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    What Drives Racial and Ethnic Disparities in Prenatal Care for Expectant Mothers?

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    Prenatal care — health care for pregnant mothers — is one of the most commonly used forms of preventive health care among women of reproductive age. Prenatal care represents an important opportunity to detect, monitor, and address risky health conditions and behaviors among expectant mothers that can impact birth outcomes.

    Both delayed prenatal care (i.e., care initiated after the first trimester of pregnancy) and inadequate prenatal care are associated with poor infant health outcomes such as low birth weight. Although researchers continue to debate precise causal effects, studies suggest that prenatal care brings important benefits — including reductions in maternal smoking, lower rates of preventable pregnancy complications like high blood pressure, and better management of the mother’s weight after giving birth. Furthermore, mothers who initiate care earlier are more likely to take their infants to well-baby visits after their babies are born.

    As with other forms of healthcare, we see significant racial/ethnic disparities in access to and use of prenatal care. Although researchers have explored overall disparities in health outcomes rooted in differences in health insurance coverage, education, family income, and county-level poverty, more remains to be learned about how such factors affect various racial/ethnic inequalities.

    Such knowledge is critical for achieving national public health goals and for addressing gaps in health outcomes for pregnant women. My research explores this area and can point to solutions that can improve and equalize health care for various groups of women and their children.

    Disparities in First Trimester Initiation and Adequacy of Prenatal Care

    My research quantifies how various factors contribute to gaps in prenatal care among non-Hispanic white, non-Hispanic black, and Hispanic women. By combining county-level U.S. Census data with rich data on children born in 2001 from the Early Childhood Longitudinal Study, I am able to pinpoint factors that typically cannot be considered simultaneously. For example, I can explore the effects of both maternal access to transportation and the availability of physicians in various counties.

    My results reveal significant disparities among black, Hispanic, and white mothers in terms of the start of prenatal care in the first trimester of pregnancy. Although approximately 89 percent of whites initiate care during the first trimester, only 75 percent of black mothers and 79 percent of Hispanic mothers do so. Mothers from these groups also experience disparities in the adequacy of prenatal care they receive. Approximately 79 percent of non-Hispanic whites experience at least adequate prenatal care, while only 68 percent of Hispanic mothers and 69 percent of black mothers receive adequate care. What explains these differences? Here are the key findings from my research:

    • Socioeconomic characteristics like education, family income, and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children explain far more of the racial/ethnic gaps in prenatal care than any other factors. These factors explain over half of black–white disparities and nearly half of Hispanic–white disparities in first trimester prenatal care initiation. Socioeconomic characteristics also explain far more of the racial/ethnic gaps in prenatal care adequacy than any other group of factors (although these factors account for considerably more of the black-white gap than the Hispanic-white gap).

    • Maternal health and characteristics of pregnancies (such as maternal age and number of previous pregnancies) explain 8.8 percent of black-white differences and 8.7 – 9.7 percent of Hispanic–white differences in the timing of the start of care in the first trimester. But differences in the adequacy of care are not related to maternal health or pregnancy characteristics.

    • Types of insurance coverage – whether women are covered by Medicaid, private insurance, or have no coverage — explain similar small percentages of differences in the timing of first trimester care, but again do not account for gaps in the adequacy of care.

    • The location of prenatal care facilities – in physicians’ offices and public health clinics — explained 4.7-6 percent of black–white gaps in timing of the start of care and 2.9-4.9 percent of Hispanic–white disparities. Location of care explained about 8.3 percent of black–white gaps in the adequacy of care but did not explain Hispanic-white gaps.

    • Maternal behaviors like smoking and state of residence and count-level conditions did not significantly contribute to racial and ethnic disparities in the initiation of prenatal care. But the availability of local gynecologists and state of residence did help to narrow black–white gaps in the adequacy of prenatal care, although these factors did not influence gaps in the adequacy of care between Hispanics and whites.

    Addressing Socioeconomic Factors to Improve Prenatal Health

    My research suggests that large and persistent socioeconomic disparities are primary contributors to racial/ethnic gaps in the timing and adequacy of prenatal care. This finding is not surprising — pregnant women with lower incomes and levels of formal education often do not have the resources necessary to obtain care early and often. However, participation in the Special Supplemental Nutrition Program for Women, Infants, and Children made a difference for pregnant women, suggesting that this public program can help meet the financial needs that remain an important barrier to timely and adequate prenatal care.

