Running head: INFANT MORTALITY 1

Health Policy: Infant Mortality Among Pinellas County African American Population

Brooke Fortner

University of South Florida

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Health Policy: Infant Mortality Among Pinellas County African American Population

Infant mortality is defined as death within the first year of life. The causes of these deaths

include birth defects, preterm birth, maternal pregnancy complications, Sudden Infant Death

Syndrome (SIDS), and injuries (Centers for Disease Control and Prevention [CDC], 2016). With

this information, health policies can be created to decrease infant mortality rates, beginning in

pregnancy and extending through infancy.

Overview of Pinellas County

Pinellas County is located on the western coast of Florida. This county encompasses a

span of 280-square miles that became its own county, separate from Hillsborough County, in

1912 (Pinellas County Florida, 2016). The estimated county population for 2015 was 949,827

(United States Census Bureau [USCB], 2016). With a population of over 50,000, Pinellas

County is classified as an urban area (United States Census Bureau [USCB], 2015). Pinellas

Countys largest employer is Raymond James Financial, a securities brokerage company

employing 3,500 people; Home Shopping Network and Bright House Networks complete the list

of this countys top three employers with 2,800 and 2,000 employees, respectively (Pinellas

County Economic Development, 2016). Major health systems in this county include Bayfront

Health, BayCare throughout various Morton Plant Hospitals in the county, and the Adventist

Health System including Florida Hospital locations (BayCare Health System, 2017; Bayfront

Health St. Petersburg, 2017; Florida Hospital North Pinellas, 2017).

Comparison of Local vs. State Populations

Data for the years 2010 to 2014 indicated that the percentage of families below the

poverty level in Pinellas County was 9.7 (Florida Health, 2015). This was less than the state

percentage of 12.2 (Florida Health, 2015). Compared to Floridas overall percentage of 86.9, the
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percentage of persons 25 years of age and older that have a high school diploma in Pinellas

County is 90.0% (USCB, 2016). In Pinellas County, 5.3% of the population ages five and older

do not speak English well, which is lower than Floridas percentage of 11.7 (Florida Health,

2015). According to the County Health Rankings (2016), 22% of persons under the age of 65 in

Pinellas County were uninsured in the year 2016 versus Floridas uninsured percentage of 24

(County Health Rankings, 2016). In Pinellas County, the ratio of primary care physicians to

population showed that for every 1,120 persons, there was one primary care physician (County

Health Rankings, 2016). This reflects more primary care physicians available to the population

in this county than overall in Florida, as the states ratio is 1,390:1 (County Health Rankings,

2016).

Analysis and Interpretation of Data

Identified Strengths

Three strengths in the health of Pinellas County include: 57.1% ages 50 and older

received sigmoidoscopy or colonoscopy in the last five years, 7.2% of adults currently have

asthma, and 79.2% of those with diabetes had a yearly eye exam completed (Florida Health,

2015). These are strengths of the county as the numbers reported for each of these are more

favorable than the averages in Florida. Overall in Florida, only 55.3% of adults ages 50 and older

received a sigmoidoscopy or colonoscopy in the past five years, 8.3% of adults currently have

asthma, and only 69.7% of those living with diabetes had an annual eye exam (Florida Health,

2015).

Identified Weaknesses

Three weaknesses in the health of Pinellas County include health behaviors and

outcomes. In Pinellas, 51.6% of women ages 40 to 74 received a mammogram in the past year;
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for every 1,000 black members of the population, 218.0 have heart disease; for every 1,000

births among the black population, there are 12.8 infant deaths (Florida Health, 2015). These are

weaknesses of the county as the numbers reported for each of these are less favorable than the

averages in Florida. Overall in Florida, 57.5% of women ages 40 to 74 received a mammogram

in the past year, the heart disease rate among the black population was 164.7, and only 6.1 infant

deaths occurred per 1,000 births (Florida Health, 2015).

Identification of a Priority Health Issue

Healthy People 2020 selected infant death as a high-priority health issue, setting a target

of reducing the baseline 6.7 infant deaths to 6.0 infant deaths per 1,000 live births (Office of

Disease Prevention and Health Promotion [ODPHP], 2014c). Healthy People 2020 determined

that in 2009 the African American population had 2.8 times more infant deaths than the

population with the lowest rates (ODPHP, 2014b). In 2013, the African American population

still had 2.7 times more infant deaths than the group with the lowest rates (ODPHP, 2014b).

