Researchers at Ball State University have developed evidence-based communication methods aimed at reducing infant mortality rates—particularly among minority populations in Indiana.

The researchers discovered gaps in how people understood infant mortality. They then developed and tested messages to address misconceptions about infant mortality and explained actions parents can take to reduce risk.

The messages involved memorable metaphors that compared pregnancy and maternal health to gardening or shining a light, according to lead researcher Dr. Jean Marie Place, associate professor of Health Promotion and Education at Ball State.

“The one that really resonated among Hispanic and Latino populations was that having a healthy child is much like growing a healthy plant,” Place said. “And so we infused this symbolism into a metaphor: that you’ve got to have good soil before you plant the seed, much like you’ve got to try to be healthy before you get pregnant; that going to a doctor’s office for prenatal care is a lot like weeding your garden; that breastfeeding your baby is a lot like watering a plant with fertilizer, etcetera.”

Now, efforts are underway to work with community health partners statewide to effectively communicate these explanatory metaphors directly with targeted members of minority populations, including pregnant women, expectant fathers, immediate family members, and teenagers.

The issue

Overall infant mortality rates in Indiana have consistently been higher than just about any other state since at least 2005.

Unfortunately, those rates are even higher for infants from minority populations. According to the Indiana State Department of Health, in 2017, the number of Hispanic/Latino children in Indiana who died before age one was significantly higher than the national rate (7.3 infant deaths per 1,000 live births compared to 5.8 nationally).

The figures are even more troubling when focusing on Black infants, who are 2.5 times more likely to die than white infants in Indiana.

From 2013 to 2017, the rate of Black infants who died before age one was 14.6 per every 1,000 live births. In Delaware County, which is the home of Ball State, the infant mortality rate of Black babies is 17 per 1,000 live births.

Health officials have long agreed that a need exists to effectively communicate with minority populations about how to reduce infant mortality risk. But very little guidance existed on how to do that in a way that resonates with those populations.

The research

Starting in 2017, Place, with funding from the Indiana Minority Health Coalition, and in partnership with the Northern Indiana Hispanic Health Coalition, started work on a community-based participatory research approach. Its design would lead to data-driven, culturally-inclusive communication recommendations intended to reduce infant mortality rates, beginning with the Hispanic/Latino population.

The group interviewed a selection of Hispanic/Latino community members to gauge their understanding of infant mortality — what it meant, what they thought caused it, and what they thought they could do to prevent it.

The results of those conversations, Place said, were eye-opening.

“A lot of them said that they felt that infant mortality was caused by child abuse, or that infant mortality and child abuse were strongly associated,” Place said.

That’s not the case. The vast majority of infant deaths are caused by complications in pregnancy or during birth, such as low birth weight or being born too early. Child abuse accounts for a small fraction of infant deaths, according to Place.

In 2019, Place and Drs. Tya Arthur and Mengxi Zhang, both assistant professors of Health Science at Ball State, turned their focus to the African American/Black population, this time working in conjunction with the Health Coalition of Delaware County.

Once again, the interviews provided plenty of context for the researchers.

“In the Black population, there was confusion around what the term infant mortality meant,” Place said. “They weren’t sure what caused it, they were shocked at the high rates of infant mortality in their community—they didn’t have a framework to define it, understand it or be aware of it.”

The action

With preliminary data at its disposal, the group of Ball State researchers turned to the Frameworks Institute, a think tank that helps mission-driven organizations communicate about social issues, and its use of explanatory metaphors to explain to these minority populations why infant mortality matters and how it can be prevented—in a way that was culturally relevant and appropriate.

These explanatory metaphors, or a “simple, concrete, and memorable comparison that quickly and effectively explains a complex topic,” were personalized for each minority population, such as the growing plant metaphor for the Hispanic/Latino population.

With the help of Dr. Linh Littleford, professor of Psychological Science at Ball State, Place’s team produced videos featuring the seed metaphor that were tested on various members of the Hispanic/Latino population visiting health clinics within the scope of the Northern Indiana Hispanic Health Coalition.

Six weeks later, researchers followed up with participants to see what they remembered about the metaphor. The results, Place said, were “really encouraging.”

For the Black population in Delaware County, researchers used a light as its metaphor.

“We said that we’ve got to shine the light on this really important problem, because babies are dying at triple the rate of White babies— the Black infant mortality rate is almost triple —and so we tried to, in this metaphor, talk about shining the light on the problem and giving information,” Place said.

The future

Ball State researchers are now working with local healthcare community partners such as Indiana University Health and Open Door Health Services to try to incorporate messaging into communications channels with minority patients and their families.

The explanatory metaphors, Place said, can be embedded into multiple contexts, including oral presentations, teaching materials, billboards, publications, activities, films/videos, public service announcements, and the WeCare Indiana SMS messaging service. In addition, Ball State’s Department of Nutrition & Health Science is creating a website to house all of its infant mortality-related information and videos.

These efforts, matched with promising trends in Indiana —which, according to Governor Eric Holcomb, has seen its infant mortality rate decrease three straight years from 2017-19— could really make a difference moving forward.

“The idea is that providers are the front line; they are the first educators,” Place said. “And so, we’re trying to identify a really easy way to communicate about infant mortality: talk about it in terms of a seed, talk about it in terms of shining a light. It’s a tool for them to use.”