Why Should Anyone Believe that Cultural Competency Training Could Help Close the Black-White Gap in Wisconsin Birth Outcomes? Beloit LIHF Pathways to Healthy.

Why Should Anyone Believe thatWhy Should Anyone Believe that Cultural Competency Training Could Help Cultural Competency Training Could Help

Close the Black-White Gap in Wisconsin Close the Black-White Gap in Wisconsin Birth Outcomes?Birth Outcomes?

Beloit LIHF Pathways to Healthy African American Families ProjectBeloit LIHF Pathways to Healthy African American Families ProjectWisconsin Health Improvement and Research Partnerships ForumWisconsin Health Improvement and Research Partnerships Forum

September 14-16, 2011September 14-16, 2011

Linda Denise Oakley, PhDLinda Denise Oakley, PhDProfessorProfessor

• Culture is often described as the combination of a body of knowledge, a body of belief and a body of behavior. It involves a number of elements, including personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions that are often specific to ethnic, racial, religious, geographic, or social groups.

• NIH Health Literacy Initiative Clear Communication

Cultural competency has a positive effect on patient care delivery by enabling providers to deliver services that respectful of and response to the health beliefs, practices, and cultural and linguistic needs of diverse patients. NIH Health Literacy Initiative Clear Communication

Office of Minority HealthOffice of Minority HealthUS Health and Human ServicesUS Health and Human ServicesNational Standards for Culturally-Linquistically National Standards for Culturally-Linquistically Appropriate Services in Health Care 2001Appropriate Services in Health Care 2001

• Defined 14 National Standards for Care

• Standard 1: Health care organizations should ensure that patients/consumers receive from all staff members effective understandable and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language

Georgetown University National Center for Cultural Georgetown University National Center for Cultural Competence Fetal-Infant Mortality Review ProgramCompetence Fetal-Infant Mortality Review ProgramOrganizational Self-Assessment to Plan Cultural Organizational Self-Assessment to Plan Cultural Competency 2009Competency 2009

• Self-Assessment addresses attitudes, behaviors, policies, structures, and practices of an organization, including those of its boards, advisory groups, staff, and volunteers

• Self-Assessment process can include structure instrument, focus groups, structured interviews, analysis of community, regional, and state demographic data, and review of the organization’s values, mission, policies, procedures, budget, and web/ print documents

• Four-Phase approach is establish a structure to guide the work, create a shared vision and shared ownership, collect, analyze, disseminate data, develop and implement a plan of action

Beloit LIHF Beloit LIHF CollaborativeCollaborativeA Wisconsin Partnership Program (WPP) initiative to address the disparity in the African American infant mortality rate in Beloit

Collaborative MissionCollaborative MissionThe mission of the Collaborative is to build a Beloit Community

Collaborative to close the black-white gap in birth outcomes by improving the health and well-being of African American Families and communities, and addressing social and economic inequalities.

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Our Presentation AimsOur Presentation Aims

We present the results of the Collaborative self-assessment and cultural competency training and address the following implementation question

Why should anyone believe that cultural competency training could help close the Black-White gap in Wisconsin birth outcomes?

Wisconsin Infant MortalityWisconsin Infant Mortality20082008

White 315 deaths for 53,561births IM Rate is 5.9 per 1,000

Black 100 deaths for 7,236 births IM Rate is 15.2 per 1,000

Hispanic 49 Deaths for 7,025 birthsIM Rate is 6.5 per 1,000

Healthy People 2010 Goal 4.5

Wisconsin Black-White IMR Wisconsin Black-White IMR GapGap 20102010

Black19.2 Deaths/1,000 Births

White 3.5 Deaths/1,000 BirthsTom Schlenker, MD

Dane County Department of Public Health

WSJ, 4/22/2011

Wisconsin Black Infant Mortality Wisconsin Black Infant Mortality 2002-20062002-2006Richard Allan Aronson, MD for WPP, 2008Richard Allan Aronson, MD for WPP, 2008

City IMR/ 1,000

Madison 7.15

Milwaukee 17.3

Kenosha 18.0

Beloit 19.2

Rock County Rock County Black Prenatal CareBlack Prenatal CareStart 2008 Births = 137

Start Prenatal Care 1st Trimester 109

Start Prenatal Care 2nd Trimester 17

Start Prenatal Care Unknown 11

Beloit Collaborative (N = 55)Beloit Collaborative (N = 55)Individual Self-AssessmentIndividual Self-Assessment

Aurora Chang, PhD

Beloit College

1. Returned Individual Surveys (n= 36, rate of 65%)

2. Completed Individual Interviews (n = 9)

3. Two Focus Groups (n = 6)

Beloit Collaborative Beloit Collaborative Self-Assessment Findings Self-Assessment Findings

•Cultural competency trainings don’t always leave a lasting impact

•When talking about culture, it leads to talking about traditions, not necessarily disparities between race and class

•People in power having the power to remove themselves

•Change happens by force, not voluntarily

•Lack of interracial interaction comes from lack of jobs

Beloit CollaborativeBeloit CollaborativeCultural Competency TrainingCultural Competency Training

