The Healthy Start scheme in England "is a lifeline for families but many are missing out": a rapid qualitative analysis.

BACKGROUND: Healthy Start (HS) is a government scheme in England, Wales and Northern Ireland that offers a financial payment card and free vitamins to families experiencing low income. Pregnant women and families with children < 4 years can use the HS card to buy fruit, vegetables, cow's milk, infant formula and pulses. HS was fully digitalised in March 2022. While digitalisation has improved the user experience for many families, in the context of the cost-of-living crisis and increasing dietary inequalities, it is important to understand why HS is not reaching more families. This study aimed to (i) assess the perceptions and experiences of HS from stakeholders across the system including those who promote, implement and are eligible for HS, and (ii) identify recommendations to improve the scheme's effectiveness and uptake. METHODS: The study design was a post-implementation rapid qualitative evaluation using stakeholder interviews. Data were collected between January and June 2023 via semi-structured interviews (50% online; 50% in person) with 112 stakeholders, including parents (n = 59), non-government organisations (n = 13), retailers (n = 11) and health and community professionals (n = 29) at national and local levels. Findings were confirmed by a sub-sample of participants. RESULTS: Six core themes cut across stakeholders' perceptions and experiences, and stakeholders collectively outlined seven recommendations they felt could be acted upon to maximise uptake and efficiency of HS, with actions at both national and local levels. A novel finding from this study is that raising awareness about HS alone is unlikely to result automatically or universally in higher uptake rate. Recommendations include: continuing to provide this scheme that is universally valued; the need for many families to be provided with a helping hand to successfully complete the application; reframing of the scheme as a child's right to food and development to ensure inclusivity; improved leadership, coordination and accountability at both national and local levels. CONCLUSIONS: HS provides benefits for child development and family wellbeing. The study's recommendations should be actioned by national and local governments to enable all families eligible for the scheme to benefit from this nutritional safety net.

Breastfeeding Intentions among Pregnant Women Enrolled in a Healthy Start Program in Arkansas.

INTRODUCTION: Exclusive breastfeeding is recognized as the optimal source of nutrition for infants. Although exclusive breastfeeding rates have increased overall in the United States, substantial inequities exist in breastfeeding among individuals of different socioeconomic statuses, races, and ethnicities. The purpose of this study was to examine characteristics associated with exclusive breastfeeding intentions among pregnant women in Arkansas enrolled in a Healthy Start program. METHODS: The current study included a cross-sectional design, with a sample of 242 pregnant women in Arkansas enrolled in a Healthy Start program. RESULTS: The majority of the participants (56.6%) indicated their infant feeding intentions included a combination of breastfeeding and formula feeding. There were substantial differences in breastfeeding intentions among women of different races/ethnicities, with 18.5% of Marshallese women indicating they planned to exclusively breastfeed, compared to 42.1% of White women, 47.6% of Black women, and 31.8% of Hispanic women (p < 0.001). Women over the age of 18 and with higher educational attainment were more likely to intend on exclusively breastfeeding. DISCUSSION: This is the first study to examine characteristics associated with exclusive breastfeeding intentions among pregnant women in Arkansas enrolled in a Healthy Start program. The study found that race/ethnicity and age were most strongly associated with breastfeeding intentions. These findings are critical to identifying populations for resource allocation and to developing culturally-tailored interventions to help women in Arkansas achieve their desired infant feeding methods.

Birth equity on the front lines: Impact of a community-based doula program in Brooklyn, NY.

BACKGROUND: We assessed whether participation in Healthy Start Brooklyn's By My Side Birth Support Program-a maternal-health program providing community-based doula support during pregnancy, labor and delivery, and the early postpartum period-was associated with improved birth outcomes. By My Side takes a strength-based approach that aligns with the doula principles of respecting the client's autonomy, providing culturally appropriate care without judgment or conditions, and promoting informed decision making. METHODS: Using a matched cohort design, birth certificate records for By My Side participants from 2010 through 2017 (n = 603) were each matched to three controls who also lived in the program area (n = 1809). Controls were matched on maternal age, race/ethnicity, education level, and trimester of prenatal-care initiation, using the simple random sampling method. The sample was restricted to singleton births. The odds of preterm birth, low birthweight, and cesarean birth were estimated, using conditional logistic regression. RESULTS: By My Side participants had lower odds of having a preterm birth (5.6% vs 11.9%, P < .0001) or a low-birthweight baby (5.8% vs 9.7%, P = .0031) than controls. There was no statistically significant difference in the odds of cesarean delivery. CONCLUSION: Participation in the By My Side Birth Support Program was associated with lower odds of preterm birth and low birthweight for participants, who were predominantly Black and Hispanic. Investing in doula services is an important way to address birth inequities among higher risk populations such as birthing people of color and those living in poverty. It could also help shape a new vision of the maternal-health system, placing the needs and well-being of birthing people at the center.

