Maternal perceptions of help from home visits by nurse-community health worker teams

Neighborhood Racialized Economic Polarization, Home Visiting Coverage, and Adverse Birth Outcomes in a Medicaid-eligible Population

BACKGROUND

Residential polarization shaped by racial segregation and concentrations of wealth (hereafter neighborhood racialized economic polarization) results in both highly deprived and highly privileged neighborhoods. Numerous studies have found a negative relationship between neighborhood racialized economic polarization and birth outcomes. We investigated whether community-informed home visiting programs achieve high rates of service coverage in highly deprived neighborhoods and can attenuate the deleterious effect of neighborhood polarization on birth outcomes.

METHODS

We used 2016-2019 data from Michigan's statewide database that links birth records, Medicaid claims, and program participation (N = 211,412). We evaluated whether 1) home visiting programs achieved high rates of service coverage in highly deprived neighborhoods, 2) participation in home visiting may help to mitigate the negative relationship between neighborhood polarization and birth outcomes, and 3) the reductions in preterm birth and low birthweight were larger among Black birthing individuals. Data were examined using multilevel generalized linear models and mediation analysis.

RESULTS

The statewide home visiting program achieved higher rates of coverage in the most deprived neighborhoods (21.0% statewide, 28.3% in the most deprived vs. 10.4% in the most privileged neighborhoods). For all, home visiting participation was associated with a decrease in the relationship between neighborhood polarization and preterm birth by 6.8% (mean indirect effect, -0.008; 95% confidence interval, -0.011 to -0.005), and by 5.2% (mean indirect effect, -0.013; 95% confidence interval, -0.017 to -0.009) for low birthweight, adjusting for individual-level risk factors. The decrease was larger among Black individuals.

CONCLUSIONS

A statewide Medicaid-sponsored home visiting program achieved high rates of service coverage in highly deprived neighborhoods. Program participation may help to mitigate the negative relationship between neighborhood polarization and birth outcomes, and more so among Black individuals. Continued support for home visiting services is required to better engage birthing individuals in neighborhoods with concentrated deprivation and to decrease disparities.

Community Health Workers: Improving Home Visiting Engagement of High-Risk Birthing People in Segregated Neighborhoods

CONTEXT

Racial and ethnic disparities in perinatal health remain a public health crisis. Despite improved outcomes from home visiting (HV) participation during pregnancy, most eligible individuals of color do not engage. Neighborhood segregation, a manifestation of structural racism, may impose constraints on engaging eligible individuals in HV.

OBJECTIVE

To examine whether race, ethnicity, and/or language-concordant community health workers (CHWs) increased HV engagement for birthing people in segregated neighborhoods.

DESIGN

Program evaluation using administrative linked data from birth records, Medicaid claims, and HV program participation. Strong Beginnings (SB), a program with HV provided by CHWs working with nurses and social workers, was compared with the Maternal Infant Health Program (MIHP), a state Medicaid-sponsored HV program without CHW involvement. Data were analyzed using χ 2 tests and Poisson regressions.

PARTICIPANTS

A total of 4560 individuals with a Medicaid-eligible birth between 2016 and 2019, including 1172 from SB and 3388 from the MIHP.

MAIN OUTCOME MEASURES

Penetration (percentage of participants in HV among all Medicaid-eligible individuals across quintiles of neighborhood segregation) and dosage (the total number of home visits from both CHWs and nurses/social workers, and then restricted to those from nurses/social workers).

RESULTS

SB penetrated more segregated neighborhoods than the MIHP (58.4% vs 48.3%; P < .001). SB participants received a higher dosage of home visits (mean [SD]: 11.9 [6.1]) than MIHP participants (mean [SD]: 4.4 [2.8], P < .001). Importantly, CHWs did not replace but moderately increased home visits from nurses and social workers (51.1% vs 35.2% with ≥5 intervention visits, P < .001), especially in more segregated neighborhoods.

