Form 001_Healthy Start 001_Healthy Start Healthy Start Survey_2010

Evaluation of Core Components of the Federal Healthy Start Program

Attachment C. HS Survey Survey Instrument_7.29.10

Healthy Start Survey

OMB: 0915-0338

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0338 can be found here:

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National Healthy Start Project Survey II ~ SURVEY DRAFT July 29, 2010~

Contents
PART A. SERVICES.................................................................................................................................. 1
Section 1: Overview of Service Components .................................................................................. 1
Section 2: Smoking and Tobacco Use Cessation ............................................................................ 8
Section 3: Healthy Weight .............................................................................................................. 12
Section 4: Breastfeeding ................................................................................................................. 16
Section 5: Cultural Competence .................................................................................................... 20
Section 6: Family Involvement....................................................................................................... 23
Section 7: Male Involvement .......................................................................................................... 24
Section 8: Domestic Violence.......................................................................................................... 28
Section 9: Child Abuse.................................................................................................................... 32
Section 10: Case Management ....................................................................................................... 36
Section 11: Home Visiting .............................................................................................................. 43
Section 12: Medical Home .............................................................................................................. 49
PART B. Systems ...................................................................................................................................... 56
Section 1: Overview of Systems Components ............................................................................... 56
Section 2: Consortium..................................................................................................................... 65
PART C: DATA SYSTEMS AND TRACKING .................................................................................... 73
Section 1: Tracking Systems.............................................................................................................. 73
Section 2: Evaluation of Components............................................................................................... 75
Section 3: Mortality Review Data ..................................................................................................... 77
PART D. REFLECTIONS AND ACCOMPLISHMENTS................................................................... 78
Section 1: Reflections on Your Healthy Start Project..................................................................... 78

National Healthy Start Project Survey II ~ SURVEY DRAFT July 29, 2010~

PART A. SERVICES
Part A of the survey asks general questions about the 5 service components that comprise the National
Healthy Start program (outreach and recruitment, case management, health education, perinatal
depression screening and referral, and interconceptional care), followed by more specific questions
related to smoking and tobacco use cessation, healthy weight, breastfeeding, cultural competence, family
involvement, male involvement, domestic violence, child abuse, case management, home visiting, and
medical home.

Section 1: Overview of Service Components
This section asks general programmatic information on the 5 service components that comprise the
National Healthy Start program (outreach and recruitment, case management, health education, perinatal
depression screening and referral, and interconceptional care) to gain an understanding of an individual
project’s service delivery model. Additional detail about case management, certain health education
topics, and other aspects of the service components will be covered in subsequent sections of the survey.
1.

Which of the following services does your Healthy Start project offer? (Check all that apply)
 Outreach & participant recruitment
 Case management
 Health education
 Perinatal depression screening
 Interconceptional Services

National Healthy Start Project Survey II ~DRAFT~
2.

How does your Healthy Start project perform the following? (Check all that apply)

Our Healthy Start
project does not
perform this
activity

Staff employed
directly by our
Healthy Start
project

A local agency or
organization under
subcontract to our
Healthy Start
project

Another agency or
org in
collaboration with
our Healthy Start
project

Other

If other, please
specify

Outreach & participant
recruitment



_______________

Case management



_______________

Health education



_______________

Perinatal depression screening



_______________

Interconceptional services



_______________

Nutrition

Mental
health

Education/
health
promotion

Other

If other, please
specify

What is the background of the staff who perform: (Check all that apply)
Our Healthy
Start project
does not
perform this
activity

Staff
indigenous
to the
community

Lay/ paraprofessional

Social
work

Nursing

Doula

Public
health

Outreach & participant
recruitment



_______________

Health education



_______________

Perinatal depression
screening



_______________

Interconceptional services



_______________

National Healthy Start Project Survey II ~DRAFT~
4.

Are any of your staff former Healthy Start participants?
 Yes
 No

What strategies do you use to…? (Check all that apply)
Community-Based Strategies

Canvass
neighborhoods or
community
settings

Organize
community
events

Conduct
classes or
make
presentations to
local groups

…raise
awareness &
name
recognition of
your project in
the community



…conduct
outreach &
participant
recruitment



…perform
health
education



Mass Media Strategies

Attend
community
events

Network
with health
care
providers,
schools or
other
agencies

Operate
hotline

Other
communitybased
strategies



Our project
does not use
any
communitybased
strategies
(N/A)

Radio

Newspaper/
advertising

Brochures

Other
mass
media
strategies



If
checked,
are PSAs
used?
 Yes
 No



If
checked,
are PSAs
used?
 Yes
 No



If
checked,
are PSAs
used?
 Yes
 No

Specify:

_______



Specify:

_______




Specify:

_______



Our
project
does not
use any
mass media
strategies
(N/A)



Specify:

_______



Specify:

_______



Specify:

_______

National Healthy Start Project Survey II ~DRAFT~
6.

Where does your Healthy Start project provide the following services: (Check all that apply)
At our
Healthy Start
project site

At
participant’s
home

Clinics

Other
communitybased settings

If other,
please specify

Outreach and participant
recruitment



__________

Case management



__________

Health education



__________

Perinatal depression
screening



__________

Interconceptional
services



__________

For each of the following services, what is your Healthy Start project’s process for following up
with a participant who did not complete a referral? (Check all that apply)

Case
management

Perinatal
depression
screening

Interconceptional services

Send
participant
reminder
notice

Contact
participant
by phone

Discuss
with
participant
in person

Our
project
does not
have a
follow up
process
(N/A)



_________



_________



_________

If checked, is
the reminder
sent:
 by phone?
 by email?
 by mail?



If checked, is
discussion
 at home?
 on project
site?



If checked, is
the reminder
sent:
 by phone?
 by email?
 by mail?


If checked, is
the reminder
sent:
 by phone?
 by email?
 by mail?

Other

If other,
please
specify


If checked, is
discussion
 at home?
 on project
site?




If checked, is
discussion
 at home?
 on project
site?

National Healthy Start Project Survey II ~DRAFT~
8.

To what extent has retention been a problem for your Healthy Start project?
 Not a problem
 Somewhat of problem
 A problem

Are there strategies that you use to help retain participants in Healthy Start during pregnancy/
prenatal period and postpartum/interconceptional period? (Check all that apply)

Pregnancy/Prenatal Period

Postpartum/
Interconceptional Period

Engage in frequent contact



Provide transportation



Provide child care



Provide incentives such as books,
graduation certificates, toothbrushes,
thermometers, etc.



Follow up at participant’s home



Check with providers, when participant
does not follow up



________________________



Other; specify
Our project does not use any particular
strategies for retention

National Healthy Start Project Survey II ~DRAFT~
10.

What types of referrals are offered through…? (Check all that apply)
Services/
shelters for
women
experiencing
domestic
violence

Transportation

Other,
specify

Our
Healthy
Start
project
does not
offer
referrals

Clinical
referral MD

Clinical
referral social
work, RN

WIC/Food
assistance

Housing/
heating

Substance
abuse
treatment/
counseling

Outreach & participant
recruitment



_________



Case management



_________



Health education



_________



Perinatal depression services



_________



Interconceptional services



_________



National Healthy Start Project Survey II ~DRAFT~
11.

What topics does your Healthy Start project address through your health education activities? For each health topic addressed, indicate
whether the topic is addressed during pregnancy/prenatal period or postpartum/interconceptional period (or both) and whether the topic is
presented to individuals or in group settings (or both). If any topics are addressed in a group setting, please also indicate whether the
group is peer-led (i.e., group session led by peer/other participant). (Check all that apply)

Labor and delivery
Immunizations
Breastfeeding*
Sudden Unexplained Infant Death
Syndrome
Parenting
Child safety/injury prevention
Perinatal depression
Stress management
Disease management
Substance abuse
Nutrition*
Physical activity*
Weight management*
Tobacco use cessation*
Second hand smoke exposure
Domestic violence/Intimate partner
abuse*
Child abuse*
Family and partner supports
HIV/AIDS
Sexually Transmitted Infections
Family planning
Reproductive life planning
Employment/ job training
Financial planning/budgeting
Education support/GED classes
Other (specify)___________

Pregnancy/
Prenatal Period




Postpartum/
Interconceptional
Period




Group Setting




If group is
checked, is the
group peer-led?




Individual




We do not
address this topic































* More detailed questions about this topic are asked in subsequent sections of this survey.

National Healthy Start Project Survey II ~DRAFT~

Section 2: Smoking and Tobacco Use Cessation
This section asks about the prevalence of smoking and tobacco use among Healthy Start
participants, how and whether tobacco use cessation is addressed through the Healthy Start
project, what types of supports and services are available to participants and staff—either on site
or through referral—to aid tobacco use cessation, and potential barriers to participants’ tobacco
use cessation efforts.
1.

Does your Healthy Start project collect data on: (Check all that apply)
 Tobacco use [ANSWER 1a -1b]
1a. In 2009, approximately what percentage of participants in your Healthy Start project used
tobacco in any form?
___%
 Unknown
1b. In 2009, approximately what percentage of participants in your Healthy Start project
were current smokers?
___%
 Unknown
 Tobacco use cessation [ANSWER 1c]
1c. In 2009, approximately what percentage of participants in your Healthy Start project have
quit using tobacco during their participation in the project?
___%
 Unknown
 Readiness for change
 Quit attempts
 Tobacco use relapse [ANSWER 1d]
1d. In 2009, approximately what percentage of participants in your Healthy Start projects
have relapsed after quitting smoking?
___%
 Unknown
 Exposure to second hand smoke
 Our Healthy Start project does not collect data smoking and tobacco use cessation

Does your Healthy Start project have a no smoking policy on the project premises?

National Healthy Start Project Survey II ~DRAFT~
 Yes
No
3.

