Addressing Social Inequality Discussion

Addressing Social Inequality Discussion ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Addressing Social Inequality Discussion Ongoing stressors, barriers to services, discrimination, stigma, and poor training among professionals are among the many factors that contribute to disparities in three populations discussed in the attached articles. These populations include Lesbian, Gay, Bisexual and Transgender (LGBT) populations, migrant women domestic workers experiencing violence, and African American women leading up to pregnancy and childbirth. Please discuss some ways that some components of either the “Life Course Approach” or the “Health Equity Promotion Model” could be used to understand and reduce disparities in each of the other two of the populations described in one of the other articles. For example, how could the Life Course Approach be used to understand and reduce violence in migrant women domestic workers, and to reduce health disparities in LGBT populations? Or how could the Health Equity Promotion Model be used to reduce infant mortality among African Americans and among migrant women domestic workers? Addressing Social Inequality Discussion Please read all attached articles prior to the completion of the discussion lu_et_al_closing_the_black_white_gap_in_birth_outcomes_2010.pdf kouta_2015_systematic_review_of_interventions_on_sexual_violence.pdf fredriksen_goldsen_lgbtq_health_equity_model_2014.pdf CLOSING THE BLACK-WHITE GAP In the United States, Black infants have significantly worse birth outcomes than White infants. Over the past decades, public health efforts to address these disparities have focused primarily on increasing access to prenatal care, however, this has not led to closing the gap in birth outcomes. We propose a 12-point plan to reduce Black-White disparities in birth outcomes using a life-course approach. The first four points (increase access to interconception care, preconception care, quality prenatal care, and healthcare throughout the life course) address the needs of African American women for quality healthcare across the lifespan. The next four points (strengthen father involvement, systems integration, reproductive social capital, and community building) go beyond individual-level interventions to address enhancing family and community systems that may influence the health of pregnant women, families, and communities. The last four points (close the education gap, reduce poverty, support working mothers, and undo racism) move beyond the biomedical model to address the social and economic inequities that underlie much of health disparities. Closing the Black-White gap in birth outcomes requires a life course approach which addresses both early life disadvantages and cumulative allostatic load over the life course. (Ethn Dis. 2010;20 [Suppl 2]:s2-62–s2-76) Key Words: Life Course Perspective, Disparities, Birth Outcomes, Programming, Allostatic Load, Preconception Care, Prenatal Care, Quality, Father Involvement, Systems Integration, Social Capital, Maternity Leave, Childcare, Racism From the Departments of Obstetrics and Gynecology (MCL) and Pediatrics (NH), David Geffen School of Medicine at UCLA; the Department of Community Health Sciences and the Center for Healthier Children, Families and Communities, UCLA School of Public Health (MCL, NH) and Department of Maternal and Child Health, Boston University School of Public Health (MK) and Department of Maternal and Child Health, University of North Carolina at Chapel Hill (VH) and Healthy African American Families, Los Angeles, CA (LJ) and UCLA School of Nursing (KW). Address correspondence or reprint request to Michael C. Lu, MD, MPH; Department of Community Health Sciences; UCLA School of Public Health; Box 951772; Los Angeles, CA; 90095-1772; 310-825-5297; 310-794-1805 (fax); [email protected] S2-62 IN BIRTH OUTCOMES: A LIFE-COURSE APPROACH Michael C. Lu, MD, MPH; Milton Kotelchuck, PhD, MPH; Vijaya Hogan, DrPH; Loretta Jones, MA; Kynna Wright, PhD, MPH; Neal Halfon, MD, MPH In the United States, Black infants are more than twice as likely to die within the first year of life as a White infant, a gap that has not substantially closed in over half a century.1,2 A significant portion of the disparity in infant mortality is attributable to the near two-fold increased rates of low birth weight (LBW) and preterm births, and the near three-fold increased rates of very low birth weight (VLBW) and very preterm births, among Black infants.3 The cause of racial disparities remains largely unexplained. Most studies focus on differential exposures to risk and protective factors during pregnancy, such as maternal behaviors,4 prenatal care utilization,5 psychosocial stress6 or infections.7 These factors however do not adequately account for the racial gap in birth outcomes.8,9 Lu and Halfon10 recently proposed an alternative approach to examining racial-ethnic disparities in birth outcomes using the life course perspective. The life course perspective conceptualizes birth outcomes as the end product of not only the nine months of pregnancy but the entire life course of the mother before the pregnancy. Disparities in birth outcomes, therefore, are the consequences of both differential exposures during pregnancy and differential developmental trajectories across the life span. Addressing