Federal Healthy Start Program Research Articles

High-Risk Pregnancies and Health Conditions in Medicaid-Insured Participants in a Federal Healthy Start Program [13F

INTRODUCTION: Decreasing disparities in maternal morbidity and mortality and addressing maternal chronic health conditions in Medicaid-insured pregnant women are important national goals. Federal Healthy Start (HS) programs provide care for underserved and racial/ethnic minority women, many with self-reported medical conditions, and address social determinants; an opportunity for strategic partnerships with clinical providers. The study objective was to use administrative data and describe health conditions and compare risks in a cohort of HS participants with a statewide population of Medicaid-insured women. METHODS: Medicaid-insured HS participants (N=389) were compared with Michigan beneficiaries (N=80,547). Linked Medicaid claims and vital record data were used to identify health conditions and high-risk pregnancy; AHRQ’s Clinical Classification Software diagnoses were used to identify behavioral health conditions and assess multiple health conditions during pre-pregnancy and pregnancy periods. IRB determined the study did not involve human subjects. RESULTS: HS participants were significantly more likely to have high-risk pregnancy claims (67.4% vs 30.2%), mental health conditions (31.9% vs. 20.2%), multiple health conditions (61% vs. 49%), prior preterm birth (6.7% vs. 3.7%), less than 12 grade education/health literacy (41.6% vs. 16.9%) and be African American (54% vs. 29%). There was a trend for chronic hypertension (5.7% vs. 4%), but no group differences for chronic diabetes (5.7% vs. 5.8%). CONCLUSION: Findings support that HS, equipped to address cultural and social determinants, serves many Medicaid-insured women with multiple, complex health problems, high-risk pregnancies, and mental health issues. Standard processes for program referral and coordination within practices who provide prenatal care could optimize services for high-risk women.

Evaluation of an Evidence-based and Community-responsive Fatherhood Training Program: Providers' Perspective.

Background And Objectives:Studies on male involvement and pregnancy outcomes have often not incorporated the providers’ perspectives, which are potentially critical to understanding program context, evolution, perceived impact, and sustainability. We sought to evaluate the 24/7 Dad® program from the viewpoint of the program providers.Methods:We conducted purposive sampling of 24/7 Dad program facilitators and administrators who were involved in recruitment, training, and follow up of program participants within a federal Healthy Start program (REACHUP) in Tampa, Florida, USA. Using a snowballing approach, we recruited six key informants who had administered the program for at least four years. We elicited and evaluated factors impacting the performance of the father involvement program using content analysis.Results:Under program participation and perceived impact, most providers thought that the program had created a safe space previously unavailable for men in the community. The most useful recruitment strategy was building partnerships with other organizations. The key informants noted an important evolutionary trend in the father involvement program over time as well as the nature of linkages to partner organizations within the area. Threats to program sustainability included the continued reluctance and scepticism to invest funds to address male issues, sub-optimal retention of participants who were living transient lives as well as geographical/transportation barriers.Conclusion and Global Health Implications:The involvement of fathers during pregnancy has significant implications for healthy babies. Our study results provide a clarion call to augment capacity and infuse more resources to improve paternal involvement in order to attain the United Nations Sustainable Goal (2015-2030) of ensuring healthy lives and the promotion of well-being for all at all ages.

Preterm Birth among African American Women in a Federal Healthy Start Program: Informing Pay for Success [12J