Does your Healthy Start project address tobacco use cessation through any project activities?
 Yes
 No [SKIP TO NEXT SECTION]

During which project activities does your Healthy Start project address or discuss tobacco use
cessation with participants? (Check all that apply)
 During home visits
 During face-to-face meetings at the Healthy Start site
 During other routine care-related contacts
 During group health education classes
 During depression screening
 During outreach activities
 Other (specify):_________________________

When does your Healthy Start project address or discuss tobacco use cessation with participants?
(Check all that apply)
 During pregnancy/prenatal period
 During the postpartum/interconceptional period

Does your Healthy Start project conduct activities on-site to support tobacco use cessation?
 Yes [ANSWER 6a-6b]
 No [ SKIP TO 7]
6a. Does your Healthy Start project offer:


Group tobacco use counseling

6a1. Which topics are covered in group tobacco use cessation counseling? (Check all
that apply)
 Nicotine replacement options
 Long-term health consequences of smoking
 Health benefits of quitting smoking
 Economic benefits of quitting smoking
 Birth outcomes associated with smoking during pregnancy
 Outcomes associated with second hand smoke exposure during infancy and
childhood
 Community/online smoking cessation networks
 Prescription medications for smoking and other tobacco use cessation
 Other (specify):___________________________________

National Healthy Start Project Survey II ~DRAFT~
 None of the above
 One-on-one tobacco use counseling
6a2. Which topics are covered in one-on-one tobacco use cessation counseling? (Check
all that apply)
 Nicotine replacement options
 Long-term health consequences of smoking
 Health benefits of quitting smoking
 Economic benefits of quitting smoking
 Birth outcomes associated with smoking during pregnancy
 Outcomes associated with second hand smoke exposure during infancy and
childhood
 Community/online smoking cessation networks
 Prescription medications for smoking and other tobacco use cessation
 Other (specify):___________________________________
 None of the above
6b. Which of the following nicotine replacement and other tobacco use cessation medication
options are available on-site for participants trying to quit using tobacco? (Check all that
apply)



Nicotine patch



Nicotine gum



Nicotine lozenge



Nicotine nasal spray



Buproprion (Zyban or Wellbutrin SR®)



Varenicline (aka Chantix/Champix®)



Tobacco cessation-related referrals



Access to 1-800 quit lines



Other (specify):___________________________________



None of the above

Are tobacco use cessation opportunities offered to: (Check all that apply)
 Partners of Healthy Start participants
 Other family members of Healthy Start participants
 Healthy Start Staff
 Only to Healthy Start participants

National Healthy Start Project Survey II ~DRAFT~
7a. [FOR EACH YES]: Which opportunities are offered?
 Group counseling
 One-on-one counseling
 Medication options
 Tobacco cessation-related referrals
 Access to state-run or other quit lines
8.

What are common barriers to smoking cessation for your Healthy Start participants? (Check all
that apply)
 Household members are smokers
 Household members are other non-smoking tobacco users
 Lack of Medicaid or other funding-source coverage of prescription medications
for smoking and other tobacco use cessation
 Lack of dedicated staff available within the Healthy Start project
 Staff prioritize other participant needs over tobacco use cessation
 Participants prioritize other needs over tobacco use cessation
 Daily stress experienced by participants
 Physical nicotine addiction
 Other (specify):__________________________________
 Unknown

National Healthy Start Project Survey II ~DRAFT~

Section 3: Healthy Weight
The Healthy Weight section captures information about the prevalence of overweight and obesity
among Healthy Start participants and how and whether three components of healthy weight
(nutrition, physical activity, and weight management) are addressed in the Healthy Start project.
This section also asks about supports and services available—either on site or through referral—
to assist participants in their efforts to achieve a healthy weight.
1.

Does your Healthy Start project collect data on: (Check all that apply)
 Overweight [ANSWER 1a]
1a. In 2009, approximately what percentage of your participants was overweight?
___%
 Unknown
 Obesity [ANSWER 1b]
1b. In 2009, approximately what percentage of your participants was obese?
___%
 Unknown
 Underweight [ANSWER 1c]
1c. In 2009, approximately what percentage of your participants was underweight?
___%
 Unknown
 Our Healthy Start project does not collect data on weight

Does your Healthy Start project encourage or promote healthy weight-related activities among
Healthy Start staff?
 Yes [ANSWER 2a]
 No

National Healthy Start Project Survey II ~DRAFT~
2a. Which of the following healthy weight-related components does your Healthy Start
project promote among Healthy Start staff? How are these components addressed?
(Check all that apply)
Literature/
reading
materials

Group
education

One-on-one
counseling

Group
counseling

Other, specify:

Nutrition

_________

Physical activity

_________

Weight management

_________

Other,
specify:_________

_________

Does your Healthy Start project address or discuss healthy weight with participants?
 Yes [ANSWER 3a]
 No [SKIP TO NEXT SECTION]
3a. Which of the following healthy weight-related components does your Healthy Start
project address or discuss with participants? (Check all that apply)
During
Home
Visits

During
Face-to Face
Meeting at
HS Site

During other
routine carerelated
contacts

During
group health
education
classes

During
depression
screening

During
outreach
activities

Other,
specify:

Nutrition



_________

Physical activity



_________

Weight management



_________

Other,
specify:__________



_________

When is healthy weight addressed with participants? (Check all that apply)
During pregnancy/
prenatal period

During postpartum/
interconceptional period

Nutrition



Physical activity



Weight management



Other,
specify:_________



National Healthy Start Project Survey II ~DRAFT~
5.

What healthy weight-related activities does your Healthy Start project offer? (Check all that
apply)
 One-on-one weight loss support
 Weight loss support groups
 Literature/reading materials
 Exercise classes
 Nutrition education
 Healthy cooking classes
 Weight and pregnancy education
 Other (specify):_________________________
 Our Healthy Start project does not offer weight-related activities

Does your Healthy Start project measure body mass index (BMI) as part of the healthy weight
services offered?
 Yes [ANSWER 6a-d]
 No
6a. Does your Healthy Start project have a protocol in place for overweight/obese women?
 Yes
 No
6b. Does your Healthy Start project have a protocol in place for underweight women?
 Yes
 No
6c. Does your Healthy Start project track (i.e. multiple measurements over time) the number
of overweight/obese participants?
 Yes
 No
6d. Does your Healthy Start project track (i.e. multiple measurement over time) the number
of underweight participants?
 Yes
 No

Does your Healthy Start project have a nutritionist or someone with a background in nutrition on
site?
 Yes
 No [ANSWER 7a]

National Healthy Start Project Survey II ~DRAFT~
7a. Does your Healthy Start project make referrals to a nutritionist or someone with a
background in nutrition?
 Yes
 No
8.

Does your Healthy Start project make referrals to exercise programs?
 Yes
 No

Does your Healthy Start project make referrals to weight loss programs?
 Yes
 No

10.

Does your Healthy Start project address: (Check all that apply)
 Children’s nutrition
 Children and exercise
 Effects of childhood obesity

National Healthy Start Project Survey II ~DRAFT~

Section 4: Breastfeeding
This section asks about rates, exclusivity, and duration of breastfeeding among Healthy Start
project participants. The section includes questions about characteristics of local hospitals,
breastfeeding training for staff and education for participants, and the types of supports and
services available for Healthy Start participants—either on site or through referral—that promote
breastfeeding.
1.

Does your Healthy Start project collect data on: (Check all that apply)
 Breastfeeding initiation [ANSWER 1a]
1a. In 2009, approximately what percentage of your participants began breastfeeding at
birth?
___%
 Unknown
 Breastfeeding duration [ANSWER 1b]
1b. In 2009, approximately what percentage of your participants breastfed, even partially,
their infants at 6 months of age?
___%
 Unknown
 Breastfeeding exclusivity [ANSWER 1c]
1c. In 2009, approximately what percentage of your participants breastfed exclusively in the
first 6 months postpartum?
___%
 Unknown
 Reasons for not initiating or stopping breastfeeding

Does your Healthy Start site(s) have a private space available for breastfeeding? (Check all that
apply)
 For Healthy Start staff
 For Healthy Start participants
 We do not have such a space

National Healthy Start Project Survey II ~DRAFT~
3.

Do the majority (at least 60%) of your participants deliver at hospitals that: (Check all that
apply)
 Have “rooming in” for newborns
 Routinely give supplementation (including formula and water)
 Provide formula discharge packs
 Have lactation consultants on staff
 Have midwives or doulas on staff
 Have been designated a Baby-Friendly Hospital by WHO (World Health
Organization)

Does your Healthy Start project conduct activities to recognize or promote National
Breastfeeding Awareness Month?
 Yes
 No

Does your Healthy Start project address breastfeeding in any project activities?
Yes [ANSWER 6]
 No [SKIP TO NEXT SECTION]

During which project activities are breastfeeding topics addressed or discussed with participants?
(Check all that apply)
 During home visits
 During face-to-face meetings at the Healthy Start site
 During other routine care-related contacts
 During group classes
 During depression screening
 During outreach activities
 Other (specify):_________________________

When are breastfeeding topics addressed with participants? (Check all that apply)
 During pregnancy/prenatal period
 During the postpartum/interconceptional period

National Healthy Start Project Survey II ~DRAFT~
8.

What specific breastfeeding-related topics are discussed with participants? (Check all that
apply)
 Infants’ health benefits from breastfeeding
 Mothers’ health benefits from breastfeeding
 Common breastfeeding challenges
 Strategies/interventions for overcoming breastfeeding challenges
 Effects of breastfeeding on fertility
 Differences between breast milk and formula
 Technique for proper latch on
 Economic benefits of breastfeeding
 Breastfeeding alternatives for mothers who cannot directly breastfeed (e.g., use of
breast pumps)
 Breastfeeding and transitioning back to work
 Other (specify):___________________________________________

Does your Healthy Start project provide staff training on breastfeeding?
 Yes [ANSWER 9a]
 No [SKIP TO 10]
9a. If yes, does the training include the following: (Check all that apply)
 Infants’ health benefits from breastfeeding
 Mothers’ health benefits from breastfeeding
 Common breastfeeding challenges
 Strategies/interventions for overcoming breastfeeding challenges
 Lactational amenorrhea and family planning
 Breastfeeding and birth control methods
 Counseling techniques for mothers with breastfeeding concerns
 The physiology of human milk production
 Differences between breast milk and formula
 Technique for proper latch on
 Economic benefits of breastfeeding
 Breastfeeding alternatives for mothers who cannot directly breastfeed their infants
(e.g., use of breast pump)
 Breastfeeding and transitioning back to work
 Other, specify: ___________________________________________

National Healthy Start Project Survey II ~DRAFT~
10.

Does your Healthy Start project have equipment available to loan or donate to participants to
support initiation and continuation of breastfeeding? (Check all that apply)
 Breast Pumps

 Breast Shells/Breast Shields
 Nursing Supplementers
 Our Healthy Start project does not loan or donate breastfeeding equipment
11.

Does your Healthy Start project offer individualized breastfeeding counseling to postpartum
participants?
 Yes [ANSWER 11a-11c]
 No [SKIP TO 11d]
11a. Does your Healthy Start project have a certified lactation consultant on site?
 Yes
 No
11b. Does your Healthy Start project have a doula on site to support breastfeeding?
 Yes
 No
11c. Does your Healthy Start project have breastfeeding peer counselors available?
 Yes
 No
11d. Does your Healthy Start project refer participants elsewhere for individualized lactation
support?
 Yes [ANSWER 11d1]
 No
11d1. Where do you refer participants for lactation support? (Check all that apply)
 WIC
 Hospital or clinic
 Other, specify:_______________________________________

National Healthy Start Project Survey II ~DRAFT~

Section 5: Cultural Competence
The Cultural Competence section collects information about the ways in which the Healthy Start
project’s delivery of services reflects the needs of the population(s) served. Specifically, we ask
about staff training and hiring, communication with non-English speaking participants, cultural
competence of outreach and recruitment efforts, and assessment of participants’ cultural
backgrounds.
1.

How does your Healthy Start project promote the cultural competence of your employees and
contractor staff? (Check all that apply)
 Hire staff who represent racial/ethnic makeup of our target population
 Require contractors to employ staff reflective of target population
 Provide cultural competence/sensitivity training
 Our Healthy Start project does not implement particular strategies to promote
cultural competence of our employees and contractor staff
 Other,
specify:_______________________________________________________

Please indicate which languages are spoken among your participant population and how your
Healthy Start staff communicate with participants who do not speak English?
Respondent Instructions: Please write in the most common languages spoken among your
participant population in the column on the left of the table.

