prenatal care and health care access on infant death outcomes in five public health districts with the highest and lowest rates of infant deaths in georgia
Infant rate mortality in Georgia is extremely high and is an indicator of the overall poor status of health among women and children in this state. Between 1990 and 2000, it is reported that Georgia was among the states with the highest rate of infant deaths. In 1990 the infant morality rate in Georgia was at 12.4 deaths for each 1,000 live births and decreasing to 8.5 per 1,000 in 1998. The infant death rate among the white population is 6.1 per 1,000 while the African-American population was stated at a much greater rate of 13.5 per 1,000, which is over twice as high as infant death rates among the white population in the state of Georgia. (Georgia Department of Human Resources: Infant Mortality Fact Sheet, 2000)
PURPOSE of STUDY
The purpose of this study is to investigate Infant mortality in African-American women in Georgia for the years 2000-2005 in five public health districts with the highest rates of infant mortality and five public health districts with the lowest infant mortality rates (so we are looking at 10 public health districts total that can be found on the OASIS website) in the state of Georgia).
It is stated by the Georgia Department of Human Resources in the work entitled: “Infant Mortality: Fact Sheet” that the primary cause of infant deaths in the state of Georgia has been found to be low birthweight, or babies who are born weighing 5.5 pounds or less. The second primary cause of infant mortality in the state of Georgia is premature birth, which is often characterized by low birthweight. Risk factors stated by the Georgia Department of Human Resources include those of:
1) Conception at a young age;
2) Poor health and/or nutritional status of the mother;
3) Some infections including reproductive tract infections and periodontal infections;
4) Substance abuse;
5) Closely-spaced pregnancies;
6) Inadequate prenatal care;
7) Inadequate folic acid intake; and 8) Positioning babies on their stomachs to sleep. (Georgia Department of Human Resources, 2000)
Reduction of infant mortality rates in the state of Georgia during the 1990s was accomplished through improvement of technologies and facilities in the treatment of severely underweight babies and increasing the access to quality prenatal care for women who are pregnant. Finally, raising the concern of the public about reduction of the risks contributing to SIDS has assisted in reducing infant mortality rates in the state of Georgia. While the survival of low birthweight babies is more likely in Georgia due to technological advances there is a great cost in the intensive and extended care necessary for these babies to survive. The Division of Public Health (DPH) in the state of Georgia has focused on combating low birthweight through placing an emphasis on prevention program improvement. The following table lists the infant mortality by health district for black infants during the period 1990-1997 in the state of Georgia.
Infant Mortality by Health Districts, Black Infants 1990-1997
Source: Perinatal Epidemiology, Epidemiology and Prevention Branch, Georgia Division of Public Health, November 1990-1997 Vital Records
The following chart lists the infant mortality by health district for black infants 1990-1997.
Infant Mortality by Health District, Black Infants, 1990-1997
Source: Perinatal Epidemiology, Epidemiology and Prevention Branch, Georgia Division of Public Health, November 1998, Source: 1990-1997 Vital Records
State of Georgia Infant Mortality by Race
Neonatal, Postnatal and Total Infant Mortality
Source: Perinatal Epidemiology, Epidemiology and Prevention Branch, Georgia Division of Public Health, November 1998, Source: 1990-1997 Vital Records
FIVE HEALTH DISTRICTS WITH HIGHEST INFANT MORTALITY RATE
The five health districts in the state of Georgia with the highest infant mortality rate for the years 2000 through 2005 are those shown in the following table.
Five Health District in the State of Georgia with the Highest Infant Mortality Rate
Infant Deaths & Infant Mortality Rate (IMR), All Causes, Race: Black
2000 2001 2002 2003 2004 2005 SELECTED YEARS TOTAL DEATHS DEATHS DEATHS DEATHS DeKalb Health District 83-76 83-70 87-68-467 Crawford 0-0 1-0 0-2-3 Jones 0-0 2-3 1-2-8 Twiggs 0-2 0-3 2-1-8 Columbia 3-2 2-2 2-4-15 Jenkins 1-0 1-1 1-0-4 Screven 3-0 1-3 3-1-11 Chattahoochee 0-1 0-1 0-2-4 Harris 0-2 2-2 0-1-7 Quitman 0-0 1-0 2-1-4 Sumter 1-5 3-3-10 6-28 Calhoun 1-1 1-0 0-3-6 Early 0-2 1-4 3-0-10 Mitchell 6-2 3-4 2-3-20 Worth 1-2 0-0 0-0 3
Source: Oasis (2008)
The infant mortality rate in these health districts is extremely higher than in other Georgia Health Districts throughout the state.
INFANT MORTALITY RATE – CONTRIBUTING FACTORS
The work of McDermott, et al. (1999) entitled: “Does Inadequate Prenatal Care Contribute to Growth Retardation among Second-Born African-American Babies” reports a study in which the relation between “adequacy of prenatal care and risk of delivery of full term small-for-gestational-age infants” was explored. Data was obtained from “…materially linked birth certificates for 6,325 African-American women whose first pregnancies ended in single, full live births in Georgia from 1989 through 1992.” (McDermott, et al., 1999) McDermott et al. states that babies whose birth weights are less than “the 10th percentile for gestational ages are considered small for gestational age and are at risk of increased morbidity and mortality. However, being small at delivery is likely to affect health primarily if the infant’s in utero growth was retarded in some way.” (1999) Small Gestational Age has been linked to smoking, insufficient weight gain, and hypertensive disease and the risk of small gestational age is higher in the first pregnancy than in following pregnancies. Mothers who have a history of delivering babies that are SGA are at a higher risk of delivery SGA babies in the future. Genetics plays a role in repeated SGA deliveries and low socioeconomic status and weight loss during pregnancy has also been linked to small gestational age babies. Prenatal care generally includes interventions that address risk factors for SGA including smoking, hypertensive disease, insufficient weight gain and obstetric complications during pregnancy. Researchers state findings that “prenatal care is associated with a reducing in SGA births” (McDermott, et al., 1999) and that prenatal care has the greatest impact on babies born at 40-42 weeks gestation.
