AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
BETH BUXTON‑CARTER: Well, hello everyone. How are you? Thank you for coming.
I want to point out a couple of things for you. On the back table there is copies of our PowerPoint presentation, as well as our final report that we'll reference throughout the presentation. So please grab those.
What I'd like to do is although Emily and Karen and I are presenting this, it's important for us to recognize that this was really a team effort and there's several people that really helped make this happen for us. Their names are included on the front of the blue packet.
Mya Brodiefield Boston Public Health Commission was an asset in bringing home the connection between this work to the community‑based services.
In addition, Claudia Claudiano, Penny Lu, I'm going to butcher her name, I apologize for this, Hasutu Deo. We all call her Fifi, she's a wonderful epidemiologist in addition Beta Vilenuevo (phonetic) was instrumental in this process. I want to recognize their work.
So I'm going to start you off. And let's see if we can get this going. There we go. For this project, just to give you an idea where we're going to go, I'm going to present to you the background of how this came about, talk a little bit about the development of project goals and talk about the community that we've connected with to do this project. Community of Springfield, Massachusetts, move into how we developed the study session.
From there I'll pass it off to Emily who will talk about the data sources we used as well as the method. She's our epidemiologist and has been very helpful for this. We are then going to move into results and how we're trying to move the data into action within our community in Springfield, and that piece is going to be presented by Karen.
For this project, we looked at ‑‑ we all know the high disparity rates based on race both nationally and locally. In Massachusetts, we were able to determine that blacks were two to three times as likely to experience very low birth weight, low birth weight and fetal infant death. Massachusetts has had a very low infant mortality rate. When we looked at the data in a different way, it emerged as a primary concern for Massachusetts.
So in looking at the data over a 14 year period we looked at preterm birth which we defined as born less than 37 weeks gestation. We looked at it by race over 14 years. You can see here, if you look at this maybe on a yearly basis, we may see that we could be, it could be perceived as we're closing the gap in the disparity when in actuality the preterm berth for 14 years for white community has written. And for the black community, it's basically stayed the same at 12. There's been no impact over the last 12 years. Looking at infant mortality rates by race during the same 14 year period, you can see from the boards it's declined, steady decline over the 14 year period.
But within the black community there's not been a significant impact at all. It's pretty well stayed the same. This is a slide that we have actually borrowed from Michael Lu and James Collins. Both of them presented here last year. They're wonderful and they provided us with a lot of inspiration to continue this project.
But really looking at thinking about pre-maturity, infant death and the cost benefits of that is really part of why we moved into this project. So AMCHP, many of you probably are familiar with the action learning labs that AMCHP has done. That's where a lot of this started with as well. Our roots are really at this conference where we're able to participate in the action learning lab around perinatal disparities. And that project really helped us to identify our focus, look at developing some strategies and looking at identifying some of our gaps in our assets within our own state.
So to give you an example around our data, the assets we have in Massachusetts a wealth of data. We have the capacity to really analyze both race and ethnic data in Massachusetts. We also have strong community organizations in place to address disparities. Partners, organizational partners such as the Boston Public Health Commission have done a lot of work around this area.
We have strong links with other programs that work in perinatal health, for instance our family planning programs, our WIC program. And we have a strong commitment and capacity to address racial disparities within Massachusetts.
But despite those, or I shouldn't say despite. It's wonderful assets, but in addition to that we do have some areas we really need to strengthen our gaps.
They include the communities may not access the data that we do have effectively. Some of our providers still don't have access to the Internet much less the training and the skills necessary to access some of our programs that are available on our website. Actually, one of my programs that I work with has one computer for the entire agency and the director only has access to that.
So to then ask them to be able to access some of our data that we have available in this state is not something that they can do. Additional surveillance systems were not in place. We have applied for PRAMS in Massachusetts to give you an example of one.
Minimal communication among regional efforts. I'll talk a little bit about that in a minute but there's some really wonderful work going on in Boston and Wooster and Massachusetts around infant fetal death but there was no communication between them for lessons learned and to be able to support each other.
No formal mechanism for networking or sharing information on a statewide basis, and overall the positive outcomes and indicators may mask some of the issues that are going on amongst some of our groups.
So out of the action learning lab, we were, excuse me, introduced to the matrix. I wrote this down because I never remember what matrix stands for. It's Matrix Analytical Training for Reproductive Infant and Child Health. It's actually a training course that was funded through the CDC and AMCHP. The contract was given to the university of Rochester. I'm too Italian to be standing straight. I move around too much.
It was implemented by the university of Rochester it was a nine month on‑line training course to help us as a training team to look at the preproductive data and use that to inform policy and program priorities. It was originally presented as a nine month program. It lasted 18 months. But we went over seven modules that included things like evaluation strategies, PPOR. As well as supporting us and really looking at our current programs and services.
When we did some data analysis, how do we then present that data in a way that was meaningful. So that training course was really powerful for us in supporting us. We do go through some of that information in the blue book for you as well.
At the end of that matrix course was the publication of that blue book, which is a final report. And it really helped us to identify two goals for the group that we then formed, which we are now calling the Massachusetts Perinatal Disparities Project. The first goal is to really look at how we can enhance the capacity of community partners to address racial disparities and birth outcomes by collecting analyzed state and local data to inform policy and identify program priorities. You notice that's very similar to what I just showed around the matrix goals and what we were able to learn through matrix. Goal two is actually the meat of what we're trying to do. It's to establish a formal communication network between Massachusetts communities to encourage information sharing, raise public awareness, advocate for resources to eliminate institutional racism. And that was an important piece for us. We really wanted to be able to put out there when we're thinking about perinatal disparities that it involves greatly institutional racism. And a lot of people have a hard time saying the word. It can be very ‑‑ it's a sensitively charged topic but it's one we wanted to address within this project.
