Table of Contents
Preface ................................................................................................................................................... 0
Overview of Healthy Start Projects .................................................................................................... 1
Introduction .................................................................................................................................. 1
Healthy Start Grantee Characteristics .......................................................................................... 1
Cultural Competence ................................................................................................................... 4
Healthy Start Service Components ..................................................................................................... 6
Outreach and Participant Recruitment ......................................................................................... 6
Case Management ........................................................................................................................ 8
Health Education ........................................................................................................................ 14
Interconception Care .................................................................................................................. 16
Perinatal Depression .................................................................................................................. 18
Support Services ................................................................................................................................. 20
Home Visiting ............................................................................................................................ 20
Breastfeeding Support ................................................................................................................ 22
Smoking Cessation..................................................................................................................... 24
Healthy Weight .......................................................................................................................... 25
Male Involvement ...................................................................................................................... 27
Family Involvement ................................................................................................................... 27
Domestic/Intimate Partner Violence and Child Abuse Screening ............................................. 28
Healthy Start Systems Components.................................................................................................. 33
Consortia .................................................................................................................................... 34
Local Health System Action Plan .............................................................................................. 41
Coordination and Collaboration ................................................................................................. 43
Sustainability.............................................................................................................................. 47
Perceived Outcomes ........................................................................................................................... 48
Intermediate and Long- Term Program Outcomes ................................................................... 48
Selected Community Outcomes ................................................................................................. 50
Appendix ............................................................................................................................................. 54
Appendix 1: Logic Model for the National Healthy Start Evaluation ....................................... 55
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Preface
The U. S. Department of Health and Human Services, Health Resources and Services Administration
(HRSA), Maternal and Child Health Bureau (MCHB) has conducted several independent evaluations
of the Federal Healthy Start Program since the program began in 1991. The Bureau awarded a multiyear contract in 2009 to Abt Associates Inc. to conduct the current evaluation.
The first national evaluation of the Federal Healthy Start Program, conducted by Mathematica Policy
Research in 1997 – 1999, examined the implementation of the 15 demonstration projects during fiscal
years 1992 and 1996, and whether these projects achieved the goals of Healthy Start in reducing
infant mortality and improving maternal and infant health. Findings suggested that Healthy Start was
associated with improvements in measurements of prenatal care utilization, preterm birth rate, low
and very-low birth weight rates, and the infant mortality rate. Specifically, several sites had
significantly better outcomes than comparison sites.
The second national evaluation was comprised of two phases. A key objective of the first phase of
this evaluation (conducted from 2002 to 2004) was to provide information about the funded grantees
and the implementation of the program components of the National Healthy Start program. Findings
from this first phase were published in a similar report in 2006.1 The second phase consisted of eight
case studies, including a survey of Healthy Start participants.2,3
The current evaluation, which builds on the previous evaluations, and uses a logic model (shown in
Appendix 1.1) to illustrate how implementation of the nine program components may lead to a
progression of the achievement of some short-term outcomes, which in turn, may translate into
intermediate outcomes and then to longer-term outcomes. This evaluation is consistent with the needs
of the MCHB to meet the requirements of the Government Performance and Results Act (GPRA).
This report provides the descriptive findings from the Grantee Project Director Survey of 2011 and
documents the accomplishments of the Federal Healthy Start Program.
1
Health Resources and Services Administration. (2006). A profile of Healthy Start: Finding from Phase 1 of
the Evaluation 2006. Rockville, MD: Health Resources and Services Administration, U.S. Department of
Health and Human Services.
2
Brand, A., Walker, D.K., Hargreaves, M., & Rosenbach, M. (September 2010). Intermediate Outcomes,
Strategies, and Challenges of Eight Healthy Start Projects. Maternal Child Health Journal, 14(5), 654-65.
3
Rosenbach, M., Cook, B., O’Neil, S., Trebino, L., & Walker, D.K. (2010). Characters, access, utilization,
satisfaction and outcomes of Healthy Start participants in eight sites. Maternal and Child Health Journal,
14(5), 666-679.
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Overview of Healthy Start Projects
Introduction
The National Healthy Start Program, funded through Health Resources and Services Administration’s
(HRSA) Maternal and Child Health Bureau (MCHB), was developed in 1991 with the goal of
reducing infant mortality disparities in high-risk populations through community-based interventions.
The program originally began as a 5-year demonstration project within 15 communities that had
infant mortality rates 1.5 to 2.5 times above the national average. By 2010, the National Healthy Start
Program had expanded in size and mission to include 96 grantees implementing 104 projects in 38
states, the District of Columbia and Puerto Rico.