The work of Ashman (2005) entitled: “Infant Mortality and Financial Stability” relates that infant mortality “is most heavily determined by the financial stability of a family. The high mortality rate in urban Atlanta, Georgia and the low mortality rate in urban White Plains, New York exemplify the correlation between the financial income and infant mortality in the Untied States. A family’s income determines access to good prenatal care.” (Ashman, 2005) Ashman relates that a mother’s access to prenatal care is the first consideration in seeking a solution to high infant mortality rates because without prenatal care “mothers increase their chances of engaging in unhealthy activities which will affect the health of the baby and of themselves; they increase the risk of having premature infants and of losing an infant to complications during the pregnancy.” (Ashman, 2005) the prenatal visit involves weighing the patient, checking blood pressure, testing urine for possible infection and monitoring of the heartbeat of the baby and checking the growth of the baby. Furthermore, “a prenatal health care team administers various tests and gives advice to mothers.
The health care provider discusses healthy eating habits, avoiding unhealthy environments and exercising carefully with the approval of the physician.” (Ashman, 2005) Ashman reports that the average costs for prenatal care include hospital costs for a delivery with no complications is approximately $6,400 however, in situations where complications exist a longer hospital stay is required for the infant resulting in “the median treatment cost of delivery averages up to $50,000.” (Ashman, 2005) Ashman states that the present “inadequate financial support for mothers and their families in Atlanta results in their dependence on the federal program Medicaid. The federal government and the governments of each state have devised this medical program to pay for medical assistance for individuals and families with low incomes and resources who meet eligibility criteria. Individuals eligible for Medicaid range from pregnant women to children to the elderly.” (Ashman, 2005)
Eligible women are able to access this program yet the eligibility requirements in the State of Georgia for pregnant women have undergone changes. Ashman states that under the plan developed by Governor Perdue “pregnant women and infants in households earning $34,040 or more for a family of four would not longer qualify for Medicaid.” (Ashman, 2005) Ashman relates that the total eligibility income for a family of four “is barely enough for an expectant mother to survive, much less for an expectant single mother. The government estimates that 12,500 women may lose prenatal care because of their inability to afford the costs of prenatal and maternity services.” (Ashman, 2005)
Ashman relates the fact that “the inconsistency of government officials in the state of Georgia affects the aid available to mothers in Atlanta. A solution capable of aiding expectant mothers in Atlanta with their financial stability needs to be implemented. In the twenty-first century, women should have easy access to available resources to assist them in their pregnancy. In addition, available technology to detect difficulties during pregnancies is widespread in the medical field; however, disadvantaged women in Atlanta, Georgia do not benefit from these resources. Each year, maternal care expands in resources and knowledge. Equipped physicians can diagnose birth defects long before a mother gives birth. Absurdly, poor twenty-first century mothers in Atlanta lack access to this prenatal care, which would play a vital role in the reduction of infant mortality. Without prenatal care, mothers endanger not only their lives but also the lives of their unborn infants.” (2005) proposed solution provision of adequate access to prenatal care for women in Atlanta by the Children’s Healthcare of Atlanta and local hospitals has been stated for free monthly screening however this provision will depend on the ability of groups in Atlanta to raise funding for this provision. Ashman (2005) states: “In urban areas such as Atlanta, Georgia, the poverty level affects the rates of infant mortality. Individuals with lower incomes and lower job status have a greater likelihood of experiencing the loss of an infant due to lack of financial accessibility to prenatal care than individuals from higher income environments such as White Plains, New York.” Ashman states that the key in reduction of infant morality begins with “addressing financial accessibility in underprivileged urban areas such as Atlanta.
The work of Ziba Kashef entitled: “Persistent Peril: Why African-American Babies Have the Highest Infant Mortality Rate in the Developed World” relates that African-American women “have long had higher rates than whites of low-birth weight and preterm babies, the leading cause of infant mortality or death in the first year of life.” (2006) Kashef relates a recent study reported in the Journal of the American Medical Association, which relates that “one particular disparity – the gap between black-white baby deaths – has not just persisted by actually grown in recent years despite federal efforts to eliminate the difference.” (Kashef, 2006) Kashef additionally states that research has “debunked the notion that socioeconomic status and related factors are the source of the problem” (2006) and points out the following facts:
1) College- and graduate-school educated black mothers have a higher infant mortality rate than white moms who did not finish high school;
2) Black women who get prenatal care in the first trimester have double the infant mortality rate of white mothers with first-trimester care; and 3) Black women with similar levels of prenatal care as Hispanic women (generally less educated and with lower incomes than blacks) have higher rates of low birth weight, preterm deliveries, and infant mortality. (Kashef, 2006)
Research has demonstrated that even when controlling for various factors such as poverty, housing employment, medical risk, abuse, social support…” And other factors that “90% of the differences in birthweight between black and white moms remains unaccounted for.” (Kashef, 2006) Genetics has failed to provide the answers as well. Experts are beginning to search beyond the woman’s individual risk factors during pregnancy and to view “a more complete, long-term perspective on women’s health. Healthy women beget healthy children…so when you start to talk about the health of the mother, you have to really look at her life course experiences, and some of that actually depends on the health of ‘her’ mother.” (Kashef, 2006) Research has shown that a child “is more likely to be born low birth weight if her mother was also born that way.” (Kashef, 2006) Kashef relates that culture has been shown to be directly related to infant mortality in African-American women in that women of the same race who are foreign-born have lower rates of infant mortality than those born in the United States and raised in the African-American culture.