Languages spoken

Participants
were assigned
to HS staff
who spoke
their language

HS project
contracted for
translation/
interpretation
services.

Friends or
family of the
participant
translated

Staff were
unable to
communicate
with
participants

Other, specify




__________




__________




__________




__________




__________




__________

National Healthy Start Project Survey II ~DRAFT~
3.

What challenges does your Healthy Start project encounter in promoting the cultural competence
of your Healthy Start staff and contracted providers? (Check all that apply)
 We do not have adequate funding to hire culturally competent staff
 There are not enough qualified staff in the community
 We don’t have staff to cover all cultural groups
 Other (specify):
_______________________________________________________

How does your Healthy Start project tailor outreach activities for particular cultural or ethnic
groups in your community? (Check all that apply)
 Translate written materials into the languages spoken by members of our
community [ANSWER 4a]
4a. For which languages?
Respondent Instructions: Please write in the most common languages spoken
in your community.
 {list of languages selected in #2 will pop up here for selection; otherwise, response
categories will include: “All, Some, Few”}
 Learn about customs and cultures and apply this knowledge when interacting with
participants [ANSWER 4b]
4b. For how many cultural groups?
 All or most (more than 60%)
 Some (~30-60%)
 Few (less 30%)
 Enlist members of the community to teach and participate in projects that are
relevant to their cultures and customs (i.e. making dream catchers) [ANSWER 4c]
4c. For how many cultural groups?
 All or most (more than 60%)
 Some (~30-60%)
 Few (less 30%)
 Contract with translation/interpreter services to attend outreach activities with
Healthy Start staff [ANSWER 4d]

National Healthy Start Project Survey II ~DRAFT~
4d. For how many cultural groups?
 All or most (more than 60%)
 Some (~30-60%)
 Few (less 30%)
 Enlist staff that reflect the community being served
 Connect with other community initiatives that reflect the cultural groups of our
participants
 Our Healthy Start project does not tailor outreach activities for particular cultural
or ethnic groups in the community
 Other, specify:
_______________________________________________________
5.

What efforts are made by Healthy Start staff to assess new participants’ cultures during
enrollment? (Check all that apply)
 Ask country of origin
 Listen to dialects
 Ask about customs/spiritual beliefs
 Ask about beliefs about pregnancy and health
 Our Healthy Start project does not perform an assessment of participant’s culture
 Other, specify:

Section 6: Family Involvement
This section asks about the kinds of activities that Healthy Start participants’ family members
may be involved in, the types of family members that are involved, and the number of Healthy
Start participants that involve one or more family members.
1.

Does your Healthy Start project encourage family involvement?
 Yes [ANSWER 1a]
 No [SKIP TO NEXT SECTION]
1a. If yes, how are families involved in services (Check all that apply)?
 Invited to attend health education classes designed specifically for family participation
(e.g., depending on the topic)
 Invited to attend any health education
 Invited to attend special outreach activities designed for family involvement
 Invited to attend any outreach activities
 Invited to be present at specific home visits that include family assessment
 Invited to be present at any home visits
 Invited to be present for developing participant written service plan
 Invited to attend consortium meetings
 Other, specify:_____________________________________________

What is the “typical family” that attends these activities/services? (Check all that apply)
 Male/female partner
 Parents or grandparents
 Aunts, uncles, or cousins
 Siblings
 Participant’s offspring (e.g. older children of participant)
 Persons not related to participant but considered family
 Other, specify:_____________________________________________________

What percent of Healthy Start participants have their “family” involved in these Healthy Start
activities/services?
 All or most (more than 60%)
 Some (~30-60%)
 Few (less 30%)

Section 7: Male Involvement
This section captures information about the number of men that participate in Healthy Start
activities, the types of activities and services offered to men, and recruitment and retention
strategies to increase/maintain male participation in the Healthy Start project.
1.

Does your Healthy Start project provide any services to men?
 Yes
 No [SKIP TO NEXT SECTION]

In 2009, approximately how many men participated in your project? _____________
2a. What percentage of these men are partners (or fathers of children) of enrolled female
participants? _____________

Are services offered to males as a male-only program (for example, males meeting at separate
time or have their own classes)?
 Yes [ANSWER 3a - 3b]
 No [SKIP TO 4]
3a. Which of the following services does your Healthy Start project offer as part of the maleonly program? How often are these services offered? (Check all that apply)

Weekly

Twice a
week

Every
other
week

Clinical services



_________

Case
Management
services



_________

Mental Health
services



_________

Health
Education



_________

Court Advocacy



_________

Other, specify:



_________

Monthly

Twice a
month

Quarterly

Other,
specify:

3b. Is there a specified program duration (i.e. program ends after a specified period of time)?
 Yes [ANSWER 3b1]
 No [SKIP TO 4]

3b1. What is the duration of the male involvement program? (Check one)
 Less than 3 months
 Up to 6 months
 12 months
 Up to, but not including, 2 years
 2 years or more
 Other (specify): __________________________
4.

What services are offered to men? (Check all that apply)
 Clinical services
 Case management services
 Mental health services
 Health Education [ANSWER 4a - 4d]
 Court advocacy
 Other (specify): _____________________________
4a. What health education topics are addressed with men in your Healthy Start project? (Check
all that apply)

Labor and delivery
Immunizations
Breastfeeding*
Sudden Unexplained Infant Death Syndrome
Parenting
Child safety/injury prevention
Perinatal depression
Stress management
Disease management
Substance abuse
Nutrition*
Physical activity*
Weight management*
Tobacco use cessation*
Second hand smoke exposure
Domestic violence/Intimate partner abuse*
Child abuse*
Family and partner supports
HIV/AIDS
Sexually Transmitted Infections
Family planning
Reproductive life planning
Employment/ job training
Financial planning/budgeting
Education support/GED classes
Other (specify)___________




























We do not address
this topic



























4b. Do you use a specific male involvement curriculum?
 Yes
 No
4c. Can males only participate as long as their partners are enrolled in the Healthy Start project?
 Yes
 No
4d. Are health education materials prepared specifically for males?
 Yes
 No
5.

Does your project have a dedicated male services coordinator?
 Yes [SKIP to 6]
 No [ANSWER 5a]
5a. What staff conduct services for males?
 Subcontracted staff [SKIP to 6]
 Healthy Start staff [ANSWER 5a1]
5a1. Which staff conduct male services/programs? (Check all that apply)
 Outreach worker(s)
 Case manager(s)
 Health educator(s)
 Clinic staff
 Other, specify:

_______________________________________

How are males recruited? (Check all that apply)
 Referrals through female partner
 Community outreach
 Referrals from others service providers
 Court referral or mandate
 Other, specify:
__________________________________________________________

What strategies does your Healthy Start project use to facilitate male participant retention?
(Check all that apply)
 Engage in frequent contact (e.g. phone, mail reminders)
 Provide transportation
 Provide child care
 Provide financial assistance (e.g. food vouchers, merchandise)
 Follow up at the participants home
 Offer services or programs specific to male needs
 Offer community-based events
 Our Healthy Start project does not use strategies to facilitate male participant
retention
 Other, specify:
__________________________________________________________

What are the challenges to retaining males?
 Lack of providers who are sensitive to male needs
 Lack of transportation
 Lack of child care
 Perceived stigma of receiving public services
 Participants don’t believe they need Healthy Start services
 Inconvenient provider hours or locations
 Participants believe they have more pressing needs
 Our Healthy Start project does not have any challenges retaining male participants
 Other, specify:
__________________________________________________________

Section 8: Domestic Violence
The Domestic Violence section asks about the prevalence of domestic violence in households of
Healthy Start participants, staff training on issues related to domestic violence, screening for
domestic violence, and the types of services and supports available—either on site or through
referral—for Healthy Start participants that experience domestic violence.
1.

Does your Healthy Start project collect data on domestic violence experienced by Healthy Start
participants?
 Yes [ANSWER 1a-c]
 No [SKIP TO 2]
1a. In 2009, approximately what percentage of women participating in your Healthy Start project
reported experiencing domestic violence?
___%
 Unknown
1b. In 2009, approximately what percentage of pregnant women participating in your Healthy
Start project reported experiencing domestic violence?
___%
 Unknown
1c. In 2009, approximately what percentage of interconceptional women participating in your
Healthy Start project reported experiencing domestic violence?
___%
 Unknown

Does your Healthy Start project provide staff training on domestic violence?
 Yes [ANSWER 2a]
 No [SKIP TO 3]

2a. Does the training include the following: (Check all that apply)1
 What constitutes domestic violence/intimate partner violence
 Effective and emerging screening tools to assess risk for domestic
violence/intimate partner violence
 How to interview survivors of domestic violence/intimate partner violence
 Available resources in the community and through the legal system
 How to make referrals to community/legal resources
 Understanding the relationship between domestic violence and child abuse
 How to assess risk of child abuse in the context of domestic violence
 Other, specify: ___________________________________________
3.

Does your Healthy Start project screen for domestic violence?
 Yes [ANSWER 3a-f]
 No [SKIP TO NEXT SECTION]
3a. Does your Healthy Start project use an evidence-based tool to screen for domestic violence?
 Yes
 No
3b. In what settings are participants screened for domestic violence? (Check all that apply)
 During home visits
 During face-to-face meetings at the Healthy Start site
 During other routine care-related contacts
 During group classes
 During depression screening
 During outreach activities
 Other, specify:_________________________
3c. Which participants are screened?
 All participants
 Only pregnant/prenatal participants
 Only postpartum/interconceptional participants

Adapted from Simmons College Domestic Violence Training Program. http://www.simmons.edu/ssw/dvtraining/.
Accessed March 22, 2010.

3d. When are Healthy Start participants screened for domestic violence? (Check all that apply)
 During pregnancy/prenatal period
 During postpartum/interconceptional period
 Other, specify:_________________________
3e. What is the frequency of screening for domestic violence?
 Once at enrollment
 Monthly
 Bi-monthly
 Twice per year
 Yearly
 Other, specify:_________________________
3f. Does your Healthy Start project have a protocol for assessment of domestic abuse
 Yes [ANSWER 3f1-2]
 No [SKIP TO 4]
3f1. Has the protocol been: (Check all that apply)
 Reviewed by participants or family members
 Translated into languages appropriate for the population your project serves
 Designed to account for cultural differences in family practices
 None of the above

3f2. Does your protocol address appropriate follow-up actions in response to cases
of suspected domestic violence?
 Yes
 No
4.