Application Status Among Women Enrolled in a Healthy Start Program in Arkansas for the Special Nutrition Program for Women and Children.

This study aimed to examine the demographic characteristics of pregnant women in a Healthy Start program who are presumed eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), but who have not yet applied for WIC benefits. We used a cross sectional evaluation of data collected from pregnant women (n=203) participating in a Healthy Start program. Data came from surveys administered at enrollment in the Healthy Start program from July 15th, 2019 until January 14th, 2022. The primary outcome was WIC application status, which was determined by whether the woman had applied or was receiving benefits at the time of enrollment. Covariates included race/ethnicity, marital status, insurance, education, income, age, employment, and having previous children/pregnancies. Fisher exact tests and logistic regression were used to examine associations. Approximately 65% of women had not yet applied for WIC benefits. Marshallese women (80.9%) and other NHPI women (80.0%) had the highest need for assistance. In adjusted analyses, White women (p = 0.040) and Hispanic women (p = 0.005) had lower rates of needing assistance applying for WIC than Marshallese women. There were higher rates of needing assistance in applying for women with private insurance or with no insurance and for those with higher incomes. Nearly two out of every three pregnant women who were eligible for WIC had not yet applied for benefits. The findings highlight the need for outreach for all populations that may be eligible, particularly among racial/ethnic minorities and those with higher incomes.

An exploration of the statutory Healthy Start vitamin supplementation scheme in North West England.

BACKGROUND: Government nutritional welfare support from the English 'Healthy Start' scheme is targeted at low-income pregnant women and preschool children, but take-up of its free food vouchers is much better than its free vitamin vouchers. While universal implementation probably requires a more extensive scheme to be cost-effective, the everyday experience of different ways of receiving or facilitating Healthy Start, especially via children's centres, also requires further evidence. This study therefore aimed to explore (in the context of low take-up levels) perceptions of mothers, health professionals, and commissioners about Healthy Start vitamin and food voucher take-up and compare experiences in a targeted and a universal implementation-area for those vitamins. METHODS: Informed by quantitative analysis of take-up data, qualitative analysis focused on 42 semi-structured interviews with potentially eligible mothers and healthcare staff (and commissioners), purposively sampled via children's centres in a similarly deprived universal and a targeted implementation-area of North West England. RESULTS: While good food voucher take-up appeared to relate to clear presentation, messaging, practicality, and monetary (albeit low) value, poor vitamin take-up appeared to relate to overcomplicated procedures and overreliance on underfunded centres, organizational goodwill, and families' resilience. CONCLUSION: Higher 'universal' vitamin take-up may well have reflected fewer barriers when it became everyone's business to be vitamin-aware. Substantive Healthy Start reform in England (not just cosmetic tinkering) is long overdue. Our study highlights that 'policy, politics, and problem' should be aligned to reach considerable unmet need.

Streamlining Universal Prenatal Screening for Risk for Adverse Birth Outcomes.

OBJECTIVE: Many of the medical risk factors for adverse birth outcomes (e.g., preeclampsia) are regularly monitored in prenatal care. However, many of the psychosocial risk factors associated with adverse birth outcomes (e.g., maternal stress, anxiety, depression, intimate partner violence) are not regularly addressed during routine prenatal care. Comprehensive prenatal screening for psychosocial risk factors for adverse birth outcomes can improve maternal and neonatal outcomes. In this study, we examine an existing tool for opportunities to streamline and improve screening. METHODS: We reviewed medical records for 528 mother-infant dyads, recording maternal responses to a 21-item prenatal risk screening tool, and gestational age/birth weight of infants. Multiple approaches to scoring were used to predict likelihood of adverse birth outcome. RESULTS: Women who answered yes to any of the top four interrelated items were 3.32 times more likely to have an adverse birth outcome. Sensitivity and specificity were 68% and 65%, respectively. CONCLUSION FOR PRACTICE: We identified a short surveillance tool to identify women who are at highest risk and require more in-depth screening, and to rule out women who are at very low risk of an adverse birth outcome.

