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 Leveraging Partnerships to Close Gaps: A Peek into the Life Course Indicator Narratives

By Andria Cornell
Program Manager, Women's and Infant Health, AMCHP

Jennifer Leone
Intern, Women's and Infant Health, AMCHP

AMCHP released a set of life course indicators late last year – so what’s been happening since then? AMCHP has been adding indicator narratives to the Life Course Indicators Online Tool, and working with states to design and provide trainings around calculating the indicator set.  This article will highlight four of the life course indicators: Voter Registration, Experiences of Race-Based Discrimination or Racism among Women, Bullying, and Adverse Childhood Experiences (ACEs). Why are these topics important in a life course framework?

  • These four indicators represent the breadth of the indicator set, and their measurement brings these nontraditional measures of risk or protective factors, capacity, and outcomes under the umbrella of those important to the MCH population and the programs and systems that serve them.
  • Each of these topics has implications for equity and are marked by significant disparities.
  • Diverse and complex partnerships and collaborations are required to close gaps and  see improvement in the indicators.  The level of systems integration and partnership required is consistent with the changing MCH landscape and the Title V MCH Services Block Grant.

The following text has been excerpted from the Leverage and Realign Resources sections of the indicator narratives developed by state teams and refined and adapted based upon external feedback. AMCHP continues to add completed narratives to the online tool on a rolling basis, but the narratives for these four indicators are currently available. Download them today!

Voter Registration
Narrative: PDF
Social Capital
Numerator: Number of adults registered to vote
Denominator: Total eligible population
Data Source: Current Population Survey (CPS)
Similar Measures in Other Indicator Sets: None
National Comparison: 71.20%, 2012

Social capital is a hard concept to measure. Measures of civic engagement help by serving as proxy measures that quantify levels of social capital within and across populations. Voter registration is a conventional proxy for measures of civic engagement (Mercyhurst Center, 2011) and can serve as an indicator of social capital within and across populations. Initiatives to improve voter registration can attract new partnerships into public health practice, including community organizers, social justice groups, civic groups, and civil rights advocates. Of note, the Affordable Care Act includes a requirement that health exchanges adhere to the National Voter Registration Act and provide information on voter registration (Sink, 2013). Voter registration information integrated into exchange enrollment provides a new opportunity to increase civic engagement and empower community members.

Experiences of Race-Based Discrimination or Racism among Women
Narrative: PDF
Discrimination and Segregation
Numerator: Number of women who answer Yes to the question “During the 12 months before your new baby was born, did you feel emotionally upset (for example, angry, sad or frustrated) as a result of how you were treated based on your race?”
Denominator: Total number of women who recently had a live birth
Data Source: Pregnancy Risk Assessment Monitoring System (PRAMS)
Similar Measures in Other Indicator Sets: None
National Comparison: 8.80%, 2009-2011 (Phase 6; calculated using states included in the national dataset)

Betancourt et al defined a framework for cultural competence that addresses barriers to appropriate care at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels (Betancourt et al 2003). Experiences of racism occur at all levels of patient interaction, therefore, work to ensure culturally and linguistically appropriate care must extend beyond just the provider-patient relationship. All members of facility or practice staff should be included in training and implementation of cultural competence. Health care systems can also engage community services that work to eliminate racism to develop programs for their institutions. Efforts to address the experiences of discrimination in health care and health research have utilized the concepts of “undoing racism” and community-based participatory research (CBPR) to begin the conversations around racism and begin to establish trust (PISAB 2013, Yonas et al 2006). Efforts to “un-do” racism and achieve equity require more than a short-term training and will include an authentic partnership between care providers, public health, and communities, including community leaders, to improve experiences of care and equity in health care in the long term.

Narrative: PDF
Discrimination and Segregation
Numerator: Number of 9th through 12th grade students (12-17 years) who reported having been bullied on school property or electronically during the past 12 months.
Denominator: 9th through 12th grade student population (12-17 years)
Data Source: Youth Risk Behavior Surveillance System (YRBSS)
Similar Measures in Other Indicator Sets: Healthy People 2020 focus area IVP-35.
National Comparison: 25.50%, 2011 

While bullying is not a new issue for programs serving youth, the awareness of the harmful effects of bullying and understanding of the risk factors is relatively new. The Task Force on Community Preventive Services found strong evidence that universal, school-based programs decrease rates of violence among school children. These programs were delivered to all children in a particular grade or school, regardless of prior violence or risk of violence, and effects of the program were found at all grade levels. The Task Force on Community Preventive Services has recommended the implementation of universal, school-based programs to prevent violent behavior, including bullying. Expanded bullying education programs for students and staff are needed in order to address this public health issue. Continued research will contribute to a better understanding of bullying risk factors and the development of effective interventions. Further school funding is needed for programs that identify support mechanisms for current bullying victims and educate students and staff on the severe impacts of bullying.  

Adverse Childhood Experiences (ACEs)
Narrative: PDF
Childhood Experiences
Numerator: Number of children whose parents responded to the National Survey of Children’s Health (NSCH) that their children were exposed to adverse childhood experiences (9 questions related to ACEs)
Denominator: Total number of children
Data Source: NSCH
Similar Measures in Other Indicator Sets: MIECHV Benchmark Area Reduction in Crime or Domestic Violence: Screening for domestic violence|
National Comparison: 0 Adverse Childhood Experiences= 52.07%
1 Adverse Childhood Experience= 25.32%
2 or More Adverse Childhood Experiences= 22.61%, 2011-2012

ACEs information provides opportunities for data-driven approaches to improving both pediatric and adult primary care. This may include mental and physical health risk screening in childhood and beyond. Innovative public health partnerships in relation to ACEs include collaborations with mental/behavioral health services, child abuse/neglect programs, and law enforcement. Additionally, the assessment of ACEs risks within the MCH community could be of use for other public health promotion and disease prevention programs including chronic disease and communicable/sexually transmitted disease (Fine and Kotelchuck 2010; Shonkoff et al 2009; Foege 1998). Protective factors (e.g., child’s positive relationship with a caring adult, easy temperament of the child, health insurance coverage for the child) can be more important than risk factors as they mitigate the negative effects of risk factors such as ACEs (Werner and Smith 1992). Public health and other partners could work together to support policy and program interventions that pay more attention to leveraging support for positive factors.