1

PerinatalPerinatal Health Disparities Health Disparities

In NCIn NC

Barbara PullenBarbara Pullen--Smith, MPHSmith, MPH

Monique C. Bethell, Ph.D. Monique C. Bethell, Ph.D.

NC Office of Minority Health and Health DisparitiesNC Office of Minority Health and Health Disparities

PerinatalPerinatal Health Task Force PresentationHealth Task Force Presentation

April 4, 2011April 4, 2011

North Carolina has one of the largest North Carolina has one of the largest

Minority PopulationsMinority Populations

African Americans remain African Americans remain

North CarolinaNorth Carolina’’s largest s largest

minority population minority population

African Americans represent African Americans represent

22% of NC22% of NC’’s population, s population,

compared with 12% of the compared with 12% of the

total U.S. populationtotal U.S. population

NC ranks 7th in the U.S. in NC ranks 7th in the U.S. in

percentage of pop that is percentage of pop that is

African AmericanAfrican American

Health Disparities DefinedHealth Disparities Defined……

““ health disparities include health and health care disparities health disparities include health and health care disparities and means populationand means population--specific differences in the presence of specific differences in the presence of disease, health outcomes, or access to health care. A populatiodisease, health outcomes, or access to health care. A population n may be delineated by race/ethnicity, primary language, sex, may be delineated by race/ethnicity, primary language, sex, sexual orientation, gender identity, disability, socioeconomic sexual orientation, gender identity, disability, socioeconomic status, or rural, urban, or other geographic setting.status, or rural, urban, or other geographic setting.””

2010 Affordable Care Act H.R.3962 2010 Affordable Care Act H.R.3962

“Significant differences or inequalities in health th at exist between whites and racial/ethnic minorities.”

NC Office of Minority Health and Health Disparitieswww.ncminorityhealth.orgwww.ncminorityhealth.org

Racial and Ethnic Health Disparities in North Carolina

REPORT CARD2010

Office of Minority Health and Health Disparities

And

State Center for Health Statistics

North Carolina Department of Health and Human Services

Health Disparities Report Card 2010 Health Disparities Report Card 2010

Focus AreasFocus Areas

��Social and economic Social and economic

wellwell--beingbeing

��Maternal and Infant Maternal and Infant

Health Health

��Adult Health Adult Health

��Communicable DiseasesCommunicable Diseases

��Violence and InjuriesViolence and Injuries

��Child and Adolescent Child and Adolescent

HealthHealth

��Risk Behaviors and Risk Behaviors and

Health PromotionHealth Promotion

Health Disparities Report CardHealth Disparities Report Card

Disparity Ratio and GradesDisparity Ratio and Grades

�� 0.0 0.0 -- 0.5 = 0.5 = AA

�� 0.6 0.6 -- 1.0 = 1.0 = BB

�� 1.1 1.1 -- 1.9 = 1.9 = CC

�� 2.0 2.0 -- 2.9 = 2.9 = DD

�� 3.0 or Greater = F3.0 or Greater = FIn cases where the minority rates are better than the white compIn cases where the minority rates are better than the white comparison rate, the arison rate, the

disparity ratio was not utilized, and the grade is reported as adisparity ratio was not utilized, and the grade is reported as an n ““A.A.””

Source: NC Division Public Health Epidemiology Team; NC OMHHD Source: NC Division Public Health Epidemiology Team; NC OMHHD Research Associate; Research Associate;

NC State Center for Health StatisticsNC State Center for Health Statistics

Guidelines Used to Assign Grades :Guidelines Used to Assign Grades

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NC Infant Mortality Disparity Ratios by Race/Ethnicity

2.4

1.0

2.1

1.0

0

0.5

1

1.5

2

2.5

3

African American American Indian Asian/PacificIslander

Hispanic/Latino

Dis

parit

y R

ate

Rat

ios

2004-2008

Grade D

GradeD

GradeA

GradeB

Any Rate Ratios that are >1.0 indicate a Disparity Gap. Here, African American and American Indian babies are more likely to die at a higher rate than Whites.