POLICY IMPLICATION

Community-informed HV models intentionally designed for people facing disparities may help facilitate program outreach to segregated neighborhoods with concentrated deprivation and reduce racial and ethnic disparities.

CONCLUSIONS

An HV program provided by CHWs working with nurses and social workers was associated with an increase in penetration and dosage in segregated neighborhoods, compared with HV without CHW involvement. This underscores the value of CHWs partnering with licensed professional workers in improving HV engagement in disadvantaged communities.

Community health workers as change agents in improving equity in birth outcomes in Detroit

We examined whether pairing pregnant women with community health workers improved pregnancy outcomes among 254 Black women with singleton pregnancies participating in the Women-Inspired Neighborhood (WIN) Network: Detroit using a case-control design. A subset (N = 63) of women were recontacted and asked about program satisfaction, opportunities, and health behaviors. Michigan Vital Statistics records were used to ascertain controls (N = 12,030) and pregnancy and infant health outcomes. Logistic and linear regression were used to examine the association between WIN Network participation and pregnancy and infant health outcomes. The WIN Network participants were less likely than controls to be admitted to the neonatal intensive care unit (odds ratio = 0.55, 95% CI 0.33-0.93) and had a longer gestational length (mean difference = 0.42, 95% CI 0.02-0.81). Community health workers also shaped participants' view of opportunities to thrive. This study demonstrates that community health workers can improve pregnancy outcomes for Black women.

Community health worker intervention improves early childhood vaccination rates: results from a propensity-score matching evaluation

BACKGROUND

Arizona's Health Start Program is a statewide community health worker (CHW) maternal and child health home visiting intervention. The objective of this study was to test if participation in Health Start during 2006-2016 improved early childhood vaccination completion rates.

METHODS

This retrospective study used 11 years of administrative, birth certificate, and immunization records. Propensity score matching was used to identify control groups, based on demographic, socioeconomic, and geographic characteristics. Results are reported by historically disadvantaged subgroups and/or with a history of low vaccine uptake, including Hispanic/Latinx and American Indian children, and children of low socioeconomic status and from rural areas, children with teen mothers and first-born children. The average treatment-on-the-treated (ATT) effect estimated the impact of Health Start on timely completion of seven early childhood vaccine series: diphtheria/tetanus toxoids and acellular/whole-cell pertussis (DTaP/DTP), Haemophilus influenzae type b (Hib), hepatitis B (Hep. B), measles-mumps-rubella (MMR), pneumococcal conjugate vaccine (PCV13), poliovirus, and varicella.

RESULTS

Vaccination completion rates (by age five) were 5.0% points higher for Health Start children as a group, and on average 5.0% points higher for several subgroups of mothers: women from rural border counties (ATT 5.8), Hispanic/Latinx women (ATT 4.8), American Indian women (ATT 4.8), women with less than high school education (ATT 5.0), teen mothers (ATT 6.1), and primipara women (ATT 4.5), compared to matched control groups (p-value ≤ 0.05). Time-to-event analyses show Health Start children complete vaccination sooner, with a hazard rate for full vaccination 13% higher than their matches.

CONCLUSION

A state-operated home visiting intervention with CHWs as the primary interventionist can effectively promote early childhood vaccine completion, which may reduce the incidence of preventable diseases and subsequently improve children's health. Effects of CHW interventions on vaccination uptake is particularly relevant given the rise in vaccine-preventable diseases in the US and globally.

TRIAL REGISTRATION

Approved by the University of Arizona Research Institutional Review Board (Protocol 1701128802), 25 January 2017.

