Appendix A - Additional tier 1 strategies supported by coalition members
Additional Tier 1 Strategies Supported by Members of the Coalition: Addressing Socio-Economic Factors
D. Increase provider knowledge of community resources addressing social needs (housing, food, mental health, childcare, transportation).
E. Identify and implement strategies aimed at reducing/eliminating institutional racism.
F. Create supportive housing initiatives for pregnant women and their families.
G. Integrate financial literacy into family planning and counseling services, as well as in other relevant programs serving MCH populations.
Strategy 1D: Increase provider knowledge of community resources addressing social needs (housing, food, childcare, legal aid, and transportation.)
Clinical providers recognize the importance of patients’ social needs and often identify their interactions within the clinical setting as an opportunity to address them. Too often, because of system-related issues such as time constraints, billing considerations, staffing issues, or lack of knowledge of available resources, this opportunity becomes a missed one.8,10 Coalition members have raised the need to identify promising strategies to provide holistic care that also addresses patients’ socio-economic needs, building on, enhancing, and optimizing existing resources such as the 2-1-1 Connecticut service.
Strategy 1D: Examples from the ground
Since 1991, via a contract with the Department of Public Health, 2-1-1 CT has been serving as the federally mandated access point for the state’s MCH population. Anyone can dial 2-1-1, 24 hours a day 7 days a week, or search the online 2-1-1 database that features over 4,600 agencies, providing 48,000 programs and services organized by location, service category, or agency. Specialized directories, including one specifically developed for the Coalition to Improve Birth Outcomes provides in-depth information and resources specific to concerns commonly faced by women, children and their families. The 2-1-1 system includes specialized call centers including 2-1-1 Child Care, which is a free, confidential, and statewide service that helps match the requests of parents with child care providers and programs. Child Care Referral Specialists help parents learn about options in their community and understand what to look for in selecting a quality child care arrangement. Child Development Infoline (CDI) is another specialized 2-1-1 call center. CDI care coordinators provide education on development, behavior management strategies and programs, make referrals to services, and provide advocacy and follow-up as needed. The CDI call center also serves as an access point for information on and referrals to home visiting programs for pregnant women and young children.
Taking the traditional database concept of the 2-1-1 service, Healthy City of California harnesses the power of Geographic Information System (GIS) technology, public datasets, and social connectivity tools to empower communities to not only access information of available resources and services, but also to participate in Community Based Participatory Action Research (CBPAR) to “build a better community.” Connecticut residents and practitioners can find a similar tool in the Connecticut
Nonprofit Strategy Platform website.
Currently operating in clinics and hospitals in a handful of major cities in the US, the HealthLeads model partners trained college student advocates with clinical providers to ensure the writing and fulfillment of prescriptions for patients’ basic needs, such as shelter, food, and heat. The model allows healthcare organizations to provide a valuable service to its patient base through a cost-contained mechanism that, on the other hand, invests in youth wishing to develop valuable experience in the social services and healthcare fields.
Medical-Legal Partnerships (MLPs)
MLPs place lawyers and paralegals at healthcare institutions to help patients address legal issues and social policies that are linked to poor health outcomes, such as income supports and insurance, personal and family stability, legal status, education and employment, and housing and utilities. For many patients, MLPs can provide much needed guidance and assistance in cases involving complicated bureaucracies, unenforced laws, and wrongfully denied benefits and rights. To learn more about which MLPs exist in Connecticut, click here.
Listing of Organizations on the Connecticut Coalition to Improve Birth Outcomes
The Connecticut Coalition to Improve Birth Outcomes at Work: Using policy analysis tools to identify priorities and recommendations
Tier 1 - Addressing Socio-Economic Factors to Improve Birth Outcomes in Connecticut
Tier 2 - Changing the Context: Improving health outcomes by making healthy choices the easy choice
Tier 4 - Ongoing Clinical Interventions: Evidence-based interventions within clinical settings
Tier 5 - Education and Counseling: Individual or public educational messages and support
Strategy 1E: Identify and implement strategies aimed at reducing/eliminating institutionalized racism.
Informed by increasing research surrounding experienced discrimination and negative birth outcomes,105,106 members of the Coalition acknowledge the need to further identify and invest in emerging and best practices for the elimination of racism in our communities. Racism is a complex and insidious phenomenon, very well explained in Dr. Camara Jones’ allegory of the Gardener’s Tale , which conveys the multi-level nature of racism in our society (i.e. institutionalized racism, personally-mediated racism, and internalized racism.) Scholars of the intersection between racism and health outcomes purport that institutionalized racism (a.k.a. structural racism) significantly compounds the effect of poverty, perpetuating segregation, chronic stress, and disparities.
