Carol C. Korenbrot, Ph.D., Sabrina T. Wong, R.N., Ph.D., Anita L. Stewart, Ph.D.,

1. Women’s Assessments of Improved Interpersonal Prenatal Care with Health Promotion and Psychosocial Services • Carol C. Korenbrot, Ph.D., Sabrina T. Wong, R.N., Ph.D., Anita L. Stewart, Ph.D., • University of California San Francisco • Collaborators • Analytical Team • Carol Korenbrot, Anita Stewart, Sabrina Wong • Survey Team • Martha Castrillo • Adrienne Brown • Phaedra Harris • Connie McCoy • Thu Quach • Survey Design and Pretest • Marie Fongwa, Allen Hom, Juanita Dimas • Funded by the Maternal and Child Health Bureau, US DHHS, grant # R40MC00137. • To be published in the • Maternal and Child Health Journal in 2005

2. Objectives • To determine whether women who reported receiving health promotion and psychosocial support services also reported they received higher quality interpersonal care • To determine whether any effects of the support services on interpersonal care help explain greater satisfaction with care. Rationale: If prenatal support services (health promotion and psychosocial services) are to remain accessible to low income eligible women, evidence is needed as to whether the services improve care and benefit women in ways that matter to Medicaid health plans.

3. Introduction The growing recognition of the importance of the patients’ role in assessing the quality of their interpersonal care, particularly among low income and racial and ethnic minority patients, presents an opportunity to test the value of support services (health promotion and psychosocial services) of enhanced prenatal care to pregnant women in Medicaid managed care plans. Enrollment in Medicaid managed care plans has the potential to reduce access to the support services because fewer women in managed care are seen by public providers, the traditional source of support services, and more are seen by private providers who are less likely to have the additional staff and materials the services can require. The plans and their providers need evidence as to whether the services improve care and benefit enrollees in ways that matter to them. The purpose of this study is to determine whether provider performance of selected health promotion advice and of psychosocial assessments in prenatal care visits as reported by African-American, US-born Latina, nonUS-born Latina, and White women in Medicaid plans is associated with their reports of higher quality of interpersonal processes of care and greater satisfaction with care.

4. Methods A telephone survey of 363 African-American, Latina (US and nonUS-born) and White women receiving prenatal care in four Medicaid health plans in California in 2001 was conducted. Respondents included pregnant women 20 to 34 weeks gestation, aged 18 to 44, with at least two prenatal care visits; who identified themselves as African American, Latino, or White. The survey was conducted in English and Spanish. The overall response rate was typical for health plan satisfaction surveys (41%), the response rate for women who were contacted was 81%.

5. Measures: Health Promotion and Psychosocial Services Health Promotion. The areas for Advice surveyed included: 1) vitamins, 2) proper foods, 3) weight gain, 4) physical activity, and 5) secondhand smoke. Reporting in one area did not correlate sufficiently with reporting in other areas so five dichotomous variables for health promotion were used, instead of a single scale, Dichotomous variables for health promotion advice in 5 areas, Psychosocial Assessment. The six areas investigated were: 1) mood/depression, 2) adequate money, 3) adequate food, 4) adequate housing, 5) parenting, and 6) mental or physical abuse (or ‘being hurt’) by spouse or partner. A composite scale for psychosocial assessment was developed summing responses of these six items (Cronbach’s alpha, 0.81). composite scales for psychosocial assessment (in 6 areas) and satisfaction with care, and three indices for Communication, Decision-making, and Interpersonal Style by adding scales originally constructed with confirmatory factor analysis in each of the three dimensions, were all tested for reliability and construct validity in each ethnic group.

6. Measure: Interpersonal Care, PIPC Prenatal Interpersonal Processes of Care. PIPC Indices were created for Communication, Decision-making, and Interpersonal Style by adding scales originally constructed with confirmatory factor analysis in each of the three dimensions, were all tested for reliability and construct validity in each ethnic group. The Communication index is constructed from three scales Empowerment, Elicitation of Patient’s Problems and Explanation of Processes of Care. The Decision Making index is composed of one scale (Responsiveness to Patient’s Preferences). The Interpersonal Style index is constructed from three scales Friendliness and Courteousness, Lack of Perceived Discrimination and Emotional Support. Satisfaction with Care was a composite scale of three items that have five level responses: an overall rating of prenatal care, how likely the woman was to recommend her prenatal provider to friends or family, and how likely the woman was to return to the prenatal provider if ever pregnant again.

7. Health Promotion Advice Vitamins Proper Food Weight Gain Physical Activity Secondhand Smoke Psychosocial Assessment Depression Inadequate Money Inadequate Food Housing Parenting Abuse (being hurt) Interpersonal Processes of Care Communication Decision-making Interpersonal Style Satisfaction with Care Figure 1. Hypothesized Associations

8. Results of Hypothesis Testing Support Services and Interpersonal Care. Regardless of the area of health promotion, receiving advice was significantly associated with higher reported interpersonal care. Providing a psychosocial assessment was associated with improved interpersonal care. The more areas in which women reported they were asked about psychosocial problems, the better their reported interpersonal care. Support Services and Satisfaction with Care. Providing health promotion advice was significantly associated with satisfaction, but its effect on satisfaction was explained by its effects on interpersonal care. The findings of the role of psychosocial assessments in explaining satisfaction with care were similar. The size and significance of the effects of support services became insignificant when PIPC scales were included in models of satisfaction, yet communication and interpersonal style still had significant direct effects on satisfaction with care. There was no independent measurable effect of the support services on satisfaction.

9. Results Handouts provide 7 detailed tables of multivariate analyses. The women who report receiving the support services also report higher quality of provider-patient interpersonal care. The support services are found to be associated with higher levels of provider-patient communication, patient-centered decision-making and supportive interpersonal style. Of the three dimensions of interpersonal care, better communication and interpersonal style explain most of the effects of the support services on satisfaction. Thus the findings of this study demonstrate that prenatal health promotion and psychosocial services can improve women’s assessments of the quality of provider care and contribute to their satisfaction with prenatal care and therefore have value in Medicaid health plans,

10. Conclusions • Support services are associated with higher quality interpersonal care and greater satisfaction with care among ethnically-diverse low-income pregnant women. • Women who report receiving health promotion or psychosocial services report receiving higher quality communication, decision-making and interpersonal style from their prenatal providers. • The effects of the support services on interpersonal care in turn explained the higher satisfaction with care associated with receiving the support services. • Prenatal health promotion and psychosocial services are associated with improved quality and satisfaction with care that should matter to Medicaid health plans and their providers.