The objective of the National Healthy Start Program is to implement evidence-based practices and
innovative community-driven interventions to promote and improve the quality of health care for
women and infants. To do this, Healthy Start works collaboratively with stakeholders and consumers
in the community to leverage existing assets at both the service and system levels to ensure continuity
of care from pregnancy through 2 years following delivery (prenatal to interconception). As specified
by the HRSA 2001 Guidance, the core program goals, or intermediate outcomes of Healthy Start,
include:
 Reduced racial and ethnic disparities in access to and utilization of health services,
 Improved local health care systems,
 Increased consumer or community voice in health care decisions.
To meet those goals, HRSA identified nine core components that grantees are required to implement.
These five service components are outreach and participant recruitment, health education, case
management, maternal depression screening and interconception care services; the four systemsbuilding components are implementation of a consortium, development of local health system action
plans, development of sustainability measures, and collaboration and coordination with Title V. The
Grantee Project Director 2011 Survey was designed to collect information related to the
implementation of the nine core program components and their features as well as additional, support
services offered by all Healthy Start projects. Information on the accomplishments of each Healthy
Start project for the subset of the service and system activities that were identified as most important
in previous evaluations was collected as well; many survey questions were drawn from the 2004
survey of Healthy Start project directors. The 2011 Survey was administered as a web-based survey
between July and September 2011. All projects completed the survey resulting in an 100 percent
response rate.
Healthy Start Grantee Characteristics
Healthy Start begins with outreach to high risk pregnant and interconceptional women, high risk
infants, and other women and male partners. Once enrolled, Healthy Start offers risk assessment and
case management, care coordination, and referrals as a way to ensure that participants receive the
services they need. Healthy Start allows each program flexibility to implement processes and
services based on the the needs of the community and those being served by Healthy Start. Therefore,
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it is not surprising that Healthy Start grantees varied on a number of characteristics. For instance,
community-based non-governmental agencies (43%) and government agencies including State and
Local health departments (41%) were most often cited as the types of Healthy Start grantee
organizations; less often reported agencies included non-profits (9%), universities (5%), tribal groups
(2%), or Federally Qualified Health Centers (1%) (Figure 1). The scope of Healthy Start projects was
predominantly local (77%); other projects reported having a multi-community scope (21%), far fewer
reported regional or state-wide (2%) scope (Figure 2).
Healthy Start projects served eligible participants in both urban and rural areas; however many more
projects served participants in urban/central city (62%) and/or metropolitan (23%) areas compared
with rural areas (27%). Few projects (5% or less) served participants in suburban areas and along the
(US-Mexico) border (Figure 3). At the time of the survey, 104 Healthy Start projects were funded by
HRSA; 17 percent of these projects were initially funded in the first phase when the program began in
1991 but most (61%) were funded during the second phase beginning in 1997 (Figure 4).
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Cultural Competence
Because the populations served by Healthy Start projects are culturally diverse, the projects
implement strategies to ensure that their staff is culturally competent. In 2010, 94 percent of all
Healthy Start projects hired staff that represented the target population and 39 percent required
contractors to do the same; 80 percent provided cultural competence training. Fifty three percent
employed two of these three strategies; and 32 percent employed all three strategies. Other strategies
used to promote cultural competence included hiring staff who were former participants, offering
Spanish language instruction, and hiring staff who spoke the primary languages of the target
population. Only three percent of all projects reported that they did not implement any of the abovementioned strategies for promoting cultural competence (Figure 5).
Sixty-six percent of HS projects (69) indicated that their target population included individuals whose
first language was not English. Of those 69 projects, 94 percent reported serving Spanish speaking
participants. Additional languages spoken by populations served included French (19%), Arabic
(10%), Hmong (7%) and Creole (7%) (data not shown). To facilitate communication with
participants who did not speak English, 90 percent of HS projects assigned these participants to staff
who spoke the same language; 43 percent allowed friends or family of the participant to translate; and
39 percent contracted with outside agencies for translation/interpretation services. Three percent
reported that staff was unable to communicate with participants who were non-English speakers.
Additionally, Healthy Start projects reported a variety of ways in which screening tools were adapted
for each participant’s cultural background. For instance, approximately 80 percent (79.8%) of projects
reported using staff who spoke the participant’s language to administer screening tools (79.8%), and
58 percent (57.7%) of the projects reported adapting tools to meet the cultural needs of their
participants. Fewer projects reported using translators, or using an advising group to review the tools
(data not shown).
