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2012 Model Practice Application (Public)Application Name: 2012 Model Practice Application (Public) : Contra Costa Health Services : Contra Costa Life Course Initiative - Staff Training Applicant Name: Ms. Padmini Parthasarathy Application Title: Contra Costa Life Course Initiative - Staff Training Please enter email addresses you would like your confirmation to be sent to. padmini.parthasarathy@hsd.cccounty.us Practice Title Contra Costa Life Course Initiative – Staff Training Submitting LHD/Agency/Organization Contra Costa Health Services Head of LHD/Agency/Organization William Walker, MD Street Address 597 Center Avenue, Suite 365 Practice Contact Person Padmini Parthasarathy, MPH Title Life Course Initiative Coordinator; Family, Maternal and Child Health Programs padmini.parthasarathy@hsd.cccounty.us Submitting LHD/Agency/Organization Web Address (if applicable) www.cchealth.org/groups/fmch Provide a brief summary of the practice in this section. This overview will be used to introduce the model or promising practice in the Model Practices Database. Although this section is not judged, the judges use it to get an overall idea about your practice. You must include answers to the following questions in your response:
• Size of population in your health department’s jurisdiction
• Who is your target population/audience, for this practice
• Size of target population/audience, if applicable
• The number or percentage of the target population/audience reached, if applicable
• Describe the nature and gravity of the public health issue addressed
• List the goal’s and objective(s) of the practice and clearly link them to the problem or issue the practice is addressing. Briefly indicate what the practice intends to accomplish overall.
• When (month and year) the practice was implemented.
• Briefly describe how the practice was implemented, what were major activities, and any start-up and in-kind costs and funding services.
• Outcomes of practice (list process milestones and intended/actual outcomes and impacts.
• Were all of the objectives met?
• What specific factors led to the success of this practice?
• Lessons learned from the practice For the past several decades, maternal and child health (MCH) experts have considered improving access to and utilization of quality prenatal care to be necessary for improving birth outcomes and reducing racial and ethnic inequities. Despite the fact that since 2000, entry into prenatal care in Contra Costa has been close to 90%, rates of preterm birth and low birth weight have risen steadily, and substantial inequities remain between racial/ethnic groups in all birth outcomes.
In response, support is shifting away from prenatal care as an all-encompassing solution. Instead, interest is increasing in frameworks that look beyond the prenatal period to a broader range of factors that may improve birth outcomes. The Life Course Perspective (LCP) suggests that a complex interplay of biological, behavioral, psychological, environmental, and social protective and risk factors contributes to health outcomes across the span of a person’s life.
Despite the complexities and challenges of integrating this framework into MCH programs, Contra Costa Health Services’ (CCHS) Family, Maternal and Child Health (FMCH) Programs launched a 15-year Life Course Initiative (LCI). The goal of the LCI is to reduce inequities in birth, infant, and maternal outcomes and improve the health of the next generation in Contra Costa County by promoting and achieving health equity, optimizing health, and shifting the paradigm of the planning, delivery, and evaluation of maternal, child, and adolescent health services. (Contra Costa County is an urban, suburban, and rural county, population 1,049,025, that is located approximately 15 miles northeast of San Francisco.)
FMCH Programs staff needed to be informed about this new approach to MCH so that they would be able to identify ways in which they could incorporate the LCP into their current and future work. We designed and conducted interactive educational sessions on the LCP for the 220 FMCH Programs staff. These educational sessions a) offered staff an overview of the theory of the LCP and social determinants of health; b) provided participants with an opportunity to experience the key concepts of the LCP through a Life Course Game; and c) engaged participants in substantive discussions about how they were already incorporating the LCP into their current work and future activities.
Project activities, implemented between April 2005 and Winter 2008, include: Overflow: Please finish the response to the question above by using this text area. Please be mindful of the word limits. 1) launched the LCI at an FMCH Programs All-Staff Meeting, with a presentation by Dr. Michael Lu about the LCP; 2) created LCP educational materials (training curriculum, and fact sheets about the LCI and Lu et al.’s 12-Point Plan to Close the Black-White Gap in Birth Outcomes); 3) conducted a series of LCP educational sessions with FMCH Programs; 4) began training other CCHS and County agencies, local public health leaders and policymakers, and community partners; 5) established a Life Course Planning Team that met regularly and oversaw LCI program planning and evaluation activities; and 6) evaluated the effectiveness of the educational sessions with our staff through a web-based staff survey.
