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INFANT MORTALITY ADVOCACY TASK FORCE Rev. Tom Rodgers - Chair

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FINAL IMPLEMENTATION REPORT

Project Term: September, 2008-September, 2010 __________________________________________

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The following individuals participated in all or some portion of the advocacy period of the Infant Mortality Task Force. Their diligence and dedication are sincerely appreciated. Rev. Tom Rodgers, Chair Subcommittee Chairs: Vicki Abrams Joy Burgess Anthony Butler Sandra Cook Bobbie O’Connor Steve Sepe Delphia Williams

Task Force Members: Tempie Alexander Wakilah Augustus David Bailey Shakera Bailey Steve Baker Dale Bell Kathy Bowles Vanessa Boyer Carol Brady Ronnie Cage

Meredith Chartrand-Frisch Dawn Clarke Rev. Alton Coles Cleshawn Cooks Helen Crawford Rae Davies Melodie Dove Lawrence DuBow Dawn Emerick Donna Ghanayem Jeffrey Goldhagen

Etoile Graves-Smith Loretta Haycock Toni Herndon Sarah Holdstein Kathy Ingram Helen Jackson Jack Johnson Casey McConnell Janet McDonald Julia Pickren Tala Reynolds

Karen Smithson Wilma Starks Carol Synkewecz Jackie Thompson Allison Vega Lowrie Ward Patricia Washington Julia Watkins Tonya Watts Karen Wolfson

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SUMMARY OF IMPLEMENTATION PROJECT A sentinel indicator of a community’s health, the infant mortality rate measures the number of children live-born who die before their first birthdays, expressed as a rate per 1000 children born. It was shocking for the Jacksonville community to discover three years ago when the JCCI study commenced that its infant mortality rate is among the worst in Florida, which is near the bottom of the 50 states. In turn, the United States ranks below nearly all other industrialized nations in the world. In short, Jacksonville’s infant mortality problem is akin to that of a thirdworld country, and the infant mortality rate here is nearly twice as high among African Americans as whites. A number of community organizations in Northeast Florida have been working tirelessly for many years to address the disturbing infant mortality issue. As the JCCI Infant Mortality study determined, however, most of the emphasis of these organizations has traditionally been focused on the period of time when the expectant mother becomes pregnant through the birth of the baby. One of the study’s primary conclusions was that the health of the mother from birth throughout her life cycle is critical in determining her pre-disposition for delivering a healthy baby. Jacksonville lacks a holistic life-course approach to women’s and girls’ health, which often leads to poor birth outcomes, and differences in the health of the mother before pregnancy contributes significantly to the disparity in infant mortality between blacks and whites. The study also found that central to the life-long health of black women and other minorities is the impact of racism, poverty, and socio-economic disparities. Racism and living in poverty cause chronic stress which takes a cumulative and insidious toll on a woman’s health, ultimately leading to a high percentage of poor birth outcomes. Areas of the city which have high rates of unemployment, poverty, and poor overall health outcomes are, not surprisingly, the same areas with the highest infant mortality rates. A series of 15 recommendations to address these and other issues were provided by the Infant Mortality Study Committee, ably chaired by Howard Korman, which was released to the community in June, 2008. Some of them were related to long-term societal changes such as reducing racism and poverty, while others were more specific in offering action steps for providing more immediate ways of helping reduce the infant mortality rate in Jacksonville. The 50-member Infant Mortality Advocacy Task Force, which I was privileged to lead, began its work in the summer of 2008. The Task Force was divided into five subcommittees with each assuming responsibility for one or more of the study’s recommendations. The full Task Force met quarterly, and the subcommittees met separately on numerous occasions, including many individual meetings with a wide range of stakeholders, elected officials, and prominent civic leaders throughout Northeast Florida. This Final Implementation Report reflects the hard work and dedication of the Task Force throughout its two-year term. In all, eight recommendations were fully implemented, three 3