Therefore, the African American population continued to have more than double the risk of

infant mortality than other populations in the United States.

The five leading causes of infant death, in order by rank, among African Americans are:

disorders related to preterm gestation and low birth weight, congenital and chromosomal

abnormalities, maternal complications, Sudden Infant Death Syndrome (SIDS), and accidents

(Mathews, MacDorman, & Thoma, 2015). Preterm birth occurs when delivery occurs prior to 37

weeks gestation. This is a major contributor to infant mortality and although efforts have been

made to decrease the rate of preterm births in the United States, there was an increase from

13.23% in 2014 to 13.39% in 2015 among the non-Hispanic black population (Hamilton, Martin,

& Osterman, 2016). In Pinellas County, between the years of 2013 and 2015, 12.5% of births
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among the black population were under 2500 grams, or low birth weight (Florida Health, 2015).

During this same time period, there were 27 documented cases of infant deaths from congenital

and chromosomal abnormalities (Florida Health, 2015). In Pinellas County, there have been zero

infant deaths due to SIDS since 2009 (Florida Health, 2015). Accidental causes of death include

unintentional injury from suffocation and strangulation in bed; from 2013 to 2015, there were 20

deaths due to these types of accidents in Pinellas County (Florida Health, 2015).

A weakness which health policy could target for positive outcomes is the increased infant

mortality among the black population in Pinellas County due to preterm births and low birth

weight as this was the major cause of death to those less than one year old. As previously

mentioned, for every 1,000 births among this population, there are 12.8 infant deaths (Florida

Health, 2015). This is not only higher than the average infant death rate in Florida, but also

higher than both white and Hispanic races. For every 1,000 births among each population, there

were only five infant deaths among the white population and 7.3 in the Hispanic population

(Florida Health, 2015). Therefore, differences in factors that cause this increased rate among the

black population may address this racial disparity.

Discussion and Application of Community Health Models

The Social Determinants of Health model is a framework of five key social factors and

physical conditions that affect health and quality of life (Savage, Kub, & Groves, 2016; ODPHP,

2014a). These five determinants include economic stability, education, health and health care,

social and community context, and the neighborhood and built environment (Savage et al.,

2016). Examples of these determinants include: availability of resources, access to health care

services, transportation options, public safety, social attitudes and support, socioeconomic

conditions, and literacy (ODPHP, 2014d). This model is useful in identifying how various
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environments and settings influence health outcomes and risks, which can then be used to

develop health policies and interventions that target the social conditions to improve health

outcomes for the population studied (ODPHP, 2014d).

In applying the Social Determinants of Health model to Pinellas County where African

Americans are a minority, there are various social factors and physical conditions that influence

infant mortality outcomes and risks among African American mothers. This population of

women is more likely to experience racial discrimination (Giurgescu, 2017). According to

Rosenthal et al. (2015), in black women who experienced discrimination, there was an increase

in symptoms of depression and a decrease in self-reported health. A review by Schetter and

Tanner (2012) stated that anxiety during pregnancy was associated with shorter gestation while

exposure to racism and symptoms of depression were associated with infants low in birth weight.

African American women are more likely to live in poor-quality neighborhoods

(Giurgescu, 2017). A systematic review by Nowak and Giurgescu (2017) suggested that a poor-

quality neighborhood is related to negative birth outcomes due to increased stress and symptoms

of depression. Among women without postsecondary education, those who reported living in

better environments had lower preterm deliveries (Sealy-Jefferson, Giurgescu, Helmkamp,

Misra, & Osypuk, 2015).

