NR 555 Week 4 Health Determinants Write-Up Example

Determinants Write-Up: Four Arrangements That Could Push Postpartum Visit Rates Further Down for Black Medicaid Enrollees Than for White Enrollees, Each Written as Something an Institution Does

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College of Nursing, Chamberlain University

NR 555: Health Policy: Advancing Health Equity & Outcomes

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Month Day, Year

Determinants Write-Up: Four Arrangements That Could Push Postpartum Visit Rates Further Down for Black Medicaid Enrollees Than for White Enrollees, Each Written as Something an Institution Does

From Nouns to Verbs

The disparity analysis found that 58% of Black Medicaid enrollees were seen for postpartum care inside 12 weeks, against 74% of white enrollees. Lists of determinants usually name nouns: poverty, transportation, racism, insurance. A noun can sit on the page without explaining anything. This write-up names four candidate causes as things an institution does, and for each states the direction of the link: how the arrangement would push the visit rate down more for Black enrollees than for white enrollees. Jones (2000) distinguished institutionalized racism, embedded in structures and policies, from personally mediated and internalized forms, and the candidates below are mostly of the first kind.

Candidate 1: The State Ended Postpartum Coverage at About 60 Days

The action. Until the recent extension, the state's Medicaid pregnancy coverage ended at the end of the month in which the 60th postpartum day fell, unless the enrollee qualified for Medicaid in another category.

The direction. Black enrollees in our state are more likely than white enrollees to qualify for Medicaid only through pregnancy, because of differences in income and household composition shaped by labor market and wealth inequities. When coverage ends, a person who has not yet had a postpartum visit, or who faces a bill for one after the cutoff, is less likely to attend. Coverage changes around childbirth are common nationally (Daw et al., 2017).

The weak joint. The visit window runs to 84 days, beyond the old coverage end, but most visits are scheduled within six weeks. The mechanism is strongest for visits scheduled late or rescheduled after a missed appointment. State data on visits by timing would test it.

Candidate 2: Clinics Schedule the Postpartum Visit After Discharge

The action. At the three hospitals delivering most Medicaid births in our region, the postpartum visit is usually scheduled by the patient calling the clinic after going home, rather than being booked before discharge.

The direction. Calling to schedule requires a working phone, time during clinic hours and knowledge of whom to call. Enrollees with unstable phone service, shift work without breaks or more children at home are less likely to complete that step. Those burdens are distributed unequally, and in our region fall more heavily on Black enrollees, who are more likely to live in neighborhoods with fewer clinics and less reliable public transit.

The weak joint. The evidence that booking before discharge raises attendance is suggestive rather than definitive. Guidance on postpartum care recommends that follow-up be arranged early and that postpartum care continue as a process instead of ending with one appointment (American College of Obstetricians and Gynecologists, 2018), but local data on booking method by race would be needed to test the link here.

Candidate 3: Clinics Are Located Away From Where Enrollees Live

The action. Obstetric practices accepting Medicaid in our largest city are concentrated in the medical district and the northern suburbs, while many Black enrollees live on the south side, where two obstetric clinics closed in the past five years.

The direction. Longer travel, often by bus with a newborn, lowers attendance, and the closures fell on the neighborhoods with the most Black enrollees.

The weak joint. Distance alone may not explain much if most enrollees have access to a car. Mapping enrollee addresses against clinic locations would show whether the distances differ by race.

Candidate 4: Care Teams Treat Black Patients With Less Respect

The action. Black women in the United States report experiences of mistreatment in maternity care, including being ignored or dismissed, more often than white women. A patient who felt disrespected during delivery has reason not to return for a postpartum visit.

The direction. If mistreatment is more common for Black enrollees, the resulting loss of trust would lower their postpartum attendance more than white enrollees'. Bailey and colleagues described how structural and interpersonal racism in health care contribute to inequities (Bailey et al., 2017).

The weak joint. Our state has no routine data on respectful care. A postpartum survey with questions on experiences of respect, linked to visit attendance, would be needed to test this candidate.

How the Candidates Interact

The four candidates are not alternatives. A person whose coverage is about to end, who was not given an appointment at discharge, who lives far from the clinic and who felt dismissed during delivery faces four barriers at once. Because each falls more heavily on Black enrollees, their combined effect can be larger than any one alone. That interaction is a feature of structural inequity: separate arrangements, each perhaps defensible on its own terms, add up to a pattern.

Candidates Considered and Set Aside

Two commonly cited explanations were considered and set aside as primary causes, though not dismissed. The first is that enrollees who feel well after birth see no need for a postpartum visit. That may be true for some people in every group, but it does not explain why the rate differs by race unless perceived need differs, and there is no evidence in our data that it does. Framing the gap as a matter of patient preference also shifts responsibility from institutions to individuals, which the course's authorship test warns against.

The second is health literacy: that some enrollees do not understand why the visit matters. Better information may help, but it is a noun-type determinant unless tied to an institutional action, such as whether discharge teaching explains the purpose of the visit and whether it is delivered in the patient's language. Written that way, it becomes a variant of the scheduling candidate, since the same discharge process that fails to book a visit may also fail to explain it.

What Would Test Each Candidate

The write-up proposes a test for each candidate before any intervention. For coverage, compare visit rates for deliveries in the year before and after the 12-month extension, by race. For scheduling, record whether each postpartum visit was booked before discharge and compare attendance. For location, map addresses and clinics. For respect, add questions to the state's postpartum survey. Evidence at the weak joints matters most, because an intervention aimed at the wrong mechanism will not narrow the gap, however well it is run.

References

American College of Obstetricians and Gynecologists. (2018). ACOG Committee Opinion No. 736: Optimizing postpartum care. Obstetrics & Gynecology, 131(5), e140-e150. https://doi.org/10.1097/AOG.0000000000002633

Bailey, Z. D., Krieger, N., Agénor, M., Graves, J., Linos, N., & Bassett, M. T. (2017). Structural racism and health inequities in the USA: Evidence and interventions. The Lancet, 389(10077), 1453-1463. https://doi.org/10.1016/S0140-6736(17)30569-X

Daw, J. R., Hatfield, L. A., Swartz, K., & Sommers, B. D. (2017). Women in the United States experience high rates of coverage "churn" in months before and after childbirth. Health Affairs, 36(4), 598-606. https://doi.org/10.1377/hlthaff.2016.1241

Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener's tale. American Journal of Public Health, 90(8), 1212-1215. https://doi.org/10.2105/AJPH.90.8.1212