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Selected Findings from the Cross-Site Evaluation of the Federal Healthy Start Program

Vonna Lou Caleb Drayton • Deborah Klein Walker •

Sarah W. Ball • Sara M. A. Donahue •

Rebecca V. Fink

Published online: 28 November 2014

� Springer Science+Business Media New York 2014

Abstract 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 implemen-

tation 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 com-

ponents with birth outcomes, adjusting for project charac-

teristics 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 find-

ings demonstrated a positive impact of Healthy Start pro-

jects on birth outcomes, only a few associations were

statistically significant.

Keywords Maternal and child health � Healthy Start Program � Cross-site evaluation � Program evaluation

Introduction

The Federal Healthy Start Program began in 1991 as a

response to high infant mortality rates (IMR) in the United

States as well as the large gap in these rates between white

and non-white infants. The first Healthy Start projects were

funded as demonstration sites in 15 communities with IMR

1.5–2.5 times the national average. By 2012, the program

had expanded in size and mission to include 105 projects in

39 states, the District of Columbia and Puerto Rico,

including projects in both urban and rural areas. As spec-

ified by Health Resources and Services Administration

(HRSA) guidance documents [1–3] the core Program goals

include: (1) a reduction of racial and ethnic disparities in

access to and utilization of health services, (2) an improved

local health care system, and (3) an increased consumer or

community voice in health care decisions.

V. L. C. Drayton (&) Booz Allen Hamilton, One Preserve Parkway, Rockville,

MD 20852, USA

e-mail: [email protected]

D. K. Walker � S. W. Ball � S. M. A. Donahue � R. V. Fink Abt Associates, 55 Wheeler Street, Cambridge, MA 02138-1168,

USA

e-mail: [email protected]

S. W. Ball

e-mail: [email protected]

S. M. A. Donahue

e-mail: [email protected]

R. V. Fink

e-mail: [email protected]

123

Matern Child Health J (2015) 19:1292–1305

DOI 10.1007/s10995-014-1635-4

The Federal Healthy Start Program focuses on improv-

ing the health and well-being of women, infants, children

and their families through the implementation of evidence-

based practices and innovative community interventions. In

2010, Healthy Start projects served almost 30,000 pregnant

women, many of whom were black or African American,

34 years and younger, with incomes below 100 percent of

the federal poverty level [4].

Healthy Start projects work collaboratively with com-

munity stakeholders and consumers to leverage existing

service and system resources so that women at risk for

adverse birth outcomes are assured continuity of care

during pregnancy through 2 years postpartum. Since 2001,

all Healthy Start projects have been required to implement

nine ‘‘core’’ program components: five service components

(outreach and recruitment, case management, health edu-

cation, interconception care (ICC), perinatal depression

screening) and four systems-building components (con-

sortia, local health systems action plan (LHSAP), coordi-

nation and collaboration with Title V, and a sustainability

plan). Healthy Start projects may also implement other

support services needed in their local communities, such as

breastfeeding support and education, screening for

domestic/intimate partner violence and child abuse, initia-

tives to improve family and/or male involvement, healthy

weight interventions, home visiting, and smoking cessation

[1–3].

National Evaluations of the Federal Healthy Start

Program

The Federal Healthy Start Program has been evaluated

from its inception in the early 1990 s. The first national

evaluation, conducted from 1997 through 1999, examined

the implementation of the 15 demonstration project activ-

ities during fiscal years 1992 and 1996 and assessed whe-

ther these projects achieved the Healthy Start Program

goals of reducing infant mortality and improving maternal

and infant health. The second national evaluation was

conducted in two phases from 2002 through 2007 and

sought to obtain information about the implementation of

program components and to identify program features

associated with improved perinatal outcomes. Findings

from this evaluation were summarized in a profile report

presenting the characteristics of all Healthy Start projects

[5] and in case studies that documented the context and

implementation of the Healthy Start Program in eight sites

[6]. The evaluation also collected information on program

implementation and outcomes through a participant survey

that was conducted in four sites [7]. The third national

evaluation is the cross-site evaluation summarized in this

article. It was conducted from 2009 through 2012 to

examine relationships between the core program

components and long-term program and birth outcomes, in

addition to factors that influence these relationships. The

primary objective of the evaluation was to assess the effect

of implementation of all nine core program components on

long-term maternal and child health outcomes.

Methods

The evaluation was guided by a logic model (Fig. 1) that

outlined the hypothesized relationships between Healthy

Start project context, implementation of core service and

system program components, and four long-term outcomes

relevant to the Healthy Start Program goals: (1) improved

birth outcomes, (2) improved maternal health, (3)

improved child health, and (4) sustained community

capacity to reduce disparities in health status in the target

community. A cross-sectional design was used to assess the

associations of implementation of the nine core program

components with (1) project characteristics, (2) achieve-

ment of intermediate project outcomes, (3) service and

system activities conducted by the Healthy Start project

that made a primary or major contribution to reducing

disparities in maternal and infant health outcomes, and (4)

achievement of long-term birth outcomes.

Data Sources

Self-reported data from the 2010 project director survey

(PD survey) and performance measure (PM) data for 2009

reported to the Maternal and Child Health Bureau (MCHB)

Discretionary Grant Information System (DGIS) were used

in all analyses. The 2010 PD survey was administered via

web to Healthy Start project staff between July and Sep-

tember 2011 and was completed for all 104 projects

(100 % response rate). The survey was designed to collect

information on implementation and features of the nine

core program components as well as additional support

services offered by each Healthy Start project and project

achievements. The DGIS is a Web-based system that

MCHB grantees use to report their data online to MCHB

through HRSA’s Electronic Handbook as a part of the

grant application and performance reporting processes; it is

the repository of PM data for all MCHB programs. During

the time period of this evaluation, the MCHB utilized 15

PMs to monitor the progress of all Healthy Start projects

towards the achievement of Program objectives. A list of

current MCHB Healthy Start Program PMs is available

from: https://mchdata.hrsa.gov/DGISReports/PerfMeasure/

default.aspx. Performance measure data for 2009 were

available for 98 projects. After a thorough examination of

the available PM data from the DGIS [8], four PMs (two

birth outcome PMs, 1 service outcome PM and 1 system

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outcome PM; Table 1) were selected for this evaluation

based on the quality and consistency of data as well as the

relevance of the PM to the evaluation objectives. Project

characteristic data that were consistently reported in the

DGIS were also used in our analyses. State Title V birth

outcome PMs (singleton LBW and IMR) and Healthy

People 2010 and 2020 objective targets (LBW and IMR)

[9, 10] were used as benchmarks for comparison.

