similar for all populations
  • The responses of persons are consistent in
    different data sources and at different times

25
Challenges
  • 1. Differences in terminology used to categorize
    race and ethnicity
  • Confusion regarding definitions of race,
    ethnicity and ancestry
  • Definition of Hispanic is often unclear and
    inconsistent across and within data sources (race
    vs. ethnicity)
  • Use of other category, without defining this
    population group

26
Challenges
  • 2. Differences in data collection procedures
  • Racial data based on self identification by
    respondents vs. perceptions of observers
  • Missing or incomplete reporting of race/ethnicity

27
Challenges
  • 3. Differences in perceptions of group identity
  • Numerous studies show that race/ethnicity
    identification is fluid and self-perceptions
    change over time and across circumstances,
    especially among individuals with heterogeneous
    ancestries
  • Increased population of multi-racial and
    multi-ethnic persons

28
Challenges
  • 4. Changing demographics
  • Difficulty capturing the increasingly more
    racially and ethnically diverse US population
  • Exclusion of racial/ethnic subgroups precludes
    understanding the distribution of disease in
    certain populations

29
Challenges
  • 5. Incomplete collection of measures of social
    and economic conditions that may confound an
    association between race/ethnicity and health
    outcomes
  • Health data often doesnt contain information on
    SES status (income, education)

30
Selected Data Sources
  • Issues and Limitations

31
Census Data
  • 1. Most rates for birth, death and morbidity are
    calculated with census population estimates as
    the denominator misreporting occurred in 1990
    Census with undercounting of Blacks, American
    Indians and Alaskan Natives, Asian and Pacific
    Islanders, and Hispanics at higher rates than
    Whites
  • Any rate that uses an undercounted denominator is
    overestimated in proportion to the undercount in
    the denominator unfortunately, estimates of
    undercount are generally only available at the
    national level

32
Birth Certificate Data
  • 1. Changing reporting standards create
    difficulties for data analysis
  • Prior to 1989, the race/ethnicity of infant was
    assigned by complex formula based on
    race/ethnicity of mother and father
  • Beginning in 1989, the self-reported
    race/ethnicity of infants mother was adopted as
    race/ethnicity of infant
  • Changes in ethnicity categories were made
    starting in 1996 with sub-population ethnic
    categories varying year to year all variations
    on other therefore also differ from year to
    year

33
Death Certificate Data
  • 1. Only race of descendents is collected data is
    not collected on race of parents
  • 2. Racial status is typically based on observer
    identification may lead to undercount problem in
    the numerator of mortality for some minority
    populations
  • 3. Death rates by race and Hispanic ethnicity may
    be biased from misreporting of race and Hispanic
    origin in the numerator of rates and misreporting
    and underrepresented in the denominator of rates
  • 4. Very little racial/ethnic subgroup data is
    available for adult mortality, masking important
    patterns of variation (identifier for Hispanic
    ethnicity was added in 1989)

34
Patient Record Data
  • 1. Variability in coding method for
    race/ethnicity(observation/proxy report/patient)
  • 2. Hospital Discharge Data
  • Race not reported in 18 of NHDS records
    Hispanic origin not reported for 85 of NHDS
    records
  • Form UP-92, which is used by many hospitals with
    automated systems, doesnt require the reporting
    of race

35
Patient Record Data
  • 3. Surveillance System Data
  • Race/ethnicity information varies by disease and
    state for the 36 noticeable diseases reported to
    the NNDSS, with as many as 35 of reports for
    measles, salmonellosis, and shigellosis not
    including race/ethnicity information
  • 4. Immunization Registry Data
  • Race/ethnicity may or may not be collected as
    part of demographic profile
  • Boston Immunization Information System does not
    include race/ethnicity in its core required data
    elements and site participants do not voluntarily
    provide that information

36
Recommendation for Federal Action
  • 1. Racial/Ethnic categories should be clearly
    defined, standardized and operationalized across
    all federal agencies so that researchers and
    respondents know what the categories mean and the
    information is compatible from source to source

37
Recommendation for Federal Action
  • Undertake validation of categories of race based
    perhaps on anthropological, archeological,
    linguistic, migration and self-perception
    evidence
  • Undertake validation of categories of ethnicity
    based perhaps on concepts of social identity and
    changes in social identity, assessment of
    membership identification and group boundaries
  • Include identifiers for subgroups on all
    government surveys and forms
  • Racial/ethnic data should be routinely utilized
    in the design, implementation and evaluation of
    health studies and health programs