Social Inequality Discussion The life course perspective synthesizes two longitudinal models: an early programming model and a cumulative pathways model.11,12 The early programming model posits that early life exposures influence future reproductive potential. For example, perinatal stress is associated with high stress reactivity that persists into adulthood.13–15,17,18 This, in turn, may be related to feedEthnicity & Disease, Volume 20, Winter 2010 back resistance from altered expression of glucocorticoid receptors in the developing brain.16 Exposure to stress hormones during sensitive periods of immune maturation in early life may also alter immune function, leading to increased susceptibility to infectious or inflammatory diseases later in life.19 Hypothetically, maternal stress during pregnancy could prime fetal neuroendocrine and immune systems with stress hormones, leading to higher stress reactivity and immune-inflammatory dysregulation that could increase a female offspring’s vulnerability for preterm labor and LBW later in life. Thus the increased risk of African American women to preterm birth and LBW may be traced to greater exposures to stress hormones during pregnancy, early life, and possibly even in utero. The cumulative pathways model proposes that chronic accommodation to stress results in wear and tear, or allostatic load,20 on the body’s adaptive systems, leading to declining health and function over time. Animals and humans subjected to chronic and repeated stress have elevated basal cortisol levels and exaggerated hypothalamic-pituitary-adrenal (HPA) response to natural or experimental stressors.21,22 This HPA hyperactivity may reflect the inability of a worn-out system for self-regulation, possibly due to loss of feedback inhibition via down-regulation of glucocorticoid receptors in the brain.21 Chronically elevated cortisol levels may also lead to immune suppression and immune-inflammatory dysregulation. 23 HPA hyperactivity and immune-inflammatory dysregulation are two of several possible mechanisms by which chronic and repeated stress over the life course may lead to increased vulnerability to preterm labor caused by stress or CLOSING GAP IN BIRTH OUTCOMES – Lu et al Table 1. A 12-point plan to close the Black-White gap in birth outcomes: A lifecourse approach 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Provide interconception care to women with prior adverse pregnancy outcomes Increase access to preconception care to African American women Improve the quality of prenatal care Expand healthcare access over the life course Strengthen father involvement in African American families Enhance coordination and integration of family support services Create reproductive social capital in African American communities Invest in community building and urban renewal Close the education gap Reduce poverty among African American families Support working mothers and families Undo racism infection. This model suggests the increased risk of African American women for preterm birth and LBW may be related to increased exposures to stress during pregnancy and possibly to increased weathering of stress over their life course, resulting in greater allostatic load which may already be present before pregnancy.24 The life course perspective suggests that closing the Black-White gap in birth outcomes requires more than improving access to prenatal care for African American women. From this perspective, it is not surprising that our national and state policies over the past two decades have not been more successful in closing the racial gap in birth outcomes. To expect prenatal care, in less than nine months, to reverse the lifelong, cumulative impact of social inequality on the health of African American mothers, may be expecting too much of prenatal care. Closing the racial gap in birth outcomes requires a life course approach, addressing both early life disadvantages and cumulative allostatic load.Addressing Social Inequality Discussion The purpose of this commentary is to propose this life course approach. We recognize we do not know all life course factors related to the disparities nor have all the answers to address them, but we believe we must do something. We present a platform of what we can do now – a 12-point plan building on previous work25 and a literature search for promising strategies. The 12 points are summarized in Table 1. The goals are to: 1) improve healthcare for African American women; 2) strengthen African American families and communities; and 3) address social and economic inequities that create a disproportionate toll on the health of African American women over their life course. This plan departs from current approaches to create a new paradigm for closing the racial/ethnic gap in birth outcomes. First, it goes beyond prenatal care and addresses healthcare needs of African American women from preconception to interconception and across the life course. Second, it goes beyond individual-level interventions and addresses family and community systems. Third, it goes beyond the medical model and addresses social and economic inequities that underlie much of health disparities. While a life course approach is needed to address health disparities in any community, we focus our discussion on its application in the African American community given the disproportionate burden of