A Healthy Start or an Unsuccessful Initiative? A Critique of the Healthy Start Initiative – Katherine Flaherty
Infant mortality is an important indicator of the health of a population. Additionally, it reflects the overall state of maternal health as well as the quality and accessibility of health care services available to pregnant women and infants.  In 2006, the infant mortality rate in the United States was 6.68 infant deaths per 1,000 live births, only a 3 percent decline from 6.86 in 2005.  Despite this slight decrease, there has been a recent stagnation in overall infant mortality and an increase in preterm births since the early 2000s.  Preterm birth, and the infant mortality associated with it, accounts for much of the plateau of the infant mortality rate in the United States from 2000 to 2005. It is also associated with various familial, social, and economic costs stemming from intensive medical care. 
Racial disparities also persist, most drastically between non-Hispanic black and white populations. In 2006, the total and preterm-related infant mortality rates were above average for non-Hispanic black mothers and more than 2 times higher than for non-Hispanic white mothers.  Non-Hispanic black women have a disproportionate burden of individual and environmental risk factors such as unmarried status and late entry into prenatal care, racial segregation, poverty, inadequate health care, substandard housing and higher incidence of crime.  The implications of these stagnant infant mortality rates are far reaching and indicate effective interventions are needed to reduce infant mortality, specifically in high-risk populations such as non-Hispanic blacks.
Healthy Start Initiative
In 1991, the national Healthy Start Initiative began with grants from the Health Resources and Services Administration, within the Department of Health and Human Services, to 15 projects. By 2005 it had grown to 97 grantees charged with addressing the racial and ethnic disparities in maternal and infant health.  Healthy Start programs have three core program goals: (1) reduce racial and ethnic disparities in access to and utilization of health services; (2) improve local health care systems; and (3) increase consumer and community voice and participation in health care decisions.
Grantees are public or private entities servicing populations, particularly women and infants, with significant perinatal health disparities. Healthy Start programs address the issue of infant mortality through community-driven approaches aimed to reduce maternal behavioral and medical risk factors and promote healthy outcomes for women and their families.
The initiative begins with prenatal care and continues through the infant’s second year of life. Services include case management, home visiting, direct outreach and peer mentoring, screening and referral for perinatal and/or postpartum depression, and coordination for substance abuse, domestic violence, mental health, early intervention, parenting and various other services for high-risk women and their families. Additionally, Healthy Start grantees are required to have a consortium composed of individuals and organizations within the community to implement an action plan to improve quality, cultural competency, and access to care. 
Enrollment in Healthy Start faces many barriers. The most common challenges reflect a complex mixture of social and financial issues including unstable housing, clients’ transient nature, clients’ belief that they had more pressing needs, and lack of child care. It is clear that there are multifaceted dimensions that the Healthy Start Initiative, grantees, and service providers need to address in order to successfully reduce infant mortality disparities among these highly vulnerable populations. 
Critique of the Healthy Start Initiative
I. Failure to Market Healthy Start to Eligible Population
The Healthy Start Initiative is attempting to sell the core value of health to communities. It is making the incorrect assumption that the target population’s core value is to be healthy, have healthy pregnancies and children. This initiative is relying on the publics’ involvement based on this incorrect assumption and neglecting three important marketing factors: framing, advertising, and branding.
First, it is necessary to market desired behaviors to the core values of the deepest aspirations of the audience. While we as public health workers want to believe that people will be motivated by health, they usually are not. Intuitive or emotional responses can play a more important role in decision-making . It is not enough to tell people they should want to have healthy pregnancies and healthy children. Healthy Start must frame the issue in a way that appeals to the target group’s emotions and core desires, keeping in mind that their target population incorporates a broad range of emotional information into decision-making .
Second, there is no strong advertising message showing women within these communities finding the control to have healthy pregnancies and healthy children. A member of the Healthy Start program in Oregon was quoted as saying “I wish people knew this resource was here. I think a lot of people don’t know about all of the benefits that are available to them, and all the resources and education that are pretty much at their fingertips.” Another member mentioned, families can “call or e-mail to figure out if they qualify for the services”.  There is an obvious disconnect here. If people are unaware of the services, they are not going to know to call or e-mail to determine if they are eligible. Healthy Start does not seem to have any advertising or marketing campaigns aimed at their target population: high-risk pregnant women and women who may soon become pregnant. Additionally, if two of the three main goals of Healthy Start are to increase health service utilization and community voice and participation in health care  the initiative seems to be failing in raising advertising and marketing awareness to achieve this goal.
Finally, Healthy Start has overlooked the opportunity to attract people to their program. Marketing the initiative as just another health program does not sell the population on its specific strengths. Again, the current program does not appeal to any of the population’s core values of freedom, belonging, individual worth or control. Without a clear brand Healthy Start is missing an important opportunity to create an association between the community and the initiative. This connection would have both social and individual implications for how these mothers view themselves, how they want to be seen by society and the context of their interactions with others. 