What on-site services/resources are available for participants who screen positive for domestic
violence? (Check all that apply)
 Individual counseling
 Support groups
 Our Healthy Start project does not offer on-site services/resources for participants
who screen positive for domestic violence
 Other, specify:__________________________________________________

Does your Healthy Start project provide referrals for women screening positive for domestic
violence?
 Yes [ANSWER 5a-b]
 No
5a. If yes, what type of referrals are offered? (Check all that apply)
 Mental health/Counseling referrals:
 For the Healthy Start participant
 For the Healthy Start participant’s child
 For other family members of Healthy Start participants
 Referrals to shelters/safe havens for women experiencing domestic violence
 Medical referrals for domestic violence-related injuries
 Referrals within the criminal justice system
 Police
 District Attorney’s office
 Court advocate
 Other, specify:_________________________________
 Crisis hotlines
 Support groups
 Other, specify:_________________________________
5b. What services/assistance does your Healthy Start project offer to assist Healthy Start
participants in completing these referrals? (Check all that apply)
 Transportation services offered to participants
 Transportation stipends offered to participants
 Healthy Start staff may accompany participant to appointments
 Translation/interpreter services
 Reimbursement for translation/interpreter services
 Assistance securing health insurance
 Supplemental health insurance
 No such enabling services are offered
 Other, specify:_________________________________

Section 9: Child Abuse
In this section, we ask about the prevalence of child abuse reported by Healthy Start participants,
the ways in which child abuse may be addressed through Healthy Start project service
components, staff training on child abuse, child abuse assessment, and supports and services
available—either on site or through referral—for women whose children experience child abuse.
1.

Does your Healthy Start project collect data on child abuse experienced by children of Healthy
Start participants?
 Yes [ANSWER 1a]
 No [SKIP TO 2]
1a. In 2009, approximately what percentage of women participating in your Healthy Start project
reported any of their children having experienced child abuse?
___%
 Unknown

Does your Healthy Start project address child abuse through any project activities?
 Yes
 No [SKIP TO NEXT SECTION]

In what settings is child abuse addressed or discussed with women participating in your project?
(Check all that apply)
 During home visits
 During face-to-face meetings at the Healthy Start site
 During other routine care-related contacts
 During group classes
 During depression screening
 During outreach activities
 Other, specify:_________________________

When is child abuse addressed with women participating in your project? (Check all that apply)
 During the pregnancy/prenatal period
 During the postpartum/interconceptional period

Does your Healthy Start project provide staff training on child abuse?
 Yes [ANSWER 5a]
 No [SKIP TO 6]

5a. Does the training include the following: (Check all that apply)2
 What constitutes child abuse/neglect
 Effective and emerging screening tools to assess risk for child abuse/neglect
 How to interview parents of children who may have suffered abuse/neglect
 Reporting requirements for suspected child abuse
 Signs and symptoms of child abuse in children who are non-verbal
 Available resources in the community and through the legal system and how to make
referrals to these resources
 Understanding the relationship between child abuse and domestic violence and how to
assess risk of child abuse in the context of domestic violence
 Other, specify:_______________________________________________
6.

Does your Healthy Start project directly assess participants’ children for child abuse?
 Yes [ANSWER 6a-c]
 No [SKIP TO NEXT SECTION]
6a. When do Healthy Start staff directly assess children for child abuse? (Check all that apply)

 During home visits
 At the Healthy Start site
 During phone contacts
 Other, specify:_______________________________________
6b. Which children are screened? (Check all that apply)

 All children
 Those children whose parents report domestic violence
 Those children with risk factors associated with child abuse
 Those children presenting with indicators of abuse
6c. Does your Healthy Start project have a set of written procedures for assessment of child
abuse?

 Yes [ANSWER 6c1-2]
 No [SKIP TO 7]

Adapted from Simmons College Domestic Violence Training Program. http://www.simmons.edu/ssw/dvtraining/.
Accessed March 22, 2010.

6c1. Has the set of written procedures been: (Check all that apply)
 Reviewed by participants or family members
 Translated into languages appropriate for the population your project serves
 Designed to account for cultural differences in family practices
 None of the above
6c2. Does your set of written procedures address appropriate follow-up actions in response
to cases of suspected child abuse?
 Yes

 No
7.

What on-site services/resources are available for women whose children screen positive for
child abuse? (Check all that apply)

 Individual counseling
 Support groups
 Our Healthy Start project does not offer on-site services/resources for women
whose children screen positive for child abuse

 Other, specify:
____________________________________________________________
8.

Does your Healthy Start project provide referrals for women whose children screen positive
for child abuse?

 Yes [ANSWER 8a-b]
 No
8a.

What type of referrals are offered? (Check all that apply)

 Mental health/Counseling referrals:
 For the Healthy Start participant
 For the Healthy Start participant’s child/children
 Referrals to shelters/safe havens for women experiencing domestic violence
 Medical referrals for domestic violence-related injuries
 Referrals within the criminal justice system
 Police
 District Attorney’s office
 Court advocate
 Other, specify:_______________________________________
 Crisis hotlines
 Support groups
 Other, specify:________________________________________________

8b.

What services/assistance does your Healthy Start project offer to assist Healthy Start
participants in completing these referrals? (Check all that apply)

 Transportation services offered to participants
 Transportation stipends offered to participants
 Healthy Start staff may accompany participant to appointments
 Translation/interpreter services
 Reimbursement for translation/interpreter services
 Assistance securing health insurance
 Supplemental health insurance
 Other, specify:________________________________________________

Section 10: Case Management
This section asks detailed information about the features of case management activities,
including service variations across participants by type (e.g. pregnant women; infants) and risk
category, participants’ role in the development of service plans, inclusion of partners and other
family members in services, and barriers to effective case management.
1.

What case management (CM) services does your Healthy Start project provide? (Check all that
apply)

Counseling Coordinaand
tion
guidance
services

CM
services are
not offered
to this
Referrals
group

Risk/
screening
assessment

Home
visiting

Health
education

...to participants



…to partners of
participants



…to (nonpartner) family
members



If risk/screening assessment is conducted, how are the screening tools adapted to each
participant’s cultural background? (Check all that apply)
 Administered by staff who speak the participant’s language
 Translated
 Assisted by translator
 Adapted for cultural needs/identity
 Advising group reviewed tools
 Screening tools are not adapted
 Other, specify:
 Our Healthy Start project does not conduct screening assessments

How are participants assigned to case managers? (Check all that apply)
 Participant health status or risk factors
 Participant demographics
 Caseload or staff availability
 Geographic location
 Other, specify:
 No particular assignment criteria are used
 Our Healthy Start project does not assign participants to case managers

Does your Healthy Start project develop written service plans for participants?
 Yes [ANSWER 4a]
 No [SKIP TO 5]
4a. How are participants involved in the development of the service plan? (Check all that apply)
 Participants attend meeting(s) to develop the service plan
 Participants sign/initial the service plan
 Participants receive a written copy of the service plan
 Participants are not involved in the development of the service plan
 Other, specify: ________________________________________________

Does your Healthy Start project offer different levels of case management, for example, based on
the number of risk factors?
 Yes [ANSWER 5a]
 No [SKIP TO 6]
5a. Please describe the risk categories that you assign based on your assessment:
Risk category 1:
Risk category 2:
Risk category 3:
Risk category 4:

How do case management features vary across participant risk levels? Please provide details of your case management activities for each category
of participant (moderate and highest risk pregnant/prenatal and postpartum/interconceptional women and infants and toddlers) in the table below.
Healthy Start Participant Categories
Pregnant/Prenatal Women

Case Management Features
6a. Frequency of case management
interactions/appointments (Check the
best response for each participant
category)

6b. Type of interaction/appointment (Check
all that apply for each participant
category)

6c. Case management services provided
(Check all that apply for each
participant category)

Moderate

Highest Risk

Postpartum/Interconceptional
Women
Moderate

Highest Risk

Infant and Toddlers
(0-23 mo)
Moderate

Highest Risk

 > Weekly
 > Monthly
 > Quarterly
 > Once/yr
 Other______

 > Weekly
 > Monthly
 > Quarterly
 > Once/yr
 Other ______

 > Weekly
 > Monthly
 > Quarterly
 > Once/yr
 Other______

 > Weekly
 > Monthly
 > Quarterly
 > Once/yr
 Other ______

 N/A
 Face to face at
HS site
 Home visit
 Telephone call
 Face to face at
other location
 Other
 N/A
 Risk/ screening
assessment
 Home visiting
 Health
education
 Counseling and
guidance
 Coordination
services
 Referrals
 N/A

Healthy Start Participant Categories
Pregnant/Prenatal Women
Case Management Features
6d. Case management assignment (Check
one for each participant category)

6e. Educational/professional background of
assigned case managers (Check all that
apply for each participant category)

6f1. In 2009, what was the average caseload,
by category of Healthy Start participant,
for Healthy Start case managers?

Postpartum/Interconceptional
Women

Infant and Toddlers
(0-23 mo)

Moderate
 Single case
manager
assigned
 Team assigned
 Our Healthy
Start project
does not assign
participants to
case managers
 N/A

Highest Risk
 Single case
manager
assigned
 Team assigned
 Our Healthy
Start project
does not assign
participants to
case managers
 N/A

Moderate
 Single case
manager
assigned
 Team assigned
 Our Healthy
Start project
does not assign
participants to
case managers
 N/A

Highest Risk
 Single case
manager
assigned
 Team assigned
 Our Healthy
Start project
does not assign
participants to
case managers
 N/A

Moderate
 Single case
manager
assigned
 Team assigned
 Our Healthy
Start project
does not assign
participants to
case managers
 N/A

Highest Risk
 Single case
manager
assigned
 Team assigned
 Our Healthy
Start project
does not assign
participants to
case managers
 N/A

 Former
participant/peer
 Lay/paraprofessional
 Social worker
 Nursing
 Behavioral/
mental health
 Public health
 Nutrition
 Health
education
 Other (specify):
______________

[# of participants
receiving CM
services divided
by number case
manager FTEs]

Healthy Start Participant Categories
Pregnant/Prenatal Women
Case Management Features
6f2. In 2009, what was the range of caseloads,
by category of Healthy Start participant,
for Healthy Start case managers?

6g1.Are case conferences/chart reviews held?
6g2.Who attends these conferences? Check
all that apply for each participant
category)

Postpartum/Interconceptional
Women

Infant and Toddlers
(0-23 mo)

Moderate
___/___
Lowest # of
cases/highest # of
cases

Highest Risk
___/___
Lowest # of
cases/highest # of
cases

Moderate
___/___
Lowest # of
cases/highest # of
cases

Highest Risk
___/___
Lowest # of
cases/highest # of
cases

Moderate
___/___
Lowest # of
cases/highest # of
cases

 Yes
 No
 Consistent team
of HS staff and
HS providers

 Only HS staff
and HS
providers
involved in the
case(s)
 External (nonHS) providers
 Participants
 Other (specify):
______________

Highest Risk
___/___
Lowest # of
cases/highest # of
cases

For how long are case management services typically offered for women in your Healthy Start
project? (Check one only)
 through pregnancy
 < 6 months postpartum
 6-11 months postpartum
 12-17 months postpartum
 18-23 months postpartum
 2 years postpartum
 25 months or more postpartum

Through what age are case management services typically offered to infants and toddlers in your
Healthy Start project? (Check one only)
 < 6 months of age
 6-11 months of age
 12-17 months of age
 18-23 months of age
 2 years of age
 3-5 years of age

What procedures are in place to coordinate services across various providers and organizations?
(Check all that apply)
 Informal mechanisms
 Interagency agreements
 Cross-training
 Team meetings
 Unified referral form
 Record sharing
 Other, specify:_________________________________________

10.

