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The Women and Girls Center for Maternal Health intergenerational approaches to address the Black maternal health crisis

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The Women and Girls Center for Maternal Health intergenerational approaches to address the Black maternal health crisis

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Content The Women and Girls Center for Maternal Health
Intergenerational Approaches to Address the Black Maternal Health Crisis
Alexia Blyther, LICSW
Capstone Project
Doctor of Social Work
Suzanne Dworek-Peck School of Social Work, University of Southern California
October 2021
December 2021 degree conferral

ii
Acknowledgement
I would like to give all honor and praise to my Heavenly Father and Creator. He has sustained
me and given me greater in every possible way. He has restored me to the fullness of all that life
could be on this Earth. My thankfulness to Him is boundless and I am eternally grateful to Him
as His daughter. Next, I want to acknowledge my home tribe, Aaron, David and Aviel. Aaron,
you have inspired me to go beyond what I thought I was capable of or what was possible for me
to achieve. You are my best friend, my protector and the love of my life, Thank you. David, my
King in the making. You have always been my greatest motivator and the reason for everything
I do. In all my achievements, nothing matters more than being your Mother. You gave my life
purpose; I love you beyond what is imaginable. Aviel, my Prince. Every day that I hear your
laugh or see you smile, my heart skips a beat. When I hold you, it is still like I am dreaming. I
cannot believe that the Creator saw fit to give me the perfect gift that is you. My sons, your lives
are miracles throughout the difficulty of my reproductive hardships. I pray that you both are
one-of-kind in this tough world and yet I have no doubt that you both will be. To my Mother and
Father. Alice and Nathaniel. I will never know what it was like to give birth and have the
burden of loving eight children, but in the good and the bad you did. Thank you. Mama, you
were so strong and unyielding in your intent to raise kind, loving and strong girls with integrity
and good character. I hope that we have made you proud. To my tribe of Queens, Allyson, my
soul sister, you are simply made of stuff that is not on this Earth. Your heart, mind and soul have
an indescribable language. Thank you for your never-ending kindness and purity in the way that
you love. Angie, my shield and defender. While you think that I have grown up and supported
you, it has been you supporting me. Thank you for always believing and wanting the best for
me. You were always there behind the scenes making sure that I was safe, healthy and happy.

iii
Thank you. Alonda, my fellow warrior. It is hard to imagine walking this life without you. You
are stronger than I will ever be. You are all that I hope to have and be in Eternity. Thank you.
Andrea, my Princess. If I had a daughter on this earth, she would be as kind and sweet as you.
You are a ray of sunshine with an amazingly delicate heart. You teach me what love should feel
like. I will always protect and guide the highest version of your Spirit. Thank you. Amia, my
Wisdom. You are the essence of unspoken grace. It is what you do not say that is the greatest
thing ever expressed. You are a gem looking for no shine, yet you have the most. Thank you. To
my brothers. Mick, my twin flame. You are beyond everything this world can hold in its hand.
Thank you for teaching me the irony and depths of life, what is understood and what will never
be. Thank you. Marcus, my quiet Lion. You said, “it’s not what you die for but it’s what you
live for”. You have taught me the epitome of living for others. Thank you. To my “rally-round-
the flag” brother Aaron. You came into our family at a transitional time and took on the
leadership and guide for the tribe of sister Queens. You took us on as your own, a son to my
mother and a trusted brother to all of us. Thank you. To Brandon, watching you grow up from
elementary school to becoming a great dad makes me so proud and our family is blessed to have
you. Thank you. To my Prince and Princess Mikka and Aniyah. Mikka, you are destined to and
will do great things. Your unquenching will-to-do has already set the course for a triumph in
anything you do. I will never stop believing in you. Aniyah, your capability is beyond the years
that you have been on the Earth. Take hold of all life has for you. Thank you both. To the rest of
the tribe; eldest brother Eric, Crystal, Malika, Aiden, Andrew, Cameron, Aria, Anorah, Derrick
and Roman. I love you with all of my heart and look forward to the rest of this journey with
each you. May Blessings, Peace, Longevity, Health and Prosperity be upon this tribe for now
and generations to come. In His grace, Amen.

