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Maternal & Child Health: A Profile of Healthy Start: Findings From Phase I of the Evaluation 2006



The U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB) has long believed in the importance of evaluation. Towards this end, in September 2002, a contract to conduct a multi-year evaluation of the implementation of the Healthy Start program was awarded to Abt Associates Inc. and its subcontractor, Mathematica Policy Research, Inc. (MPR). The purpose of the evaluation was to examine the projects involved during the funding cycle that covered the project period 2001-2005. The evaluation relies on a set of logic models (see Appendix) to illustrate how implementation of the nine program components may lead to the achievement of core program goals, which in turn, may translate into improved maternal and child health outcomes. The national evaluation is designed to provide information for quality improvement by assessing implementation and program performance while also tracking program outcomes. The evaluation is consistent with the needs of MCHB to meet its Government Performance and Results Act (GPRA) requirements, and it is consistent with the nature of the program as a community-based intervention. The Healthy Start evaluation contract was awarded in two phases. This report is the result of the findings from Phase I of the evaluation. More information is presented below regarding the two phases of the evaluation.


In the late 1980’s, national concerns about persistently high levels of infant mortality led to a number of efforts to address this problem. Although infant mortality rates had declined over time, the rate of decline had slowed by the mid- 1980’s, and relative to other developed nations, the United States’ ranking had slipped. Even more alarming was the racial disparity in infant mortality rates; Black infants in the 1980’s were more than twice as likely to die in their first year of life as White infants. A White House study recommended the development of a major initiative to mobilize and coordinate the resources available in selected communities and demonstrate effective approaches to reduce infant mortality.

In response to this recommendation, the national Healthy Start program was initiated in 1991 as a demonstration project with 15 grantees. By 2005, Healthy Start had evolved into a broad effort to address racial and ethnic disparities in maternal and infant health outcomes utilizing the efforts of 97 grantees.

Healthy Start has more recently incorporated past program experience and new knowledge related to services and systems interventions to improve maternal and child health, with an expanded target population to include women and infants through two years postpartum. That is, as specified by the HRSA 2001 Guidance, the three core program goals for Healthy Start are to (1) reduce racial and ethnic disparities in access to and utilization of health services; (2) improve the local health care system; and (3) increase consumer/ community voice and participation in health care decisions.

The 2001 HRSA Guidance identified nine core components that grantees were required to implement. They included five service components (outreach, case management, health education, perinatal depression screening, interconceptional care) and four systems components (consortium, Local Health System Action Plan, collaboration and coordination with Title V, a sustainability plan).

Throughout the evaluation, considerable input was provided by HRSA/MCHB staff, the Healthy Start Panel for the Evaluation of Healthy Start (HSP), the Secretary’s Advisory Committee on Infant Mortality (SACIM), and Healthy Start grantees, which helped to refine and guide the approach.

The national evaluation is comprised of two phases. A key objective of the first phase of the evaluation was to provide information about the funded grantees and the implementation of the components that now comprise the national Healthy Start program. The following three questions directed the first phase of the evaluation: What are the features of the individual Healthy Start projects? By features, we mean the characteristics of a project that reflect how that individual project operates.

What results have Healthy Start projects achieved? By results, we mean the intermediate outcomes a project has achieved. Is there an association or link between certain project features and the achievement of project results?


A survey of all grantees served as the primary data source to address these questions. The survey provided a “point-in-time snapshot” of the implementation of the Healthy Start program components, including the characteristics, activities, and results achieved by Healthy Start grantees during calendar year 2003. The survey was augmented by the abstraction of selected secondary data from grantees’ continuation applications. The survey was conducted using an electronic survey instrument. In June 2004, grantees were mailed a packet containing the instrument on CD-ROM with instructions describing how to install, complete, and return the survey. Over the next three months, several e-mail reminders and phone calls were made to non-respondents to increase the response rate. Out of a total of 97 grantees, 96 were eligible to participate as recipients of an Eliminating Disparities in Perinatal Health grant. The survey was completed by 95 grantees.

This report describes the results of the first phase of the evaluation effort. It provides a profile of the universe of Healthy Start grantees based on selfreported data. The data were collected in 2004, but asked about the grantees’ Calendar Year 2003 activities and projects. All findings reported are statistically significant. Building on the findings from the first phase of the evaluation, the second phase will provide more in-depth analysis of a subset of eight grantees. The second phase concluded in 2007 and will result in a better understanding of Healthy Start’s direct link to improved perinatal outcomes.

In addition to further examining the three research questions mentioned above, the second phase will explore a fourth question: What Healthy Start features are associated with improved perinatal outcomes? The second phase includes site visits to assess program implementation and outcomes, as well as a survey of Healthy Start program participants to ascertain their perspectives on services received during pregnancy and the interconceptional period.

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