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The healthy start program: Mobilizing to reduce infant mortality and morbidity
CHILD HEALTH POLICY Column Editors: Barbara Velsor-Friedrich, PhD, RN and Stephanie L. Ferguson, Phi), RN
The Healthy Start Program: Mobilizing to Reduce Infant Mortality and Morbidity Maribeth Badura, MSN, RN ~OR DECADES, infant mortality has been recognized as a key indicator of a society's health status. Since the founding of the Children's Bureau in 1912, a reoccurring focus of the federal government has been infant mortality. The federal government was forced to reexamine its approach to the issue in the late 1980s when the US ranked 21st among industrialized nations in infant mortality. As a result of this, a White House Task Force to Reduce Infant Mortality was convened in 1989. In 1990, recommendations from this task force began to be operationalized into a targeted approach to high-risk, vulnerable communities. In 1991, the Healthy Start Initiative (HSI) was launched under the direction of the Health Resources and Services Administration (HRSA), US Department of Health and Human Services. Administered by HRSA's Maternal and Child Health Bureau (MCHB), the Healthy Start Initiative was founded on the premise that the communities themselves could best develop the strategies necessary to attack the causes of infant mortality and low birth weight, especially among high-risk populations. Healthy Start promotes communitybased, culturally competent, family-centered, comprehensive perinatal care and other facilitating services to women, infants, and their families. These services are integrated into existing systems of perinatal care. For the HSI, perinatal is defined as the 21-month period from conception to the infant's first birthday. For fiscal year 1999 (FY99) the Initiative was appropriated $105 million by Congress (Federal Interagency Forum, 1999). Healthy Start empowers communities to fully address the medical, behavioral, cultural, and social service needs of women and their infants in 3 key ways: increasing community and personal awareness of what the contributing factors are to infant mortality and how to prevent it; streamlining and
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Jaurnal of PediatricNursing, Vol 14, No 4 (August), 1999
coordinating services between public and private agencies; and building partnerships and commitment among families, volunteers, businesses, and health care and social service providers. Baseline data indicate that the current Healthy Start communities have infant mortality rates greater than one and one half times the national average, with African-American infant mortality rates 2 to 4 times the white infant mortality rate, and low birth-weight rates typically one and one half times the national average. Significantly for pediatric nurses, the postneonatal infant mortality rate (infants aged 28 days to 364 days) typically is twice the national average. From 1991 to 1997, Healthy Start supported demonstration projects in 22 communities to learn what works best in reducing infant deaths in diverse settings (i.e., 15 projects were funded in 1991, and 7 additional ones in 1994). The national evaluation, an extensive outcomes and processoriented study, of the 15 original HSI demonstration sites will conclude early next year with the final report due in the spring of 2000. The preliminary findings from 10 of the 15 original Healthy Start communities funded in 1991 for the period through 1995 indicate that one community had a statistically significant reduction in infant mortality, 2 had significantly reduced low birth weights, and 4 had significant reductions in preterm births. For African Americans, who represented more than 88% of the women participating, the infant mortality rate was reduced from 19.1 (1989-1991) to 14.4
From Healthy Start, Rockville, MD. Address reprint requests to Maribeth Badura, MSN, RN, Health)" Start, Division of Perinatal Systems and Women's Health, MCHB, HRSA, 5600 Fisher's Lane, Suite llA05, Rockville, MD 20857. Copyright 9 1999 by W.B. Saunders Company 0882-5963/99/1404-0008510.00/0 263
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(1995) infant deaths per 1000 live births for participants in Healthy Start programs compared with 18.1 to 15.1 in the comparison communities. Nationally, the rate for African Americans declined from 17.1 to 14.5 during the same period (Center for Disease Control, 1999). In 1997, HSI-Phase /I began by supporting additional communities seeking to adapt successful Healthy Start strategies. This phase also awarded limited funds for infrastructure building and program planning at the community level to assess a community's needs, resources, and capability to adapt Healthy Start models via peer mentoring. Twenty of 22 HSI projects from Phase I successfully competed for continued support of their successful strategies and interventions. These projects serve as the peer mentor for new Healthy Start communities and other health-care providers, including managed care organizations in applying the practical knowledge and specific strategies developed during Healthy Start's initial demonstration phrase. Today there are a total of 55 new communities and 20 mentors including projects in Puerto Rico and 3 tribal organizations representing over 30 tribes. Later this summer, with a focus on the US-Mexican border and low-income communities, several additional sites will be funded to begin adapting Healthy Start strategies. Approximately 10 communities will receive funds for planning.