were partially implemented, and four have not yet been implemented (some due to funding issues related to the severe economic recession). As is the norm in JCCI implementation projects, the Task Force frequently deflects direct credit for accomplishments to the community group or agency assisting in the work. So, while the citizen volunteers of the Task Force often work in anonymity, they have assisted in making many positive things happen much more than initially meet the eye. Results released this fall indicate there is cause for cautious optimism. Improvements from 2009 in both the white and black infant mortality rates in Duval County have been realized, and the total Duval County rate of 8.4 deaths per 1000 live births is below 9.0 for the first time on record (see appendix 1). The rate among blacks fell from 13.9 to 13.6, and among whites from 7.1 to 5.5, both of which are encouraging. But while we are pleased that the rate among blacks declined, our enthusiasm is tempered somewhat by the fact that the disparity gap between blacks and whites increased from 6.8 to 8.1, due to the 22.5% decrease in the white rate. On balance, however, grass-roots efforts to address Jacksonville’s alarming infant mortality problem appear to be taking hold. While it is certainly premature to consider the recent results a trend, we are nonetheless heartened that the increased focus on the issue, resulting at least in part from JCCI advocacy activities, is helping to establish long-term successes. Even one infant death is too many, and you can be assured that none of the dedicated individuals involved in the JCCI project will be satisfied until our infant mortality rate drops well below state and national averages. I would be remiss in not offering a special thank you to The Chartrand Foundation, a local philanthropic organization, and to a group of young philanthropists at The Community Foundation in Jacksonville. Both groups provided significant financial support to infant mortality efforts during our advocacy work, and they are to be applauded for their invaluable assistance in the development of new programs that have improved the long-term outlook for meaningful declines in the City’s infant mortality rates. My sincere thanks go also to each of the 49 persons who participated with me on the Infant Mortality Task Force, and particularly to the subcommittee chairs (Vicki Abrams, Joy Burgess, Anthony Butler, Sandra Cook, Bobbie O’Connor, Steve Sepe, and Delphia Williams) who guided their efforts. All of them share a unifying desire to see infant mortality eliminated in Jacksonville, and I’m certain their dedication to the cause will not diminish in the years to come.

Rev. Tom Rodgers Chair Infant Mortality Advocacy Task Force October, 2010

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RECOMMENDATIONS AND OUTCOMES OF ADVOCACY EFFORTS

Recommendation 1: The City of Jacksonville should seed an Ombudsperson program, fashioned after the model of the St. Johns Riverkeeper, to represent and advocate for the interests of children and the women who will bear the children, at all levels of governmental policy and actions. The Ombudsperson should make regular reports to the community. Considerable background work was undertaken by the Task Force during its term to determine the best way to establish an Ombudsperson program in Jacksonville. Unfortunately, the effort coincided with the nation’s economic recession and was ill-timed from a fund-raising standpoint. While such a program is not likely to be embraced until a turnaround in the economy has been achieved, the general parameters have been established and can be advanced at the most opportune time. The general framework of an Ombudsperson program for children and women are as follows:  An Ombudsperson representing and advocating for children and maternal issues should manifest a presence at all levels of government and regularly make reports to the community.  The Ombudsperson should be an independent institution, guided by the best interests of the child, able to monitor and evaluate all proposed actions that will impact children.  The St. Johns Riverkeeper provides a good model for the Ombudsperson.  Outside “seed money” will be necessary to found this institution.  Many of the current ideas come from the Convention of the Rights of the Child (1989) adopted by the General Assembly of the United Nations – it is a rights-based framework.  Local pediatrician Dr. Jeff Goldhagen has developed a “tool kit” to provide the framework for the Ombudsperson program (e.g., Legal Assessment, Health Impact Assessment, Analysis of Budget and Decisions).  The Ombudsperson will need to: - Have sufficiently high qualifications to guarantee credibility, respect and authority - Receive an appointment that cannot be terminated without exceptional cause - Receive independent and continuous funding (presumably from business and/or citizen sources) - Have full access to government statistics and records - Be housed in an office adequately supplied and funded - Be able to investigate individual complaints and have authority to monitor data at the system level - Be able to make recommendations to the Mayor and City Council that will impact change on the system level 5


So, while an Ombudsperson program has not yet been established in Jacksonville, a working model has been developed and could be implemented relatively quickly in a more favorable economic climate. It will be important to effectively advocate the importance of the position to the next administration at the appropriate time. A sustained advocacy effort for an Ombudsperson program by the Jacksonville Children’s Commission, Northeast Florida Healthy Start Coalition, and other impacted stakeholders is necessary as the JCCI project concludes. Result:

Not yet implemented -

X

Recommendation 2: The Mayor, City Council, and the Duval Delegation should lead and support efforts, including funding, to expand access to health care services that are relevant, accessible, and available to all citizens to: a. expand the Federally Qualified Family Health Centers in Jacksonville to provide greater access to preconceptional (prior to pregnancy) and interconceptional (between pregnancies) care for women, and; b. explore the possibilities of One-Stop Family Resource Centers, especially in low-income neighborhoods. While there has been little movement at the local or state levels in regard to expansion of health care services for women who lack health insurance, the landscape will change considerably once Federal health reform takes full effect. Primary health care for the previously uninsured is a fundamental aspect of the legislation. Women of childbearing age, in particular, are expected to benefit from expanded insurance coverage available throughout the Affordable Care Act (ACA) of 2010. Women, age 15-44, are more likely than their male counterparts to be uninsured and face higher insurance premiums because of risks associated with pregnancy. There are currently two Federally Qualified Health Centers (FQHC’s) in Jacksonville: Agape Health Center, and the Sulzbacher Health Center. Primary discussions have been initiated to establish a third FQHC site at the proposed Gateway Medical Plaza. While there is significant potential to expand services in the long-term, short-term budget cuts have resulted in reduced access to primary care services. The Duval County Health Department recently eliminated women’s health services, including primary care, at several clinics. There has, however, been excellent progress in Jacksonville regarding expansion of Family Resource Centers due to the combined efforts of Family Support Services (FSS) and the Department of Children and Families (DCF). After receiving community input and technical assistance from Casey Family Program on what makes neighborhood centers work, FSS and DCF have teamed up to support three family centers: Cassat House; Schell Sweet Center; and Brentwood Library. The centers are in different stages of development, with Cassat and Schell Sweet more mature at this point, while Brentwood is a grassroots collaboration with Jacksonville Public Library.