INTRODUCTION: Providers are dependent on community-based, enhanced prenatal care (EPC) and home visiting (HV) programs to augment prenatal care and address health disparities. Given uncertain public resources for EPC/HV, innovative financing models are needed to support effective services. Pay-for-Success, a social impact bond model, partners federal/local governments, private investors, health systems, and providers to fund and deliver effective services to at-risk pregnant women and achieve predetermined health outcomes. If outcomes are achieved, savings repay investors and fund continued services. This comparative study examined baseline preterm birth (PTB) and very preterm birth (VPTB) rates for African American (AA) women enrolled in a federal Healthy Start (HS) program (Strong Beginnings), to explore program effectiveness, guide development of a PFS, and structure financial modeling. METHODS: A quasi-experimental study of AA HS participants (n=488; 2009-2014), propensity score matched with non-participants, was conducted using linked HS program, vital record, and Medicaid claims data. The objective was to examine the robustness of the comparison of PTB and VPTB outcomes utilizing multiple statistical methods. RESULTS: AA women who enrolled in the HS program were less likely to have a preterm or very preterm birth compared to matched Medicaid-insured AA women in the county (PT: 11% vs. 13.1-18.0%, range p values .003-.465); (VPT: 1.8% vs. 3.0-4.1%, range p values .035-.247). Comparisons excluding women who received other HV programs yielded similar results. CONCLUSION: Baseline preterm birth findings were positive, although varied dependent on statistical methods, and supported investment in a five year Pay for Success demonstration project.

Understanding Perspectives of African American Medicaid-Insured Women on the Process of Perinatal Care: An Opportunity for Systems Improvement.

Objectives To address disparities in adverse birth outcomes, communities are challenged to improve the quality of health services and foster systems integration. The purpose of this study was to explore the perspectives of Medicaid-insured women about their experiences of perinatal care (PNC) across a continuum of clinical and community-based services. Methods Three focus groups (N = 21) were conducted and thematic analysis methods were used to identify basic and global themes about experiences of care. Women were recruited through a local Federal Healthy Start (HS) program in Michigan that targets services to African American women. Results Four basic themes were identified: (1) Pursuit of PNC; (2) Experiences of traditional PNC; (3) Enhanced prenatal and postnatal care; and (4) Women's health: A missed opportunity. Two global themes were also identified: (1) Communication with providers, and (2) Perceived socio-economic and racial bias. Many women experienced difficulties engaging in early care, getting more help, and understanding and communicating with their providers, with some reporting socio-economic and racial bias in care. Delays in PNC limited early access to HS and enhanced prenatal care (EPC) programs with little evidence of supportive transitions to primary care. Notably, women's narratives revealed few connections among clinical and community-based services. Conclusions The process of participating in PNC and community-based programs is challenging for women, especially for those with multiple health problems and living in difficult life circumstances. PNC, HS and other EPC programs could partner to streamline processes, improve the content and process of care, and enhance engagement in services.

The impact of dose of the St. Louis Healthy Start program and prenatal care adequacy on birth outcomes

The federal Healthy Start program began over 20 years ago to reduce disparities in infant mortality. Data on outcomes of the program, in particular related to the amount of exposure to Healthy Start, are lacking in the literature. This study was designed to assess the impact of dose of a Healthy Start program on prenatal care adequacy (defined using the Kotelchuck Index) and birth outcomes. Two hundred and thirty African American women were included in the study sample. Participants were women served by their local Healthy Start program between 2007 and 2012. Traditional multivariable logistic and linear regression analyses were employed to determine the impact of the Healthy Start program. Dose of Healthy Start (OR = 1.296, 95% CI [1.060, 1.585]) was found to be positively predictive of prenatal care adequacy. Because significant interaction effects were found between dose and prenatal care adequacy, the sample was then stratified by level of prenatal care adequacy, and dose was assessed as an independent variable on birth outcomes (infant birth weight and pre-term birth). Dose was negatively predictive of infant birth weight (β = -60.015, p < .10) among women with adequate plus prenatal care; dose was positively predictive of pre-term birth (OR = 1.427, 90% CI [1.104, 1.845]) among women with adequate plus prenatal care. Dose was found to be an important predictor of birth outcomes across varying categories of prenatal care adequacy and probably works synergistically through prenatal care. Future research should continue to explore these relationships at each level of prenatal care adequacy.

Effectiveness of a federal Healthy Start Program on HIV/AIDS risk reduction among women in Hillsborough County, Florida.