Measurement of Variables

Variable selection was informed by program components

and expected outcomes, the logic model, and previous

studies of birth outcomes [11]. The primary exposure of

interest was the implementation of all nine core program

components: outreach and recruitment, case management,

health education, interconception care (ICC), perinatal

depression screening, consortia, local health systems action

plan (LHSAP), coordination and collaboration with Title

V, and a sustainability plan. Implementation was deter-

mined using data from the 2010 PD survey (yes/no

response for each component). The birth outcomes of

interest were measured using two PMs reported in the

DGIS in 2009: percent singleton low birth weight (PM 51)

and infant mortality rate (PM 52).

We examined characteristics hypothesized to influence

the association of implementation of program components

with birth outcomes. We obtained information on these

characteristics from the 2010 PD survey and the DGIS.

Maternal demographic characteristics were not available

for this analysis. Project characteristics (Table 2) that were

examined were length of funding (initial project funding

received in Phase 1 [1991–1996], 2 [1997–2000], 3

[2001–2004], or 4 [2005–2010]), geographic location

(urban, not urban), and organization type (government

agency, community-based non–governmental agency or

other organization type). Project director report of

achievement of intermediate outcomes (eleven outcomes;

see Table 2) (yes/no), service and systems activities that

made a primary or major contribution to reducing dispar-

ities in maternal and infant health outcomes (fourteen

activities; see Table 2) (yes/no), and achievement of long-

term maternal and child health and community capacity

outcomes (five outcomes; see Table 2) (yes/no) were

examined in descriptive analyses and included as covari-

ates in multivariable analyses. One service outcome PM

Fig. 1 Logic model for the cross-site evaluation of Healthy Start

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(PM 20, the percent of women participants who have an

ongoing source of primary and preventive care services for

women) and one system outcome PM (PM 22, a score

between 0 and 64 representing the degree to which the

project facilitated health providers’ screening of women

participants for eight risk factors) were examined in

descriptive analyses and included as covariates in multi-

variable analyses (see Table 1).

Analysis

We calculated descriptive statistics for all variables across

all Healthy Start projects. We then performed bivariate

analyses using Pearson’s Chi square test and Fisher’s exact

test to (1) describe implementation of the nine core Healthy

Start Program components by project characteristics; (2)

examine the association of implementation of all core

components with each of (a) intermediate outcomes,

(b) service and systems activities that made a primary or

major contribution to reducing disparities in maternal and

infant health outcomes, and (c) long-term maternal and

child health and community capacity outcomes; and (3)

examine the association of intermediate outcomes and

service and systems activities that made a primary or major

contribution to reducing disparities in maternal and infant

health outcomes with (a) long-term maternal and child

health and community capacity outcomes and with b) birth

outcome PMs. We also compared the birth outcome PM

rates among Healthy Start projects with their state’s Title V

Program rates and with achievement of national Healthy

People (HP) 2010 and 2020 objective targets.

We developed multivariable linear and logistic regres-

sion models to examine the independent associations of

implementation of all core program components with birth

outcomes, adjusting for project characteristics, project

director-reported intermediate outcomes, and service and

system PMs. We developed linear regression models to

examine continuous outcomes (singleton LBW, IMR) and

logistic regression models to examine achievement (yes/

no) of state Title V rates or national HP objectives. We

Table 1 MCHB performance measures (PM) used in multivariate analyses

Category/

PM

Definition/elements Components/Scale

Birth outcomes

PM 51 Percent of live singleton births weighing less than 2,500 g Numerator: Number of live singleton births less than 2,500 g in

the calendar year to program participants

Denominator: Live singleton births in the calendar year among

program participants

PM 52 The infant mortality rate per 1,000 live births Numerator: Number of deaths to infants from birth through

364 days of age to program participants

Denominator: Number of live births in the calendar year among

program participants

Service outcomes

PM 20 The percent of women participating in MCHB supported

programs who have an ongoing source of primary and

preventive care services for women

Numerator: The number of women participating in MCHB-

funded projects who have an ongoing source of primary and

preventive care services during the reporting period

Denominator: The number of women participating in MCHB-

funded projects during the reporting period

Systems outcomes

PM 22 The degree to which MCHB supported programs facilitate health

providers’ screening of women participants for risk factors

Total possible score: 0–64

Scoring instructions: Using a scale of 0-2, indicate the degree to

which your grant has performed each activity to facilitate

screening for each risk factor by health providers in your

program

Scale definitions:

0 = Grantee does not provide this function or assure that this

function is completed,

1 = Grantee sometimes provides or assures the provision of this

function but not on a consistent basis,

2 = Grantee regularly provides or assures the provision of this

function

Risk factors

1. Smoking

2. Alcohol

3. Illicit drugs

4. Eating disorders

5. Depression

6. Hypertension

7. Diabetes

8. Domestic violence

A list of all current MCHB Healthy Start Program PMs is available from: https://mchdata.hrsa.gov/DGISReports/PerfMeasure/default.aspx

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calculated betas or odds ratios with 95 % confidence

intervals. Variables that were included in the models were

those found to be associated with the birth outcomes of

interest in previous studies or in the bivariate analyses as

well as any other characteristics of a priori interest

according to the evaluation logic model (Fig. 1). The

multivariate models to examine birth outcomes included

only those projects with PM data.

The model to examine the association of implementa-

tion of all core components with singleton LBW (PM 51)

included the following covariates: initial funding (Phase 1

versus all other phases), urban geographic location, not

urban geographic location, grantee organization type,

Healthy Start project facilitation of provider screening for

risk factors (PM 22, score greater than mean of all pro-

jects), percent of women participants with ongoing source

of primary and preventive care (PM 20), self-reported

improved birth spacing in 2010 (yes/no), self-reported

increased cultural competence of providers (yes/no), and

self-reported increased participant involvement in Healthy

Start decision-making (yes/no). The model to examine the

IMR outcome (PM 52) included many of the same covar-

iates, in addition to percent singleton LBW (PM 51), an

independent risk factor for infant mortality.

This evaluation was determined exempt from IRB

review by the Abt Associates Institutional Review Board

on September 1, 2010 (Abt IRB # 0499).

Results

Descriptive Characteristics

Table 2 presents the distribution of project characteristics

as well as project director-reported implementation of the

core components, intermediate project outcomes, service

and systems activities that made a primary or major con-

tribution to reducing disparities in maternal and infant

health outcomes, and long-term maternal and child health

and community capacity outcomes. All 104 Healthy Start

projects implemented all five core service components.

