Helping Mothers Have Healthy Babies

Baltay, M., McCormick, M., & Wise, P. (1999). Implementation of Fetal and Infant Mortality Review (FIMR): Experience from the National Healthy Start Program. Maternal and Child Health Journal, 3(3): 141-150.

Objectives: The implementation of the Fetal and Infant Mortality Review (FIMR) process was examined as part of the evaluation of the national Healthy Start program, a federal program designed to reduce infant mortality in several communities. The implementation of the FIMR process over the 5-year funding period is described in terms of productivity, barriers and facilitators to implementation, and project expenditures. Methods. Data were derived from grant continuation applications and personal interviews with program staff to produce a qualitative description. Results: As of the summer of 1996, 14 of the 15 Healthy Start sites in the national evaluation had successfully implemented the FIMR process. Most sites had developed a two-tiered review process for examination of case data in which a review by health and social services professionals was followed by community review. In the period 1993 to 1995, the percentage of fetal and infant deaths reviewed had a median of 34% with a range of 4-79% across the sites at a cost of $600 to $3400 per death reviewed. Recommendations were variably implemented. Conclusions: The FIMR process provides an important opportunity to contribute to the knowledge base regarding infant mortality in these communities. The process, however, has important logistical requirements and may require substantial financial resources that may affect implementation of confidential inquiries into infant mortality and other health problems.

Berlin, L., Brooks-Gunn, J., & Aber, J.L. (2001). Promoting early childhood development through comprehensive community initiatives. Children's Services, 4(1): 1-24.

Recent advances in developmental psychology, social services, and social policy have converged to highlight 3 issues: (a) the importance of early development; (b) the importance of the contexts, or "ecology," of early development, especially with respect to the ill effects of early childhood poverty; and (c) the promise of intervention programs for low-income children, families, and communities, including comprehensive community initiatives (CCIs). CCIs, however, generally have not focused on young children. In this article, we synthesize developmental science and current understanding of CCIs to suggest a number of ways for CCIs to increase their emphasis on early development. We begin with a review of developmental research that illustrates the effects of community characteristics on children's development. We then review the goals, strategies, and principles of CCIs. These reviews illustrate that despite overlapping emphases, developmental science and CCIs could be linked more generatively. We propose ways in which CCIs can be geared more specifically toward promoting early child development. Finally, we suggest strategies for evaluating these types of initiatives.

Boroff, M., & O'Campo, P. (1996). Baltimore City Healthy Start Medical Reform for reducing infant mortality. Patient Education & Counseling, 27(1): 41-52.

This paper describes the Medical Reform Component of Baltimore City's Healthy Start Program and how it works toward the goals of reducing infant mortality (IMR) and improving infant health by making services more user-friendly and family-oriented.

Brodsky, A., O'Campo, P., & Aronson, R. (2000). PSOC in community context: Multi-Level correlates of a measure of psychological sense of community in low-income, urban neighborhoods. Journal of Community Psychology, 27(6): 659-679.

Recent years have seen a steady increase in attention to communities as a source of both risk and protective factors for various individual outcomes. Psychological sense of community (PSOC) is one concept which can be important in describing the ways in which real and perceived aspects of community might mediate both individual and community outcomes. To understand the setting-specific interaction of individual and community, it is necessary to examine how individual and community level factors are simultaneously associated with psychological sense of community. As part of a larger study of community influence on health, we conducted a random household survey in three geographically defined low-income communities in Baltimore City. Nine hundred fourteen individuals were surveyed with a questionnaire that included a measure of psychological sense of community. This article describes the variability of PSOC in these communities and identifies individual- and community-level characteristics associated with varying levels of PSOC. Statistical methods of multi-level analysis were employed. Individuals in low-income communities showed heterogeneity for PSOC that is partially explained by variation in individual- and community-level characteristics. We suggest that this variability, as well as the promotion of positive PSOC within low-income communities, has implications for the development and implementation of community-based interventions.

Grason, H., & Misra, D. (1999). Assessment of Healthy Start Fetal and Infant Mortality Review recommendations. Maternal and Child Health Journal, 3(3): 151-159.