In order to address the importance of access to care as a determinant of health outcomes,

the various racial demographics of Pinellas County should be noted. The areas with the largest

percentages of African Americans include south Saint Petersburg, east Tarpon Springs, and north

Greenwood (Florida Health, 2012). These locations are also considered to be three of the five at-

risk communities who face barriers to health care due to economic, cultural, or linguistic factors

(Florida Health, 2012). The other two locations within Pinellas County include central
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Clearwater and Largo (Florida Health, 2012). Within these five communities, the Pinellas

County Economic Impact of Poverty report found that there were not only higher unemployment

rates, but also that the number of births to teenage females was double the average rate (Florida

Health, 2012). During the time period from 2013 to 2015, for every 1,000 females there were

42.4 births to mothers ages 15 to 19 in Pinellas County (Florida Health, 2015). In comparison,

this was more than double the rate of births to white mothers in the same age group, whose rate

was 15.2 (Florida Health, 2015). Births to teenage females are associated with a greater risk of

complications (Florida Health, 2012). A lack of access to care is also evident in the statistics of

prenatal care use in the black population. In Pinellas County, 69.8% of births to African

American females had prenatal care begun in the first trimester of pregnancy (versus 82.3% in

births to white females), while 6.7% of births had late or no prenatal care (versus 4% in births to

white females) (Florida Health, 2012).

Population Diagnosis

African Americans in Pinellas County are at risk for increased infant mortality due to

deficient prenatal care.

Community/ Population-based Interventions

Primary Level of Prevention

Primary prevention to reduce infant mortality aims to prevent death by preventing illness.

An example of an intervention for primary prevention would be the administration of

vaccinations at the individual level. Infants less than six months old are most at risk for

complications of a vaccine-preventable disease called pertussis (Wisner, 2017). Complications

include pneumonia, apnea, and death, which can be prevented by administering the diphtheria,

tetanus, and acellular pertussis (DTaP) vaccine (Wisner, 2017). Vaccinations should be given to
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all mothers during pregnancy (Wisner, 2017). Females vaccinated during pregnancy develop

antibodies that cross the placenta and provide passive immunity to the infant until they can

receive the first DTaP vaccination at two months of age (Barber, Muscoplat, & Fedorowicz,

2017). By vaccinating mothers as part of routine prenatal care, this can decrease the risk of

infants dying from pertussis within the first few months of life. Stakeholders toward whom the

intervention is geared include community members who will come in contact with the infant,

county officials who oversee implementation of government funding of vaccinations, and health

care providers who will administer the vaccinations. Funding will occur through private

insurance and government-funded programs such as Medicaid and Medicare. The community

health nurses role in this intervention is two-fold: adequate patient education on the importance

of the vaccine as well as the vaccination schedule and administration of the vaccine to the

patients.

Secondary Level of Prevention

Secondary prevention to reduce infant mortality aims to prevent death by screening for

risks. An example of an intervention at this level would be the implementation of a program

based on the Baby Behavioral Educational Enhancement of Pregnancy (Baby BEEP) study that

provided support to low-income, pregnant women through weekly telephone conversations that

may screen for infant mortality risk factors (Evans & Bullock, 2017). Stakeholders toward

whom the intervention is geared include community members who utilize the intervention,

county officials who oversee implementation of government funding of the intervention, hospital

administrators who collaborate in sponsoring the intervention, and health care providers engaged

in the telephone conversation. Funding will occur through private insurance and government-

funded programs such as Medicaid and Medicare, and through hospital systems that sponsor the
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use of the program in exchange for referrals to their health services when needed. The

community health nurses role in this intervention is to conduct the telephone intervention to

build rapport and trust with the patient, provide counseling, and perform risk assessments.

Tertiary Level of Prevention

Tertiary prevention to reduce infant mortality aims to prevent death in those at high risk

of death within the first year of life. An example of an intervention at this level would be

providing training to individuals, specifically Neonatal Intensive Care Unit (NICU) patients

caregivers, prior to discharge. This hospital-based program would provide caregivers with

hands-on training in cardiopulmonary resuscitation (CPR) in the event that an emergency occurs

at home (Murray & Joseph, 2016). Continuing practices performed at Nemours Alfred I. duPont

Hospital for Children, the training will be tailored to the caregivers needs and teach-back

methods will be utilized (Murray & Joseph, 2016). Stakeholders toward whom the intervention

is geared include caregivers of NICU infants, hospital administrators who collaborate in

sponsoring the intervention, American Heart Association instructors, and health care providers

engaged in referring caregivers to, and teaching, the CPR program. Funding will occur through

the hospital system that implements this program. The community health nurses role in this

intervention is to provide referrals to this program, complete training through the American

Heart Association as CPR instructors, and to teach the CPR course.

