Assigment .Apa seven . All instructions attached.

74 Case Study 4 P is for Practice

Case Study 4: Addressing Birth Outcomes

Pre-Test

1. Which of the following are examples of community stakeholders who may be

affected by a public health problem or goal?

a. Service providers b. Affected community members c. Advocacy and faith organizations d. Media e. All of the above f. A, B, and C only

2. True or False: When engaging stakeholders you should focus your efforts on

presenting your own interests and needs of the project.

3. Which of the following is a method in which to prioritize risk factors?

a. Rank factors on their importance and changeability and choose those that are most important and most changeable

b. Choose factors which have the highest return on investment c. Choose factors of particular interest to stakeholders d. Identify the most urgent problem e. All are methods in which to prioritize risk factors f. A, B , and D only

4. True or False: Evidence-based strategies can be modified to a local population.

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Case Study 4: Addressing Birth Outcomes

Student Guide

Situation

You are the Director of Nursing at the Evergreen County Health Department. Last week you learned that all local health departments in the state will receive state funding to address birth outcomes over a 5 year period. The goals are to reduce premature birth and infant mortality. To receive the initial funding, your health department must convene a group of community stakeholders, identify specific objectives to address, and choose an evidence-based intervention. You decide to begin by meeting with a small group of health department staff members, including the Coordinator of the WIC program and the Health Educator. Your goal for the meeting is to identify community partners or stakeholders that could participate in this initiative.

1. Group Brainstorm: Have one member of the group write ideas on the flip

chart. Which community members or groups should be involved in this new initiative?

2. Once you have identified possible stakeholders, what are some strategies you can use

to invite and engage them?

Update 1

You have spent the last several weeks contacting potential stakeholders and inviting them to participate in a kickoff meeting. As the Nursing Director, one of your agenda items at the kickoff meeting is to present the trends of infant mortality in Evergreen County. In preparation for the meeting, you compile some background information on the county from the most recent Census. Then you gather surveillance data on infant mortality for Evergreen County and the state as a whole (see both Table 1 and Figure 1 below). You and your health department colleagues review the data to present at the meeting.  Population: 168,148 (60% White, 34% African American, 2% Asian, 6%

Hispanic/Latino)  Median Income: $40,718 ($5,000 lower than the state average)  25% of population lives in poverty, compared to 18% in the state overall  86% have at least a high school education  7% speak a language other than English at home  18% did not have health insurance in 2010, prior to the implementation of the

Affordable Care Act (ACA or Obamacare)  County includes the urban area of Cobalt, and the surrounding rural farmland

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Table 1. Infant (<1 Year) Death Rates per 1,000 Live Births, State and County, 2009-2013

Total Infant Deaths

White Infant Deaths

Black Infant Deaths

Other Non- Hispanic Infant Deaths

Hispanic Infant Deaths

Number Rate Number Rate Number Rate Number Rate Number Rate

State 4,441 7.3 1,850 5.4 1,967 13.6 178 5.7 446 4.8

Evergreen County

111 10.2 30 5.9 76 17.1 1 - 4 -

Note: Rates based on small numbers (< 20 cases) are unstable and are not reported.

Figure 1. Infant mortality rates, state and county, 5-year averages, 1999-2013.

3. Complete the following questions to summarize the data.

a) What is the baseline infant mortality rate in Evergreen County? How does it compare to the state rate?

b) What are the county and state trends (are rates increasing, decreasing, or remaining steady)?

c) Are there racial disparities in Evergreen County? 4. Discuss the data. What strikes you as most important to address? Why? 5. The data presented above is largely focused on the problem (infant mortality). How

do you determine what assets already exist in the community, region, or state to

0

2

4

6

8

10

12

State Evergreen County

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address this issue? Once you identify the assets, how can you leverage those existing efforts for your current initiative?

