The New and Improved BIHThe New and Improved BIH

Reggie Caldwell, LCSWReggie Caldwell, LCSWHealth Equity AnalystHealth Equity Analyst

California Department of Public HealthCalifornia Department of Public HealthMaternal, Child and Adolescent Health DivisionMaternal, Child and Adolescent Health Division

ThanksThanks CDPH/MCAHCDPH/MCAH

Karen RamstromKaren Ramstrom Laurel CimaLaurel Cima Janet BaisdenJanet Baisden Anita MitchellAnita Mitchell Michelle WoodsMichelle Woods Mike CurtisMike Curtis Chris KrawczykChris Krawczyk David DoddsDavid Dodds Nichole SturmfelsNichole Sturmfels

UCSF Center for UCSF Center for Social Disparities Social Disparities in Healthin Health Paula BravemanPaula Braveman Kristen MarchiKristen Marchi Sue EgerterSue Egerter Mercy DekkerMercy Dekker Jane AnJane An Gina NicholsonGina Nicholson

Work Group MembersWork Group Members Janet BaisdenJanet Baisden Paula BravemanPaula Braveman Bernestine BentonBernestine Benton Reggie CaldwellReggie Caldwell Laurel CimaLaurel Cima Dawn DaileyDawn Dailey Cynthia HardingCynthia Harding Jenee JohnsonJenee Johnson

Gerri Perry-WilliamsGerri Perry-Williams Kristen MarchiKristen Marchi Anita MitchellAnita Mitchell Karen RamstromKaren Ramstrom Vashon StraussVashon Strauss Norma ThigpenNorma Thigpen Candice ZimmermanCandice Zimmerman

Additional SubcommitteesAdditional Subcommittees Data Collection and EvaluationData Collection and Evaluation AssessmentAssessment Case ManagementCase Management Group InterventionGroup Intervention Community EngagementCommunity Engagement RecruitmentRecruitment

•Members were from CDPH/MCAH, UCSF, and local Members were from CDPH/MCAH, UCSF, and local MCAH & BIHMCAH & BIH•~80 participants from all subcommittees~80 participants from all subcommittees

Rationale for Revising BIHRationale for Revising BIH An assessment conducted by UCSF found:An assessment conducted by UCSF found:

Great work happening in sites, but was not Great work happening in sites, but was not consistent across sites, but there was a lack of consistent across sites, but there was a lack of standardizationstandardization

Science governing model was outdatedScience governing model was outdated Limited data collectedLimited data collected Recommended the development of a single Recommended the development of a single

core modelcore model Did not consider the other factors that Did not consider the other factors that

influence health seeking behaviorinfluence health seeking behavior

Literature Review ConclusionsLiterature Review Conclusions No definitive scientific evidence showing the No definitive scientific evidence showing the

best path best path But knowledge suggests promising directions, But knowledge suggests promising directions,

including by addressing:including by addressing: Health & social conditions (including stress) across Health & social conditions (including stress) across

the life coursethe life course Social supportSocial support Empowerment/capacity building of individuals and Empowerment/capacity building of individuals and

communitiescommunities Group-based approachesGroup-based approaches

Decisions will rely heavily on judgment as well Decisions will rely heavily on judgment as well as scienceas science

Get Them In EarlyGet Them In Early African American babies are two times more African American babies are two times more

likely to be born with low birth weight than likely to be born with low birth weight than infants of other racial/ethnic groups. infants of other racial/ethnic groups.

African American infants are about 1 and 1/2 African American infants are about 1 and 1/2 times more likely to be born too early when times more likely to be born too early when compared to White infants. compared to White infants.