Trauma-Informed Home Visiting Models in Public Health Nursing: An Evidence-Based Approach

Traumatic experiences can have significant health effects, particularly when they are experienced during childhood. Structural determinants of health including environmental disasters and limited access to mental health services and affordable housing can contribute additional stress for parents with a personal history of childhood adversity. These factors can directly affect their children, contributing to intergenerational trauma. Pregnant people and families with young children are often referred to public health nursing maternal and child home visiting (HV) programs when there are concerns about historical or evolving childhood trauma. The strict eligibility and participation requirements of existing evidence-based maternal and child HV programs can exclude families that have experienced or are experiencing childhood trauma and its effects and can limit innovation by public health nurses, a hallmark of the field. Therefore, we advocate and describe the implementation of the Trauma Informed Approach in Public Health Nursing (TIA PHN) model, which incorporates a trauma-informed approach into a traditional maternal and child HV program in 3 California counties. TIA PHN, which began enrollment in March 2021, involves public health nurses and community health workers and integrates program evaluations in pursuit of evidence-based status. (Am J Public Health. 2022;112(S3):S298-S305. https://doi.org/10.2105/AJPH.2022.306737).

Implementation of Health-Related Social Needs Screening at Michigan Health Centers: A Qualitative Study

PURPOSE

Federally qualified health centers (FQHCs) are leaders in screening for and addressing patient's health-related social needs but variation exists in screening practices. This variation is relatively unexplored, particularly the influences of organizational and state policies. We employed a qualitative descriptive approach to study social needs screening practices at Michigan FQHCs to characterize screening processes and identify drivers of variation in screening implementation.

METHODS

Site visits and semistructured interviews were conducted from October 2016 through March 2017, to explore implementation of social needs screening in clinical practice. Five FQHCs were selected through maximum variation sampling. Within each site, snowball sampling identified care team members highly knowledgeable about social needs screening. We conducted 4 to 5 interviews per site. Transcripts were analyzed using a thematic approach.

RESULTS

We interviewed 23 participants from 5 sites; these sites varied by geography, age distribution, and race/ethnicity. We identified 4 themes: (1) statewide initiatives and local leadership drove variation in screening practices; (2) as community health workers (CHWs) played an integral role in identifying patients' needs, their roles often shifted from that of screener to implementer; (3) social needs screening data was variably integrated into electronic health records and infrequently used for population health management; and (4) sites experienced barriers to social needs screening that limited the perceived impact and sustainability.

CONCLUSIONS

FQHCs placed value on the role of CHWs, on sustainable initiatives, and on funding to support continued social needs screening in primary care settings.

Addressing maternal and child health equity through a community health worker home visiting intervention to reduce low birth weight: retrospective quasi-experimental study of the Arizona Health Start Programme

OBJECTIVE

To test if participation in the Health Start Programme, an Arizona statewide Community Health Worker (CHW) maternal and child health (MCH) home visiting programme, reduced rates of low birth weight (LBW), very LBW (VLBW), extremely LBW (ELBW) and preterm birth (PTB).

DESIGN

Quasi-experimental retrospective study using propensity score matching of Health Start Programme enrolment data to state birth certificate records for years 2006-2016.

SETTING

Arizona is uniquely racially and ethnically diverse with comparatively higher proportions of Latino and American Indian residents and a smaller proportion of African Americans.

PARTICIPANTS

7212 Health Start Programme mothers matched to non-participants based on demographic, socioeconomic and geographic characteristics, health conditions and previous birth experiences.

INTERVENTION

A statewide CHW MCH home visiting programme.

PRIMARY AND SECONDARY OUTCOME MEASURES

LBW, VLBW, ELBW and PTB.

RESULTS

Using Health Start Programme's administrative data and birth certificate data from 2006 to 2016, we identified 7212 Health Start Programme participants and 53 948 matches. Programme participation is associated with decreases in adverse birth outcomes for most subgroups. Health Start participation is associated with statistically significant lower rates of LBW among American Indian women (38%; average treatment-on-the-treated effect (ATT): 2.30; 95% CI -4.07 to -0.53) and mothers with a pre-existing health risk (25%; ATT: -3.06; 95% CI -5.82 to -0.30). Among Latina mothers, Health Start Programme participation is associated with statistically significant lower rates of VLBW (36%; ATT: 0.35; 95% CI -0.69 to -0.01) and ELBW (62%; ATT: 0.31; 95% CI (-0.52 to -0.10)). Finally, Health Start Programme participation is associated with a statistically significant lower rate of PTB for teen mothers (30%; ATT: 2.81; 95% CI -4.71 to -0.91). Other results were not statistically significant.