The work of Collins et al. (2005) entitled: “Very Low Birthweight in African-American Infants: The Role of Maternal Exposure to Interpersonal Racial Discrimination” relates a study with the objectives of determining whether the lifetime exposure of African-American women to “interpersonal racial discrimination is associated with pregnancy outcomes.” The method of the study reported by Collins et al. is a case-control study among 104 African-American women who delivered very low birthweight preterm infants and 208 African-American women who delivered non-low-birthweight term infants in Chicago Illinois. Collins et al. relates that for many years it has been acknowledged that African-American infants are more than twice as likely as White infants to die in their first year of life.” (2005) Collins et al. relate that infant birthweight “is a primary determinant of infant mortality risk.” (2005) Collins et al. states that “An extensive literature has treated pregnancy as a condition influenced by proximal events and ahs been unable to delineate the mechanisms underlying African-American infants’ threefold greater rate of VLBM.” (2005) a study reported by Kleinman and Kessel, said to be a seminal study in the work of Collins et al. (2005) state findings that “not only a persistent but a widening racial gap in the incidence of VLBW infants…” (Collins et al., 2005) Also reviewed are findings that behavioral risk factors such as smoking cigarettes and using alcohol and illicit drugs during pregnancy have “a negligible impact on the racial gap. Numerous epidemiological studies have found that the racial differential in the rate of VLBW infants exists among women who reside in nonimpoverished neighborhoods.” (Collins, et al., 2005) Quite a number of epidemiological studies have stated findings that “the racial differential in the rate of VLBW infants exists among women who reside in impoverished neighborhoods.” (Collins et al., 2005)
The work of Rich-Edwards et al. is reported by Collins et al. To have stated speculation of maternal lifetime exposure to interpersonal racism related chronic stress as a factor putting African-American women and their newborn babies at risk for infant VLBW There have been formulation of new conceptual models in an attempt to disseminate the stress of a chronic nature and any link to stress of the preterm or prematurely delivered infant less than 37 gestational weeks and the consequent risk of VLBM. In the speculation of Rich-Edwards et al. is the idea that “chronic stress from a maternal lifetime exposure to interpersonal racism is a risk factor for infant VLBW.” (Collins et al., 2005) it was proposed by Misra et al. that “social factors are antecedent to both psychosocial and biomedical factors; the latter are in turn risk factors for infant VLBW.” (Collins et al., 2005) Collins et al. reviews the work of Hogue et al. who held that the ‘classic host’ or the ‘pregnant woman’ along with the ‘environment’ such as chronic stressors added to the third element or the ‘agent’ meaning the “immediate emotional or physical stressors” (Collins et al., 2005) formed what was termed to be a “triangle of epidemiological causality.” (Collins et al., 2005) Chronic stress is more prominently featured in the life of an African-American woman than in the daily lives of women who are of the White race. There have been former studies on “the relation between chronic stress and infant birthweight” yet few studies have focused on the possible link between the normal range of exposure to discrimination based on race “a nonrandom and race-related source of stress – and infant VLBW.” (Collins et al., 2005)
Collins et al. relates: “To the extent that population differences in chronic stress from lifetime exposure to interpersonal racial discrimination underlie the observed racial differential in the rate of VLBW infants, one would expect an association between this exposure and VLBW among African-Americans.” (2005) it is held to be plausible on a biological level that a causal association exists between the exposure to chronic stress among African-American women due to interpersonal racism and infant VLBW. The work of Wadhwa et al. states findings that “chronic maternal exposure to stress – through maternal cardiovascular, immune/inflammatory, and neuroendocrine processes – is detrimental to infants’ birthweight.” (Collins et al., 2005) Even more important is the finding that “psychophysiological stress is likely to accelerate the release of corticotrophin-releasing hormone, which initiates cascade of events leading to preterm delivery.” (Collins, et al., 2005) the response of African-American women to perceived racial bias and internalization that response shows a “…fourfold greater risk of hypertension.” (Collins, et al., 2005) Because of all this information Collins et al. conducted a case-control study of African-American women in urban Chicago in order to determine the extent of chronic stress due to racial discrimination on the interpersonal level in terms of the effect upon VLBW births.