Objectives: We examine the scope and nature of the recommendations that emerged from the Healthy Start Fetal and Infant Mortality Review (FIMR) projects and explore their use to promote systems change. Methods: The FIMR process of 16 of the 22 federal Healthy Start projects was reviewed. We analyzed data from a June 1996 survey developed and administered by the MCH Bureau, which gathered information about recommendations produced by the FIMRs. We supplemented these data with information gathered through follow-up telephone interviews and by abstracting information from grant documents. Results: The 16 Healthy Start FIMRs reviewed approximately 1300 cases between 1991 and 1996. A total of 303 specific action strategies were recommended, reflecting eighteen specific substantive areas of concern. Overall, 65% of recommendations fell under the rubric of "program" functions, 31% under "practice," and 4% under "policy." Healthy Start itself was most commonly targeted for action. The second most frequent target for action were public and private provider institutions. Public policymaking entities were rarely targeted. Conclusions: In the first several years of implementation, with few exceptions these FIMRs sought limited change. They worked almost exclusively within their own span of control to effect important, but limited changes in systems serving women and their infants. As public health professionals seek to monitor population health, the field must strengthen any and all vehicles that draw upon collaborative structures at the community level to not only uncover problems, but to address them as well.

Howell, E. M., Dulvaney, B., McCormick, M., & Raykovich, K. T. (1998). Back to the future: Community involvement in the Healthy Start program. Journal of Health Politics, Policy and Law, 23: 291-317.

This article discusses how community involvement is incorporated into Healthy Start, a major initiative to reduce infant mortality in selected communities with disproportionately high levels of infant mortality. Based on site visits to each of the fifteen original Healthy Start project areas, we discovered that two main community involvement strategies were used: a service consortium model and a community empowerment model. In the service consortium model, the community is involved primarily through a consortium of local providers, other professionals, and some governmental representatives who help to plan services. The community empowerment model involves the community by engaging neighborhood-based groups, contracting with community-based organizations, employing community residents as lay workers in the Healthy Start program, and creating other economic development initiatives. Important lessons drawn from this study are that the purpose and commitment to community involvement is not always clear; that it is difficult to involve community residents; that efforts to involve the community are extremely labor intensive; that given monetary incentives, it is easier to involve community providers than residents; that community involvement may conflict with efficient program operations; that increased community involvement may create program goals that differ from the program's original goals; and that community involvement may slow program development.

Jones, J. (1999). Don't take no for an answer: Lessons from the field for reaching dads. Children and Families, 18(4): 44-45.

Describes the lessons learned from the Baltimore City Healthy Start Men's Services program, the goal of which was to encourage fathers' involvement in their children's lives. Notes that the right philosophical mindset of actively seeking out fathers was crucial for Men's Services, and could be crucial to Head Start's efforts to reach fathers.

McCormick, M., Deal, L., Devaney, B., Chu, D., Moreno, L., & Raykovich, K. (2001). The impact on clients of a community-based infant mortality reduction program: The national Healthy Start Program survey of postpartum women. American Journal of Public Health, 91(12).

Objectives. This study assessed the effect of the national Healthy Start Program on its clients. Methods. We used a cross-sectional survey of a sample from Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) rosters of women less than 6 months postpartum who were residents of Healthy Start Program areas. Results. Healthy Start clients revealed higher sociodemographic risk, but not behavioral risk, for adverse pregnancy outcome than other area residents. They did not differ from other residents in receipt of services except for a greater likelihood of receiving case management, using birth control at the time of the interview, and rating their prenatal care more highly. Conclusions. The Healthy Start Program succeeded in enrolling women at high risk. It had little effect on the immediately concluded pregnancy, but it might influence future outcomes.

