Having provided a snapshot of individual program components, it is important to reflect on the Healthy Start program as a whole. Figure 28 indicates the percentage of grantees that selfreported achievements in 11 intermediate outcomes based on the Healthy Start logic model (see appendix). They are grouped into four categories: participant/service outcomes, increased awareness outcomes, systems-of-care outcomes, and consumer involvement outcomes. Grantees were more likely to report improvements in services than systems-related activities. This is consistent with the finding that grantees devoted the majority of their grant funding to the services components, with the average allocation being 80 percent to services and 20 percent to systems. Grantees also were more likely to report that they achieved outcomes related to increasing awareness than increasing consumer involvement. The former targeted providers and the general public, while the latter targeted consumers, perhaps signifying that there are greater challenges in reaching consumers than other populations.

To understand the extent to which particular program activities contributed to achieving the intermediate outcomes, the survey asked grantees to rate the perceived contribution of seven services-related and eight systems-related Healthy Start activities. For each activity, grantees indicated whether it made a primary contribution, a major contribution, a moderate contribution, a minor contribution, or no contribution at all. Grantees were more likely to report that services activities made a primary or major contribution to achieving their intermediate program outcomes. Case management was perceived to make the largest contribution, followed by client health education. Far fewer grantees reported that systems activities made a primary or major contribution, in particular, provider education, consortia, local health system action plan, and collaboration with State Title V agencies.

In addition to reflecting on their projects’ inter-mediate outcomes and relative contributions of program components, grantees commented on 16 statements concerning Healthy Start’s relationships to the communities in which they are based. These statements represented a continuum of program change, beginning with the identification of issues, progressing to building capacity for change, seeing tangible results, and finally, offering evidence of sustainable change. It was expected that grantees would be at different points along this trajectory and, indeed, found that grantees were more likely to report outcomes within the first three stages of systems change than in the final stage of sustainability.

All grantees (100 percent) expressed agreement that Healthy Start has identified access problems in the health care system and 99 percent agreed that Healthy Start has identified strategies for addressing disparities. In addition, a large majority of grantees agreed that Healthy Start has made progress in developing the basis for change. In particular, grantees reported the project was an integral part of the service delivery system in the community (96 percent) and that community residents are aware of the project (95 percent). Grantees were less likely to report that policymakers participate in or are accessible to the Healthy Start project (87 percent); and that Healthy Start is connected to the community’s power structure (79 percent) such as local government representatives and decision-makers within local institutions.

The majority of grantees agreed that the Healthy Start project yielded actual changes in results. Of the six items in this domain, at least 94 percent of the grantees agreed (either strongly or somewhat) with five of them. Grantees were less likely to report that many changes/solutions have been implemented as a result of Healthy Start recommendations (81 percent).

The final stage of the trajectory is sustainability. A relatively smaller number of grantees agreed that maternal and child health agencies/providers take ownership of Healthy Start goals (78 percent), or that an institutional and fiscal base of support sustains Healthy Start activities (52 percent).

The presence of a LHSAP has a significant effect on the assessment of the effect of the Healthy Start project on the community. Projects with a LHSAP were more likely to agree (either strongly or somewhat) that Healthy Start is connected to the community’s power structure, has led to improved communications among agencies in the community, has contributed to the community’s capacity for needs assessment, has created solutions to access problems, and can document a positive impact. These results suggest that a LHSAP may help Healthy Start grantees move along the trajectory toward having a lasting effect on their communities.