Data Source: State Center for Health Statistics

Health Disparities in Health Disparities in PerinatalPerinatal Health: Health:

AfricanAfrican--American WomenAmerican Women

�� Race as a marker for certain Race as a marker for certain

health problemshealth problems

�� AfricanAfrican--American women American women

overall suffer more adverse overall suffer more adverse

maternal and infant health maternal and infant health

outcomesoutcomes

Social Determinants and Health Social Determinants and Health

DisparitiesDisparities

�� Social Determinants affecting Social Determinants affecting perinatalperinatal healthhealth

–– Access to care (and medicine)Access to care (and medicine)

––Utilization of servicesUtilization of services

–– Physical and mental healthPhysical and mental health

–– Poverty/SocioPoverty/Socio--economic statuseconomic status

–– Environmental hazards Environmental hazards

–– Racism and stressRacism and stress

Not everything that can be counted counts,

and not everything that counts can be counted.Albert Einstein

What does

the Data

tell us?

NC Infant Mortality RatesNC Infant Mortality Rates

6.36.3

5.95.9

13.213.2

15.115.1

6.26.2

8.48.4

20042004--20082008

6.16.1HispanicHispanic

5.45.4AsianAsian

11.011.0American IndiansAmerican Indians

15.015.0AfricanAfrican--Americans Americans

6.36.3WhiteWhite

8.48.4AllAll

19991999--20032003

(Infant Deaths per 1,000 Live Births) Source: NC Vital Statistics, Birth & Death Certificates

Major Causes of Infant Deaths in North Carolina

25%

49%13%

13%

Prematurity/LBW

SIDSRespiratory diseases

Sepsis

Data: NC Division of Public Health – Women’s and Children’s Health SectionState Center for Health Statistics

Slide: A. Barbry-Crawford, Research Associate. Office of Minority Health and Health Disparities

Pre maturity/LBW

Sepsis

Respiratory Diseases

SIDS

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NC Low Birthweight RatesNC Low Birthweight Rates

6.36.3

8.58.5

10.710.7

14.414.4

7.87.8

9.19.1

20042004--20082008

6.26.2HispanicHispanic

7.97.9AsianAsian

10.810.8American IndiansAmerican Indians

13.913.9AfricanAfrican--Americans Americans

7.57.5WhiteWhite

8.98.9AllAll

19991999--20032003

(Percent of births that were low birthweight <2500) Source: NC Vital Statistics, Birth & Death Certificates

Minority Infants are more than twice as likely to be under 1500 g at birth.

Late or No Prenatal Care RatesLate or No Prenatal Care Rates

30.530.5

14.614.6

20.920.9

23.723.7

10.310.3

16.916.9

20042004--20082008

30.130.1HispanicHispanic

15.815.8AsianAsian

22.222.2American IndiansAmerican Indians

23.823.8AfricanAfrican--Americans Americans

9.09.0WhiteWhite

15.315.3AllAll

19991999--20032003

(Percent of women with late prenatal care – After 1st trimester or no prenatal care)

Source: NC Vital Statistics, Birth & Death Certificates

NC Teen Pregnancy RatesNC Teen Pregnancy Rates

Source: NC Vital Statistics, Birth, Fetal Death, & Abortion Data

173.2173.2

41.641.6

85.785.7

86.986.9

43.943.9

64.564.5

20042004--20082008

175.5175.5HispanicHispanic

60.960.9AsianAsian

91.591.5American IndiansAmerican Indians

97.397.3AfricanAfrican--Americans Americans

51.951.9WhiteWhite

71.371.3AllAll

19991999--20032003

Selected Risk Factors for Selected Risk Factors for

NC women with Live BirthNC women with Live Birth

18.118.1

25.325.3

3.33.3

31.031.0

64.964.9

36.736.7

WhiteWhite

17.017.0Mother reported smoking after Mother reported smoking after

pregnancypregnancy

41.641.6Mother did not breastfeed at allMother did not breastfeed at all

7.47.4Mother reported physical violence Mother reported physical violence

during pregnancyduring pregnancy

53.153.1Usual sleeping position for baby was Usual sleeping position for baby was

not on back not on back

80.580.5Mother did not take folic acid every day Mother did not take folic acid every day

before pregnancybefore pregnancy

61.261.2Pregnancy was unintended (wanted Pregnancy was unintended (wanted

later or not at all)later or not at all)