CONCLUSION

A state health department-operated MCH home visiting intervention that employs CHWs as the primary interventionist may contribute to the reduction of LBW, VLBW, ELBW and PTB and could improve birth outcomes statewide, especially among women and children at increased risk for MCH inequity.

Instructive roles and supportive relationships: client perspectives of their engagement with community health workers in a rural south African home visiting program

Background

Community health worker (CHW) programs have been positioned as a way to meet the needs of those who experience marginalization and inequitable access to health care, and current global health narratives also emphasize their adaptable nature to meet growing health burdens in low-income settings. However, as CHW programs adopt more technical roles, the value of CHWs in building relationships with clients tends to be overlooked. More importantly, these programs are often reframed and redeployed without attending to the interests and needs of program clients themselves. We set out to gather perspectives of program and CHW engagement from clients of a maternal and child health program in rural South Africa.

Methods

We conducted 26 interviews with pregnant or recently-delivered clients of the Enable Mentor Mother program between February–March 2018. After obtaining informed consent, a trained research assistant conducted all interviews in the clients’ home language, isiXhosa. Interviews, translated and transcribed into English, were organized and coded using ATLAS.ti software and thematically analyzed.

Results

We found that clients’ home-based interactions with Mentor Mothers were generally positive, and that these engagements were characterized by two core themes, instructive roles and supportive relationships.. Instructive roles facilitated the transfer of knowledge and uptake of new information for behavior change. Relationships were developed within the home visit setting, but also extended beyond routine visits, especially when clients required further instrumental support. Clients further discussed a sense of agency gained through these interactions, even in cases where they chose not to, or were unable to, heed their Mentor Mother’s advice.

Conclusions

These findings highlight the important roles that CHWs can assume in providing both instructive and supportive care to clients; as deepening relationships may be key for encouraging behavior change, these findings pinpoint the need to bolster training and support for CHWs in similar programs. They also emphasize the importance of integrating more channels for client feedback into existing programs, to ensure that clients’ voices are heard and accounted for in shaping ongoing engagement within the communities in which these programs operate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01377-z.

A mixed methods evaluation of the feasibility, acceptability, and impact of a pilot project ECHO for community health workers (CHWs)

BACKGROUND

Despite the positive effects of community health workers (CHWs) on addressing social determinants of health, improving patient health outcomes, and decreasing overall healthcare costs, there is a lack of standardization in training and certifying this workforce, resulting in different approaches to integrating this role into medical home models. The purpose of the current study is to evaluate the application of Project ECHO (Extension for Community Healthcare Outcomes) in enhancing CHWs' capacity to address health and social issues of vulnerable populations.

METHODS

An explanatory sequential mixed methods design was applied in which all participants (N = 49) completed pre (January 2019) and post (July 2019) quantitative online surveys measuring changes in self-efficacy, behavior change intent, and knowledge. Virtual focus groups were conducted with a subset of participants (n = 20) in July 2019 to assess the feasibility, acceptability, and impact of Project ECHO.

RESULTS

There was a statistically significant difference of + 0.453 in the composite self-efficacy mean score pre- to post-series. For every 1 additional Project ECHO CHW session attended, there was a .05 improvement in participants' self-efficacy to perform CHW-related job duties and address social determinants of health (SDOH). Four major themes emerged from the qualitative focus group data: value in learning from other participants' caseloads, CHW-care team integration, availability of training and resources, and shared decision-making with patients.

CONCLUSIONS

This evaluation suggests that ECHO is a viable means of increasing access to training resources for CHWs. Future studies on the ECHO model as a means of educating and broadening implementation of CHWs are warranted. Programs such as Project ECHO can support CHWs by providing continuing education opportunities, as well as standardizing training content across large geographic areas.