The work of Steven J. Hoffman entitled: “Progressive Public Health Administration in the Jim Crow South: A Case Study of Richmond, Virginia, 1907-1920” relates that the work of Levy (1910) acknowledged that he had “felt for some time that no further lowering of the infant mortality could be brought about by the further improvement in the general milk supply of the city” and added that he had long ago become “convinced that the next move should be to instruct the mothers in the care of their babies” (Hoffman, 2001) Levy realized success in gaining funding for the Health Department’s adoption of a visiting nurse program in 1910 to help stem the rising tide of infant mortality.” (Hoffman, 2001) This program targeted African-American women and white women and three nurses were appointed to the job of instructing mothers on taking proper care of newborn babies. Many changes followed in this program and the infant mortality fell from 149.8 in 1911 to 98.8 in 1912. Furthermore, this rate continued on a steady decline throughout the remainder of the decade decreasing to 39.3 per 100,000 in 1920. (Hoffman, 2001; paraphrased) Hoffman reports that the visiting nurse program appeared more beneficial to African-American mothers than to white mothers. Between the years beginning in 1907 and ending in 1920 infant mortality among white babies fell 71.7% from 101.2 per 100,000 to 28.6. During the same time period African-American infant mortality fell 70.1% from 215.4 to 62.8. Hoffman states “despite the progress made in reducing deaths from infantile diarrhea, the single largest cause of infant mortality in the city, Richmond’s African-American babies were still dying at almost twice the race of whites.” (Hoffman, 2001) in the 1890s the leaders and officials in the city of Richmond became concerned with the extremely high infant mortality rate as Richmond was consistently ranked four or fifth among the nation’s cities with the highest death rates. In 1893 only New Orleans, Charleston and Mobile recorded higher death rates than Richmond, and by 1905 Richmond’s death rate had been ranked “higher than that of any city its size in the country.” (Hoffman, 2001; p.2) Blame was shuffled about among public officials and city leaders who had previously ignored the problem however, now that the city of Richmond had appeared badly due to the high rate of African-American infant mortality rates inflating the rates of the city as a whole officials and leaders knew they must address the problem. Following Levy’s recommendation and the report being accepted by the City Council in Richmond, Levy became the first Chief Health Officer in the city of Richmond. Hoffman relates that “institutional inattention to most of the health needs of Richmond’s African-Americans was deeply imbedded in the racial attitudes of the time.” (2001) Hoffman notes the statement of Mayor of Richmond, Carlton McCarthy who stated in 1907 that the simple facts associated with infant mortality among African-Americans “show that the negroes furnish the culture beds for tuberculosis, and constitute a serious menace to the health of the white population of the city.” (Brandt, 1985; in Hoffman, 2001)
Instead of addressing the health problem in terms of a solution, or making an investment of resources of the city to understand why tuberculosis was so high among African-Americans, McCarthy is said to have stated a warning “against the indiscriminate employment of negroes in our households, and also a suggestion that we ought to be very careful where we send our clothing to be laundered.” (Hoffman, 2001) Hoffman states: “In part, the failure to adequately address the health needs of Richmond’s African-American community resulted from the expectation of many educated southerners, including health officials that African-Americans naturally died at a much higher rate than whites. Accepting a kind of scientific racism based on a theory of Social Darwinism popular at the turn of the century, many health authorities concluded that the city’s African-Americans were, in the words of one historian, “in the throes of a degenerative evolutionary process.” (2001) it was pondered among city officials if African-Americans would not still have a higher mortality rate than white individuals in the larger cities and this belief “made it easy for city officials to ignore the pressing health concerns of African-Americans.” (Hoffman, 2001)
The work of the National Center for Chronic Disease Prevention and Health Promotion – Centers for Disease Control and Prevention document entitled: “Testimony on Infant Mortality and Prenatal Care” states a ‘Racial Ethnic Variation’ among African-American infants exist and that the main contributors to the excess morality rate among these infants are “the high rate of very low birth weight and the excess rate of postneonatal mortality among normal birthweight babies. Although very low birthweight infants represent a tiny fraction of all lives births in the United States they account for almost two-thirds of the disparity in infant mortality between African-Americans and whites. The majority of all very low birth-weight infants are born as a result of preterm delivery.” (National Center for Chronic Disease Prevention and Health Promotion, 1997) Further, the more prematurely born the infant, the more difficulty in medical treatment of that infant. The report additionally states that approximately 25% of the gap in infant mortality between the white and African-American race is derived from deaths “among normal birth-weight babies, many of whom survive the first 28 days of life but die during the postneonatal period. Patterns of postneonatal mortality suggested that with few exceptions, such as congenital birth defects, excess deaths among normal birth-weight black infants generally resulted from potentially preventable causes such as infections, injuries, and sudden infant death syndrome (SIDS).” (National Center for Chronic Disease Prevention and Health Promotion, 1997) Study of the African-American experience of infants born in families of college-educated women and families in which the women have “occupational stability, health insurance, access to services and early entry into care” has been conducted. Similar mortality rates among African-American and white infants born to college educated mothers existed for many causes and this included infant mortality from SIDS, injuries and respiratory disease. The findings state however, that among infants born to this group of college-educated parents that infants “born to African-American college graduates had an 80% higher risk of dying during their first year of life than babies born to white college graduates. This excess was related most notably to a three times higher rate of very low birth-weight in the African-American than in the white college educated population. Thus, the disparity in the very low birth-weight rate for infants of African-American college educated parents is almost as large as for the general population.” (National Center for Chronic Disease Prevention and Health Promotion, 1997)