infant mortality and other poor maternal and child health (MCH) outcomes borne by that community. IMPROVING HEALTHCARE FOR AFRICAN AMERICAN WOMEN While health care alone cannot close the gap, it is a good place to start. Ethnicity & Disease, Volume 20, Winter 2010 Health care has a vital role, especially if provided over the woman’s life course, and not only during pregnancy. The right health care can promote positive development in early life and reduce cumulative allostatic load over the life course. Expanding access to interconception care, preconception care, quality prenatal care, and health care over the life course are important strategies in closing the racial gap in birth outcomes. Provide Interconception Care for Women with Prior Adverse Pregnancy Outcomes Interconception care allows for continuity of health care from one pregnancy to the next.26 Ideally interconception care should be provided to all women between pregnancies as part of comprehensive women’s health care. However, given resource constraints, it could be initially targeted to women with prior adverse pregnancy outcomes (ie, preterm birth, LBW, intrauterine growth restriction, fetal or infant death). Women with a poor pregnancy outcome are at substantial risk for having another poor pregnancy outcome.27,28 Many biobehavioral risk factors for preterm birth are carried from one pregnancy to the next. The interconception period offers an important window of opportunity for addressing these risk factors and optimizing women’s health before their next pregnancy. However, present access to health care in the interconception period is limited for many African American women, particularly low-income women whose pregnancy-related Medicaid coverage generally terminates at sixty days postpartum.26 African American women would benefit more from interconception programs given their greater risk from prior adverse pregnancy outcomes and less access to health care during the interconception period. There have been several interconception care demonstration projects, most notably programs in Atlanta, Denver, Jacksonville, Philadelphia, and S2-63 CLOSING GAP IN BIRTH OUTCOMES – Lu et al several Healthy Start sites.29,30 Since 2005,Addressing Social Inequality Discussion Healthy Start programs are required to include an interconception care component. The interconception care program in Denver was shown to reduce the risk of recurrent LBW births by one-third, though this finding must be interpreted with caution because of potential selection bias. Most interconception programs consist of four components: risk assessment, health promotion, medical and psychosocial interventions, and outreach and case management. The initial risk assessment should be comprehensive to detect factors associated with adverse birth outcomes, including expert review of medical records. Risk assessment should be on-going throughout the interconception period, and help guide development of an individualized care plan for health promotion and medical/psychosocial interventions. Core services should include family planning,31,32 screening for maternal depression and intimate partner violence, assessing social support for the pregnant woman, smoking cessation and substance treatment programs, physical activity and nutritional education and intervention, management of chronic diseases, and education on back-to-sleep and parenting skills. The individualized interconception care plan should also address known biobehavioral pathways to a particular outcome. For example, in preventing recurrent preterm birth, interventions should consider neuroendocrine, infectious-inflammatory, vascular, and behavioral pathways to recurrence.33 Potential strategies may include those that reduce chronic stress and increase social support, 34,35 decrease chronic infections, 36,37 restore immune allostasis,38,39 address vascular causes40 and improve health-promoting behaviors.41 Arguably, many interventions could be adopted on the basis of promoting women’s health alone, even in the absence of data on their effectiveness in preventing recurrence of adverse birth S2-64 outcomes.42,43 The program should be multi-level and include communitylevel interventions promoting interconception care. Interconception care programs could be funded through a Medicaid waiver, expansion of State Children’s Health Insurance Program (SCHIP) to cover adult family members, increased scope of services for Title X or state family planning programs, or direct funding from Title V or non-governmental sources. While more work is needed to explore financing, content, and cost-benefit of interconception care, it is an important first step to move us beyond current focus on prenatal care and toward a more expanded, longitudinally-integrated approach for addressing disparities in birth outcomes. Increase Access to Preconception Care for African American Women As with interconception care, the goal of preconception care is to restore allostasis and optimize women’s health prior to pregnancy. Many pathophysiologic processes leading to adverse pregnancy outcomes may have their onset early in pregnancy. For example, an infection associated with preterm delivery may be present in the urogenital tract before pregnancy.43 If it is not cleared by midgestation, preterm labor or preterm premature rupture of membranes may ensue. Screening for and