The primarily qualitative staff survey was created by the Life Course Planning Team and sent to 107 FMCH Programs staff. Of these staff, 64% responded; 14% were managers and 86% were non-managers. The survey results suggested that our staff trainings were successful. We found that as a result of the educational sessions, our staff had gained a deeper understanding of LCP concepts, identified strategies for incorporating the LCP into their work, and became catalysts for change as they integrated the LCP into their existing scopes of work following the educational sessions.
We have experienced several challenges and learned many lessons about making an organizational paradigm shift. For some of our staff, this was an entirely new way of thinking about their job responsibilities and for others, this fell in line with what they had been working on for many years. Not everyone was ready to embrace this new direction. Many staff asked difficult, complex questions that provided us with additional opportunities for valuable discussion and critical thinking.
Changing a long-standing paradigm is a slow process and that we have had to have a long view. Gaining the buy-in of our staff took much longer than we expected. It was crucial for us to a) start with staff where they were, so that they were receptive to and engaged with the new ideas being presented; b) enable staff to each have their own “A-ha!” moment; c) recognize and acknowledge our staff’s existing work related to the LCP and build on this; and d) utilize the imagination and experience of staff to plan for the future. Describe the public health issue that this practice addresses. (350 word limit)
For the past several decades, maternal and child health (MCH) experts have considered improving access to and utilization of quality prenatal care to be necessary for improving birth outcomes and reducing racial and ethnic inequities. As a result, the federal government has made a large investment in ensuring that women have access to prenatal care early in pregnancy. Despite the fact that since 2000, entry into prenatal care in Contra Costa has been close to 90%, rates of preterm birth and low birth weight have risen steadily, and substantial inequities remain between racial/ethnic groups in all birth outcomes.
Existing and emerging research show that social, political and physical environments are major determinants of family health, and especially of health inequities. As the national health agenda begins to move more deliberately toward implementing interventions, programs, and policies that are designed to eliminate health inequities to improve the health of this and future generations, support is shifting away from the model of prenatal care as a single all-encompassing solution. Instead, interest is increasing in frameworks that look beyond the prenatal period to a broader range of factors that may improve birth outcomes. Over the past several years, several academic publications in both MCH and chronic disease epidemiology have drawn attention to newer theoretical constructs that address both health and well-being across the life span as well as social determinants of health, prompting a shift in the way MCH practitioners and researchers are approaching their work.
One such model is Lu and Halfon’s Life Course Perspective (LCP), which suggests that a complex interplay of biological, behavioral, psychological, environmental, and social protective and risk factors contributes to health outcomes across the span of a person’s life, and that inequities in birth outcomes, such as low birth weight and infant mortality, result from differences in protective and risk factors between groups of women over the course of their lives. The LCP also integrates a focus on critical periods of development and early life events with an emphasis on cumulative risk, also described as the wear and tear a person experiences over time. What process was used to determine the relevancy of the public health issue to the community? (350 word limit) The discrepancy between the services FMCH Programs was providing and the outcomes they were meant to improve prompted us to intensify our efforts to collaborate with community groups, including housing, transportation and social service organizations, in the county’s zip codes that had the worst health outcomes. These partnership efforts focused on improving and expanding available services and gaining a deeper understanding from community partners of what we should be doing differently to reduce infant mortality and low birth weight births. We conducted a Photovoice project to learn first-hand from community residents what they believed were the pressing issues that FMCH Programs should be addressing to improve birth outcomes.
Community residents pointed to the general state of their neighborhoods, particularly a preponderance of trash, understaffed and underfunded after-school programs, and unsafe neighborhoods as issues they wanted us to address. We knew that these were important and significant quality-of-life issues that needed attention. However, given our mandate to reduce low birth weight births, infant mortality, and births to teens, we were hard-pressed to find strategies for translating these pressing social and environmental issues into practical, measurable objectives that were relevant to the mission of FMCH Programs. The Life Course Perspective offered us a logical and intuitive framework for addressing these social determinants of health. How does the practice address the issue? Despite the complexities and challenges of integrating this framework into MCH programs, Contra Costa Health Services’ (CCHS) Family, Maternal and Child Health (FMCH) Programs launched a 15-year Life Course Initiative (LCI) based on the work of Lu and Halfon. The goal of the LCI is to reduce inequities in birth, infant, and maternal outcomes and improve the health of the next generation in Contra Costa County by promoting and achieving health equity, optimizing health, and shifting the paradigm of the planning, delivery, and evaluation of maternal, child, and adolescent health services.