The work of Gates-Williams, Jackson, Jenkins-Monroe and Williams (1992) entitled: “The Business of Preventing African-American Infant Mortality” relates that the risk of an African-American woman having a baby with low birth weight resulting in infant mortality is twice as high as other ethnic groups and in fact the problem is so “endemic in black communities in Alameda County, California, that numerous programs have been developed over the past decade to reduce maternal risk factors and eliminate barriers to prenatal care.” Additionally related in this work is the well-established fact that “antecedents of birth-weight and non-birth-weight specific mortality are multifactorial and complex. The research generally fits into three categories: epidemiologic study, prenatal care promotion and clinically oriented ethnomedical research.” (Gates-Williams, Jackson, Jenkins-Monroe and Williams, 1992) Ethnomedical studies are those related to ‘folk medicine’ or ‘traditional medical beliefs and practices of cultural groups.” (Gates-Williams, Jackson, Jenkins-Monroe and Williams, 1992) the focus on these types of studies is upon the “traditional medical systems that diverge from the biomedical model of the disease. All of these studies, however, have important clinical and policy implications.” (Gates-Williams, Jackson, Jenkins-Monroe and Williams, 1992) Furthermore, the studies may potentially challenge current misconceptions and cultural biases regarding overrepresented populations in data on infant mortality rates. Smith (1990) in a study on ‘prenatal care promotion’ relates findings that the health care system is “uncoordinated and inadequate to meet demand and recommends targeting high-risk interventions with emphasis on prenatal education.” (Gates-Williams, Jackson, Jenkins-Monroe and Williams, 1992) in a separate study Johnston et al. (1978) reports an ethnomedical study relating to the sociodemographic and medical conditions of women as well as cultural beliefs about reproductive health and contraception and states findings that “reproductive folklore influences incorrect and inadequate information among high-risk pregnant patients.” (Gates-Williams, Jackson, Jenkins-Monroe and Williams, 1992) in yet another study conducted by Snow and Johnson (1978) it is reported that an ethnomedical study was conducted relating to “socio-demographic conditions of women and cultural beliefs about menstruation and states findings that “women are victims of their reproductive folklore” (Gates-Williams, Jackson, Jenkins-Monroe and Williams, 1992) and that this folklore has the power to influence negative health practices as well as compliance among these patients. The Institute of Medicine, Committee to Study Outreach for Prenatal Care (1988) conducted a prenatal care promotion study focusing on the socio-demographic and medical conditions of women as well as prenatal behavior and cultural beliefs. Findings are stated by the Institute of Medicine study that further initiatives should target a culturally sensitive, high-risk-health education and media campaign as well as eliminate financial and system barriers and institute universal maternity care. The study reported by Kotch (1986) conducted on prenatal care promotion focusing on the socio-demographic condition of women, prenatal care, and cost efficiency along with prenatal behavior states findings that requirements exist for improving the social conditions of the childbearing population in combination with development of universal maternity care as part of a national health program in the United States. The work of Boone (1989) reports an epidemiological/anthropological study relating to the socio-demographic, medical conditions and prenatal behavior of women. Findings in this study state the need for development of “innovative prenatal care and targeted outreach for high-risk women…[and]…culturally relevant programs. The study of Emanuel et al. (1989) is a study that focuses on theoretic policy as relating to the childhood and current pregnancy of women and the socio-demographic conditions and states findings that further study relating to biologic mechanisms of infant mortality should be focused upon in keeping programs for women and children.
SOCIAL COGNITIVE THEORY
Social Cognitive Theory has as its main construct learning through behavioral change with the main independent construct being personal factor, behavior and environment. This theory provides a framework that assists in understanding human behavior related to changing human behavior as well as for prediction of human behavioral changes. The Social Cognitive theory identifies human behavior as an interaction occurring between personal factors of the individual, the initial’s behavior nd the environment. (Bandura, 1977; Bandura, 1986)
This model holds that interaction between the individual and the behavior affects the individual’s actions and thoughts while the interaction between the individual and the environment develops and changes the individual’s thoughts and actions relating to the beliefs and cognitive competencies of the individual, which are developed and changed by social influences and environmental structures. The third interaction is between the environment and the behavior of the individual in which the individual’s behavior determines the aspects of the environment and the behavior is modified by the environment. Miller and Dollard first proposed the theory of social learning in 1941 and in 1963 Bandura and Walters expanded the social learning theory with observational learning and vicarious reinforcement principles. In 1977 Bandura added the concept of self-efficacy. The Social Cognitive Theory relates to health communication and cognitive, emotional aspects of behavior and understanding behavior focused toward behavioral change. Social Cognitive Theory is also useful in areas such as psychology in which new insights and understanding are needed. The work of Glanz et al. (2002) states the following concepts of the Social Cognitive Theory:
Environment: Factors physically external to the person; Provides opportunities and social support;
Situation: Perception of the environment; correct misperceptions and promote healthful forms;
Behavioral capability: Knowledge and skill to perform a given behavior; promote mastery learning through skills training;
Expectations: Anticipatory outcomes of a behavior; Model positive outcomes of healthful behavior;
Expectancies: The values that the person places on a given outcome, incentives; Present outcomes of change that have functional meaning
Self-control: Personal regulation of goal-directed behavior or performance; Provide opportunities for self-monitoring, goal setting, problem solving, and self-reward;
Observational learning: Behavioral acquisition that occurs by watching the actions and outcomes of others’ behavior; Include credible role models of the targeted behavior;
Reinforcements: Responses to a person’s behavior that increase or decrease the likelihood of reoccurrence; Promote self-initiated rewards and incentives;
Self-efficacy: The person’s confidence in performing a particular behavior; Approach behavioral change in small steps to ensure success;
Emotional coping responses: Strategies or tactics that are used by a person to deal with emotional stimuli; provide training in problem solving and stress management; and Reciprocal determinism: The dynamic interaction of the person, the behavior, and the environment in which the behavior is performed; consider multiple avenues to behavioral change, including environmental, skill, and personal change.