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Healthy Start Service Components
As described above, the Healthy Start Program consists of five core service components: outreach,
case management, health education, perinatal depression and interconception care. All 104 Healthy
Start projects were implementing all five core service components.
Outreach and Participant Recruitment
Outreach and client recruitment are the point of entry for Healthy Start project participants. A
project’s ability to reach out to women and families in the community, and recruit their participation,
is a key first step in impacting access to needed services. For the most part, Healthy Start projects
employed their own project staff to perform outreach and recruitment; however, staff from other
agencies under subcontract or organizations in collaboration with Healthy Start staff (41%) also
conducted outreach and recruitment in addition to a combination of Healthy Start and contracted staff.
Fewer projects (approximately 3%) reported using other staff, including Title V employees and other
grant-funded employees (Figure 6).
Outreach was targeted to the eligible cultural and ethnic groups within the communities using specific
strategies that included utilizing staff reflective of the community being served (86%); connecting
with community initiatives that reflect the participants’ cultural group (74%); translation of written
materials (74%); and applying knowledge of customs and cultures during participant interactions
(68%) (Figure 7).
Major client outreach and recruitment strategies included both community-based strategies and mass
media approaches. Community events (98%), brochures (94%) and networking with health care
providers, schools, or other agencies (93%) were common community-based strategies. Fewer
Healthy Start projects utilized mass media; 51 percent implemented newspaper or advertising
campaigns as a way to reach participants. Many projects also used classes or presentations as a way to
reach potential participants (83%), as well as neighborhood canvassing (82%). Other strategies
included informal networking such as word of mouth through current or former participants, or
advertising on websites of other local organizations (Figure 8).
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Case Management
Case management is a required core service of the Healthy Start Program and an important
mechanism for understanding the often complex needs of Healthy Start participants. It is essential for
linking women with needed referrals to care. The majority of Healthy Start projects engage
participants in their home (92%), which allows staff to engage their clients in surroundings that are
comfortable to the participant, and also allow staff to better understand the varying facets of each
participant’s life. Many projects also report (71%) providing case management at the project site,
while others do so in clinics (51%), or in other community- based settings (41%). A few (25%)
projects reported delivering case management in other settings such as schools, WIC offices, or other
places convenient for the participant (Figure 9). Case management services were mainly provided by
Healthy Start project staff (76%); staff from other agencies and organizations (34%) and a
combination of Healthy Start and subcontracted staff (11%) also provided case management services
(Figure 10). Case management staff was mostly social workers (67%) or nurses (63%); over half
were staff indigenous to the community (59%). Less than one-third of case managers had
backgrounds in health education (32%) behavioral/mental health (29%), public health (28%) or
something else (Figure 11).
Case management provides a prime opportunity for Healthy Start staff to assess the needs of the
participant, and then to provide referrals as needed. As such, case management services occurred in a
variety of settings, for prenatal/pregnant women, and women during the interconception period. The
majority of projects reported providing case management services prenatally or during pregnancy
through home visiting (93%), at the Healthy Start project site (79%), or over the phone (88%).
Similar case management services were offered to women during the interconceptional period.
The vast majority of Healthy Start projects offered some referrals through case management (Figure
12). The type of referrals varied, although most projects reported that case managers made referrals
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for many critical social services such as domestic violence/shelters (97%), WIC/food assistance
(97%), substance abuse treatment and counseling (96%), housing/heating (96%), mental/behavioral
health (96%), clinical services (92%) and transportation services (89%). Other reported referrals
included childbirth, childcare, breastfeeding classes, GED and employment services, family planning
services, and Medicaid enrollment assistance. In addition, most projects (89.4%) reported developing
written service plans as a part of their case management activities (data not shown).
Several barriers to accessing care through primary care providers were identified by respondents
(Figure 13). The most predominantly reported barrier was lack of transportation to and from
appointments (79%); lack of health insurance (78%) and participant perceptions or misperceptions of
primary care (68%) of respondents. Less frequently, Healthy Start projects reported lack of available
providers (41%) and language barriers between the participant and provider (35%). Other barriers
reported included lack of child care, and competing priorities.
Similarly, barriers to accessing referrals made through case management were reported (Figure 14).
The most predominantly reported barrier was unstable housing (91%), followed by lack of
transportation (85%); lack of child care (78%) and depression or other mental health conditions
(76%). Other barriers again included competing priorities.