    My findings suggest that policymakers should endeavor to help disadvantaged populations gain expanded access to healthcare. Medicaid expansions through the 2010 Affordable Care Act provide one promising intervention. Although such expansions target childless poor and near-poor adults, women who receive coverage prior to pregnancy can end up enrolling earlier in prenatal care; and they can obtain continuing help with the management of chronic health problems, potentially improving outcomes when their babies are born.

    Ultimately, as my research shows, reducing economic inequality may help to close racial and ethnic disparities in prenatal care. Read more in Tiffany L. Green, “Unpacking Racial/Ethnic Disparities in Prenatal Care Use: The Role of Individual-, Household-, and Area-Level Characteristics,” Journal of Women’s Health 27, no.9 (2018).

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    Tiffany Green is an Assistant Professor of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University. Green's research focuses on the individual-, family-, and environmental determinants of maternal and child health disparities, with a focus on racial/ethnic minorities and immigrant populations. This article is published in conjunction with Scholar Strategy Network.

    Education

    The Push for Healthy Communities

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    As COVID-19 took its toll on the U.S. in 2020, the numbers began to show that not everyone was equally affected by the virus. Data from the CDC and National Center for Health Statistics showed Black and Latinx populations were almost three times more likely to be hospitalized for COVID-19 than white populations, and it was two times more likely that their cases resulted in death.

    But COVID-19 only revealed the health disparities that were already rampant in the nation. And, these underlying disparities did not only affect people of color, but also occurred based on other factors such as socioeconomic status, gender, sexual orientation, geography and age.

    As the most economically and ethnically diverse university in the nation, the CSU is committed to ensuring all community members are served equally, including access to health care. Here are a few ways campuses are pushing for that access.​

    A Little Motivation

    The Stanislaus Recovery Center (SRC), which provides addiction recovery treatment for patients on Medicaid or Medi-Cal who are often unemployed or unhoused, is the site of a pilot study led by Shrinidhi Subramaniam, Ph.D., assistant professor of psychology at California State University, Stanislaus.

    Working together since 2018, Dr. Subramaniam and the SRC team noticed when patients were transferring from residential to outpatient care, their participation in treatment dropped off. To address the issue, Subramaniam, her students and the SRC launched the project—funded by a Research, Scholarships and Creative Activities grant—to study whether monetary incentives, paid on reloadable credit cards, increased patient participation in outpatient services as well as improved abstinence and treatment outcomes.

    “I expect the participants in our study to all be in the category of socioeconomic disadvantage, and hopefully the little bit of money that we can give them with the incentives will also encourage them to access other recovery resources through continuing care,” Subramaniam says.

    This pilot study is based off research she conducted during her post-doc at the Johns Hopkins School of Medicine on motivational incentives in health care, including encouraging HIV patients to take their medication and chronically unemployed individuals recovering from substance use disorder to abstain from drug use. Another study also looked at the efficacy of incentivizing patients to do other important tasks like sign up for health insurance, complete job training or acquire identification like a Social Security card or ID.

    Subramaniam hopes her work can expand to incentivize patients to use other services at SRC, includin​g its existing resources that link clients to training or local job opportunities—with the ultimate goal of setting up her own “therapeutic workplace” where individuals can receive treatment as well as help securing education, employment and housing.

    “We have to deal with a lot of stigmas working with this population; both the stigma of addiction and the stigma that comes along with poverty,” Subramaniam says. “So, one of the major goals of my research program is to figure out what it takes to help people with that combination of addiction, unemployment and poverty to get out of their situation to the best of our ability. Of course, there are structural changes that need to be made to help people in that position, but there are also things psychology can do on an individual basis to help people access resources that are available. And incentives are a great way to help motivate people to do those difficult tasks.”​

    The Next Generation

    Named in honor of the unsung medical personnel dubbed heroes during the COVID-19 pandemic, the proposed Regional Healthcare Initiative Health Education, Research, and Clinical Outcomes (HEROs) Institute at San Diego State University would seek to improve health care services and reduce disparities in its community by addressing issues in health education.

    “We can’t address access to health care if we don’t address access to health care education,” says Harsimran Baweja, Ph.D., associate professor in exercise and nutritional sciences. “Our idea is to make a grassroots-up change to health care delivery, so that these students who go out now, our alumni, will be the changemakers.”

    Specifically, the goal is to implement interprofessional education, in which classrooms would bring together students from different health care programs, reflecting the interdisciplinary teams they will experience in the workforce. By introducing this type of learning, their training times would be significantly shortened, and they could independently serve patients more quickly. In addition, the institute will form clinical partnerships with community health care providers, who will likewise provide instruction and training in the classroom and likely employ the students post-graduation.