Update 2

Infant mortality can be related to risk factors before and during pregnancy, during labor and delivery, and after birth. Some examples of risk factors during each period include:  Preconception: Poor maternal nutrition (including low folic acid intake),

overweight/obesity, use of tobacco and other substances, low socioeconomic status, sexually transmitted infections, short inter-pregnancy interval, poor mental health, lack of access to family planning and health care providers

 Pregnancy: Insufficient or excess gestational weight gain, use of tobacco or other substances, lack of social support, inadequate prenatal care, hypertension, diabetes

 Labor and Delivery: lack of insurance, delivery complications, hypertension, cesarean section delivery

 Birth Outcomes: low and very low birthweight, preterm and very preterm, birth defects

County data on some risk factors is included below (See Table 2). Table 2. Certain Risk Factors for Infant Mortality

Evergreen County State

Total White African-

American Total White African-

American

Number of Live Births 2,111 977 883 118,983 66,181 28,865

% Low Birth Weight (<2,500 g) 7.2 5.7 10.1 8.8 7.3 13.4

% Very Low Birth Weight (< 1,500 g)

2.7 1.8 4.1 1.7 1.2 3.2

% Preterm (<37 weeks gestation)

14.4 11.4 18.3 11.4 9.8 15.6

% Maternal Age < 18 years 2.7 0.5 4.8 2.1 1.3 3.4

% Maternal Education < High School

17.1 5.9 22.8 17.0 8.6 16.6

% Multiple Births 5.0 5.1 5.3 3.5 3.6 4.1

% No or Unknown Prenatal Care 5.7 2.7 8.1 3.8 3.2 4.7

% Smoked 11.6 11.7 14.2 10.3 13.0 9.8

% Not Breastfed at Discharge 26.0 15.7 41.3 22.0 18.2 36.6

6. Given all of the information available on possible determinants of infant death in Evergreen County, how do you decide which risk factors to address?

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Update 3

Your health department has recently starting using mapping software to identify areas of particular need. Below are two maps of Evergreen County; the map on the left shows the percent of babies who are low birthweight (<2500 grams) by zip code (Fig. 2), while the map on the right shows the percent of families living in poverty by Census tract (Fig. 3).

7. How does this information help to inform the new initiative?

Figure 2. Percent of Babies with Low Birthweight Figure 3. Percent of Families Living in Poverty

Map credit: Matt Simon, NCIPH

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Update 4

The kickoff meeting happened yesterday. The group chose a name for itself – Evergreen Healthy Births, Healthy Babies (EHBHB). In addition to health department staff, the following stakeholders attended:  Local health care providers (a neonatologist from the hospital, an OB/GYN with an

interest in prenatal care, a pediatrician from private practice, and a nurse practitioner from a community health clinic)

 Non-profits -Local United Way manager -Executive director of Inspire, a group advocating for educational opportunities,

healthcare access, and employment for girls and women in poverty -Pastor of a local church in an area with high rates of teen pregnancy  Other

-Professor of Maternal and Child Health from a nearby university

Unfortunately, there were no members of the affected community (women at high risk for having a poor birth outcome) at the meeting. One young mother had agreed to attend but canceled at the last minute. You are disappointed and want to focus on engaging more community members before the next meeting.

8. Group Brainstorm: Have one group member record answers on a flip

chart. Think about ways to include at-risk community members in this initiative. How can you identify them and increase the likelihood that they are willing and able to participate?

9. How important is the racial/ethnic make-up of the group? Should having a diverse

group be a priority?

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Update 5

Using the strategies you identified above, you successfully recruit a community organizer from a low-income housing community and several teens and young mothers to participate in the task force. To better accommodate these members, you will now have meetings in a small multi-purpose room in that community. Your purpose for the next meeting is for EHBHB to identify goals and objectives for the 5-year program period. A goal is an overarching principle that guides decision making. Objectives are specific, measurable steps that can be taken to meet the goal. In general, goals are broad, abstract, and difficult to measure, while objectives are narrow, concrete, and measurable. In the most recent community health assessment (3 years ago), a community survey revealed the following top priorities among residents: chronic disease, obesity, drug/alcohol abuse, and gangs/violence. Child abuse and teen pregnancy were mentioned less frequently, and infant mortality was not cited as a problem.

