Opportunities to Improve Health Equity for Mothers, Babies and Children
When someone mentions health improvement, it often conjures up images of hospitals, doctors and nurses. But these images only paint part of the picture. To understand health holistically, we need to consider it outside the silo of a healthcare system. We need to take into account the many other factors that impact our individual health, factors like the schools we attend, the conditions in which we work, our culture and religion, and the relationships we experience.
These factors are known as social determinants of health (SDOH) and are what the World Health Organization defines as “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.” Understanding the connection between non-medical factors and health, and how best to address these conditions is critical to NICHQ’s approach to driving equitable change in children’s health outcomes. Too many of our children don’t have the same opportunities to be as healthy as others.
Consider two children with an auto-immune disorder. The first child receives regular wellness check-ups and, as a result, is diagnosed when exhibiting early symptoms. The second child’s family is struggling to get by, does not have a car, and lives in a small community without public transportation. As a result, the second child’s access to healthcare is compromised, the diagnosis is delayed and her resulting prognosis suffers. The second child’s worsened health condition is a result of the conditions in which she lives, rather than any physical trait or predisposition she possesses. In other words, a SDOH impacted her overall health outcome.
“To pursue equity in children’s health it is essential to account for the unique circumstances into which each child is born,” says NICHQ Executive Project Director Pat Heinrich, RN, MSN, CLE. “We need strategies that address both the bio-medical and social determinants that affect children’s health and well-being.”
State teams across the country worked to uncover these strategies during a national collaborative improvement and innovation network to reduce infant mortality (Infant Mortality CoIIN) that sought to improve birth outcomes, address racial disparities and reduce infant mortality rates (IMR). States leveraged 20 strategies to shift SDOH and increase equity by addressing economic, policy and social factors. These strategies, while developed to target IMR, offer a hopeful roadmap for addressing SDOH across the full childhood health sphere.
Below, we have honed in on the best practices and lessons learned from these innovative improvement teams. Read on to uncover three tried and tested ways to make changes in your state and help ensure that all children, regardless of circumstance, achieve equity in health outcomes.
Capitalize on Tax Credits for Families
Helping families use the Earned Income Tax Credit (EITC) and the Child Tax Credit (CTC) can improve health outcomes related to income disparities. The two tax credits help families rise out of poverty by encouraging workforce participation and helping supplement the wages of low income workers. They are especially valuable for reducing infant mortality because of the proven link between higher IMRs and higher poverty levels, and because they are particularly focused on families in their childbearing years. Research shows that among families receiving EITC, both maternal health and birth outcomes improve.
When Wisconsin discovered that the EITC was underutilized in their state, with one in five eligible taxpayers not taking advantage of the credit, they partnered with programs already working with low-income families and, together, ensured that more Wisconsin families understood and could benefit from the EITC. Their methods included encouraging home visiting nurses to visit low income families and share information about the EITC, helping create informational brochures in 24 languages to be distributed to families by home visiting and public health nurses, and developing informational videos in English and Spanish that promoted the EITC.
Afford Access to Paid Family Medical Leave
Expanding access to family medical leave improves the health of families and can lower infant mortality. With family leave, pregnant women with risks for preterm labor can take time off work; new mothers are better able to continue breastfeeding; and parents can more easily bring their children and babies to the doctor for well child check-ups and immunizations. Unpaid leave under the federal Family and Medical Leave Act (FMLA) provides job protection but it is available to fewer than 60 percent of workers, many of whom can’t afford to take time without pay. Only 15 percent of workers have access to paid family leave through their employers.
To address this discrepancy, Colorado launched an initiative to increase access to family medical leave by promoting family-friendly employment policies. The efforts of a public-private coalition resulted in a family-friendly policy reform. The reform was passed thanks to Colorado’s efforts to build awareness among employers about the importance of family-friendly working conditions for community and personal health, as well as workforce participation and productivity. They built this awareness by promoting the policies at the community level: local public policy health agencies established lunch and learns and business forums to engage with employers throughout their communities. Their initiative was not limited to paid family leave, but tackled multiple workplace issues, such as increased on-site childcare and support for breastfeeding in the workplace. Engaging multiple stakeholders helped them secure more allies.
