The New and Improved BIH

The New and Improved BIH Reggie Caldwell, LCSW Health Equity Analyst California Department of Public Health Maternal, Child and Adolescent Health Division

CDPH/MCAH Karen Ramstrom Laurel Cima Janet Baisden Anita Mitchell Michelle Woods Mike Curtis Chris Krawczyk David Dodds Nichole Sturmfels UCSF Center for Social Disparities in Health Paula Braveman Kristen Marchi Sue Egerter Mercy Dekker Jane An Gina Nicholson Thanks

Janet Baisden Paula Braveman Bernestine Benton Reggie Caldwell Laurel Cima Dawn Dailey Cynthia Harding Jenee Johnson Gerri Perry-Williams Kristen Marchi Anita Mitchell Karen Ramstrom Vashon Strauss Norma Thigpen Candice Zimmerman Work Group Members

Additional Subcommittees • Data Collection and Evaluation • Assessment • Case Management • Group Intervention • Community Engagement • Recruitment • Members were from CDPH/MCAH, UCSF, and local MCAH & BIH • ~80 participants from all subcommittees

Rationale for Revising BIH • An assessment conducted by UCSF found: • Great work happening in sites, but was not consistent across sites, but there was a lack of standardization • Science governing model was outdated • Limited data collected • Recommended the development of a single core model • Did not consider the other factors that influence health seeking behavior

Literature Review Conclusions • No definitive scientific evidence showing the best path • But knowledge suggests promising directions, including by addressing: • Health & social conditions (including stress) across the life course • Social support • Empowerment/capacity building of individuals and communities • Group-based approaches • Decisions will rely heavily on judgment as well as science

Get Them In Early • African American babies are two times more likely to be born with low birth weight than infants of other racial/ethnic groups. • African American infants are about 1 and 1/2 times more likely to be born too early when compared to White infants. • African American women in the US have consistently experienced risk of death from pregnancy complications almost four times higher than white women • This increase appears to be independent of age, parity or education

To Impact Birth Outcomes, BIH Needed To • Decrease isolation • Increase social support • Increase health knowledge and intent • Empower • Decrease stress • Improve coping skills

Evidence-based Standardized Culturally relevant Client-centered Strength based Contextual Measurable Acceptable Accessible Feasible Evaluable The “What’s Most Likely” Principle “BIH can’t be ALL to ALL women”

Conceptual Framework for the Black Infant Health Program Intermediate Outcomes BIH Activities • 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 • INDIVIDUAL • Services 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 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 Ultimate Goal To improve African American infant and maternal health in California and decrease Black:White health disparities and social inequities for women and infants GUIDING PRINCIPLES 1. Comprehensive and integrated: Address multiple risk factors and use multiple strategies 2. Multi-level: Address individual, community, service systems and societal levels, with empowerment focus 3. Collaborative: Partner with community providers and agencies with similar activities 4. Community-driven: Developed, implemented and evaluated by local communities 5. Evidence-based: Developed from proven or promising strategies; impact is measurable 6. Culturally competent: Designed & implemented in a culturally-competent manner 7. Staff training and professional development: Conducted to ensure the BIH activities are provided effectively DRAFT

I pay tribute to the mothers and wives and sisters of our nation. You are the rock-hard foundation of our struggle. -Nelson Mandela

Governing Concepts • Cultural competence • Provide services to people of divers values and beliefs that meet their social, cultural and linguistic needs • Client-centered • All people have a tendency to strive toward growth so the clients needs and desires are at the core of any interaction • Strength based • All people have strength so interactions access and use those strengths • Cognitive skills-building approaches • Solve problems through a goal-oriented process

Program Tenets • Designed to encourage and support a healthy pregnancy • Builds upon client’s strengths to enrich them, their families and their community by empowering them to make healthy decisions • Culturally relevant and honors the unique history and traditions of people of African descent • Information included is important to African American women • Everything is intentional to help close the health gap in Black-White disparities.

Black Infant Health Program Client Flow Chart Recruitment Meets program requirements? Standardized health promotion message & Refer out to appropriate agency No Yes • Intake • Program orientation and consent • Referrals • Prenatal Assessment 1 • Initiation of Individual Client Plan (ICP) • Case Conferencing Enhanced Case Management Prenatal Group Sessions 1-10 Birth Group Sessions 11-20 Postpartum • Program Completion • Complete ICP • Complete Life Plan • Complete Case Closure

Recruitment • Provider/Agency Outreach (Required) • Identify provider/agency and develop MOU • Maintain relationships • Follow established procedure for referrals • Street Outreach (optional) • Identify “hot spots” through various epidemiological methods • Develop local safety protocol • Follow established procedure for referrals • Media Outreach (optional) • Develop messages and materials • Follow established procedure for referrals

Black Infant Health Program Client Flow Chart Recruitment Meets program requirements? Standardized health promotion message & Refer out to appropriate agency No Yes • Intake • Program orientation and consent • Prenatal Assessment 1 • Initiation of Individual Client Plan (ICP) • Referrals • Case Conferencing Enhanced Case Management Prenatal Group Sessions 1-10 Birth Group Sessions 11-20 Postpartum • Program Completion • Complete ICP • Complete Life Plan • Complete Case Closure