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The goals of the Family Resource Centers are to deliver: food assistance/food stamps; domestic violence therapy and training; substance abuse therapy and training; job preparation training; parenting training; etc. As Jacksonville emerges from the severe economic downturn, continued diligence by local and state government officials is required to identify the funding necessary to expand vital health care services to all women in the community. Result:

Partially Implemented -

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Recommendation 3: To eradicate food insecurity and “food deserts” (areas of the city, most often in high poverty, predominantly black neighborhoods, where no large, completely stocked grocery store exists and fast-food, convenience stores, and “fringe food” proliferate, making a healthy well-balanced diet more difficult to obtain), the City of Jacksonville should encourage fully-stocked grocery stores to locate in zip codes and neighborhoods with high infant mortality rates through tax and other incentive packages so that nutritious food is available, accessible, and affordable to residents to encourage well-balanced diets, lower obesity rates, and better birth outcomes. Grass-roots efforts by the Task Force to address the “food deserts” issue have helped bring attention to the need to find ways to get healthy foods into portions of the city lacking in fullservice groceries. A significant program to allow the use of EBT/Snap cards (Federal Food Stamps) at Jacksonville’s largest farmers’ market (Beaver Street) was the result of the combined efforts of Subcommittee B members, the Chartrand Foundation, Second Harvest Food Bank, and Beaver Street Fisheries. Situated in the heart of the economically disadvantaged Health Zone 1, the Beaver Street Farmers’ Market now provides area residents on Food Stamps with the opportunity to purchase fresh fruits and vegetables not otherwise available in many nearby neighborhoods. When the program was inaugurated in November, 2009, JTA partnered with Second Harvest Food Bank in promoting its free trolley service to the Beaver Street Farmers’ Market by placing ad panels outside and inside buses (Appendix 2). Since transportation options are often limited in the impoverished urban core, the JTA service is an important factor in making the Market accessible to those in food desert areas. Another initiative spearheaded by Lawrence DuBow of the Task Force’s Subcommittee B is called the Nutrition for Mothers, Nourishment for Babies Healthy Food Program. It involves the distribution of healthy bags of food to pregnant women as they leave their prenatal appointments at Shands Jacksonville’s OB/Gyn Clinic (see Appendix 2A). As patients arrive for their appointments, they are provided with a brief educational program on nutrition and healthy foods while in the waiting room, and they are given a healthy food bag as they leave the Clinic. Initiated on April 5, 2010, the program is administered by Second Harvest Food Bank through a grant from Walmart State Foundation.

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In addition, a monthly food distribution program occurs on the Edward Waters College campus as part of the New Town Success Zone project. A collaborative effort between Second Harvest Food Bank and New Town steering committee, the program also includes staff from the Department of Children and Families who are available on food distribution days to accept applications for Food Stamps and Medicaid. Other initiatives to address “food deserts” include the establishment of several community gardens in areas where fruits and vegetables are scarce; and expansion of the WIC food package to include fresh fruits and vegetables. A federally funded health and nutrition program for pregnant women, new mothers, infants, and children under the age of five, WIC provides financial assistance in purchasing healthy foods for those who could not otherwise afford them. Regrettably, a full-service grocery (Bravo Supermarket) which opened in October, 2008, on the city’s North side, closed just seven months later, highlighting the scarcity of food stores where residents can readily obtain fresh fruits and vegetables. Result:

Implemented -

Recommendation 4: The Jacksonville Children’s Commission’s Fathers Make a Difference and the Urban League of Jacksonville should launch a community effort in collaboration with other men’s groups – fraternities, Mad Dads, etc. – to promote men taking responsibility in caring for and supporting women who are bearing children for better health outcomes for mothers and babies. Healthy Start and Healthy Families should stress the importance of men in the lives of women and families. The North Florida Chapter of the E3 Business Group, working closely with Subcommittee E, produced a successful series of community forums focusing on fatherhood issues and the importance of the role of the male partner in raising healthy babies. Real Talk, Real Change, a community dialogue event held at WJCT studios in July, 2009(see Appendix 3), was attended by more than 325 concerned citizens and was viewed online by over 1500 others. The event featured a panel of experts and included frank discussions on issues often swept under the rug and brought together a number of grassroots and professional organizations for the first time in one public environment. Included were NE Florida Healthy Start Coalition, Family Support Services, Duval County Health Department, Jacksonville Birthing Project, and Healthy Mothers Healthy Babies. To further the dialogue, four other smaller forums were held in the aftermath of Real Talk, Real Change, dealing with topics such as absentee fatherhood, parental involvement, and “Ending the Blame Game” which collectively reached an additional 400 citizens and encouraged involvement in local programs which help this work. A second major event – Real Talk, Real Change II – is currently being organized and will be held on January 27, 2010. Its focus will be on the mindset, perceptions, and current racial climate in Jacksonville. The collective efforts of the committee and E3 spurred a number of articles in local newspapers, radio and television exposure, and a variety of internet blogs on the topic of infant mortality. 8


Other local initiatives focusing on fatherhood and male involvement continue to raise awareness of various aspects of the issue throughout the community. Among them are: Boot Camp for New Dads (Shands Jacksonville); Project MALE (Cage Consulting); Real Dad, Real Man (NE Florida Healthy Start Coalition); Responsible Fatherhood (Jacksonville Urban League); Man Up for Health Summit (100 Black Men of Jacksonville); and Mad Dads (national organization headquartered in Jacksonville). Result:

Implemented -

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Recommendation 5: The Duval Delegation should support state legislation to expand evidence-

based sex education for all students in public school to include a comprehensive curriculum taught by certified teachers that is age appropriate and medically accurate, including facts on contraception and how to avoid sexually transmitted infections. Task Force chair Tom Rodgers and JCCI staff member Steve Rankin met with State Representative Mia Jones in January, 2009, to solicit her support of prospective legislation advancing comprehensive health education in public schools. Rep. Jones was and still is the lone Duval Delegation member on the Florida House Education Policy Council. In the meeting, Tom Rodgers stressed the need for more consistent and evidence-based comprehensive health education in schools, including a focus on sex education. Specifically, a request was made to Rep. Jones for her assistance in steering through the Legislature two bills, one requiring a minimum of one semester of health education as a prerequisite for graduation from Florida public high schools; and another providing specifics regarding comprehensive health education, including sex education. Similar bills had been tabled during the 2008 Legislative Session, and they would require a committed steward to avoid being derailed a second time. While it is recognized that one semester of health education is hardly sufficient, we regarded it as critical for high school students to be exposed to at least some range of life management education not being made available to them. Subsequently, Ms. Jones agreed to support House Bills 1503 and 265 (see Appendix 4) and to assist in shepherding them through the legislative process. HB 1503 would require one-half credit in health education; and HB 265, called the Florida Healthy Teens Act, stipulated that any public school that receives state funding and that provides information regarding family planning, pregnancy, or STD’s, shall provide comprehensive, medically accurate, and factual information that is age-appropriate. Such information should help young people gain knowledge about: (a) human maturation and adolescence; (b) the specific involvement and responsibilities of sexual decision making for boys and girls; (c) medically accurate information about the health benefits and side effects of contraceptives; and (d) the value of abstinence while not ignoring those adolescents who have had sexual intercourse and who thereafter may remain sexually active. Despite the support and efforts of Rep. Jones, these bills have not yet survived the Legislative committee process and have regrettably not yet become Florida law. Although improved 9


comprehensive health education is yet to become a reality, we consider this recommendation partially implemented since we have been successful in gaining a champion for the legislation in the Duval Delegation (Rep. Jones). We are optimistic that with her continued support, similar efforts will be successful in the next Legislative Session. Result:

Partially Implemented -

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Recommendation 6: The School Board and Superintendent of the Duval County Public Schools should:  Establish policy requiring the teaching of a comprehensive, evidence-based, age and developmentally appropriate sex education curriculum based on the findings and recommendations of the Centers for Disease Control and Prevention;  Ensure action is taken to determine community and other statutory standards for curriculum in human health and development, including sex and healthy living education; family and consumer science; and physical education for all students.  Prepare and teach – employing a health education certified teacher – a developmentally and age appropriate curriculum to start in elementary school and be repeated annually to prepare all males and females to have healthy babies and become capable and responsible parents; and  Prepare a simplified educational program – in booklet form – for parents, families, churches, and other agencies for the same purposes.