iv
Executive Summary
The Grand Challenges of Social Work (GCSW) include some of the most persistently
challenging social issues. The American Academy of Social Workers and Social Welfare led
this initiative that called for collective action to address significant social problems (Fong,
Lubben, & Barth, 2018). A key feature of the GCSW is its intractable nature requiring
multivariate solutions. The grand challenge of Closing the Health Gap, which supports
eradicating health and mental health disparities across race, ethnicity, gender, and social classes,
is the basis for this project (Bent-Goodley, Williams, Teasley, & Gorin, 2019).
The Centers for Disease Control and Prevention (CDC) have maintained national
statistics on maternal mortality across racial categories since the early 1900s (Holdt Somer,
Sinkey, & Bryant, 2017). Maternal mortality for Black women has historically and consistently
surpassed that of white women. As recent as 2018, the CDC reports that roughly 700 women in
the United States die a pregnancy-related death each year (Building U.S. Capacity to Review and
Prevent Maternal Deaths, 2018). The rate of Black maternal deaths is 3 to 4 times that of white
women (Hoyert & Minino, 2020). The top causes of pregnancy-related deaths are cardiovascular
conditions, infection, and hemorrhage (Building U.S. Capacity to Review and Prevent Maternal
Deaths, 2018). Cardiovascular disease has the most significant impact on Black women and
causes this increased mortality rate (Petersen et al., 2019). This disparity historically has affected
Black women, men, children, and the community.
A review of the current literature on the intersection between Black maternal health,
African American health behaviors, cardiovascular disease development across the lifespan, and
the development of intergenerational norms related to health behaviors all point to a pervasive
cycle. Research findings indicate that pregnancies complicated by maternal obesity alter the

v
cardiovascular development of the fetus (Roberts, Frias, & Grove, 2015). Studies have
highlighted the connection between Black mothers’ dietary intake and their young children,
specifically girls (Wang, Li, & Caballero, 2009). Research also shows that social and dietary
aspects of the home environment mitigate that childhood obesity (Campbell et al., 2007). Black
girls (ages 6-11) have one of the nation’s highest obesity rates (National Center for Health
Statistics, 2018). Black women have the highest obesity rate compared to other groups in
America (National Center for Health Statistics, 2018). Obesity pre-disposes offspring to
develop obesity (Roberts, Frias, & Grove, 2015). Obesity is a precursor for cardiac disease
(Teefey & Durnwald, 2017). Finally, cardiac disease is the primary factor that leads to Black
maternal deaths and near-death events (Building U.S. Capacity to Review and Prevent Maternal
Deaths, 2018). This cycle could provide a more in-depth understanding of the root cause of poor
maternal outcomes for Black mothers.
This project proposes expanding and partnering with a current community health center
that provides accessible care that would not be otherwise available in a predominantly African
American community. Specifically, this project intends to open a Women and Girls Center for
Maternal Health (WGC-MH) that sits within a larger pre-established Federally Qualified Health
Center (FQHC). Traditional medical services available at FQHCs will include prenatal care,
post-partum care, health screenings and visits, obesity prevention, and management.
Additionally, the WGC-MH will provide services that improve social and environmental norms
that contribute to poor health behaviors in the home and the community. These services will
include home nutrition support and guidance, exercise training and support, health counseling
services, and community planning and organizing. All services will focus on the WGC-MH’s
goal of improving intergenerational health behaviors, primarily among women and girls,

