African American and Latino patient versus provider perceptions of determinants of prenatal care initiation.

Few studies have compared provider and patient perceptions of barriers, motivators and facilitators of prenatal care (PNC) initiation. The current study compared these perceptions in providers and patients in Washington, DC, a city characterized by infant mortality and low birth weight rates that are among the highest in the nation, and poor utilization of PNC, particularly among minority groups. The results reported here were part of a larger study of barriers, motivators and facilitators influencing PNC utilization in Washington, DC. A convenience sample of 331 African American and Latino patients and 61 providers were interviewed to identify which of 63 motivators, facilitators, and barriers significantly influenced PNC initiation. Both sample groups were recruited at 14 PNC facilities, selected to represent all sites in DC known to serve high-risk, low-income minority women, including hospital-based clinics, community-based clinics, and private practices. Data were analyzed using Fisher exact tests and Kendall's concordance tests. Results indicated that there was good agreement between patients and providers about the relative importance of the various barriers (especially psychosocial), motivators, and facilitators. However, differences were found between patients and providers in the response frequencies. Providers were more likely to report barriers while patients were more likely to report certain motivators (especially learning better health habits and how to protect health). These results indicate that despite widespread agreement on most issues, especially psychosocial barriers, patients rated health education higher than providers.

Adapting evidence-based strategies to increase physical activity among African Americans, Hispanics, Hmong, and Native Hawaiians: a social marketing approach.

INTRODUCTION: Using a social marketing approach, we studied how best to adapt proven, evidence-based strategies to increase physical activity for use with underserved racial or ethnic groups. METHODS: We conducted focus groups with low-income Hispanic women in Texas, Hmong parents and their children in California, low-income African American women and men in the Mississippi Delta, and Native Hawaiian college students in Hawaii. We also interviewed key leaders of these communities. Topics of discussion were participants' perceptions about 1) the benefits of engaging in physical activity, 2) the proposed evidence-based strategies for increasing each community's level of physical activity, and 3) the benefits and barriers to following the proposed interventions for increasing physical activity. A total of 292 individuals participated in the study. RESULTS: All groups considered that being physically active was part of their culture, and participants found culturally relevant suggestions for physical activities appealing. Overwhelmingly, strategies that aimed to create or improve social support and increase access to physical activity venues received the most positive feedback from all groups. Barriers to physical activity were not culturally specific; they are common to all underserved people (lack of time, transportation, access, neighborhood safety, or economic resources). CONCLUSION: Results indicate that evidence-based strategies to increase physical activity need to be adapted for cultural relevance for each racial or ethnic group. Our research shows that members of four underserved populations are likely to respond to strategies that increase social support for physical activity and improve access to venues where they can be physically active. Further research is needed to test how to implement such strategies in ways that are embraced by community members.

Determinants of inadequate prenatal care utilization by African American women.

A convenience sample of city-dwelling African American women (n=246) was interviewed during each woman's postpartum stay at one of five hospitals in Washington, D.C. to determine their perceptions of factors influencing their prenatal care utilization. The Kotelchuck Adequacy of Prenatal Care Utilization Index was used to classify prenatal care utilization as either adequate (Adequate Plus and Adequate groups combined) or inadequate (Intermediate and Inadequate groups combined). Of the 246 women studied, 40% (99) had adequate prenatal care utilization. Using Classification and Regression Trees analysis, the following risk groups for inadequate prenatal care utilization were identified: women who reported psychosocial problems as barriers and who were not participants in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) (percent adequate=8.8); women who reported psychosocial problems as barriers, were participants of the WIC program, and reported substance use (percent adequate=13.8); and women who reported psychosocial problems as barriers, were participants of the WIC program, denied substance use, and reported childcare problems as barriers (percent adequate=20.0).

Determinants of late prenatal care initiation by African American women in Washington, DC.