The following figure illustrates the Social Cognitive Theory Conceptual Model.
Social Cognitive Theory Conceptual Model
Source: Pajares (2002)
The Social Cognitive Theory is useful in the conception of the design of health education initiatives and health behavior programs. This theory is useful in describing how individuals acquire and maintain specific behavioral patterns and is useful as well in the provision of the basis for strategies focused toward intervention. This type of social learning is one that proposes that individuals learn from each other through observation, imitation and modeling. Through observation of the behavior of others, the attitudes of others and the outcomes associated with those behaviors the individual is able to learn through a process of modeling. Necessary for effective modeling are the following conditions:
1) Attention — ” various factors increase or decrease the amount of attention paid. Includes distinctiveness, affective valence, prevalence, complexity, functional value. One’s characteristics (e.g. sensory capacities, arousal level, perceptual set, past reinforcement) affect attention;
2) Retention — ” remembering what you paid attention to. Includes symbolic coding, mental images, cognitive organization, symbolic rehearsal, motor rehearsal;
3) Reproduction — ” reproducing the image. Including physical capabilities, and self-observation of reproduction;
4) Motivation — ” having a good reason to imitate. Includes motives such as past (i.e. traditional behaviorism), promised (imagined incentives) and vicarious (seeing and recalling the reinforced model)
It was the belief of Bandura that the individual’s behavior and the world are causative of each other. This was termed ‘reciprocal determinism’ by Bandura. Behaviorism holds that the individual’s environment causes the individuals’ behavior however, in the view of Bandura this explanation was too simple leading him to posit that the individual’s behavior causes specifics in the individual’s environment as well. This theory is closely related to the Social Development Theory of Vygotsky.
The work of Frank Parajes relates that the individual’s belief of ‘self-efficacy’ has the power to enhance the accomplishment of the individual in numerous ways. Self-efficacy beliefs..” influence the choices people make and the courses of action they pursue.” (Parajes, 2002) Self-efficacy beliefs of the individual are determinative in the effort the individual will put toward an activity and how long they will continue to persevere when obstacles are faced as well as determining the resilience of the individual in situations of adversity. The higher the individual’s sense of efficacy the greater the effort, persistence and resilience of the individual. Parajes states that self-efficacy beliefs further assist in the determination of the “individual’s thought patterns and emotion reactions. High self-efficacy helps create feelings of serenity in approaching difficult tasks and activities. Conversely, people with low self-efficacy may believe that things are tougher than they really are, a belief that fosters anxiety, stress, depression, and a narrow vision of how best to solve a problem. As a consequence, self-efficacy beliefs can powerfully influence the level of accomplishment that one ultimately achieves. This function of self-beliefs can also create the type of self-fulfilling prophecy in which one accomplishes what one believes one can accomplish. That is, the perseverance associated with high self-efficacy is likely to lead to increased performance, which, in turn, raises one’s sense of efficacy and spirit, whereas.” (Parajes, 2002) Parajes relates that the: “…mediational role that judgments of self-efficacy play in human behavior is affected by a number of factors.” (Parajes, 2002) it is not considered unusual for the individual to either over- or under-estimate their own abilities and the experience the consequences of this error in judgment.
Self-efficacy beliefs are formed by the individual through interpretation of information derived from four primary sources, which include mastery experience. It is related that individuals “engage in task and activities, interpret the results of their actions, use the interpretations to develop beliefs about their capability to engage in subsequent tasks or activities, and act in concert with the beliefs created. Typically, outcomes interpreted as successful raise self-efficacy; those interpreted as failures lower it.” (Parajes, 2002) Individuals further form self-efficacy beliefs through the ‘vicarious experience’ of observing others perform tasks and while “this source of information is weaker than mastery experience in helping to create self-efficacy beliefs…when people are uncertain about their own abilities or when they have limited prior experience, they become more sensitive to it.” (Parajes, 2002)
The third way in which individuals form self-efficacy beliefs is “as a result of the social persuasions they receive from others. These persuasions can involve exposure to the verbal judgments that others provide. Persuaders play an important part in the development of an individual’s self-beliefs. But social persuasions should not be confused with knee-jerk praise or empty inspirational homilies. Effective persuaders must cultivate people’s beliefs in their capabilities while at the same time ensuring that the envisioned success is attainable. and, just as positive persuasions may work to encourage and empower, negative persuasions can work to defeat and weaken self-efficacy beliefs. In fact, it is usually easier to weaken self-efficacy beliefs through negative appraisals than to strengthen such beliefs through positive encouragement.” (Parajes, 2002)
The four ways in which self-efficacy beliefs are formed is through somatic and emotional states such as “anxiety, stress, arousal, and mood states” which also provide information about efficacy beliefs. Social Cognitive Theory holds that if the individual believes they are capable that they will thereby become capable by learning from others. Since the introduction of self-efficacy by Bandura in 1977, research has successfully demonstrated that the individual’s self-efficacy beliefs “powerfully influence their attainments in diverse field.” (Parajes, 2002) Research has been generated by self-efficacy in areas “as diverse as medicine, athletics, media studies, business, social and political change, psychology, psychiatry, and education.” (Parajes, 2002) Furthermore, self-efficacy has gained prominence in study focusing on “educational constructs such as academic achievement, attributions of success and failure, goal setting, social comparisons, memory, problem solving, career development, and teaching and teacher education.” (Pajares, 2002)