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Health Education
All 104 Healthy Start projects provided health education to participants. Health education was most
often conducted at a participant’s home (90%), the Healthy Start project site (85%), or other
community-based setting (84%). Fewer projects reported conducting health education at clinics
(59%) (Figure 15). Eighty four percent of Healthy Start projects used project staff to perform health
education activities. Less than half reported using staff from another agency or organization (37%) or
a mix of Healthy Start and subcontracted staff (23%) (Figure 16). A large proportion of health
education staff were indigenous to the community (76%). Projects also utilized staff with health
education (64%) or nursing backgrounds (57%) (Figure 17).
Projects reported a wide array of educational offerings. Some key educational topics reported by 103
of the 104 projects included: immunization, breastfeeding, sudden unidentified infant deaths/sudden
infant death syndrome (SUID/SIDS), child safety and injury prevention, perinatal depression,
substance abuse, nutrition, and tobacco use cessation (data not shown).
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Interconception Care
Beginning in 2001, the Division of Healthy Start and Perinatal Services (DHSPS) formally introduced
interconception care as a core component of Healthy Start in recognition of the important role of
interconception care in eliminating disparities and improving maternal and infant outcomes. Since
2005, all grantees have been required to incorporate an interconception care component into the
services offered by their Healthy Start projects. All Healthy Start projects reported offering
interconception care services to participants. The majority (94%) of Healthy Start projects provide
interconception care (ICC) services in the participant’s home, while many participants receive these
services at the project site (75%). More than half of the projects provided ICC services at clinical
(56%) and other community-based settings (53%) (Figure 18). Interconception care services were
provided predominantly by Healthy Start project staff (76%) (Figure 19). Staff backgrounds of those
providing interconception care services included social work (65%) and nursing (61%) (Figure 20).
Referrals are a key component of Healthy Start interconception care services. For example, more
than 80percent of projects offered the following through the interconception care component of their
projects: clinical or mental health services, food assistance, housing and heating assistance, substance
abuse treatment and counseling services for women experiencing domestic violence, and
transportation referrals (data not shown).
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Perinatal Depression
Evidence has shown links to depression and adverse pregnancy outcomes, as well as risk of
depression for women following the birth of their babies. Furthermore, low-income mothers of young
children experience particularly high levels of depression, often in combination with other risk
factors. Perinatal depression screening became a required component in the third funding cycle of
Healthy Start, beginning in 2001. All projects currently provide perinatal depression screening.
The majority (91%) of Healthy Start projects provide perinatal depression screening services in the
participant’s home, while some offer services at the project site (67%). Close to half perform perinatal
depression screening services at clinics (47%) and in other community based settings (47%) (Figure
21). Perinatal depression screening services are provided mainly by Healthy Start project staff (73%)
(Figure 22), and staff with social work (64%) and nursing (55%) backgrounds or staff indigenous to
the community (56%). Less than 50 percent (44%) of all staff providing perinatal depression
screening services have a mental health background (Figure 23).
Although information on the screening tools most often used to screen for perinatal depression was
not collected through the 2011 Survey, many of the Healthy Start projects that participated in the
Interconception Care Learning Collaborative (ICC LC) from 2009-2011 indicated that they used the
Edinburgh or the PHQ-9 scale to assess depression (data not available).
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Support Services
A total of 68 Healthy Start projects (35%) reported offering all of the following support services:
home visiting, breastfeeding support and education, smoking and other tobacco use cessation, healthy
weight services, male and family involvement, domestic/intimate partner violence screening and child
abuse screening or services.
Home Visiting
Evidence-based home visiting programs have been shown to reduce adverse birth outcomes such as
low birth weight, decrease the incidence of child abuse and neglect, and positively impact child
development, including literary skills and test scores. The Patient Protection and Affordable Care Act
of 2010 authorized the creation of a Maternal, Infant and Early Childhood Home Visiting Program,
which is providing funding to states to establish home visiting program models for at-risk pregnant
women and children from birth to age 5. The new funding has heightened the attention to and need
for home visiting program models that target families with pregnant women and young children and
rigorous evaluation to assess the effectiveness of these home visiting models.
Home visiting is a core mechanism through which Healthy Start programs deliver preventive services
that address disparities in perinatal health and infant mortality. Approximately half (51%) of all
Healthy Start projects conduct home visits based on a model. Many projects use State or local models
or a combination of models. A few projects use existing evidence-based models or promising
practices such as Parents as Teachers (23%), Healthy Families America (19%), and Nurse Family
Partnerships (19%). Several projects also reported the use of curricula such as Florida State
University’s Partners for a Healthy Baby (Figure 24).
Of the 82 Healthy Start projects that offered home visiting through required components, the majority
of projects conducted home visiting for case management (93%) and interconception care services
(82%). Many also offer home visiting through health education (60%) and some offer home visiting
via outreach services (39%) (Figure 25).