McCoy-Thompson, M. (1994). Consortium development: The Healthy Start Initiative-A community-driven approach to infant mortality reduction (Vol. 1). National Center for Education in Maternal and Child Health. The purpose of the Healthy Start Initiative, a national demonstration program, is to reduce infant mortality by 50 percent in 15 communities. At the heart of the initiative is the belief that the community, guided by a consortium of individuals and organizations from many sectors, can best design and implement the services needed by the women and children in that community. This report examines the challenges the Healthy Start projects have faced in developing consortia. Five consortia--Baltimore, Maryland; Chicago, Illinois; New Orleans, Louisiana; northwest Indiana; and Pee Dee, South Carolina--were chosen as a representative cross section. Information was gathered from as many participants as possible through site visits, consortia and committee meetings, and interviews with project directors, staff, consortium members and consumers. These five Healthy Start projects exemplify how five critical factors--climate, people, resources, processes, and policies--shape the development of collaboratives. Also noted are several common challenges that quickly emerged: determining the structure of management and governance, increasing consumer involvement, handling race and class issues, and boosting economic development. By examining the approaches used by the five projects to deal with these challenges, this report presents an understanding of how consortia can develop effective strategies. The report includes brief descriptions of the project sites and contains 13 references.

Minkler, M., Thompson, M., Bell, J., Rose, K., & Redman, D. (2002). Using community involvement strategies in the fight against infant mortality: Lessons from a multisite study of the national Healthy Start experience. Health Promotion Practice, 3(2): 176-187.

This article presents the findings of a multisite qualitative study of the community involvement experience of nine Healthy Start sites in their efforts to reduce infant mortality. Empowerment theory was used as a broad theoretical framework, and in-depth interviews, focus groups, observation, and documents review were the primary data collection methods utilized. Six key ways in which community involvement was found to enrich the program are described. These ranged from creating the conditions in which individuals could improve their parenting skills to mobilizing communities to help change programs, practices, and policies. Lessons learned for this program and for other initiatives aimed at eliminating health disparities are discussed.

Minkler, M., Thompson, M., Bell, J., & Rose, K. (2001). Contributions of community involvement to organizational level empowerment: The federal Healthy Start experience. Health Education and Behavior, 28, 783-807.
This article presents findings of a multisite case study of the experience of nine federal Healthy Start Program sites in using consortia and other community involvement strategies in the fight against infant mortality. Using empowerment theory as a conceptual framework, qualitative data are employed to examine how community involvement in the program through community-based consortia and other means contributed to empowerment at the organizational level. The article concludes with implications of the study findings for practice both within Healthy Start and in the context of other community-based health initiatives.

O'Brien Caughy, M., Brodsky, A., O'Campo, P., & Aronson, R. (2001). Perceptions of parenting: Individual differences and the effect of community. American Journal of Community Psychology, 29(5): 679-699.

Neighborhood norms are an important determinant of beliefs and attitudes about parenting, and measuring changes in community norms is an important component of evaluating community-based programs for improving child outcomes. The purpose of this study was to determine whether or not a survey of community residents' perceptions of parenting could be used to measure community parenting norms and whether these perceptions differed by individual or community characteristics. Two community surveys with 870 and 914 respondents, respectively, were conducted in 3 low-income neighborhoods. Results indicated that perceptions of parenting could be measured reliably at the community level although it is important to consider the presence of multiple norms when using such measures. Furthermore, differences in perceptions of parenting associated with individual characteristics were markedly decreased when neighborhood characteristics were considered, suggesting that the association of individual characteristics with perceptions of parenting is confounded by neighborhood characteristics.

O'Brien Caughy, M., O'Campo, P., & Brodsky, A. (1999). Neighborhoods, families, and children: Implications for policy and practice. Journal of Community Psychology, 27(5): 615-633.

Recent global and national trends have put a growing number of families and children living in the United States at risk for adverse health and developmental outcomes. Policies and programs designed to address these problems have too often focused on the characteristics of individuals as the root cause and have failed to address significantly core problems. The research reported here suggests that researchers, program planners, and policy makers should go beyond the focus on individuals to incorporate and target larger structural issues such as increasing poverty, growing economic inequalities between rich and poor, and eroding public social programs. This research demonstrates the importance of larger social structures for individuals' health. It also has implications for policy, namely: Neighborhoods are an important target for intervention; policy makers must take a multi-issue approach to addressing problems of the inner city; programs should look at building on community resources and infrastructure, as well as address the needs of individual community residents; and a one-size-fits-all mentality is not appropriate when designing programs to serve neighborhoods.