Over two-thirds of projects implemented the four core

systems-building components: 99 % implemented one or

more consortium, 91 % implemented a LHSAP, 87 %

collaborated with Title V, and 66 % had a sustainability

plan. Overall, 57 (55 %) projects implemented all nine core

program components; this group includes 10 of the 18

projects that were first funded during Phase 1 (1991-1996)

of the Healthy Start Program. Most projects were in

operation for at least 10 years at the time the PD survey

was administered; 17 % were first funded in Phase 1 and

61 % in Phase 2. Approximately 75 % of projects were

located in urban areas, including cities and metropolitan

areas; and 40 % of grantee organizations were state or local

government agencies.

Approximately two-thirds of all projects reported that in

2010 the project had accomplished a number of interme-

diate outcomes including increased awareness of the

importance of interconception care and of disparities in

birth outcomes as a community priority, increased positive

health behaviors among participants, increased access to

available services for participants, and increased number of

participants with a medical home.

More than two-thirds of all projects reported that case

management, enabling services such as transportation and

translation, and interconception care activities conducted

by the project made a primary or major contribution to

reducing disparities in maternal and infant health out-

comes. Less than two-thirds of projects reported that other

service and systems activities conducted by the project,

such as collaboration with consumers, community-based

organizations, and public and private agencies, made a

similar contribution to reducing disparities in maternal and

infant health outcomes.

Sixty-eight percent of project directors reported that the

project had achieved improvements in birth outcomes in

2010 and 39 % reported achieving improvements in

maternal health. Less than one-third of project directors

reported that the Healthy Start project had achieved sus-

tained capacity to reduce disparities in health status in the

community (32 % of projects); improvements in child

health (31 %); and increased birth spacing (19 %). A small

proportion (12 %) of project directors reported that the

Healthy Start project had not achieved any long-term out-

comes in 2010.

Bivariate Analyses: Core Program Components

Table 3 presents the results of bivariate analyses examin-

ing the relationship between implementation of the nine

core program components and project characteristics, as

well as relationships between implementation of program

components and three categories of project director-

reported outcomes: (1) intermediate outcomes, (2) activi-

ties that contributed to reducing disparities in maternal and

infant health outcomes, and (3) long-term maternal and

child health and community capacity outcomes. The 57

projects that implemented all core components were used

as the reference group. Only results that were statistically

significant (p B 0.05) are reported in the table.

Healthy Start projects whose grantee organizations were

state or local government agencies were significantly

(p B 0.05) less likely to implement all core components

compared with projects whose grantee organizations were

a community-based non-governmental organization or

other type of organization.

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Table 2 Distribution of Healthy Start project characteristics and project director-reported implementation of program components,

intermediate outcomes, service and systems activities that contributed

to reducing disparities in maternal and infant health outcomes, and

long-term maternal and child health and community capacity out-

comes, among all Healthy Start projects (N = 104 projects)

All

projects

(N = 104)

n (%)

Project characteristics a

Length of funding

Initial Funding Phase 1 (1991–1996) 18 17

Initial Funding Phase 2 (1997–2000) 63 61

Initial Funding Phase 3 (2001–2004) 10 10

Initial Funding Phase 4 (2005–2010) 13 12

Geographic location: Urban [urban/central city,

metropolitan area (city and suburbs)]

Yes 78 75

No 26 25

Geographic location: Not urban (suburban, border US-

Mexico, rural)

Yes 28 27

No 76 73

HS grantee organization type

Government agency (state agency, community

government agency such as a local health

department)

42 40

Community-based non-governmental organization

(health care or non-health care) or Other

organization (including academic medical center,

non-profit organization, tribal organization,

Federally Qualified Health Center)

62 60

Implementation of all nine core program components b

Yes 57 55

No 47 45

Intermediate outcomes c

Increased awareness of the importance of interconception care

Yes 80 77

No 24 23

Increased awareness of disparities in birth outcomes as community

priority

Yes 76 73

No 28 27

Increased positive health behaviors among our participants

Yes 74 71

No 30 29

Increased access to the services available for our participants

Yes 71 68

No 33 32

Increased number of participants with a medical home

Table 2 continued

All

projects

(N = 104)

n (%)

Yes 70 67

No 34 33

Increased screening for perinatal depression among providers in the

community

Yes 51 49

No 53 51

Increased participant involvement in Healthy Start decision-making

Yes 50 48

No 54 52

Increased integration of prenatal, primary care, and mental health

services

Yes 47 45

No 57 55

Increased cultural competence of providers in our community

Yes 43 41

No 61 59

Increased participant involvement in other community activities

addressing systems change

Yes 39 37

No 65 63

Increased participant involvement in decision-making among partner

agencies

Yes 22 21

No 82 79

Service and systems activities that contributed to reducing disparities

in maternal and infant health outcomes d

Case management

Yes 90 87

No 14 13

Enabling services

Yes 73 73

No 31 30

Interconception care

Yes 70 67

No 34 33

Perinatal depression screening

Yes 66 63

No 38 37

Outreach and client recruitment

Yes 64 62

No 40 39

Collaboration with consumers

Yes 60 58

No 44 42

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Table 2 continued

All

projects

(N = 104)

n (%)

Collaboration with community-based organizations

Yes 53 51

No 51 49

Collaboration with public agencies

Yes 49 47

No 55 53

Collaboration with private agencies

Yes 46 44

No 58 56

Consortium

Yes 45 43

No 59 57

Local Health System Action Plan

Yes 43 41

No 61 59

Collaboration with local Title V

Yes 34 33

No 70 67

Collaboration with State Title V

Yes 31 30

No 73 70

Provider education

Yes 39 38

No 65 62

Long-term maternal and child health and community capacity

outcomes e

Improved birth outcomes

Yes 71 68

No 33 32

Improved maternal health

Yes 41 39

No 63 61

Sustained community capacity to reduce disparities in health status in

the community

Yes 33 32

No 71 68

Improved child health

Yes 32 31

No 72 69

Increased birth spacing

Yes 20 19

No 84 81

No long term outcomes were achieved in 2010

Yes 13 12

Table 2 continued

All

projects

(N = 104)

n (%)

No 91 88

a Data source: Maternal and Child Health Bureau Discretionary Grant

Information System b

Data source: 2010 Project Director survey. To determine imple-

mentation of core service components, project directors were asked,

‘‘Which of the following services does your Healthy Start project

offer?’’ (response options: ‘‘Outreach and participant recruitment,’’