Program

• 1.5 days

• 3 Modules

Activities• Pre-Post Test (n = 33)

• Individual Training Expectations

• Individual Assessment Expectations

• Domain Groups Initiatives Identified

• Conversation with a Black infant

• Conversation with Colleagues

• Conversation with your values

• Health and Racism

• Social Determinants and Risk Factors

• Cultural Competency

• Post-Test (n = 28)

• Evaluation Forms (n = 25)

Beloit Collaborative Beloit Collaborative Cultural Competency Training Cultural Competency Training

“Incorrect“Incorrect” ” Pre-Test Items (2/10)Pre-Test Items (2/10)

• Income level predicts the health of African Americans and Caucasians,(n = 30, false)

• Researchers have shown that social stress can produce unhealthy changes in amniotic fluid in pregnant black women (n=9 don’t know, false)

Beloit Collaborative Beloit Collaborative Cultural Competency TrainingCultural Competency Training

Personal Training ExpectationsPersonal Training Expectations

• “To better understand how one individual’s behavior can impact so many lives”

Beloit Collaborative Beloit Collaborative Cultural Competency TrainingCultural Competency Training

““What Appreciative Inquiry Question would I ask What Appreciative Inquiry Question would I ask myself about the Beloit Black IMR?”myself about the Beloit Black IMR?”

• Why is the black IM rate important to me? How can I be part of the solution?

• I watched my sister bury her 3-month old son. She did everything right in her pregnancy and with him after he was born. We are white. I don’t understand. I’m sorry. I try. Why Anyone wouldn’t do everything they could for the health of their child. Yes there are barriers-Fight them! So my question for myself, am I prejudice?”

Beloit Collaborative Beloit Collaborative Cultural Competency TrainingCultural Competency Training

One reason I doubt that racism affects the One reason I doubt that racism affects the health of African Americans is:health of African Americans is:

• “I know healthy African Americans in communities with much racism”

• “Free healthcare is provided for African Americans to access health care”

• “One reason I doubt racism affects health of African Americans is that sometime we do not get the same treatment and care as another race

would”

WPP Risk FactorsWPP Risk Factors

Risk Factors: Non-Modifiable Risk Factors: Non-Modifiable (LIHF WPP)(LIHF WPP)

1. African-American Race

2. Prior Preterm Birth

3. Maternal Age <18 or >40 Years

4. Poor Nutrition

5. Poor Vitamin Intake Prior to Pregnancy

6. Low Socioeconomic Status

7. Cervical- Uterine Anomaly

8. Premature Cervical Dilatation or Effacement

9. Multiple Pregnancy

10. Polyhydramnios (excessive amniotic fluid)

Risk Factors: Modifiable Risk Factors: Modifiable (LIHF WPP)(LIHF WPP)

1. Use of tobacco, alcohol, medications, recreational drugs

2. Short interpregnancy interval

3. Absent prenatal care

4. Anemia

5. Infection [bacteriuria/urinary tract infection (UTI), Sexually-transmitted infection (STI)], such as gonorrhea, Chlamydia, bacterial vaginosis, Group B β-hemolytic streptococcus, HIV/AIDS; Periodontal Disease)

6. Chronic Disease (diabetes, hypertension/ preeclampsia/ eclampsia, asthma, and obesity)

7. Depression (prenatal and post-partum), other mental-health conditions

8. Strenuous work

9. High environmental stress

What does the research say? What does the research say?

CytokinesCytokines

4. Cytokines 4. Cytokines (Kunz-Ebrecht, Mohamed-Ali, Feldman, Kirschbaum, Steptoe, 2003)(Kunz-Ebrecht, Mohamed-Ali, Feldman, Kirschbaum, Steptoe, 2003)

• Repeated episodes of acute stress and chronic stress affect immune system

• Stress can cause chronic release of pro-inflammatory cytokines

• Inflammatory response to stress increases risk of infection

• Cytokines in vaginal fluid and infection are associated with PTB in black women

3. Pro-inflammatory Immune Response3. Pro-inflammatory Immune Response(Woodworth, Grenache, Gronowski, 2011)(Woodworth, Grenache, Gronowski, 2011)

• Corticosteroid (anti-inflammatory medication) given 48+ hours prior to PTB decreases the risk of infant morbidity and mortality

• Biomarkers in vaginal fluid are used to predict time to PTB

• Two biomarker s Fetal Fibronectin and Pro-inflammatory cytokine IL-6. This study tested both markers in 343 black women and 324 white women

• Cytokines in fluid is associated with vaginal bacterial infection and chorioamninonitic –membranes

• Study found cytokines associated with delivery in black women--with and without symptoms of preterm labor– no cytokine association with delivery in white women.

• Conclusion: Cytokine test “markedly improved” prediction of delivery in black women

……QuestionQuestion

• Why should anyone believe that cultural competency training could help close the Black-White gap in Wisconsin birth outcomes?

……AnswerAnswer

The data supports “competency” models aimed at make effective treatment, effective for black women

Thank youThank you