O'Campo, P., Rao, R., Carlson Gielen, A., Royalty, W., & Wilson, M. (2000). Injury-producing events among children in low-income communities: The role of community characteristics. Journal of Urban Health, 77(1): 34-49.

Study Purpose. Injury remains the leading cause of death in children aged 1 to 4 years. Past studies of determinants of injuries among young children have most often focused on the microlevel, examining characteristics of the child, parent, family, and home environments. We sought to determine whether and how selected neighborhood economic and physical characteristics within these low-income communities are related to differences in risk of events with injury-producing potential among infants and young children. Methods. Our study used both individual-level data and information on the characteristics of the neighborhood of residence to describe the prevalence of events with injury-producing potential among infants and young children in three low-income communities in Baltimore City, Maryland. Our sample was 288 respondents who participated in a random household survey. Information on respondent (age, employment, and length of residence in the neighborhood) and neighborhood characteristics (average per capita income, rate of housing violations, and crime rate) were available. Methods of multilevel Poisson regression analysis were employed to identify which of these characteristics were associated with increased risk of experiencing an event with injury-producing potential in the month prior to the interview. Results. Although all three communities were considered low income, considerable variation in neighborhood characteristics and 1-month prevalence rates of events with injury-producing potential were observed. Younger age of respondent and higher rates of housing violations were associated significantly with increased risk of a child under 5 years old in the household experiencing an event with injury-producing potential. Conclusions. Information on community characteristics was important to understanding the risks for injuries and could be used to develop community-based prevention interventions.

O'Campo, P., Xue, X., Wang, M., O'Brien Caughy. (1997). Neighborhood risk factors for low birthweight in Baltimore: A multilevel analysis. American Journal of Public Health, 87(7): 1113-1119.

Ojectives: Past research on low birthweight has focused on individual-level risk factors. We sought to assess the contribution of macrolevel social factors by using census tract-level data on social stratification, community empowerment, and environmental stressors. Methods: Census tract-level information on social risk was linked to birth certificate records from Baltimore, Md, for the period 1985 through 1989. Individual level factors included maternal education, maternal age, medical assistance health insurance (Medicaid), and trimester of prenatal care initiation. Methods of multilevel modeling using two-stage regression analyses were employed. Results: Macrolevel factors had both direct associations and interactions with low birthweight. All individual risk factors showed interaction with macrolevel variables; that is, individual-level risk factors for low birthweight behaved differently depending upon the characteristics of the neighborhood of residence. For example, women living in high-risk neighborhoods benefited less from prenatal care than did women living in lower-risk neighborhoods. Conclusions: Multilevel modeling is an important tool that allows simultaneous study of macro- and individual-level risk factors. Multilevel analyses should play a larger role in the formulation of public health policies.

O'Campo, PJ., Guyer, B., Squires, B., Weiss, J., Sweitzer, J., & Coyle, T. (1993). Needs Assessment for Reducing Infant Mortality in Baltimore City: The Healthy Start Program. Southern Medical Journal, 86(12): 1342-1349.

Needs assessments are essential for policy formulation and the appropriate design of intervention programs. Recent nationwide data show that among large metropolitan areas of the United States, Baltimore has one of the highest infant mortality rates and ranks in the worst top 10 for blacks and the top 5 for whites for most indicators of poor pregnancy outcome. In this paper, we present the methods and results of a needs assessment that used multiple sources of routinely collected data and was conducted for the purpose of identifying intervention factors contributing to infant mortality in Baltimore City. This needs assessment was used by the Baltimore City Health Department to successfully secure funding for the federal Healthy Start Infant Mortality Prevention Initiative. We present the results of the analyses, along with some of the proposed interventions that resulted from the needs assessment. We also discuss the limitations of this type of needs assessment as well as suggestions for future needs assessments for the design of interventions to improve perinatal health.