38
Recommendation for Federal Action
  • 2. Routinely monitor and update current measures
    of race and ethnicity
  • Flexibility of the system may require compromises
    in the consistency of categories
  • 3. Build and sustain communication mechanisms
    with racial/ethnic communities to ensure that
    they assist in defining racial/ethnic categories,
    receive findings from current studies, and
    participate in designing future research and
    interventions

39
Local Response
  • 1. Establish and articulate clearly the reason
    why measures of race ethnicity are used
  • 2. Assess the reliability, validity,
    generalizability and applicability of each data
    set
  • Determine presence of ethnicity and national
    origin fields, who obtains this information, when
    and how, and assess its completeness and probable
    reliability

40
Local Response
  • Determine size of samples in each data set and
    the probable representativeness of the sample
  • Determine usefulness of each data set for
    research and planning purposes and the specific
    kinds of questions it may answer
  • Note any limitations of racial/ethnic data

41
Local Response
  • 3. Support, advocate and work for improvements in
    existing data systems and collection of
    additional needed data
  • Assess the way in which different segments of the
    population identify themselves by
    race/ethnicity
  • Identify gaps and inconsistencies in available
    data and set priorities for correcting them
  • Work collaboratively to promote awareness of the
    importance of distinguishing among national
    origin groups, reliable methods of determining
    national origin and ethnic identity in data
    systems, and improvements in sampling and
    interviewing methods

42
Local Response
  • 4. Attempt to design studies that identify the
    specific factors linked to race that affect
    health (acculturation, economic, and non-economic
    aspects of discrimination)
  • Design a construct which can measure and/or
    reflect racism--capturing the experience of
    racial discrimination at both the individual and
    institutional level
  • 5. Involve racial/ethnic communities in the
    design, implementation and evaluation of all
    efforts to assess and address racial/ethnic
    disparities in health outcomes

43
Current Projects to Reduce Racial Disparities in
Health Outcomes
  • Womens Health Demonstration Project
  • REACH 2010 Eliminating Racial Disparities in
    Breast and Cervical Cancer Among Women of African
    Descent
  • Latino Health Needs Assessment

44
Bostons Womens Health Demonstration Project
  • A Collaboration of the
  • Health of Women and Infants
  • Working Group
  • Boston Public Health Commission

45
Health of Women and Infants Working Group (HWIWG)
  • Convened in June of 1998 to guide the Boston
    Public Health Commissions efforts at improving
    birth outcomes.
  • HWIWG represents state and city agencies, the
    Boston Healthy Start Initiative, community health
    centers, public health schools, and hospitals and
    includes providers of all types, policy makers,
    researchers, and women from the community.

46
Boston Womens Health Demonstration Project -
Rationale
  • Continuing disparities in infant mortality rates,
    low birth weight, and adequacy of prenatal care
  • Infant deaths attributable to poor health of
    women prior to conception
  • Womens reports of fragmentation of services and
    dissatisfaction with care

47
Boston Infant Mortality Review
1990-93 (McCloskey L, et.al. Public Health
Reports 1999114165)
  • Women experiencing an infant death were more
    likely than other women to
  • Be homeless or near homeless (30 vs 11)
  • Be abused by partner (25 vs 6)
  • Have an unintended pregnancy (63 vs 41)
  • Have used alcohol (23 vs 8)

48
Boston Infant Mortality Review 1990-93
(McCloskey L, et.al. Public Health Reports
1999114165)
  • Themes from review panel findings
  • Women experience fragmentation and discontinuity
    of care (73)
  • Severe social risk is unrecognized and/or
    unmatched by needed services in the health care
    setting (50)
  • Recurring UTIs, genital infections, and STIs
    (44)
  • Repeat unintended pregnancies closely spaced
    pregnancies (40)
  • Low satisfaction with interpersonal aspects of
    care (38)

49
Recommendations from IMR
  • Comprehensive care for women regardless of
    pregnancy status.
  • Multi-disciplinary team of providers to address
    needs of women from low-income communities in
    context of primary clinical care.
  • Improved interpersonal patient/provider
    relationships.
  • Integration between clinical and social services
    in primary care setting.
  • Systematic approach to reducing barriers to care
    for women.
  • Source McCloskey L, Bigby J, Brand A. for the
    Working Group on Case Management, Outreach, and
    Community Partnerships, Beyond Prenatal Care
    Improving Birth Outcomes in Low-Income
    Communities Through Enhancements to Clinical
    Services for Women, 1997.

