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Haitian Prenatal Health Education

State: FL Type: Promising Practice Year: 2018

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Florida Department of Health in Collier County
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Haitian Prenatal Health Education
LHD-location, demographics of population served in your community: Collier County is in the southern end of Florida's Gulf Coast. Located in the southwest portion of the state, Collier County is the largest county in Florida by land area and second largest by total area. Collier County is comprised of the Naples-Immokalee-Marco Island, FL Metropolitan Statistical Area. According to the U.S. Census Bureau, the population estimates as of July 1, 2016 is 365,136. The white alone population estimate is 89.5% and make up the majority racial group, while the 7.3% Black or African Americans alone make up the minority. Collier County is comprised of 27.0% from Hispanic origin. Naples-Immokalee-Marco Island, FL Metropolitan Area has the 7th highest immigrant population in the country from Haiti with 10,000 and 3rd highest in Florida equivalent to 3% of Metro Area Population (Source: MPI tabulation of data from the U.S Census Bureaus pooled 2011-2015 ACS). Public Health Issue: Infant Mortality Rate (IMR) is defined as the number of infant deaths under 1 year of age per 1000 live births. The Center for Disease Control and Prevention acknowledges the sensitivity of infant mortality as not only an indicator for maternal and infant health but also an indicator for the overall health of a community. In Collier County, the problem of health disparities among birth outcomes was identified as the highest for the Haitian population. Comparing to all ethnic groups, the average Haitian Infant Mortality Rate is significantly higher compared with Hispanics and Non-Hispanics/Non-Haitians. On average, Haitians have almost twice the percentage of low birth weight (less than 2500 grams) babies as Hispanics. Goals/Objectives: To address the public health issue of health disparities among birth outcomes, the Florida Department of Health-Collier determined the goal to initiate a project focused on the development and implementation of a pregnancy health program geared specifically to the Haitian population in their native language of Creole. The program focuses on early entry and maintenance of prenatal care, informing Haitian women on prenatal/postnatal education and safe newborn practices. Objective 1: Design and implement tailor made classes to the Haitian population addressing cultural myths utilized among this group of prenatal women. Objective 2: Develop and foster community partnerships and intradepartmental collaboration and track participant recruitment strategies. Objective 3: Implement format and recruitment modification based on initial evaluation outcomes. Results/Outcomes: The program has been successful and process milestones were all met. Classes were designed for various prenatal topics in Creole including: importance of prenatal care, nutrition, preterm labor, childbirth, breastfeeding, safe sleep, shaken baby prevention, family planning and post-partum care (Objective 1). Partnerships were developed among local Ob-Gyn offices, local coalitions and a collaboration with Healthy Start and Women, Infant and Children (WIC) programs was initiated (Objective 2). The initial participation rate was lower than expected but after recruitment modifications, class participation was tripled and participant retention increased (Objective 3). The specific factors which led to the success of this practice included understanding the mistrust of the medical community, utilizing Haitian Health Educators and Haitian Certified Community Health Workers in the design and implementation of the program. Program modification based on participant evaluation and honing in on recruitment strategies contributed greatly to the success of the program. This program was successful based on the feasibility of the program implementation and resulting increased recruitment and retention outcomes. Public Health Impact: Providing education to the Haitian Prenatal population directly provides an increase in knowledge on the topics discussed. By educating the target population we have seen the infant mortality of the Haitian population have the lowest rate in the past 10 years of 3.3% per 1000 live births (2016). There has also been small successes in the low birth weight and very low birth weight categories. (Websites: http://collier.floridahealth.gov/index.html, https://www.census.gov/quickfacts/fact/table/colliercountyflorida/PST045216, https://www.migrationpolicy.org/article/haitian-immigrants-united-states, http://www.flhealthcharts.com/charts/default.aspx)
The infant mortality rate or the number of infant deaths before their first birthday for every 1,000 live births are influenced by factors such as socioeconomic, education as well as racial and ethnic disparities. An analysis of a ten-year period from 2006 to 2015 allowed for a time series or trend analysis of the present situation and the recent past of infant mortality and low birth weight rates of all ethnic groups including Haitian, Hispanics and Non-Haitian/Non-Hispanics. Collier County has significantly higher rates of infant mortality among the black racial group more specifically those of the Haitian ethnicity. Although the overall trend for the infant mortality rate even among Haitians is on a declining slope, it is still at a much higher level than any other ethnic groups. When analyzing low birth weight by ethnicity from 2006 to 2015, on average Haitians have almost twice the percentage of low birth weights of live births as Hispanics. According to the U.S. Census Bureau, populations estimate of Collier County as of July 1, 2016 was 365,136. The white alone population is 89.5% of the total population. The black or African American alone is7.3% of the total population. During the period 1994 and 2014, the black population increased by 152%, propelled mostly by Haitian Immigration. Collier County's population is comprised of 27% from Hispanic origin. When looking at