AfricanAfrican--

AmericanAmerican

Source: Minority Health Facts African-Americans July 2010

Based on weighted 2003-2007 PRAMS Survey Data

SIDS

RespiratoryDisease

Sepsis

Prematurity/LBW

Breastfeeding5% - 17% Reduction

Connection:Breastfeeding has been shown to reduce mortality

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Social Policy ImplicationsSocial Policy Implications

�� CommunityCommunity--based approaches to addressing based approaches to addressing

perinatalperinatal health disparitieshealth disparities

�� Interdisciplinary leadership strategiesInterdisciplinary leadership strategies

�� Monitoring progress (intermediate goals) Monitoring progress (intermediate goals)

toward HP 2020 goalstoward HP 2020 goals

�� Address interaction of racism with other risk Address interaction of racism with other risk

factors that impact factors that impact perinatalperinatal healthhealth

““Knowing what to do is not enough, Knowing what to do is not enough,

People need support to be healthy.People need support to be healthy.””Barbara PullenBarbara Pullen--Smith, Director, NC OMHHDSmith, Director, NC OMHHD

NC Office of Minority Health and Health NC Office of Minority Health and Health

Disparities (OMHHD) & Minority Health Disparities (OMHHD) & Minority Health

Advisory Council (MHAC)Advisory Council (MHAC)

Established in 1992 by House Bill 1340, Part Established in 1992 by House Bill 1340, Part

2424--Section 165Section 165--166166

�� 15 Member Minority Health Advisory Council15 Member Minority Health Advisory Council

�� Appointed by House, Senate, GovernorAppointed by House, Senate, Governor

�� Advises Governor, Legislature, and NC DHHS Advises Governor, Legislature, and NC DHHS SecretarySecretary

�� Focus on Policy, Legislation & Advocacy Focus on Policy, Legislation & Advocacy

Source: NC Office of Minority Health and Health Source: NC Office of Minority Health and Health

DisparitiesDisparities

Office of Minority Health and Health DisparitiesOffice of Minority Health and Health Disparities’’

Call To Action ModelCall To Action Model

Develop Partnerships Engage Communities Influence Policy Equip the DisparityGap Coordinator

Integrated Approach to Eliminating Health Dispariti es

Equip The Staff

OMHHDOMHHD

Our MissionOur Mission……

“ To promote and advocate for the elimination of health

disparities among all racial/ ethnic minorities and other underserved populations in

North Carolina”.

Contextual Factors Influencing HealthContextual Factors Influencing Health

Social

Systemic

Genetic Behavioral

Economic

Environmental

Cultural

Health

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NC OMHHD Core NC OMHHD Core ““Systems ChangeSystems Change””

StrategiesStrategies

�� Research and DataResearch and Data

�� Community Engagement/Leadership Community Engagement/Leadership

DevelopmentDevelopment

�� Workforce Development (Language & Workforce Development (Language &

Culture)Culture)

�� Partnership Development/Capacity Partnership Development/Capacity

Building Building

�� Policy DevelopmentPolicy Development

Research and Data Research and Data

�� Ensure that health status outcome data by Ensure that health status outcome data by race/ethnicity & regarding promising race/ethnicity & regarding promising models are available and disseminated models are available and disseminated

�� Annual Progress/Evaluation Report to Annual Progress/Evaluation Report to General Assembly on Community Focused General Assembly on Community Focused Eliminating Health Disparities Initiative Eliminating Health Disparities Initiative (CFEHDI)(CFEHDI)

�� Health Disparities Data Tools Health Disparities Data Tools

––Report Card ( every 3 years) Report Card ( every 3 years)

––Fact Sheets (every 3 years) Fact Sheets (every 3 years)

Community Engagement/Leadership Community Engagement/Leadership

DevelopmentDevelopment

�� expand network of community based leaders who expand network of community based leaders who are equipped to address local health issuesare equipped to address local health issues

�� Community Health Ambassador ProgramCommunity Health Ambassador Program

(C.H.A.P.)(C.H.A.P.)