Development of Health Policy

Health policy seeks to create positive goals and outcomes through the health care system

and interventions. The focus of this health policy proposal is to reduce infant mortality among

Pinellas County African Americans by utilizing secondary intervention. This policy proposes the

implementation of a program based on the Baby Behavioral Educational Enhancement of

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Pregnancy (Baby BEEP) study that provides support to low-income, pregnant women through

weekly telephone conversations (Evans & Bullock, 2017). The Baby BEEP study delivered

social support to this vulnerable population of women in the midwestern region of the United

States who experience disparities in access to adequate care (Evans & Bullock, 2017). Peplaus

theory of Interpersonal Relations served as the basis for the therapeutic nurse-patient interactions

and enhanced development of trust (Evans & Bullock, 2017).

The telephone conversation would include screening for maternal health factors and

practices that increase infant mortality risk. Signs and symptoms of pregnancy complications,

nutritional deficiencies, and tobacco use will be assessed. In order to reach the five at-risk

communities of Pinellas, sponsored advertisements will be displayed on all Instagram, Facebook,

and Snapchat applications opened on devices with location services identifying the device is

within five miles of the zip codes of these communities. As the program reaches success and

increased funding, advertisement can be extended to larger geographic locations. Stakeholders

toward whom the intervention is geared include female community members who utilize the

intervention, county officials who oversee implementation of government funding of the

intervention, hospital administrators who collaborate in sponsoring the intervention, Smart

device application advertisement administrators, and the baccalaureate-prepared nurses who will

engage with patients in the telephone conversation. Funding will occur through private

insurance and government-funded programs such as Medicaid and Medicare, and through

hospital systems that sponsor the use of the program in exchange for referrals by the nurses to

their health services when needed.

Supporters of this health policy include female community members who utilize the

program, county government officials, hospital administrators, Smart device application

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advertisement administrators, and the baccalaureate-prepared nurses involved in the program.

Additionally, private insurance companies and government-funded programs will support this

policy as it decreases health risk and health care costs. Opposing forces of the health policy

include fiscally conservative community members who believe that this program is an inefficient

use of taxpayer money.

The first step toward presenting the health policy is to form a committee in support of the

policy including other nurses and health care providers. The committee will draft a final

proposal to be presented first at city council meetings across Pinellas County. The goal of

presenting at city council meetings is to garner the support of mayors and city managers to create

a stronger momentum to then move forward and seek the support of government funding

agencies and hospital administrators. Local news networks will be contacted in order to create

public awareness of the proposal as well.

This health policy addresses the needs of the underserved populations throughout five

specific communities in Pinellas County. Advertisement efforts will focus on these communities

to raise awareness of the programs availability to pregnant women who are most at risk of

lacking access to adequate prenatal care. The policy proposal can enhance this populations

health by providing a relatively less expensive access point to healthcare information. Trained

nurses will provide patients with therapeutic communication and social support. Additionally,

pregnant women will be provided with screenings covering various topics such as intimate

partner violence, depression risk, and maternal health complications. This provides vital health

care to women who may otherwise not have received care. Valuable information on prenatal

health, including diet, lifestyle, smoking cessation, supplementation, and symptoms of

complications will be provided to enhance the health of the women during pregnancy.
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Ultimately, this policy proposal will decrease infant mortality rates among the Pinellas County

African American population.

Conclusion

Infant mortality rates among the African American population remain higher than other

racial groups in Pinellas County and above goals set by Healthy People 2020. Failure to

adequately address this racial disparity through previous interventions creates the need for a

health policy that can serve this population. A telephone intervention program that has the

ability to reach low-income, pregnant women who lack access to other means of health care can

be the difference for infants who otherwise would not survive their first year of life.

As a nurse entering the profession in 2017, the possibilities to make a difference in the

healthcare field are infinite. With a prospective interest in labor and delivery nursing, I can

advocate for a program that would create more positive outcomes for my patients in Pinellas

County. If I choose another field of nursing, this policy may still be relevant as specialty fields

observe the success of this program using telephone access to care and choose to implement

similar programs to reach the needs of underserved patient populations.

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