Advancing Health Equity Conference 2024

Sandi L. Bates, MLIS, SW Clinical Campus Librarian

Background: The Alive Library is an oral storytelling program giving voice to those who have experienced health disparities or discrimination. It provides “an opportunity for individuals to connect with people they may not normally have the occasion to speak to within their community, to better understand the life experiences of others, and to challenge their own assumptions, prejudices and stereotypes. It provides a safe environment and encourages active and engaging conversations.” (The University of Sidney Living Library Project)

Purpose: The primary goal for UND SMHS’s Alive Library is to address health disparities and marginalized populations in North Dakota through educating students to practice cognitive empathy in clinical encounters with patients.

Methods/Procedures: An Alive Library has three parts: Books, readers and moderators.

Books are used as a metaphor. Books within this context are people who have experienced prejudice, discrimination, and/or stereotyping or have a lived experience that could enhance individual understandings of another culture. For example, a book might discuss their experiences with BIPOC, LGBTQIA+ and religious identities; diverse abilities, body sizes, cultural and geographic backgrounds; living with medical or mental health conditions and how these can affect their daily life and work. Readers are people who “check out” the books. Readers engage in real-time conversations with the person represented as a book. This safe space offers an opportunity to ask questions which may not be considered appropriate in everyday conversation with a stranger. Librarians and volunteer moderators sustain a safe environment, facilitate conversations, and assist with surveys / questionnaires.

Results: The project addresses health disparities through: Generating awareness and empathy – developing cognitive empathy (the ability to perceive and understand the emotions of another) and withholding judgment; introducing diversity – the Alive Library provides the opportunity to have uncomfortable conversations, ask questions, uncover implicit biases, and challenge explicit biases; providing a brave space – a space for vulnerability, listening to understand, leaning into fear, thinking critically and expanding our ways of thinking, examining intentions, and mindfulness – a space to encourage all questions, allow awkward phrasing, and accept outdated language in the context of building understanding.

Limitations: The concept of a living library is difficult to convey. Participants during a pilot run indicated they thought they needed to read a book prior to participating in the event.

Conclusions/Implications for Practice: Through the practice of cognitive empathy, practitioners will be better able to understand and give the best care to their patients.

Brenna Hanson , B.S., Ethlyn Voorhies, B.S., James R Beal, Ph.D., Abe E. Sahmoun, Ph.D.

Purpose: Due to the increased risk for health conditions that children from low food security homes face, identifying their key demographics and urban-rural residency is important for future endeavors to better the overall health of our community. The purpose of this study is to determine the association between urban-rural residence and food insecurity among children in the United States.

Method: A cross-sectional analysis of the pediatric population using the National Health Interview Survey (NHIS- Child-) for 2021 to compare the level of food security between children 2-17 years old living in rural settings to those in urban settings was performed. Data to be analyzed will include: race, age, sex, citizen status, number of children less than 18 in family, health insurance status, sample child family poverty ratio, parent education level, household income, access to care, social support, parent demographics (marital status, ethnicity), food stamp enrollment, free or reduced price meals at school, household income will be evaluated, residence county code, and food security status. Analysis was done using summary statistics and bivariate comparisons (Chi-square tests and GLM Means). All significance tests will be two-sided, with aP-value < .05. Sampling errors will be determined using the appropriate survey procedure, which takes into account the clustered nature of the sample.

Results: A total of 7464 participants 2-17 years old were included in our study. 13.1% of these participants lived in a rural setting. Rural families were less likely to have parents with a college degree or more (50.1%) than their urban counterparts (61.4%)(p=0.000). Rural families were more likely to have three or more children (44.9%) than urban (38.7%) (p=0.001). 5.4% of urban children, and 1.6% of rural children were living within the poverty index (p=0.000). Additionally, children in rural areas were more likely to receive free or reduced meals (67.1%, p=0.002) and food stamps (29.2%, p=0.006) than their urban counterparts (58.4%, 22.6%, and 10.1%, respectively). Age distribution, gender distribution, insurance status, parental marital status, social support, PCP, usual place of care, WIC benefit status, and food insecurity were not found to be statistically significant in our study.

Conclusions: Our research shows that rural youth are more likely to be living in poverty, part of a large family, have less educated parents, and take greater advantage of government funded programs like free lunch and food stamps. However, the rates of food insecurity in rural vs urban families was not found to be statistically significant, indicating that these government funded programs may be fundamental in reducing food insecurity in our youth.

Madelyn V. Jablonski, B.S., Jonah W. Muller, B.A., Thomas F. Arnold, M.D., Steffen P. Christensen, M.D., Dennis J Lutz, M.D.