African American women in the US have African American women in the US have consistently experienced risk of death from consistently experienced risk of death from pregnancy complications almost four times pregnancy complications almost four times higher than white womenhigher than white women

This increase appears to be independent of age, This increase appears to be independent of age, parity or educationparity or education

To Impact Birth Outcomes, To Impact Birth Outcomes, BIH Needed ToBIH Needed To

Decrease isolationDecrease isolation Increase social supportIncrease social support Increase health knowledge and intentIncrease health knowledge and intent EmpowerEmpower Decrease stressDecrease stress Improve coping skillsImprove coping skills

The “What’s Most The “What’s Most Likely” PrincipleLikely” Principle

Evidence-basedEvidence-based StandardizedStandardized Culturally relevantCulturally relevant Client-centeredClient-centered Strength basedStrength based ContextualContextual

MeasurableMeasurable AcceptableAcceptable AccessibleAccessible FeasibleFeasible EvaluableEvaluable

“BIH can’t be ALL to ALL women”

Intermediate Outcomes

DRAFT

To improve African American infant and maternal health in

California anddecrease

Black:White health disparities and

social inequities for women and infants

BIH Activities

Ultimate Goal

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

INDIVIDUALServices 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

GUIDING PRINCIPLES1. Comprehensive and integrated: Address multiple risk factors and use multiple strategies 2. Multi-level: Address individual, community, service systems and societal levels, with empowerment focus3. Collaborative: Partner with community providers and agencies with similar activities4. Community-driven: Developed, implemented and evaluated by local communities5. Evidence-based: Developed from proven or promising strategies; impact is measurable6. Culturally competent: Designed & implemented in a culturally-competent manner7. Staff training and professional development: Conducted to ensure the BIH activities are provided effectively

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

Conceptual Framework for the Black Infant Health Program

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

-Nelson Mandela-Nelson Mandela

Governing ConceptsGoverning Concepts Cultural competenceCultural competence

Provide services to people of divers values and beliefs that Provide services to people of divers values and beliefs that meet their social, cultural and linguistic needsmeet their social, cultural and linguistic needs

Client-centered Client-centered All people have a tendency to strive toward growth so the All people have a tendency to strive toward growth so the

clients needs and desires are at the core of any interactionclients needs and desires are at the core of any interaction

Strength basedStrength based All people have strength so interactions access and use All people have strength so interactions access and use

those strengthsthose strengths

Cognitive skills-building approachesCognitive skills-building approaches Solve problems through a goal-oriented processSolve problems through a goal-oriented process

Wisdom & Knowledge

Cognitive strengths involve gaining and using knowledge

Creativity Thinking of creative, new and productive ways to do things

Curiosity Taking an interest in experiences around you

Open-mindedness Thinking things through and viewing them from all sides

Love of learning Mastering new skills, topics, and knowledge

Perspective Being able to provide wise advice and guidance to others

Courage Emotional strengths that involve the will to accomplish goals in the face of opposition, from yourself or others

Authenticity Speaking the truth and presenting oneself in a genuine way

Bravery Not shrinking from threat, challenge, difficulty, or pain

Persistence Not giving up

Zest Approaching life with excitement and energy

Humanity Interpersonal strengths that involve “tending and befriending” others

Kindness Doing favors and good deeds for others

Love Valuing close relations with others

Social intelligence Being aware of the motives and feelings of self and others

Justice Civic strengths that are important for healthy community life

Fairness Treating all people the same, with fairness and justice

Leadership Organizing group activities and seeing that they happen

Teamwork Working well as member of a group or team

Temperance Strengths that protect against excess

Forgiveness Forgiving those who have done wrong

Modesty Letting one’s accomplishments speak for themselves

Prudence Being careful about one’s choices; not saying or doing things that we might later regret

Self-Regulation Controlling what one feels and does

Transcendence Strengths that build connections to the larger universe and provide meaning to life

Appreciation of beauty & excellence

Noticing and appreciating beauty and excellence

Gratitude Being aware of and thankful for good things that happen

Hope Expecting the best and working to achieve it

Humor Liking to laugh and tease; bringing smiles to other people

Religiousness Having coherent beliefs about a higher purpose and meaning of life

Program TenetsProgram Tenets Designed to encourage and support a healthy Designed to encourage and support a healthy

pregnancypregnancy Builds upon client’s strengths to enrich them, their Builds upon client’s strengths to enrich them, their

families and their community by empowering them families and their community by empowering them to make healthy decisions to make healthy decisions

Culturally relevant and honors the unique history Culturally relevant and honors the unique history and traditions of people of African descent and traditions of people of African descent

Information included is important to African Information included is important to African American womenAmerican women

Everything is intentional to help close the health gap Everything is intentional to help close the health gap in Black-White disparities.in Black-White disparities.