‘‘Case management,’’ ‘‘Health education,’’ ‘‘Perinatal depression

screening,’’ and ‘‘Interconceptional services’’). To determine imple-

mentation of the core systems-building component of having a con-

sortium, project directors were asked ‘‘Does your Healthy Start

project have at least one active consortium that addresses maternal

and child health issues’’ (response options: Yes/No). To determine

implementation of the core systems-building component of having a

Local Health System Action Plan, project directors were asked ‘‘Does

your Healthy Start project have a Local Health System Action Plan

(LHSAP)?’’ (response options: Yes/No; a follow up question was

asked to determine if the LHSAP was specific to the Healthy Start

project). To determine implementation of the core systems-building

component of coordination and collaboration with Title V, project

directors were asked to specify the types of collaborative activities

that their Healthy Start project established with the State Title V

agency. Projects were classified with a ‘‘yes’’ response if the project

director indicated that the State Title V agency ‘‘is a member of the

Healthy Start consortium,’’ ‘‘has a written memorandum of under-

standing or agreement with Healthy Start,’’ ‘‘provides contracted

services to Healthy Start,’’ ‘‘hosts out-stationed Healthy Start staff,’’

‘‘participates in joint training with Healthy Start,’’ ‘‘has a shared

staffing arrangement with Healthy Start,’’ ‘‘coordinates case man-

agement or is planning with Healthy Start for shared participants,’’

‘‘shares protocols with Healthy Start,’’ ‘‘is involved in Healthy Start

sustainability planning,’’ ‘‘has a data-sharing arrangement with

Healthy Start,’’ ‘‘contributes to pooled funding streams to support

joint services,’’ ‘‘has a Healthy Start employee on their board,’’

‘‘works with Healthy Start to develop consistent health messages for

participants,’’ and/or ‘‘receives cultural competence training from

Healthy Start.’’ To determine implementation of the core systems-

building component of having a sustainability plan, project directors

were asked ‘‘Does your Healthy Start project have a sustainability

plan, that is, a plan to maintain services to the target population after

federal Healthy Start funding ends?’’ (response options: Yes/No) c

Data source: 2010 Project Director survey. Project directors were

asked, ‘‘Which of the following intermediate outcomes did your Healthy

Start project achieve in 2010?’’. Multiple responses were allowed d

Data source: 2010 Project Director survey. Project directors were

asked, ‘‘To what extent did the following activities conducted by your

Healthy Start project contribute to reducing disparities in maternal

and infant health outcomes?’’. Response options included Primary

contribution, Major contribution, Moderate contribution, Minor con-

tribution, and No contribution or N/A. Primary contribution and

Major contribution were classified as ‘‘Yes.’’ e

Data source: 2010 Project Director survey. Project directors were

asked, ‘‘Which of the following long term outcomes did your Healthy

Start project achieve in 2010?’’. Multiple responses were allowed

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Table 3 Association of implementation of Healthy Start Program components with project characteristics and project director-reported inter- mediate outcomes, service and systems activities that contributed to reducing disparities in maternal and infant health outcomes, and long-term

maternal and child health and community capacity outcomes (N = 104 projects)

Implementation of all required

core program components

Yes

(n = 57)

No

(n = 47)

p value*

n (%) n (%)

Project characteristics a

HS grantee organization type

Government agency (state agency, community government agency such as a local health department) 18 32 24 51 0.04

Community-based non-governmental organization (health care or non-health care) or Other organization

(including academic medical center, non-profit organization, tribal organization, Federally Qualified Health

Center)

39 68 23 49

Intermediate outcomes b

Increased access to the services available for our participants

Yes 46 80 25 53 0.00

No 11 20 22 47

Increased screening for perinatal depression among providers in the community

Yes 33 58 18 38 0.04

No 24 42 29 62

Increased integration of prenatal, primary care, and mental health services

Yes 31 54 16 34 0.03

No 26 46 31 66

Service and systems activities that contributed to reducing disparities in maternal and child health outcomes c

Enabling services

Yes 46 81 27 58 0.01

No 11 19 20 42

Interconception care

Yes 44 77 26 55 0.01

No 13 23 21 45

Long-term maternal and child health and community capacity outcomes d

Improved child health

Yes 22 39 10 21 0.05

No 35 61 37 79

Increased birth spacing

Yes 16 28 4 9 0.01

No 41 72 43 91

* Pearson’s Chi square or Fisher’s exact test a

Data source: Maternal and Child Health Bureau Discretionary Grant Information System b

Data source: 2010 Project Director survey. Project directors were asked, ‘‘Which of the following intermediate outcomes did your Healthy

Start project achieve in 2010?’’. Multiple responses were allowed. Only outcomes with statistically significant (p B 0.05) relationships with

implementation of all core program components are reported c

Data source: 2010 Project Director survey. Project directors were asked, ‘‘To what extent did the following activities conducted by your

Healthy Start project contribute to reducing disparities in maternal and infant health outcomes?’’. Response options included Primary contri-

bution, Major contribution, Moderate contribution, Minor contribution, and No contribution or N/A. Primary contribution and Major contribution

were classified as ‘‘Contributed.’’ Only activities with statistically significant (p B 0.05) relationships with implementation of all core program

components are reported d

Data source: 2010 Project Director survey. Project directors were asked, ‘‘Which of the following long term outcomes did your Healthy Start

project achieve in 2010?’’. Multiple responses were allowed. Only outcomes with statistically significant (p B 0.05) relationships with imple-

mentation of all core program components are reported

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Although projects implementing all core components more

frequently reported achievement of the majority of interme-

diate outcomes than projects that did not implement all core

components, the intermediate outcomes for which the rela-

tionship between implementation of all core components and

the outcome were statistically significant were (1) increased

access to services available for participants, (2) increased

integration of prenatal, primary care and mental health ser-

vices and (3) increased screening for perinatal depression.

Projects implementing all core components were signifi-

cantly more likely to report that enabling and interconception

care services conducted by the project made a primary or

major contribution to reducing disparities in maternal and

infant health, when compared with projects that did not

implement all required core components. Additionally, pro-

jects implementing all core components were significantly

more likely to report that their project had achieved increased

birth spacing and improved child health in 2010, compared

with projects that did not implement all core components.

Bivariate Analyses: Intermediate Outcomes, Service

and Systems Activities that Contributed to Reducing

Disparities in Maternal and Infant Health Outcomes,

and Long-Term Maternal and Child Health

and Community Capacity Outcomes

Results of the bivariate analyses examining the relationship

between project director-reported intermediate outcomes,

service and systems activities that made a primary or major

contribution to reducing disparities in maternal and infant

health outcomes and long-term outcomes revealed many

significant associations (data not shown). Intermediate out-

comes that were significantly associated (p B 0.05) with

project director-reported improvements in birth outcomes

and/or maternal health included: increased cultural compe-

tence of providers in the community; increased number of

participants with a medical home; increased awareness of the

importance of interconception care; increased screening for

perinatal depression; and increased participant involvement

in community activities addressing systems change. Healthy

Start project activities, such as interconception care, peri-

natal depression screening, enabling services, collaboration

with consumers, and LHSAP, that made a primary or major

contribution to reducing disparities in maternal and infant

health outcomes were each significantly (p B 0.05) associ-

ated with project director-reported improvement in birth,

maternal, and/or child health outcomes (data not shown).

