The Life Course Approach
Faye Johnson
Project Director
The Magnolia Project
July 9, 2014
 The Life Course in MCH
 Implications for practice
 From theory to practice
 Planning framework
 Prenatal Care & Case
 Leadership Academy
Life Course Perspective
 Back to the future!
 MCH historically focused on broader public health
 Shift in focus over last decade
Individual knowledge, skills
Community, provider education
Individual interventions
 Efforts to improve birth outcomes limited to nine
months of pregnancy
 Improvements in maternal and infant survival
Infant Mortality
 Infant mortality rate (2012): 8.4 deaths per 1,000 live
births (2005 rate 11.6)
 IM driven by disparities
 45% of births to Blacks & other nonwhites
 Blacks historically have poorer outcomes in Jax than other urban
areas of state
 IM rate 2.5x higher than White rate
Infant Mortality Duval County
Total County
Target Area
Linear (Target Area)
Beyond pregnancy
 Birth outcomes reflect life course of mother, not just
 Proposed by Michael Lu & Neal Halfon (2003)
 Synthesis of two biomedical models
Early programming
Cumulative pathways
Synthesis of Biomedical Models
Early programming
Exposures in early life could influence
future reproductive potential
Cumulative pathways
Chronic accommodations to stress
results in wear & tear contributing to
declining health over time.
Life Course Perspective
 Rather than focusing on risks, behaviors & services during
pregnancy, CUMULATIVE effects of health, life events are
 Health & socioeconomic status of one generation directly
affects the health status --- and REPRODUCTIVE HEALTH
CAPITAL – of the next one.
Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective.
Matern Child Health J. 2003;7:13-30
Life Course Perspective
 Approach suggests a complex interplay of biological,
behavioral, psychological and social protective
factors contributes to health outcomes across the
span of a person’s life.
 Factors impact racial, ethnic groups differently and
may explain disparities despite equal access to care
during pregnancy.
 Life-course model BROADENS the focus of MCH to include
both health and social equity.
 Socioeconomic status, race and racism, health care, health
status, stress, nutrition and weight, and a range of other
behaviors impact birth outcomes.
 Factors impact racial, ethnic groups differently and may
explain disparities despite equal access to care.
Social Determinants of Health
The social determinants of health are the conditions in which people are born, grow, live,
work and age, including the health system. These circumstances are shaped by the
distribution of money, power and resources at global, national and local levels, which are
themselves influenced by policy choices.
The influence of "social determinants" on health begins even before we are born. Study
after study has outlined the ways in which a woman's health, diet and stress level during
pregnancy affects her newborn's life chances: everything from neurological and
emotional development to the likelihood of adult obesity. Proper nutrition, prenatal care,
and exercise are important, but class, racism, loving relationships and place can also
affect pregnant women.
Socioeconomic Status. Lower socioeconomic status in childhood has been linked
repeatedly with lower educational and income levels in adulthood, which in turn predict
health status. Children in poor families are about seven times as likely to be in poor or
fair health as children in the highest-income families.
The social determinants of health are mostly responsible for health inequities - the unfair
and avoidable differences in health status seen within and between countries. Examples
of social determinants are: Lack of income, housing, poverty, unemployment, crime,
poverty, racism etc….
Life Course Perspective Implications
 Life course framework in Maternal and Child
Changing practice
 Content of care is expanded
 Poverty
 Economic
 Education
Changing practice
 Services are organized and delivered in ways that
build resiliency and social capital and reduce
 Group care
 Self care
Changing practice
 Requires inter-disciplinary, inter-agency
collaboration to address complex needs
From Theory to Community Practice
• Planning Framework
• Case Management
• Reproductive Health
• Preconception Care
• Prenatal Care
• Community Advocacy
Planning Framework
Planning Framework
 The Healthy Start program: individual case
management and risk reduction services, not
directly responsible for addressing social
 Plan strategies developed on two levels:
What actions can be implemented through Healthy
 What partnerships are needed between Healthy Start and
other organizations working to address social equity?
 Looks at four phases:
 Infancy
 Childhood & Adolescence
 Preconception
 Pregnancy & Childbirth
A Life Course Case Management Model
 The Magnolia Project, federal HS initiative in
Jacksonville uses a preconception strategy to
address racial disparities in birth outcomes.
 Two stage approach:
 Crisis
stabilization, deal with immediate
 Longer term work to change trajectory (Life
Case Management
 The individual Life Plan is participant- driven with
established goals that address needs in three
 Access to preventive health care
 Family & community support
 Reduction of poverty and social inequity
 Participants are enrolled in group activities that
are specific to their Life Plan.
 Addresses the social determinants that influence
poor birth outcomes.
 Promotes inter-and independence while building
reproductive capital in the community.
 Contributes to improved self esteem of
 Hard work! Staff vs. participant response.
Life Course Service Delivery Model
Individual services
(mitigate, reduce risks)
Group services
(inter-dependence, self-reliance)
Community capacity building
(social determinants)
Benefit of Integrating The Life Course Perspective
into Case Management
 The participants welcomed the change and were
excited during the group activity.
An opportunity to address the social determinants that
influence poor birth outcomes
Promoted inter-and independence while building
reproductive capital in the community.
Participants moved from relying on case managers to
becoming leaders of group activities.
The approach can contribute to improved self esteem
among the women enrolled in case management.
Life Course Plan
The individual Life Course Plan is participantdriven with established goals and address needs in
three areas:
Access to preventive health care and related risk
reduction services that improve a woman’s chances for healthy
birth in the future. This includes basic reproductive health
services, such as GYN care and family planning, as well as care
for chronic diseases like diabetes, hypertension and obesity
Life Course Plan
Family and Community support including activities that
provide at-risk women with the skills to develop healthy
relationships and connectedness with communities through
civic engagement and participation.
Reduction of poverty and social inequities that assist
participants in completing their education, gaining job skills,
confronting discrimination and racism, and developing
financial literacy.
Community Advocacy
The Make a Difference! Leadership Academy
develops leadership skills and promotes civic
engagement of case management participants
and residents in high-risk neighborhoods.
The Make a Difference Leadership Academy
utilizes training material developed by the
University of Arizona in 12 weekly sessions.
The program is a research-based curriculum of
current practices and theories designed to build
capacity for grassroots leadership. The
curriculum has been evaluated and demonstrated
as effective for emerging leaders, individuals who
have little or no leadership experience.
The Make a Difference Leadership Academy
changes the trajectory of a community through
individuals being trained and assisted in the
development of a Community Action Plan to
move a community to action.
The Life Course Perspective
 Change in approach = positive response from
participants, MOST staff
 Model has impacted the way we do business
Use of life course framework in update of Healthy Start Service
Delivery Plan
New collaborations in economic self-sufficiency, community
How to incorporate in the State HS care coordination system??
Developed the Make a Difference Leadership Academy
Thank you!