Recruitment

Meets program requirements?

Black Infant Health Program Client Flow Chart

Yes

Program Completion•Complete ICP•Complete Life Plan•Complete Case Closure

NoStandardized health promotion message

&

Refer out to appropriate agency

EnhancedCase

Management

Group Sessions 11-20

Group Sessions 1-10

Intake1. Program orientation and consent 2. Referrals3. Prenatal Assessment 14. Initiation of Individual Client Plan (ICP)5. Case Conferencing

Birth

Postpartum

Prenatal

RecruitmentRecruitment1.1. Provider/Agency Outreach (Required)Provider/Agency Outreach (Required)

Identify provider/agency and develop MOUIdentify provider/agency and develop MOU Maintain relationshipsMaintain relationships Follow established procedure for referralsFollow established procedure for referrals

2.2. Street Outreach (optional)Street Outreach (optional) Identify “hot spots” through various Identify “hot spots” through various

epidemiological methodsepidemiological methods Develop local safety protocolDevelop local safety protocol Follow established procedure for referralsFollow established procedure for referrals

3.3. Media Outreach (optional)Media Outreach (optional) Develop messages and materialsDevelop messages and materials Follow established procedure for referralsFollow established procedure for referrals

Recruitment

Meets program requirements?

Black Infant Health Program Client Flow Chart

Yes

Program Completion•Complete ICP•Complete Life Plan•Complete Case Closure

NoStandardized health promotion message

&

Refer out to appropriate agency

EnhancedCase

Management

Group Sessions 11-20

Group Sessions 1-10

Intake1. Program orientation and consent 2. Prenatal Assessment 13. Initiation of Individual Client Plan (ICP)4. Referrals5. Case Conferencing

Birth

Postpartum

Prenatal

Individual Client Plan (ICP)Individual Client Plan (ICP)

Harm Reduction TheoryHarm Reduction Theory Based in Cognitive Behavioral Therapy Based in Cognitive Behavioral Therapy A set of practical strategies to reduce the negative A set of practical strategies to reduce the negative

consequencesconsequences Any reduction in harm is a step in the right Any reduction in harm is a step in the right

direction and encourages even the smallest direction and encourages even the smallest accomplishment toward self-efficacy--validates accomplishment toward self-efficacy--validates the participant’s current attemptsthe participant’s current attempts

Abstinence is not the goal—success is measured Abstinence is not the goal—success is measured by quality of life and well-being by quality of life and well-being

Views the participant as capable of taking a Views the participant as capable of taking a greater degree of control in their own livesgreater degree of control in their own lives

Recruitment

Meets program requirements?

Black Infant Health Program Client Flow Chart

Yes

Program Completion•Complete ICP•Complete Life Plan•Complete Case Closure

NoStandardized health promotion message

&

Refer out to appropriate agency

EnhancedCase

Management

Group Sessions 11-20

Group Sessions 1-10

Intake1. Program orientation and consent 2. Referrals3. Prenatal Assessment 14. Initiation of Individual Client Plan (ICP)5. Case Conferencing

Birth

Postpartum

Prenatal

Case Management Case Management Practice & TheoryPractice & Theory

Strength Model of Case Management:Strength Model of Case Management: Identifies clients’ strengths and triages needsIdentifies clients’ strengths and triages needs Helps client access medical/social/community Helps client access medical/social/community

servicesservices Identifies and removes barriers to services Series of Identifies and removes barriers to services Series of

logical stepslogical steps Services provide in a client-centered Services provide in a client-centered

mannermanner Maximize clients receipt of services Maximize clients receipt of services

outlined in ICPoutlined in ICP

The EnhancementsThe Enhancements Conduct formal assessmentsConduct formal assessments Help client create a Help client create a Birth PlanBirth Plan Conduct Conduct Safety ChecklistSafety Checklist Conduct Conduct Edinburgh Postpartum Depression Edinburgh Postpartum Depression

ScreeningScreening at between 6-8 weeks postpartum at between 6-8 weeks postpartum Remind client about postpartum groupRemind client about postpartum group

[You are KEY to retention][You are KEY to retention] Complete the Complete the Life PlanLife Plan that was started in group that was started in group If a women reports smoking or alcohol use, If a women reports smoking or alcohol use,

provide information/referralsprovide information/referrals

Recruitment

Meets program requirements?