Is the healthy start scheme associated with increased food expenditure in low-income families with young children in the United Kingdom?

BACKGROUND: Healthy Start is a food assistance programme in the United Kingdom (UK) which aims to provide a nutritional safety-net and enable low-income families on welfare benefits to access a healthier diet through the provision of food vouchers. Healthy Start was launched in 2006 but remains under-evaluated. This study aims to determine whether participation in the Healthy Start scheme is associated with differences in food expenditure in a nationally representative sample of households in the UK. METHODS: Cross-sectional analyses of the Living Costs and Food Survey dataset (2010-2017). All households with a child (0-3 years) or pregnant woman were included in the analysis (n = 4869). Multivariable quantile regression compared the expenditure and quantity of fruit and vegetables (FV), infant formula and total food purchases. Four exposure groups were defined based on eligibility, participation and income (Healthy Start Participating, Eligible Non-participating, Nearly Eligible low-income and Ineligible high-income households). RESULTS: Of 876 eligible households, 54% participated in Healthy Start. No statistically significant differences were found in FV or total food purchases between participating and eligible non-participating households, but infant formula purchases were lower in Healthy Start participating households. Ineligible higher-income households had higher purchases of FV. CONCLUSION: This study did not find evidence of an association between Healthy Start participation and FV expenditure. Moreover, inequalities in FV purchasing persist in the UK. Higher participation and increased voucher value may help to improve programme performance and counteract the harmful effects of poverty on diet.

A Methodological Approach for Evaluating the Enterprise Community Healthy Start Program in Rural Georgia: An Analysis Using Linked PRAMS, Birth Records and Program Data.

INTRODUCTION: Community Healthy Start program evaluations are often limited by a lack of robust data and rigorous study designs. This study describes an enhanced methodological approach using local program data linked with existing population-level datasets for external comparison to evaluate the Enterprise Community Healthy Start (ECHS) program in two rural Georgia counties and presents results from the evaluation. METHODS: ECHS program data were linked to birth records and the Pregnancy Risk Assessment Monitoring System (PRAMS) for 869 women who delivered a live birth in Burke and McDuffie counties from 2010 to 2011. Multivariate logistic regressions with and without propensity score methods modeled the association between ECHS participation and maternal health indicators and pregnancy outcomes. RESULTS: 107 ECHS participants and 726 non-participants responded to PRAMS and met eligibility criteria. Compared with non-participants, ECHS participants were younger, completed fewer years of education, and were more likely to be non-Hispanic Black, unmarried, insured with Medicaid, participating in WIC, and having an unintended pregnancy. Models with and without propensity score weighting derived similar results: there was a positive association between ECHS participation and receiving adequate or adequate plus prenatal care (p < 0.05); no statistically significant associations were observed between ECHS participation and any other health behaviors, health care access and utilization measures or pregnancy outcomes. DISCUSSION: Rigorous evaluation of a local Healthy Start program using linked PRAMS and birth records with a population-based external comparison group and propensity score methods is an enhanced and feasible approach that can be applied in other local and state jurisdictions.

Community Healthy Workers Fill in the Gaps for Participants Who Became Lost to Follow-up in a Healthy Start Program.

The purpose of this mixed methods study was to solicit information from Community Health Workers (CHWs) in order to further understand reasons for Healthy Start participants becoming lost to follow-up after delivery. Four CHWs from a local Healthy Start Program completed questionnaires for participants in their caseloads who had become lost to follow-up from the program (n = 146) between Sep 2018 and Jan 2020. The questionnaire included open ended items about ease of contact before and after delivery, changes in contact information, compliance with prenatal care visits, other life challenges (such as housing, legal, transportation, and family support), family size, living arrangements, working/student status, and substance use. Participants were categorized by ease of contact throughout participation into Easy (28.8%), Easy then Difficult (11%) and Difficult (60.3%). Responses to questions were reviewed and coded to identify common themes. Groups differed on: having a change in contact information, having challenges with transportation, having lots of help, having other children between 6 and 10 years old, compliance with prenatal care, and race being non-Black. Areas where groups differed may indicate possible reasons for participants becoming lost to follow up after delivery. The descriptive results from this study can help CHWs address these issues with participants during prenatal care, when they are easier to contact, to develop contingency plans for remaining in contact after delivery.

