Partnering with American Indian communities in health using methods of strategic collaboration.

BACKGROUND: The Association for Prevention Teaching and Research (APTR) sponsored six regional workshops in 2010 on community engagement and community-engaged research. One of the six workshops was a collaborative effort between the Great Plains Tribal Chairman's Health Board (GPTCHB)-Northern Plains Tribal Epidemiology Center and the College of Public Health at the University of Nebraska Medical Center (UNMC-COPH). OBJECTIVES: To create a meaningful and dynamic forum for the exchange of ideas and co-learning between researchers from urban, tribal and nontribal communities and to build the groundwork for development of sustainable partnerships between researchers and American Indian (AI) communities to eliminate health disparities. METHODS: To enhance meaningful community engagement, we utilized methods of Strategic Collaboration using the Appreciative Inquiry, 4D Change Process Model and designed several interactive group activities including Collaborative Learning and Understanding Exercises (CLUE) and the Research Café. RESULTS: The key themes that emerged from the interactive sessions stressed the importance of building relationships and trust; mutual use and sharing of data; and acquiring knowledge, skills, and abilities to enable sustainable research partnerships with AI communitiesConclusions: Innovative, dynamic, and strategic collaborative methods of Appreciative Inquiry and the World Café can served to engage people in a constructive dialogue to create a shared vision and plan for more meaningful research partnerships based on principles of equity and social justice, essential for the elimination of health disparities. These collaborative methods can be replicated and adapted in diverse communities, locally, nationally, and globally.

Recommendations of the IOM clinical preventive services for women committee: implications for obstetricians and gynecologists.

PURPOSE OF REVIEW: In July 2011, in response to language in the Affordable Care Act (ACA) the Office of the Assistant Secretary for Planning and Evaluation of the US Department of Health and Human Services (HHS) tasked the Institute of Medicine (IOM) to develop a report on the clinical preventive services necessary for women. The committee proposed eight new clinical preventive service recommendations aimed at closing significant gaps in preventive healthcare. This article reviews the process, findings, and the implications for obstetrician gynecologists and other primary care clinicians. Obstetricians and gynecologists play a major role in delivering primary care to women and many of the services recommended by the Committee are part of the core set of obstetrics and gynecology services. RECENT FINDINGS: The women's health amendment to the ACA (Federal Register, 2010) requires that new private health plans cover - with no cost-sharing requirements - preventive healthcare services for women. Congress requested that a review be conducted to ascertain whether there were any additional needed preventive services specific to women's health that should be included. SUMMARY: The IOM Committee on Preventive Services for Women recommended eight clinical measures specific to women's health that should be considered for coverage without co-payment. The US Department of HHS reviewed and adopted these recommendations, and, as a result, new health plans will need to include these services as part of insurance policies with plan years beginning on or after 1 August 2012. The authors discuss the implications of the IOM recommendations on practicing clinicians and on their potential impact on women's health and well being.

Perinatal periods of risk: a community approach for using data to improve women and infants' health.

This paper provides an overview of the origins, purpose, and methods of the Perinatal Periods of Risk (PPOR) approach to community-based planning for action to improve maternal and infant health outcomes. PPOR includes a new analytic framework that enables urban communities to better understand and address fetal and infant mortality. This article serves as the core reference for accompanying specific PPOR methods and practice articles. PPOR is based on core principles of full community engagement and equity and follows a six stage community-based planning process. In Stage 1, communities are mobilized and engaged, related planning efforts aligned, and community and analytic readiness assessed. In Stage 2, feto-infant mortality is mapped, excess mortality is estimated, likely causes of feto-infant mortality are determined, and appropriate actions are suggested. Stage 3 produces action plans for targeted prevention strategies. Stages 4 and 5 include implementation, monitoring, and evaluation. Stage 6 fosters political will to sustain efforts. PPOR can be used in local maternal child health (MCH) practice for improving perinatal outcomes. MCH programs can use PPOR to integrate health assessments, initiate planning, identify significant gaps, target more in-depth inquiry, and suggest clear interventions for lowering feto-infant mortality. PPOR enables greater cooperation in improving MCH through more effective data use, strengthened data capacity, and greater shared understanding of complex infant mortality issues. PPOR offers local health departments and their community partners a comprehensive approach to address the health of women and infants in their jurisdictions.