treating bacterial vaginosis (BV) with antibiotics during pregnancy may be less effective in preventing preterm birth. This may partially explain the disappointing results of several antibiotic trials in pregnancy.44,45 Even if the infection is treated, it may be too late to stop immune-inflammatory processes.Addressing Social Inequality Discussion Preconception care provides an important opportunity to treat ongoing infection and restore immune allostasis. Most models of preconception care were developed with the primary aim of preventing congenital anomalies.46 Further research is needed to develop Ethnicity & Disease, Volume 20, Winter 2010 preconceptional strategies for preventing preterm births and LBW by addressing stress reduction, social support, immune response, chronic infections, inflammation, and behavioral and nutritional risk factors. Recruiting women into preconception care programs without a specific intervenable event and a targetable time period may be difficult.47 Targeting preconception care to couples actively planning a pregnancy will miss about half of all live births unintended at conception.48 Therefore, preconceptional health promotion and disease prevention should be integrated into a continuum of care throughout the life cycle.48 Every routine visit by any woman who may become pregnant at some time should be viewed as an opportunity to provide preconception care.49 Public health efforts should focus on increasing access to, setting standards for, and assuring quality of preconception care. Since Medicaid covers about half (51%) of African Americans with family incomes below the poverty level and 17% of those between 100% and 199% of the poverty level (near-poor),50 expanding Medicaid to cover preconception care could substantially increase access for low-income African American families. Another 15% of the poor and nearly half (48%) of the near-poor African Americans have job-based insurance;50 mandating or subsidizing job-based health insurance coverage of preconception care could further increase access. These expansions will still leave out three in ten African American women who are uninsured.50 Strategies must also consider how to provide preconceptional education and services to adolescents (eg, school-based clinics or family planning programs). The surest way to increase access to preconception care is through a national health insurance program which provides coverage for comprehensive women’s health care. More work is still needed to explore the financing, standards, and quality CLOSING GAP IN BIRTH OUTCOMES – Lu et al assurance for preconception care. In 2005, the Centers for Disease Control and Prevention (CDC) issued recommendations to improve preconception health and health care.51 These recommendations begin to lay out a roadmap toward universal preconception care in the United States. We believe ‘‘preconception care, focusing on women’s overall health … prior to pregnancy, will serve as a key component of the next wave of low-birthweight and infant mortality reduction strategies – and may provide increased savings beyond those experienced from prenatal care alone.’’52 We join the call for this nation to make ‘‘a commitment to advance preconceptional services to a similar extent as it has prenatal care.’’Addressing Social Inequality Discussion 52 Improve the Quality of Prenatal Care for African American Women The life course perspective sees prenatal care as vitally important, both as part of the continuum of health care for the mother, and as the starting point for the child’s developmental trajectory. It recognizes the potential contributions of prenatal care to optimal developmental programming of the baby’s vital organs and systems. For example, poor glycemic control in mothers with pregestational or gestational diabetes has been linked to suboptimal fetal development of pancreatic beta-cell structures and functions and greater adult susceptibility for insulin resistance and diabetes.53 By promoting optimal antenatal glycemic control, prenatal care may reduce intergenerational transmission of insulin resistance and diabetes. Thus prenatal care has an important role in closing the racial gap in not only birth outcomes but possibly in health and developmental outcomes over the life course and across generations. Over the past decade, the racial gap in access to prenatal care has been closing. Today nearly 95% of African American women access prenatal care at some point during pregnancy; three in four do so in the first trimester.3 However, little has been done to close the racial gap in the quality of prenatal care. More than one-third of US women reported receiving no advice on tobacco or other substance use during prenatal care.54 Black women were significantly less likely than White women to receive health behavior advice from prenatal care providers, and women who received insufficient health behavior advice were at higher risk of delivering a LBW infant.54,55 Other studies have documented similar racial gaps in the quality of prenatal care.56 Quality is also determined by the availability of services. Many ancillary services (eg, childbirth education classes, mental health or periodontal services, breastfeeding support), are often unavailable or in short supply in underresourced African American communities. 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