HEALTHY START STRATEGIES Through sustained experience with a broad range of strategies, Healthy Start has learned what works best to break down barriers and encourage women to seek care. The following 9 models provide intervention strategies that guide the communities as they strive to reduce infant mortality and low birth weight: (1) Outreach and Client Recruitment; (2) Care Coordination and Case Management; (3) Family Resource Centers; (4) Enhanced Clinical Services; (5) Risk Prevention and Reduction; (6) Training and Education; (7) Adolescent Programs; (8) Facilitating Services; (9) Community-Based Consortia. 9
Community-Based Consortia, the foundation of every Healthy Start project, focus the power of collaboration on the problem of infant mortality. Formal partnerships and networks of community leaders, consumers and families, clinical and social service providers, and public- and privatesector organizations provide guidance to the projects and mobilize local and state resources.
9 Care Coordination/Case Management involves total coordinated care for pregnant and parenting women and their families. Individual needs assessments and service plans are developed, and close contact with clients is maintained to ensure continuity of care. 9 Outreach and Client Recruitment interventions use resourceful ways to identify pregnant and parenting women and enroll them in needed care, especially those women and families who have been underserved by the health-care, social services, and mental-health systems. Included are interventions for substance-abusing and incarcerated women. 9 Family Resource Centers. also called "one-stop shops," provide multiple services such as prenatal care: Women, Infants, and Children (WIC) serwces; and counseling at one community location. The centralization of services improves women's access to and enrollment in health and social programs. 9 Enhanced Clinical Services models improve the quality, availability, and user-friendliness of services through various strategies, such as improving providers' cultural sensitivity, hiring additional providers and expanding clinic hours, and creating settings that encourage the involvement of male partners. 9 Risk Prevention and Reduction strategies focus on nonmedical factors that affect pregnancy. Specialized services include mental-health counseling, self-esteem enhancement, smoking cessation and substance-abuse treatment, violenceprevention programs, General Educational Development Test (GED) classes, and employment training. 9 Facilitating Services break down barriers and increase women's access to care by providing resources such as language translation, transportation to perinatal appointments, and on-site child care. With improved access, Healthy Start clients are more likely to continue to use services throughout the perinatal period. 9 Training and Education interventions involve broad strategies to improve the knowledge and skills of diverse community members who work with the HSI. Through mechanisms such as community events and media outreach, Healthy Start sites inform local residents and recruit those committed to improving community wellbeing. Projects also advance staff knowledge and skills by jointly developing and refining materials such as training manuals for outreach work-
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265
ers, male support groups, and paraprofessional case managers, as well as guides for managed care.
9 Adolescent Programs focus on (1) providing young women and men with sexuality education and information and activities that encourage abstinence, healthy behavior, and self-esteem; and (2) providing pregnant and parenting teens with information on child development, parenting, and the importance of education. The model incorporates feedback and directly involves local teens in its efforts to convey the risks of pregnancy and the challenges of parenting. To address the high rate of infants dying before their first birthday (postneonatal mortality) and the infant morbidities associated with low birth weight and poverty, many programs have developed aggressive case-management/home-visiting programs, parenting classes, strong back-to-sleep initiatives, training for infant day-care workers in health and safety, programs for parenting adolescents, injuryprevention programs, and programs to address child abuse and neglect, along with strong linkages to State Zero to Three programs and programs for children with special health-care needs.
The initiative also supports the National Healthy Start Resource Center (NHSRC) at the National Center for Education in Maternal and Child Health to enable the Healthy Start communities and the public to gain access to technical assistance, data, materials, and other resources. The center has compiled all the materials developed by the mentoring projects, as well as other tools developed, into a printed resource guide and a database organized by the models. Materials include curricula, training manuals, position descriptions, sample contracts, educational tools, videos, quality assurance, and other policies and protocols. The center has also published with the National Healthy Start Association a report describing the challenges the mentor communities faced and the impact of the demonstration phase on their communities. Publications can be ordered by calling the NHSRC at (703) 5247802 or by fax at (703) 524-9335. The easiest way to access material is through the Healthy Start website at www.healthystart.net. Further information about the Healthy Start Initiative can be obtained from the Maternal and Child Health Bureau's (MCHB) Division of Perinatal Systems and Women's Health at (30 l) 443-0543 or on the MCHB website at www.mchb.hrsa.gov.
REFERENCES Center for Disease Control, National Center for Health Statistics, National Vital Statistics System. (1999) Health, United States, 1998. Hyattsville, MD: US Department of Health and Human Services (DHHS).