What are the barriers to your Healthy Start project’s participants receiving the necessary services
that may be identified by the case manager/team? (Check all that apply)
 Lack of insurance coverage
 Lack of access to service providers who are sensitive to participants’ beliefs and
values
 Lack of transportation
 Lack of child care
 Substance abuse
 Depression or other mental health conditions
 Domestic violence
 Unstable housing
 Language barriers
 Inconvenient provider office hours
 Long waits for appointments with provider
 Lack of culturally appropriate mental health services
 Lack of substance abuse treatments
 Concern of stigma
 Other, specify:

11.

Among the barriers selected in question 10, please select the top 3 barriers to your Healthy Start
project’s participants receiving the necessary services that may be identified by the case
manager/team.
Barrier 1:
Barrier 2:
Barrier 3:

Section 11: Home Visiting
The home visiting section captures features of home visiting implemented by Healthy Start
projects including the use of evidence-based home visiting models; staff background and
training; population served; the onset, duration, and intensity of visits; and the activities
conducted at home visits.
1.

Does your Healthy Start project conduct home visits to clients?
 Yes
 No [SKIP TO NEXT SECTION]

Are your home visits based on a model?
 Yes [ANSWER 2a-b]
 No [SKIP TO 3]
2a. Which model(s) do you use? (Check all that apply)
 Nurse Family Partnership, a nurse home visitation program developed by David Olds
 Parents as Teachers (PAT), program to promote development of children from birth to
age three
 The Home Instruction Program for Preschool Youngsters (HIPPY), seeks to prepare three
to five-year olds for kindergarten and first grade
 Healthy Families America (HFA), a child abuse prevention program that evolved from
Hawaii’s Healthy Start
 Other, specify: _____________________________________________
 We do not use a specific home visiting model. [SKIP TO 3]
2b. Have you adapted the model for your Healthy Start project?
 Yes
 No

How is home visiting offered? (Check one only)
 Home visiting is operated as a unique service component separate from the other
required components [SKIP TO 4]
 Home visiting is offered through other Healthy Start required service components
[ANSWER 3a]

3a. If offered through other required components, which ones? (Check all that apply)
 Case management services (integrated into case management)
 Health education services
 Outreach services
 Interconceptional care services
4.

How many staff conduct home visits?
___________

Are these Healthy Start staff, contracted staff, or both? (Check one only)
 Healthy Start staff only
 Contracted staff only
 Both Healthy Start and contracted staff

What is the educational background of the home visitors? (Check all that apply)
High School or
GED

Bachelor’s degree

Master’s degree

Other degree
(specify)



Nurses

______________
Doulas





______________

Social workers





______________

Health educators





______________

Lay/paraprofessionals





______________

Other professionals
Specify:_____________________




______________

What are the minimum training requirements for home visitors? (Check all that apply)
 Pre-service training [ANSWER 7a-7a1]
7a. If pre-service training, how many trainings are required?
____ # of trainings
7a1. How many hours of pre-service training is this?
_____# hours [total]
 In-service training [ANSWER 7b-7b1]
7b. How often does in-service training occur?
 Weekly
 Monthly
 Other, specify: __________________________________________
 N/A – There are no specific training requirements beyond educational degrees
7b1. How many hours of in-service training is this?
_____# hours [total]

Who is served through home visits? (Check only one)
 Infants only [SKIP TO 9]
 Women only [ANSWER 8a]
 Women and infants [ANSWER 8a]
 First-time mothers only (can include infants) [ANSWER 8a]
 Families – women, infant and partners [ANSWER 8a]
8a. Are the women served adults, teens, or both?
 Adults
 Teens
 Both

When are home visits initiated? (Check only one)
 During pregnancy/prenatal period only
 During the postpartum/interconceptional period only
 As needed, determined by initial assessment

10.

When do home visiting services typically end? (Check only one)
 At birth
 Up to two years postpartum (child’s second birthday)
 Beyond two years postpartum – please specify:______________________
 Varies by needs

11.

How long is each scheduled home visit? (Check only one)
 30 minutes or less
 45 to 60 minutes
 2-3 hours
 Half-day (4 hours)
 Varies by needs

12.

How often are home visits conducted for a participant? Check the best response for each
participant served through home visits.
Moderate Risk Mothers

Highest Risk Mothers
Postpartum/
Interconceptional Period

For Infants
and
Toddlers
(0-23 mo)

Weekly

Pregnancy/
Prenatal
Period


Postpartum/
Interconceptional Period


Pregnancy/
Prenatal
Period




Monthly



2x/month



Every other month



Quarterly



As needed



Our Healthy Start
project does not
conduct home visits for
these participants



Frequency

13.

Which activities might take place at a home visit? (Check all that apply)
 Risk assessment
 Reproductive health, contraception education
 Health education (e.g., nutrition, substance abuse, etc.)
 Parenting education
 Depression screening
 Child development assessment
 Group meetings or group education sessions (held at a participant’s home)
 Health services (e.g., well-baby checkups)
 Referrals to health services
 Enabling services – transportation, job training/placement, educational
support/tutoring
 Referrals to enabling services
 Individual counseling
 Other, specify:

14.

Are you conducting an evaluation of your home visiting?
 Yes [ANSWER 14a]
 No [SKIP TO 15]
14a. Does the evaluation use: (Check all that apply)

15.



Pre-post design



Comparison groups



Qualitative data (e.g., key informant interviews, focus groups)



Other, Specify:_____________________________________________

Do you collect data on any of the following outcomes as a result of your home visitation
program?
Maternal outcomes
 Parental attitudes, knowledge and parenting behavior
 Educational and employment outcomes
 Interconception outcomes (birth spacing, pregnancy deferment, maternal
depression status, pregnancy weight gain and nutrition, prenatal care)
 Health indicators (pre-pregnancy weight, smoking status)
 Use of preventative health services/medical home access
 Our Healthy Start project does not collect these types of data
Child outcomes

 Birth outcomes, child’s health outcomes
 Child development, achievement and behavior
 Child abuse and neglect
 Use of preventative health services/medical home access –immunizations, wellbaby checkups
 Our Healthy Start project does not collect these types of data [SKIP TO NEXT
SECTION]
16.

How are data collected?
 Standardized tests or questionnaires
 Interviews
 Observation
 Clinical records or case management records
 Data tracking system
 Other, specify:

Section 12: Medical Home
The medical home section asks about identification of and referrals to regular sources of primary
care for Healthy Start participants, partnerships with primary care providers, and processes for
tracking referrals and coordinating care.
1.

Do you track the number of women with a primary care provider or a usual source of care?
 Yes [ANSWER 1a]
 No [SKIP TO 3]
1a. The Healthy Start project tracks: (Check all that apply)
 Medical home providers available for referral of clients
 Referrals made
 Referrals completed
 Services provided
 Diagnoses, outcomes
 Other, specify:__________________________________________________

What percentage of women participating in your Healthy Start project during calendar year 2009
had a primary care provider or usual source of care?
_______%

Does your Healthy Start project make referrals for those participants who do not have a primary
care provider or usual source of care?
 Yes
 No

What services are offered through the primary care providers that your Healthy Start project
refers participants to? (Check all that apply)
Women
 Routine primary care/ postpartum care
 OB/GYN services
 Preventative care
 Medical specialist referrals
 Mental health care/referrals
 Referrals to other health services (dental, eye care, nutrition)
 Referrals to other social services (WIC, Housing)
 Care for chronic conditions
 Weight management
 Emergency services
 Other, specify:_____________________________________________________
Infants
 Routine well baby care
 Medical specialist referrals
 Referrals to other health services
 Referrals to other social services
 Emergency services
 Other, specify:_____________________________________________________

At what point in a participant’s involvement in your Healthy Start project is a primary care
provider/usual source of care established?
 Prenatally/during pregnancy
 Postnatally/during interconceptional period
 A primary care provider is established immediately upon entry into the project
regardless of pregnancy status
 Our Healthy Start project does not establish a primary care provider for
participants.

How are participants followed by your Healthy Start project once they are referred to a primary
care provider?
 Chart review/medical record review [ANSWER 6a]
6a. Are these electronic records?
 Yes
 No

 Case conferences/team meetings [ANSWER 6b-d]
6b. Does the participant attend?
 Yes
 No
6c. Does the primary care provider attend?
 Yes
 No
6d. Do other medical specialists attend?
 Yes
 No
 Regular communication with the participant [ANSWER 6e-g]
6e. What is the frequency of communication?
 Daily
 Weekly
 Two to three times per week
 Every other week
 Monthly
 Two to three times per month
 Every other month
 Quarterly
6f. Does the frequency vary by participant level of risk?
 Yes
 No
6g. How is communication made? (Check all that apply)
 Phone
 In-person
 Email
 Regular communication with the primary care provider [ANSWER 6h-j]

6h. What is the frequency of communication?
 Daily
 Weekly
 Two to three times per week
 Every other week
 Monthly
 Two to three times per month
 Every other month
 Quarterly
6i. Does the frequency vary by participant level of risk?
 Yes
 No
6j. How is communication made? (Check all that apply}
 Phone
 In-person
 Email
 Our Healthy Start project does not have a system to follow participants once they are
referred to a primary care provider.
7.

Does your Healthy Start project have a process for following up with participants who do not
complete a referral?
 Yes [ANSWER 7a]
 No [SKIP TO 8]
7a. What is your Healthy Start project’s process for following up with a participant who did
not complete a referral? (Check all that apply)
 Send participant reminder notice by mail
 Send participant reminder notice by email
 Contact participant by phone
 Discuss with participant in person
 Other, specify:

What services/assistance does your Healthy Start project offer to assist Healthy Start participants
in establishing (or completing a referral to) primary/ usual source of care?
 Transportation services offered to participants
 Transportation stipends offered to participants
 Healthy Start staff may accompany participant to first few appointments
 Translation/interpreter services are paid for participants
 Assistance with securing health insurance
 Supplemental health insurance offered
 Free health services offered onsite at Healthy Start project
 No such enabling services are offered
 Other, specify:
____________________________________________________________

Does your Healthy Start project have partnerships with primary care providers?
 Yes [ANSWER 9a-e]
 No [SKIP TO 10]
9a.

How many primary care providers did your Healthy Start project partner with in 2009:
________

9b.

How formalized is the partnership? (Check all that apply)
 Informal (verbal agreement)
# of informal partnerships in 2009 __________
 We have an Memorandum of Understanding (MOU) with the primary care
provider
# of MOUs in 2009 __________
 We have a subcontract with the primary care provider:
# of subcontracts in 2009 __________

9c.

Who delivers the primary care to women? (Check all that apply)
 Nurse practitioner
 MD (please specify specialty):
 Internal Medicine
 Primary Care/General Medicine
 Pediatrician
 OB/GYN
 Other, specify: __________________________________

9d.