The 103 Healthy Start projects that reported conducting home visits all provided home visiting to
their participants and 42 percent provided these services to partners of participants and 16 percent to
non-partner family members. The majority of Healthy Start projects provide home visiting services to
high risk women in either the interconception period (94%), or prenatally and during pregnancy
(93%). Furthermore, the majority of projects also offer services to high risk infants and toddlers
through 23 months (92%). Approximately 90 percent of projects also report serving women and
infants at moderate risk through home visits (Figure 26).
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Breastfeeding Support
Evidence shows that breastfeeding plays a central role in the development and maturation of immune
systemof infants. Breast-fed infants were less likely to develop gastrointestinal illness compared with
infants in the control group. The health and bonding benefits to baby and mother, as well as potential
cost savings make breastfeeding an important option for new mothers. Yet, the rates of breastfeeding
are particularly low among African American women, making breastfeeding support an important
part of the support services offered by Healthy Start projects.
All Healthy Start projects reported addressing breastfeeding either during pregnancy or during the
prenatal period; most (92%) also discuss breastfeeding during the interconception period.
Additionally, 85% also offer individual breastfeeding support to postpartum participants (Figure 27).
Of the projects that offer individual support, most have peer counselors available for individual
breastfeeding support (67%), and some have certified lactation consultants (49%) or doulas (18%)
onsite for consultation (Figure 28). Breastfeeding is encouraged through offering private space for
participants (65%) as well as Healthy Start staff (61%) (Figure 29).
Additional breastfeeding support is offered through loaning or donating breastfeeding equipment to
participants at some Healthy Start projects, with 44 percent offering breast pumps, 23 percent offering
breast shells or shields, and 10 percent offering nursing supplementers to participants (Figure 30).
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Figure 30: Breastfeeding Equipment Available to Loan or donate to
Healthy Start Participants, 2010
Breast Pumps
44%
Breast Shells/Shields
Nursing Supplementers
23%
10%
Smoking Cessation
The association between maternal smoking and low birthweight is well established. The importance
of smoking and tobacco use cessation among women of childbearing age is reflected in the fact that
Healthy Start projects address this topic during many interactions with participants including home
visits (98%), face to face meetings (82%), and group health education classes (85%) (data not shown)
In fact, the majority of (99%) of the Healthy Start projects offer participants a number of opportunities for smoking/tobacco use cessation. The opportunities are primarily through access to
community, state-run or other quit lines (86%), referrals (84%) and one-on-one counseling (63%). A
few projects offer group counseling (30%) and even fewer offer medication options (18%) (Figure
31).
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Healthy Weight
Obesity has reached epidemic proportions in the United States. Among women the correlates of
obesity are increasing age, low education and/or low economic status. Additionally, there is an
increasing prevalence of overweight and obesity among women of childbearning age, and currently
1out of 5 women are obese at the beginning of their pregnancy and obesity has been linked to a
number of adverse reproductive outcomes.
Given the risk factors for and prevalence of obesity, as well as the known links between obesity and
adverse outcomes in women and children, addressing Healthy Weight is a priority for Healthy Start
projects.The majority (97%) of Healthy Start projects discussed healthy weight with participants and
most (80%) encouraged or promoted weight-related activities with staff . Among the 101 Healthy
Start projects addressing healthy weight with participants, the majority addressed nutrition (100%),
physical activity (97%) and weight management (94%) during home visits (89%), group education
classes (73%), face to face meetings (68%), other routine care-related contacts (56%), and outreach
activities (49%). Additionally, these projects report offering literature on weight and nutrition (93%),
nutrition-related education (91%), and education about weight and pregnancy (87%) (data not
shown). Of the 83 projects that addressed healthy weight with staff, 99 percent discussed physical
activity, as well as nutrition (94%), and weight management (93%) (Figures 32 & 33 & 34).
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Male Involvement
Healthy Start enables men to play a positive role in the lives of Healthy Start women participants and
their children. The majority of Healthy Start projects (69%) offer services to men either as part of a
male-only program or through services offered to female participants (data not shown). These
services primarily include health education (96%), but case management (65%), court advocacy
(43%), mental health services (42%) and clinical services (25%) are also offered to men by some
Healthy Start projects (Figure 35).
Family Involvement
Healthy Start projects encourage family involvement in services and activities, and all projects
indicated that family involvement is an important part of the activities offered to participants.