Study protocol for the implementation of the Gabby Preconception Care System - an evidence-based, health information technology intervention for Black and African American women.

BACKGROUND: Improving the health of women before pregnancy and throughout a woman's lifespan could mitigate disparities and improve the health and wellbeing of women, infants and children. The preconception period is important for reducing health risks associated with poor maternal, perinatal and neonatal outcomes, and eliminating racial and ethnic disparities in maternal and child health. Low cost health information technology interventions provided in community-based settings have the potential to reach and reduce disparities in health outcomes for socially disadvantaged, underserved and health disparity populations. These interventions are particularly important for Black and African American women who have a disproportionate burden of pregnancy-related complications and infant mortality rates compared to any other racial and ethnic group in the U.S. METHODS: This is a hybrid type II implementation-effectiveness cohort study aimed at evaluating appropriateness, acceptability and feasibility implementation outcomes, while also systematically examining the clinical effectiveness of a preconception care (PCC) intervention, the Gabby System, for Black and African American women receiving health services in community-based sites. The intervention will be implemented in six Community Health Centers and six Healthy Start programs across the U.S. Each study site will recruit and enroll 25-50 young Black and African American women who will participate in the intervention for a 6-month period. Appropriateness, acceptability and feasibility of implementing the PCC intervention will be assessed using: 1) Qualitative data derived from individual interviews with Gabby System end-users (clients and patients) and site staff; and, 2) Quantitative data from staff surveys, Gabby System usage and uptake. Aggregate health risk and utilization measures collected directly from the Gabby server will be used to examine the effectiveness of the Gabby System on self-reported behavior change. DISCUSSION: This study will examine implementation outcomes and clinical effectiveness of an evidence-based PCC intervention for Black and African American women receiving services in Healthy Start programs and Community Health Centers. Contextual factors that influence uptake and appropriate implementation strategies will be identified to inform future scalability of the intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT04514224 . Date of registration: August 14, 2020. Retrospectively Registered.

Assessing the utility of the Healthy Start Screen to predict an elevated Edinburgh Postnatal Depression Scale score.

Objective To examine the utility of the Healthy Start Screen (HSS), which is an assessment of health, environment, and behavioral risk factors offered to all pregnant women in the state of Florida, in identifying women at risk for developing postpartum depression (PPD). Methods The sample for this Institutional Review Board (IRB)-approved, retrospective study consisted of patients who presented to a women's clinic for a new prenatal visit. Those patients who completed both the HSS at their prenatal visit and the Edinburgh Postnatal Depression Scale (EPDS) at their postpartum visit were included. We focused on items 1-10 of the HSS, where patients could respond with either "yes" or "no", and identified a positive EPDS as any score greater than or equal to 12. Results Women who identified as feeling down, depressed or hopeless, feeling alone when facing problems, to having ever received mental health services, or to having any trouble paying bills were more likely to have an EPDS score greater than or equal to 12. Conclusion The HSS, currently mandated by the state of Florida to be offered to all pregnant women, is a useful tool for identifying women at increased risk of developing PPD.

Evaluation of the Implementation of the Healthy Start Program: Findings from the 2016 National Healthy Start Program Survey.

Objectives The Healthy Start Program has taken a community-based approach to improving maternal and child health outcomes among underserved populations for 25 years. Although the program has been evaluated in the past, it has not undergone a national evaluation since it was transformed in 2014. The purpose of this study is to present data from an early component of the latest national evaluation-the 2016 National Healthy Start Program Survey, which includes information describing grantees, the risk profile of participants served, and the scope of services offered to meet participant needs. Methods Ninety-five grantees completed the survey, and responses are reported at the aggregate level. Study analyses are descriptive. Results Grantees reported serving a population with a high-risk profile characterized by chronic medical conditions or risk behaviors. Most grantees conduct comprehensive needs/risk assessments for participants upon program entry, yet service delivery strategies were mixed, with some differences found by geographic region. Grantees provide a core set of services to participants, including case management and health promotion/education, and tend to refer participants to community providers for services that are deemed appropriate during individual risk assessments. While most grantees have protocols in place related to these priority services, participants may not have been universally offered all services across sites. Conclusions for Practice Although grantees often highlight their facilitation of service/care coordination with existing resources, findings suggest potential areas on which to focus strategic efforts to ensure that the Healthy Start Program is successfully bridging gaps in access and utilization of services for underserved communities.