Black Infant Health Program Client Flow Chart

Yes

Program Completion•Complete ICP•Complete Life Plan•Complete Case Closure

NoStandardized health promotion message

&

Refer out to appropriate agency

EnhancedCase

Management

Group Sessions 11-20

Group Sessions 1-10

Intake1. Program orientation and consent 2. Referrals3. Prenatal Assessment 14. Initiation of Individual Client Plan (ICP)5. Case Conferencing

Birth

Postpartum

Prenatal

Why A Group?Why A Group? Researched and are one the most powerful Researched and are one the most powerful

mechanism to help women mechanism to help women Very effective in many other areas like addictions Very effective in many other areas like addictions

(i.e. AA, WeightWatchers)(i.e. AA, WeightWatchers) Decrease isolation and increases social supportDecrease isolation and increases social support Improves social skillsImproves social skills Allows opportunity of open and honest discussion Allows opportunity of open and honest discussion

about issuesabout issues The issues that will be addressed are common to all The issues that will be addressed are common to all

the womenthe women They can help others with their knowledge and They can help others with their knowledge and

informationinformation

Stages of Group Development Stages of Group Development

Forming (pre-affiliation)Forming (pre-affiliation)

Storming (power and control)Storming (power and control)

Norming (intimacy)Norming (intimacy)

Performing (differentiation)Performing (differentiation)

Adjourning (separation)Adjourning (separation)

GroupsGroups Facilitative learning is used to access and Facilitative learning is used to access and

enhance the knowledge and skills that the women enhance the knowledge and skills that the women possesspossess

Activities from a women’s health perspectiveActivities from a women’s health perspective Skill-building to help with better physical and Skill-building to help with better physical and

mental healthmental health Personal goal setting is used weekly and Personal goal setting is used weekly and

culminates in the creation of a Life Planculminates in the creation of a Life Plan Focus on being empowered which allows the Focus on being empowered which allows the

participants to:participants to: Make good choices to have a healthy pregnancy Make good choices to have a healthy pregnancy Be a good role model to their child.Be a good role model to their child.

Leadership StylesLeadership Styles

ListensListens Asks questionsAsks questions Directs group processDirects group process CoachesCoaches Builds consensusBuilds consensus Shares in goal-setting and Shares in goal-setting and

decision-makingdecision-making Empowers othersEmpowers others

Directive Participatory

TellsTells SellsSells DirectsDirects Solves problemsSolves problems DecidesDecides DelegatesDelegates Sets GoalsSets Goals

Leadership StylesLeadership Styles

During first group – need to be During first group – need to be clear about role, expectations. clear about role, expectations.

When giving instructionsWhen giving instructions When a physical or emotional When a physical or emotional

safety concern arises in the safety concern arises in the group (e.g. confidentiality is group (e.g. confidentiality is breached, member is breached, member is threatening, etc.)threatening, etc.)

When group is straying too When group is straying too much from agenda/purposemuch from agenda/purpose

Ask the group what they Ask the group what they know about a topic instead know about a topic instead of telling themof telling them

Get the group to respond to Get the group to respond to one anotherone another

Facilitate interactive Facilitate interactive exercisesexercises

Let the group develop own Let the group develop own agendaagenda

Provide optional activitiesProvide optional activities

Directive Participatory

Group Session TopicsGroup Session Topics African American African American

heritageheritage Stress and stress Stress and stress

reductionreduction Understanding how to Understanding how to

meet our needsmeet our needs Self-advocacySelf-advocacy Nutrition and exerciseNutrition and exercise