Florida Statutes require that students be “health literate”, by which they mean that they have the ability to “research” health information they might need. The statutes require that health education instruction be aligned with the Sunshine State Standards and dictate the content and course of study. The requirements are to teach abstinence and monogamy – that people have the power to control their behaviors or take the consequences. The Florida Statutes also require that local values and norms have the final say in local public school health education curriculum. Statute 1003.46, dealing specifically with health education, stipulates that health educated curricula include the following:  Teach abstinence from sexual activity outside of marriage as the expected standard for all school-age students while teaching the benefits of monogamous heterosexual marriage.  Emphasize that abstinence from sexual activity is a certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, including AIDS and other associated health problems.  Teach that each student has the power to control personal behavior and encourage students to base actions on reasoning, self-esteem, and respect for others.  Provide instruction and material that is appropriate for the grade and age of the student.

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The Duval County Public Schools’ health education curriculum is aligned with the Sunshine State Standards and is age and developmentally appropriate and evidence-based. All topics required by Statute and recommended by Centers for Disease Control and Prevention (CDC) are included within the curricula. Health education is required in grades K-8, but at the high school level, the only graduation requirement is for completion of one credit of physical education (to include integration of health education). The high school teacher, a physical education instructor, needs no health education skills or background, although the course is allowed to be teamtaught with a health educator. A Life Management Skills class, required at the high school level until recently, is still offered as an elective, but with increased graduation requirements, little room is left in a student’s schedule for this course. It should be noted that DCPS does not teach “abstinence only” sex education, but “abstinence based.” Facts on the prevention of sexually transmitted infections are taught beginning in sixth grade. Information on birth control is included in the health education curriculum starting in seventh grade within the context of marriage and family planning. In keeping with Statute 1003.46, abstinence is taught as the expected standard for all school-age children. In summary, DCPS is required to – and does - follow the Florida Sunshine State Standards regarding comprehensive health education. Florida Statutes provide some leeway, stipulating that local values and norms have the final say in determining curriculum. The School Board engaged the community on the issue of sex education in the early 1990’s and created a major firestorm they are apparently not anxious to repeat. The current abstinence-based curriculum was the compromise position between the two extremes. After nearly 20 years, the Task Force believes it is time to revisit the issue and determine what the community attitude is. While sex education is a controversial subject and convening the community to hash it out will not be a comfortable exercise, we believe the School Board and Superintendent should make the effort necessary to find out whether the health education curriculum is aligned with current community opinion. Having said that, the DCPS health education division is proactive in pushing for comprehensive health education in schools, including support of proposed legislation noted in Recommendation 5 above. We applaud their diligence and dedication to ensuring a well-rounded education for all of Jacksonville’s students. Result:

Partially Implemented -

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Recommendation 7: The Jacksonville Juvenile Justice System should adopt and teach the above developmentally and age appropriate educational program to youth incarcerated or otherwise engaged in the Juvenile Justice System, and the Jacksonville Sheriff’s Office should provide similar instruction to incarcerated adults. An educational booklet as contemplated in Recommendation 6 was not produced and was therefore not available for distribution in the Juvenile Justice System. Result:

Not Yet Implemented -

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Recommendation 8: The Duval County School Board should partner with various agencies – including WorkSource, the Women’s Center of Jacksonville and various other literacy, social service, mental health and faith-based programs – by making available the simplified educational booklet to be taught in conjunction with other adult education and training programs. A community-wide effort should be implemented to educate everyone on responsible sexual behaviors and other habits promoting good health. While a significant number of local agencies actively promote responsible sexual behaviors and other habits involving good health, the educational booklet discussed in Recommendation 6 was not produced and therefore not available to the organizations noted above. Result:

Not Implemented -

X

Recommendation 9: The Duval County Health Department, in partnership with the Healthy Start Coalition of Northeast Florida, in order to reduce fetal and infant deaths, should:  Organize and lead a task force to coordinate and collaborate with all agencies and programs – medical, social service, and governmental – providing services to potential mothers, pregnant women, and mothers with their babies, partners and families;  Share information and coordinate programs so that every woman in Jacksonville has a full range of services to improve birth outcomes;  Ensure that all programs schedule flexible evening hours convenient to working mothers;  Ensure that every woman has a personal medical home (the central point to organize and coordinate her health care based on her needs and priorities) using the Magnolia Project as a care model. Several local non-profit organizations offer resource guides that provide valuable information regarding programs for women and families. United Way, Department of Children and Families, Healthy Start Coalition, Jacksonville Children’s Commission, and others are proactive in distributing literature that documents the agencies and programs offered throughout the community. In addition, some progress has been realized with regard to expanded hours for programs providing services to women and families. Several clinics now offer evening and Saturday hours. Unfortunately, recent funding cuts by the city and state have disrupted progress in this area, and have, in fact, resulted in reduced services for women, including prenatal care, family planning and STI treatment. Three public health clinics operated by the Duval County Health Department ceased treating adults on September 1, 2010 (see Appendix 5) due to a $2.8 million drop in DCHD’s health care services budget. More than 6,000 patients, including many pregnant women, have been forced to seek care elsewhere. While children’s health services are unaffected, adult primary care has been reduced, including those in the Medicaid and uninsured populations who are most at risk.