Background: This study highlights how education and race impact maternal mortality in North Dakota. Lower educational attainment often correlates with reduced socioeconomic status and healthcare access, potentially contributing to escalating maternal mortality rates, especially among Native American communities. North Dakota's demographic composition, with significant Native American and Caucasian populations, offers insights into persistent disparities in healthcare. Systemic challenges, including limited obstetric care and healthcare underfunding, exacerbate health inequities, with Native American/Alaska Native peoples experiencing higher rates of poverty, unemployment, and lack of insurance coverage. Targeted interventions to address structural inequities are essential for improving maternal health. This study underscores the urgency of promoting educational opportunities and healthcare accessibility within vulnerable populations to combat the rising maternal mortality rates and advance maternal well-being.

Objective: The study aimed to analyze maternal mortality trends in North Dakota from 2008 to 2022 and assess how education level and racial background affect these rates, specifically whether lower education correlates with higher mortality and exploring disparities between Native American and Caucasian populations.

Methods: Maternal mortality data was obtained from the North Dakota Department of Health and Human Services. In North Dakota, maternal mortality is defined as a death while pregnant or within one year of the end of pregnancy from any cause related to or aggravated by the pregnancy. The dataset consisted of 119 unique records of maternal deaths, including information on race, education level, year of death, and underlying cause of death. The data was analyzed using IBM SPSS software and was stratified by education level and race to evaluate potential associations with maternal mortality rates.

Results: Analysis of the dataset revealed a concerning trend of increasing maternal mortality rates in North Dakota, with rates well exceeding the national average. Mothers without a college degree accounted for 75% of all maternal deaths in North Dakota, indicating a significant association between lower education levels and heightened maternal mortality rates. In North Dakota, Native Americans constitute the largest minority group, warranting a focused examination of their maternal mortality rates. Over the past 15 years, 25 of the 86 maternal deaths were among Native American women. Of these, 76% did not have a college degree. The findings of this study highlight the critical importance of addressing education, race, and socioeconomic factors in maternal health interventions. Lower education levels were identified as a significant risk factor for maternal mortality, emphasizing the need for targeted initiatives to improve educational opportunities and socioeconomic conditions, particularly within vulnerable populations.

Conclusion: In summary, this study highlights the critical role of education and race in maternal mortality in North Dakota. Identifying these factors as key determinants underscores the need for targeted interventions. Collaborative efforts among healthcare systems, policymakers, and educators are vital to reducing maternal mortality and enhancing maternal well-being. Improving data practices, raising awareness, and implementing evidence-based strategies are essential for achieving better maternal health outcomes and ensuring equitable access to care.

Anna Charlotta Kihlstrom, Tara Stiller, Nishat Sultana, Grace Njau, Matthew Schmidt, Anastasia Stepanov, and Andrew Williams

Funding Source: This project was supported by funding from the North Dakota Department of Health and the Centers for Disease Control and Prevention (G21.255 – COVID-19 Health Disparities). For more information contact Andrew Williams at andrew.d.williams@UND.edu.

Conflicts of interest: None

Background: Marriage promotes breastfeeding duration through economic and social supports. The COVID-19 pandemic disproportionately affected low-income communities and negatively impacted interpersonal dynamics. This study explored the association between marital status and breastfeeding duration during the pandemic and the potential modifying effect of income.

Purpose: The purpose of this study is to provide data relevant to low-income and racially minoritized families regarding social supports during a public health crisis.

Methods: Data were drawn from the 2017-2021 North Dakota Pregnancy Risk Assessment Monitoring System (weighted n=41433). Breastfeeding duration was self-reported, and 2-, 4-, and 6-month duration variables were calculated. Marital status (married, unmarried) was drawn from linked birth certificates. Income (≤$48,000, >$48,000) was self-reported. Infant birth date was used to identify pre-COVID(2017-2019) and COVID(2020-2021) births. Logistic regression estimated odds ratios and 95% confidence intervals for the association between marital status and breastfeeding duration outcomes. Models were fit overall, by COVID-19 era and by income. Lastly, income models were further stratified by COVID era. Models were adjusted for maternal health and sociodemographic factors.

Results: Overall, married women consistently had 2-fold higher odds of breastfeeding across all durations during both pre-COVID and COVID eras. Pre-COVID, marriage was associated with at least 2-fold higher odds for all breastfeeding durations in low-income women (4-month duration OR 4.07,95%CI 2.52,6.58) and less so for high-income women (4-month duration OR 1.76,95%CI 1.06,2.91). During COVID, being married was a stronger predictor of breastfeeding duration for high-income women (4-month duration OR 2.89,95%CI1.47,5.68) than low-income women (4-month duration OR 1.59,95%CI0.80, 3.15).

