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ISSUE BRIEFNational Healthy Start Association | November A?@?

Two Pieces ofThe Puzzle:

Infant mortality and low birth weight continue to be issues of concern for the maternal and child health community. Disparitiesin infant mortality and low birth weight rates are still persistent among racial and ethnic subgroups. For years, programs havebeen developed to monitor and address maternal behaviors that may contribute to adverse birth outcomes. Two of theseprograms are PRAMS and Healthy Start. Given today’s economic and budget constraints, collaborative efforts of these programs

and others are imperative to adequately identify, assess, and address maternal behaviors and conditions that prevent women fromhaving a healthy pregnancy.

What is PRAMS?The Pregnancy Risk Assessment Monitoring System (PRAMS) ispart of the U.S. Centers for Disease Control and Prevention (CDC)initiative to reduce infant mortality and low birth weight. PRAMS,developed in 1987, is an ongoing, state-specific, population-basedsurveillance system designed to identify and monitor selectedmaternal behaviors and experiences before, during, and afterpregnancy. PRAMS state-specific data can be used to:

plan and assess perinatal health programs, andinfluence maternal and child health programs and policies,for example, by identifying prevalence of risk behaviors orpopulations at greater risk, which in turn helps programsdetermine their focus.

PRAMS uses standardized data collection methods allowing datato be compared among states. The questionnaire consists of acore component used by all participating states and a state-specific component developed to address each state’s particulardata needs. Core component topics include the following:

Cigarette smoking and alcohol useInterconceptional careDepressionBarriers to careMedicaid and WIC participationFolic acid awarenessPregnancy intentionBreast-feedingPrenatal careHIV counselingInfant health and careInfant sleep positionPhysical abuseInsurance coverage

A Collaboration Between The Pregnancy RiskAssessment Monitoring System (PRAMS) andThe Federal Healthy Start Initiative

What is Healthy Start?Healthy Start is a national initiative developed in 1991 by theHealth Resources and Services Administration, Maternal andChild Health Bureau (MCHB). Project sites were funded in ruraland urban communities with infant mortality rates that were1.5-2.5 times the national average. They were created ascommunity-based maternal and child health programs aimed atreducing infant mortality in high-risk communities andaddressing significant disparities in perinatal health.

The goals of federal Healthy Start projects are to improve thequality of the local perinatal system of care, to enhance thecultural competence of providers who work within the system,and to increase consumer or community voice in health caredecisions. Healthy Start projects provide comprehensive servicesto achieve the overall goal of the program – reduction of infantmortality:

Case Management/Care CoordinationDirect OutreachScreening and referral for depressionInterconceptional CareHealth EducationFamily Resource CenterEnhanced Clinical ServicesRisk Prevention and ReductionAdolescent ProgramsFacilitating ServicesCommunity Consortium

The federal Healthy Start programs were established to addresssignificant disparities in perinatal health experienced by Hispanics,American Indians, African Americans, Asian Americans andimmigrant populations. The activities of the federal Healthy Startprogram are designed to improve birth and pregnancy outcomeswithin these populations while working with providers andcommunity stakeholders to address the risk factors associated withpoor perinatal health outcomes.

Why Work Together?PRAMS and Healthy Start share the common mission of reducinginfant mortality and low birth weight. Healthy Start is a provenevidence-based model that is having a positive impact onmaternal behaviors in communities.1 PRAMS can provide thedata to evaluate these programs. Because the Healthy Startprojects provide direct services to the population surveyed byPRAMS, this contact can improve the visibility of PRAMS to

potential respondents and provide guidance on how to improvePRAMS operations (e.g., response rates) and direct PRAMSpriorities, such as research agendas. Healthy Start success storiescan also provide a voice and provide examples of the utility ofPRAMS data. This collaboration can promote the quality andusefulness of PRAMS and Healthy Start for addressing andinfluencing maternal and child health programs and policies. Byworking together at the national and state level, programs canhelp each other better achieve measurable results that addressinfant mortality and low birth weight.

PRAMS AND HEALTHY START SITES, /-.-PRAMS is conducted in 37 states, New York City, and a SouthDakota Tribal Project. There are 104 Healthy Start projects in 38states, DC, and Puerto Rico.

How are we already working together?PRAMS states and Healthy Start sites are already collaborating inseveral areas. These areas include Healthy Start representationon PRAMS Steering Committees to inform project guidance anddata sharing to inform needs assessments, initiatives, andcampaigns. Below are other examples in which PRAMS andHealthy Start work together to establish the common goal ofimproving the health of mothers and babies.

Two Pieces of the Puzzle: A Collaboration Between The Pregnancy Risk Assessment Monitoring System (PRAMS) and The Federal Healthy Start Initiative

PRAMS ongoing surveillancePRAMS point-in-time surveillanceHealthy Start site

1 http://mchb.hrsa.gov/healthystart/phase1report/intermediateOutcomes.htm


OBTAINING COMMUNITY LEVEL DATAGeorgia PRAMS and Enterprise Community Healthy StartGeorgia’s Enterprise Community Healthy Start (ECHS) andGeorgia PRAMS are sharing their data in efforts to improveECHS’s ability to deliver core services and to improve knowledgeabout health service utilization and health outcomes of thepopulation served by ECHS. Georgia PRAMS is oversampling thetwo rural counties served by ECHS, and ECHS promotes GeorgiaPRAMS in its communities and encourages its clients toparticipate in the PRAMS survey. Pending institutional reviewboard approvals, ECHS client data will be linked with PRAMSsurvey data for those ECHS clients that responded to the survey.This will allow inferences and comparisons to be made aboutmaternal behaviors and outcomes of women served by ECHSand other Georgia women with similar profiles.

