1. The Life Course Approach
From Theory to community practice
Faye Johnson
Project Director
The Magnolia Project
July 9, 2014

2. Overview The Life Course in MCH Implications for practice
From theory to practice
Planning framework
Prenatal Care & Case management
Leadership Academy

3. Life Course Perspective
Back to the future!
MCH historically focused on broader public health perspective
Shift in focus over last decade
Individual knowledge, skills
Community, provider education
Individual interventions
Efforts to improve birth outcomes limited to nine months of pregnancy
Improvements in maternal and infant survival
Policy brief: A new agenda for MCH policy and programs-integrating a life course perspective by Amy Fine, Milt Kotelcheck, Nancy Adess and Cheri Pies National Life Course meeting sponsored by the CA endowment and Contra Costa Health Services.

4. Infant Mortality
Infant mortality rate (2012): 8.4 deaths per 1,000 live births (2005 rate 11.6)
IM driven by disparities
45% of births to Blacks & other nonwhites
Blacks historically have poorer outcomes in Jax than other urban areas of state
IM rate 2.5x higher than White rate

5. Infant Mortality Duval County

6. Beyond pregnancy
Birth outcomes reflect life course of mother, not just pregnancy
Proposed by Michael Lu & Neal Halfon (2003)
Synthesis of two biomedical models
Early programming
Cumulative pathways

7. Synthesis of Biomedical Models
Early programming
Exposures in early life could influence
future reproductive potential
Cumulative pathways
Chronic accommodations to stress results in wear & tear contributing to declining health over time.

8. Life Course Perspective
Rather than focusing on risks, behaviors & services during pregnancy, CUMULATIVE effects of health, life events are examined.
Health & socioeconomic status of one generation directly affects the health status --- and REPRODUCTIVE HEALTH CAPITAL – of the next one.

9. Life Course Perspective
Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30

10. Life Course Perspective
Approach suggests a complex interplay of biological, behavioral, psychological and social protective factors contributes to health outcomes across the span of a person’s life.
Factors impact racial, ethnic groups differently and may explain disparities despite equal access to care during pregnancy.

11. Life-course model BROADENS the focus of MCH to include both health and social equity.
Socioeconomic status, race and racism, health care, health status, stress, nutrition and weight, and a range of other behaviors impact birth outcomes.
Factors impact racial, ethnic groups differently and may explain disparities despite equal access to care.

12. Social Determinants of Health
The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices.
The influence of "social determinants" on health begins even before we are born. Study after study has outlined the ways in which a woman's health, diet and stress level during pregnancy affects her newborn's life chances: everything from neurological and emotional development to the likelihood of adult obesity. Proper nutrition, prenatal care, and exercise are important, but class, racism, loving relationships and place can also affect pregnant women.
Socioeconomic Status. Lower socioeconomic status in childhood has been linked repeatedly with lower educational and income levels in adulthood, which in turn predict health status. Children in poor families are about seven times as likely to be in poor or fair health as children in the highest-income families.
The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. Examples of social determinants are: Lack of income, housing, poverty, unemployment, crime, poverty, racism etc….

13. Life Course Perspective Implications
Life course framework in Maternal and Child Health has PROGRAMMATIC and POLICY implications.

14. Changing practice Content of care is expanded Poverty
Economic security
Education

15. Changing practice
Services are organized and delivered in ways that build resiliency and social capital and reduce dependency
Group care
Self care

16. Changing practice
Requires inter-disciplinary, inter-agency collaboration to address complex needs

17. From Theory to Community Practice
Planning Framework
Case Management
Reproductive Health
Preconception Care
Prenatal Care
Community Advocacy

18. Planning Framework

19. Planning Framework
The Healthy Start program: individual case management and risk reduction services, not directly responsible for addressing social determinants.
Plan strategies developed on two levels:
What actions can be implemented through Healthy Start?
What partnerships are needed between Healthy Start and other organizations working to address social equity?
Looks at four phases:
Infancy
Childhood & Adolescence
Preconception
Pregnancy & Childbirth

20. A Life Course Case Management Model
The Magnolia Project, federal HS initiative in Jacksonville uses a preconception strategy to address racial disparities in birth outcomes.
Two stage approach:
Crisis stabilization, deal with immediate risks
Longer term work to change trajectory (Life Plan)

21. Case Management
The individual Life Plan is participant- driven with established goals that address needs in three areas:
Access to preventive health care
Family & community support
Reduction of poverty and social inequity
Participants are enrolled in group activities that are specific to their Life Plan.

22. Benefits
Addresses the social determinants that influence poor birth outcomes.
Promotes inter-and independence while building reproductive capital in the community.
Contributes to improved self esteem of participants.
Hard work! Staff vs. participant response.

23. Life Course Service Delivery Model
Individual services
(mitigate, reduce risks) 
Group services
(inter-dependence, self-reliance)
Community capacity building
Advocacy
(social determinants)

24. Benefit of Integrating The Life Course Perspective into Case Management
The participants welcomed the change and were excited during the group activity.
An opportunity to address the social determinants that influence poor birth outcomes
Promoted inter-and independence while building reproductive capital in the community.
Participants moved from relying on case managers to becoming leaders of group activities.
The approach can contribute to improved self esteem among the women enrolled in case management.

25. Life Course Plan
The individual Life Course Plan is participant- driven with established goals and address needs in three areas:
Access to preventive health care and related risk reduction services that improve a woman’s chances for healthy birth in the future. This includes basic reproductive health services, such as GYN care and family planning, as well as care for chronic diseases like diabetes, hypertension and obesity

26. Life Course Plan
Family and Community support including activities that provide at-risk women with the skills to develop healthy relationships and connectedness with communities through civic engagement and participation.
Reduction of poverty and social inequities that assist participants in completing their education, gaining job skills, confronting discrimination and racism, and developing financial literacy.

27. Community Advocacy
The Make a Difference! Leadership Academy develops leadership skills and promotes civic engagement of case management participants and residents in high-risk neighborhoods.
The Make a Difference Leadership Academy utilizes training material developed by the University of Arizona in 12 weekly sessions.
The program is a research-based curriculum of current practices and theories designed to build capacity for grassroots leadership. The curriculum has been evaluated and demonstrated as effective for emerging leaders, individuals who have little or no leadership experience.
The Make a Difference Leadership Academy changes the trajectory of a community through individuals being trained and assisted in the development of a Community Action Plan to move a community to action.

28. The Life Course Perspective
Change in approach = positive response from participants, MOST staff
Model has impacted the way we do business
Use of life course framework in update of Healthy Start Service Delivery Plan
New collaborations in economic self-sufficiency, community development
How to incorporate in the State HS care coordination system??
Developed the Make a Difference Leadership Academy

29. Thank you!