vi
impacting Black maternal health. This expansion’s goal would enhance Black maternal health
services by encompassing a life course approach that addresses childhood obesity in Black girls.
The life course approach strategically focuses on intergenerational health behaviors.
The target population for this project includes Black women and girls and the health
programs that serve them. The community of focus for this project is Washington D.C. (WDC).
WDC has a significantly higher Black maternal morbidity and mortality rate than nearby regions
(Russell, Rondeau, & Quinn, 2018).
Social Cognitive Theory provides a framework for the cyclical problem of health
behaviors and disease outcomes among Black women and girls. Its basic supposition is that
people learn not only by their own experiences but by observing others in their environment.
These observations are in the context of social, emotional, and physical interactions and the
corresponding outcomes of these interactions (Glanz, Rimer, & Lewis, 2002). This theory
supports the idea that health behaviors developed and observed intergenerationally influence
maternal health outcomes for Black women.
Research indicates a 20-year lag between improvement in early childhood health and its
manifestation in maternal health in later life. Therefore, health behaviors that reduce chronic
disease risks must begin early in childhood (Almond, Currie, & Hermann, 2012).
The conceptual focus of this project is if Black women and girls, who model each other in a
family, community, and cultural settings, can increase their confidence in the ability to exert
control over their motivation, behavior, and social environment (self-efficacy), they can improve
lasting motivation to change health behaviors.
The critical elements of human-centered design include empathy, defining, ideate,
prototyping, and testing (Stanford d.school: The Bootcamp Bootleg, 2013). It has been essential

vii
to a user-centered process to gain a clear perceptual understanding from Black mothers and
families who have experienced maternal health disparities, including whether they consider this a
wicked problem. Interviewing Black women and families who have experienced maternal health
challenges has provided crucial insight into their perspectives. These interviews have been
critical to understanding how this problem has impressed their lives and how I can best relate to
their experiences without overshadowing them with my own. Insights gained while engaging
Black mothers and families are incorporated into my perspective and fed into the problem
definition. User experiences, the current maternal health solutions landscape, research, and
networking with stakeholders have resulted in various solutions that take an alternative view of
maternal health disparities. Prototyping allows for the physical expression of ideas. Black
mothers and critical stakeholders can interact with solution concepts to visualize and explore
their feasibility through prototyping. Prototype development of the WGC-MH’s user journey
map is in progress. Testing will allow for the feedback and refinement of solution concepts.
Additionally, this phase provides empathy by displaying the value of user feedback. Finally,
testing allows for multiple iterations of innovative ideas.
Lifestyle behavioral change and maintenance are complex processes involving an
individual’s motivation and preparedness for change. A significant life incident or a novel
appreciation and acceptance of maladaptive health behavior consequences often initiates the
health behavior change process (Street & Lacey, 2017). The WGC-MH’s programming will
provide a culturally relevant lens to the consequences of maladaptive health behaviors and
measure participants’ readiness for change.
The long-term strategy for the WGC-MH’s program model will be to provide the
evidence base to utilize intergenerational preventative health programs to fulfill the national

viii
performance measures within the federal Maternal and Child Health Block Grant (MCHBG)
Program. Based on the success of this sustainability plan, the scalability plan will be that the
WGC-MH will serve as a Technical Assistance Center for Excellence in Maternal Health
Innovations. This Center for Excellence’s goal would be to assist state program recipients of
MCHBG funds in developing similar programs that provide life course and intergenerational
approaches to the Black maternal health crisis.

ix
Table of Contents
Executive Summary ii
List of Tables ix
List of Figures x
Part One Conceptual Framework 1
Definition of Relevant Concepts 1
Problem Significance & Implications 3
Research Practice & Innovations in Maternal Health 4
Conceptual Framework Summary 8
Part Two Problems of Practice and Solutions/Innovations 10
Stakeholder Perspectives & Existing Evidence 10
Overview of Solution/Innovation 10
Description of Solution/Innovation 11
Considerations for Existing Innovations 16
Proposed Innovation Alignment with Theory of Change 16
Success Prospect for the Women & Girls Center for Maternal Health 16
Part Three Project Structure, Methodology, and Action Components 18
Project Implementation & Analysis of Facilitators and Barriers 18
EPIS (Exploration, Preparation, Implementation, & Sustainment) Model 19
Analysis of Market & Alternative Strategies 21
Financial Plans 22
Opinion Leaders and Change Agents 29
Diversity and Inclusion 30
Methods for Assessment of Impact 31
Ethical Considerations 31
Part Four Conclusions, Actions, and Implications 33
Title V Maternal and Child Health (MCH) Block Grant 33
MCH Block Grant and Impact 33
Implications for the WGC-MH Programming on Maternal and Child Health 35
Project’s Future Aim: Black Maternal Health Innovations Center for Excellence 36

x

Next Steps and Prototype Dissemination 37
Alternative Next Steps 37
References 38
Appendices 45

xi
List of Tables
Page
Table 1..........................................................................................................................15
Table 2..........................................................................................................................23
Table 3..........................................................................................................................34

xii
List of Figures

Figure 1........................................................................................................................35