Perinatal periods of risk: analytic preparation and phase 1 analytic methods for investigating feto-infant mortality.

The Perinatal Periods of Risk (PPOR) methods provide the necessary framework and tools for large urban communities to investigate feto-infant mortality problems. Adapted from the Periods of Risk model developed by Dr. Brian McCarthy, the six-stage PPOR approach includes epidemiologic methods to be used in conjunction with community planning processes. Stage 2 of the PPOR approach has three major analytic parts: Analytic Preparation, which involves acquiring, preparing, and assessing vital records files; Phase 1 Analysis, which identifies local opportunity gaps; and Phase 2 Analyses, which investigate the opportunity gaps to determine likely causes of feto-infant mortality and to suggest appropriate actions. This article describes the first two analytic parts of PPOR, including methods, innovative aspects, rationale, limitations, and a community example. In Analytic Preparation, study files are acquired and prepared and data quality is assessed. In Phase 1 Analysis, feto-infant mortality is estimated for four distinct perinatal risk periods defined by both birthweight and age at death. These mutually exclusive risk periods are labeled Maternal Health and Prematurity, Maternal Care, Newborn Care, and Infant Health to suggest primary areas of prevention. Disparities within the study community are identified by comparing geographic areas, subpopulations, and time periods. Excess mortality numbers and rates are estimated by comparing the study population to an optimal reference population. This excess mortality is described as the opportunity gap because it indicates where communities have the potential to make improvement.

Integrated approaches to improve birth outcomes: perinatal periods of risk, infant mortality review, and the Los Angeles Mommy and Baby Project.

This article provides an example of how Perinatal Periods of Risk (PPOR) can provide a framework and offer analytic methods that move communities to productive action to address infant mortality. Between 1999 and 2002, the infant mortality rate in the Antelope Valley region of Los Angeles County increased from 5.0 to 10.6 per 1,000 live births. Of particular concern, infant mortality among African Americans in the Antelope Valley rose from 11.0 per 1,000 live births (7 cases) in 1999 to 32.7 per 1,000 live births (27 cases) in 2002. In response, the Los Angeles County Department of Public Health, Maternal, Child, and Adolescent Health Programs partnered with a community task force to develop an action plan to address the issue. Three stages of the PPOR approach were used: (1) Assuring Readiness; (2) Data and Assessment, which included: (a) Using 2002 vital records to identify areas with the highest excess rates of feto-infant mortality (Phase 1 PPOR), and (b) Implementing Infant Mortality Review (IMR) and the Los Angeles Mommy and Baby (LAMB) Project, a population-based study to identify potential factors associated with adverse birth outcomes. (Phase 2 PPOR); and (3) Strategy and Planning, to develop strategic actions for targeted prevention. A description of stakeholders' commitments to improve birth outcomes and monitor infant mortality is also given. The Antelope Valley community was engaged and ready to investigate the local rise in infant mortality. Phase 1 PPOR analysis identified Maternal Health/Prematurity and Infant Health as the most important periods of risk for further investigation and potential intervention. During the Phase 2 PPOR analyses, IMR found a significant proportion of mothers with previous fetal loss (45%) or low birth weight/preterm (LBW/PT) birth, late prenatal care (39%), maternal infections (47%), and infant safety issues (21%). After adjusting for potential confounders (maternal age, race, education level, and marital status), the LAMB case-control study (279 controls, 87 cases) identified additional factors associated with LBW births: high blood pressure before and during pregnancy, pregnancy weight gain falling outside of the recommended range, smoking during pregnancy, and feeling unhappy during pregnancy. PT birth was significantly associated with having a previous LBW/PT birth, not taking multivitamins before pregnancy, and feeling unhappy during pregnancy. In response to these findings, community stakeholders gathered to develop strategic actions for targeted prevention to address infant mortality. Subsequently, key funders infused resources into the community, resulting in expanded case management of high-risk women, increased family planning services and local resources, better training for nurses, and public health initiatives to increase awareness of infant safety. Community readiness, mobilization, and alignment in addressing a public health concern in Los Angeles County enabled the integration of PPOR analytic methods into the established IMR structure and [the design and implementation of a population-based l study (LAMB)] to monitor the factors associated with adverse birth outcomes. PPOR proved an effective approach for identifying risk and social factors of greatest concern, the magnitude of the problem, and mobilizing community action to improve infant mortality in the Antelope Valley.