[Becoming breastfeeding friendly in Germany-an international research project to assess the readiness to scale up breastfeeding]. / Das internationale Forschungsvorhaben Becoming Breastfeeding Friendly. Untersuchung von Rahmenbedingungen zur Stillförderung.

Despite known positive effects for breastfed children and their mothers, only one third of children under four months of age are breastfed exclusively. In addition, an overview of structures, actors, and measures to promote breastfeeding in Germany is missing. In a two-year international research project entitled Becoming Breastfeeding Friendly (BBF), the current status of German breastfeeding support is systematically evaluated on the basis of the Breastfeeding Gear Model (BFGM) which was developed by the Yale School of Public Health. Therefore, committee members with expertise in the healthcare sector, science, policy, and communication evaluate 54 benchmarks of the eight relevant gears: advocacy, political will, legislation & policies, funding & resources, training & program delivery, promotion, research & evaluation, coordination, and goals & monitoring. Based on the identified strengths and needs, concrete calls to action for scaling up breastfeeding promotion are derived and prioritized. BBF started in September 2017 and is conducted in cooperation with the Yale School of Public Health by the Healthy Start - Young Family Network as well as the National Breastfeeding Committee as an initiative of the Federal Ministry of Nutrition and Agriculture. The project assesses the framework conditions for breastfeeding and thus makes a valuable contribution to the health promotion of mother and child and to breastfeeding protection in Germany.

The Saskatchewan/New Brunswick Healthy Start-Départ Santé intervention: implementation cost estimates of a physical activity and healthy eating intervention in early learning centers.

BACKGROUND: Participation in daily physical activity and consuming a balanced diet high in fruits and vegetables and low in processed foods are behaviours associated with positive health outcomes during all stages of life. Previous literature suggests that the earlier these behaviours are established the greater the health benefits. As such, early learning settings have been shown to provide an effective avenue for exploring and influencing the physical activity and healthy eating behaviours of children before school entry. However, in addition to improving individual level health of children, such interventions may also result in a number of social benefits for the society. In fact, research among adult populations has shown that sufficient participation in physical activity can significantly lower hospital stays and physician visits, in turn leading to positive economic outcomes. To our knowledge there is very limited literature about economic evaluations of interventions implemented in early learning centers to increase physical activity and healthy eating behaviours among children. The primary purpose of this paper is to identify inputs and costs needed to implement a physical activity and healthy eating intervention (Healthy Start-Départ Santé (HS-DS)) in early learning centres throughout Saskatchewan and New Brunswick over the course of three years. In doing so, implementation cost is estimated to complete the first phase of a social return on investment analysis of this intervention. METHODS: In order to carry out this evaluation the first step was to identify the inputs and costs needed to implement the intervention, along with the corresponding outputs. With stakeholder interviews and using existing database, we estimated the implementation cost by measuring, valuing and monetizing each individual input. RESULTS: Our results show that the total annual cost of implementing HS-DS was $378,753 in the first year, this total cost decreased slightly in the second year ($356,861) and again in the third year ($312,179). On average, the total annual cost is about $350,000 which implies an annual cost of $285 per child. Among all inputs, time-cost accounted for the larger share of total resources need to implement the intervention. Overall, administration and support services accounted for the largest portion of the total implementation cost each year: 74% (year 1), 79% (year 2), and 75% (year 3). CONCLUSIONS: The results from this study shed lights for future implementation of similar interventions in this context. It also helps to assess the cost effectiveness of future interventions.

Design and Operation of the Transformed National Healthy Start Evaluation.