We wanted to make this paradigm shift throughout our constellation of MCH-related programs that not only includes perinatal services coordination, but also programs such as Child Health and Disability Prevention Program, California Children’s Services, Children’s Oral Health Program, Medically Vulnerable Infant Program, Prenatal Care Guidance, TeenAge Program, and Women, Infants and Children Program. We also hoped to influence change throughout the larger Contra Costa Public Health Division.
To refocus public health work at the local level, FMCH Programs staff needed to be informed about this new approach to MCH so that they would be able to identify ways in which they could incorporate the LCP into their current and future work. To this end, we developed easy-to-understand informational materials and fact sheets about the LCP for staff at all levels. We also designed and conducted interactive educational sessions on the LCP for the 220 FMCH Programs staff. These educational sessions a) offered staff an overview of the theory of the LCP and social determinants of health; b) provided participants with an opportunity to experience the key concepts of the LCP through a Life Course Game; and c) engaged participants in substantive discussions about how they were already incorporating the LCP into their current work and future activities.
In subsequent educational sessions, we reviewed LCP theory and facilitated in-depth discussions about Lu et al.’s 12-Point Plan to Close the Black-White Gap in Birth Outcomes, in which FMCH Programs staff were asked to identify how and if the points of the 12-Point Plan were reflected in their current work. Is the practice new to the field of public health? If so, answer the following questions. Yes What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review. The Life Course Perspective (LCP) was new to the field of maternal and child health (MCH) when we launched our Life Course Initiative in 2005. Lu and Halfon’s seminal article outlining this new framework was published just two years prior, and we first heard Dr. Lu speak about the LCP shortly thereafter. Based on our conversations with Dr. Lu and other maternal and child health experts, it appeared that we were one of the very first local health departments to begin training staff on the integration of the LCP into MCH practice. How does this practice differ from other approaches used to address the public health issue? When FMCH Programs took on the challenge of integrating the LCP into our work, we knew we would have to shift the paradigm in which we were currently working. We were moving away from a primary focus on prenatal care to a focus on health and wellbeing across the life span including more concentrated attention on social determinants of health such as housing, wealth, community violence, access to healthy foods, and education. The LCI aims to identify ways to apply and operationalize the LCP, which includes a focus on health equity and social determinants of health, into the dynamic day-to-day practice of maternal and child health.
We were well aware that moving away from a mindset that health care is the key to better health outcomes would require regular discussions about an “upstream” approach to reducing disparities and inequities in health outcomes and a reiteration of the influence of early life exposures, community environmental factors, and cumulative wear and tear on lifelong health. Individual behavior and individual choices were still discussed, but in a different context: Are we creating environments in which women and children, youth and families have good choices to make? How are our efforts contributing to their health across their life course? Is the practice a creative use of an existing tool or practice? If so, answer the following questions. No What tool or practice (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, etc.); did you use in a creative way to create your practice? (if applicable) (300 word limit total)
a. Is it in NACCHO’s Toolbox; (if not, have you uploaded it in the Toolbox)?
b. If you used a tool or practice to implement your practice, how was your approach to implementing the tool unique and innovative for your target area/population?