Specifically, the linked data can be used by ECHS to:strengthen health educationapproaches where clients showthe greatest lack ofunderstanding of a specific topic,identify client sub-groups, suchas teens, who need additionalservices,target staff education to improvetheir effectiveness, andpinpoint opportunities forimprovement ininterconceptional care.

PRAMS will be able to evaluate anumber of topics, which include:

how perinatal programs impactinfluenza vaccination amongpregnant women, andhow ECHS impacts breastfeedinginitiation and duration.

EVALUATING A PROGRAMNew York City PRAMS and HealthyStart Brooklyn ProgramHealthy Start Brooklyn (HSB) and New York City PRAMS arecollaborating to identify methodologies for assessing familyplanning practices during the interconceptional period to supportHSB participation in the Healthy Start’s Interconception CareLearning Community (ICC-LC). IIC-LC is a partnershipsupported by MCHB’s Division of Healthy Start and PerinatalServices and its members include Healthy Start grantees and anexpert work group, composed of leaders in women’s health,primary care, and public health. The community works toadvance the quality and effectiveness of interconception care inHealthy Start project areas by focusing on improving the health ofhigh-risk woman through the implementation of evidence-basedpractices and innovative community-driven interventions.

While investigating validated family planning data instruments,it became immediately apparent to HSB that PRAMS familyplanning questions would be the best option for the program fora variety of reasons:

PRAMS has a nationally recognized and validated datacollection instrument,New York City PRAMS collects data on women residing inthe five boroughs,the program can compare its population to other groupsaround the country, andthe survey question can be self-administered and easilyintegrated into the HSB’s other data collection instruments.

In addition to the family planning questions, HSB decided touse the PRAMS breastfeeding questions as well. HSB plans touse the data to tailor family planning health education messagesand to design additional program components to addressidentified needs.

INCREASING RESPONSE RATESSouth Dakota Tribal PRAMS and NorthernPlains Healthy StartSouth Dakota Tribal (SDT) PRAMS wasawarded to Yankton Sioux Tribe and wasthe first tribal-led and tribal-focused PRAMSproject in the country. SDT PRAMSimplemented alternative methods ofcontacting hard to reach American Indianwomen and mothers of American Indianinfants on reservations and in remote rurallocations by initiating a partnership with theNorthern Plains Healthy Start Program.Both SDT PRAMS and the Northern PlainsHealthy Start Program are based in theGreat Plains Tribal Chairmen’s Health Board(formerly Aberdeen Area Tribal Chairmen’sHealth Board).

The SDT PRAMS project provided fundingto the Northern Plains Healthy StartProgram so that tribal field staff could allot

time to delivering or picking up PRAMS surveys to Healthy Startparticipants in the communities served by the tribal field staff.This included the development of a specific protocol with scriptsfor the tribal field to follow, and an 8-hour training regardingprocedures for the hand delivery of surveys and protection ofhuman subjects. The tribal field staff also provided updatedcontact information to the PRAMS project.

The partnership was very successful in terms of reachingwomen, enabling SDT PRAMS to achieve a 73% response rate.It built on the strength of the Northern Plains Healthy Start’sestablished presence in the community and potentialrespondents received the survey from trusted and familiarcommunity members.


ADDITIONAL EXAMPLES

How can you begin to collaborate?Information on PRAMS and Healthy Start can be found atthe following websites:

PRAMS: http://www.cdc.gov/pramsNational Healthy Start Association:http://www.healthystartassoc.org/HRSA MCHB: http://mchb.hrsa.gov/programs/default.htm

Michigan

• Strong Beginnings Healthy Start in Grand Rapids, Michiganuses PRAMS data for grant applications, advocacy efforts(including a successful Medicaid Family Planning Waiver to helpreduce unintended pregnancy), and to inform policies andprogram development and implementation.

• Strong Beginnings encourages their clients to return PRAMSsurveys in order to help Michigan PRAM’s response rates.

North Carolina

• The North Carolina Healthy Start Foundation has incorporatedPRAMS data on infant sleep position into a statewide publiceducation and awareness campaign to reduce the risk ofSudden Infant Death Syndrome through its “Back to Sleep”campaign.

• NC PRAMS received $5,000 from the Healthy Start for dailyoperations.

New Mexico

• The La Clinica de Familia Healthy Start Program Director is amember of the New Mexico PRAMS Steering Committee andhas provided input on the PRAMS survey development.

• The Director analyzed PRAMS maternal depression data andwill be presenting to providers about the screening, data, andfollow up for women in La Clinica de Familia Healthy Start.

Oklahoma

• The Central Oklahoma Healthy Start is a member of theOklahoma PRAMS Steering Committee and is very active inPRAMS activities including: survey revisions, data dissemination,and developing fact sheets (recent topics included stressors andsocial support among African American maternal population andNative American perinatal health disparities).

• The Tulsa Healthy Start has also used PRAMS data forpublications, grants, and advocacy.

NHSA would like to acknowledgethe following for their contributionsto this issue brief:

Letitia Williams, MPHEpidemiologistCenters for Disease Control andPrevention PRAMS Project

Mary Elizabeth O’Neil, MPHEpidemiologistCenters for Disease Control andPrevention PRAMS Project

PRAMS Projects:

Georgia PRAMS

PRAMS NewYork City

South Dakota Tribal PRAMS

Michigan PRAMS

New Mexico PRAMS

Oklahoma PRAMS

North Carolina PRAMS

Healthy Start Projects:

Enterprise Community Healthy Start

Healthy Start Brooklyn

Northern Plains Healthy Start

Strong Beginnings Healthy Start

La Clinica de Familia Healthy Start

Central Oklahoma Healthy Start

Tulsa Healthy Start

North Carolina Healthy StartFoundation

National Healthy Start Association1411 K Street, NW, Suite 1350

Washington, DC 20005www.healthystartassoc.org

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