Assigment 6 modules reflexion 2-3 pages.Apa seven . All instructions attached.

Population Health Training

Module 1: Case Report | 2

Module

1

Case Report #2: Infant Mortality

Module 1. Social Determinants of Health

1A) Background

Infant mortality refers to the death of an infant prior to their first birthday (Centers for Disease Control and Prevention [CDC], 2020a). The

infant mortality rate quantifies the number of infant deaths per 1000 live births. The United States has one of the worst infant mortality rates compared to other industrialized nations. In 2019, the infant mortality rate in the United States was 5.8 per 1000 live births, which resulted in a ranking of 33 of the 36 countries that are members of the Organization for Economic Co- operation and Development (International Comparison, n.d.). Despite awareness of and efforts to address the problem, the average infant mortality rate in the United States has not improved. The CDC aims to reduce the infant mortality rate to 5.0 as part of the Healthy People 2030 objectives (Office of Disease Prevention and Health Promotion, n.d.).

Infant mortality varies within the United States. In the map below, darker colors indicate a higher (or worse) infant mortality rate (number of infant deaths per 1000 live births).

(Rate per 1000 live births)

By examining the map, you will notice that the infant mortality rate is higher in the southeast region of the country, and in some northern and midwestern states like North Dakota, South Dakota, Wyoming, Indiana, and Ohio.

There is also significant variability in the infant mortality rate by race and ethnicity in the United States. In 2018, the infant mortality rate was highest among non-Hispanic Black infants (10.8),

followed by Native Hawaiian or other Pacific Islander infants (9.4) and American Indian/Alaskan Native infants (8.2). Hispanic infants, non-Hispanic white infants, and Asian infants had infant mortality rates below the national average (CDC, 2020b). Since race and ethnicity are social constructs, they should not be considered causal factors in explaining variability in infant mortality; the discrepancies in infant mortality rates are driven by racism perpetuated by institutional, political, and societal factors.

The most common causes of infant mortality include congenital malformations, disorders connected to premature births and low birthweight, maternal complications, sudden infant death syndrome and unintentional injuries (CDC, 2020b). Most commonly, it is not possible to discern what led to many of these causes, though risk factors that contribute to the common causes of infant mortality have been identified. Common risk factors include maternal malnutrition (e.g., no folic acid early in pregnancy), environmental teratogens (i.e., harmful exposure to the fetus), inadequate prenatal care, maternal chronic health conditions, an unsafe sleep environment for the baby, and a failure to properly screen newborns to detect hidden conditions (National Institutes of Health, 2016).

1B) Reflection Question

State M has an average infant mortality rate of 7.0. Within State M, higher rates of infant mortality are observed in rural counties compared to urban and suburban counties. Given the variability in infant mortality rate observed in the United States, as well as the most common causes of infant mortality, what social determinants of health might contribute to infant mortality in State M’s rural counties? Consider social determinants connected to the six main categories reviewed in Module 1: economic stability, neighborhood/physical environment, education, food, community/social context, and the healthcare system.

1C) Considerations

Consider the following social determinants of health that could contribute to the high infant mortality rate in rural counties in State M.

Economic stability

· In State M, rural counties have higher unemployment rates. Unemployment is a multifaceted social determinant of health. For example, unemployment can impede a mother’s access to adequate prenatal and newborn healthcare, and adequate nutrition prior to, during and after pregnancy, and increase stress, which may contribute to numerous acute and chronic health conditions.

· State M did not expand Medicaid coverage, which means that fewer low-income mothers have access to adequate prenatal care, and fewer newborns receive proper screenings for hidden conditions.

Neighborhood/physical environment

· Unsafe living and workplace conditions, prevalent in rural counties in State M, can increase exposure to pathogens that are risk factors for infant mortality and maternal disease.

· Several communities in State M’s rural counties were recently in the news because their drinking water was declared unsafe and they were under a water boil advisory. Lack of access to safe drinking water is an environmental pathogen that can be a risk factor for birth defects and other infant mortality causes.

Education

· Adults in State M’s rural counties are less educated. Mothers with less education may have fewer job opportunities and may be more likely to work for employers who do not provide benefits like paid maternity leave, meaning they need to choose between a paycheck and providing proper care for their newborn.

Food

· As noted earlier, economic instability can impede a family’s ability to purchase healthy foods, which can contribute to malnutrition in mothers and infants. State M cut its budget for supplemental nutritional income, which means that fewer families have support for addressing food insecurity.

· Rural communities in State M have fewer stores with healthy food options within a 20- mile radius, which makes it harder for families to purchase healthy food.

Community/social context

· On a survey of State M residents, 72% of Black, Indigenous, People of Color residents who live in a rural county reported feeling discriminated against in the past month. Discrimination can contribute to increased stress, anxiety, and the onset of chronic health conditions, as well as exacerbate existing chronic health conditions in mothers.