Who delivers the primary care to infants? (Check all that apply)
 Nurse practitioner
 MD (please specify specialty):
 Internal Medicine
 Primary Care/General Medicine
 Pediatrician
 OB/GYN
 Other, specify:_________________________________

9e.

In what setting(s) are the primary care providers located? (Check all that apply)
Women
 Community Health Center
 Hospital Clinic
 Private practice
 Other, specify:_____________________________________
Infants
 Community Health Center
 Hospital Clinic
 Private practice
 Other, specify: _____________________________________

10.

Do the partnering primary care providers use electronic medical records or electronic health
records (Electronic Medical Record [EMR]/Electronic Health Record [EHR])?
 Yes [ANSWER 10a]
 No [SKIP TO 11]
10a. If yes, is there a system in place to link participants to Healthy Start for tracking
purposes?
 Yes
 No

11.

Are the primary care providers in your Healthy Start project’s network considered medical home
providers?
 Yes [ANSWER 11a]
 No [SKIP TO 12]
11a. What percentage of primary care providers in your Healthy Start project’s network
were considered medical home providers in 2009? __________%

12.

In 2009, what percent of participants’ primary care costs was covered by the following?
______% Medicaid
______% Free care
______% Private insurance
______% Other, specify:

13.

Does your Healthy Start project use protocols to: (Check all that apply)
 Assess whether participants have a primary care provider
 Assess whether participants’ children have a primary care provider
 Assess the fit between participants and available primary care providers
 Educate participants on the importance of primary care for their health and the
health of their children
 No such protocols are used for our Healthy Start project
 Other, specify:____________________________________________________

14.

What are the barriers to Healthy Start participants accessing care through a primary care
provider? (Check all that apply)
 Lack of health insurance or inability to pay
 Language barrier between participant and provider
 Lack of available referrals (i.e. not enough providers)
 Participant perceptions/misperceptions of primary care
 Lack of transportation to and from appointments
 Other, specify:__________________________________________________
 Our Healthy Start participants do not experience barriers accessing a primary care
provider

15.

Among the barriers selected in question 14, please select the top 3 barriers to your Healthy Start
participants accessing care through a primary care provider.
Barrier 1:
Barrier 2:
Barrier 3:

PART B. SYSTEMS
Part B of the survey asks general questions about the 4 service components that comprise the National
Healthy Start program (consortium, local health action plan, collaboration/coordination with Title V, and
sustainability planning), followed by additional questions about consortium.

Section 1: Overview of Systems Components
In this section of the survey, we ask you for some basic information about the 4 systems
components of the Healthy Start Program (consortium, Local Health System Action Plan,
collaboration with State Title V, and sustainability activities) and how these and other systems
activities are implemented by the project. Additional details about consortium are collected in the
next section.
1.

Does your Healthy Start project have at least one active consortium that addresses maternal and
child issues?
 Yes
 No

Does your consortium have an executive or other sub-committee that provides leadership for the
entire consortium?
 Yes [ANSWER 2a]
 No [SKIP TO 3]
2a. If yes: # of members on this executive or sub-committee in 2009 _______

Does your Healthy Start project have a Local Health System Action Plan (LHSAP)?
 Yes [ANSWER 3a-b]
 No [SKIP TO 6]
3a. Is the LHSAP specific to the Healthy Start project?
 Yes
 No
3b. Is the LHSAP connected to or part of another community or child health plan?
 Yes [ANSWER 3b1]
 No [SKIP TO 4]

3b1. What plan is it connected to? (Check all that apply)
 MCH Block grant
 Local public health department
 Other, specify:
4.

_________________________

Who is involved in the development of the LHSAP? (Check all that apply)
 Healthy Start staff
 Healthy Start consortium or subcommittee of the consortium
 State Title V agency
 Local Title V grantee
 Local health department
 Local government agencies
 Key community partners
 Participants
 Other,
specify:___________________________________________________________

To what extent do you agree with the following statement: The goals outlined in the LHSAP
guide the consortium’s work. (Check one only)
 Strongly agree
 Agree somewhat
 Neither agree nor disagree
 Disagree somewhat
 Strongly disagree

Were your Healthy Start project’s goals drawn from the State Title V plan?
 Yes
 No

Describe relationship between your Healthy Start project and State Title V agency. (Check all
that apply)
 State Title V agency is the Healthy Start grantee
 Management is shared between Healthy Start project and State Title V agency
 Healthy Start project and State Title V are housed in the same organization
 State Title V funds some Healthy Start programming or services
 Informal relationship
 Other, specify:
 Healthy Start project does not have a relationship with State Title V agency
[SKIP TO 10]

What are the benefits to your Healthy Start project of coordination with the State Title V agency?
(Check all that apply)
 State Title V provides resource materials for health education programs
 State Title V provides training for staff
 State Title V provides data and other information for needs assessment
 State Title V provides funds or in-kind contributions that helped sustain Healthy
Start initiatives
 State Title V helps with efforts to advocate for Healthy Start target populations
 State Title V helps coordinate care for our participants
 State Title V helps increase our visibility in policy arenas
 Other, specify:
 There are no perceived benefits

What are the benefits to the State Title V agency of coordination with Healthy Start (Check all
that apply)
 Healthy Start provides the State Title V agency with a community perspective on
issues and problems
 Healthy Start’s local needs assessment data are used by the State Title V agency in
its own needs assessment for the State Block grant
 Healthy Start provides a local partner that could implement and/or augment State
Title V initiatives and programs on the local level
 Healthy Start projects could be replicated by the State Title V agency
 Healthy Start provides data to help change policy
 Healthy Start makes policy/funding recommendations to the State Title V agency
on important policy and funding issues
 Other, specify:
 The State Title V agency does not perceive any benefit from coordination with
Healthy Start

10.

Does your Healthy Start project participate in any formal alliance(s) with other Healthy Start
grantees (not including the National Healthy Start Association)?
 Yes [ANSWER 10a]
 No [SKIP TO 12]
10a.

What is/are the purpose(s) of this/these alliance(s)? (Check all that apply)
 Information sharing
 Pooling resources
 Joint training
 Educating policy makers
 Working with state agencies
 Other, specify:

11.

What benefits have resulted from the alliance(s) to date? (Check all that apply)
 Increased access to information
 Expanded resources available to use for common activities such as evaluation,
training, and health education
 Enhanced ability to work with state policy makers on common issues
 Other, specify:
 No benefits have resulted to date

12.

Does your Healthy Start project have a sustainability plan, that is, a plan to maintain services to
the target population after federal Healthy Start funding ends?
 Yes
 No

13.

What strategies is your Healthy Start project using to ensure sustainability? (Check all that
apply)
 Seeking additional Healthy Start funding
 Seeking other federal funding
 Seeking state or local funding
 Implementing a fund-development strategy
 Incorporating (such as obtaining 501(c)(3) status) in order to apply for other funds
 Developing collaborative efforts with the State or Local Title V
 Developing collaborative efforts with other organizations
 Packaging services to secure Medicaid or other health plan reimbursement
 Other, specify:

14.

Will any of the services provided by your Healthy Start project be absorbed by the Title V Block
Grant or other funders? (Check all that apply)
 Yes, by Title V
 Yes, by other funders (please explain):
___________________________________________
 No

15.

What are the challenges to sustainability faced by your Healthy Start project? (Check all that
apply)
 Fiscal climate
 Unstable collaborative relationships
 Political climate
 Organizational setting not supportive
 Unable to document results of our Healthy Start project
 Healthy Start is no longer a unique project
 Our Healthy Start project does not have any challenges to sustainability
 Other, specify:

16.

Which of the following “systems activities” does your Healthy Start project engage in? (Check
all that apply)
 Conduct needs assessment
 Develop priorities to direct Healthy Start activities
 Coordinate existing services and resources (such as building referral networks or
reducing service duplication)
 Expand existing services for the target population
 Create new services for the target population
 Improve cultural competence of the providers serving the target population
 Address other access barriers in the community
 Enhance community participation in identifying community needs, setting
priorities, and implementing changes
 Influence (or change) state or local policy (please provide an example):
__________________________________________________________________
 Other, specify:

17.

Is your Healthy Start project involved in community-wide collaborative efforts related to:
 Smoking and tobacco use cessation
 Healthy weight
 Breastfeeding
 Other, specify:____________________________________________________
 Our Healthy Start project is not involved in community-wide collaborative efforts

18.

What types of collaborative activities does your Healthy Start project establish with the health
agencies or providers listed below? NOTE: For each activity, please check only the agencies or
providers to which the activity or relationship applies. Check the box in row 18a if the agency
does not exist in your community, or check the box in row 18b if the agency does exist in your
community but there is no collaborative relationship with that agency.
Check the appropriate box(es) below for each health agency or
provider. At least one box should be checked in each column:

Medicaid

Local
health
department

Private
Physicians



18b. Agency/provider has no collaborative
relationship with Healthy Start



18c. Agency/provider is a member of the Healthy
Start consortium



18d. Agency/provider has a written memorandum
of understanding or agreement (MOU/MOA)
with Healthy Start

State
Title V
Agency

Hospitals

Mental
health
agency

Substance
abuse
treatment

18a. Agency/provider does not exist in my
community



18e. Agency/provider provides contracted services
to Healthy Start



18f. Agency/provider hosts outstationed Healthy
Start staff



18g. Agency/provider participates in joint training
with Healthy Start



18h. Agency/provider has a shared staffing
arrangement with Healthy Start



18i. Agency/provider coordinates case
management or is planning with Healthy Start
for shared participants



18j. Agency/provider shares protocols with
Healthy Start (such as intake, risk/needs
assessment)



18k. Agency/provider is involved in Healthy Start
sustainability planning



18l. Agency/provider has a data-sharing
arrangement with Healthy Start (such as
shared case files or MIS)



18m. Agency/provider contributes to pooled
funding streams to support joint services



18n. Agency/provider has a Healthy Start
employee on their board



18o. Agency/provider works with Healthy Start to
develop consistent health messages for
participants



18p. Agency/provider receives cultural
competence training from Healthy Start



Collaborative Activities

19.

What types of collaborative activities does your Healthy Start project establish with the social
service agencies or public institutions listed below? NOTE: For each activity, please check only
the agencies or providers to which the activity or relationship applies. Check 19a if the agency
does not exist in your community or check 19b if the agency does exist in your community but
there is no collaborative relationship with that agency.
Check the appropriate box(es) below for each social service agency or
public institution. At least one box should be checked in each column:

Welfare

Child
protective
services

19a. Agency/institution does not exist in my
community



19b. Agency/institution has no collaborative
relationship with Healthy Start



19c. Agency/institution is a member of the
Healthy Start consortium



19d. Agency/institution has a written
memorandum of understanding or
agreement (MOU/MOA) with Healthy
Start



19e. Agency/institution provides contracted
services to Healthy Start



19f. Agency/institution hosts outstationed
Healthy Start staff



19g. Agency/institution participates in joint
training with Healthy Start



19h. Agency/institution has a shared staffing
arrangement with Healthy Start



19i. Agency/institution coordinates case
management or is planning with Healthy
Start for shared participants



19j. Agency/institution shares protocols with
Healthy Start (such as intake, risk/needs
assessment)



19k. Agency/institution is involved in Healthy
Start sustainability planning



19l. Agency/institution has a data-sharing
arrangement with Healthy Start (such as
shared case files or MIS)



19m. Agency/institution contributes to pooled
funding streams to support joint services



19n. Agency/institution has a Healthy Start
employee on their board



19o. Agency/institution works with Healthy
Start to develop consistent health messages
for participants



19p. Agency/institution receives cultural
competence training from Healthy Start



Collaborative Activities

Head
Start

Child
care
agencies

Schools

Courts

WIC

20.