OBJECTIVES: The objective of this study was to identify the determinants of late prenatal care (PNC) initiation among minority women in Washington, DC. METHODS: DC-resident, African American women (n = 303) were recruited at 14 PNC facilities, representing the various types of PNC facilities located in DC: 4 hospital-based clinics, 5 community-based clinics, and 5 private practices. The women were interviewed at their first prenatal care visits to determine their perceptions of 63 barriers, motivators and facilitators influencing PNC initiation; substance use; and sociodemographic background. PNC initiation was classified as early (prior to the 20th week of gestation) or late (after the 20th week of gestation). The responses of women who initiated PNC early versus late were compared using bivariate and multivariate statistical procedures. Classification and Regression Trees analysis was used to identify groups at risk of late initiation. RESULTS: Variables contributing to late PNC initiation included maternal age not between 20 and 29 years, unemployment, no history of previous abortions, consideration of abortion, lack of money to pay for PNC, and no motivation to learn how to protect ones health. Three risk groups for late PNC initiation included 1) women consideringabortion and not employed outside their homes; 2) women not considering abortion who had no previous abortion experience; and 3) teenagers not considering abortion and with no previous abortions. CONCLUSIONS: The results of this study indicate that psychosocial barriers are more important than structural barriers. Of the psychosocial barriers, the major determinants of late PNC initiation were consideration of abortion and previous abortion experience.

The effect of a parenting education program on the use of preventive pediatric health care services among low-income, minority mothers: a randomized, controlled study.

OBJECTIVE: To determine if a community-based intervention program focusing on parenting education will have an impact on preventive health care utilization behaviors among low-income, minority mothers in Washington, DC. DESIGN: The experimental design was a randomized, controlled study in which 286 mother-infant dyads were assigned to either the standard social services (control) group or to the intervention group. Women and their newborn infants were recruited during the immediate postpartum period in 4 Washington, DC, hospital sites from April 1995 to April 1997. The year-long multicomponent intervention included home visits and hospital-based group sessions in addition to the standard social services available at the hospital sites. A total of 286 postpartum women with inadequate prenatal care were assigned randomly to the control or the intervention group. Women and their infants were followed for 1 full year. Outcome measures included usage of preventive health care services including well care infant visits and adherence to immunization schedules during the first year of the infant's life. RESULTS: Infants in the intervention group initiated well care at an earlier age than controls (by 6 weeks, 62.5% vs 50% had received their first well infant visit). Infants in the intervention group had more frequent well visits (by 12 months of age, 3.5 vs 2.7 visits). Multivariate analyses showed infants in the intervention group to be more likely to complete their scheduled immunizations (by 9 months, odds ratio = 2.2, 95% confidence interval: 1.09-4.53). Those in the intervention group with more frequent contacts (30+ visits) with study personnel were most likely to have followed age-appropriate immunization schedules when compared with controls (at 9 months odds ratio = 3.63, 95% confidence interval: 1.58-8.33). CONCLUSIONS: It is possible to influence health care usage patterns of high-risk minority populations through public health interventions that are global in their perspective. Focusing on parental knowledge and beliefs regarding health-related issues and life skills in a self-efficacy model is associated with improved usage of infant health care resources.

Perceptions about prenatal care: views of urban vulnerable groups.

BACKGROUND: In the United States, infant mortality rates remain more than twice as high for African Americans as compared to other racial groups. Lack of adherence to prenatal care schedules in vulnerable, hard to reach, urban, poor women is associated with high infant mortality, particularly for women who abuse substances, are homeless, or live in communities having high poverty and high infant mortality. This issue is of concern to the women, their partners, and members of their communities. Because they are not part of the system, these womens' views are often not included in other studies. METHODS: This qualitative study used focus groups with four distinct categories of people, to collect observations about prenatal care from various perspectives. The 169 subjects included homeless women; women with current or history of substance abuse; significant others of homeless women; and residents of a community with high infant mortality and poverty indices, and low incidence of adequate prenatal care. A process of coding and recoding using Ethnograph and counting ensured reliability and validity of the process of theme identification. RESULTS: Barriers and motivators to prenatal care were identified in focus groups. Pervasive issues identified were drug lifestyle, negative attitudes of health care providers and staff, and non-inclusion of male partners in the prenatal experience. CONCLUSIONS: Designing prenatal care relevant to vulnerable women in urban communities takes creativity, thoughtfulness, and sensitivity. System changes recommended include increased attention to substance abuse treatment/prenatal care interaction, focus on provider/staff attitudes, and commitment to inclusion of male partners.