· Data from the most recent survey that assesses behavioral risk factors for disease like smoking, physical inactivity, unhealthy diet, indicate that the prevalence of adult smoking in rural counties in State M ranges from 24 – 30%, which is substantially higher than the national average of 14%. Counties with a higher smoking prevalence suggest that residents spend more time with those who smoke, which can impede quit attempts and increase exposure to pathogens. Smoking is a risk factor for infant mortality.

Healthcare system

· Rural counties in State M tend to have fewer health care clinics per capita, which impedes access to adequate prenatal and newborn healthcare.

· State M spends less of its budget on maternal and child health than other states with lower infant mortality rates, which impacts the state and local health department’s ability to implement programs designed to reduce infant mortality such as the CDC’s Safe Sleep for Babies campaign (CDC, 2018).

Population Health Training

Module 2: Case Report | 5

Module

2

Module 2. Population Health Assessment

2A) Background

Building on our example from the social determinants of health module, consider the case of County H. County H is a rural county in State M with an infant mortality rate of 8.2 per 1,000 live births. The county is racially diverse with 15% of the community identifying as Hispanic (most of whom are Mexican or Puerto Rican) and 10% of the

community identifying as Black or African American. The unemployment rate is 8.9% and the median household income is $29,200.

2B) Reflection Question

Imagine you are a public health worker in County H. What would you do as part of your county’s population health assessment to ensure you understand the needs of your county regarding infant mortality? Consider who you would want to include in the assessment process, and what steps you would take to conduct a thorough population health assessment. Focus on three areas in your response: community engagement, diverse data collection sources and identifying priorities.

2C) Considerations

County H’s public health department conducted a population health assessment, part of which focused on understanding the high infant mortality rate in their county. County H emphasized community engagement, diverse sources of data collection and priority identification in the following ways via their approach to population health assessment.

Community engagement

· The county health department first connected with community partners to serve as co- leaders of the population health assessment. The health department connected with community organizations they had worked with previously to help identify community partners. Community partners included a mother who had experience with the supplemental nutritional assistance program, an immigrant who obtained US citizenship 3 years ago, a recently laid off factory worker, and others who could ensure that diverse perspectives were included in the population health assessment.

· The health department created a community advisory board to inform their health assessment. The board included members of the following County H communities and organizations: community health clinic, religious institutions, school district, and social services like food banks, housing, and job training. The community advisory board provided guidance on the creation of a survey of community members, strategies for reaching diverse and hard to reach communities, interpretation of results, prioritization of health needs, and communication of results to community members.

Diverse sources of data collection

· County H’s public health department and their community partners used existing resources to help guide their population health assessment. Specific to infant mortality, they accessed a framework for infant mortality assessment provided by the Association of Maternal & Child Health Programs (n.d.).

· To understand the county’s high infant mortality rate and other problematic health outcomes, the health department used a combination of secondary data available from the state and county health departments, the Centers for Disease Control and Prevention (CDC), and other national organizations. For example, they obtained maternal and infant health data from the March of Dimes and information on county level exposure to toxic substances from Agency for Toxic Substances and Disease Registry (March of Dimes Foundation, n.d.; Agency for Toxic Substances and Disease, 2021).

· County H’s public health department also collected primary survey and key informant interview data from community members to supplement existing data and understand what factors may contribute to poor health outcomes, and to identify community assets. Specific to infant mortality, primary data collection included topics such as perinatal care and general healthcare experiences, breastfeeding, co-sleeping, social support, community resources for new parents, and maternity and paternity leave. All survey and interview questions were reviewed by the community advisory board; they also provided guidance on how to sample diverse and hard to reach county residents.

Identifying priorities

· After data were collected, the Hanlon method was used to identify priorities. The county health department and partners created the Hanlon method ratings, which were reviewed and agreed upon by the community advisory board. Infant mortality was identified as a priority based on the elevated infant mortality rate, the seriousness of the problem, and the availability of effective interventions to address the identified factors contributing to the high infant mortality rate (e.g., socio-economic disparities, low healthcare access, pollution, and other environmental toxins).

· Available assets (e.g., community center with existing parenting classes, strong social ties among cultural groups, grass roots social justice efforts) that would be important in facilitating implementation of possible interventions were also noted and served as further justification for prioritizing infant mortality.

· Other priorities connected to infant mortality included high income inequality and environmental toxins.

