PREFACE
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.
INTRODUCTION
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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of Healthy Start Projects
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