The Genesee County REACH (Racial and Ethnic Approaches to Community Health) 2010 initiative, conducted between 2000 and 2007, focused on reducing infant mortality, particularly the disparity in rates among African Americans and European Americans, in Genesee County, Michigan. The Community Action Plan (CAP) was derived from a community-based participatory research approach and based on a socioecological model.
The plan derived both from "bench” science and “trench” study with community residents. Its theoretical foundations were grounded in a philosophy of public health as social justice and based on the understanding that culture can be both protective and harmful. No single intervention will eliminate racial health disparities. Interventions aimed at reducing infant mortality must precede, include, and follow the period of pregnancy. Core themes for the work of this initiative included fostering community awareness and mobilization, enhancing the “baby care” (medical care and social services) system, and reducing racism.
The over-arching goal of the REACH project was to effect community and systems change sufficient to improve the local infant mortality problem. At the start of the project, African American infants in Genesee County were dying at a rate greater than three times that of European American infants. Major outcome objectives in the project’s logic model included: (1) reducing racism; and (2) reduction in infant mortality rates and the disparity ratio from 1999-2000 baseline data.
Project interventions within this successful model’s three interconnected spheres of activity included: community dialogue sessions; undoing racism workshops; university cultural competency in health care curriculum; African Culture Education Development Center; maternal/infant health advocates; PRIDE (Programs to Reduce Infant Deaths Effectively) medical services committee; community media campaign; healthy eating curriculum; and Harambee celebrations. Through this multifaceted array of successful practice-based interventions, the REACH Community Action Plan contributed significantly to the decline in the infant mortality disparity ratio and a historic low rate of African American and overall infant deaths in Genesee County.
The REACH planning process examined racial disparities in infant mortality from both “bench” (science) and “trench” (community) perspectives. Racial disparities in infant mortality in Genesee County have persisted despite at least two decades of applied contributions from the clinical, scientific laboratory, and legislative “benches” to reduce these gaps.
Although many explanations have been proposed for the failure of standard interventions to reduce racial disparities, two of the most compelling explanations have been central to the REACH project: 1. No single intervention is likely to eliminate racial disparities in infant health. Racial disparities arise from multiple factors: poor outreach to and coordination of public health and medical services for high-risk patients; informal access barriers to needed services; cultural barriers that hinder access and patient adherence to beneficial health behaviors; structural inequalities that promote poverty and community dislocation; and internalized racism that fosters desperation and spiritual exhaustion in those communities at greatest risk. 2. The period of pregnancy is simply too short to address effectively many risk factors important to infant health. A life-course perspective that focuses on improved maternal health is essential to improve birth outcomes in the African American population. From this perspective, effective infant mortality prevention requires varied interventions that go beyond prenatal or postpartum clinical care, to include primary prevention well before first pregnancies; preconceptional care for planned pregnancies; postnatal intervention to prevent adverse outcomes among newborns and older infants and also to provide primary prevention for future pregnancies and to increase intervals between pregnancies.
Given the multifaceted nature of this public health problem, multifaceted solutions are required. The Genesee County REACH initiative set in motion a comprehensive and sustainable process to improve maternal and infant health rather than provide for a specific high-profile intervention in the hope of dramatic short-term gains.
Agency Community RolesWith a vision of "Better Life Through Better Health" and a mission to protect and promote the community's health, the Genesee County Health Department (GCHD) was asked by its community partners to serve as the Central Coordinating Organization (CCO) because of its experience and recognized success in facilitative, coordinating roles and its leadership in community-based public health work. The GCHD has broad experience as a coordinator of and participant in community-based work and as a catalyst for planning and implementing change in public health practice, academic training, and community-based work.
The membership of the Genesee County REACH Coalition has been composed of 10 core partners over the past seven years: (1) the Genesee County Health Department; (2) University of Michigan-School of Public Health-Ann Arbor, (3) University of Michigan-Flint; (4) Faith Access to Community Economic Development; (5) the Greater Flint Health Coalition; (6) Genesee County Community Action Resource Department; (7) PRIDE (Programs to Reduce Infant Deaths Effectively) Medical Services Committee; (8) Flint Odyssey House Health Awareness Center; (9) Priority Children; and (10) Flint Family Road.
The coalition adheres to the principles of community-based research developed by the University of Michigan School of Public Health and adopted by the Prevention Research Center of Michigan. RESPECTFUL represents the approach that steers community-based participatory research in Genesee County: Respect each other’s contributions; Encourage change and promote knowledge in ways that benefit communities; Share credit and responsibility for results; Promote an emphasis on locally relevant health issues; Examine the social, economic, and cultural influences on health; Collaborate on all major phases of the research process; Treat research participants ethically; Furnish results to the community in a useful manner; Utilize community strengths and expertise; and Link research to action to enhance community capacity. In its role as the CCO, the GCHD had responsibility for management and oversight of the REACH CAP.