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Module 3: Case Report | 7

Module

3

Module 3. Population Health Surveillance

3A) Background

As part of the population health assessment, County H’s public health department and its partners recommended improving the county’s population health surveillance specific to infant mortality since the only data that was routinely collected by the county included premature births and infant mortality. These data were not consistently connected

to relevant place and individual factors like maternal age, race/ethnicity, income, and zip code. Hospitals varied in how they characterized infant deaths

at the time of delivery, which created confusion about the accuracy of County H’s infant

mortality rate.

3B) Reflection Question

You are a public health worker in County H and have been asked to provide input on the county’s approach to surveillance related to infant mortality. What would you focus on to improve surveillance in County H? Consider how the strategies identified for rigorous population health surveillance (involvement of community members, strategic plan, interconnected systems, routine evaluation, and workforce training) could be applied in this example.

3C) Considerations

Consider the following ways in which County H could approach population health surveillance to address the high infant mortality rate in the county.

Involvement of community members

· County H’s health department solicited input from their community advisory board on how to improve surveillance in their county.

· They created a website to make their surveillance data accessible to community partners and residents.

· They generated annual reports that were posted on the website and discussed with the community advisory board to review progress as they introduced interventions and policies to address the prioritized areas, and to identify ways to improve upon existing surveillance efforts.

Strategic plan

· In tandem with feedback from their community advisory board, County H’s health department created a comprehensive population health surveillance plan to monitor the prioritized areas.

· They recognized that some surveillance improvements would take additional funding and staff training, so their strategic plan included time to identify and obtain funding.

Interconnected systems

· As part of a larger state effort, they obtained funding to automate and standardize the exchange of electronic health records between County H’s hospitals and the county health department so that relevant infant (e.g., birth weight) and maternal health (e.g., birth complications, multiple births) data could be systematically tracked to ensure that data were consistently collected, and infant deaths were identified in the same way.

· They connected geographic information system (GIS) data with the hospitals’ data, environmental toxin data, health behavior data and demographic data, to understand which areas of the county may be particularly impacted by social determinants of health and high infant mortality.

Routine evaluation

· As part of their plan, County’ H’s health department built in quarterly reviews of their surveillance efforts to ensure that all of the interconnected systems were working, and the quality of the data could be trusted.

· In addition to the regular review conducted within the health department, the

community advisory board annually reviewed the health department’s surveillance

efforts and reports.

Workforce training

· The automation of data exchanges with electronic health records and integration of data from multiple sources, necessitated that public health workers at County H’s health department obtain advanced training in areas such as data management, big data, and data analysis.

Population Health Training

Module 4: Case Report | 8

Module

4

Module 4. Population Health Interventions

4A) Background

Based on the results of the population health assessment and surveillance, County H’s public health department decided to focus on identifying population health interventions that could reduce the infant mortality rate in their county. County H includes preconception maternal health as one aspect of their community health improvement

plan. Since the county is racially diverse (15% Hispanic and 10% Black or African American) and low-income (unemployment rate is 8.9%, median

household income is $29,200), County H wants to ensure that the interventions selected will reduce infant mortality in those who are most at risk.

4B) Reflection Question

What should County H consider when selecting, implementing, and evaluating population health interventions to address preconception maternal health to reduce infant mortality?

4C) Considerations

Consider the following approach County H could use to incorporate population health interventions to address the high infant mortality rate in the county.

Selecting

· County H’s public health department first focused on identifying evidence-informed population health interventions that have demonstrated success with improving preconception maternal health (their primary goal) and hence, infant mortality.

· Of the available evidence-informed interventions (Johnson et al., 2006), they selected ones that were feasible for County H to implement and would require minimal adaptation.

· They identified the following interventions for implementation:

· Health promotion campaigns to reduce tobacco use, promote responsible use of alcohol, and encourage healthy diet and optimal weight.

· Integrating preconception interventions like comprehensive risk screening, reproductive health promotion, and reproductive life planning, into existing public health programs that serve women.

· The community advisory board provided input on County H’s approach.

Implementing

· Partners from a variety of different sectors (e.g., schools, businesses, healthcare organizations, community organizations) were solicited to assist with implementation.

· A plan, do, study, act framework was created to begin the implementation process.

· For the health promotion campaigns, materials were translated into Spanish and used images of ethnically and racially diverse families. All campaign materials were reviewed

by community members to ensure they were appropriate and were accessible for most literacy levels. The community advisory board and other partners provided input on the best way to implement the campaigns to maximize exposure.

· A plan was identified for modifying existing public health programs that serve women by incorporating preconception interventions. The plan included translation into Spanish and input from community members to ensure that the modified programs would still meet the goal, while being expanded to address maternal health prior to conception.

Evaluating

· Upon initial implementation, simple metrics of exposure to the interventions were used to evaluate the success of the interventions.

· Modifications were made, with input from community members and partners to ensure that diverse and low-income populations were reached.