    Specifically, the goal is to implement interprofessional education, in which classrooms would bring together students from different health care programs, reflecting the interdisciplinary teams they will experience in the workforce. By introducing this type of learning, their training times would be significantly shortened, and they could independently serve patients more quickly. In addition, the institute will form clinical partnerships with community health care providers, who will likewise provide instruction and training in the classroom and likely employ the students post-graduation.

    “We will be accelerating the delivery [of health care] from bench to bedside or to the community, because the problem in health care access and delivery is the pace at which it’s given,” Dr. Baweja explains. “We need to reduce the burden on the health care system and reduce the burden on the money that is spent. Our trainees who will go out will know how to run the system more efficiently. We really have to create a better and more efficient work system and workflow.”

    Spearheaded by Baweja, María Luisa Zúñiga, Ph.D., campus director of the Joint Doctoral Program in Interdisciplinary Research in Substance Abuse, and other faculty in research and innovation, public health and physical therapy, the HEROs Institute will also consolidate efforts currently occurring separately in the colleges. For example, the NIH-funded Addiction Scientists Strengthened Through Education and Training (ASSET) Program aims to increase the number of Black and Latinx scientists in substance abuse addiction and education, while the California Outreach Challenge, which SDSU participates in, has physical therapy programs compete for the most community service hours. Under the institute, similar programs could be implemented that extend across SDSU’s health care disciplines.

    Lastly, professors in the participating programs would imbue students with the values, cultural competence and community understanding that would prepare them to drive health care policy changes in the future.

    “If we not just prep students to be ready for whatever is coming in the future, but we guide them with the value system that you have to serve your community before they graduate, then the health care system is going to be better prepared for itself than it was in the past 12 months,” Baweja says. “These are going to be the people who are going to be not only informing the workforce, but will be informing the policies in the future.”

    The team is currently seeking public, private and industry partnerships to jumpstart the HEROs Institute, which is part of the​ SDSU Big Ideas Initiative​.

    A Health Care Transformation

    Building on the campus’s Mi Gente, Nuestra Salud (My People, Our Health) effort, California Polytechnic State University, San Luis Obispo is piloting a new institute that facilitates community-led initiatives to address health equity around the cities of Santa Maria and Guadalupe on California’s Central Coast.

    “Our solution is a people’s movement for health ownership,” says Suzanne Phelan, Ph.D., professor of kinesiology and public health and co-principal investigator of Mi Gente, Nuestra Salud. “The Mi Gente, Nuestra Salud initiative flips our current system upside down, empowering people—and especially those who are currently minoritized in America—to identify and address their most pressing health concerns. We aim to transform health care into health ownership.”

    To meet this goal, the Cal Poly Institute for Community Health Training and Research will largely provide resources that enable existing groups to better serve all members of the community with the help of collaborators from all six of the school’s colleges. These resources will include training in health equity principles, data on the community, funding opportunities and strategies for community partnerships, health advocacy and program evaluation.

    “We see this effort as collaborative and, ultimately, community-driven,” says Marilyn Tseng, Ph.D., assistant professor of kinesiology and public health and co-principal investigator of Mi Gente, Nuestra Salud. “We see the institute as providing resources that will help the process along; we are only one piece in the complex health ecosystem in Santa Maria. If we can help generate ripples that will produce larger beneficial impacts on community mobilization, health ownership and health equity, we will consider the effort to be completely worthwhile.”

    To secure support for the project, the team has already forged partnerships with the city of Santa Maria, nonprofits and University of California, Santa Barbara. It also recently received funding from the California Breast Cancer Research Program to study breast cancer risk disparities in the Latinx and immigrant communities of Santa Maria.

    These efforts will also be bolstered by Cal Poly San Luis Obispo’s Women and Infants Mobile Health Unit, which, in addition to supporting local health workers and providing free medical care to uninsured women and infants, will serve as a connection point between the institute and the community.

    Finally, the team hopes to introduce health advocacy and ambassadorship training into the classroom, preparing Cal Poly San Luis Obispo students to effectively care and advocate for these communities.

    Inspiration for these efforts grew out of a program in Jamkhed, India, called the Jamkhed Comprehensive Rural Health Project (CRHP), aimed at empowering people to address health disparities in their communities by first addressing the social, cultural and economic challenges that exacerbate those inequities.

    “All of us conduct research and teach courses in which we confront issues of health inequities rooted in systemwide, structural inequities in access to healthy environments, opportunities and resources,” Dr. Tseng says. “The Jamkhed CRHP has been successful and cost-effective in India, but more importantly, its principles resonated with all of us. We felt that health ownership was something we would like to see here given the stark disparities in health, even in our region.”