Federal Interagency Forum on Child and Family Statistics. (1999). America's children: Key indicators of national well-being.Washington, DC: US Government Printing Ofrice.
The Healthy Start Program: Mobilizing to Reduce Infant Mortality and Morbidity Maribeth Badura, MSN, RN ~OR DECADES, infant mortality has been recognized as a key indicator of a society's health status. Since the founding of the Children's Bureau in 1912, a reoccurring focus of the federal government has been infant mortality. The federal government was forced to reexamine its approach to the issue in the late 1980s when the US ranked 21st among industrialized nations in infant mortality. As a result of this, a White House Task Force to Reduce Infant Mortality was convened in 1989. In 1990, recommendations from this task force began to be operationalized into a targeted approach to high-risk, vulnerable communities. In 1991, the Healthy Start Initiative (HSI) was launched under the direction of the Health Resources and Services Administration (HRSA), US Department of Health and Human Services. Administered by HRSA's Maternal and Child Health Bureau (MCHB), the Healthy Start Initiative was founded on the premise that the communities themselves could best develop the strategies necessary to attack the causes of infant mortality and low birth weight, especially among high-risk populations. Healthy Start promotes communitybased, culturally competent, family-centered, comprehensive perinatal care and other facilitating services to women, infants, and their families. These services are integrated into existing systems of perinatal care. For the HSI, perinatal is defined as the 21-month period from conception to the infant's first birthday. For fiscal year 1999 (FY99) the Initiative was appropriated $105 million by Congress (Federal Interagency Forum, 1999). Healthy Start empowers communities to fully address the medical, behavioral, cultural, and social service needs of women and their infants in 3 key ways: increasing community and personal awareness of what the contributing factors are to infant mortality and how to prevent it; streamlining and
F
Jaurnal of PediatricNursing, Vol 14, No 4 (August), 1999
coordinating services between public and private agencies; and building partnerships and commitment among families, volunteers, businesses, and health care and social service providers. Baseline data indicate that the current Healthy Start communities have infant mortality rates greater than one and one half times the national average, with African-American infant mortality rates 2 to 4 times the white infant mortality rate, and low birth-weight rates typically one and one half times the national average. Significantly for pediatric nurses, the postneonatal infant mortality rate (infants aged 28 days to 364 days) typically is twice the national average. From 1991 to 1997, Healthy Start supported demonstration projects in 22 communities to learn what works best in reducing infant deaths in diverse settings (i.e., 15 projects were funded in 1991, and 7 additional ones in 1994). The national evaluation, an extensive outcomes and processoriented study, of the 15 original HSI demonstration sites will conclude early next year with the final report due in the spring of 2000. The preliminary findings from 10 of the 15 original Healthy Start communities funded in 1991 for the period through 1995 indicate that one community had a statistically significant reduction in infant mortality, 2 had significantly reduced low birth weights, and 4 had significant reductions in preterm births. For African Americans, who represented more than 88% of the women participating, the infant mortality rate was reduced from 19.1 (1989-1991) to 14.4
From Healthy Start, Rockville, MD. Address reprint requests to Maribeth Badura, MSN, RN, Health)" Start, Division of Perinatal Systems and Women's Health, MCHB, HRSA, 5600 Fisher's Lane, Suite llA05, Rockville, MD 20857. Copyright 9 1999 by W.B. Saunders Company 0882-5963/99/1404-0008510.00/0 263
264
MARIBETH BADURA
(1995) infant deaths per 1000 live births for participants in Healthy Start programs compared with 18.1 to 15.1 in the comparison communities. Nationally, the rate for African Americans declined from 17.1 to 14.5 during the same period (Center for Disease Control, 1999). In 1997, HSI-Phase /I began by supporting additional communities seeking to adapt successful Healthy Start strategies. This phase also awarded limited funds for infrastructure building and program planning at the community level to assess a community's needs, resources, and capability to adapt Healthy Start models via peer mentoring. Twenty of 22 HSI projects from Phase I successfully competed for continued support of their successful strategies and interventions. These projects serve as the peer mentor for new Healthy Start communities and other health-care providers, including managed care organizations in applying the practical knowledge and specific strategies developed during Healthy Start's initial demonstration phrase. Today there are a total of 55 new communities and 20 mentors including projects in Puerto Rico and 3 tribal organizations representing over 30 tribes. Later this summer, with a focus on the US-Mexican border and low-income communities, several additional sites will be funded to begin adapting Healthy Start strategies. Approximately 10 communities will receive funds for planning.
