Defined 14 National Standards for Care

1. Why Should Anyone Believe that Cultural Competency Training Could Help Close the Black-White Gap in Wisconsin Birth Outcomes?Beloit LIHF Pathways to Healthy African American Families ProjectWisconsin Health Improvement and Research Partnerships ForumSeptember 14-16, 2011Linda Denise Oakley, PhDProfessor

2. 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

3. 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

4. Office of Minority HealthUS Health and Human ServicesNational Standards for Culturally-Linquistically Appropriate 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

5. Georgetown University National Center for Cultural Competence Fetal-Infant Mortality Review ProgramOrganizational Self-Assessment to Plan Cultural Competency 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

6. Beloit LIHF Collaborative A Wisconsin Partnership Program (WPP) initiative to address the disparity in the African American infant mortality rate in Beloit

7. Collaborative Mission The 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. .

8. Our 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?

9. Wisconsin Infant Mortality2008

10. Wisconsin Black-White IMR Gap2010 Black19.2 Deaths/1,000 Births White 3.5 Deaths/1,000 Births Tom Schlenker, MD Dane County Department of Public Health WSJ, 4/22/2011

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

12. Rock County Black Prenatal Care

13. Beloit Collaborative (N = 55)Individual Self-Assessment Aurora Chang, PhD Beloit College Returned Individual Surveys (n= 36, rate of 65%) Completed Individual Interviews (n = 9) Two Focus Groups (n = 6)

22. Beloit Collaborative 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

23. Beloit CollaborativeCultural Competency Training Program 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) • 1.5 days • 3 Modules

24. Beloit Collaborative Cultural Competency Training “Incorrect” 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)

25. Beloit Collaborative Cultural Competency TrainingPersonal Training Expectations • “To better understand how one individual’s behavior can impact so many lives”

26. Beloit Collaborative Cultural Competency Training“What Appreciative Inquiry Question would I ask 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?”

27. Beloit Collaborative Cultural Competency TrainingOne reason I doubt that racism affects the 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”

28. WPP Risk Factors

29. Risk Factors: Non-Modifiable (LIHF WPP) • African-American Race • Prior Preterm Birth • Maternal Age <18 or >40 Years • Poor Nutrition • Poor Vitamin Intake Prior to Pregnancy • Low Socioeconomic Status • Cervical- Uterine Anomaly • Premature Cervical Dilatation or Effacement • Multiple Pregnancy • Polyhydramnios (excessive amniotic fluid)

30. Risk Factors: Modifiable (LIHF WPP) • Use of tobacco, alcohol, medications, recreational drugs • Short interpregnancy interval • Absent prenatal care • Anemia • 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) • Chronic Disease (diabetes, hypertension/ preeclampsia/ eclampsia, asthma, and obesity) • Depression (prenatal and post-partum), other mental-health conditions • Strenuous work • High environmental stress

31. What does the research say?

33. Cytokines

34. 4. Cytokines (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

35. 3. Pro-inflammatory Immune Response(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

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

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

38. Thank you