The work of Johnson, et al. entitled: “Recommendation to Improve Preconception Health and Health Care – United States: A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care” is a report that makes recommendations for improvement of both preconception and health care. The CDC developed the recommendations in the respond based on a review of published research findings and the opinions of CIC/ATSDR Preconception Care Work Group specialists and the Select Panel on Preconception Care. There are four goals stated and an accompanying ten recommendations for achieving these four goals. The four goals are to:
1) Improve the knowledge and attitudes and behaviors of men and women related to preconception health;
2) Assure that all women of childbearing age in the United States receive preconception care services (i.e. evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health;
3) Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother and her future children; and 4) Reduce the disparities in adverse pregnancy outcomes. (Johnson, et al., nd)
Preconception care “aims to promote the health of women of reproductive age before conception and therefore improve pregnancy related outcomes. Therefore it can be understood that the goal of the research reported by Johnson et al. Of the CDC is to bring about improvement prior to having conceived the child thereby negating greatly the risk of infant mortality. The recommendations that arose from the CDC study reported by Johnson et al. include those as follows:
1) Individual responsibility across the lifespan;
2) Consumer awareness;
3) Preventive visits;
4) Interventions for identified risks, 5) Interconception care, 6) Prepregnancy checkup, 7) Health insurance coverage for women with low incomes, 8) Public health programs and strategies, 9) Research, and 10) Monitoring improvements.” (Johnson, et al., nd)
Preconception care should ideally an “essential part of primary and preventive care, rather than an isolated visit. Women who are of childbearing age are known to suffer from chronic conditions of a various nature as well as being exposed to substances that may have an adverse effect on pregnancy outcomes which may lead to miscarriages, infant death, birth defects and other various complications for both mothers and infants alike. Many times the greatest affect to the development of the fetal and the subsequent outcomes are incidents of non-care, or lax care during the period of time prior to the woman even knowing that she is pregnant. Social determinants of women’s health also play a role in pregnancy outcomes.
SUMMARY and CONCLUSION
The literature reviewed in this study has found that there is an excessively high rate of infant mortality in the five health districts in the state of Georgia reviewed in this study. The infant mortality rate has been found to be an indicator of the overall poor health of African-American women in the state of Georgia. Infant mortality has also been found to be linked to factors which include African-American women conceiving at very young ages, the poor health and nutritional status of the mother, infections including reproductive tract infections and periodontal infections, substance abuse, closely-spaced pregnancies, inadequate prenatal care, inadequate folic acid intake, and positioning babies wrong for them to sleep. (Georgia Department of Human Resources, 2000) While infant mortality rates have been reduced in Georgia there is still much that can be done to reduce this rate further. The five-health district with the highest infant mortality rate in the state of Georgia are: (1) Dekalb Health District; (2) North Central Health District (Macon); (3) East Central Health District (Augusta); (4) West Central Health District (Columbus); and (5) Southwest Health District (Albany). While genetics has been shown to play a role in infant mortality, it is believed that poor health care during the lifetime of the mother is the largest contributing factor to infant mortality rates. Financial stability also plays a great role in infant mortality rates since those who are not financially stable generally do not have access to prenatal care. Visits to prenatal health care allows the woman to receive advice and counseling concerning their health care during pregnancy and reduces the hospital costs at the time the infant is born. One problem that has been noted in this study is the changing of eligibility requirements in the state of Georgia enacted by Governor Perdue (Ashman,2005). Government estimates are that 12,500 women will lose prenatal care due to these changes in eligibility. There has been a solution proposed in Atlanta Georgia by the Children’s Healthcare organization in which hospitals in Atlanta would provide free monthly screening however, this is dependent upon fund-raising ability of this group. The problem with access to healthcare has long been a problem and appears to be entangled with the Jim Crow South. Furthermore, instead of the public seeking a solution or making investments to aid African-American women in overcoming the high infant mortality rate, this problem has been historically held that African-Americans have a high death rate anyway which allowed for the pressing problems of infant mortality among African-American women to be ignored. (Hoffman, 2001) the National Center for Chronic Disease Prevention and Health Promotion states findings that a ‘Racial Ethnic Variation’ among African-American infants exist and that the main contributors to the excess morality rate among these infants are “the high rate of very low birth weight and the excess rate of postneonatal mortality among normal birthweight babies. Although very low birthweight infants represent a tiny fraction of all lives births in the United States they account for almost two-thirds of the disparity in infant mortality between African-Americans and whites. The majority of all very low birth-weight infants are born as a result of preterm delivery.” (National Center for Chronic Disease Prevention and Health Promotion, 1997) Further, the more prematurely born the infant, the more difficulty in medical treatment of that infant. The report additionally states that approximately 25% of the gap in infant mortality between the white and African-American race is derived from deaths “among normal birth-weight babies, many of whom survive the first 28 days of life but die during the postneonatal period. Patterns of postneonatal mortality suggested that with few exceptions, such as congenital birth defects, excess deaths among normal birth-weight black infants generally resulted from potentially preventable causes such as infections, injuries, and sudden infant death syndrome (SIDS).” (National Center for Chronic Disease Prevention and Health Promotion, 1997) Study of the African-American experience of infants born in families of college-educated women and families in which the women have “occupational stability, health insurance, access to services, and early entry into care” has been conducted. Similar mortality rates among African-American and white infants born to college educated mothers existed for many causes and this included infant mortality from SIDS, injuries and respiratory disease. The