Community-based partners have been responsible for guiding the "trench" work, which explained during the planning phase why the disparity continued to exist despite two decades of contributions from the "bench". Reasons included problems of language, communication, trust, culture and racism. Partners helped to link “bench” and “trench” by building shared language and trust to promote improved understanding and communication, while at the same time addressing structural problems in institutions and systems to accomplish the goal of reducing African American infant mortality and racial disparity.
Costs and ExpendituresDuring the first year of implementation, the Genesee County REACH project was funded at $988,968, including $37,631 in in-kind contributions. In subsequent years (2-7), the funding was reduced to $912,062 including $28,595 in in-kind contributions.
ImplementationThe REACH CAP interventions were conducted locally over a seven-year project period (October 1, 2000–September 30, 2007): Maternal and Infant Health Advocates (MIHAs) worked directly with pregnant women, new mothers and families in the high-risk zip codes, providing support and helping them navigate appropriately and successfully through the medical/social services systems. Community Media Campaign helped raised awareness about racial differences in infant mortality, communicated culturally-relevant messages important to reducing African American infant mortality, and reinforced the work of REACH activities.
The PRIDE Medical Services Committee concentrated its work on the clinical environment in Genesee County. The committee is composed of maternal/infant health hospital administrators, obstetricians and gynecologists, perinatologists, neonatologists, pediatricians, social workers, nurses, and representatives of the largest health insurer and other healthcare organizations in the County. This goal of the committee is to shape the future direction of maternal and infant health in Genesee County to increase healthy birth outcomes, especially among African American, by influencing health policies, and supporting training and research. Community Windshield Tours provided a visual perspective to groups of physicians, hospital administrators, medical residents, and others working within Genesee County to assist them in gaining an understanding of the neighborhood environmental conditions and experience of women and families at risk for poor birth outcomes. The Undoing Racism Workshops help participants develop their own analysis of history, culture, and power relationships. They move beyond a focus on the symptoms of racism to an understanding of what racism is, where it comes from, how it functions, why it persists, and how it can be undone. The workshops were offered twice a year to Genesee County residents and individuals working in Genesee County.
Community Dialogue Sessions guided participants through a structured dialogue to develop supportive relationships and learn from each other about infant mortality, African American culture, racism, and systemic community health care and economic problems, and then led them to develop a plan of action to combat these issues. This process has yielded two particularly active action groups: Black Men for Social Change and Women Taking Charge of Their Health Destiny. The African Culture Education Development Center provided an environmental milieu and curriculum that supported a positive view and understanding of pride and respect of African Americans and their culture. It also challenged and changed the thinking of the healthcare providers and business/economic sectors. The Healthy Eating Curriculum was developed to reduce maternal nutritional risks and enhance protective factors. The curriculum was offered during one-on-one visits made by MIHAs as well as classes taught at various Genesee County venues. Harambee (“coming together”) Celebrations were held annually to demonstrate and celebrate lessons learned resulting from the work of REACH. These events brought together individuals from all sectors of the community to update them for continued support of REACH activities. “Cultural Competency in Health Care” Curriculum was developed and offered at the local University of Michigan-Flint to educate future healthcare professionals about issues impacting health disparities.
During the period of this initiative, the African American infant mortality rate dropped from a high of 23.5 deaths per 1,000 live births to an all-time low of 15.2. The European American rate dropped from a high of 13.1 to 8.9, with the overall county rate dropping from 13.1 to 8.9. The disparity ratio dropped from a high of 3.6 African American infant deaths for every white infant death to 2.4.
Eight years prior to the REACH initiative, in 1992, the GCHD was the coordinating organization of a partnership with the University of Michigan School of Public Health, University of Michigan-Flint, and six predominately African-American-led community-based organizations who together worked and identified themselves as the Broome Team. The Broome Team was part of a four-year initiative to change public health professional education and practice. This was accomplished by linking practitioners and academia in partnerships with community-based organizations, thereby enhancing the ability of public health systems to address societal health issues, particularly in multicultural communities.
Funded in 1992 as part of the W.K. Kellogg (WKK) Foundation's Community-Based Public Health (CBPH) Initiative, this project has led to improved social and preventive health services through innovative programs and approaches incorporating community residents as equal partners in efforts to design and improve the public's health. An Institute of Medicine report featured the Broome Team in a section about community collaboration: "Over the four years of the CBPH partnership, wide gaps in culture, race, trust, orientation, and history have been bridged among team members whose experience working jointly now forms the foundation for work with an expanded network of community residents and organizations." In the evaluator's report back to WKK, the Broome team was described as "a beacon of hope for others who believe that healthy communities can be created within a common vision through respectful, effective partnerships." When the WKK funding ended in 1996, the partners continued to meet regularly and work on projects at their own expense in order to sustain the commitment and relationships developed.
It was upon this foundation that the Genesee County REACH initiative was built. As testament to the sustainability of the REACH infant mortality and health disparity work, the project was just refunded for another five years, through 2012, and designated as a Center of Excellence in the Elimination of Health Disparities under the CDC’s REACH US program. Some REACH 2010 interventions have become “institutionalized” within the regular programming and operating budgets of partner agencies. Some are now being supported by philanthropic grant resources. Opportunities to leverage further community and financial commitments continue to be pursued.