Specifically, 80 percent of Healthy Start projects reported that at least some (30 % or more)
participants had family involved in their Healthy Start activities. For example, 88 percent invite
family members to attend any health education opportunities, 86 percent offer the opportunity to
attend consortium meetings, and 84 percent encourage family members to attend outreach activities.
Many projects encourage family involvement through health education (80%) or outreach (75%)
designed specifically for family involvement. Fifty three percent of projects reported that family
members are invited to be present in the development of a written service plan for participants.
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Projects also reported encouraging family participation in other ways, including designing brochures
and PSAs, participating in focus groups, or serving on consortia (Figure 36).
Domestic/Intimate Partner Violence and Child Abuse Screening
Domestic violence/intimate partner violence (IPV) during pregnancy not only has serious
consquences for the health of the mother, but can also negatively impact pregnancy and the
subsequent health of the infant, with outcomes such as premature labor and low birthweight
associated with IPV during pregnancy.
Healthy Start projects overwhelmingly offer training about domestic IPV and child abuse to their
staff, and most report offering referrals to their participants. Eighty four percent of Healthy Start
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projects offered staff training on child abuse, and 95 percent offered training on Domestic/Intimate
Partner Violence(DV/IPV); similarly 47 percent of projects provided referrals for child abuse, and 95
percent provided referrals for DV/IPV. Training on a variety of topics related to child abuse and
DV/IPV were offered. Most projects offered staff training on what constitutes child abuse (98%),
reporting requirements for suspected child abuse or neglect (97%), and how to make referrals to
community or legal services (93%), among other topics. Other training topics included in-house
protocols on child abuse reporting (Figure 37). Training on domestic/intimate partner violence
included: what constitutes domestic/intimate partner violence (98%), resources in the community or
through the legal system (94%), and how to make referrals (91%) (Figure 38).
Referrals most often provided for suspected child abuse included referrals to protective services
(96%), referrals to shelters or safe havens (96%), and referrals to mental health services (96%)
(Figure 39). Of those Healthy Start projects making referrals for DV/IPV (99), all referred to shelters
and safe havens for participants experiencing domestic/intimate partner violence. Other referrals
included referrals to mental health services (97%), and medical referrals for domestic violence related
injuries (84%), among others (Figure 40).
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Healthy Start Systems Components
Community wellness and transformation requires significant collaborative efforts among various
public and private partners for addressing environmental changes in combination/unison with
individually focused behavior changes. Healthy Start systems components underscore the importance
of local and State collaboration, stakeholder engagement, and sustainability planning for effecting
systems-level change.
Consortium and collaboration with Title V were the two original systems components required by
Healthy Start; local health systems action plan (LHSAP) and sustainability planning were added
during the third funding cycle (2001-2005) on the recommendation of Secretary’s Advisory
Committee on Infant Mortality. These four required systems components – consortium, local health
systems action plan, collaboration with Title V, and sustainability plan – were being implemented to
varying degree by all Healthy Start projects (from 99% to 66%). Overall, however, all Healthy Start
projects were more likely to implement service components than systems components (Figure 41).
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Consortia
All projects have at least one consortium through which community stakeholders are engaged; the
majority (77%) had one, with 11 percent reporting two consortia. Fewer Healthy Start projects
reported 3 (6%), 4 (2%), or 5 or more (4%) consortia (Figure 42).
Most Healthy Start projects reported that the purpose of a consortium was to share information with
the community and raise awareness of maternal and child health issues (95%), bring together
potential partners and enhance collaboration (91%), and to fulfill the requirements of the grant
guidance (89%) (Figure 43). Systems activities conducted through the consortium included
developing priorities to direct Healthy Start activities (88%), coordinating existing services and
resources, such as building referral networks (87%), and enhancing community participation in
identifying community needs, setting priorities, and implementing changes (82%) (Figure 44).
Several accomplishments of the consortia were reported. The most often cited accomplishment was
an increased awareness of infant mortality in the community (87%). Other accomplishments included
an enhanced ability of Healthy Start projects to address disparities in access to and utilization of
health services (65%), creating sustainable partnerships among member agencies (61%), and
increasing Healthy Start participant involvement in the project's decision-making activities (57%).
Approximately half of the projects reported increased integration of service systems (52%) and
increased service capacity in the community (47%), as well as increasing the amount of, or access to,
data available to partner organizations on the health status of the target population (46%). Fewer
projects reported influencing policy affecting access to care for the Healthy Start target population
(30%), using funds in an innovative manner (29%), or obtaining new grants or funding (19%) as
accomplishments of the consortium (Figure 45). Additional accomplishments reported included
increased provider or member knowledge, needs assessment development, and joint funding
applications. Only 2 percent reported no accomplishments associated with the consortium in 2010.