II. Failure to Provide the Tools Needed to Positively Change Behaviors
The basis for the Healthy Start Initiative is to educate high-risk mothers and provide adequate access to appropriate health care to both them and their children. It appears the Healthy Start Initiative is based on the Health Belief Model, geared toward the individual decision-maker  (the mother) utilizing health promotion messages. These messages include education about preventative measures such as: increasing folic acid consumption, laying infants on back to sleep to minimize risk of sudden infant death syndrome, early detection and treatment of diseases such as HIV and other sexually transmitted diseases, and reducing stress in order to help reduce disability or suffering caused by chronic conditions. Areas of intervention include education about drug abuse, alcohol abuse, depression, family planning, and domestic violence, exercise.
Healthy Start is trying to promote maternal behavior change based on the four facets of the Health Belief Model: maternal perceived susceptibility regarding the chance of having complications during pregnancy or the chance of losing their child; maternal perceived severity of how serious adverse perinatal outcomes are; maternal perceived benefits of perinatal health and family planning; and perceived barriers to ability to access proper care, make it to appointments, and the psychological costs associated with advised actions. While the Health Belief Model is common in public health initiatives, this type of model may inadvertently threaten clients’ freedom by insinuating their lifestyles are dangerous and need to be changed. It is possible, instead of learning from these educational encounters, the clients might act as predicted by the psychological reactance theory. Psychological reactance theorizes that in order to mediate the threats against their freedom of choice they may continue (or begin) the opposite of what is recommended. 
Additionally, Healthy Start does not seem to take into account irrational decision making due to expectation (stereotyping and labeling), ownership, framing (as mentioned before), or fundamenatal attribution error (context in which behaviors take place).  All of these factors must be accounted for if Healthy Start wishes to impact vast population level changes in disparities surrounding infant mortality.
III. Individual Approach
As mentioned in critique two, Healthy Start mainly focuses on women, utilizing the Health Belief Model. Less than 50% of the grantees have programs that include male involvement such as: participation in prenatal and pediatric visits, classes on parenting skills, and counseling and support about men’s role in family planning.  Individual-level models ignore important social factors such as social support and a feeling of belonging and focus on individual analysis. Thus, Healthy Start is executing a program based on an incomplete picture of human motivations and behavior by ignoring the innate social nature of their clients. 
Healthy Start should stop overlooking vital resources within the community and engage greater male participation and other social factors that could contribute to a decrease in infant mortality. Without taking into account these social contributors, the best service and care is not able to have a community level impact and Healthy Start is not optimally utilizing its resources.
Proposed Modification of the Healthy Start Initiative
The Healthy Start Initiative has many strengths, but these strengths are limited by the weaknesses mentioned above. Ideally, if applied, the following suggestions will complement and strengthen the current Healthy Start Initiative. First, Healthy Start must incorporate marketing theory principles in order to engage populations as a whole. Second, the reliance on the Health Belief Model must be complemented with a better understanding of how and why people’s behaviors change. Finally, Healthy Start should look beyond the individual and engage group level theories that would result in higher male participation rates in family planning, healthy pregnancies, and parenting. It is believed these three suggestions would transform the current Healthy Start Initiative. This transformation is hoped to have a broader effect on community knowledge surrounding infant mortality and improve the social support system necessary for the reduction of infant mortality in high-risk populations.
I. Incorporating Marketing Theory Principles
As mentioned earlier, the client belief that Healthy Start services were not a priority is the greatest barrier to enrollment and maintenance services for pregnant women. The findings from the Healthy Start Phase I evaluation showed that earlier enrollment among pregnant participants may increase percentages of clients who receive timely prentatal care or receive necessary services to address behavioral risks such as smoking or drug use. Among interconceptional women (women between pregnancies), earlier enrollment may help staff to more rapidly identify and address health concerns that may arise later, such as postpartum depression or infant safety issues.  In order to successfully increase and maintain enrollment, Healthy Start must market the healthy behaviors and social change associated with initiative. Healthy Start must move beyond simply addressing health, healthy pregnancy, and interconceptional care. This change in strategy towards must incorporate the specific population’s core values. This can be accomplished by combining multiple marketing theories such as framing, advertising theory, and branding. 
Advertising is a theory by which the human emotion can be engaged in a way that is not necessarily consistent with what the mind believes. Healthy Start can use this to its advantage in three important ways: 1) create emotionally invested consumers; 2) control the consumption of their product by increasing Healthy Start participation and decreasing unhealthy behaviors; and 3) shape the entire community’s opinions and behaviors regarding healthy pregnancy, women, and children. In advertising theory it is necessary to make the audience a promise, the larger the promise the more effective the advertisement will be.  Healthy Start should re-frame its promise, making it clear that participation in the program will provide people with control over their future. It is necessary for the advertisements to be supported with emotional evidence such as stories, images, real people, and emotive music. In advertising theory, the promise and support go hand in hand. Healthy Start should make a promise that is offering basic needs and wants of their target population: control over their future and that of their children. This promise should be supported by stories of women and families who successfully participated in Healthy Start and how it gave them control over their and their children’s life. 