Perinatal periods of risk: phase 2 analytic methods for further investigating feto-infant mortality.

The perinatal periods of risk (PPOR) methods provide a framework and tools to guide large urban communities in investigating their feto-infant mortality problem. The PPOR methods have 11 defined steps divided into three analytic parts: (1) Analytic Preparation; (2) Phase 1 Analysis-identifying the opportunity gaps or populations and risk periods with largest excess mortality; and (3) Phase 2 Analyses-investigating these opportunity gaps. This article focuses on the Phase 2 analytic methods, which systematically investigate the opportunity gaps to discover which risk and preventive factors are likely to have the largest effect on improving a community's feto-infant mortality rate and to provide additional information to better direct community prevention planning. This article describes the last three PPOR epidemiologic steps for investigating identified opportunity gaps: identifying the mechanism for excess mortality; estimating the prevalence of risk and preventive factors; and estimating the impact of these factors. While the three steps provide a common strategy, the specific analytic details are tailored for each of the four perinatal risk periods. This article describes the importance, prerequisites, alternative approaches, and challenges of the Phase 2 methods. Community examples of the methods also are provided.

Where are the data to drive policy changes for preconception health and health care?

Improving preconception health is recognized as being crucial to improving reproductive health outcomes for women and infants. At the same time, there is increasing pressure on public health and clinical medicine programs to have evidence that documents positive health impact for continued support for program implementation and policy change. In the field of preconception health and health care, there is a growing body of evidence to support the implementation of public health programs and clinical practice. One current challenge is the unavailability of a comprehensive surveillance system providing data to demonstrate the need for such programs and to monitor the impact of programs and services. There is no single source of data or evidence for policy and financing support for preconception care; however, there are a number of related data resources that can be used to inform and support such programs. We describe national and state-level data sources from which data relevant to preconception health and health care can be extracted as well as steps that can be taken to improve the quantity and quality of preconception health data.

Integrating preconception health into public health practice: a tale of three cities.

In 2006, the national Select Panel on Preconception Care published a set of 10 recommendations on how to improve preconception health and healthcare in the United States. Since then, CDC has been engaged in efforts to ensure that those recommendations are implemented. To help translate the national recommendations into action at the local level, CDC funded CityMatCH, a national maternal and child health organization representing urban health departments, to coordinate a practice collaborative. Beginning in October 2006, multidisciplinary teams from Hartford, Connecticut, Nashville, Tennessee, and Los Angeles County, California, have engaged in the CityMatCH Urban Practice Collaborative on Preconception Health. The CityMatCH practice collaborative process includes team building and leadership development, community assessment, identification of strategies, and action planning around those strategies. The Hartford team's strategies are broad--conducting a scan of preconception health-related activity in Hartford and promoting public policy-and intended for building awareness of preconception health and healthcare among multiple audiences while strengthening the systems necessary to provide women's services. The Nashville team has focused on sickle cell trait as a point of entry into preconception care for women of reproductive age and has developed strategies involving extensive collaboration, a public awareness campaign, and data gathering. The Los Angeles County, California, team is strengthening and more explicitly connecting work related to preconception health that was already being performed in the public sector and the community. This paper describes the collaborative process designed by CityMatCH and highlights the three participating teams' experiences in implementing the national recommendations at the local urban level.