Descriptive and Comparative Analyses: Birth Outcome

Performance Measures

In 2009, 20 % of Healthy Start projects had singleton LBW

rates and 59 % had IMR that were less than or equal to the

Healthy People 2010 (HP2010) LBW targets of 5 % and

4.5 per 1,000 live births [9], respectively. The Healthy

People 2020 (HP2020) targets were revised to 7.8 % (LBW

rate) and 6 per 1,000 live births (IMR) [10], and a higher

proportion of Healthy Start projects achieved these targets

than achieved the HP2010 targets (33 % achieved the

LBW target and 60 % achieved the IMR target) (data not

shown). Compared with Healthy Start projects that did not

meet the HP2020 LBW target, projects that achieved the

HP2020 target were significantly (p B 0.05) more likely to

report achieving increased access to services available for

participants and increased integration of prenatal, primary

care, and mental health services. Similarly, these projects

were significantly more likely to report that their outreach

and client recruitment, collaboration with community-

based organizations, collaboration with private and public

agencies, and/or collaboration with local Title V activities

made a primary or major contribution to reducing dispar-

ities in maternal and infant health outcomes. Achieving the

HP2020 target for IMR was not significantly associated

with project director-report of achieving intermediate out-

comes or of (conducting) service or system activities that

made a primary or major contribution to reducing dispar-

ities in maternal and infant health outcomes (Table 4).

Similar results were observed when comparing Healthy

Start project PM rates with state birth outcome rates. In

2009, over one quarter (27 %) of all Healthy Start projects

had a singleton LBW rate less than the rate in their state,

and 62 % had an IMR that was less than the rate in their

state. Healthy Start projects that had a lower singleton

LBW rate in 2009 than the rate reported for their state were

significantly (p B 0.05) more likely to report achieving

increased positive health behaviors among participants and

increased number of participants with a medical home in

2010 (data not shown).

Multivariate Analyses

The results of the multivariate analyses are presented in

Tables 5 and 6. After controlling for project characteristics,

project director-reported intermediate outcomes and other

covariates consistent with the logic model, there were no

significant associations of implementation of all core pro-

gram components with singleton LBW and/or infant mor-

tality rates. Urban project setting and state/local

government agency grantee organization were significantly

associated with higher rates of LBW, and non-urban pro-

ject setting was significantly associated with higher IMR.

As expected, LBW rates were significantly associated with

higher IMR. Intermediate and long-term program outcomes

reported in the 2010 PD survey were not significantly

associated with either singleton LBW or infant mortality.

1300 Matern Child Health J (2015) 19:1292–1305

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Table 4 Association of percent singleton low birth weight (LBW) and infant mortality rates (IMR) among project participants’ infants meeting HP2010 and HP2020 objective targets with Healthy Start project director-reported achievement of intermediate outcomes and conduct of service

and systems activities that contributed to reducing disparities in maternal and infant health outcomes (N = 104)

PM 51 (% singleton LBW) PM 52 (IMR)

Less than

HP2010 LBW

target of 5 %

(n = 20

projects)

Less than

HP2020 LBW

target of

7.8 %

(n = 32

projects)

Less than

HP2010 IMR

target of 4.5

deaths per

1,000 live

births

(n = 58

projects)

Less than

HP2020 IMR

target of 6

deaths per

1,000 live

births

(n = 59

projects)

%

Yes

%

No

%

Yes

%

No

%

Yes

%

No

%

Yes

%

No

Intermediate outcomes a

Increased awareness of the importance of interconception care 85 15 84 16 79 21 80 20

Increased awareness of disparities in birth outcomes as community priority 75 25 75 25 71 29 71 29

Increased positive health behaviors among our participants 85 15 84 16 71 29 71 29

Increased access to the services available for our participants 85* 15 81* 19 69 31 69 31

Increased number of participants with a medical home 85 15 75 25 76 24 76 24

Increased screening for perinatal depression among providers in the community 60 40 59 41 48 52 49 51

Increased participant involvement in Healthy Start decision-making 45 55 50 50 47 53 47 53

Increased integration of prenatal, primary care, and mental health services 60 40 66* 34 40 60 41 59

Increased cultural competence of providers in our community 55 45 53 47 36 64 37 63

Increased participant involvement in other community activities addressing systems

change

20 80 31 69 34 66 36 64

Increased participant involvement in decision-making among partner agencies 10 90 16 84 24 76 25 75

Service and systems activities that contributed to reducing disparities in maternal and child health outcomes b

Case management 90 10 88 12 93 7 93 7

Enabling services 75 25 69 31 78 22 78 22

Interconception care 65 35 63 37 66 34 66 34

Perinatal depression screening 60 40 56 44 69 31 69 31

Outreach and client recruitment 50 50 47** 53 62 38 63 37

Collaboration with consumers 60 40 50 50 57 43 58 42

Collaboration with community-based organizations 30* 70 28** 72 55 45 56 44

Collaboration with public agencies 35 65 31* 69 50 50 51 49

Collaboration with private agencies 30 70 25** 75 48 52 49 51

Consortium 35 65 37 63 41 59 42 58

Local Health System Action Plan 30 70 31 69 40 60 41 59

Collaboration with local Title V 15 85 19* 81 40 60 39 61

Collaboration with state Title V 30 70 25 75 36 64 36 64

Provider education 35 65 31 69 41 59 42 58

Note that Healthy People (HP) LBW targets are for LBW among all live births, whereas Healthy Start PM 51 and State Title V HSI 01B

measures the singleton LBW rate

* Pearson’s Chi square or Fisher’s exact test p value B 0.05

** Pearson’s Chi square or Fisher’s exact test p value B 0.01 a

Data source: 2010 Project Director survey. Project directors were asked, ‘‘Which of the following intermediate outcomes did your Healthy

Start project achieve in 2010?’’. Multiple responses were allowed. A ‘‘yes’’ response indicates that the project director reported that the project

achieved the intermediate outcome. A ‘‘no’’ response indicates that the project director did not report that the project achieved the intermediate

outcome b

Data source: 2010 Project Director survey. Project directors were asked, ‘‘To what extent did the following activities conducted by your

Healthy Start project contribute to reducing disparities in maternal and infant health outcomes?’’. Response options included Primary contri-

bution, Major contribution, Moderate contribution, Minor contribution, and No contribution or N/A. A ‘‘yes’’ response indicates that the project

director reported that the service or system activity made a primary or major contribution to reducing disparities in maternal and infant health

outcomes. A ‘‘no’’ response indicates that the project director reported that the service or system activity did not make a primary or major

contribution to reducing disparities in maternal and infant health outcomes

Matern Child Health J (2015) 19:1292–1305 1301

123

Table 5 Adjusted associations of implementation of Healthy Start Program components with singleton low birth weight (LBW) among Healthy Start project participants’ infants (N = 98 projects)