Finally, it is necessary to brand healthy lifestyles and market social change. There is a complex set of associations between an individual and a health behavior or set of behaviors that embody a lifestyle. In order to create a brand out of Healthy Start, grantees must create a set of associations for the initiative specific to their community. A few ways to begin branding is to clarify their message by creating a catch phrase, distinctive mission, or logo to correlate with the promise mentioned above. It is necessary to create a phrase or slogan that will mean something to the mothers and that the community will internalize. 
By combining framing, advertising theory and branding, Healthy Start can brand its initiative by using a core value, such as control, of the target population. If Healthy Start uses the power of the population’s core values and sell the program in a way that harnesses the audience’s emotions, Healthy Start can create associations that will transcend any singular advertisement or promotional event.
Ideally, the brand will embed itself in the lives of the participating mothers, the community, and physical environments in which they live.  If Healthy Start successfully utilizes marketing theories, there will be an increased community awareness surrounding Healthy Start leading to earlier enrollment and continued participation.
II. Providing Families with the Tools Needed to Positively Change Behaviors
Often health education can result in psychological reactance. When behavior modification is suggested people often react as if it is a threat against their freedom to choose by doing the opposite.  When trying to encourage healthier behaviors, reactance is a worrisome response to suggested behavior modification. It is pertinent in an initiative such as Healthy Start to overcome such reactance.
An important step in persuasive health communication is measuring psychological reactance within the target population. There are three important factors to be aware of when developing persuasive health communication to overcome reactance: 1) explicitness, the degree to which the language in the message makes plain the source’s intent; 2) dominance, the extent to which a message reveals that the source believes he or she can control the message recipient; and 3) reason, present in any given message when justifications are offered in support of the claim that audience members should adopt the behavior advocated by the health educators. 
One way Healthy Start can deflecting reactance is by use of a similar source as the target population to deliver a explicit, clearly defined message that will hopefully minimize any perceived threats to their freedom. Thus, Healthy Start should work with leaders in the community and local celebrities to deliver its message and advertisements, hopefully reducing reactance in the audience.
III. Incorporating Group Approaches and Social Influences
Healthy Start must evolve to include more group and community-level programs to increase social support and male participation. Several theories support these group level strategies. Presented here are two theories that are believed to complement the previously suggested changes in Healthy Start. Both of these theories are based on human social nature and the fundamental idea that socialization is necessary for the survival of a stable system within society. 
First, Social learning theory describes how people acquire new forms of behavior by observing other people’s actions.  Since Healthy Start’s main goal is to encourage healthy behavior change to reduce adverse maternal and infant outcomes, social learning theory could be incorporated into group prenatal care health education, or support groups. Social learning theorizes that groups are more than just a collection of individuals and public health initiatives should harness the vast power groups have over individual behavior.  This could be accomplished in Healthy Start by using more peer mentoring, group prenatal, or parental education groups for both men and women. The returning clients or community mentors will exemplify the desired behaviors in these group settings. Newer clients will see the reward of participation in Healthy Start in the modeled healthy pregnancies and healthy children of their peers. In this way, by highlighting women and families who are already doing the desired behaviors newer Healthy Start clients could have the social support to model healthier behaviors and be encouraged to continue in the program through interconceptional care and subsequent pregnancies.
Additionally, social expectations theory suggests that people make their decisions and behave according to others’ expectations of them. Thus, most people behave according to what they interpret to be the norms of society and more specifically, their community. Social expectation theory also proposes that people fall into specific roles in order to coordinate and accomplish common goals. Healthy Start should incorporate people’s desire to have specialized roles by creating a social network through various groups within the program. By including families more actively in their care and creating these group environments, participants will have the opportunity to learn from, educate, and encourage one another. In these ways, Healthy Start can take advantage of the interdependent nature of people. 
While the Healthy Start Initiative has many strengths, it is limited by its reliance on individual level models and lack of social media usage. By combining group level models for behavior change, the positive care coordination, community involvement, and recruitment of high-risk individuals Healthy Start can harness additional power and influence within the community. Marketing, advertising and group level models are complementary to one another and Healthy Start should take advantage of their cohesive nature. By linking the public health brand of Healthy Start with increased community awareness and social support, the target population should readily hear the promise of control over their lives, children’s lives, and future within a supportive community and changing social norms. It is important for Healthy Start to continue to incorporate the health education surrounding risky behaviors; the theoretical interpretation of demographics, family makeup and child-rearing responsibilities; as well as the psychological factors that go into decision making. If Healthy Start can effectively expand its’ vision to include these proposed modifications, perhaps it will more successfully impact infant mortality in high-risk populations.
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