Prioritize Justice System Reform
When a parent is imprisoned, children and infants suffer. An absent father or mother can mean less support for the child’s caregiver, emotional trauma for the child and instability at home. Equally pressing, formerly incarcerated parents and caregivers often face difficulty finding a job, leading to economic hardships that can adversely affect maternal, infant and child health and well-being. Because of the negative consequences of imprisonment, improvements to the criminal justice system—such as reconsidering mandatory minimums and advocating for policy changes that champion post-incarceration employment—can improve infant and childhood health.
Recognizing the importance of justice system reform, Wisconsin leaders took action at the state and community level: they set a goal of reducing the incarceration rates and training those who had formerly been incarcerated to take on leadership roles. Successful efforts included neighborhood canvassing on the issue, forums to facilitate dialogue between employers and those who had been incarcerated, screening of educational films and training workshops. State Maternal and Child Health Program funds were used to help support community forums and related efforts.
These examples are just a handful of the strategies employed throughout the Infant Mortality CoIIN SDOH Learning Network. States also expanded use of medical-legal partnerships, place-based initiatives, equity training and health in all policies approaches, among other strategies.
Explore additional SDOH case studies and strategies for improving children’s health in our Infant Mortality CoIIN Prevention Toolkit, a free online, interactive guide. We encourage you to dive into the toolkit, which also brings to life the five other strategy areas for reducing IMR: safe sleep practices, pre- and early-term births, pre- and interconception care, smoking cessation, and risk-appropriate perinatal care. Along with case studies from other states, users can drill down to specific drivers and change ideas and watch videos from state teams sharing their experiences.
North Carolina’s Strategy to Address Social Determinants of Health
North Carolina is developing a system that connects individuals with resources to address social, economic and environmental barriers to their health—such as housing, food insecurity, and transportation. By putting funding and policy efforts into addressing social determinants of health, North Carolina is building a system that can improve health outcomes for children and families across the state.
Breastfeeding in 2019: Safe Sleep, Bias, Gender Equitable Norms, and Paid Leave
In honor of National Breastfeeding Month, we’ve taken time with NICHQ Faculty Expert, Lori Feldman-Winter, MD, MPH, an internationally and nationally recognized expert on breastfeeding nutrition, education and policy, to recognize successes and learn about opportunities for improvement. Her frank description of bias and her passion for promoting gender-equitable social norms have inspired us to continue pursuing sustainable improvements.
Successful Strategies Hospitals Can Use to Support Safe Sleep
Hospitals on a national initiative to improve safe sleep came together to share successes and lessons-learned. Here, find their highest-rated strategies and change ideas, all of which reflect early successes in their work. Hospitals seeking to improve safe sleep education can refer to this list as a place to start and guide for gaining quick wins.
Improving Transitions in Care Saves Lives
Advancements in care have helped more children with rare diseases reach adulthood, but health systems and providers have struggled to help children transition to adult care, resulting in high rates of complications and mortality for young adults. These strategies for helping young adults with sickle cell disease transition to adult care can save lives.
“The Act of Making a Referral is Not Enough”
Universal developmental screenings can help identify children at risk for developmental delays and connect them with needed supports. An effective screening process relies on successful referrals though—if there is no follow-up with the referred child, families can never access the supports the child may need, and that child may ultimately fall through the cracks. Here, Dipesh Navsaria, MPH, MSLIS, MD, Associate Professor of Pediatrics at the University of Wisconsin School of Medicine and Public Health provides five steps to build a referral process that works.
Neonatologist Shares Successful Strategies for Improving Infant Health Outcomes
Babies born in the United States have a higher chance of death than babies born in more than 50 other countries in the world. Harnessing lessons-learned from successful improvement initiatives can help hospitals and state health systems address this alarming statistic. Here, pioneer for improvement Deborah Campbell, MD, FAAP, shares strategies and lessons-learned from three successful improvement efforts: improving nutrition protocols for preterm infants; spreading safe sleep messages to reduce infant deaths; and testing strategies to lower rates of maternal hemorrhage, and related mortality and morbidity.