findings state however, that among infants born to this group of college-educated parents that infants “born to African-American college graduates had an 80% higher risk of dying during their first year of life than babies born to white college graduates. This excess was related most notably to a three times higher rate of very low birth-weight in the African-American than in the white college educated population. Thus, the disparity in the very low birth-weight rate for infants of African-American college educated parents is almost as large as for the general population.” (National Center for Chronic Disease Prevention and Health Promotion, 1997) the risk that African-American women will have a baby with low birth weight resulting in infant death is twice as high as other ethnic groups. This work has reviewed the study conducted by the Institute of Medicine, Committee to Study Outreach for Prenatal Care (1988) conducted a prenatal care promotion study focusing on the socio-demographic and medical conditions of women as well as prenatal behavior and cultural beliefs. Findings are stated by the Institute of Medicine study that further initiatives should target a culturally sensitive, high-risk-health education and media campaign as well as eliminate financial and system barriers and institute universal maternity care. The study reported by Kotch (1986) conducted on prenatal care promotion focusing on the socio-demographic condition of women, prenatal care, and cost efficiency along with prenatal behavior states findings that requirements exist for improving the social conditions of the childbearing population in combination with development of universal maternity care as part of a national health program in the United States. The work of Boone (1989) reports an epidemiological/anthropological study relating to the socio-demographic, medical conditions and prenatal behavior of women. Findings in this study state the need for development of “innovative prenatal care and targeted outreach for high-risk women…[and]…culturally relevant programs.
This work has reviewed the Social Cognitive Theory of Bandura, which has as its main construct that learning takes place through behavioral change. This theory provides a framework not only for understanding the behavior of humans but as well for changing the behavior of humans through the individual’s interaction with their environment and the impact on the individual’s resulting behavior.. The Social Cognitive Theory relates to health communication and cognitive, emotional aspects of behavior and understanding behavior focused toward behavioral change. Social Cognitive Theory are also useful in areas such as psychology in which new insights and understanding are needed. The concepts of this theory include elements of: (1) environment, or the factors that are physically external to the individual in providing support and opportunities; (2) situation, or the individuals perception of the environment and the correction of misconceptions and the promotion of health; (3) Behavioral capability or the knowledge and skills to perform a given behavior; (4) expectations or the anticipated outcomes of a behavior; (5) Self-control, or the ability of the individual to self-regulate or self-direct behavior; (6) observational learning or the individual self-modeling their own behavior following observation of others; and (7) reinforcement, or the promotion of self-initiated incentives; (8) self-efficacy; (9) emotional coping responses and (10) reciprocal determination. Application of the Social Cognitive Theory is useful in the conception of the design of health education initiatives and health behavior programs. This theory is useful in describing how individuals acquire and maintain specific behavioral patterns and is useful as well in the provision of the basis for strategies focused toward intervention. This type of social learning is one that proposes that individuals learn from each other through observation, imitation and modeling. Through observation of the behavior of others, the attitudes of others and the outcomes associated with those behaviors the individual is able to learn through a process of modeling.
Recommendations of this study are that these five health districts in Georgia utilize the social cognitive theory in the initiative to address and reduce the infant mortality rate in these five health districts in the state of Georgia. Through empowering these women and enabling their self-efficacy these women will be empowered in the choices that they make concerning their health, which will impact the infant mortality rate. Parajes ahs informed this study of the fact that the higher the individual’s sense of efficacy “…the greater the effort, persistence and resilience of the individual. Parajes states that self-efficacy beliefs further assist in the determination of the “individual’s thought patterns and emotion reactions. High self-efficacy helps create feelings of serenity in approaching difficult tasks and activities. Conversely, people with low self-efficacy may believe that things are tougher than they really are, a belief that fosters anxiety, stress, depression, and a narrow vision of how best to solve a problem. As a consequence, self-efficacy beliefs can powerfully influence the level of accomplishment that one ultimately achieves. This function of self-beliefs can also create the type of self-fulfilling prophecy in which one accomplishes what one believes one can accomplish. That is, the perseverance associated with high self-efficacy is likely to lead to increased performance, which, in turn, raises one’s sense of efficacy and spirit, whereas.” (Parajes, 2002) Self-efficacy beliefs are formed by the individual through interpretation of information derived from four primary sources, which include mastery experience. It is stated by Parajes that individuals “engage in task and activities, interpret the results of their actions, use the interpretations to develop beliefs about their capability to engage in subsequent tasks or activities, and act in concert with the beliefs created. Typically, outcomes interpreted as successful raise self-efficacy; those interpreted as failures lower it.” (Parajes, 2002) Individuals further form self-efficacy beliefs through the ‘vicarious experience’ of observing others perform tasks and while “this source of information is weaker than mastery experience in helping to create self-efficacy beliefs…when people are uncertain about their own abilities or when they have limited prior experience, they become more sensitive to it.” (Parajes, 2002) Through interaction with public health nursing staff who assisting these women with attaining better health for themselves and a resulting better health for their offspring and the reduction of infant mortality rates these women and future generations of African-American women in these five health districts in Georgia will be positively affected.
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