What We KnowWhat We KnowPaula Braveman, MD, MPH

Reggie Caldwell, LCSW

The ProblemThe Problem 2-3 times higher rates of adverse birth

outcomes among African American babies 4 times higher ratio of maternal mortality

among African American women Traditional prenatal care has not improved

birth outcomes but some promising results from Centering

Pregnancy

The ScienceThe Science The 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 pathways Social support may directly improve health; affects health

behaviors; buffers stress effects Empowerment --Self-efficacy plays key role in health

behaviors; key to escaping poverty; lack of control at work strongly linked with heart disease

Empowerment-focused group approaches may be more effective than 1:1 (based on theory and data)

In other words: SSE WAS ON THE RIGHT TRACK!

Rationale for Rationale for Revising BIHRevising BIH

Great work happening, but varied across sites so impossible to evaluate impact

Bring BIH up to date with science More emphasis on systematically

addressing social factors as key determinants of health and health behaviors

Focus efforts to maximize impact

The Revised BIH ModelThe Revised BIH Model Combined the best of original BIH models with

promising practices: Amplified SSE strength-based group intervention, supported by empowerment- & referral-oriented case mgmt

Goal: Decrease disparities by improving African American infant and maternal health May not be able to see a difference in birth outcomes,

especially short-term But 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

DRAFTDRAFT

To improve African American infant and maternal health in

California anddecrease Black:White health disparities and social inequities for women and infants

BIH Activities

Ultimate Goal

INDIVIDUAL•Increased health knowledge•Increased healthy behaviors•Increased empowerment through improved life skills and coping skills•Increased receipt of quality medical, social & mental health services•Decreased unplanned pregnancy•Increased social support both for & among the women•Decreased stress by mobilizing resources and services•Improved parenting•Increased bonding between mother & infant•Improved infants’ developmental milestones

COMMUNITY•Increased community and provider knowledge & cultural competence•Increased community partnerships & linkages among service agencies•Decreased stressors in the community through community & provider/agency action•Improved understanding among community and providers of influence of social inequities on health

INDIVIDUALServices provided to African-American women, infants, and their families & partners include:• Referrals to medical, social & mental health services• Health education• Social and group support• Identifying resources• Self-advocacy

COMMUNITY•Promote community and provider engagement and advocacy•Educate community and providers about influence of social inequities on health

GUIDING PRINCIPLES1. Comprehensive and integrated: Address multiple risk factors and use multiple strategies 2. 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 effectively

Problem

• Poor birth outcomes• Social isolation• Lack of health knowledge

• Lack of access to quality health care

• Poverty• Racism• Environmental stressors

• Maximizing impact of the program (numbers served & effect size)

• Lack of cultural awareness and skills among providers

Conceptual Framework

Intermediate Outcomes

To Impact Maternal & Infant To Impact Maternal & Infant Health, BIH Needed To:Health, BIH Needed To:

Decrease isolation/increase social support

Build self-esteem and empower women to make better choices about their health

Decrease stress/improve coping skills Involve communities

Program TenetsProgram 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 decisions

Culturally relevant and honor the unique history and traditions of people of African descent

Address issues important to African American women

Reduce disparities by improving African American maternal and infant health.

Black Infant Health Program - Revised ModelRecruitment

Meets program requirements?

Yes

Program Completion•Complete ICP•Complete Life Plan•Complete Case Closure

No

Intake1. Program orientation and consent 2. Referrals3. Prenatal Assessment 14. Initiation of Individual Client Plan (ICP)5. Case Conferencing

Standardized health promotion message

&

Refer out to appropriate agency

Case Managementthat compliments

the group sessions

Group Sessions 11-20

Group Sessions 1-10

Birth

Postpartum

Prenatal

Core Intervention

GroupsGroups Use facilitative learning to access and

enhance women’s knowledge and skills Group format means women draw strength

from each other Skill-building to achieve better physical and

mental health Weekly personal goal setting culminating in

the creation of a Life Plan Focus on empowerment to:

Make good choices to have a healthy pregnancy Be a good role model for one’s child.

Challenges IdentifiedChallenges Identified Staff

Resistant to change Reluctant about the revised model’s success Great facilitation Focused on “What If’s”

Clients Retaining them in groups (transportation and

child care issues) Motivation for long-term

participation/competing priorities

Themes from theThemes from theProgress ReportProgress Report

Successes Collaborations with

providers, community partners, and Board

Received or applied for a grant

Positive feedback from clients about new model

In-kind donations Flexibility by training all staff

as group facilitators

Challenges Some staff are having

difficulty embracing the new model

New data book Client transportation Time for case conferences

and other staff meetings Serving clients with

multiple stressors

The “Magic” is HappeningThe “Magic” is Happening

Staff I learn about myself

while I conduct the group

It’s challenging and worth it!

I used harm reduction strategies to help a pregnant client stop smoking

Clients A place where negative

messages are countered with positive ones

I now have a vision for my life

The group constantly reminds me that we ALL have talent

How to we keep the “magic” going?

ImplementationImplementationTimelineTimeline

Activity Start Date

Transition begin for Group 1 7/1/10

Official start for Group 1 11/1/10

Feedback from Group 1 of the revised model 11/1/10

Revise intervention based on feedback 7/1/11

Transition begins for Group 2 7/1/11

Official start date for Group 2 10/1/11

Interim Report of Findings 2/1/12

Feedback from Group 1 and 2 of the revised model 10/1/11

Final Report of Findings 1/1/13

Reconvene Expert Panel ~2/1/13

Revise intervention based on feedback 3/1/13

Transition begins for Group 3 4/1/13

Official start for all sites 7/1/13