Project characteristic %

Singleton

LBW a

% Singleton LBW

less than State

Title V rate b

% Singleton LBW less

than HP2010 LBW

target of 5 % b

% Singleton LBW less

than HP2020 LBW

target of 7.8 % b

Implemented all 5 core service components and all 4 core

systems components versus did not implement all core

components c

0.4 0.5 0.4 0.4

Initial funding received in Phase 1 (1991–1996) versus

initial funding received in Phase 2, 3, or 4 d

1.2 1.3 0.6 0.4

Urban geographic location [urban/central city,

metropolitan area (city and suburbs)] versus not urban d

2.9 0.4 0.8 0.4

Not urban geographic location (suburban, border US-

Mexico, rural) versus not not urban d

1.6 0.6 1.7 0.4

State or local government agency grantee organization

versus community-based non-governmental

organization (health care or non-health care) or other

organization (including academic medical center, non-

profit organization, tribal organization, Federally

Qualified Health Center) d

1.5 0.1 0.1 0.4

PM 20 (% women participants with an ongoing source of

primary and preventive care for women) (%, 2009) d

0.0 1.0 1.0 1.0

PM 22 (degree to which Healthy Start project facilitates

health providers’ screening of women participants for

risk factors) (score greater than mean of all projects,

2009) d

0.8 1.3 0.5 1.1

Achieved increased birth spacing e

0.5 0.4 0.8 2.1

Achieved increased cultural competence of providers in

the community f

-1.3 2.1 2.4 1.9

Achieved increased participant involvement in Healthy

Start decision-making f

0.9 0.9 0.8 0.6

Results based on multivariable linear or logistic regression models (separate models for each outcome), with each model adjusted for the other

variables in the table. Bold font indicates effect estimate was significant at p \ 0.10 or 95 % confidence interval \[1 a

Linear model: values are b coefficients. The effect estimate represents the effect per percent increase of LBW b

Logistic model: values are odds ratios. The effect estimate represents the effect of having a rate less than the state Title V rate or less than the

Healthy People (HP) target. Note that HP2010 and HP2020 LBW targets are for LBW among all live births, whereas Healthy Start PM 51 and

State Title V HSI 01B measures the singleton LBW rate c

Data source: 2010 Project Director survey. To determine implementation of core service components, project directors were asked, ‘‘Which of the

following services does your Healthy Start project offer?’’ (response options: ‘‘Outreach & participant recruitment,’’ ‘‘Case management,’’ ‘‘Health

education,’’ ‘‘Perinatal depression screening,’’ and ‘‘Interconceptional services’’). To determine implementation of the core systems-building com-

ponent of having a consortium, project directors were asked ‘‘Does your Healthy Start project have at least one active consortium that addresses maternal

and child health issues’’ (response options: Yes/No). To determine implementation of the core systems-building component of having a Local Health

System Action Plan, project directors were asked ‘‘Does your Healthy Start project have a Local Health System Action Plan (LHSAP)?’’ (response

options: Yes/No; a follow up question was asked to determine if the LHSAP was specific to the Healthy Start project). To determine implementation of

the core systems-building component of coordination and collaboration with Title V, project directors were asked to specify the types of collaborative

activities that their Healthy Start project established with the State Title V agency. Projects were classified with a ‘‘yes’’ response if the project director

indicated that the State Title V agency ‘‘is a member of the Healthy Start consortium,’’ ‘‘has a written memorandum of understanding or agreement with

Healthy Start,’’ ‘‘provides contracted services to Healthy Start,’’ ‘‘hosts out-stationed Healthy Start staff,’’ ‘‘participates in joint training with Healthy

Start,’’ ‘‘has a shared staffing arrangement with Healthy Start,’’ ‘‘coordinates case management or is planning with Healthy Start for shared participants,’’

‘‘shares protocols with Healthy Start,’’ ‘‘is involved in Healthy Start sustainability planning,’’ ‘‘has a data-sharing arrangement with Healthy Start,’’

‘‘contributes to pooled funding streams to support joint services,’’ ‘‘has a Healthy Start employee on their board,’’ ‘‘works with Healthy Start to develop

consistent health messages for participants,’’ and/or ‘‘receives cultural competence training from Healthy Start.’’ To determine implementation of the

core systems-building component of having a sustainability plan, project directors were asked ‘‘Does your Healthy Start project have a sustainability

plan, that is, a plan to maintain services to the target population after federal Healthy Start funding ends?’’ (response options: Yes/No) d

Data source: Maternal and Child Health Bureau Discretionary Grant Information System e

Data source: 2010 Project Director survey. Project directors were asked, ‘‘Which of the following long term outcomes did your Healthy Start

project achieve in 2010?’’. Multiple responses were allowed f

Data source: 2010 Project Director survey. Project directors were asked, ‘‘Which of the following intermediate outcomes did your Healthy Start

project achieve in 2010?’’. Multiple responses were allowed

1302 Matern Child Health J (2015) 19:1292–1305

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Table 6 Adjusted associations of implementation of Healthy Start Program components with infant mortality rate (IMR) among Healthy Start project participants’ infants (N = 98 projects)

Project characteristic a

Infant

mortality

rate a

Infant mortality

rate less than

State Title V

IMR b

Infant mortality rate less than

HP2010 IMR target of 4.5

deaths per 1,000 live births c

Infant mortality rate less

than HP2020 IMR target of

6 deaths per 1,000 live

births c

Implemented all 5 core service components and

all 4 core systems components versus did not

implement all core components d

-0.7 1.2 1.1 1.1

Initial funding received in Phase 1 (1991–1996)

vs. initial funding received in Phase 2, 3, or 4 e

4.9 0.4 0.5 0.4

Urban geographic location (urban/central city,

metropolitan area [city and suburbs]) versus

not urban e

-4.1 1.6 1.5 1.3

Not urban geographic location (suburban, border

US-Mexico, rural) versus not urban e

7.4 0.5 0.6 0.5

State or local government agency grantee

organization versus community-based non-

governmental organization (health care or non-

health care) or other organization (including

academic medical center, non-profit

organization, tribal organization, Federally

Qualified Health Center) e

0.7 1.0 0.9 1.1

PM 51 (% low birth weight) (%, 2009) 0.5 0.9 0.9 0.9

PM 20 (% women participants with an ongoing

source of primary and preventive care for

women) (%, 2009)