What types of collaborative activities does your Healthy Start project establish with the
community-based agencies or providers listed below? For each activity, please check only the
agencies or providers to which the activity or relationship applies. Check the box in row 20a if
the agency does not exist in your community, and check the box in row 20b if there is no
collaborative relationship.
Check the appropriate box(es) below for each community-based agency or
provider. At least one box should be checked in each column:
FQHCs
(330
Centers)

Faithbased
groups

Advocacy
groups

Professional
assocs.

Ethnic
orgs.

Diseasebased
orgs.

Civic
groups

20a. Agency/provider does not exist in my
community



20b. Agency/provider has no collaborative
relationship with Healthy Start



20c. Agency/provider is a member of the
Healthy Start consortium



20d. Agency/provider has a written
memorandum of understanding or
agreement (MOU/MOA) with Healthy
Start



20e. Agency/provider provides contracted
services to Healthy Start



20f. Agency/provider hosts outstationed
Healthy Start staff



20g. Agency/provider participates in joint
training with Healthy Start



20h. Agency/provider shares staffing
arrangement with Healthy Start



20i. Agency/provider coordinates case
management or is planning with
Healthy Start for shared participants



20j. Agency/provider shares protocols with
Healthy Start (such as intake,
risk/needs assessment)



20k. Agency/provider is involved in
Healthy Start sustainability planning



20l. Agency/provider has a data-sharing
arrangement with Healthy Start (such
as shared case files or MIS)



20m. Agency/provider contributes to
pooled funding streams to support
joint services



20n. Agency/provider has a Healthy Start
employee on their board



20o. Agency/provider works with Healthy
Start to develop consistent health
messages for participants



20p. Agency/provider receives cultural
competence training from Healthy
Start



Collaborative Activities

Section 2: Consortium
This section asks for information that will enhance our understanding of the various models by
which the Healthy Start projects have structured their consortia. Questions also focus on the
specific roles, activities and impacts of the consortia, with particular attention to the role of
Healthy Start participants in consortium activities and decisions.
1.

How many consortia does your Healthy Start project operate?
# in 2009_____
[IF 1 CONSORTIUM, ANSWER #2, THEN SKIP TO #5]
[IF MORE THAN 1 CONSORTIUM, SKIP TO #3]

Does your consortium have an executive committee, board of directors, advisory committee, or
other smaller body of the whole?
 Yes [SKIP TO #5]
 No [SKIP TO #5]

Do the consortia vary by: (Check all that apply)
 Focus (e.g. one consortium focuses on sustainability planning, another on
strengthening community partnerships, a third on Healthy Start programming)?
 Composition (e.g. one consortium is composed, by design, solely of Healthy Start
participants, another has representatives from community based organizations and
providers)?
 Region(s) covered (e.g. one consortium per county within the Healthy Start
catchment area)?
 Decision-making authority (e.g. some consortia act in an advisory capacity, others
have decision-making authority)?
 Other, specify:

Which model best describes the structure of your consortia? (Check all that apply)
 All consortia are governed by an overarching executive committee, board of
directors, advisory committee, or other smaller body
 Each consortium is governed by a consortium-specific executive committee, board
of directors, advisory committee, or other smaller body of the whole
 Individual members of each consortium have equal voting rights/decision-making
authority
 Other, specify:

Approximately how long had the consortium/set of consortia (in its current structure) been in
place in 2009?
# years:________# months:________

How has the consortium/a’s structure(s) changed since the first Healthy Start funds were
awarded? (Check all that apply)
 Larger consortium/a divided into sub-committees or task forces
 Multiple smaller consortia or committees consolidated into one larger group
 Executive committee formed
 Executive committee dissolved
 New consortium/a formed or added
 One or more consortia dissolved
 Other, specify
 No changes to the consortium/a’s

If you indicated that you operate more than one consortium in question #1, above, please respond
to the following set of questions for each level of consortia you have. By level we mean the

location of the consortium within the hierarchical structure of all of your Healthy Start
project’s decision-making and advisory bodies. For example, if your Healthy Start project
has a consortium for each site that it operates and a separate consortium that guides
Healthy Start efforts at the project level, please respond to questions 7-15 for the site-level
consortia considered as a whole and then repeat questions 7-15 for the project-level
consortium. You may repeat questions 7-15 as many times as needed to cover the levels of
consortia that your Healthy Start project has.
If you indicated that you have one consortium in question #1, above, please respond to the
following set of questions for that consortium.
7.

What groups are included in the active membership of the consortium? By active membership, we
mean members that attend at least half of the consortium’s meeting. (Check all that apply)
 Healthy Start staff
 State government
 Local government
 Project participants (i.e., recipient of Healthy Start services)
 Community participants
 Community-based organizations
 Private agencies or organizations (not community –based)
 Providers contracting with the Healthy Start project
 Other providers
 Faith-based participants
 Academic participants
 Other, specify:

What is/are the main purpose(s) of the consortium? (Check all that apply)
 Fulfill requirements of grant guidance
 Change MCH policy in the state
 Change maternal and child health practices in the target community or system
 Share information with the community and raise awareness of maternal and child
health issues
 Oversee Healthy Start project operations
 Work toward goals in the LHSAP (if applicable) or other action plan
 Bring together potential partners and enhance collaboration
 Other, specify:

What is/are the main area(s) of the consortium’s activity? (Check all that apply)
 Budget/finance planning and monitoring
 Personnel recruiting/ hiring
 Developing the scope of Healthy Start service offerings
 Bring together potential partners and enhance collaboration
 Awareness, communication, and media efforts
 Data collection/evaluation
 Sustainability planning
 Other, specify:

10.

What events are conducted by the consortium, and how often?
Activity

Frequency

10a. Meetings

 Monthly
Quarterly
Annually
Twice per year
Other (specify): ____________________________________
N/A

10b. Public Forums

 Monthly
Quarterly
Annually
Twice per year
Other (specify): ____________________________________
N/A

10c. Training/conferences

 Monthly
Quarterly
Annually
Twice per year
Other (specify): ____________________________________
N/A

10d. Other
(specify):______________

 Monthly
Quarterly
Annually
Twice per year
Other (specify): ____________________________________
N/A

11.

To what extent do you agree with the following statement: In 2009, the Healthy Start participants
on the consortium were culturally representative of the target community. (Check one only)
 Strongly agree
 Agree somewhat
 Neither agree nor disagree
 Disagree somewhat
 Strongly disagree
 There are no Healthy Start participants on the consortium

12.

To what extent do you agree with the following statement: In 2009, the provider membership on
the consortium was culturally representative of the target population. (Check one only)
 Strongly agree
 Agree somewhat
 Neither agree nor disagree
 Disagree somewhat
 Strongly disagree
 There are no providers on the consortium

13.

To what extent do you agree with the following statement: In 2009, the consortium made
considerable progress toward meeting its goals. (Check one only)
 Strongly Agree
 Agree Somewhat
 Neither Agree nor Disagree
 Disagree Somewhat
 Strongly Disagree

14.

What did the consortium accomplished during 2009? (Check all that apply)
 Increased awareness of infant mortality in the community
 Increased service capacity in the community
 Obtained new grants or funding
 Used funds in an innovative manner
 Increased integration of service systems
 Created sustainable partnerships among member agencies
 Influenced policy affecting access to care for the Healthy Start target population
 Enhanced cultural competence of providers
 Enhanced ability of Healthy Start project to address disparities in access and
utilizing health services
 Increased Healthy Start participant involvement in our project’s decision-making
activities
 Increased the amount of, or access to, data available to partner organizations on
the health status of the target population
 Other, specify:______________________________
 There were no accomplishments made in 2009

15.

What barriers challenged the effectiveness of the consortium in 2009? (Check all that apply)
 Insufficient staff time dedicated to assisting the consortium in its efforts
 Lack of resources for consortium activities
 Lack of collaboration/cooperation from necessary partners/stakeholders
 Irregular consortium attendance by key members
 Competing agendas member organizations
 Unstable relationships among consortium members
 Lack of history of collaborative effort among maternal and child health providers
in our Healthy Start project’s target area
 Unsupportive political climate
 Insufficient resources in the state or community to support our consortium’s goals
 Lack of participant involvement
 Lack of strong consortium leadership
 Lack of a strategic plan for the consortium’s work
 Other, specify:______________________________
 Our consortium did not have any challenges in 2009

If you indicated that you operate more than one consortium in question #1, above, please respond
to the following set of questions for your entire set of consortia considered together. If you

indicated that you have one consortium in question #1, above, please respond to the
following set of questions for that consortium.
16.

What consortium activities are Healthy Start participants involved in?
 Strategic planning
 Budget/finance
 Personnel recruiting/hiring
 Developing the scope of Healthy Start service offerings
 Communication/media efforts
 Data collection/evaluation
 Sustainability activities
 Other, specify:______________________________
 There are no Healthy Start participants on the consortium

17.

What strategies are used to facilitate involvement of Healthy Start participants in the consortium?
(Check all that apply)
 Project outreach at local health centers, schools, etc.
 Flyer distribution, mailings
 Design meetings to be welcoming and interesting
 Participation in other local consortia
 Hold meetings and events at times that are convenient for participants
 Hold meetings at locations that are convenient for participants.
 Provide participation supports (e.g. hot meals, transportation, child care) (specify):
 Other, specify:______________________________
 No particular strategies are used
 There are no Healthy Start participants on the consortium

18.

What strategies are used to promote leadership among Healthy Start participants in the
consortium? (Check all that apply)
 Conduct leadership training sessions for participants
 Send participants to relevant conferences
 Pay tuition for workshops or institutes
 Invite participants to facilitate meetings
 Invite participants to participate in or lead data collection efforts
 Invite participants to serve on subcommittees
 Hold retreats to include participants
 Other, specify:______________________________
 No particular strategies are used
 There are no Healthy Start participants on the consortium

19.

To what extent do you agree with the following statement: In 2009, leaders within
agencies/programs/organizations and the community who have a stake in the Healthy Start
project were aware of the Healthy Start consortium and its activities. (Check one only)
 Strongly agree
 Agree somewhat
 Neither agree nor disagree
 Disagree somewhat
 Strongly disagree

20.

To what extent do you agree with the following statement: In 2009, the consortium included
members who were decision-makers (that is, people who could influence funding, policy, and
programming of the organization that they represent). (Check one only)
 Strongly agree
 Agree somewhat
 Neither agree nor disagree
 Disagree somewhat
 Strongly disagree

21.