the top concentrations by Metropolitan Area for Foreign Born from Haiti, 2011-2015, the Naples-Immokalee-Marco Island, FL Metropolitan Area has the 7th highest immigrant population from Haiti in the country with 10,000 which is equivalent to 3.0% of the Metro Area Population. At the end of 2014, two classes were conducted and considered a pre-phase cohort of the Haitian Prenatal Parenting Classes. The services provided were 11. (Services are defined as total number of participants in all classes-which includes not only the pregnant participant but also spouses, partners and grandparents.). The following year of 2015, designated as Cohort 1, had a total of 26 services provided. Cohort 2 in 2016 the number of services provided were tripled to 83. As of date in Cohort 3-2017, services provided more than tripled from the previous year with 289 services. Previously, no programs existed to address the public health disparity of the infant mortality rate of the Haitian ethnic group. When investigating and researching for programs targeting the prenatal Haitian population in Florida as well as the United States, very little to no information was found. This practice is a tremendous improvement to reaching the Haitian population of Collier County due to it being non-existent in years prior. The Haitian Prenatal Parenting Program fit the definition of innovation in its entirety. The Haitian Prenatal Parenting Program is a creative solution which has allowed us to manage our resources wisely. The team is committed to success motivated by the needs of the Haitian community. After analyzing the data and making observations from the field, cultural myths practiced by Haitian immigrants and lack of prenatal health education pointed to the direct need for classes created in the native language of Creole for this target population. This innovative Haitian Prenatal Parenting Program aligns directly with the following Healthy People 2020 objectives of the Maternal, Infant and Child Health Section: MICH-1.3-Reduce the rate of all infant death(within 1 year), (also a Leading Health Indicator(LHI) subset of Healthy People 2020 objectives selected to communicate high priority health issues), MICH-8-Reduce low birth weight (LBW) and very low birthweight(VLBW), MICH-9-Reduce Preterm births, MICH-10-Increase the proportion of pregnant women who receive early and adequate prenatal care, MICH-20-Increase the proportion of infants who are put to sleep on their backs, MICH-21-Increase the proportion infants who are breastfed, and MICH-28-Reduce the occurrence of neural tube defects. The Healthy People 2020 objectives (as stated above) are embedded in the foundation of the Haitian Prenatal Parenting Program. The classes are interactive and include: PowerPoint presentations, demonstration, hands-on activities and videos. The curriculum incorporates evidence based resources recommended by Healthy People 202 from the U.S. Preventive Services Task Force (USPSTF). The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding (B recommendation). Also, USPSTF recommends that all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg of folic acid (A recommendation). (Sources: https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives, https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations/, http://www.flhealthcharts.com/charts/default.aspx )
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The goal of the Florida Department of Health-Collier was to develop and implement a pregnancy health education program tailored to the target population in their native language of Creole. The program has a direct impact on the public health issue of health disparities among birth outcomes. Objective 1: Design and implement tailor made classes for the Haitian ethnic group. The class topics include: importance of prenatal care, nutrition, preterm labor, childbirth, breastfeeding safe sleep, shaken baby prevention, family planning and post-partum care. Just as the world of public health is ever changing and evolving so are the topics of our class. We most recently added Zika education to the program as this infectious disease has directly impacted both Florida and Haiti. Haitian Health Educators and Certified Community Health Workers (CCHW) were instrumental in the program design. The program considers cultural sensitivity along with addressing cultural myths of Haitian migrants. Objective 2: Develop and foster community partnerships, nurture intradepartmental collaborations and track participant recruitment strategies. Key stakeholders include local obstetricians/gynecologist (OB/GYN) offices and local coalitions whose partners center around early childhood initiatives. These stakeholders come into direct contact and serve our target population. They are the boots on the ground and come in direct contact daily with those we want to reach. Likewise, the intradepartmental collaborations with Healthy Start and Women, Infant and Children (WIC) programs were a natural fit serving the Haitian women and families of Collier County. All stakeholders and collaborators are invaluable to the success of the program. Objective 3: Implement format and recruitment modifications based on initial evaluation outcomes. The only criteria needed to participate in this practice is for the participants to be of Haitian descent. We strongly encouraged participation from not only pregnant and parenting Haitian women but also spouses, fathers, and grandparents. This is an ongoing practice at Florida Department of Health-Collier and will continue implementation as long as the need for the program exists. In, March 2016, …the Florida Department of Health designated $1.4 million in funding for Florida's Healthy Babies, a collaborative statewide initiative to positively influence social determinants and reduce racial disparity in infant mortality.”. Florida's 67 counties were each provided with 10,000 to focus on this initiative. The Florida department of Health-Collier used the $10,000 to supplement staff salary of those who are diligently working on this practice. The Healthy Babies funding of $10,000 was renewed for 2017 and will continue through 2018. (Source: http://www.floridahealth.gov/newsroom/2016/03/031016-healthy-babies.html)