Fifty-six percent of Healthy Start projects reported irregular attendance at meetings as a barrier to
consortia accomplishments; other reported barriers included lack of resources to support the
consortium (39%), insufficient staff time to assist with the efforts of the consortium (38%), and lack
of participant engagement (36%). Among those projects reporting other barriers, budget cuts were
among the most often-offered response. Forty two percent of projects reported that their consortium
did not have any challenges in 2012 (Figure 46).
Consumer involvement is key to the success of a consortium, yet lack of Healthy Start participant
involvement in consortia remains a barrier to consortia accomplishments, as reported by Healthy Start
projects. In an effort to encourage Healthy Start participant involvement in consortia, several
strategies were employed including providing supports such as child care or transportation to
participants (77%), designing the consortia meetings to be both welcoming and interesting to
participants (75%), choosing convenient meeting and event times (74%) as well as convenient
locations (73%) and actively recruiting Healthy Start participants to be a part of the consortia (72%).
Other strategies reported included incentivizing participants, and involving case managers in
recruiting participants for consortia participation (Figure 47).
A variety of methods were also used to promote leadership among Healthy Start participants involved
in consortia. Most commonly reported methods for promoting leadership included inviting
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participants to serve on subcommittees (65%), sending participants to conferences (65%), conducting
leadership training sessions (45%) and inviting participants to facilitate meetings (42%) (Figure 48).
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Local Health System Action Plan
The development of a Local Health System Action Plan (LHSAP) became a required component
during the third funding cycle, beginning in 2001. A total of 95 Healthy Start projects (91%) currently
have a Local Health System Action Plan, with 68 percent reporting that their LHSAP is specific to
Healthy Start (Figure 49). The majority of those projects with a LHSAP report that Healthy Start staff
(89%), key community partners (79%), Healthy Start consortium members or a consortium
subcommittee (77%), and the local health department (73%) are involved in the development of the
LHSAP. Fewer projects reported involving Healthy Start participants (56%), the state Title V agency
(44%) and local Title V grantees (42%), as well as local government agencies (36%) (Figure 50).
Strategies used to facilitate consumer involvement in consortia with and without LHSAP were
examined. Among those projects with a LHSAP, 40 percent reported communication improvements
between community agencies and institutions as a result of Healthy Start efforts, 39 percent reported
that Healthy Start had created solutions to address health care access problems, and 36 percent
reported that Healthy Start was able to document a positive effect on local maternal and child health
issues. Twenty five percent of the projects with a LHSAP reported that Healthy Start contributed to
the community’s capacity for assessing maternal and child health issues (data not shown).
In terms of developing a basis for change, of those projects with a LHSAP, 53 percent reported that
Healthy Start is connected to the community’s power structure, and 16 percent reported that Healthy
Start is an integral part of the delivery system in the community (data not shown).
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Coordination and Collaboration
Healthy Start projects have established relationships with many entities in their communities and are
engaged in a wide range of collaborative activities. Almost all Healthy Start projects reported
collaboration with health-related organizations such as local health departments (94%), mental health
agencies (94%), WIC programs (92%), hospitals (91%) substance abuse programs (90%), and
Federally Qualified Health Centers (88%). In addition, most projects also reported collaborating with
State Title V (87%), private physicians (86%), and Medicaid (84%) (Figure 51).
Projects reported collaborating with several community-based organizations such as faith-based
groups (98%), civic groups (92%), professional associations (82%), advocacy groups (81%), diseasebased organizations (80%), and ethnic organizations (76%) (Figure 52). Healthy Start projects
collaborated with service-related organizations including schools (88%), child protective services
(87%), Head Start/Early Head start (83%), welfare agencies (79%), and courts (64%) (Figure 52).
Of projects that coordinate with State Title V, the most common reported benefit was access to data
and other information provided by State Title V for needs assessment (74%). The majority of projects
also reported that State Title V agencies help with efforts to advocate for Healthy Start target
populations (66%) and provides resource materials for health education (63%). Approximately half of
those projects that responded to the survey questions about State Title V reported State Title V’s
assistance with increasing Healthy Start’s visibility in policy arenas (51%) as well as providing
training for staff (51%) (Figure 53). Only five percent of Healthy Start projects reported no
perceived benefits to this collaboration.
Healthy Start projects also reported on their involvement in community-wide collaborative efforts
related to a variety of important topics. Eighty three percent collaborated with the community on
breastfeeding initiatives and 61 percent reported collaboration around the topics of smoking and other
tobacco use cessation and healthy weight. Other areas of collaboration included infant mortality and
prematurity, family planning, and access to care (Figure 54).
