The impact on clients of a community-based infant mortality reduction program: the National Healthy Start Program Survey of Postpartum Women.

OBJECTIVES: This study assessed the effect of the national Healthy Start Program on its clients. METHODS: We used a cross-sectional survey of a sample from Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) rosters of women less than 6 months postpartum who were residents of Healthy Start Program areas. RESULTS: Healthy Start clients revealed higher sociodemographic risk, but not behavioral risk, for adverse pregnancy outcome than other area residents. They did not differ from other residents in receipt of services except for a greater likelihood of receiving case management, using birth control at the time of the interview, and rating their prenatal care more highly. CONCLUSIONS: The Healthy Start Program succeeded in enrolling women at high risk. It had little effect on the immediately concluded pregnancy, but it might influence future outcomes.

Programs that mitigate the effects of poverty on children.

This article reviews six federally funded in-kind public assistance programs that are intended to mitigate the effects of poverty on low-income children by providing access to basic human necessities such as food, housing, education, and health care. The evidence suggests that, while each program can be improved, these programs do achieve their basic objectives. In general, food stamps, the Special Supplemental Food Program for Women, Infants, and Children (WIC), and school nutrition programs are successful at providing food assistance to low-income children, starting with the prenatal period and continuing through the school years. The Food Stamp Program provides food assistance nationwide to all households solely on the basis of financial need and is central to the food assistance safety net for low-income children. The WIC program has helped reduce the prevalence of iron-deficiency anemia in infants and children and has increased intakes of certain targeted nutrients for program participants. The school nutrition programs provide free or low-cost meals that satisfy the dietary goals of lunches and breakfasts to most school-age children. The Medicaid program has extended health insurance coverage to millions of low-income children. However, many children remain uninsured, and children enrolled in Medicaid do not have the same access to medical care as privately insured children. Relatively little is known about the effects of Medicaid on children's health status. For Head Start, empirical evidence suggests that participating children show enhanced cognitive, social, and physical development in the short term. Studies of the longer-term impacts of Head Start are inconclusive. Although housing assistance improves housing quality and reduces housing costs for recipients, there is a large unmet need for acceptable, affordable housing among poor families. Important gaps remain in our knowledge of the effects of these programs on the well-being of children. Questions regarding a program's effects over time on health and developmental outcomes particularly need more study.

Evaluating the Healthy Start program. Design development to evaluative assessment.

The national evaluation of the federally funded Healthy Start program involved translating a design for a process and outcomes evaluation and standard maternal and infant data set, both developed prior to the national evaluation contract award, into an evaluation design and client data collection protocol that could be used to evaluate 15 diverse grantees. This article discusses the experience of creating a process and outcomes evaluation design that was both substantively and methodologically appropriate given such issues as the diversity of grantees and their community-based intervention strategies; the process of accessing secondary data sources, including vital records; the quality of client level data submissions; and the need to incorporate both qualitative and quantitative approaches into the evaluation design. The relevance of this experience for the conduct of other field studies of public health interventions is discussed.

Background of the School Nutrition Dietary Assessment Study.

The National School Lunch Program (NSLP) and the School Breakfast Program (SBP) are federally sponsored nutrition programs operating daily in the nation's schools. The School Nutrition Dietary Assessment Study had three primary objectives: 1) to describe the nutrient composition of NSLP lunches and SBP breakfasts as offered to students, 2) to analyze the dietary intakes of students, and 3) to compare the dietary intakes of program participants with nonparticipants. This paper describes the school nutrition programs, discusses current program issues and policy concerns, and provides an overview of the study objectives and papers included in this journal issue.

Dietary intakes of students.

This paper relies on 24-h dietary recall data from a nationally representative sample of approximately 3350 students to analyze the dietary intakes of students. Most US students eat at least five times during the day, and nearly all eat at least three times per day. The average daily intake of vitamins and minerals at least meets the recommended dietary allowances (RDAs). Overall, students consume more food energy on average than recommended, suggesting that some may be at risk of consuming more food energy than is optimal. Students also consume more protein, total fat, saturated fat, and sodium than is recommended for good health. National School Lunch Program (NSLP) participants' mean intakes of most nutrients at lunch meet the program goal of at least one-third of the RDA. NSLP participants, however, consume more fat, saturated fat, and sodium than is recommended. School Breakfast Program (SBP) participants' mean intakes of most nutrients at breakfast also exceed the program goal of one-fourth of the RDA. However, their breakfast intakes of saturated fat as a percentage of food energy, cholesterol, and sodium exceed dietary recommendations.

Dietary effects of the National School Lunch Program and the School Breakfast Program.

In this paper we use 24-h dietary recall data to assess the dietary effects of participation in the National School Lunch Program (NSLP) and the School Breakfast Program (SBP). After adjustment for differences in characteristics between NSLP participants and nonparticipants, NSLP participation is associated with higher lunch intakes of vitamin A, calcium, and magnesium, and a lower intake of vitamin C. Although mean intakes of other key dietary components such as food energy, iron, cholesterol, and sodium are higher for NSLP participants than for nonparticipants, these differences appear to be due to underlying differences in unobserved characteristics (eg, food preferences, appetites, or food energy needs) rather than to the NSLP. Both at lunch and over 24 h, NSLP participation is associated with consumption of a higher percentage of food energy from fat and saturated fat. SBP participation is associated with higher breakfast intakes of food energy, calcium, riboflavin, phosphorus, and magnesium, and with a higher percentage of breakfast food energy from fat and saturated fat, and a lower percentage of food energy from carbohydrate.

The School Nutrition Dietary Assessment Study: summary and discussion.

This paper summarizes the key findings of the School Nutrition Dietary Assessment Study and discusses the implications for policy and practice in the National School Lunch Program (NSLP) and the School Breakfast Program (SBP). Reducing total fat offered in NSLP lunches to the amount set in the Dietary Guidelines, as called for in the proposed regulations published by the US Department of Agriculture in June 1994, would be facilitated by changing the legislative requirement to serve whole milk. In addition, the following menu choices and meal preparation methods would reduce considerably the amounts of fat in NSLP lunches: reducing the average meat serving from 2 to 1.5 oz; eliminating high-fat meats, high-fat cheese, nuts, and nut butters; eliminating high-fat desserts and milk-based desserts; and reducing sharply the use of added fats in food preparation.