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This is clearly a disturbing development that threatens progress in efforts to reduce the infant mortality rates in Jacksonville. It provides one of the most disappointing results encountered by the Infant Mortality Task Force. It is critical that as the economic situation in Jacksonville improves over the next several years, funding be made available from city and state sources to restore and improve upon health care services for women. Result:

Not Implemented -

X

Recommendation 10: The Duval County Health Department, the Jacksonville Human Rights Commission, and partners should:  Bring together organizations in Jacksonville whose primary mission focuses on race relations to discuss the impact of racism and racial disparities on infant mortality;  Coordinate community viewings of the documentary series, Unnatural Causes, to open discussions throughout Jacksonville’s CPAC areas and neighborhoods on the implications of inequities in health and infant mortality;  Expand educational materials and programs of the JHRC Study Circles to focus on the disproportionate rate of infant mortality and its root causes based in racism and socioeconomic inequities. The Duval County Health Department and the Jacksonville Human Rights Commission (JHRC) formed a Health Equity Initiative to develop a strategy to improve outcomes in Health Zone 1 (zip codes 32202, 04, 06, 08, 09, and 32254). This work, which is ongoing, is being done with a group of grassroots community leaders. The strategy uses a structural racism lens which focuses on what public policies, social and institutional practices and messages (cultural representations) need to be in place for improvement goals to be achieved. The structural racism lens is a part of Project Breakthrough – Changing the Story of Race in Jacksonville. This Project is a collaborative effort involving OneJax, JHRC, Aspen Institute and the Community Foundation in Jacksonville. While all of this work under girds efforts to reduce infant mortality, some of the defined objectives relate specifically to the issues described in Recommendation 10:  People should be aware of the social and cultural factors that impact their health outcomes as well as programs and resources available to improve them.  People should have access to affordable healthy food choices through education, community gardening, and policy changes.  Health Zone 1 should have an integrated health care delivery system that is readily accessible, affordable, and accountable with health care professionals who are trained in cultural sensitivity. In regard to other portions of Recommendation 10, a coordinated effort between the Duval County Health Department and Jacksonville Human Rights Commission to provide viewings of the Unnatural Causes documentary series was successful, with 15 showings and follow-up discussions held in 2009-10 (see Appendix 6). Group sizes varied from as few as 10 to as many 13


as 100 people. In addition, JHRC included the subject of infant mortality in the curriculum of its Study Circles sessions to enhance awareness of the health disparities present in Jacksonville. Specifically, Study Circles facilitators were asked to distribute the JCCI Infant Mortality Study to participants during the 3rd and 4th weeks of the process and incorporate infant mortality into their discussions on race-related disparities. Result:

Implemented -

Recommendation 11: The Duval County Health Department – in partnership with the print, radio and television media (especially African American focused media), universities, professional public relations groups, and any other appropriate group – should develop and deliver a series of messages, regarding make good choices for better birth outcomes and initiate and coordinate a community-wide education program. Topics to be covered should include: alcohol and tobacco use; contraception and family planning; exercise; life-course health stressors and strategies; male involvement in the family; nutrition, healthy diets, and the importance of taking vitamins; obesity, diabetes, and heart disease; prevention of sexually transmitted infections; safe-sleep practices; strategies to mitigate the stresses of racism; the high infant mortality rate, especially for the black community; and the importance of the health of young girls long before becoming pregnant. Most of the activities documented in the results of Recommendation 15 (below) also positively addresses Recommendation 11. The Make a Noise! Make a Difference! Prevent Infant Mortality campaign was a collaborative effort that involved partnerships within the Healthy Start Coalition’s Black Infant Health Community Council, including the Duval County Health Department and others. Each of the topics highlighted in Recommendation 11 were addressed in the social marketing campaign which occurred over several months in 2009-10. In addition, Subcommittee D worked with local Rotary Clubs to establish a program at Shands and Orange Park hospitals highlighting safe sleep practices. A package of safe sleep educational materials is provided to new mothers upon their release from maternity wards to encourage appropriate behaviors when new-born babies arrive home. Included in the packages are a tee shirt for the infant, a door hangar, a refrigerator sticker, and a shopping bag, all equipped with safe sleep information. Other important, new safe sleep practices programs include Brighter Beginnings, a prenatal education/breastfeeding community outreach campaign conducted by Seton Center for Women and Infants’ Health at St. Vincent’s; and an initiative managed by Healthy Mothers, Healthy Babies to reduce sleep-related deaths by infants by distributing free Pack ‘n Play portable cribs to parents without resources. Both programs are funded by the Chartrand Foundation. Result:

Implemented -

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Recommendation 12: The Duval County Health Department should work with area health-care associations and institutions to ensure that members are educated on current racial disparities in health-care outcomes and treatment and to train medical professionals in best practices to improve health-care delivery for all people. In addition, the Duval County Health Department should lead an effort by all health care professionals who treat women, mothers, and babies to promote and provide good preconceptional and interconceptional education and to care for their patients giving birth. All healthcare professionals should deliberately and explicitly discuss the importance of birth spacing (18 to 24 months), contraceptive practices, hygiene practices, breastfeeding, nutrition, and baby’s safe sleeping practices. Work with health care professionals on a variety of issues relating to infant mortality was a regular occurrence during the term of the project. “Grand Rounds” educational sessions for physicians were held at Baptist Medical Center to advocate for breastfeeding, as well as the impact of racism on infant mortality (see Appendix 7). An international teleconference on children’s health issues was organized by local pediatrician Dr. Jeff Goldhagen and successfully staged in 2009, with representatives from countries around the world participating. Other examples of efforts to influence health care providers included: the Pediatric Resource Advocacy Network was organized, and it conducted meetings, presentations and service/learning projects for implementation. UNF’s Brooks College of Health held a one-day seminar for health professionals on various aspects of childhood obesity, a precursor to poor birth outcomes later in life. The Office of Minority Health sponsored a Jacksonville appearance by national infant mortality spokesperson Tonya Lewis Lee in September, 2009; a Health Equity Center was established at UNF; a Women’s Health Symposium sponsored by BET and Duval County Health Department was conducted with over 900 women in attendance; 20 Americorps members, who are preparing for future careers in health care, were recruited, trained and placed in community partner sites with a focus on disparity reduction; and numerous viewings of the Unnatural Causes television series on public health disparities were offered throughout the health system. Result:

Implemented -

Recommendation 13: The Department of Children and Families should immediately restructure all Medicaid processes and retrain all personnel serving all people including pregnant women to assure expedited, encouraging, and respectful “customer-friendly” services, so that women who may begin their prenatal medical attention without delay. All in-person and telephone contacts with pregnant women should ensure that women can receive prenatal benefits immediately. Through a collaborative effort involving the Department of Children and Families (DCF) and UFShands Medical Center, significant improvements have been made in streamlining the Medicaid application process for pregnant women. DCF met with OB clinic staff personnel at area hospitals to identify ways to improve the Medicaid process. As a result, DCF successfully realigned their processes making it easier for hospital admissions personnel to handle applications more quickly. Public assistance applications now red-flag applicants who are 15


pregnant, allowing the assigned DCF workers to prioritize pregnancy cases and reducing the number of days required for Medicaid processing. DCF has also committed more personnel resources toward this effort, co-locating staff at the Schell Sweet Center in the New Town Success Zone in Health Zone 1. It has also provided funding to Family Support Services to hire support staff to help those applying for public assistance at Cassat House, an outreach center for at-risk children. Shands, located in the middle of Jacksonville’s Health Zone 1 where the highest percentages of Medicaid-eligible women reside, also took decisive action to improve Medicaid processing. Shands now has three employees dedicated to processing Medicaid applications and assisting patients with any problems they may have in being approved for Medicaid. One is assigned to the OB/Gyn clinic and works specifically with pregnant women in helping to iron out any issues they may have with the Florida Medicaid system. Result:

Implemented -

Recommendation 14: Jacksonville’s hospital obstetric departments should stop automatically furnishing baby formula and institute aggressive breast-feeding educational and support programs for new mothers. In addition, the hospitals and birth centers should seek the status of a Baby Friendly hospital. “Baby Friendly” is a designation achieved by a select number of hospitals worldwide, connoting their adherence to a dedicated effort to promote breastfeeding for new mothers. At the time the Infant Mortality Task Force began its work, only two hospitals in the State of Florida had earned the Baby Friendly designation. A joint initiative of UNICEF and the World Health Organization, Baby Friendly hospitals agree to a 10-step program of specific criteria that must be met to achieve the designation. One of the steps prohibits the acceptance and distribution of free baby formula by participating hospitals, a significant hurdle for most of them since they receive financial considerations from pharmaceutical companies that manufacture formula. After consultation with the Task Force, ICARE, a local advocacy consortium of religious institutions, agreed in March, 2009, to assist in encouraging Jacksonville-area hospitals to work toward the Baby Friendly designation. With its strength in numbers (nearly 2000 attend its annual conference), ICARE is an influential group with a reputation for perseverance that adopts two or three quality of life issues annually to address with key stakeholders, including local government officials, civic leaders, and the business sector. One year later, through the efforts of the North Florida Breastfeeding Coalition and ICARE, every single hospital in Jacksonville is actively engaged in working toward Baby Friendly status. We are pleased to report that the NAS Jacksonville Hospital recently completed the ten requirements and could become the first locally - and third state-wide - to earn the designation.