What process was used to determine that the practice is a creative use of an existing tool or practice? Please provide any supporting evidence you may have, for example, literature review. How does this practice differ from other approaches used to address the public health issue? Who were the primary stakeholders in the practice? This staff training component of our Life Course Initiative was focused primarily on building the internal capacity of maternal and child health staff at our health department around the Life Course Perspective (LCP). The main external stakeholder in this process was Dr. Michael Lu. What is the LHD's role in this practice? Staff of Contra Costa Health Services’ Family, Maternal and Child Health (FMCH) Programs were responsible for the planning, implementation, and evaluation of the Life Course Initiative, and they were also the audience for the staff trainings. What is the role of stakeholders/partners in the planning and implementation of the practice? Dr. Michael Lu acted as an advisor to us for the development of the staff training curriculum, and he also participated in several discussions with FMCH Programs’ management team about how to apply the LCP in our maternal and child health practice. What does the LHD do to foster collaboration with community shareholders? Describe the relationship(s) and how it furthers the practice's goals. Providing education on the Life Course Perspective to other Contra Costa Health Services (CCHS) and County agencies, local public health leaders and policymakers, and community partners, has helped all of collectively advance a countywide movement towards health equity, with a focus on social determinants of health and building cross-sector partnerships to address community health. Describe lessons learned and barriers to developing collaborations Offering these educational sessions to partners outside FMCH Programs helped to bring attention to the LCI educate this group of influential individuals about the new we hoped to pursue, and allow time for substantive discussion that hopefully would lead to “buy-in.” We learned that it was important to involve our local public health leaders and policy makers early on, in order to obtain support for investing the immense amount of staff time and program resources needed to implement the LCI and lay the groundwork for mobilizing political will. In addition, we recognized the value of the skeptics of our Initiative, and the importance of engaging in meaningful and substantive dialogue with them, as they were the ones who were asking us the hard questions. Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.
Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
List up to three primary objectives for the practice. For each objective, provide the following information: (750 word limit per objective)
Objective 1: Shift the paradigm of the planning, delivery, and evaluation of maternal, child, and adolescent health services. • Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation. Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback: List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.
In the first few years of our Life Course Initiative (LCI), we focused on staff training as the first step to achieving a paradigm shift based on the Life Course Perspective (LCP). To evaluate the success of our staff training, we conducted a web-based survey of our staff in June 2007 to assess their understanding of the LCP and gather their ideas for how they were incorporating this approach into their work. The primarily qualitative survey was created by the Life Course Planning Team and sent to 107 FMCH Programs staff. Of these staff, 64% responded; 14% were managers and 86% were non-managers.
The survey results suggested that our staff trainings were successful. We found that that as a result of the educational sessions, our staff had gained a deep understanding of LCP concepts. When asked to describe the LCP in their own words, they utilized phrases such as “a holistic approach;” “a focus on future generations;” “begins in the womb;” and “the Life Course Perspective looks at the impact of social, emotional, and physical stressors on a woman’s health across her lifespan.”
Seventy-two percent of staff reported that they had changed something about their work as a result of learning about the LCP. Responses included: “I remember the importance of other issues for clients such as lack of transportation;” “Encourage women to take care of themselves;” “Focus on how we may influence our clients’ ability to improve their health and well-being throughout their life span;” “Realizing that change will impact future generations has been a shift in thinking;” and “More aware of the importance of building youth resiliency.” In addition, one staff person said, “I hadn’t thought about health in that way before. It also made me think about the importance of life experiences and stresses on future generations and how important it is to make sure everyone has access to health care and a method to create a supportive family network for them and their families so all can thrive.” Of the 28% of staff who said they had not changed something about their work most said that this was because they were…
Overflow (Objective 1): Please finish the response to the question above by using this text area. Please be mindful of the word limits. …already incorporating the LCP into their work.
We heard a variety of suggestions from staff about what FMCH Programs should do in the future with the Life Course Initiative, but by far the most common request was to receive continued training and information about the LCP, as well as concrete ideas for how to integrate the LCP into practice.
The results of the LCI staff training, including the staff survey, have been shared with FMCH Programs staff, at professional conferences, and in a recent journal article.
Six years into making this paradigm shift and integrating the LCP into FMCH Programs, the landscape has changed. We have observed that our staff have altered how they talk and think about their work in maternal and child health, “Life Course” is now part of their vernacular, and they recognize how their day-to-day tasks and direct services to clients fit into the larger puzzle of achieving health equity and improving health outcomes. They understand that the concepts of the LCP required that we look beyond individual and clinical approaches to population-based strategies that address the many compelling social determinants of health. In addition, they acknowledge the importance of influencing these social determinants, particularly economic and educational factors.
We have experienced several challenges and learned many lessons about making an organizational paradigm shift. For some of our staff, this was an entirely new way of thinking about their job responsibilities and for others, this fell in line with what they had been working on for many years. Not everyone was ready to embrace this new direction. Many staff asked difficult, complex questions that provided us with additional opportunities for valuable discussion and critical thinking.