To what extent do you agree with the following statement: In 2009, nearly all of the
agencies/programs/organizations that have a stake in what our Healthy Start project is trying to
accomplish were represented in the consortium. (Check one only)
 Strongly agree
 Agree somewhat
 Neither agree nor disagree
 Disagree somewhat
 Strongly disagree

22.

Please list the stakeholder agencies/programs/organizations that you have not been able to
engage with your consortium, or check the box below to indicate that all stakeholder
agencies/programs/ organizations are represented on your consortium.

Stakeholder group #1:___________________
Stakeholder group #2:___________________
Stakeholder group #3:___________________
Stakeholder group #4:___________________
Stakeholder group #5:___________________
 Our consortium includes representation from all agencies/programs/organizations
that have a stake in what our Healthy Start project is trying to accomplish

PART C: DATA SYSTEMS AND TRACKING
Part C of the survey asks questions about tracking systems, local evaluation efforts, and mortality reviews
that may have been conducted in the communities of Healthy Start projects.

Section 1: Tracking Systems
In this section, we collect information about the Healthy Start project’s ability to track information at the
participant-level on services received, referrals made and completed, and health outcomes and how these
data are used.
1.

Does your Healthy Start project have a tracking system for each Healthy Start participant?
(Check all that apply)
 Yes, a record is maintained by Healthy Start project [ANSWER 1a-b]
 Yes, a record is maintained by contractor [ANSWER 1a-b]
 No [SKIP TO 2]
1a. If yes, please specify what data are collected at the participant level:
 Referrals made
 Referrals completed
 Services provided
 Diagnoses, health outcomes
 Other, specify:
1b. Are these records maintained electronically or in a hard-copy format? (Check one only)
 Electronic format only
 Hard-copy format only
 Some types of records are maintained electronically and other types are maintained in a
hard-copy format
 Our project maintains both electronic and hard-copy records for each participant
 Other, specify:

Does your Healthy Start project have a tracking system by service?
 Yes [ANSWER 2a-b]
 No [SKIP TO 4]

2a. Is participation tracked for the following services:
 Outreach/recruitment
 Health education
 Home visiting
 Case management
 Use of enabling services
 Other, specify:_________________________________________________
2b. Do these records include only services provided within your Healthy Start project or also
services delivered by outside providers as a result of a Healthy Start referral? (Check one
only)
 Only Healthy Start services
 Both Healthy Start services and services delivered by referral to outside providers
 Other, specify:
3.

[If yes to 1 and 2]: Are the tracking systems for services and participants linked?
 Yes
 No

Does your Healthy Start project share case files or MIS with other agencies/providers (with
appropriate approvals/consent)?
 Yes
 No

Are data examined?
 Yes [ANSWER 5a]
 No [SKIP TO NEXT SECTION]
5a. For what purpose are data examined?
 Project evaluation
 Project planning
 Required reporting (performance measures, impact reporting)
 Reporting to consortium
 Grant-writing
 Media campaigns
 Other, specify:_________________________________________________

Section 2: Evaluation of Components
The Evaluation section of the survey asks about the Healthy Start project’s local evaluation efforts,
including the types of studies and evaluations that have been conducted and the services that have been
evaluated.
1.

Do you have a dedicated staff person for data tracking and analysis?
 Yes
 No

Do you have a local evaluator?
 Yes [ANSWER 2a-c]
 No [SKIP TO 3]
2a. Is your local evaluator on staff?
 Yes [SKIP TO 3]
 No
2b. Is your local evaluator contracted?
 Yes
 No [SKIP TO 3]
2c. If contracted, is your local evaluator university affiliated?
 Yes
 No

Does your local evaluator collect data in addition to the requirements of the National Healthy
Start program?
 Yes
 No

Have you ever conducted an evaluation of any of the services offered by your Healthy Start?
 Yes [ANSWER 4a-b]
 No [SKIP TO 5]
4a. Did the evaluation use: (Check all that apply)
 Pre-post design
 Comparison group
 Other, specify:___________________________________________

4b. Which services were evaluated?
 Outreach/recruitment
 Health education
 Home visiting
 Case management
 Use of enabling services
 Other, specify:________________________________________
5.

Do you collect data on any of the following as a result of the services offered?
Maternal
 Parental attitudes, knowledge and parenting behavior
 Educational and employment outcomes
 Interconception outcomes (birth spacing, pregnancy deferment, maternal
depression status, pregnancy weight gain and nutrition, prenatal care)
 Health indicators (pre-pregnancy weight, smoking status)
 Use of preventative health services/medical home access
 Our Healthy Start project does not collect these types of data
Child
 Birth outcomes, child’s health outcomes
 Child development, achievement and behavior
 Child abuse and neglect
 Use of preventative health services/medical home access –immunizations, wellbaby checkups
 Our Healthy Start project does not collect these types of data

Section 3: Mortality Review Data
This section collects information about maternal, fetal, infant, and child mortality reviews that may be
conducted in the Healthy Start project’s community and how and whether these data reviews are used to
inform Health Start project Activities.
1.

In 2009, did any of the following exist in your community?
 Fetal mortality review
 Infant mortality review
 Maternal mortality review
 Child mortality review
 Other, specify: ________________________________________
 No mortality reviews existed in our community during 2009
1a. If yes, was Healthy Start represented?
 Yes
 No

Does your Healthy Start project use data from any mortality reviews?
 Yes [ANSWER 2a]
 No [SKIP TO NEXT SECTION]
2a. In 2009, how were mortality review data used by your project?
 To track mortality by age group, race/ethnicity, socioeconomic group, and /or
neighborhood
 To target outreach or health promotion
 To generate systems change goals



Other, specify:________________________________________________

PART D. REFLECTIONS AND ACCOMPLISHMENTS
Section 1: Reflections on Your Healthy Start Project
This section assesses grantees’ perceived accomplishments and progress towards intermediate
and long-term outcomes. Finally, questions related to changes over time capture information
about key contextual factors and barriers.
1.

Which of the following intermediate outcomes did your Healthy Start project achieve in 2009?
(Check all that apply)
 Increased access to the services available for our participants
 Increased positive health behaviors among our participants
 Increased number of participants with a medical home
 Increased integration of prenatal, primary care, and mental health services
 Increased awareness of the importance of interconceptional care
 Increased awareness of disparities in birth outcomes as a priority in the
community
 Increased screening for perinatal depression among providers in the community
 Increased cultural competence of providers in our community
 Increased participant involvement in Healthy Start decision-making
 Increased participant involvement in decision-making among partner agencies
 Increased participant involvement in other community activities addressing
systems changes
 Other, specify:_________________________________________________
 No intermediate outcomes were achieved in 2009

1a. If any of the above are checked, ask 1a (for each): What evidence/findings does
your project have to support this?
 Healthy Start Impact Reports
 MCHB Performance Measures
 New and Continuing Applications
 Local Evaluation Findings
 Anecdotal/ Case Study Findings [ANSWER 1ai]
1ai Is this verified?

 Yes
 No
 Other, specify:____________________
 No intermediate outcomes were achieved in 2009
2.

Which of the following long term outcomes did your Healthy Start project achieve in 2009?
(Check all that apply)
 Improved birth outcomes
 Improved maternal health
 Increased birth spacing
 Improved child health
 Sustained community capacity to reduce disparities in health status in the
community
 No long-term outcomes were achieved in 2009
2a. If any of the above are checked, ask 2a (for each): What evidence/findings does
your project have to support this?
 Healthy Start Impact Reports
 MCHB Performance Measures
 New and Continuing Applications
 Local Evaluation Findings
 Anecdotal/ Case Study Findings [ANSWER 2ai]
2ai Is this verified?

 Yes
 No
 Other, specify:_________________________________

To what extent did the following activities conducted by your Healthy Start project contribute to
reducing disparities in maternal and infant health outcomes? For each activity listed in 3a –3s,
indicate the extent of the contribution. If your Healthy Start project did not perform an activity,
please check column E, “No contribution.”
Check one box only for each row below:
A

Primary
contribution

Major
contribution

Moderate
contribution

Minor
contribution

No
contribution
or N/A

Activities



3a. Outreach and client
recruitment



3b. Case management



3c. Client health education



3d. Consortium



3e. Local health systems action
plan



3f. Collaboration with
participants



3g. Collaboration with State
Title V



3h. Collaboration with Local
Title V



3i. Collaboration with other
public agencies



3j. Collaboration with
community-based
organizations



3k. Collaboration with private
agencies (including private
health care providers)



3l. Provider education



3m. Perinatal depression
screening



3n. Interconceptional care



3o. Enabling services



3p. Home visiting services



3q. Male involvement



3r. Medical Home partnerships



3s. Other, specify:
____________________

Below are some general statements about how a Healthy Start project may relate to the
community in which it is based. For each statement (4a-4p), check one box only to indicate how
strongly you agree or disagree with the statement.
Check one box only for each row:
A

Strongly
Agree

Agree
Somewhat

Neither
Agree nor
Disagree

Disagree
Somewhat

Strongly
Disagree



4a. Many changes/solutions have been
implemented as a result of Healthy Start
recommendations



4b. Healthy Start is connected to the
community’s power structure



4c. Policy-makers participate in or are
accessible to the Healthy Start program



4d. An institutional and fiscal base of support
sustains Healthy Start activities



4e. MCH agencies/providers take ownership
of Healthy Start goals



4f. Healthy Start contributes to the
community’s capacity for assessing
maternal and child health



4g. Healthy Start is an integral part of the
delivery system in the community



4h. Healthy Start has identified access
problems in the health care system



4i. Healthy Start has created solutions to
address health care access problems



4j. Healthy Start has identified strategies for
addressing disparities



4k. Healthy Start has implemented strategies
for reducing disparities



4l. Healthy Start processes maintain a good
balance between medical, public health,
and community viewpoints



4m. Communication between community
agencies and institutions has improved as a
result of Healthy Start



4n. The consortium takes into account
participants’ views



4o. Residents of our community are aware of
the Healthy Start program



4p. Healthy Start can document a positive
effect on local maternal and child health
issues



Please indicate whether the following community-related factors remain unchanged, have
improved, or have declined over the past 5 years:
Unchanged


Improved


Declined


5a. Poverty/Income level



5b. Availability of mental health providers



5c. Unemployment



5d. Availability of funding



5e. Access to health care



5f. Crime rate



5g. Quality/adequacy of available care



5h. Disease burden



Community Factors

5i. Other, specify: __________________

Over the past 5 years, has the racial/ethnic make up of the community in which your Healthy
Start project operates changed?
 Yes
 No

Please indicate whether the following project-related factors remain unchanged, have increased or
decreased over the past 5 years:
Unchanged

Improved

Declined

Community Factors



7a. Number of eligible women



7b. Availability of funding



7c. Type of collaborations



7d. Number of collaborations



7e. Availability of culturally competent
staff



7f. Participant involvement



7g. Other, specify:
__________________________



File Type	application/pdf
File Title	Microsoft Word - Attachment C. HS Survey Survey Instrument.doc
Author	BaytopC
File Modified	2010-11-14
File Created	2010-10-28