To examine the impact of the Central Hillsborough Healthy Start Project (CHHS) on human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) diagnosis rates in women in Hillsborough County, Florida. Project records were linked to hospital discharge data and vital statistics (Florida, 1998-2007; N = 1,696,221). The χ(2) test was used to compare rates for HIV/AIDS and pregnancy-related complications for mothers within the CHHS service area with mothers in Hillsborough County and the rest of Florida. During a 10-year period, HIV/AIDS diagnosis rates among women in the CHHS service area declined by 56.3% (P = 0.01). The observed decline was most evident among black women. HIV/AIDS diagnosis rates in the rest of Hillsborough County and Florida remained unchanged (P = 0.48). Lessons learned from the CHHS Project can be used to develop effective and comprehensive models for addressing the HIV epidemic.

Selected findings from the cross-site evaluation of the Federal Healthy Start Program.

Initiated in 1991, the Federal Healthy Start Program includes 105 community-based projects in 39 states, the District of Columbia and Puerto Rico. Healthy Start projects work collaboratively with stakeholders to ensure participants' continuity of care during pregnancy through 2 years postpartum. This evaluation of Healthy Start projects examined relationships between implementation of nine core service and system program components and improvements in birth and project outcomes. Program components and outcomes were examined using data from a 2010 Healthy Start project director (PD) survey (N = 104 projects) and 2009 performance measure data from the Maternal and Child Health Bureau Discretionary Grant Information System (N = 98 projects). We explored bivariate relationships between the nine core program components and (a) intermediate and long-term project outcomes and (b) birth outcomes. We assessed independent associations of implementation of all core program components with birth outcomes, adjusting for project characteristics and activities. In 2010, 57 projects implemented all nine core program components: 104 implemented all five core service components and 69 implemented all four core systems components. Implementation of all core program components was significantly associated with several PD-reported intermediate and long-term project outcomes, but was not associated with singleton low birth weight or infant mortality among participants' infants. This evaluation revealed a mixed set of relationships between Healthy Start projects' implementation of the core program components and achievement of project outcomes. Although the findings demonstrated a positive impact of Healthy Start projects on birth outcomes, only a few associations were statistically significant.

Impact of a Federal Healthy Start Program on Feto-infant Morbidity Associated with Absent Fathers: A Quasi-experimental Study

The absence of fathers during pregnancy increases the risk of feto-infant morbidities, including low birth weight (LBW), preterm birth (PTB), and small-for-gestational age. Previous research has shown that the Central Hillsborough Healthy Start project (CHHS)-a federally funded initiative in Tampa, Florida-has improved birth outcomes. This study explores the effectiveness of the CHHS project in ameliorating the adverse effects of fathers' absence during pregnancy. This retrospective cohort study used CHHS records linked to vital statistics and hospital discharge data (1998-2007). The study population consisted of women who had a singleton birth with an absent father during pregnancy. Women were categorized based on residence in the CHHS service area. Propensity score matching was used to match cases (CHHS) to controls (rest of Florida). Conditional logistic regression was employed to generate odds ratios (OR) and 95 % confidence intervals (CI) for matched observations. Women residing in the CHHS service area were more likely to be high school graduates, black, younger (<35 years), and to have adequate prenatal care compared to controls (p < 0.01). These differences disappeared after propensity score matching. Mothers with absent fathers in the CHHS service area had a reduced likelihood of LBW (OR 0.76, 95 % CI 0.65-0.89), PTB (OR 0.72, 95 % CI 0.62-0.84), very low birth weight (OR 0.50, 95 % CI 0.35-0.72) and very preterm birth (OR 0.48, 95 % CI 0.34-0.69) compared to their counterparts in the rest of the state. This study demonstrates that a Federal Healthy Start project contributed to a significant reduction in adverse fetal birth outcomes in families with absent fathers.

Moving Toward Evidence-Based Federal Healthy Start Program Evaluations: Accounting for Bias in Birth Outcomes Studies

We used administrative and screening data from 2009 to 2010 to determine if Healthy Start (HS), an enhanced prenatal services program, is reaching the most vulnerable African American women in Kent County, Michigan. Women in HS are at higher risk of key predictors of birth outcomes compared with other women. To advance toward evidence-based HS program evaluations in the absence of randomized controlled trials, future studies using comparison groups need to appropriately establish baseline equivalence on a variety of risk factors related to birth outcomes.