Strategy 1E: Examples from the ground
New Haven Action Learning Collaborative - Supported by the Partnership to Eliminate Disparities in Infant Mortality (PEDIM), the State of Connecticut was able to begin efforts to explore issues tied to racism in our state, and more specifically within the Greater New Haven area. Members from other Action Learning Collaborative (ALC) groups around the nation, shared valuable lessons learned and tools created as a result of the process. One such tool may be useful for local coalitions, organizations, and groups planning to move forward with initiatives aimed at reducing and eliminating racism: Exercises for Team-Building and Community Action Planning: A Toolkit for MCH Leaders Addressing Racism's Impacts on Infant Mortality.
The Center for Health Equity and Social Justice - This Boston-based center, combines the efforts of the REACH Coalition and the Office of Healthy Equity to expand its impact in achieving health and racial equity in the City of Boston (MA), through the promotion of community mobilization, community-based participatory research, program development and evaluation.
The W.K. Kellogg Foundation has been a leader in funding initiatives aimed at healing racial inequities and eradicating institutionalized racism.
Black Males Achievement Data Dashboard
The Institute for Black Male Achievement (IBMA) is committed to tackling long-standing systemic barriers to black male achievement so all black boys and men have equal opportunity to lead successful and meaningful lives. The IBMA provides capacity building support and resources to the many organizations belonging to its national network. It has also recently unveiled the Black Male Achievement Data Dashboard which features 17 indicators that track measures of opportunity for black men over the course of their lives, often highlighting striking disparities and providing a data-driven launching pad for action aimed at tackling systemic barriers. While no communities in Connecticut are currently included in this dashboard, it may be worthwhile exploring opportunities to expand the dashboard’s reach to include large urban centers in our state to help propel Connecticut’s concerted efforts to eliminate institutionalized racism affecting families of color.
Strategy 1F: Create supportive housing initiatives for pregnant women and their families.
Homelessness often occurs in conjunction with experiences of violence, poor nutrition, adverse mental health, substance use, and prior trauma, placing homeless pregnant women at particularly increased risk for physiologic and psychological stress, impacting overall health outcomes. Homelessness alone has been documented as being independently associated with poor perinatal health outcomes, including preterm birth and low birth weight.107 Studies concerned with substance use by pregnant women have shown higher treatment success rates in domiciled women, compared to homeless women, and therefore advocate for housing needs to be addressed as part of effective comprehensive treatment approaches.108
Unstable housing during pregnancy has also been associated with reduced rates of compliance with the recommended postpartum visit, which usually occurs four to six weeks postpartum and is often used to evaluate a mother’s overall physical and mental wellbeing as well as to initiate a family planning method.109 Housing insecurity is also associated with lower rates of breastfeeding initiation and continuation, suboptimal compliance with well-baby checkups, and higher rates of asthma and chronic health conditions that extend throughout childhood and adult life.110
Strategy 2F: Examples from the ground
Healthy Start in Housing (HSiH)
Implemented in Boston (MA) HSiH is an innovative program that seeks to use housing as a strategy to improve birth outcomes among populations disproportionately affected by socio-economic risk factors.110 Through a collaboration of non-traditional partners with seemingly different missions, the Boston Housing Authority and the Boston Public Health Commission were able to prioritize placement of pregnant women in supportive housing that provided stable shelter as well as ongoing case management and support from Healthy Start staff. Preliminary evaluation results indicate significant improvements in maternal physical and mental health.111
Strategy 1G: Integrate financial literacy into family planning and counseling services, as well as in other relevant programs serving MCH populations.
In keeping with the Coalition’s focus on improving social determinants of health, as a means of improving birth outcomes, innovative cross-sector approaches are needed to reach the population of interest and address inequities. One such approach, is the integration of strategies addressing poverty reduction, with wrap-around services targeting MCH populations (i.e. home visiting, family planning, WIC, etc.) While funding sources and logistical considerations may need to be restructured to allow for non-traditional MCH services to be integrated into MCH programs, the colocation of such services allows for a more streamlined and non-duplicative approach. Promising examples of such approaches have shown that colocation and integration of such services can more effectively reach families, while reducing the burden on families who selectively choose to engage with supportive systems and programs, given their limited time and resources. This planned integration can also serve as a way to advance research about the effectiveness of novel approaches addressing social determinants of health, while also more explicitly educating stakeholders about the connection between income inequality, poverty, and health outcomes.
Strategy 1G: Examples from the ground
Building Economic Security Today (B.E.S.T.)
Partnering with a local home visiting service and the Women, Infants, and Children (WIC) program, the Contra Costa Family, Maternal and Child Health (FMCH) Programs Life Course Initiative implemented a program focused on family financial literacy as a way to improve birth outcomes and family health.112 Program evaluation results showed that clients increased their awareness of financial issues, as well as their confidence in regards to their ability to improve their financial situations. A welcomed unintended consequence of the program was also an increase in knowledge about community financial resources among program staff. WIC and FMCH staff members valued the opportunity to engage in non-traditional, cross-sector partnerships to address clients’ pressing social determinants of health.112 The referenced article also shares lessons learned in terms of actual implementation logistics.