�� Leadership Engagement & Empowerment Project Leadership Engagement & Empowerment Project (L.E.E.P.)(L.E.E.P.)

�� Consultation/TA/Training (Board members, Consultation/TA/Training (Board members, volunteers, etc) volunteers, etc)

Community Level Capacity BuildingCommunity Level Capacity Building

(Individuals) (Individuals)

Community Health Ambassador Program Community Health Ambassador Program

�� Trusted leadersTrusted leaders

�� Volunteers In Community Volunteers In Community

�� ““ Bridge BuildersBridge Builders””

�� ““ AdvocatesAdvocates”” not Experts not Experts

Community Health Ambassador Program Community Health Ambassador Program

Major ComponentsMajor Components……

�� Curriculum = Curriculum = 22 Classroom Hours22 Classroom Hours

�� Approved for Approved for 2.0 CEU s2.0 CEU s

�� Focus Areas = Focus Areas = Diabetes, CancerDiabetes, Cancer

�� Requirements=Requirements=–– Test (80%)Test (80%)–– Resource DirectoryResource Directory–– 100 Encounters in Year 1 100 Encounters in Year 1 –– Sign MOA ( Healthy Lifestyles)Sign MOA ( Healthy Lifestyles)–– Continuing Education Session (1/year)Continuing Education Session (1/year)

Workforce Development Workforce Development

(Culture & Language)(Culture & Language)

�� increase the number of health and human increase the number of health and human services staff who provide effective and services staff who provide effective and culturally appropriate outreach and services to culturally appropriate outreach and services to racial ethnic minoritiesracial ethnic minorities

�� Cultural Diversity Training Initiative:Cultural Diversity Training Initiative:–– FoundationFoundation

–– Hispanic/Latino CultureHispanic/Latino Culture

–– African American CultureAfrican American Culture

–– Interpreter TrainingInterpreter Training

�� LHD CC Teams/Action PlansLHD CC Teams/Action Plans

�� DHHS EHD Steering Committee &Disparity DHHS EHD Steering Committee &Disparity TeamsTeams

�� Mentoring for EHD staff in Mentoring for EHD staff in LHDsLHDs

�� Workshops/Training Workshops/Training

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Partnership Development/Capacity Partnership Development/Capacity

BuildingBuilding

[Increase the number of sustainable agencies [Increase the number of sustainable agencies

and organizations with the capacity to and organizations with the capacity to

provide effective health programs and provide effective health programs and

services]services]

�� Community Focused Eliminating Community Focused Eliminating

Health Disparities Initiative Health Disparities Initiative

(community grants)(community grants)

�� Consultation/ TA to CBOs, FBOs, AI Tribes Consultation/ TA to CBOs, FBOs, AI Tribes

LHDsLHDs

�� OMHHD Serve on Committees/ OMHHD Serve on Committees/

Workgroups/ Task ForcesWorkgroups/ Task Forces

Legislative MandateLegislative Mandate

2005 General Assembly 2005 General Assembly

�� Community Focused Eliminating Health Community Focused Eliminating Health Disparities Initiative (CFEHDI)Disparities Initiative (CFEHDI)

�� Session Law 2005Session Law 2005--276 Section 10.59E276 Section 10.59E–– Close the gap in health status of African Close the gap in health status of African Americans, Hispanics/Latinos, American Americans, Hispanics/Latinos, American IndiansIndians

–– Build the capacity of faithBuild the capacity of faith--based and community based and community based organizations, local health departments & based organizations, local health departments & American Indian TribesAmerican Indian Tribes

