Co-creation of a training for community health workers to enhance skills in serving LGBTQIA+ communities

This paper describes creating and implementing a 30-h LGBTQIA+ specialty training for community health workers (CHWs). The training was co-developed by CHW training facilitators (themselves CHWs), researchers with expertise in LGBTQIA+ populations and health information, and a cohort of 11 LGBTQIA+ CHWs who theater tested and piloted the course. The research and training team collected cohort feedback through focus groups and an evaluative survey. Findings stress the importance of a curriculum designed to elicit lived experiences and informed by a pedagogical framework centered on achieving LGBTQIA+ visibilities. This training is a vital tool for CHWs to foster cultural humility for LGBTQIA+ populations and identify opportunities to support their health promotion, especially considering their limited and sometimes absent access to affirming and preventative healthcare. Future directions include revising the training content based on cohort feedback and adapting it to other contexts, such as cultural humility training for medical and nursing professionals and staff.

"Community health workers bring value and deserve to be valued too:" Key considerations in improving CHW career advancement opportunities

Introduction

Community health workers (CHWs) are critical members of the public health workforce, who connect the individuals they serve with resources, advocate for communities facing health and racial inequities, and improve the quality of healthcare. However, there are typically limited professional and career building pathways for CHWs, which contribute to low wages and lack of career advancement, further resulting in turnover, attrition, and workforce instability.

Methods

The Center for Community Health Alignment (CCHA), within the Arnold School of Public Health at the University of South Carolina, utilized a mixed-method data collection strategy to provide a more in-depth understanding of this issue and ways that employers, advocates, and CHWs can address it.

Results

Themes across data sources emphasized the importance of retaining skilled and experienced CHWs and educating other health professions about CHWs' critical roles, and reported that doing so will result in decreased attrition professional growth, and improved program quality. CHWs and allies concluded that higher wages, valuing lived experience over formal education, and participation in additional training opportunities should be the primary factors considered for career advancement.

Discussion

Utilizing input from experienced CHWs and CHW allies nationally, this article describes the importance of supporting CHW career advancement, shares best practices, and suggestions for designing strategies that organizations/employers can use to improve CHW career pathways to better support the CHW workforce and reduce attrition.

Group vs traditional prenatal care for improving racial equity in preterm birth and low birthweight: the Centering and Racial Disparities randomized clinical trial study

BACKGROUND

The United States has persistently high rates of preterm birth and low birthweight and is characterized by significant racial disparities in these rates. Innovative group prenatal care models, such as CenteringPregnancy, have been proposed as a potential approach to improve the rates of preterm birth and low birthweight and to reduce disparities in these pregnancy outcomes.

OBJECTIVE

This study aimed to test whether participation in group prenatal care would reduce the rates of preterm birth and low birthweight compared with individual prenatal care and whether group prenatal care would reduce the racial disparity in these rates between Black and White patients.

STUDY DESIGN

This was a randomized controlled trial among medically low-risk pregnant patients at a single study site. Eligible patients were stratified by self-identified race and ethnicity and randomly allocated 1:1 between group and individual prenatal care. The primary outcomes were preterm birth at <37 weeks of gestation and low birthweight of <2500 g. The primary analysis was performed according to the intent-to-treat principle. The secondary analyses were performed according to the as-treated principle using modified intent-to-treat and per-compliance approaches. The analysis of effect modification by race and ethnicity was planned.

RESULTS

A total of 2350 participants were enrolled, with 1176 assigned to group prenatal care and 1174 assigned to individual prenatal care. The study population included 952 Black (40.5%), 502 Hispanic (21.4%), 863 White (36.8%), and 31 "other races or ethnicity" (1.3%) participants. Group prenatal care did not reduce the rate of preterm birth (10.4% vs 8.7%; odds ratio, 1.22; 95% confidence interval, 0.92-1.63; P=.17) or low birthweight (9.6% vs 8.9%; odds ratio, 1.08; 95% confidence interval, 0.80-1.45; P=.62) compared with individual prenatal care. In subgroup analysis, greater attendance in prenatal care was associated with lower rates of preterm birth and low birthweight. This effect was most noticeable for the rates of low birthweight for Black participants in group care: intent to treat (51/409 [12.5%]), modified intent to treat (36/313 [11.5%]), and per compliance (20/240 [8.3%]). Although the rates of low birthweight were significantly higher for Black participants than White participants seen in individual care (adjusted odds ratio, 2.00; 95% confidence interval, 1.14-3.50), the difference was not significant for Black participants in group care compared with their White counterparts (adjusted odds ratio, 1.58; 95% confidence interval, 0.74-3.34).

