Earnestine Willis

Conquering Racial Disparities in Perinatal Outcomes

Infant mortality rate (IMR) is a reference indicator for societal health status. Trend analysis of IMR highlights 2 challenges to overcome in the United States: (1) US IMR is higher than most industrialized countries and (2) there are persistent racial/ethnic disparities in birth outcomes, especially for blacks. Racial/ethnic infant mortality disparities result from the complex interplay of adverse social, economic, and environmental exposures. In this article, racial/ethnic disparities are discussed, highlighting trends, the role of epigenetics in understanding mechanisms, key domains of community action planning, and programs and policies addressing the racial gaps in adverse birth outcomes.

High-Deductible Health Plans

High-deductible health plans (HDHPs) are insurance policies with higher deductibles than conventional plans. The Medicare Prescription Drug Improvement and Modernization Act of 2003 linked many HDHPs with tax-advantaged spending accounts. The 2010 Patient Protection and Affordable Care Act continues to provide for HDHPs in its lower-level plans on the health insurance marketplace and provides for them in employer-offered plans. HDHPs decrease the premium cost of insurance policies for purchasers and shift the risk of further payments to the individual subscriber. HDHPs reduce utilization and total medical costs, at least in the short term. Because HDHPs require out-of-pocket payment in the initial stages of care, primary care and other outpatient services as well as elective procedures are the services most affected, whereas higher-cost services in the health care system, incurred after the deductible is met, are unaffected. HDHPs promote adverse selection because healthier and wealthier patients tend to opt out of conventional plans in favor of HDHPs. Because the ill pay more than the healthy under HDHPs, families with children with special health care needs bear an increased cost burden in this model. HDHPs discourage use of nonpreventive primary care and thus are at odds with most recommendations for improving the organization of health care, which focus on strengthening primary care. This policy statement provides background information on HDHPs, discusses the implications for families and pediatric care providers, and suggests courses of action.

Workplace Lactation Support in Milwaukee County 5 Years After the Affordable Care Act

Background: Workplace lactation support has become increasingly important because returning to work is associated with discontinuing breastfeeding and women in the workforce are increasing. Research aim: This study examined workplace lactation support among Milwaukee County businesses 5 years after implementation of the Affordable Care Act’s Break Time for Nursing Mothers provision. Methods: A cross-sectional survey of Milwaukee County businesses was conducted in the summer of 2015 that inquired about workplace policies, lactation spaces, and other lactation resources offered. Business supports were stratified based on employer sizes: large (> 500 employees), medium (50-499 employees), and small (20-49 employees). A lactation amenity score was calculated for each business based on lactation resources available. Results: Three hundred surveys were distributed and 71 businesses voluntarily completed the survey. Small employers were excluded from statistical analysis due to fewer responses (n = 8). Overall, 87.3% (n = 55) of respondents reported providing access to a multiuser space for lactation and 65.1% (n = 41) reported providing a designated lactation space. Large employers (n = 30) were more likely than medium employers (n = 33) to provide a designated lactation space for breastfeeding or expressing (86.7% vs. 45.5%, p < .001). Large employers’ mean amenity score was significantly higher than that of medium employers (3.37 vs. 2.57, p = .014), and they were also more likely to offer additional supports including access to a lactation consultant, classes, and materials (46.7% vs. 12.1%, p < .01). Conclusion: Large employers provide more lactation support than medium employers in Milwaukee County. All employers, regardless of size, need to increase additional lactation support for women in the workplace.

Guiding Principles for Managed Care Arrangements for the Health Care of Newborns, Infants, Children, Adolescents, and Young Adults

By including the precepts of primary care and the medical home in the delivery of services, managed care can be effective in increasing access to a full range of health care services and clinicians. A carefully designed and administered managed care plan can minimize patient under- and overutilization of services, as well as enhance quality of care. Therefore, the American Academy of Pediatrics urges the use of the key principles outlined in this statement in designing and implementing managed care programs for newborns, infants, children, adolescents, and young adults to maximize the positive potential of managed care for pediatrics. These principles include the following:

Wisconsin's Welfare Reform and Its Potential Effects on the Health of Children

Wisconsin, like many other states seeking increased state flexibility in federalized programs, is in the midst of a bold welfare reform initiative entitled Wisconsin Works (W-2), which was signed into law on April 25, 1996. This study reviews the states transition from the existing welfare program to one in which participants are required to work. The primary concerns with this new system are the potential consequences of higher poverty status and worsening health status among children. As details of W-2 are clarified, government benefits for children, such as child care and health care, need to be protected and/or enhanced. Close scrutiny is warranted to avert severe consequences in these areas as well as in family-supporting wages. The authors suggest that in monitoring W-2, several important principles should be considered to ensure that families become financially independent and able to maintain secure lifestyles for their children.

Commentary on Workplace Lactation-Support

Breastfeeding and the use of human milk provide infants with unique benefits that are both nutritional and non-nutritional. The literature supports that infants who are breastfed have a reduced risk of otitis media, gastrointestinal infections, lower respiratory infections, asthma, childhood leukaemia, diabetes and obesity

Improving Immunization Rates Through Community-Based Participatory Research: Community Health Improvement for Milwaukee's Children Program

Background: Nationally, immunization coverage for the DTaP/3HPV/1MMR/3HepB/3Hib/1VZV antigen series in children ages 19–35 months are near or above the Healthy People 2020 target (80%). However, children in lower socioeconomic families experience lower coverage rates.Objective: Using a community-based participatory research (CBPR) approach, Community Health Improvement for Milwaukee Children (CHIMC) intervened to reduce disparities in childhood immunizations.Methods: The CHIMC adopted a self-assessment to examine the effectiveness of adhering to CBPR principles. Using behavior change models, CHIMC implemented education, social marketing campaign, and theory of planned behavior interventions. Community residents and organizational representatives vetted all processes, messages, and data collection tools.Results: Adherence to the principles of CBPR was consistently positive over the 8-year period. CHIMC enrolled 565 parents/caregivers with 1,533 children into educational and planned behavior change (PBC) interventions, and enrolled another 406 surveyed for the social marketing campaign. Retention rate was high (80%) with participants being predominately Black females (90%) and the unemployed (64%); children’s median age was 6.2 years. Increased knowledge about immunizations was consistently observed among parents/caregivers. Social marketing data revealed high recognition (85%) of the community-developed message (“Take Control: Protect Your Child with Immunizations”). Barriers and facilitators to immunize children revealed protective factors positively correlated with up-to-date (UTD) status (p < 0.007). Ultimately, children between the ages of 19 and 35 months whose parents/caregivers completed education sessions and benefitted from a community-wide social marketing message increased their immunization status from 45% baseline to 82% over 4 years.Conclusions: Using multilayered interventions, CHIMC contributed to the elimination of immunization disparities in children. A culturally tailored CBPR approach is effective to eliminate immunization disparities.

Field methods for discovering practical wisdom: the microdynamics of going beyond technical rationality in real-world practice.

Practical wisdom is essential to occupational and professional practice. However, the emphasis on technical rationality in these domains neglects the necessity of practical wisdom in doing specialized, skilled work. Microdynamic methods for analyzing social action enabled the discovery and examination of practical wisdom in two interactional episodes from community health work. Practical wisdom was found in specific acts: in adaptation to and interpretation of logical forces and interactional rules of these acts; and in deliberation among choices to reach intended outcomes. Cultivating skills in microdynamic methods for finding and analyzing practical wisdom is an essential tool for practitioners and organizations.