HEALTHY START STRATEGIES Through sustained experience with a broad range of strategies, Healthy Start has learned what works best to break down barriers and encourage women to seek care. The following 9 models provide intervention strategies that guide the communities as they strive to reduce infant mortality and low birth weight: (1) Outreach and Client Recruitment; (2) Care Coordination and Case Management; (3) Family Resource Centers; (4) Enhanced Clinical Services; (5) Risk Prevention and Reduction; (6) Training and Education; (7) Adolescent Programs; (8) Facilitating Services; (9) Community-Based Consortia. 9
Community-Based Consortia, the foundation of every Healthy Start project, focus the power of collaboration on the problem of infant mortality. Formal partnerships and networks of community leaders, consumers and families, clinical and social service providers, and public- and privatesector organizations provide guidance to the projects and mobilize local and state resources.
9 Care Coordination/Case Management involves total coordinated care for pregnant and parenting women and their families. Individual needs assessments and service plans are developed, and close contact with clients is maintained to ensure continuity of care. 9 Outreach and Client Recruitment interventions use resourceful ways to identify pregnant and parenting women and enroll them in needed care, especially those women and families who have been underserved by the health-care, social services, and mental-health systems. Included are interventions for substance-abusing and incarcerated women. 9 Family Resource Centers. also called "one-stop shops," provide multiple services such as prenatal care: Women, Infants, and Children (WIC) serwces; and counseling at one community location. The centralization of services improves women's access to and enrollment in health and social programs. 9 Enhanced Clinical Services models improve the quality, availability, and user-friendliness of services through various strategies, such as improving providers' cultural sensitivity, hiring additional providers and expanding clinic hours, and creating settings that encourage the involvement of male partners. 9 Risk Prevention and Reduction strategies focus on nonmedical factors that affect pregnancy. Specialized services include mental-health counseling, self-esteem enhancement, smoking cessation and substance-abuse treatment, violenceprevention programs, General Educational Development Test (GED) classes, and employment training. 9 Facilitating Services break down barriers and increase women's access to care by providing resources such as language translation, transportation to perinatal appointments, and on-site child care. With improved access, Healthy Start clients are more likely to continue to use services throughout the perinatal period. 9 Training and Education interventions involve broad strategies to improve the knowledge and skills of diverse community members who work with the HSI. Through mechanisms such as community events and media outreach, Healthy Start sites inform local residents and recruit those committed to improving community wellbeing. Projects also advance staff knowledge and skills by jointly developing and refining materials such as training manuals for outreach work-
HEALTHY STARTPROGRAM
265
ers, male support groups, and paraprofessional case managers, as well as guides for managed care.
9 Adolescent Programs focus on (1) providing young women and men with sexuality education and information and activities that encourage abstinence, healthy behavior, and self-esteem; and (2) providing pregnant and parenting teens with information on child development, parenting, and the importance of education. The model incorporates feedback and directly involves local teens in its efforts to convey the risks of pregnancy and the challenges of parenting. To address the high rate of infants dying before their first birthday (postneonatal mortality) and the infant morbidities associated with low birth weight and poverty, many programs have developed aggressive case-management/home-visiting programs, parenting classes, strong back-to-sleep initiatives, training for infant day-care workers in health and safety, programs for parenting adolescents, injuryprevention programs, and programs to address child abuse and neglect, along with strong linkages to State Zero to Three programs and programs for children with special health-care needs.
The initiative also supports the National Healthy Start Resource Center (NHSRC) at the National Center for Education in Maternal and Child Health to enable the Healthy Start communities and the public to gain access to technical assistance, data, materials, and other resources. The center has compiled all the materials developed by the mentoring projects, as well as other tools developed, into a printed resource guide and a database organized by the models. Materials include curricula, training manuals, position descriptions, sample contracts, educational tools, videos, quality assurance, and other policies and protocols. The center has also published with the National Healthy Start Association a report describing the challenges the mentor communities faced and the impact of the demonstration phase on their communities. Publications can be ordered by calling the NHSRC at (703) 5247802 or by fax at (703) 524-9335. The easiest way to access material is through the Healthy Start website at www.healthystart.net. Further information about the Healthy Start Initiative can be obtained from the Maternal and Child Health Bureau's (MCHB) Division of Perinatal Systems and Women's Health at (30 l) 443-0543 or on the MCHB website at www.mchb.hrsa.gov.
REFERENCES Center for Disease Control, National Center for Health Statistics, National Vital Statistics System. (1999) Health, United States, 1998. Hyattsville, MD: US Department of Health and Human Services (DHHS).
Federal Interagency Forum on Child and Family Statistics. (1999). America's children: Key indicators of national well-being.Washington, DC: US Government Printing Ofrice.