For us we defined institutional racism as differential access to the goods, services and opportunities of society by race. That really should be an of not an or. Sorry about that typo.
So we then looked to how can we start this. Partner. Find a partner community in the state of Massachusetts. We really wanted to look for these characteristics that would begin to help the process. First a community that had high racial disparities in their birth outcomes. A community that had social capital to facilitate coordination and cooperation. And a community that was looking at FEMR, and in Massachusetts for Boston and Wooster, they had all of those, and they also had epidemiology support that the community in Springfield did not have. Springfield was just starting to come together and say, hey, we really want to do FEMR, this is a really big issue for us. But we're not sure where to go in terms of the next step. When we approached them, we decided to approach them and say, okay, we have all this information around data, can we partner? They were wonderful. This is Springfield. It is actually spread out significantly. But they were very welcoming to us. We've actually done some work in Springfield before. I'm going to tell you a little bit about Springfield. It is called the City of First. They have a long history particularly in the metal crafts industry. They are actually known for their manufacturing of firearms. They were a major arsenal during the Revolution for firearms. And since then Springfield is the birth place of a gentleman called Daniel Wesson, founder of Smith and Wesson guns. There's still a factory there. The residents is about 152,000. It did drop a little from 1990. They had about 158,000 in 1990. I just checked the 2003 data. They're pretty stable. At 152, 157. That's the number for residents. About half are white. 27 Hispanic and 21 black African American. In thinking about the white, I did look a little bit further. There's a growing population in Springfield of immigrants from Eastern Europe, particularly the Czechoslovakian area, Russia. Latino Hispanic population is a large Puerto Rican in Springfield and a growing Somalia community in Springfield as well. So these may be a little misleading. The average age is similar to Massachusetts, only about two years off.
The history around the culture again comes back to the armory. They have a lot of museums. There's a lot of culture around this. City hall actually burned down in 1990 because a monkey turned over ‑‑ swear to God ‑‑ turned over a kerosene lamp. So there's a large Greek and Irish community from the 1990s that built city hall with two Greek columns coming up from city hall, and there's a Greek orthodox church sitting right beside city hall. It is also home of someone you may know, Theodore Seuss Giesel, the author of Dr. Seuss. There's a lot of support, pride in that community around that history.
It connects closely to the metal crafts of printing, railroads and guns from the community. It's also the birth place of basketball. Kind of strange. One of the physical Ed teachers in Springfield needed to do something with the kids between the football and baseball season. So they developed basketball. And there is the hall of fame for basketball. The median income, poverty is a big issue in Springfield. Median income is about 20,000 less compared to the state average. And for those who are not familiar with Massachusetts, our average single‑family home goes for about a quarter of a million dollars. So even $50,000 a year for a family of four is cutting it really tight. The per capita income, again, you can see poverty is a big issue across all races.
And there are other challenges facing Springfield. Springfield has a very large migrant community that comes in with the crops and leaves. A lot of fluctuation there. A lot of unemployment, homelessness. High risk behaviors, particularly Springfield has the highest rates of HIV transmission in the state, and obviously prematurity as well.
So I actually took a walking tour once of Springfield with a community health worker. I actually was doing some work out there. I said take me for a walking tour, let me see what's going on out there, what's going on. Jorge brought me out. I knew well enough I better throw on a pair of jeans baseball hat and T‑shirt and sneakers to go out into the community. A student came along with us. The student was very insistent on bringing along a clipboard, wanted to take notes. You probably don't want to do that. She wanted to do that anyway. So we took a walking tour to really look at some of the disparities within the community.
As we were walking down a street, she was, the student was beside me. I looked up at a three tenement, on the top floor there was a mother with her little baby. She took one look at us with that clipboard and the terror in her face was pronounced. It was profound. And she ran into the house. Locked the doors, the shades came down. And Jorge said to me that's a common reaction in his community. That that level of fear and anxiety among in his community is very pronounced. And again thinking about how that affects birth outcomes that level of stress, that level of fear was pretty pronounced. But he also taught me to think outside of public health a little. Look at the disparities outside of my little bubble of public health, and what he was able to ‑‑ we were standing on a street. It was Gorham Street. We were standing on the sidewalk on the north end which he was walking me through, largely Puerto Rican community and there was a lot of Catholic churches, lot of three‑decker apartments, also a lot of dirt on the streets, a lot of garbage piled up on the edges. And the sidewalks were really ripped up. The roots from trees were ripping up. If you had a baby carriage you were not getting down these sidewalks.
But directly across the street. It was a very wide street, wider than this room, was the Brightwood community, lot of single‑family homes and it was very pronounced that directly across the street there was no dirt from the winter, no sand build up, no trash on the streets. The sidewalks were perfect. You could walk down it if you were in a wheelchair, had a baby, you could walk down those streets.
And instead of having maybe a yellow line to have in between the roads to direct traffic, they actually had it manicured with lawn and trees as the divider in the road and it was such a pronounced disparity. Just from across the street. It was just really powerful for me.
So it was a wonderful lesson for me to actually go on a walking tour.So based on this I'm going to wrap it up with really based on all this information we collected we actually looked at developing a study question. And the study question for us is within the last five‑year period, which was for us '98 to 2002, in Springfield, Massachusetts what factors contributed to the excess of poor birth outcomes, including fetal infant death, preterm birth and very preterm birth among blacks. So that's my piece. I'll pass it off to Emily and she'll take us forward.