0.0 1.0 1.0 1.0

PM 22 (degree to which Healthy Start project

facilitates health providers’ screening of

women participants for risk factors) (score

greater than mean of all projects, 2009) e

-3.0 0.7 0.8 0.6

Achieved increased birth spacing f

3.8 0.6 0.3 0.5

a Results based on multivariable linear or logistic regression models (separate models for each outcome), with each model adjusted for the other

variables in the table. Bold font indicates effect estimate was significant at p \ 0.10 or 95 % confidence interval \[1 b

Linear model: values are b coefficients. The effect estimate represents the effect per increase in the infant mortality rate (deaths per 1,000 live births) c

Logistic model: values are odds ratios. The effect estimate represents the effect of having a rate less than the state Title V rate or less than the

Healthy People (HP) target d

Data source: 2010 Project Director survey. To determine implementation of core service components, project directors were asked, ‘‘Which of

the following services does your Healthy Start project offer?’’ (response options: ‘‘Outreach and participant recruitment,’’ ‘‘Case management,’’

‘‘Health education,’’ ‘‘Perinatal depression screening,’’ and ‘‘Interconceptional services’’). To determine implementation of the core systems-

building component of having a consortium, project directors were asked ‘‘Does your Healthy Start project have at least one active consortium

that addresses maternal and child health issues’’ (response options: Yes/No). To determine implementation of the core systems-building

component of having a Local Health System Action Plan, project directors were asked ‘‘Does your Healthy Start project have a Local Health

System Action Plan (LHSAP)?’’ (response options: Yes/No; a follow up question was asked to determine if the LHSAP was specific to the

Healthy Start project). To determine implementation of the core systems-building component of coordination and collaboration with Title V,

project directors were asked to specify the types of collaborative activities that their Healthy Start project established with the State Title V

agency. Projects were classified with a ‘‘yes’’ response if the project director indicated that the State Title V agency ‘‘is a member of the Healthy

Start consortium,’’ ‘‘has a written memorandum of understanding or agreement with Healthy Start,’’ ‘‘provides contracted services to Healthy

Start,’’ ‘‘hosts out-stationed Healthy Start staff,’’ ‘‘participates in joint training with Healthy Start,’’ ‘‘has a shared staffing arrangement with

Healthy Start,’’ ‘‘coordinates case management or is planning with Healthy Start for shared participants,’’ ‘‘shares protocols with Healthy Start,’’

‘‘is involved in Healthy Start sustainability planning,’’ ‘‘has a data-sharing arrangement with Healthy Start,’’ ‘‘contributes to pooled funding

streams to support joint services,’’ ‘‘has a Healthy Start employee on their board,’’ ‘‘works with Healthy Start to develop consistent health

messages for participants,’’ and/or ‘‘receives cultural competence training from Healthy Start.’’ To determine implementation of the core

systems-building component of having a sustainability plan, project directors were asked ‘‘Does your Healthy Start project have a sustainability

plan, that is, a plan to maintain services to the target population after federal Healthy Start funding ends?’’ (response options: Yes/No) e

Data source: Maternal and Child Health Bureau Discretionary Grant Information System f

Data source: 2010 Project Director survey. Project directors were asked, ‘‘Which of the following long term outcomes did your Healthy Start

project achieve in 2010?’’. Multiple responses were allowed

Matern Child Health J (2015) 19:1292–1305 1303

123

Discussion

This evaluation of the Federal Healthy Start Program using

both data from a survey of project directors and Healthy

Start project birth, service, and system outcome perfor-

mance measures data revealed a mixed set of relationships

between implementation of core program components and

long-term maternal and child health outcomes. Analyses of

the 2010 PD survey data indicate that implementation of all

core components was associated with better project direc-

tor-reported intermediate and long-term project outcomes.

This is the first analysis to use MCHB performance mea-

sure data in a national evaluation to assess Healthy Start

projects’ progress toward achieving outcomes that are

expected to occur if program elements are successfully and

completely implemented. Results from this evaluation are

consistent with our hypothesis (illustrated in the logic

model, Fig. 1) of a progression of achievement of inter-

mediate outcomes leading to long-term outcomes. For

example, increased screening for perinatal depression, case

management and interconception care services may have

led to PD-reported improvement in maternal health. In

addition, we found that Healthy Start projects that reported

an increase in the number of participants with a medical

home in 2010 and an increase in positive behaviors among

participants had a significantly better (lower) singleton

LBW rate among project participants’ infants than the rate

in their state.

Our analyses used state and national benchmarks, and

our findings are reinforced by the results of previously

published evaluations that were conducted by Healthy Start

projects using vital records, clinical services and program

data. Site-specific evaluations conducted by individual

Healthy Start projects have identified components of the

program that show a positive effect on birth outcomes of

participants’ infants when compared with demographically

similar women who did not participate in the program. For

example, evaluations of individual Healthy Start projects

found that services provided to high risk participants

resulted in improved birth outcomes such as reduced rates

of LBW, preterm birth, and infant mortality [12–14] in

addition to lower rates of sexually transmitted diseases

[15].

Although previous national evaluations of the Federal

Healthy Start Program helped to establish the importance

of the Healthy Start program components for achieving

Program goals, these evaluations relied solely on grantees’

perspectives because objective performance measure data

were not adequate for use in national evaluations. A thor-

ough examination of the PM data reported by Healthy Start

projects revealed that the quality of reported data is suffi-

cient for evaluation activities but also identified several key

challenges to using these data for program evaluation [8].

Our review of the notes and detailed explanations that

accompanied the PM data that grantees submitted to the

DGIS revealed data quality issues, including: 1) inconsis-

tency in the definition of the measure used by the project

with the definition specified by MCHB; 2) lack of verifi-

cation of some measures, e.g. PM 52, due to the timing of

the completion of birth–death linked files prepared by the

state vital records department; and 3) missing and incom-

plete data. These data limitations may introduce bias if the

projects that had missing data or provided incomplete data

are different from those who provided accurate and com-

plete data, or if the under-reporting or erroneous reporting

is related to the performance measures used as the out-

comes for this analysis (PM 51 and PM 52).