Purpose Improving pregnancy outcomes for women and children is one of the nation's top priorities. The Healthy Start (HS) program was created to address factors that contribute to high infant mortality rates (IMRs) and persistent disparities in IMRs. The program began in 1991 and was transformed in 2014 to apply lessons from emerging research, past evaluation findings, and expert recommendations. To understand the implementation and impact of the transformed program, there is a need for a robust and comprehensive evaluation. Description The national HS evaluation will include an implementation evaluation, which will describe program components that affect outcomes; a utilization evaluation, which will examine the characteristics of women and infants who did and did not utilize the program; and an outcome evaluation, which will assess the program's effectiveness with regard to producing expected outcomes among the target population. Data sources include the National HS Program Survey, a HS participant survey, and individual-level program data linked to vital records and the Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Assessment Descriptive analyses will be used to examine differences in risk profiles between participants and non-participants, as well as to calculate penetration rates for high-risk women in respective service areas. Multivariable analyses will be used to determine the impact of the program on key outcomes and will explore variation by dose, type of services received, and grantee characteristics. Conclusion Evaluation findings are expected to inform program decisions and direction, including identification of effective program components that can be spread and scaled.

Is Timing of Enrollment Associated with Birth Outcomes? Findings from a Healthy Start Program in Kansas.

Objective The Sedgwick County Healthy Babies Healthy Start (HBHS) program provides community-based services (including care coordination, interconception care and home visiting) aimed at reducing racial/ethnic disparities in poor birth outcomes. The purpose of this study is to assess the effectiveness of the Sedgwick County HBHS program by comparing the birth outcomes of program participants who enrolled prenatally and those who did not participate while pregnant. Methods In this retrospective cohort study, we used data drawn from the Sedgwick County HBHS program. The sample included 280 clients who were enrolled in the Sedgwick County HBHS program between September 2014 and December 2015. We performed logistic regression analyses to assess the associations between enrollee type (prenatal enrollee vs. interconceptional enrollee) and birth outcomes (low birth weight, preterm birth). Results The majority of the sample consisted of racial/ethnic minority women (32.1% non-Hispanic black, 31.8% Hispanic). After adjusting for covariates, women who enrolled in the Sedgwick County HBHS program prenatally were less likely than women who were not enrolled during pregnancy to have a preterm birth (OR 0.19, [CI 08, 0.43]) and deliver a low birth weight infant (OR 0.31, [CI 0.10, 0.97]). Conclusions for Practice Women, particularly minority women, who participate in the HBHS program experienced better birth outcomes than women who did not participate in the program during pregnancy. However, findings also suggest that interconceptional enrollees may stand to benefit from continued participation in the program.

Building Healthy Start Grantees' Capacity to Achieve Collective Impact: Lessons from the Field.

Purpose While Healthy Start has emphasized the need for multi-sectorial community engagement and collaboration since its inception, in 2014 Healthy Start adopted Collective Impact (CI) as a framework for reducing infant mortality. This paper describes the development of a peer-focused capacity-building strategy that introduced key elements of CI and preliminary findings of Healthy Start grantees' progress with using CI as an approach to collaboration. Description The Collective Impact Peer Learning Networks (CI-PLNs) consisted of eight 90-min virtual monthly meetings and one face-to-face session that reviewed CI pre-conditions and conditions. Evaluation sources included: a facilitated group discussion at the final CI-PLN exploring grantee CI and CAN accomplishments (n = 57); routine evaluations (n = 144 pre, 46 interim, and 40 post PLN) examining changes in knowledge and practices regarding CI; and post CI-PLN implementation, three in-depth interviews with grantees who volunteered to discuss their experience with CI and participation in the CI-PLN. Assessment CI-PLN participants reported increased knowledge and confidence in the application of CI. Several participants reported that the CI-PLN created a space for engaging in peer sharing challenges, successes, and best practices. Participants also reported a desire to continue implementing CI and furthering their learning. Conclusion The CI-PLNs met the initial goal of increasing Healthy Start grantees' understanding of CI and determining the initial focus of their efforts. By year five, the EPIC Center anticipates Healthy Start CANs will have a sustainable infrastructure in place that supports the established common agenda, shared measures, and ongoing and meaningful inclusion of community members.

Infant Mortality Lessons Learned from a Fetal and Infant Mortality Review Program.