Limitations: First, the cross-sectional study design limits causal interpretations. However, we were able to examine breastfeeding duration at three time periods, allowing us to understand how the effect of marriage may change during the postpartum period. Second, PRAMS only captures a binary yes/no response on breastfeeding initiation and lacks data on the exclusivity of breastfeeding or mixed feeding. Last, self-reported data are susceptible to recall bias. Nonetheless, recall concerning events during the perinatal period is generally high, mitigating concerns about recall bias.

Conclusion/Implications for Practice: Before COVID-19, marriage promoted breastfeeding duration among low- and high-income women. However, the protective effect of marriage was lost for low-income women during the pandemic. These findings highlight the need to strengthen social safety nets and provide more robust supports to vulnerable populations during public health emergencies. Policies like paid parental leave, and enhanced access to lactation consultants, could help mitigate disproportionate impacts and promote equitable breastfeeding practices. Continued research examining how major societal disruptions intersect with social determinants to shape maternal and child health outcomes can inform more resilient and inclusive systems of care.

Kilyn Parisien, M.P.H.

Introduction: American Indian and Alaska Native (AI/AN) women are more likely to die from severe maternal morbidity and pregnancy-related causes than most other racial groups. Data on the maternal health of AI/AN people is severely limited.

Purpose: This study aims to understand the pregnancy journeys of AI/AN people to inform medical care, future research, and digital interventions.

Methods: A Community-Based Participatory Research (CBPR) approach was used to collect data from AI/AN mothers in the Plains region. Surveys were distributed to study applicants to capture demographics and pregnancy statuses. Semi-structured interviews were conducted via Zoom to learn about participants’ experiences, needs, and desires. Semi-structured participant interview data was coded using grounded theory and team ethnography. Data was organized by responses to each question. Memos and illustrated excerpts were saved and categorized.

Results: Thirty individuals were eligible and contacted for scheduling, 10 of those individuals participated in interviews. Majority (90%) of the participants identified as female. All participants identified as enrolled members of an American Indian/Alaska Native tribe. The most prevalent age group of participants was 36 to 41 years old (40%, n=4). Participants reported healthcare coverage from Indian Health Service or Tribal Clinics (70%, n=7), government health insurance (60%, n=6), private health insurance (10%, n=1), and other health insurance (10%, n=1). When analyzing the interviews, eight themes emerged regarding the pregnancy journeys of Indigenous women in the Plains region. The themes are as follows: 1) Traditional Pregnancy Care and Practices, 2) Fertility Concerns, 3) Prenatal Health Care, 4) Stressors, 5) Support, 6) Mental Health, 7) Pregnancy Delivery Experiences, 8) Postpartum Health Care.

Limitations: There were several limitations of this study. First, there is severely limited research data on the pregnancy experiences of AI/AN women. Second, investigators' use of internet-mediated recruitment methods, like social media, to engage diverse and historically resilient populations heightens the need to address threats to data validity. Ensuring the security of internet-mediated research not only supports research accessibility and inclusion for historically resilient populations but also protects the integrity of participant data. Lastly, this was an investigator funded study with no external support, which limited our capacity to reach more AI/AN mothers in the Plains region. With only 10 participants, we have yet to achieve data saturation and are not likely to gain additional insights. Additional interviews are needed to achieve data saturation.

Conclusions/Implications: American Indian and Alaska Native women face many barriers throughout their unique pregnancy journeys. This study suggests that AI/AN mothers are integral stakeholders in providing information and guidance to reduce adverse maternal health outcomes in Indigenous communities.

Emilee Ohman, Chloe Bakkum, Jack Gibbons, Susan Thompson, Jeremy Holloway, Gunjan Manocha, Donald Jurivich

Funding Sources: Project sponsored by Dakota Geriatrics, a Geriatric Workforce Enhancement Program. Dakota Geriatrics is supported by funding from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling 3.75M with 15% financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by HRSA, HHS, or the U.S. Government.

Conflicts of Interest: No conflicts of interest to disclose.

Introduction: Student centered Community Service Learning (CSL) is utilized by health professions training programs as an avenue to strengthen interprofessional (IP) education and experiential learning along with opportunities for population health training. Thus, the University of North Dakota (UND) School of Medicine and Health Sciences (SMHS) launched a student-led Health Promotions Program (HPP) to address these educational needs. This report describes a proof-of-concept project that entails wellness and motivational interviewing sessions between students and public housing residents.

Purpose: The mission of the UND Health Promotion Program is to advance the health and wellness of the greater Grand Forks area with a focus on increasing health equity within the community. The program centers around promoting psychosocial and physical wellbeing with residents through the provision of resident centered health counseling and motivational interviewing. The program places an emphasis on underserved populations of the area, including low income and minority residents, as well as those with substance use disorders.