Integrating the Life Course into MCH Service Delivery: From Theory to Practice

To describe the efforts of a community-based maternal and child health coalition to integrate the life course into its planning and programs, as well as implementation challenges and results of these activities. Jacksonville-Duval County has historically had infant mortality rates that are significantly higher than state and national rates, particularly among its African American population. In an effort to address this disparity, the Northeast Florida Healthy Start Coalition embraced the life course approach as a model. This model was adopted as a framework for (1) community needs assessment and planning; (2) delivery of direct services, including case management, education and support in the Magnolia Project, its federal Healthy Start program; (3) development of community collaborations, education and awareness; and, (4) advocacy and grass roots leadership development. Implementation experience as well as challenges in transforming traditional approaches to delivering maternal and child health services are described. Operationalizing the life course approach required the Coalition to think differently about risks, levels of intervention and the way services are organized and delivered. The organization set the stage by using the life course as a framework for its required local planning and needs assessments. Based on these assessments, the content of case management and other key services provided by our federal Healthy Start program was modified to address not only health behaviors but also underlying social determinants and community factors. Individual interventions were augmented with group activities to build interdependence among participants, increasing social capital. More meaningful inter-agency collaboration that moved beyond the usual referral relationships were developed to better address participants' needs. And finally, strategies to cultivate participant advocacy and community leadership skills, were implemented to promote social change at the neighborhood-level. Transforming traditional approaches to delivering maternal and child health services and sustaining change is a long and laborious process. The Coalition has taken the first steps; but its efforts are far from complete. Based on the agency's initial implementation experience, three areas presented particular challenges: staff, resources and evaluation. The life course is an important addition to the MCH toolbox. Community-based MCH programs should assess how a life course approach can be incorporated into existing programs to broaden their focus, and, potentially, their impact on health disparities and birth outcomes. Some areas to consider include planning and needs assessment, direct service delivery, inter-agency collaboration, and community leadership development. Continued disparities for people of color, despite medical advances, demand new interventions that purposefully address social inequities and promote advocacy among groups that bear a disproportionate burden of infant mortality. Successful transformation of current approaches requires investment in staff training to garner buy-in, flexible resources and the development of new metrics to measure the impact of the life course approach on individual and programmatic outcomes.

The Impact of SLHS Program on Perinatal Indicators

The federal Healthy Start program began 20 years ago, yet outcome evaluations lack sufficient rigor to draw conclusions on program impact. We evaluated the impact of the Healthy Start program on birth outcomes, prenatal care, and public services utilization. Birth record data for the St. Louis Healthy Start Program (SLHS) and non-SLHS controls (matched using a propensity score technique) were assessed for differences. Propensity score matching techniques matched SLHS to non-SLHS clients on potentially confounding variables for births from years 2006 to 2008. Traditional multivariable logistic regression on the full, unmatched sample was also conducted for comparison. Matching eliminated any prior statistical differences between groups on covariates. 168 controls and 84 SLHS participants remained in the final matched analysis group. Both analysis techniques were similar on all outcomes, revealing significant group differences for low birth weight (matched OR = 0.28, p = 0.023) and prematurity (matched OR = 0.25, p = 0.012) but not for prenatal care (matched OR = 0.76, p = 0.414), or public services utilization (matched OR = 3.31, p = 0.121). Early results for this Healthy Start project are positive in key areas directly impacting infant mortality. However, continued analysis of this program for sustained impact in these areas and ultimately, a reduction in infant mortality is needed. Additionally, more rigorous experimental and quasi-experimental evaluation designs are needed to assess the impact of other Healthy Start programs around the country.