CONCLUSION

There was no difference in the overall rates of preterm birth or low birthweight between group and individual prenatal care. With increased participation in group prenatal care, lower rates of preterm birth and low birthweight for Black participants were observed. The role of group care models in reducing racial disparities in these birth outcomes requires further study.

Core strategies, social processes, and contextual influences of early phases of implementation and statewide scale-up of group prenatal care in South Carolina

This mixed-methods process evaluation examined a state-wide, interagency collaborative in South Carolina that expanded CenteringPregnancy group prenatal care from two to five additional healthcare practices from 2012 to 2015. The evaluation focused on delineating core processes, strategies, and external contextual elements of group prenatal care implementation and scale-up. Success of this scale-up was enhanced by the effective use and creation of windows of opportunity, which allowed stakeholders to pursue actions consistent with their own values, at both state and organizational levels. Most importantly, strong political advocacy and state-level financial commitment for group prenatal care made it possible for clinics throughout South Carolina to begin providing CenteringPregnancy to their patients. Improved understanding of the processes involved in scaling-up pilot interventions may enhance the effectiveness and efficiency of future expansion efforts.

Assessing Adverse Childhood Experiences during Pregnancy: Evidence toward a Best Practice

Objective  To quantify the prevalence of adverse childhood experiences (ACEs) among a diverse urban cohort of pregnant women. Study Design  The ACE survey was self-administered to 600 women categorized evenly between the waiting room, private examination rooms, and CenteringPregnancy group spaces. The percentage of women willing to complete the survey per location was compared using chi-square tests, and the mean ACE score per arm was compared using Wilcoxon's rank-sum test. Results  Of the 660 women approached for participation, 5% declined; 67% reported ≥ 1 ACE exposure and 19% reported an ACE score of ≥ 4. By domain, 59% experienced household dysfunction, 25% abuse, and 25% neglect. Women in the waiting room were more likely to decline participation ( p  < 0.01), and those participating in the postpartum inpatient arm had a significantly lower proportion affirming 8 of 10 ACE questions, were less likely to report ≥1 ACE, and had a lower mean ACE score when compared with the outpatient arm ( p  < 0.01). Conclusion  The prevalence of ACEs in this diverse pregnant cohort was high. The ideal locations to distribute the survey are the outpatient examination rooms.

Group Prenatal Care Results in Medicaid Savings with Better Outcomes: A Propensity Score Analysis of CenteringPregnancy Participation in South Carolina

Objectives This study was undertaken to determine the cost savings of prevention of adverse birth outcomes for Medicaid women participating in the CenteringPregnancy group prenatal care program at a pilot program in South Carolina. Methods A retrospective five-year cohort study of Medicaid women was assessed for differences in birth outcomes among women involved in CenteringPregnancy group prenatal care (n = 1262) and those receiving individual prenatal care (n = 5066). The study outcomes examined were premature birth and the related outcomes of low birthweight (LBW) and neonatal intensive care unit (NICU) visits. Because women were not assigned to the CenteringPregnancy group, a propensity score analysis ensured that the inference of the estimated difference in birth outcomes between the treatment groups was adjusted for nonrandom assignment based on age, race, Clinical Risk Group, and plan type. A series of generalized linear models were run to estimate the difference between the proportions of individuals with adverse birth outcomes, or the risk differences, for CenteringPregnancy group prenatal care participation. Estimated risk differences, the coefficient on the CenteringPregnancy group indicator variable from identity-link binomial variance generalized linear models, were then used to calculate potential cost savings due to participation in the CenteringPregnancy group. Results This study estimated that CenteringPregnancy participation reduced the risk of premature birth (36 %, P < 0.05). For every premature birth prevented, there was an average savings of $22,667 in health expenditures. Participation in CenteringPregnancy reduced the incidence of delivering an infant that was LBW (44 %, P < 0.05, $29,627). Additionally, infants of CenteringPregnancy participants had a reduced risk of a NICU stay (28 %, P < 0.05, $27,249). After considering the state investment of $1.7 million, there was an estimated return on investment of nearly $2.3 million. Conclusions Cost savings were achieved with better outcomes due to the participation in CenteringPregnancy among low-risk Medicaid beneficiaries.