Methods: UND partnered with Grand Forks Housing Authority to hold monthly group wellness sessions and weekly individual interviewing sessions. Volunteer SMHS students receive comprehensive online training in geriatric care, health coaching, substance use screening, confidentiality, open-ended questioning, trust-building, and cultural sensitivity prior to starting their visits. 4 MD, PT, OT, PA, and/or SW students and 1 faculty mentor attend weekly sessions to interview interested residents regarding what matters most, wellness, and their health goals. Based on responses, residents receive service recommendations, resources, and community referrals. Students also work with residents on building confidence and techniques for talking to their primary care providers about what aspects of their health are most important to them.

Results: HPP engages residents through group meetings and a weekly information table. Approximately 50 students (from both the MS1 and MS2 classes combined) volunteered along with 5 faculty members. The inaugural quarter period drew ~10% of the housing residents (10) for individual interviews. To enhance resident recruitment, student organizers developed a set of Plan-Do-Study-Act cycles of change, thus introducing them to the AAMC competency of Health Systems.

Limitations: There are notable barriers to IP engagement, such as need for on-site faculty from specific domains, preference for credit-based curriculum in some academic units over CSL, and Public Housing residents’ mistrust of the healthcare system. Addressing these issues is essential for successfully implementing the proposed curriculum and realizing its potential benefits.

Conclusion: This proposal emphasizes student competence in developing a health promotions curriculum that encourages collaboration among key stakeholders, public health, health systems, academia, and public housing. The Health Promotion Program aims to help close the gap in health care equity in the Grand Forks community by providing education and information on resources free of charge to any residents looking to improve their health and wellbeing. Students are also able to practice skills in patient centered care, effective communication, motivational interviewing, and cultural competence through participation in a community service learning project.

Mary Ann Sens, M.D., Ph.D., and Susan Roe, M.D.

Background/Introduction:  For millennia, the death of a child was accompanied by profound grief and an outpouring of community support, sympathy, and concern for the parents and family. In recent years, a noticeable shift toward blame is present, resulting in the investigation and prosecution of parents who lost a child from a potentially preventable cause of death, even when prevention is scientifically speculative. Coupled with pervasive social media presence with unfiltered, accusatory remarks, the increased social isolation of sub-nuclear, temporary, and blended families provides an unsettling foundation when the loss of a child occurs, severely complicates mental health, and may drastically curtail maternal-child public health initiatives.

Purpose: To highlight the increasing accusatory environment, from courts to social media, in cases of childhood deaths. This undercuts the necessary social network needed for the family and places the family in danger of prosecution, separation, and foster care placement of the remaining children. This massive and unprecedented encroachment by the legal system into public and private health matters creates a difficult, hostile, and often unworkable environment to gather critical public health information that targets improved safety and risk reduction. It further accelerates mental health issues and likely causes permanent mental dysfunction and maladaptive responses, creating a vicious cycle of self-fulling accusations.

Methods: A review of cases from consultation practice reveals increasing prosecution for accidental and “preventable” natural deaths.

Examples: 1) An Indigenous mother of three was pressured into accepting a plea agreement following the loss of her child while co-sleeping. She was told the autopsy report would contain trauma and she would get a better deal by pleading before the release of the report. The cause of death was “Unexplained sudden infant death with intrinsic and extrinsic factors” (essentially SIDS) with NO evidence of trauma or neglect. With assistance from the Great Northern Plains Innocence Project, the mother petitioned for relief through the State Supreme Court, which ordered her release. Her two children in foster care were returned; the family was connected to social and tribal resources, and she is progressing well. 2) A father was arrested following the death of his 4-month-old while the infant slept on a couch. The father placed the child on a couch and started the telecommunications link a few minutes before a business meeting. Upon entering the telework connection a few minutes later, his boss awakened him, admonishing him that he was sleeping on the job and asking why a baby was there. The man turned to put the baby in a bouncy chair and discovered the infant was unresponsive. His wife accused him of child endangerment, and her family pressured courts for criminal prosecution. Despite strong supporting defense witnesses, he took a plea deal with three years of imprisonment as court expenses exceeded his ability to pay. 3) Following several prosecutions and convictions for child deaths following possible overlay, doll scene re-enactments, a critically needed public health tool for investigating unexplained sudden death, now require a Miranda warning and the presence of police while interviewing and recording caretakers in an increasing number of jurisdictions.

Limitations: Recollections from a single practice are not scientifically or statistically based.

Conclusions/Implications for the Practice: Child deaths, outside of abuse and neglect, are traditionally the domain of public health but are increasingly the target of court activism – placing culpable and criminal blame on deaths resulting from accidents or deaths that are unexplained but apparent natural deaths. Increased pressure and complications on a grief-stricken and often fragile family support system horrifically complicates public health efforts in safety, maternal, and child health.