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Sustainability
The requirement that all projects develop a plan to sustain Healthy Start services at the end of the
grant began in the third funding cycle; sixty nine Healthy Start projects (66%) had a sustainability
plan (Figure 55) in 2010. Among the 69 Healthy Start projects with a sustainability plan ,
sustainability strategies included seeking state or local funding (84%), collaborating with other
organizations (83%) and seeking other federal funding (83%). More than half of the projects reported
seeking additional Healthy Start funding (84%) and collaborating with State or local Title V (72%) as
strategies used for sustainability. Fewer projects reported packaging services for Medicaid or health
plan reimbursement (54%).
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Perceived Outcomes
Intermediate and Long- Term Program Outcomes
Healthy Start projects reported on several intermediate and long- term outcomes in a number of areas
including increased awareness, improved systems of care, participant involvement, and participant
service outcomes. With respect to outcomes around increasing awareness, many projects reported
increasing awareness of the importance of interconception care (77%) and increasing awareness of
disparities in birth outcomes as a priority in the community (73%). Furthermore, 71 percent of
Healthy Start projects increased positive health behaviors among participants, 68 percent increased
access to services available for participants, and 67 percent increased the number of participants with
a medical home (Figure 56).
Less than half of all projects reported achievement of outcomes related to improving systems of care;
49 percent increased screening for perinatal depression among providers in the community, 45
percent increased integration of prenatal, primary care and mental health services, and 41 percent
increased the cultural competence of providers in the community. In terms of participant involvement,
fewer projects reported increased participant involvement in Healthy Start decision making (48%),
and participant involvement in other community activities addressing systems change (38%), and
only 21 percent of Healthy Start projects increased participant involvement in decision making among
partner agencies (Figure 56).
Healthy Start projects further reported findings in support of intermediate outcomes. The majority of
projects reported that evidence of project outcomes could be found in the MCHB performance
measures (63%), local evaluation findings (60%), and in the Healthy Start Impact Reports (58%).
Other evidence included new and continuing applications (49%), case study findings (13%), among
others (data not shown).
Finally, 88 percent of all projects reported achieving some long- term outcomes. Improved birth
outcomes was the most often reported long -term outcome with 68 percent of projects reporting this
achievement in 2010. Fewer projects reported improved maternal or child health, birth spacing, or
sustained community capacity to reduce disparities in health status in the community (data not
shown).
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Selected Community Outcomes
Healthy Start projects engage with the community through a myriad of mechanisms including
community outreach and recruitment, hiring staff indigenous to the community, encouraging
community members to participate in consortia, and partnering with other community organizations
to foster sustainability and to ensure that participants have access to needed care.
Healthy Start projects were asked to report on a select set of community outcomes such as reduction
in MCH disparities. Projects most often cited case management (87%) as a service activity that
contributed to a reduction of disparities in maternal and infant health outcomes. Other services cited
for playing a role in these efforts included interconception care (70%), perinatal depression screening
(67%), enabling services (63%) and outreach and client recruitment (62%) (Figure 57).
Collaboration with consumers (58%) was reported by many projects as a system activity that
contributed to reducing disparities in maternal and infant health outcomes. Collaboration with
community–based organizations (CBOs) (51%), provider education (47%), and collaboration with
public (47%) and private (44%) agencies, consortium (43%), LHSAP (41%), as well as collaboration
with State (30%) and local (33%) Title V were less often reported as contributing to reducing
disparities (Figure 58).
Additional outcomes were reported as a result of Healthy Start’s community relationships. For
instance, 43 percent of the Healthy Start projects reported that changes or solutions have been
implemented in the community as a result of Healthy Start recommendations. Forty one percent of
projects reported improved communication between community agencies and institutions as a result
of Healthy Start (Figure 59). Fifty four percent of projects reported that MCH agencies and providers
take ownership of Healthy Start goals; 41 percent reported an institutional and fiscal base of support
sustains Healthy Start. With regard to identifying issues, 38 percent of Healthy Start projects reported
identification of strategies for addressing disparities, and 38 percent identified access problems in the
health care system.
Fifty one percent of projects also reported that Healthy Start was connected to the community’s
power structure and that Healthy Start processes maintain a good balance between medical, public
health, and community viewpoints (48%), as well as the fact that residents of the community are
aware of Healthy Start (48%) (Figure 60).
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Appendix
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Appendix 1: Logic Model for the National Healthy Start Evaluation
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