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    Disability

    Unpacking the Historical Relationship of Racism and Ableism

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    A key part of anti-racist social work practice is engaging in the art of reflection as we consider the person in the environment. This also involves being aware of the larger social context in which we live and practice. The social context can, for some people, include experiences of racism and ableism. Recently, I wrote about the symbiotic relationship between racism and ableism and why social workers should care about it. Now, I want to take a step back and look at the historical context that leads us to where we are today with the relationship for disabled people of color. Through the consideration of history, we can understand how to better move forward with integrity as anti-racist social work practitioners.

    As the poet Maya Angelou said “History, despite its wrenching pain, cannot be unlived, but if faced with courage, need not be lived again.” So what are the historical roots of this relationship between racism and ableism? Let’s explore.

    Historical Roots of Ableism and Racism

    We began to see the interaction between ableism and racism way back in our nation’s history. Let’s look at four examples to make this relationship clear. During slavery times, slaveowners conjured up the idea of drapetomania, the alleged psychosis that was experienced by runaway slaves which in retrospect was emblematic of the interaction of ableism and racism. This is an example of how race is pathologized to create racism. In other words, people of color were treated in specific oppressive ways in order to create barriers and conditions that resulted in the origination of disability categories. In reflecting on drapetomania, Isabella Kres-Nash points out that “the concept of disability has been used to justify discrimination against other groups by attributing disability to them.” Of drapetomania specifically, Kres-Nash says this is an example of a “disability being created by people in power in order to preserve social order” all of which occurred in a racialized context during slavery.

    Moving into the 19th century, we can point to the popularity of phrenology, a pseudoscientific technique originally developed in the late 1700s which purports to determine an individual’s character and abilities (and therefore, alleged superiority). This could be deduced from the size and shape of various bumps on a person’s head. Phrenology, among other things, was used to justify the practice of slavery, as was depicted in the film Django, Unchained. Although this pseudoscience has long been discredited, this technique is considered a precursor to modern neuropsychology and rears its ugly head once in a while in current-day conversations about the use of technology and facial recognition (which is known to be much less accurate for people of color).

    Scientific Racism

    If we look to more recent times, such as the turn of the 20th century, we can see connections between racism and the ableist Eugenics movement which sought to breed a perfect human race through a form of “scientific racism.” This movement often targeted what were known as “feebleminded” people (now known as intellectually and developmentally disabled people), among others, for sterilization, many of whom were people of color. In his discussion on the treatment of African American and Black “feebleminded” people, historian Gregory Dorr says “African Americans had become the targets of extra-institutional and extra-legal sterilizations, reflective of a more general southern racist view that it was necessary to further protect the white race itself from black folks.” Thus, scientific racism is a prime example of the relationship between racism and ableism.

    An Unusual Island in Maine

    In the early 1900s, what transpired with the inhabitants of Malaga Island in Maine is also emblematic of the relationship between racism and ableism. This small coastal island was a multiracial fishing community originally founded by an ex-slave. While inter-racial marriage was illegal, the community apparently allowed people to live and let live in this regard. It is said that many of the inhabitants of the island were “feebleminded” or intellectually and developmentally disabled, as we would now say. Whether this is accurate is unknown. As the Eugenics movement gained popularity and as the value of Maine’s coastal islands became more clear as potential tourist destinations, state government officials issued an eviction order to all of the Malaga residents – of all races and ethnicities. All residents who had no place to go were to be placed in the Maine School for the Feebleminded, where some were eventually sterilized and lived out the rest of their lives. The price of miscegenation was banishment from a happy community due in large part to ableism and racism.

    An Inextricable Link

    These four historical lessons give us some important context for what we may see in social work practice today. So, to put it all together, when we look at how structural racism works, we see the ways in which it has pathologized Black and Brown bodies for the purpose of keeping the White status quo in place. We can see how a society that benefits from structural racism is simultaneously responsible for facilitating environments that promote the development or highlighting of disability. These historical situations set the foundations for present day scenarios in which racism and ableism interact regularly – in our criminal justice system, in our education system, in our health care system, in our child welfare system and beyond.