Centering and Racial Disparities (CRADLE study): rationale and design of a randomized controlled trial of centeringpregnancy and birth outcomes

Background

In the United States, preterm birth (PTB) before 37 weeks gestational age occurs at an unacceptably high rate, and large racial disparities persist. To date, medical and public health interventions have achieved limited success in reducing rates of PTB. Innovative changes in healthcare delivery are needed to improve pregnancy outcomes. One such model is CenteringPregnancy group prenatal care (GPNC), in which individual physical assessments are combined with facilitated group education and social support. Most existing studies in the literature on GPNC are observational. Although the results are promising, they are not powered to detect differences in PTB, do not address the racial disparity in PTB, and do not include measures of hypothesized mediators that are theoretically based and validated. The aims of this randomized controlled trial (RCT) are to compare birth outcomes as well as maternal behavioral and psychosocial outcomes by race among pregnant women who participate in GPNC to their counterparts in individual prenatal care (IPNC) and to investigate whether improving women’s behavioral and psychosocial outcomes will explain the potential benefits of GPNC on birth outcomes and racial disparities.

Methods/design

This is a single site RCT study at Greenville Health System in South Carolina. Women are eligible if they are between 14–45 years old and enter prenatal care before 20 6/7 weeks of gestational age. Eligible, consenting women will be randomized 1:1 into GPNC group or IPNC group, stratified by race. Women allocated to GPNC will attend 2-h group prenatal care sessions according to the standard curriculum provided by the Centering Healthcare Institute, with other women due to deliver in the same month. Women allocated to IPNC will attend standard, traditional individual prenatal care according to standard clinical guidelines. Patients in both groups will be followed up until 12 weeks postpartum.

Discussion

Findings from this project will provide rigorous scientific evidence on the role of GPNC in reducing the rate of PTB, and specifically in reducing racial disparities in PTB. Establishing the improved effect of GPNC on pregnancy and birth outcomes can change the way healthcare is delivered, particularly with populations with higher rates of PTB.

Trial registration

NCT02640638 Date Registered: 12/20/2015.

Effects of Group Prenatal Care on Food Insecurity during Late Pregnancy and Early Postpartum

OBJECTIVE

This study compared the effects of group to individual prenatal care in late pregnancy and early postpartum on (1) women's food security and (2) psychosocial outcomes among food-insecure women.

METHODS AND RESULTS

We recruited 248 racially diverse, low-income, pregnant women receiving CenteringPregnancy™ group prenatal care (N = 124) or individual prenatal care (N = 124) to complete surveys in early pregnancy, late pregnancy, and early postpartum, with 84 % completing three surveys. Twenty-six percent of group and 31 % of individual care participants reported food insecurity in early pregnancy (p = 0.493). In multiple logistic regression models, women choosing group versus individual care were more likely to report food security in late pregnancy (0.85 vs. 0.66 average predicted probability, p < 0.001) and postpartum (0.89 vs. 0.78 average predicted probability, p = 0.049). Among initially food-insecure women, group participants were more likely to become food-secure in late pregnancy (0.67 vs. 0.35 individual care average predicted probability, p < 0.001) and postpartum (0.76 vs. 0.57 individual care average predicted probability, p = 0.052) in intention-to-treat models. Group participants were more likely to change perceptions on affording healthy foods and stretching food resources. Group compared to individual care participants with early pregnancy food insecurity demonstrated higher maternal-infant attachment scale scores (89.8 vs. 86.2 points for individual care, p = 0.032).

CONCLUSIONS

Group prenatal care provides health education and the opportunity for women to share experiences and knowledge, which may improve food security through increasing confidence and skills in managing household food resources. Health sector interventions can complement food assistance programs in addressing food insecurity during pregnancy.

The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population

OBJECTIVE

The purpose of this study was to evaluate the impact of group prenatal care on rates of preterm birth.

STUDY DESIGN

We conducted a retrospective cohort study of 316 women in group prenatal care that was compared with 3767 women in traditional prenatal care. Women self-selected participation in group care.

RESULTS

Risk factors for preterm birth were similar for group prenatal care vs traditional prenatal care: smoking (16.9% vs 20%; P = .17), sexually transmitted diseases (15.8% vs 13.7%; P = .29), and previous preterm birth (3.2% vs 5.4%; P = .08). Preterm delivery (<37 weeks' gestation) was lower in group care than traditional care (7.9% vs 12.7%; P = .01), as was delivery at <32 weeks' gestation (1.3% vs 3.1%; P = .03). Adjusted odds ratio for preterm birth for participants in group care was 0.53 (95% confidence interval, 0.34-0.81). The racial disparity in preterm birth for black women, relative to white and Hispanic women, was diminished for the women in group care.

CONCLUSION

Among low-risk women, participation in group care improves the rate of preterm birth compared with traditional care, especially among black women. Randomized studies are needed to eliminate selection bias.