Medicaid member perspectives on innovation in prenatal care delivery: A call to action from pregnant people using unscheduled care

BACKGROUND

Low-income women using prenatal care have shared concerns as well as unique needs not met by traditional prenatal care. Our objective was to explore user ideas on addressing unmet needs driving unscheduled care utilization and use findings to inform interventions to improve perinatal outcomes.

METHODS

We performed a secondary analysis of qualitative interviews among purposively sampled, Medicaid-insured pregnant women with varied degrees of unscheduled care utilization. Interviews explored barriers and facilitators of health and ideas for improvement in care delivery, with a focus on the potential role of community health workers and social support. We extracted material on participants' perceived gaps and ideas, used modified grounded theory to develop general and subset themes by study group, and then mapped themes to potential intervention features.

RESULTS

We identified intervention targets in three thematic domains: social support, care delivery, and access, noting sub-group differences. Participants with four or more unscheduled visits during pregnancy ("Group 1") wanted individualized help navigating resources, coaching, and peer support, while participants with a first unscheduled care visit after 36 weeks of pregnancy ("Group 2) wanted these services to be optional. Group 1 participants wanted flexible appointments, less wait time, discharge education and improved communication with providers, while Group 2 participants sought stable insurance coverage.

CONCLUSIONS

Findings suggest acceptable approaches to improve social support, care delivery, and access via stratified, targeted interventions.

IMPLICATIONS

Targeted interventions to improve prenatal care that incorporate user ideas and address unique unmet needs of specific subgroups may improve perinatal outcomes.

LEVEL OF EVIDENCE

III.

Integrative and complementary practices: use by community health agents in self-care

OBJECTIVE

To verify the use of integrative and complementary practices (ICPs) by community health agents working in family health teams.

METHODS

Cross-sectional, quantitative research, conducted in the city of Montes Claros, Minas Gerais. An structured form was used for the characterization of participants and use of ICPs. Descriptive and bivariate analyses were conducted.

RESULTS

Use of ICPs was referenced by 94 (40.7%) agents. The use of medicinal plants was predominant (32.5%). There were associations between: ICPs in general and negative self-perception of health (p=0.032), homeopathy and higher education (p=0.015), massage and living with partner(p=0.024), chiropractic care and income equal to or greater than four minimum wages (p=0.031), relaxation/meditation and religion (p=0.028).

CONCLUSION

The use of ICPs was verified in the healthcare of community agents. It is necessary to strengthen these practices for the promotion of health and prevention of diseases.

The work of the community health worker from the perspective of popular health education: possibilities and challenges

This article addresses the possibilities and challenges in the performance of the community health worker (CHW) from the perspective of the National Policy of Popular Health Education. It is based on the analysis of findings from a research-intervention carried out at a Family Health Center in a small city in the southern region of Brazil. The data analyzed was produced in meetings with the research team, in activities with the CHWs (individual interviews and workshops), and in feedback sessions with the team regarding the intervention. Among the results, the intertwined role of the CHW within the team was emphasized. In situating themselves between technical and popular forms of knowledge, the work of the CHW potentializes the actions of the Popular Health Education program, as it points to the need for training, agreement of the developed practices, and professional valorization. From these findings we were able to approach and understand the results in terms of the National Policy of Popular Health Education. Based on the analyses, we recommend the establishment of practices associated with the broader concept of health sustained in holistic teamwork that valorizes the knowledge/action of CHW and of the community, inspired in the guiding principles of PNEP-SUS.

Measuring the Developing Therapeutic Relationship Between Pregnant Women and Community Health Workers Over the Course of the Pregnancy in a Study Intervention

The Scale to Assess the Therapeutic Relationship in Community Mental Health Care (STAR) is a frequently-administered tool for measuring therapeutic relationships between clinicians and patients. This manuscript tested the STAR's psychometric properties within a community health worker (CHW)-led intervention study involving pregnant and postpartum women. Women (n = 141) enrolled in the study completed the 12-item participant STAR survey (STAR-P) at two time points over the course of pregnancy and at two time points after delivery. The factor structure of the STAR-P proved to be unstable with this population. However, a revised 9-item STAR-P revealed a two-factor model of positive and negative interactions, and demonstrated strong internal consistency at postpartum time points. The revised STAR-P shows strong psychometric properties, and is suitable for use to evaluate the relationship developed between CHWs and pregnant and postpartum women in an intervention program.