50
Boston Womens Health Demonstration Project -
Goals
  • Reduce fragmentation and discontinuity in care
  • Systematic identification of medical and social
    risks
  • Comprehensive response to medical and social
    problems
  • Improve patient satisfaction with care and with
    providers

51
Boston Womens Health Demonstration Project
  • Components of project
  • Standardized risk assessment tool
  • Focus groups with clients from health centers and
    Boston Healthy Start Initiative
  • Review of assessment tool by HWIWG members
  • Assessment results shared with women and
    providers
  • Case management

52
Boston Womens Health Demonstration Project
  • Each site will identify 50 women aged 18-45 to
    participate in the pilot study
  • Each site receives a case manager and necessary
    computer equipment
  • Each site identifies target populations
  • e.g. women with walk-in or ED visits, repeat
    pregnancy tests, women no longer coming in for
    care

53
Boston Womens Health Demonstration Project
  • Reduce fragmentation and discontinuity in care
  • outreach to women who are not receiving regular
    care
  • develop interdisciplinary teams with clear roles
    and strategies for communication
  • share processes of care and outcomes

54
Boston Womens Health Demonstration Project
  • Systematic identification of medical and social
    risk
  • 9 page Womens Health Questionnaire -
  • Basic information
  • Physical health (preventive habits pap smear and
    mammography use immunization FH heart disease,
    cancer, or SA medical problems and sxs,
    reproductive health, meds, health insurance)
  • Social and emotional health (housing concerns,
    social support, mental health, work hx, home
    safety, domestic violence, and sources of stress)

55
Boston Womens Health Demonstration Project
  • Comprehensive response to medical and social
    problems
  • WHQ results generate report to women and
    providers
  • provider training
  • recommendations to providers about clinical
    strategies
  • on line resource directory to assist case
    managers
  • track success of interventions, connection to
    community resources

56
Boston Womens Health Demonstration Project
  • Improve patient satisfaction with care and with
    providers
  • meeting the identified needs of women
  • provider training
  • case managers as bridges between women and
    providers

57
Boston Womens Health Demonstration Project
Provider visits
Women receive results
Providers, case managers, women devise strategies
to address problems
Women complete WHQ
Results scanned, report generated
Providers receive results
Case manager interactions
58
Boston Womens Health Demonstration Project
Evaluation
  • Satisfaction surveys
  • assess womens experience with questionnaire
  • provider satisfaction with questionnaire and
    assessment of impact on process
  • Case manager logs
  • Chart reviews of women in project and comparison
    group

59
Boston Womens Health Demonstration Project
Evaluation
  • Women asked to complete satisfaction survey
    following their provider appointment.
  • How do women find the process of completing the
    questionnaire with the case manager?
  • How do women perceive the questionnaires effect
    on their clinical encounters?

60
Boston Womens Health Demonstration Project
Evaluation
  • Provider questionnaire at 1 and 6 months
  • Does process expand knowledge of patients lives,
    or change the kind of care that is delivered?
  • How has questionnaire impacted encounters?
  • How has patient flow been affected by the
    process?
  • Monthly follow-up
  • What do you like/not like about the
    questionnaire?
  • Describe the communication and collaboration
    among primary care team members

61
Boston Womens Health Demonstration Project
Evaluation
  • Documentation in medical record and case manager
    log includes problem, type of service needed,
    referrals made, and referral outcome.
  • Questions to answer
  • Are project participants more likely than others
    to use primary and preventive health services?
  • Measures include annual exam, number of no
    show visits, use of prenatal care if pregnant,
    and identification of a regular provider.
  • To what extent are referrals completed among
    project participants?

62
Boston Womens Health Demonstration Project
  • Desired outcomes
  • Women engaged in care
  • Identify medical and social risks and high
    quality standard of care in response
  • Improved provider/patient interactions
  • Improved linkage of community resources to
    clinical settings
  • Increased patient satisfaction and knowledge of
    own health
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