Infant and toddler Infant and toddler parentingparenting

Preparing for the Preparing for the babybaby

SafetySafety Healthy Healthy

relationshipsrelationships Planning for the Planning for the

futurefuture

Transtheoretical Model for Transtheoretical Model for Behavior ChangeBehavior Change

Stage One: Pre-contemplationStage One: Pre-contemplation

Stage Two: ContemplationStage Two: Contemplation

Stage Three: Preparation/DeterminationStage Three: Preparation/Determination

Stage Four: ActionStage Four: Action

Stage Five: MaintenanceStage Five: Maintenance

Practice SessionPractice SessionSelect two participants to facilitate group 7Select two participants to facilitate group 7 You may have heard about the controversy with You may have heard about the controversy with

vaccinating your child. One way to be empowered and vaccinating your child. One way to be empowered and informed is to be able to discuss those controversies. informed is to be able to discuss those controversies. Ask participants to respond to the following questions:Ask participants to respond to the following questions:

What problems have you heard vaccinations or What problems have you heard vaccinations or immunizations? ______________________immunizations? ______________________

What are the benefits?_____________________What are the benefits?_____________________[Facilitator Note: Write the statements on a piece of flipchart [Facilitator Note: Write the statements on a piece of flipchart

paper.]paper.]

Summarize the value of the activitySummarize the value of the activity

The FactsThe Facts Vaccines are shots that prevent your baby from Vaccines are shots that prevent your baby from

getting certain illnesses/diseasesgetting certain illnesses/diseases Many times people are scared of vaccines, but Many times people are scared of vaccines, but

vaccines saves livesvaccines saves lives When we don’t see people dying or getting When we don’t see people dying or getting

sick, that means the vaccines are working—sick, that means the vaccines are working—when was the last time you saw someone with when was the last time you saw someone with polio?polio?

Your baby will need to get routine Your baby will need to get routine vaccinations—which will continue until vaccinations—which will continue until they’re adult. they’re adult.

There is a schedule in your HandbookThere is a schedule in your Handbook

Comments from the FieldComments from the Field ““Have a better understanding of myself”Have a better understanding of myself” ““Learned what a BASIC NEED is…did not Learned what a BASIC NEED is…did not

know before group today. Learning why it is so know before group today. Learning why it is so important to identify what I need in my life to important to identify what I need in my life to be HAPPY or close to it! There are Negative be HAPPY or close to it! There are Negative Results in your Life when your basic NEEDS Results in your Life when your basic NEEDS are neglected. Clearly see what areas in my life are neglected. Clearly see what areas in my life I need to work on to develop myself into a good I need to work on to develop myself into a good parent, thanks!”parent, thanks!”

““Realizing I can CHOOSE HAPPINESS.”Realizing I can CHOOSE HAPPINESS.”

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

Why is Program Fidelity Important?Why is Program Fidelity Important?

The current BIH Program successful, but The current BIH Program successful, but there was no way to measure successthere was no way to measure success

To be able to successfully evaluate the To be able to successfully evaluate the programprogram

Scientific evidence to prove that the BIH Scientific evidence to prove that the BIH Program worksProgram works

To maintain current funding and advocate To maintain current funding and advocate for additional fundingfor additional funding

Program Program ImplementationImplementation

Group 1 started 11/1/10Group 1 started 11/1/10 Contra CostaContra Costa FresnoFresno KernKern SacramentoSacramento San DiegoSan Diego San FranciscoSan Francisco San MateoSan Mateo SolanoSolano

Group 2 starts 7/1/11Group 2 starts 7/1/11 AlamedaAlameda BerkeleyBerkeley Long BeachLong Beach Los AngelesLos Angeles PasadenaPasadena San JoaquinSan Joaquin Santa ClaraSanta Clara

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

Nelson MandelaNelson Mandela

Thank YouThank YouReggie Caldwell, LCSWReggie Caldwell, LCSW

California Department of Public HealthCalifornia Department of Public Health

Maternal, Child and Adolescent Health DivisionMaternal, Child and Adolescent Health Division

Reggie.Caldwell@cdph.ca.govReggie.Caldwell@cdph.ca.gov

916-650-0373916-650-0373