Summary: Pregnancy can be a difficult time for those that have experienced ACES. Being diagnosed with Gestational Diabetes Mellitus (GD), can compound the ability to cope on a daily basis. GDM is associated with adverse outcomes for mother and baby (Herrick et al, 2021) and encompasses a wide range of glucose intolerance, including preexisting Type 1 (T1DM) or Type 2 Diabetes (T2DM), GDM in previous pregnancies and in a current pregnancy (Hartling et al, 2014). The highest at-risk are women from disadvantaged socioeconomic (SES) backgrounds and minorities that are Black, Hispanic and/or Native American (Herrick et al, 2021). The target audience to be enrolled in the project are pregnant women, screening positive for GDM, lower SES, residing in Florida and being referred to high risk OB/GYN care at University of Florida (UF) Shands Hospital (UF, Shands Hospital, 2022). As part of their obstetric care, these pregnant women will complete an Adverse Childhood Experiences (ACES) and be assigned a Peer Support Specialist. The project will enroll a maximum of 100 pregnant women or postpartum women (within the first year of delivery) that meet the target audience criteria. Project participants will receive services in person, by phone, by email and through virtual communication to coordinate trauma informed services that include: (1) access to healthcare insurance (Medicaid) and a medical home (OB/GYN and primary doctor); (2) access to transportation (public and private); (3) Prenatal & Postpartum Diabetes Education; and (4) post-partum T2D diabetes screening and management (Herrick et al, 2021). This project also seeks to build networks with providers of health and human services, throughout the State of Florida, in order to strengthen partnerships, increase quality of health care and improve efficiency of time and resources (UWGPSNJ et al, Volume 1 & 2, 2022). It is estimated that direct cost savings could be as much as 16% per patient, without comprising quality of care, safety, or satisfaction (Lemelin et al, 2020). In summary, there is a need to address health disparities in pregnant and postpartum women who experience GDM, with trauma informed support, to build resilience by improving wellness, access, education, engagement, self-sufficiency, partnership, and increase the quality of care and the efficiency of time and resources (UWGPSNJ et al, Volume 1 & 2, 2022).
Trauma-Informed Principles Utilized by Project: Understanding the trauma-informed approaches with a public health approach and differentiating between the six principles are important for this project as it works to improve health and build resilience for project participants (UWGPSNJ, 2022, Volume 1). Substance Abuse and Mental Health Services Administration (SAMHSA) promotes the use of six broad principles that include: (1) safety; (2) trustworthiness and transparency; (2) peer support; (3) collaboration and mutuality; (4) empowerment, voice, and choice; and (5) cultural, historical and gender issues (Substance Abuse and Mental Health Services Administration (SAMHSA), 2014). These trauma-informed principles will be built into this project. Safety will be provided physically and emotionally to pregnant and postpartum women and their families at all provider sites and in interactions with project staff (SAMHSA, 2014). Participants can participate from the comfort of their homes through virtual communication and private rooms at clinics/hospitals will be set aside that are warm and inviting (UWGPSNJ, 2022, Volume 1). Project staff will receive trauma informed training that will promote trust and transparency in their interactions with participants and ensure confidentiality (SAMHSA, 2014). Peer Support Specialists (PSS) will ensure collaboration and mutuality, empowerment, voice, and choice for the pregnant and post-partum women that they serve by building relationships with their participants through sharing their own stories, challenges, and successes. Project leadership will ensure PSS receive reflective supervision for compassion fatigue (UWGPSNJ, 2022, Volume 1). Training will be provided to staff on cultural competence, historical trauma, and women’s issues (SAMHSA, 2014). Trauma informed principles should be implemented to address organization and systematic changes that include ten domains: (1) governance and leadership; (2) policy; (3) physical environment; (4) engagement and involvement; (5) cross sector collaboration; (6) screening, assessment, treatment services; (7) training and workforce development; (8) progress monitoring and quality assurance; (9) financing; and (10) evaluation (UWGPSNJ, 2022, Volume 2).
Levels of the Social Ecological Model: The framework for this project will utilize McLeroy’s Social Ecological Model (SEM) to target individual and social environmental factors of this health promotion intervention (McLeroy et al, 1988). More specifically, the focus will be on intrapersonal, interpersonal and community levels of change. The intrapersonal level will focus on the developmental history of the individual through taking an ACEs survey and patient history collected to assess the participants knowledge, attitudes, behaviors, self-concept, and skill sets in order to provide direct support and education by medical staff (McLeroy et al, 1988). The interpersonal level will utilize Peer Support Specialists to provide formal and informal connections to social networks and support systems to build resilience, by improving wellness, access, education, engagement, self-sufficiency for project participants. The community level of this model focuses on creating relationships among organizations to build networks with providers of health and human services (McLeroy et al, 1988). By strengthening partnerships, it can increase quality of health care and improve efficiency of time and resources. Although this model only focuses on three of the five social ecological model levels in the short term, data from this project such as access to healthcare, establishing a medical home, providing transportation and prenatal/postpartum diabetes education may provide evidence in the long term to effect institutional and public policy level change (McLeroy et al, 1988). In the long term, this model focuses on changing interpersonal, organization, community, and public policy factors to improve health outcomes of participants (McLeroy et al, 1988).