–– Honor the Memory of 7 deceased African Honor the Memory of 7 deceased African American Legislators ( Memorial Fund)American Legislators ( Memorial Fund)

–– Annual ReportAnnual Report

OMHHD: Rationale for Investing in OMHHD: Rationale for Investing in

Community Owned Approaches Community Owned Approaches

�� Solutions are Local Solutions are Local

�� Economic Development Economic Development

�� Commitment = Sustainability Commitment = Sustainability

�� CBO, FBO,LHD & CBO, FBO,LHD & Tribes=Partners Tribes=Partners

�� Health Advocates Not Health Advocates Not ExpertsExperts

�� Access to PeopleAccess to People

OMHHD: Rationale for Investing in OMHHD: Rationale for Investing in

Community Owned Approaches Community Owned Approaches contcont’’dd

�� Effective Translators (Health Literacy)Effective Translators (Health Literacy)

�� Extend Public Health ServicesExtend Public Health Services

�� Link to Existing ResourcesLink to Existing Resources

�� Cultural Competence Cultural Competence

�� Reduced Healthcare CostsReduced Healthcare Costs

CFEHDI Grants Focused on Infant CFEHDI Grants Focused on Infant

Mortality PreventionMortality Prevention

�� Duplin County Health Department (AA & Duplin County Health Department (AA &

H/L)H/L)

�� Guilford County Health Department (AA)Guilford County Health Department (AA)

�� Pitt County Health Department (AA) Pitt County Health Department (AA)

�� Mt Zion Community Development, Inc. Mt Zion Community Development, Inc.

(Buncombe County) (Buncombe County)

Policy DevelopmentPolicy Development

[promote policies to increase services and [promote policies to increase services and resources to racial and ethnic minorities and resources to racial and ethnic minorities and underserved populations]underserved populations]

�� MHAC (Legislative Agenda)MHAC (Legislative Agenda)

�� PH Division Management TeamPH Division Management Team

�� Hispanic/Latino Health Advisory Group Hispanic/Latino Health Advisory Group

�� DHHS EHD Steering committeeDHHS EHD Steering committee

�� Title VI Committee (language access)Title VI Committee (language access)

�� Medicare Advisory Board (Minority Medicare Advisory Board (Minority Outreach)Outreach)

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How do WE measure Progress?How do WE measure Progress?

Eliminating Health Disparities…Intermediate Goals (Measures) Intermediate Goals (Measures)

�� Engage CommunitiesEngage Communities

––Leadership developmentLeadership development

––Partnership development Partnership development

�� Increase ResourcesIncrease Resources

––Investment of time, information Investment of time, information

& $$$& $$$

Intermediate Goals (Measures) Intermediate Goals (Measures)

�� Change SystemsChange Systems

––Increase services & accessIncrease services & access

––Influence policiesInfluence policies

�� Improve HealthImprove Health

––Increase awarenessIncrease awareness

––Primary preventionPrimary prevention

––Secondary prevention Secondary prevention

––FollowFollow--up & support up & support “It is easier to raise a strong child than to repair broken men”-Frederick Douglass-

1817-1895

Dr Julius

Mallette

On Behalf of the OMHHD Thank You for Being a Partner On Behalf of the OMHHD Thank You for Being a Partner in the Fight to Eliminate Health Disparities!in the Fight to Eliminate Health Disparities!

Office of Minority Health and Health DisparitiesOffice of Minority Health and Health DisparitiesNC Department of Health and Human ServicesNC Department of Health and Human Services

5606 Six Forks Road5606 Six Forks Road1906 Mail Service Center1906 Mail Service Center

(919) 707(919) 707--50405040www.ncminorityhealth.orgwww.ncminorityhealth.org

Barbara PullenBarbara Pullen--SmithSmithbarbara.pullenbarbara.pullen--smith@dhhs.nc.govsmith@dhhs.nc.gov

Monique BethellMonique Bethellmonique.bethell@dhhs.nc.govmonique.bethell@dhhs.nc.gov