10. Group activity. Write 1-3 overall goals to accomplish over the 5-year program

period. Some questions to consider as you write goals are:  What effect do we want to have on the “problem” in the community?  What does the community want to see happen?  What is the overall improvement we want to achieve?

11. Group Activity. Choose one of the goals above and write three outcome objectives

to achieve it. Keep in mind that objectives should be SMART (specific, measurable, achievable, relevant, and time-bound). In other words, explain how much of what will be accomplished by when.

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Update 6

The Evergreen Healthy Births, Healthy Babies group identified the following goal and objectives. GOAL: Reduce the infant mortality rate in Evergreen County.

Objective 1. Reduce the percent of low birth weight infants among African- Americans in Evergreen County by 5% in Year 5.

Objective 2. Reduce the teen pregnancy rate in Evergreen County by 5% in Year 5.

Objective 3. Increase the percentage of pregnant women who receive prenatal care in Evergreen County by 10% in Year 5.

To address these objectives, participants were very interested in using evidence-based strategies and programs. The group asked the health department to help identify potential evidence-based strategies to present at the next meeting.

12. What is an evidence-based strategy? Where would you search to find evidence-based

public health strategies and programs?

Update 7

Your team has identified three potential evidence-based strategies to present to the Evergreen Healthy Births, Healthy Babies group for selection (see summaries below). 1. Nurse-Family Partnership (NFP) (National, Best Practice) is an evidence-based,

community health program that helps transform the lives of vulnerable mothers pregnant with their first child. Each mother served by NFP is partnered with a registered nurse early in her pregnancy and receives ongoing nurse home visits that continue through her child’s second birthday. NFP has been extensively evaluated over the last three decades, including through randomized, controlled trials. For low-income women and their children, the program has been successful in: improving women's prenatal health-related behaviors (especially reducing cigarette smoking and improving diet); reducing pregnancy complications, such as hypertensive disorders and kidney infections; reducing harm to children, as reflected in fewer cases of child abuse and neglect and injuries to children revealed in their medical records; and improving women's own personal development, indicated by reductions in the rates of subsequent pregnancy, an increase in spacing between first and second born children, a reduction in welfare dependence, and reductions in behavioral problems due to substance abuse and in criminal behavior on the part of

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mothers who were unmarried and from low-income households at registration during pregnancy.” – AMCHP Best Practices

2. Prenatal Plus Program (Colorado, Promising Practice) is “a Medicaid-funded program that provides care coordination, nutrition and mental health counseling to Medicaid-eligible pregnant women in Colorado who are at a higher risk for delivering low birthweight infants. The goal is to reduce the number of low birthweight infants born to women in the program. The program uses the Client-Centered Counseling approach with all participants to address a variety of issues that have been shown to have a negative impact on birth outcomes. Providers are required to assist the client in developing a goal during one of the first three visits and then follow-up on this goal at subsequent visits. The key health areas targeted by this program are healthy weight, smoking/cessation and depression. In order to encourage providers to offer model care for all women in the program, the Medicaid reimbursement structure has been adapted to offer a greater monetary incentive for completing the required number of visits (10) for model care. In 2007, the low birthweight rate for infants born to Prenatal Plus participants who remained in the program through delivery was 10.7%; 22.5% less than the expected rate for this population without Prenatal Plus services (13.8%). This reduction in the low birthweight rate resulted in an estimated savings of 2.7 million dollars in health care costs for Medicaid during 2007.” – AMCHP Best Practices

3. Healthy Women, Healthy Futures (HWHF) (Oklahoma, Promising Practice): “Offered at early childhood education centers (ECECs), this program aims to improve the physical, emotional, social, dental, and vision health of at-risk women living in poverty before they become pregnant again, thereby minimizing their risk of future premature birth or infant death. HWHF is based in Life Course Theory (LCT), and attempts to reduce participants‟ risk factors, which diminish health, and improve their protective factors by improving their equity to primary care and other health services, through health education and care coordination. Participants attend weekly one hour classes offered in Spanish and English on site at the ECECs, and develop health and reproductive life plans while consulting with HWHF staff during home visitation. Participants have provided written and verbal feedback about the program from inception. Comments are reviewed by all the HWHF staff and are considered for program revision. Classes and services have been modified to meet participants‟ needs or health interests. Evaluation data to this point have shown health improvements due to improved knowledge and resultant behavior change; lifestyle improvements, such as increased exercise and better nutrition; and healthy, full-term pregnancies among participants.