This practice has informed Florida Department of Health-Collier of the cultural/traditional practices and health beliefs associated with prenatal, postnatal and infant care that are still being utilized by the most recent Haitian immigrants. Although the mistrust of the medical community continues to exist, since the inception of the program in 2014, great strives have been made to build trust in the Haitian community. Trust is beginning establishment as the team demonstrates consistent effort to continually care about the health of the Haitian community. Prior to the initiation of the Haitian Prenatal Parenting Program, no program existed to educate, inform and empower the Haitian population in their native language of Creole on safe and healthy prenatal and newborn practices, along with dispelling cultural myths. The implementation process has been continually evaluated by both the program team as well as class participants. Objective 1: Design and implement tailor made classes to the Haitian population addressing prenatal/postnatal education, safe newborn practices and cultural myths was successfully achieved in conjunction with the first portion of Objective 3: Implement format modifications. It is important to note that major program improvements were from the feedback of class participants. In the pre-phase Cohort and Cohort 1, suggestions were made on the evaluations to shorten the class timeframe. At the time, the class covered multiple topics over a morning and afternoon session with a lunch break. The participants recommended shorter classes with few topics covered at each session. The classes are now taught three times a month with topics rotating each week. This lead to the knowledge of transportation not being as big of a barrier as initially understood, as evidenced by the drastic increase in total services per calendar year from 26 in Cohort 1 (2015) to 289 thus far in Cohort 3 (2017 with one class remaining for the year) and the increase in retention of class participants. Objective 2: Develop and foster community partnerships and intradepartmental collaborations and track participant recruitment strategies was successfully achieved in conjunction with the second portion of Objective 3: implement recruitment modifications based on initial evaluation outcomes. From its inception data is collected from each participant on how they heard about the class, the data was used to track recruitment trends. This lead to the continual development and fostering of relationships with community partners and intradepartmental programs. The modifications made were to not only tell their respective patients or clients about the program and hang flyers around the office or patient rooms but to give each Haitian patient or client a flyer, discuss the benefits of the class and ask for contact information if they would like to receive reminder telephone calls. This collaboration has been vital to the growth and success of the practice. Each participant is given a pre and post survey which consistently demonstrate an overall increase in knowledge. The survey results are also a form of evaluation as it signals to the team which topics need additional emphasis or a different delivery approach. FL Health Charts is the primary source of data for infant mortality rates and low birth weight (<2500 grams) rates. The 2016 Haitian infant mortality rate of 3.3% per 1000 live births was the lowest it has been in the past 10 years. Long term results will take time to manifest and the team hopes to see the health disparity gap of birth outcomes decreased. (Source: http://www.flhealthcharts.com/charts/default.aspx)
The program is sustainable in multiple facets. The team has created a program manual which contains the class material in Creole and English. The manual serves several purposes, in the event of staff turnover the program can continue utilizing the manual. We are also in the process of developing class videos which will further create sustainability. The manual is also designed to allow the program to be replicated in other counties which serve the Haitian population. This practice would be easily replicated by other areas dues to the simplicity of the program design and common interest of the stakeholders. The cost savings for the lives of babies in our community are priceless. The March of Dimes Perinatal Data Center states, The medical and social services that are required by low birth and very low birth weight infants are significant and the costs are high to society and the American taxpayer. Those babies that survive the first year incur medical bills averaging $93,800. (Rogowski). The stakeholders are devoted in sustaining the practice due to the vested interest in reducing the disparity gap of birth outcomes in this specific population. The program participants are ultimately the patients or clients of the stakeholders and collaborators, and everyone at the table is motivated to improve the birth outcomes of not only this pregnancy but future pregnancies. The most significant lessons learned in relation to partner collaboration was the consistent personal invitation from staff in their respective agencies. The staff would take the time to not only put a flyer in the hand of each individual patient or client but discuss with them the benefits of attending a class designed with them in mind. The Florida Department of Health-Collier is committed to sustain this practice as long as the disparity exists among the Haitian population, under the auspice of the Department are Healthy Start and WIC programs. The local Ob-Gyns and coalitions are committed to the improved long-term outcomes of this practice. Stakeholders will continue to communicate monthly about class updates, trends and feedback from patients and clients and stakeholders are committed to having a minimum of one designated contact person for their office or program. (Source: March of Dimes Perinatal Data Center. Rogowski, J. (1998) Cost-effectiveness of Care for Very Low Birthweight Infants. Pediatrics 012(1):35-43.)
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