    Action Steps

    How can you learn from this history and move on in a positive direction? Your job is to reflect on the ways in which the past plays out in the present day, and to identify the ways in which you can disrupt the powerful relationship between ableism and racism in your social work practice. Here are five steps you can consider taking today as an equity-minded social work practitioner:

    1. Become aware of all of your client’s social identities, think about disability as an identity, not just race.
    2. Use data to identify inequitable processes and outcomes based on both race and disability.
    3. Reflect on the differential consequences of social work practices on people and communities based on race and disability.
    4. Exercise agency to produce equity across racial and disability groups.
    5. View the practice context as a potentially oppressive and marginalizing space and self-monitor interactions with clients/patients/constituents of different racial and disability social identities.
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    Disability

    Sexual Education & Disability: Why it Should Matter to Social Workers

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    What do you get when you mix the taboo nature of discussing sexual intimacy with the social stigma surrounding intellectual and developmental disabilities? The answer: a heck of a lot more problems than you might think. Sexual education in the school setting is already a hot-button issue for non-disabled students. But when students with intellectual and developmental disabilities are introduced into the mix, so too are the ableist stigmas we all hold.

    Taboo-Nature

    I would like to start this piece with a brief exercise one of the health teachers at my high school conducted at the beginning of sex ed. Repeat after me: Penis. Vagina. Penis. Vagina. Why do you think she would make a room of teenagers yell these words in school? Isn’t that inappropriate? If you think it is, you proved my point from earlier. Sexual intimacy and anything loosely related to sex are currently incredibly taboo topics. To help break down the air of discomfort surrounding such topics, that health teacher did something many are afraid to do: she spoke openly and encouraged others to follow suit.

    One could argue these topics are not to be spoken about simply because we are taught to not speak about them. A child can ask why their anatomy is different from their siblings, but they will often be met with shushes or roundabout answers. In many cases, there is no reason for this reaction other than traditional values. Those same values are often times what causes conflict in regard to sexual education in public schools.

    My sex ed experience at a public school was mediocre at best. Genitalia, STIs, and contraceptive methods were discussed. Consent was not taught nor were the proper ways to actually engage in sex, just that if we did it we should do it safely. This was not the most educational experience. And if this is what I received, what is the experience of children and adolescents with intellectual and developmental disabilities?

    The Institutional Deficit

    Working in a behavioral school for boys with emotional, developmental, and intellectual disabilities yields an interesting perspective. These students are taught the same subjects most other students in the country are taught just with more academic and therapeutic support. However, they are not always provided with a health class.

    I worry greatly about this institutional deficit, partly due to my own ableism. These students are receiving very little, if any, sexual education during the school year from our faculty and who knows what they see on the Internet and what their families and friends are telling them. As they get older and begin to develop their curiosity, I am worried that they might not always have a reliable source of sexual education. With that, the concept of consent is often discussed but not in the context of intimacy. I don’t know if the connection between consent and sexual activities has been made or if it ever will be in this school setting. I don’t know if some of these students would understand the magnitude of these topics. I’d like to think these kids can do anything, but from what I’ve seen I don’t know if I would feel confident in their understanding. I wish I could feel otherwise.

    Deeper Issues

    Individuals with an intellectual or developmental disability are seven times more likely to experience sexual assault than non-disabled people. In many cases, the perpetrator is another individual with an intellectual or developmental disability. Ableism likely prevents people from thinking this to be possible. Common stereotypes around this population convince the non-disabled community that these individuals can do no wrong and are by default sweet and innocent. Of course, this is not realistic. Another ableist stereotype, as seen above, is the incapability of this population to understand topics related to sexual education and sexual intimacy. Like the non-disabled community, however, individuals with an intellectual or developmental disability prove that idea wrong.

    Why This Matters to Social Workers

    So, if people with intellectual and developmental disabilities are able to learn about sexual education, and learning about sexual education dramatically decreases instances of sexual assault, then what is the reason for this population to not receive sexual education? The signs point towards ableism held by those in helping professions, with social workers being a perfect example. While the social work community prides itself on how educated and accepting they are of different identities, very rarely do social workers take the time to reflect upon identities they may not be as familiar with. Race and sexual orientation are examples of identities social workers study extensively, but disability as an identity and the depths of disability culture are rarely examined. To combat this, social workers need to begin the process of confronting personal ableism.

    Confronting personal ableism is difficult, but doing so will only benefit social workers and others who choose to do so. It is important and necessary to challenge internal biases. Critically examining personal ableist ideas pushes social workers to gain a different perspective. Through this difficult process, one gains clarity in the issues they may not even know they wrestle with. Understanding how ableism impacts perceptions allows social workers to get a firm grasp on the disability community. They may begin to feel empowered to advocate for a change they never once considered, such as a stronger sexual education program for people with an intellectual or developmental disability. The importance of critically examining personal biases should be emphasized throughout the entirety of the social work community and by every social worker.

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