Individual Client Plan (ICP)

Harm Reduction Theory • Based in Cognitive Behavioral Therapy • A set of practical strategies to reduce the negative consequences • Any reduction in harm is a step in the right direction and encourages even the smallest accomplishment toward self-efficacy--validates the participant’s current attempts • Abstinence is not the goal—success is measured by quality of life and well-being • Views the participant as capable of taking a greater degree of control in their own lives

Case Management Practice & Theory • Strength Model of Case Management: • Identifies clients’ strengths and triages needs • Helps client access medical/social/community services • Identifies and removes barriers to services Series of logical steps • Services provide in a client-centered manner • Maximize clients receipt of services outlined in ICP

The Enhancements • Conduct formal assessments • Help client create a Birth Plan • Conduct Safety Checklist • Conduct Edinburgh Postpartum Depression Screening at between 6-8 weeks postpartum • Remind client about postpartum group [You are KEY to retention] • Complete the Life Plan that was started in group • If a women reports smoking or alcohol use, provide information/referrals

Why A Group? • Researched and are one the most powerful mechanism to help women • Very effective in many other areas like addictions (i.e. AA, WeightWatchers) • Decrease isolation and increases social support • Improves social skills • Allows opportunity of open and honest discussion about issues • The issues that will be addressed are common to all the women • They can help others with their knowledge and information

Stages of Group Development • Forming (pre-affiliation) • Storming (power and control) • Norming (intimacy) • Performing (differentiation) • Adjourning (separation)

Groups • Facilitative learning is used to access and enhance the knowledge and skills that the women possess • Activities from a women’s health perspective • Skill-building to help with better physical and mental health • Personal goal setting is used weekly and culminates in the creation of a Life Plan • Focus on being empowered which allows the participants to: • Make good choices to have a healthy pregnancy • Be a good role model to their child.

Listens Asks questions Directs group process Coaches Builds consensus Shares in goal-setting and decision-making Empowers others Tells Sells Directs Solves problems Decides Delegates Sets Goals Leadership Styles Participatory Directive

During first group – need to be clear about role, expectations. When giving instructions When a physical or emotional safety concern arises in the group (e.g. confidentiality is breached, member is threatening, etc.) When group is straying too much from agenda/purpose Ask the group what they know about a topic instead of telling them Get the group to respond to one another Facilitate interactive exercises Let the group develop own agenda Provide optional activities Leadership Styles Directive Participatory

African American heritage Stress and stress reduction Understanding how to meet our needs Self-advocacy Nutrition and exercise Infant and toddler parenting Preparing for the baby Safety Healthy relationships Planning for the future Group Session Topics

Transtheoretical Model for Behavior Change • Stage One: Pre-contemplation • Stage Two: Contemplation • Stage Three: Preparation/Determination • Stage Four: Action • Stage Five: Maintenance

Practice Session Select two participants to facilitate group 7 • You may have heard about the controversy with vaccinating your child. One way to be empowered and informed is to be able to discuss those controversies. Ask participants to respond to the following questions: What problems have you heard vaccinations or immunizations? ______________________ What are the benefits?_____________________ [Facilitator Note: Write the statements on a piece of flipchart paper.] • Summarize the value of the activity

The Facts • Vaccines are shots that prevent your baby from getting certain illnesses/diseases • Many times people are scared of vaccines, but vaccines saves lives • When we don’t see people dying or getting sick, that means the vaccines are working—when was the last time you saw someone with polio? • Your baby will need to get routine vaccinations—which will continue until they’re adult. • There is a schedule in your Handbook

Comments from the Field • “Have a better understanding of myself” • “Learned what a BASIC NEED is…did not know before group today. Learning why it is so important to identify what I need in my life to be HAPPY or close to it! There are Negative Results in your Life when your basic NEEDS are neglected. Clearly see what areas in my life I need to work on to develop myself into a good parent, thanks!” • “Realizing I can CHOOSE HAPPINESS.”

Comments from the Field “Participants expressed a lot of energy regarding last week’s topic on stress. They talked about the immediate impact/effect it had on their lives at home, with their children, as well as with their partners…and the action they were able to take to keep peace in the household; such as meditating, encouraging everyone in the household to have a goal…”

Why is Program Fidelity Important? • The current BIH Program successful, but there was no way to measure success • To be able to successfully evaluate the program • Scientific evidence to prove that the BIH Program works • To maintain current funding and advocate for additional funding

Group 1 started 11/1/10 Contra Costa Fresno Kern Sacramento San Diego San Francisco San Mateo Solano Group 2 starts 7/1/11 Alameda Berkeley Long Beach Los Angeles Pasadena San Joaquin Santa Clara Program Implementation

There can be no keener revelation of a society's soul than the way in which it treats its children. Nelson Mandela

Thank You Reggie Caldwell, LCSW California Department of Public Health Maternal, Child and Adolescent Health Division Reggie.Caldwell@cdph.ca.gov 916-650-0373

The New and Improved BIH