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As far as anyone knows, no other city in the world is engaged in a coordinated effort to get all of its hospitals under the Baby Friendly banner. Work continues with the other area hospitals, and we remain committed to having all of them achieve Baby Friendly status as soon as possible. Other work by the Task Force related to breastfeeding included a community outreach program presented by the St. Vincent’s Seton Center for Women and Infants’ Health called called Brighter Beginnings, made possible through a grant from the Chartrand Foundation. The program focuses on prenatal education issues in the New Town Success Zone and is held the second Saturday of each month at Edward Waters College. Topics include basic nutrition for mother and baby, parenting skills, newborn care, safe sleep practices, and the benefits of breastfeeding. Result:

Implemented -

Recommendation 15: Black Infant Health Community Council of Duval County should lead a sustained effort to engage and mobilize the black community to address the problem of black infant mortality in Jacksonville. The council along with partners, such as African American Sororities and Fraternities, and faith-based groups should:

Initiate communication, awareness and education programs in the predominantly black neighborhoods which have the highest infant mortality rates based on the example of the community focus groups conducted by JCCI in the Black Infant Health Initiative community meetings; and Plan mentoring programs, Sister to Sister, Mother to Mother, Father to Father, Family to Family.

Excellent progress was realized on this recommendation, due largely to a $70,000 grant from the Community Foundation to the Black Infant Health Community Council that supported the “Make a Noise! Make a Difference! Prevent Infant Mortality” awareness campaign. The professionally-produced campaign included the following components: a. Brochures, magnets, male passports, women’s inserts, and other marketing materials were created b. 11 community events were held to increase infant mortality awareness, as well as influence behavioral change among individuals. The events were as follows: 1. Granny Said (2) – Faith-based initiatives targeting grandparents. Fifteen grandparents joined the informational session on infant mortality, safe sleep and the importance of being a strong and understanding role model. The sessions were held at Historic Mt. Zion AME Church. 2. Barbers for Babies (1) – An event focused strictly on male involvement. More than 200 men and families attended the event at the Cut Above Barber Shop. Prior to its staging, 12 barbers completed a training about the social and health-related

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3.

4.

5.

6.

7.

8.

determinants of infant mortality and the importance of being a responsible father. Chat and Chew (2) – Nearly 70 individuals attended to discuss infant mortality and its impact on families. The events were held at Brentwood Lakes Apartments and Cleveland Arms. Teen Talk (2) – Teens attended a game of free bowling, pizza and drinks and discussed infant mortality and the impact on families. Teens were able to ask questions and get real answers. Color our World – Color our Future (1) – The Federal Office of Minority Health and national spokesperson Tonya Lewis Lee (“A Healthy Baby Begins with You”) supported a reception of over 100 community leaders to raise awareness of infant mortality. The reception was held at Wolfson Children’s Hospital. Family Reunion for our Future (1) – As part of a health fair at Edward Waters college, area leaders, city officials and health advocates participated in the Pink & Blue Parade. Participants marched along Kings Road pushing 75 empty baby strollers, symbolizing the number of black babies who dies in 2008. Walk for Awareness and Health Fair (1) – The organized walk through a neighborhood disproportionately affected by infant mortality was followed by a health fair in A. Philip Randolph Park. More than 170 people attended the event which was supported by the Buffalo Soldiers. Community Breakfast (1) – BIHCC sponsored an appearance on September 17, 2010 by Dr. Fleda Mask Jackson, nationally known researcher on infant mortality and the impact of stress on poor birth outcomes. The breakfast and free workshop were held at Edward Waters College.

Due to the success of the Make a Noise! Make a Difference! Campaign, the Chartrand Foundation recently approved a five-year program in which dollars would be matched up to $35,000 per year for continuation of infant mortality awareness and mobilization efforts in the black community. In addition to these efforts, the Chartrand Foundation provided grants of nearly $50,000 to improve infant health and wellness in the New Town Success Zone. They include: a Lutheran Social Services program to purchase equipment required for Farmers’ Market vendors to accept food stamps; an initiative through Healthy Mothers, Healthy Babies to reduce sleep related infant deaths by distributing free portable cribs to parents without resources; The Birthing Project under the supervision of the Healthy Start Coalition to provide guidance and mentoring to at-risk expectant mothers; and a breastfeeding outreach campaign at Edward Waters College run by Seton Center for Women and Infants at St. Vincent’s Medical Center. Result:

Implemented -

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APPENDICES

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Infant Mortality Final Advocacy Report