Changing a long-standing paradigm is a slow process and we have had to have a long view. Gaining the buy-in of our staff took much longer than we expected. It was crucial for us to a) start with staff where they were, so that they were receptive to and engaged with the new ideas being presented; b) enable staff to each have their own “A-ha!” moment; c) recognize and acknowledge our staff’s existing work related to the LCP and build on this; and d) utilize the imagination and experience of staff to plan for the future. Overflow (Objective 2): Please finish the response to the question above by using this text area. Please be mindful of the word limits. Overflow (Objective 3): Please finish the response to the question above by using this text area. Please be mindful of the word limits. What are the specific tasks taken that achieve each goal and objective of the practice? 1. Launched the Life Course Initiative (LCI) at an FMCH Programs All-Staff Meeting, with a presentation by Dr. Michael Lu about the Life Course Perspective (LCP).
2. Created LCP educational materials (training curriculum, fact sheets about the LCI and the 12-Point Plan).
3. Conducted a series of LCP educational sessions with FMCH Programs.
4. Began training other Contra Costa Health Services (CCHS) and County agencies, local public health leaders and policymakers, and community partners.
5. Established a Life Course Planning Team that met regularly and oversaw LCI program planning and evaluation activities.
6. Evaluated the effectiveness of the educational sessions with our staff through a web-based staff survey. What was the timeframe for carrying out these tasks? 1. Launched the Life Course Initiative (LCI) at an FMCH Programs All-Staff Meeting, with a presentation by Dr. Michael Lu about the Life Course Perspective (LCP): April 2005.
2. Created LCP educational materials (training curriculum, and fact sheets about the LCI and the 12-Point Plan): Spring-Summer 2005.
3. Conducted a series of LCP educational sessions with FMCH Programs: Summer 2005 – Winter 2008.
4. Began training other Contra Costa Health Services (CCHS) and County agencies, local public health leaders and policymakers, and community partners: Fall 2005.
5. Established a Life Course Planning Team that met regularly and oversaw LCI program planning and evaluation activities: Spring 2007.
6. Evaluated the effectiveness of the educational sessions with our staff: June 2007. Is there sufficient stakeholder commitment to sustain the practice? Describe how this commitment is ensured. To date, FMCH Programs has made substantial progress in integrating the Life Course Perspective into programs and services. The data from early efforts suggest that there is a substantial amount of foundational work required to make this kind of major paradigm shift. The integration has required us to foster understanding and secure support for the Life Course Imitative (LCI) from multiple County departments and external partners. We expect continued support for the LCI from our Public Health Director and other senior health department leadership, which has been crucial to our success thus far.
Due to the cutting-edge nature of LCI, it has received much national and local interest. Since October 2007, we have made 57 presentations to over 2,800 health and human service professionals and students about the project and it’s grounding in the Life Course Perspective and social determinants of health. In addition, we provide technical assistance on a regular basis, by phone and e-mail, to local health departments and other health and social justice organizations across the country who would like to implement similar interventions.
Beyond the local level, state and federal maternal and child health (MCH) agencies have committed to incorporating the LCP into their strategic plans and performance measures. The understanding that the LCP is important in a range chronic disease and health promotion projects has started to take hold and create a change in the landscape. This recognition has helped bring a broader range of partners to the table for FMCH Programs in developing and implementing the LCI. Describe plans to sustain the practice over time and leverage resources. The Contra Costa Life Course Initiative currently receives the majority of its funding from the California Department of Public Health’s Maternal, Child and Adolescent Health Program and federal matching funds. Traditionally these have been relatively stable sources of funding, but they are now vulnerable due to the instability of federal, State, and County budgets. Consequently, to truly sustain and expand this project over the next few years, we must bring in more outside funding, and we continue to build new partnerships with organizations in multiple sectors and seek cross-sector grant funding. Practice Category Choice 1: Health Disparities Practice Category Choice 1, Part 2: Maternal and Child Health (Teen pregnancy, Mother to Child transmission of HIV and AIDS) Practice Category Choice 2: Practice Category Choice 2, Part 2: Workforce Development Practice Category Choice 3: Practice Category Choice 3, Part 2 Check all that apply. NACCHO Web Site E-mail from NACCHO Other Model Practice Brochure Other (please specify): NACCHO staff |
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