Application of a Mixed Methods Approach to Identify Community-Level Solutions to Decrease Racial Disparities in Infant Mortality

J. Racial and Ethnic Health Disparities (2014) 1:69–84 DOI 10.1007/s40615-014-0008-4 Application of a Mixed Methods Approach to Identify Community-Level Solutions to Decrease Racial Disparities in Infant Mortality Laurin J. Kasehagen & Kathleen Brandert & Brenda Nickol & Maureen Gatere & Piia Hanson & Jane Bambace & Rita Beam & Shin Margaret Chao & Cheryl L. Clark & Carrie Y. Hepburn & Maria A. L. Jocson & Millie Jones & Patricia McManus Received: 27 August 2013 / Revised: 9 December 2013 / Accepted: 2 January 2014 / Published online: 11 February 2014 # Cobb/NMA Health Institute (outside the USA) 2014 Abstract Objectives This study aimed to identify community-level actions to decrease racial disparities in infant mortality (IM). Design Six urban multidisciplinary teams generated ideas for decreasing racial disparities in IM using a mixed methods concept mapping approach. Participants rated each idea as to its necessity and action potential and grouped ideas by theme. A cluster analysis produced a series of visual representations, showing relationships between the identified actions and the clustering of actions into themes. Multidimensional scaling techniques were used to produce analyses describing the necessity of and action potential for implementing the proposed ideas. Participants identified actions communities could take to decrease racial disparities in IM and suggested applications of the knowledge gained from the mapping process. Results Participants produced a total of 128 actions, within 11 thematic clusters, for decreasing racial disparities in IM. The thematic clusters contained a range of elements designed to promote knowledge and understanding of the relationship between health and racism; improve educational systems and community opportunities; facilitate community-driven health promotion, marketing, and research; improve health services L. J. Kasehagen (*) MCH Epidemiology Program, Field Support Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention & Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, NE, MS F74, Chamblee, GA 30341, USA e-mail: S. M. Chao Los Angeles Department of Public Health, 600 S. Commonwealth Ave. #800, Los Angeles, CA 90005, USA L. J. Kasehagen : M. Gatere CityMatCH, University of Nebraska Medical Center, 982170 Nebraska Medical Center, Omaha, NE 68198-2170, USA K. Brandert : B. Nickol College of Public Health, University of Nebraska Medical Center, 984355 Nebraska Medical Center, Omaha, NE 68198-4355, USA P. Hanson Association of Maternal & Child Health Programs, 2030 M Street NW, Suite 350, Washington, DC 20036, USA C. L. Clark MCH Practice & Analysis Unit, Division of Community Health Promotion, Florida Department of Health, 4052 Bald Cypress Way, Bin A-13, Tallahassee, FL 32399-1723, USA C. Y. Hepburn Tampa Bay Healthcare Collaborative, P.O. Box 2252, Dunedin, FL 34697-2252, USA M. A. L. Jocson Maternal, Child and Adolescent Health Division, California Department of Public Health, 1615 Capitol Avenue, MS 8306, P.O. Box 997420, Sacramento, CA 95899-7420, USA J. Bambace Pinellas County Health Department, 205 Dr. Martin Luther King Jr. Street North, St. Petersburg, FL 33701, USA M. Jones Wisconsin Division of Public Health, 1 West Wilson, Rm 351, Madison, WI 53703, USA R. Beam Tri-County Health Department, 4857 S. Broadway St., Englewood, CO 80113, USA P. McManus Black Health Coalition of Wisconsin, Inc., 3020 West Vliet, Milwaukee, WI 53208-2461, USA 70 for women; address physical and social environments that impact community health; prioritize resource allocation of community-based services; institutionalize strategies that promote equity across all systems; and create and support legislation and policies that address social determinants of health. Correlation coefficients of the clusters ranged from 0.17 to 0.90. Average necessity ratings ranged from 2.17 to 3.73; average action potential ratings ranged from 1.64 to 3.61. Conclusion Findings suggest that thematic clusters with high action potential usually represented ongoing community activities or actions communities could easily initiate. Community size, existing programs, partnerships, policies, and influential advocates were among the factors cited affecting feasibility of implementation. Clusters with lower action potential require broader, longer term, policy, institutional or systemwide changes, and significant resources. High necessity clusters often contained actions perceived as essential for change, but sometimes outside of a community’s control. Participants identified a number of practical actions that were considered to hold potential for individual, community, and institutional changes which could result in decreasing racial disparities in IM. Keywords Infant mortality . Racial disparities . Racism . Community . Concept mapping . Mixed methods Introduction The relationship between racism and discrimination (i.e., social constructs of attitudes, beliefs, behaviors, and practices of individuals or institutions which systematically prescribe and attempt to legitimize the subordination of a group of people by claiming that that group is biogenetically or culturally inferior) and adverse health outcomes has been well described [1–8]. While the direct and indirect effects of racism and discrimination on health have been difficult to establish and prove [4, 9, 10], there is growing consensus among researchers that the health effects of racism and race-related exposures are cumulative [11–15]. In addition to the cumulative effects on individuals and subpopulations, racism and race-related exposures likely contribute to persistent disparities in birth outcomes over generations [14–18]. Communities have used participatory research methods and community models to explore and address disparities relating to public health policies, environment, neighborhood, transportation, housing, access to goods and services, physical activity, and a myriad of physical and mental health conditions [19–23]. Rarely, however, has the focus of communityinformed disparity work been to address the nexus of racial disparities and infant mortality [24, 25]. Community-informed solutions to racial disparities and infant mortality are necessary because, despite the significance of the adverse outcome J. Racial and Ethnic Health Disparities (2014) 1:69–84 (i.e., infant mortality and persistent racial disparities in birth outcomes) [16–18, 26, 27] and the persistent conditions that contribute to poor outcomes [4, 5, 11, 28–31], much of the literature is problem focused. Medical treatment and prevention strategies tend to be narrowly focused, failing to take into account the complex nature of racism [32–35]. Byrd et al., for example, concluded that improving both prenatal care and maternal education attainment in Wisconsin would decrease infant mortality rates; however, these strategies would be unlikely to eliminate th (...truncated)