Public Health Framework: In order to have a wider ranging impact, the public health framework to be utilized for this project is based on the Trauma-Informed Philanthropy document, Volume 1, that discusses public health levels of prevention with the purpose to focus on population health disparities such as poverty, education, transportation, and health equity. It is important to “break down silos” with a multi-disciplinary, intersectoral approach that engages stakeholders that serve pregnant and post-partum women that are at risk for GDM, come from disadvantaged SES and are minorities. This public health framework seeks to use innovative strategies to inform and advocate for public policies and practices at a local, state, and federal level. Project participants will address their ACEs and trauma in a cross-sector public health approach that includes health care, mental health, education, welfare, housing, justice, and corrections that are the pillars of primary, secondary, and tertiary prevention (UWGPSNJ, 2022, Volume 1). This project will seek to improve health outcomes, with GDM, based on evidence published in 2021 that recommends: (1) offering Prenatal Certified Diabetes Education (adjusted hazard ratio=1.74, 95% CI=1.22, 2.49) and (2) providing access to public transportation (adjusted hazard ratio=1.70, 95% CI=1.13, 2.54), which are primary and secondary prevention (UWGPSNJ, 2022, Volume 1). This type of diabetes intervention is associated with increased screening postpartum (in a model adjusted for race/ethnicity), total number of prenatal visits, use of diabetes medication during pregnancy, and pregnancy-specific comorbidity index that incorporated age (Herrick et al, 2021) which will promote tertiary prevention as well (UWGPSNJ, 2022, Volume 1).
References
Centers for Disease Control & Prevention (CDC). (2021). Diabetes Risk Factors: Gestational Diabetes. Retrieved on December 2, 2021, from: https://www.cdc.gov/diabetes/basics/risk-factors.html
Hartling, L., Dryden, D.M., Guthrie, A., Muise, M., Vandermeer, B., &Donovan, L. (2014). Systematic review or meta-analysis diagnostic thresholds for gestational diabetes and their impact on pregnancy outcomes: a systematic review. Diabetic Medicine, 2014(31), 319–331. DOI: 10.1111/dme.12357
Herrick, C.J., Keller, M.R., Trolard, A.M., Cooper, B.P., Olsen, M.A., and Colditz, G.A. (2021). Factors associated with postpartum diabetes screening in women with gestational diabetes and Medicaid during pregnancy. American Journal of Preventive Medicine, 60(2), 222-231. DOI: https://doi.org/10.1016/j.amepre.2020.08.028
Lemelin, A., Pare, G., Bernard, S. and Godbout, A. (2020). Demonstrated cost-effectiveness of a Telehomecare Program for gestational diabetes mellitus management. Diabetes Technology & Therapeutics, 22(3), 195-202.DOI: 10.1089/dia.2019.0259
McLeroy KR, Bibeau D, Steckler A, Glanz K. (1988). An ecological perspective on health promotion
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United Way of Greater Philadelphia and Southern New Jersey (UWGPSNJ). (2022). Trauma-Informed Philanthropy: A funder’s resource guide to supporting trauma-informed practice in Delaware Valley [Volume 1]. Retrieved on February 10, 2022, from: https://ufl.instructure.com/co.../assignments/4968046
United Way of Greater Philadelphia and Southern New Jersey (UWGPSNJ). (2022). Trauma-Informed Philanthropy: Leveraging resources and relationships to advance trauma-informed practice and move from knowledge to action [Volume 2]. Retrieved on February 10, 2022, from: https://ufl.instructure.com/co.../assignments/4968046
University of Florida, Project ECHO Diabetes. (2022). Project ECHO Diabetes. Retrieved on April 1, 2022, from: https://diabetes.ufl.edu/resea...grams/echo-diabetes/
University of Florida (UF), Shands Hospital. (2022). Women and Children’s Services: Gestational Diabetes. Retrieved on February 11, 2022, from: https://ufhealth.org/gestational-diabetes
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Policy, Planning and Innovation (SAMHSA). (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Retrieved on March 17, 2022, from: https://store.samhsa.gov/produ...r=from_search_result
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