· Population health surveillance data were helpful for monitoring the success of the interventions

Population Health Training

Module 5: Case Report | 10

Module

5

Module 5. Policy Innovations in Population Health

5A) Background

In addition to the population health interventions, County H’s public health department recognized the need for policy changes at the federal, state, and local levels to facilitate greater improvements in

infant mortality in their county. Based on the results of the population health assessment and ongoing surveillance efforts, County H’s leaders are

convinced that federal changes in health care coverage before and during

pregnancy, and during the post-partum period would substantially reduce the infant mortality rate in their county. They also note that policy changes at the state and county level could also improve County H’s infant mortality rate. Specifically, they were interested in reducing exposure to environmental toxins that could contribute to infant mortality.

5B) Reflection Question

Based on the CDC’s policy process, in what ways might County H’s public health officials be involved in county and state policies to address infant mortality? Consider their role at each step of the process: 1) problem identification, 2) policy analysis, 3) strategy and policy development, 4) policy enactment, and 5) policy implementation.

5C) Considerations:

At every step of the policy process, public health workers from County H played a key role in ensuring that the relevant stakeholders have a voice in the process, and that evaluation is built into the process. Consider the following ways County H’s public health workers may be involved in the different steps of the policy process.

Problem identification

· Public health workers in County H assisted with the accumulation of information that identified the key causes of the infant mortality problem in County H (e.g., lack of access to proper prenatal and post-partum care and exposure to environmental toxins). Surveillance data and information from the population health assessment was used to identify key causes in County H.

Policy analysis

· Once the key causes were identified, public health workers from County H helped identify and prioritize policy options to address the lack of appropriate prenatal and post-partum care and environmental toxins in County H.

· Public health workers from County H reached out to other rural counties to understand what other counties were doing to address these infant mortality causes. They also

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reviewed the literature for evidence of how relevant policies had reduced infant mortality.

· They partnered with community members, policy makers, healthcare system administrators and other stakeholders to evaluate relevant policies and prioritize ones that were most likely to be widely acceptable and improve infant mortality, with minimal costs. The following policies were prioritized:

· Adequate enforcement of new and existing air pollution standards

· Promoting cleaner sources of energy

· Encourage State M to use their federal waiver authority to expand family planning services to women who do not qualify for Medicaid. Family planning services offer more comprehensive risk screening and health promotion to women, which results in improved maternal health prior to conception.

Strategy and policy development

· County H public health workers helped clarify how the prioritized policies can operate and what steps are necessary prior to policy implementation

· They also assisted with the creation of policy briefs and presentations that were shared with key stakeholders to garner support for the policies.

Policy enactment

· County H’s public health department monitored how the policies were enacted.

Policy implementation

· For the policy that expanded family planning services, County H’s public health department assisted with health care provider training and partnered with community organizations to encourage eligible women to take advantage of the health promotion services.

· For policies connected to air pollution and increased use of clean energy sources,

County H’s public health department coordinated the evaluation of these policies.

Module 5: Case Report | 11

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References

Agency for Toxic Substances and Disease Registry. (2021, August 10). Public Health Assessments & Health Consultations. https://wwwn.cdc.gov/TSP/PHA/PHALanding.aspx

Centers for Disease Control and Prevention. (2018, January 9). Safe Sleep for Babies. https://www.cdc.gov/vitalsigns/safesleep/index.html

Centers for Disease Control and Prevention. (2020, July 16). Infant Mortality in the United States, 2018: Data From the Period Linked Birth/Infant Death File. National Vital Statistics Reports, 69(7) . https://www.cdc.gov/nchs/data/nvsr/nvsr69/NVSR-69-7- 508.pdf

Centers for Disease Control and Prevention. (2020, September 10). Infant Mortality.

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm

Johnson, K.J., Posner, S.F., Biermann, J.B., Cordero, J.F., Atrash, H.K., Parker, C.S., Boulet, S., &Curtis, M.G. (2006, April 21). Recommendations to Improve Preconception Health and Health Care—United States: A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. Morbidity and Mortality Weekly Report, 55(RR06);1-23. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm

March of Dimes Foundation (n.d.). Covid-19 Pandemic Resources and Support.

https://www.marchofdimes.org/peristats/Peristats.aspx

National Institutes of Health. (2016, December 1). Are there ways to reduce the risk of infant mortality? https://www.nichd.nih.gov/health/topics/infant-mortality/topicinfo/reduce- risk

Office of Disease Prevention and Health Promotion. (n.d.). Reduce the rate of infant deaths — MICH-02. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/browse- objectives/infants/reduce-rate-infant-deaths-mich-02

United Health Foundation. (2019). International Comparison: 2019 Annual Report. America’s Health Rankings. https://www.americashealthrankings.org/learn/reports/2019-annual- report/international-comparison

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