AGENTES COMUNITÁRIOS DE SAÚDE NA ATENÇÃO PRIMÁRIA NO BRASIL: MULTIPLICIDADE DE ATIVIDADES E FRAGILIZAÇÃO DA FORMAÇÃO

Resumo O estudo teve como objetivo avaliar, mediante revisão integrativa, o conhecimento produzido na literatura acerca das atividades desempenhadas pelos agentes comunitários de saúde no Brasil e em outros países. A busca de dados, realizada no período de 2010 a 2014, abrangeu: Portal de Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior; biblioteca eletrônica Scientific Electronic Library Online; Literatura Latino-Americana e do Caribe em Ciências da Saúde; Medical Literature Analysis and Retrieval System On-line e US National Library of Medicine National Institutes of Health. Dos 240 estudos identificados, 27 foram incluídos nesta revisão. A literatura evidencia as funções que os agentes comunitários de saúde exercem, em variedade de ações em diversos contextos geográficos e culturais. O agente tem diferentes inserções no mercado de trabalho e vivencia fragilidades, oriundas de contextos socioculturais da comunidade, da necessidade de maior reconhecimento do sistema de saúde e da equipe. Sua posição entre a comunidade e a equipe de saúde é estratégica, contribuindo para a saúde da comunidade. Deve-se proporcionar formação propícia à sua atuação e possibilitar o acesso à educação permanente, além de se promoverem recursos para maior valorização da equipe de saúde em sua relação com a sociedade.

Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome

Rates of maternal morbidity and mortality are rising in the United States. Non-Hispanic Black women are at highest risk for these outcomes compared to those of other race/ethnicities. Black women are also more likely to be late to prenatal care or be inadequate users of prenatal care. Prenatal care can engage those at risk and potentially influence perinatal outcomes but further research on the link between prenatal care and maternal outcomes is needed. The objective of this article is to review literature illuminating the relationship between prenatal care utilization, social determinants of health, and racial disparities in maternal outcome. We present a theoretical framework connecting the complex factors that may link race, social context, prenatal care utilization, and maternal morbidity/mortality. Prenatal care innovations showing potential to engage with the social determinants of maternal health and address disparities and priorities for future research are reviewed.

Perspectives of Low Socioeconomic Status Mothers of Premature Infants

BACKGROUND AND OBJECTIVES

Transitioning premature infants from the NICU to home is a high-risk period with potential for compromised care. Parental stress is high, and families of low socioeconomic status may face additional challenges. Home visiting programs have been used to help this transition, with mixed success. We sought to understand the experiences of at-risk families during this transition to inform interventions.

METHODS

Mothers of infants born at <35 weeks' gestation, meeting low socioeconomic status criteria, were interviewed by telephone 30 days after discharge to assess caregiver experiences of discharge and perceptions of home visitors (HVs). We generated salient themes by using grounded theory and the constant comparative method. Interviews were conducted until thematic saturation was achieved.

RESULTS

Twenty-seven mothers completed interviews. Eighty-five percent were black, and 81% had Medicaid insurance. Concern about infants' health and fragility was the primary theme identified, with mothers reporting substantial stress going from a highly monitored NICU to an unmonitored home. Issues with trust and informational consistency were mentioned frequently and could threaten mothers' willingness to engage with providers. Strong family networks and determination compensated for limited economic resources, although many felt isolated. Mothers appreciated HVs' ability to address infant health but preferred nurses over lay health workers.

CONCLUSIONS

Low-income mothers experience significant anxiety about the transition from the NICU to home. Families value HVs who are trustworthy and have relevant medical knowledge about prematurity. Interventions to improve transition would benefit by incorporating parental input and facilitating trust and consistency in communication.