A potential limitation of these analyses was the possible

variation in the information source(s) used to complete the

PD survey. Healthy Start project staff, including the project

director and other project staff, were asked to complete the

survey, and the staff member(s) who provided responses

could have varied by project. The survey was pilot-tested

with representatives of different Healthy Start project staff

roles, but allowing survey completion by more than one

type of respondent can increase the potential for variation

in the interpretation of the survey questions and lead to

variation in responses. Responses may also have varied

based on the length of time the respondent had been with

the project, in addition to the length of time that the project

had been in operation and the program components that

were implemented. We did not have access to complete,

reliable information about other project characteristics and

program components needed to perform a comprehensive

evaluation of project implementation in a variety of com-

munity settings and to conduct analyses that adequately

addressed all of the relationships outlined in the logic

model. For example, participant demographic data cap-

tured by the MCHB DGIS were not available for use in

these analyses. The eligibility criteria for participation in

Healthy Start lead to some demographic similarities across

project sites; however, other important differences in the

populations served by sites may exist. More detailed

information about program implementation and outcomes

achieved by individual Healthy Start projects is needed to

improve the specificity of future evaluations.

Healthy Start projects provide services to high risk

women in the most vulnerable communities in our country.

Improving birth outcomes for project participants requires

intensive and focused services and policies that will assure

quality services within communities. Ongoing monitoring

and assessment of the implementation of these programs

and routine, standardized collection of essential birth out-

come and project implementation data will provide critical

information for evaluating what is and is not working in

individual Healthy Start projects and the Program as a

1304 Matern Child Health J (2015) 19:1292–1305

123

whole. MCHB could provide Healthy Start Program staff

with online tools and training to improve the reliability of

data collection and reporting. Future Healthy Start Program

evaluations should build on more robust local evaluations

at the project level as well as employ a set of focused

questions for the national evaluation that specifically

address the major issues of interest to state and national

policy-makers. Improved capacity for data collection and

documentation by individual projects would help assure

that comprehensive cross-site evaluations could be con-

ducted in the future. Resources should be provided to

assure that the systems required to conduct this type of

evaluation are in place.

Based on our experience conducting national evalua-

tions of the Federal Healthy Start Program, we recommend

that future evaluations explicitly connect to local, state, and

national frameworks and agendas for improving birth

outcomes and reducing health inequities. The evaluation

plan should incorporate analyses at multiple levels to

provide a robust and comprehensive examination of

Healthy Start Program activities and achievements. Most

importantly, monitoring and evaluation activities con-

ducted by individual Healthy Start projects must be

strengthened to help ensure systematic and standardized

annual reporting to MCHB of performance measure data,

program activities and accomplishments, and other data

needed for evaluation.

Acknowledgments Financial support for this study was provided by the Health Resources and Services Administration, Maternal and

Child Health Bureau under Contract No. HHSH250200646015I Task

Order HHSH25034002T: An Evaluation of the Core Components of

the Federal Healthy Start Program: A Cross-site Examination. The

authors would like to acknowledge the contributions of the Healthy

Start Grantees who participated in this evaluation, the staff of the

National Healthy Start Association, the Healthy Start Project Officers

at MCHB, especially Dr. David de la Cruz and Dr. Keisher High-

smith, and the Healthy Start project team at Abt, including Dr.

Chanza Baytop, Ms. Meredith Eastman, Ms. Carolyn Robinson, and

Dr. Meghan Woo.

References

1. Health Resources and Services Administration. (2001). Healthy

Start Guidance, 2001. Rockville, MD: Health Resources and

Services Administration, U.S. Department of Health and Human

Services.

2. Health Resources and Services Administration. (2005). Healthy

Start Guidance, 2005. Rockville, MD: Health Resources and

Services Administration, U.S. Department of Health and Human

Services.

3. Health Resources and Services Administration. (2009). Healthy

Start Guidance, 2010. Rockville, MD: Health Resources and

Services Administration, U.S. Department of Health and Human

Services.

4. Maternal and Child Health Bureau. (2013). DGIS Reports: Pro-

gram Data Reports. Retrieved https://perf-data.hrsa.gov/MCHB/

DGISReports/PerfMeasure/PerfMeasureReports.aspx?Report=

ProgramPerfMeasures&Archived=0.

5. Health Resources and Services Administration. (2006). A Profile

of Healthy Start: Findings From Phase I of the Evaluation, 2006.

Rockville, MD: Health Resources and Services Administration,

U.S. Department of Health and Human Services.

6. Brand, A., Walker, D. K., Hargreaves, M., & Rosenbach, M.

(2010). Intermediate outcomes, strategies, and challenges of eight

Healthy Start Projects. Maternal and Child Health Journal, 14(5),

654–665.

7. Rosenbach, M., O’Neil, S., Cook, B., Trebino, L., & Walker, D.

K. (2010). Characteristics, access, utilization, satisfaction, and

outcomes of healthy start participants in eight sites. Maternal and

Child Health Journal, 14(5), 666–679.

8. Abt Associates. (2012). Methodology for Analysis of Health

Resources Service Administration, Maternal and Child Health

Bureau Healthy Start Performance Measures, September 2012.

Cambridge, MA: Abt Associates.

9. Centers for Disease Control and Prevention. National Center for

Health Statistics. Healthy People Objective Targets: Maternal,

Infant, and Child Health. Retrieved http://www.cdc.gov/nchs/

data/hpdata2010/hp2010_final_review_focus_area_16.pdf.

10. Centers for Disease Control and Prevention. National Center for

Health Statistics. Healthy People Objective Targets: Maternal,

Infant, and Child Health. Retrieved http://www.healthypeople.

gov/2020/topicsobjectives2020/overview.aspx?topicid=26.

11. Taylor, Y. J., & Nies, M. A. (2012). Measuring the impact and

outcomes of maternal child health federal programs. Maternal

Child Health Journal, 17(5), 886–896. doi:10.1007/s10995-012-

1067-y.

12. Will, J. A., Hall, I., Cheney, T., & Driscoll, M. (2005). Flower

Power: Assessing the impact of the Magnolia Project on reducing

poor birth outcomes in an at-risk neighborhood. Journal of

Applied Sociology/Sociological Practice, 22.2/7(2), 74–90.

13. Salihu, H. M., Mbah, A. K., Jeffers, D., Alio, A. P., & Berry, L.

(2009). Healthy Start program and feto-infant morbidity out-

comes: Evaluation of program effectiveness. Maternal and Child

Health Journal, 13(1), 56–65. doi:10.1007/s10995-008-0400-y.

14. Kothari, C. L., Wendt, A., Oemeeka, L., Overton, J., & Sweezy,

L. C. (2011). Assessing maternal risk for fetal-infant mortality: A

population-based study to prioritize risk reduction in a Healthy

Start community. Maternal and Child Health Journal, 15(1),

68–76. doi:10.1007/s10995-009-0561-3.

15. Livingood, W. C., Brady, C., Pierce, K., Atrash, H., Hou, T., &

Bryant, T, 3rd. (2010). Impact of pre-conception health care:

evaluation of a social determinants focused intervention. Mater-

nal and Child Health Journal, 14(3), 382–391.

Matern Child Health J (2015) 19:1292–1305 1305

123

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