Effectiveness of a Federal Healthy Start Program in Reducing the Impact of Particulate Air Pollutants on Feto-Infant Morbidity Outcomes

We sought to assess (1) the relationship between air particulate pollutants and feto-infant morbidity outcomes and (2) the impact of a Federal Healthy Start program on this relationship. This is a retrospective cohort study using de-identified hospital discharge information linked to vital records, and air pollution data from 2000 through 2007 for the zip codes served by the Central Hillsborough Federal Healthy Start Project in Tampa, Florida. Mathematical modeling was employed to compute minimal Euclidean distances to capture exposure to ambient air particulate matter. The outcomes of interest were low birth weight (LBW), very low birth weight (VLBW), small for gestational age, preterm (PTB), and very preterm birth. We used odds ratios to approximate relative risks. A total of 12,356 live births were analyzed. Overall, women exposed to air particulate pollutants were at elevated risk for LBW (AOR=1.24; 95% CI=1.07-1.43), VLBW (AOR=1.58; 95% CI=1.09-2.29) and PTB (AOR=1.18; 95% CI=1.03-1.34). Analysis by race/ethnicity revealed that the adverse effects of air particulate pollutants were most profound among black infants. Infants of women who received services provided by the Central Hillsborough Federal Healthy Start Project experienced improved feto-infant morbidity outcomes despite exposure to air particulate pollutants. Environmental air pollutants represent important risk factors for adverse birth outcomes, particularly among black women. Multi-level interventional approaches implemented by the Central Hillsborough Federal Healthy Start were found to be associated with reduced likelihood for feto-infant morbidities triggered by exposure to ambient air particulate pollutants.

Effectiveness of a Federal Healthy Start Program in Reducing Primary and Repeat Teen Pregnancies: Our Experience over the Decade

Study Objective To evaluate the effectiveness of a Federal Healthy Start program in reducing primary and repeat teen pregnancies in a disadvantaged community. Design An ecological study that compares trends in teen pregnancy in the catchment area in which the community-based intervention was administered with two ecologic controls: the county (Hillsborough) and the state (Florida). Setting Our catchment area is East Tampa, a socio-economically disadvantaged community in Hillsborough County, Florida. Participants Preconception care targeted teenagers between the ages of 10 and 19 years. Interconception care involved young mothers under the age of 20 with a previous birth. The population was comprised primarily of African Americans. Intervention Preconception care services for primary teen pregnancy reduction offered sex education, family planning, drug and violence prevention education, and communication and negotiation skills acquisition. Interconception care service offered young women health education through monthly home visitation or monthly peer support group meetings addressing a range of topics using the life course perspective as framework. Main Outcome Measure Reduction in primary teen pregnancy and repeat teen pregnancy among adolescents. Results The decline in primary teen pregnancy in the catchment area was 60% and 80% greater than the reduction experienced at the county level and at the state level respectively over the period of the study. However, efforts to prevent repeat pregnancy were not successful. Conclusion The Federal Healthy Start Preconception Care program, in collaboration with community partners, contributed to the prevention of first-time teen pregnancy in a community faced with significant social and economic challenges.

Healthy Start: Lessons Learned on Interconception Care

The Federal Healthy Start program was started in 1991 to address the factors that contribute to the Nation's high infant mortality rate, particularly among populations with disproportionately high rates of adverse perinatal health outcomes. The goals of Healthy Start are to reduce disparities in access to and utilization of health services by using a lifespan approach, improving the local health care system, and increasing consumer and community input into health care decisions. In 2007, Healthy Start served 99 communities in 38 states, the District of Columbia, and Puerto Rico. Most Healthy Start grantees are nonprofit organizations. Since 2005, all 97 Healthy Start grantees (and the 2 additional grantees funded in 2007) have been required to include an interconception care component. Three quarters of grantees enrolled the majority of their interconception clients during the prenatal period. Most grantees used care coordination and case management as the primary approach to improving interconception health care. In 2007, 93 interconception projects reported that 9 out of 10 women had an ongoing source of primary care. Grantees screened to detect health conditions and risks, as well as provided an opportunity to provide vital information to women about their risks for chronic conditions such as obesity, hypertension, and diabetes. The Healthy Start interconception components demonstrate a critical need for and the potential impact of a strong interconception care program for high-risk populations such as women living in poverty, in medically underserved communities, and without health coverage.