Objective To review fetal and infant deaths from women enrolled in Indianapolis Healthy Start using the National Fetal and Infant Mortality Review (FIMR) methods to provide strategies for prevention. METHODS: Marion County Public Health Department (MCPHD) FIMR staff identified and reviewed 22 fetal and infant deaths to Indianapolis Healthy Start program participants between 2005 and 2012. Trained FIMR nurses completed 13 of 20 maternal interviews and compiled case summaries of all deaths from the MCPHD FIMR database.. Results Case review teams identified a total of 349 family strengths, 219 contributing factors, and made 220 recommendations for future pregnancies. FIMR deliberation values for Healthy Start program participant deaths were similar to other infant deaths in Marion County during the same time period. Common themes that emerged from the reviews included lack of social support, absence of paternal involvement, substance abuse, non-compliance, and poor health behaviors leading to chronic health conditions that complicated many pregnancies. Conclusions A number of the infant deaths in this review could have been prevented with preconception and inter-conception education and by improving the quality and content of prenatal care.

A Process Evaluation of the WV Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Dissemination Initiative: Assessing the Fidelity and Impact of Delivery for State-Wide, Home-Based Healthy Start Services.

Objectives Process evaluation data are essential to document the fidelity of program implementation by clinical staff and confirm patient behavior change. This report presents a process evaluation model applied to the Smoking Cessation and Reduction in Pregnancy Treatment Dissemination Initiative for the statewide, home-based West Virginia Right From The Start Project. Methods Trained RFTS Designated Care Coordinators, nurses and social workers, of 50+ primary care agencies in all 55 counties, delivered SCRIPT to Medicaid patients who smoked. Results The process evaluation defined the level of DCC delivery of seven core SCRIPT procedures to produce a Program Implementation Index: a summary performance metric. A SCRIPT PII > 0.80 was established as the RFTS adoption standard. The PII increased from 0.53 in 2004 to 0.65 in 2006-2007 to 0.77 in 2009-2010. Although the PII > 0.80 was not achieved, exposure rates were increased for all seven SCRIPT procedures. Agency and DCC turnover, a transient patient population, and recession of 2008-2010 were barriers to achieving the adoption metric and implementation of an experimental design. A quasi-experimental Stratified, Matched Comparison (C) Group Design was selected to evaluate behavioral impact differences between a RFTS-Comparison (C) Group from 2006 to 2007 and the RFTS-SCRIPT E Group from 2009 to 2010. Impact analyses of the DCC delivery of the SCRIPT Program with higher fidelity documented a statistically significant increase in the cessation rate from 4.6 % and significant reduction rate from 6.9 % for the (C) Group in 2006-2007 to 13.9 % and 11.22 % respectively for the E Group in 2009-2010. Conclusion The PEM can assist statewide, home-based prenatal care programs to improve the quality of delivery and evaluate counseling programs.

Strengthening the Healthy Start Workforce: A Mixed-Methods Study to Understand the Roles of Community Health Workers in Healthy Start and Inform the Development of a Standardized Training Program.

Introduction Healthy Start (HS) is dedicated to preventing infant mortality, improving birth outcomes, and reducing disparities in maternal and infant health. In 2014, the HS program was reenvisioned and standardization of services and workforce development were prioritized. This study examined how HS community health workers (CHW), as critical members of the workforce, serve families and communities in order to inform the development of a CHW training program to advance program goals. Methods In 2015, an online organizational survey of all 100 HS programs was conducted. Ninety-three sites (93%) responded. Three discussion groups were subsequently conducted with HS CHWs (n = 21) and two discussion groups with HS CHW trainers/supervisors (n = 14). Results Most (91%) respondent HS programs employed CHWs. Survey respondents ranked health education (90%), assessing participant needs (85%), outreach/recruitment (85%), and connecting participants to services (85%) as the most central roles to the CHW's job. Survey findings indicated large variation in CHW training, both in the amount and content provided. Discussion group findings provided further examples of the knowledge and skills required by HS CHWs. Conclusions The study results, combined with a scan of existing competencies, led to a tailored set of competencies that serve as the foundation for a HS CHW training program. This training program has the capacity to advance strategic goals for HS by strengthening HS CHWs' capacity nationwide to respond to complex participant needs. Other maternal and child health programs may find these results of interest as they consider how CHWs could be used to strengthen service delivery.