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Additionally the program has an 85% retention rate in a population frequently characterized as non-compliant, apathetic, disinterested, mobile and difficult to retain in a program.” – AMCHP Best Practices

13. Which program would you recommend Evergreen Healthy Births, Healthy Babies

choose to replicate? Explain the rationale for your choice. Which of the objectives will the program address?

14. How would you modify the program you chose to best serve your local population?

Update 8

It is now Year 3 (2015) of the Evergreen Healthy Births, Healthy Babies initiative. Representatives from the state office funding your initiative are coming to the next meeting, where you would like to share updates on program impact. You have received Evergreen County birth data for 2013 (final data) and 2014 (provisional data) (Table 3).

Table 3. Final Birth Data (2013) and Provisional Birth Data (2014)

Total White African-

American

Year 1 (2013)

Number of Live Births 2,111 977 883

Infant Deaths 21 11 9

Year 2 (2014)

Number of Live Births 2,144 1008 887

Infant Deaths 20 12 8

15. Given the small numbers of infant deaths each year, the infant mortality rates for

Year 1 and Year 2 are not stable. What is the best way to interpret this information? At this time, is it possible to draw meaningful conclusions regarding program impact on overall Evergreen County infant mortality rates?

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Update 9

For the upcoming meeting, you decide to share updates on one aspect of the program: the impact on smoking cessation among program participants (pregnant mothers). Your team has been collecting outcome evaluation data from program participants using in- person interviews at the time a woman enters the program (first trimester of pregnancy) and the time she delivers her baby. Below are preliminary results for maternal smoking during Year 1 and Year 2 (Table 4).

Table 4. Maternal Smoking Year 1 and Year 2

Year 1 N (%)

Year 2 N (%)

Total program participants 105 (100) 115 (100)

Smoked at program entry 35 (33) 41 (36)

Smoked at delivery 18 (17) 20 (17)

16. What conclusions can be made about preliminary program impact on smoking

cessation during pregnancy? What limitations are important to share about this data?

Update 10

In an effort to plan ahead, EHBHB wants to secure sustainable funding to continue its initiatives after the 5-year state funding cycle has ended. The group holds a meeting to brainstorm ideas for program sustainability.

17. Group Brainstorm: Have one member of the group write ideas on the flip

chart. What are some strategies to ensure that evidence-based initiatives to decrease infant mortality will continue? Consider funding, staff, politics, community engagement, etc.

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References Association of Maternal and Child Health Programs. State Infant Mortality Toolkit: a standardized approach for examining infant mortality. Available at: http://www.amchp.org/programsandtopics/data- assessment/InfantMortalityToolkit/Pages/default.aspx. Accessed April 6, 2016. Association of Maternal and Child Health Programs. Innovation station: emerging, promising, and best practices on infant mortality and improving birth outcomes. Available at http://mchb.hrsa.gov/pdfs/amchpbestpractices.pdf. Accessed April 6, 2016. North Carolina Institute of Medicine. Improving North Carolina’s health: applying evidence for success. 2012. Available at http://www.nciom.org/publications/?improving-north-carolinas-health-applying- evidence-for-success. Accessed April 6, 2016. North Carolina State Center for Health Statistics. County Health Data Book. 2015. NC Infant Mortality Rates by County (2009-2013) and Birth Indicator Tables by State and County. Available at http://www.schs.state.nc.us/schs/data/databook/2015/. Accessed April 6, 2016. North Carolina State Center for Health Statistics. Pregnancy Risk Assessment and Monitoring System (PRAMS) Annual Survey Results. Available at http://www.schs.state.nc.us/data/prams/survey.htm. Accessed April 6, 2016.