Olson, G., Saade, G., & Nagey, D. (1997). Active recruitment into health care and its effect on birth weight and gestational age at delivery. Journal of Maternal-Fetal Investigation, 7(3): 122-125.

Objective: To analyze the effect of active recruitment of pregnant women into the health care system and to determine whether pregnancy outcomes differ when compared with a non-solicited group. Methods: The Baltimore Project began in November 1989 and was continued until April 1993 when it was supplanted by Baltimore's Healthy Start Project. Both projects involved the active recruitment of pregnant women into the health care system. The catchment area was characterized by the highest infant mortality rate in Baltimore City, as identified by census tract data. During the study period 138 women who delivered at the University of Maryland Hospital had been contacted by the Baltimore Project and comprised the case group. Two comparison groups were identified. The first, a historic group, was derived from the same census tract catchment area but delivered at the University of Maryland Hospital in the 2 years prior to the initiation of the project. The second, a contemporaneous group, was comprised from similar but adjacent census tracts, with deliveries occurring during the same time frame as the Baltimore Project. Variables of interest included gestational age at the first prenatal visit, gestational age at delivery, and birth weight. Statistical analysis was performed using the Mann-Whitney U test. Results: The only statistically significant difference was noted for the gestational age at delivery between the case and historic control groups. This difference was a lower gestational age at delivery in the group receiving the intervention. Conclusion: A program that includes active recruitment into the health care system appears to have no detectable impact on the number of prenatal visits, gestational age at delivery, or birth weight in the population studied.

Raykovich, KST., McCormick, MC., Howell, EM., & Devaney, BL. (1996). Evaluating the Healthy Start Program: Design development to evaluative assessment. Evaluation & the Health Professions, 19:342-362.

The national evaluation of the federally funded Healthy Start program involved translating a design for a process and outcomes evaluation and standard maternal and infant data set, both developed prior to the national evaluation contract award, into an evaluation design and client data collection protocol that could be used to evaluate 15 diverse grantees. This article discusses the experience of creating a process and outcomes evaluation design that was both substantively and methodologically appropriate given such issues as the diversity of grantees and their community-based intervention strategies; the process of accessing secondary data sources, including vital records; the quality of client level data submissions; and the need to incorporate both qualitative and quantitative approaches into the evaluation design. The relevance of this experience for the conduct of other field studies of public health interventions is discussed.

Strobino D, O'Campo P, Schoendorf K, et al. (1995). A strategic framework for the reduction of infant mortality: implications for "Healthy Start." Milbank Quarterly, 73(4).

The high infant mortality rate in the United States, especially in urban areas, remains a major federal concern. Four strategies for reducing infant mortality in cities participating in the federal "Healthy Start" are reducing high-risk pregnancies; reducing the incidence of low birthweight and preterm births; improving birthweight-specific survival; and reducing specific causes of post-neonatal mortality. Estimates of the impact of known interventions indicate that the reduction in infant mortality would be large for only one strategy: improving birthweight-specific survival. Most interventions yield a 2 percent reduction, or less, in mortality and, when combined, would amount to about 30 percent. This strategic model provides a realistic framework to assess the impact of the Healthy Start demonstration and is useful in highlighting the interventions most likely to reduce infant mortality in a population.

Thompson, M., Minkler, M., Bell, J., Rose, K., & Butler, L. (2003). Facilitators of well-functioning consortia: National Healthy Start program lessons. Health & Social Work, 28(3).

Social workers often are central to the work of community-based consortia to improve service delivery and enhance community participation in health initiatives. This article presents qualitative findings from a multisite case study of consortia in the federal Healthy Start Initiative to reduce infant mortality in high-risk communities. The authors examine the facilitators of well-functioning consortia in a framework of empowerment theory and community organizing with women of color. These facilitators include flexibility in the design of locally appropriate consortia structures; broad institutional support; diverse incentives for participation; adequate resources on multiple levels; and identification with the program and its mission. Implications for social work practice and for policy are provided.

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