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Part One: Conceptual Framework
Black women experience a disproportionate rate of pregnancy-related deaths, which
creates a significant health disparity. These deaths are primarily due to cardiovascular conditions
and are largely preventable. Maternal mortality in the African American community is a
devastating problem in this Nation (Government Accountability Office 20-248, 2020).
The Grand Challenges of Social Work were designed as a clarion call to focus the field
of Social Work around 12 fundamental social problems that are considered “wicked” (Bent-
Goodley et al., 2019). Wicked problems are defined in this manner because their causes are
multifactorial, and they do not have a single ideal solution. Closing the Health Gap (specifically
the maternal health gap) is one of these wicked problems.
Definition of Relevant Concepts
Key concepts in this project that drive Black maternal health outcomes include
intergenerational health behaviors, culturally relevant health promotion, community-wide
development of health norms, and advancement through Stages of Change (Prochaska, 2008).
Intergenerational health behaviors are spread cyclically throughout familial generations based on
norms within that family. Health behaviors are all activities that impact health (Short &
Mollborn, 2015). These activities can be intentional or unintentional based on fixed cultural or
familial norms. Health activities that are relatable to the culture of the participant comprise
culturally relevant health promotion. The PEN-3 cultural model focuses on culture in
conceptualizing health beliefs, behaviors, and health outcomes. The model provides a cultural
framework when defining health problems and framing their solutions and has three dimensions:
1) cultural identity, 2) relationships and expectations, and 3) cultural empowerment (Iwelunmor
et al., 2014). Each dimension includes three factors that form the acronym PEN; Person,
Extended Family, Neighborhood (Cultural Identity); Perceptions, Enablers, and Nurturers

2
(Relationship and Expectation); Positive, Existential and Negative (Cultural Empowerment)
(Iwelunmor et al., 2014). Socially enforced rules or expectations are norms (Bicchieri, 2016).
Community-wide development of health norms creates agreed-upon norms that support health
and are practiced collectively within a community. In the process of unraveling social norms in
the African American community that contribute to poor intergenerational health behaviors, we
must preserve the cultural and identity features of these norms. Improving family health norms
among Black women and girls is the basis for designing intergenerational health promotion
projects. These could include cooking or exercise challenges in the home. Community-driven
projects include those that address health behaviors in the Black community. These could
consist of cultivating a community garden, drafting a petition to local leaders for healthier
grocery options, or organizing community fitness efforts.
Finally, attainment and maintenance of lifestyle behavior change is an intricate process
that encompasses an individual’s motivation and preparedness for change (Lacey & Street,
2017). The Transtheoretical Model of Behavior Change includes the Stages of Change
construct (Prochaska, 2008). The Stages of Change include five distinct stages that represent
stages in preparedness to change. These stages consist of 1) pre-contemplation: the individual is
uninformed of the consequences of their behavior and has no intent to change; 2) contemplation:
the individual is becoming informed of the consequences of their behavior and open to change;
3) action: the individual begins some modifications in behavior and shows enthusiasm towards
the change process, and 4) maintenance: the individual exhibits sustainment in behavior changes
for more than six months and exhibits persistence in the changed behaviors (Prochaska, 2008).
Black women and girls who advance through the stages of change will have an increased ability

3
to control their motivation, behavior, and social environment, supporting an enduring aim to
change health behaviors.
Problem Significance & Implications
In the United States, the overall percentage of preventable maternal deaths is above sixty
percent (Building U.S. Capacity to Review and Prevent Maternal Deaths, 2018). Black women
comprise most of these preventable deaths (Louis et al., 2015). The economic effect of
preventable poor maternal health outcomes substantially advances the cause for health reform in
maternal health disparities. The Centers for Medicare and Medicaid Services provide insurance
coverage through State Medicaid agencies for one-third of the births in the United States (Zhang
et al., 2013). Among these births, adverse outcomes most occur among Black women. The
adverse outcomes include increased unplanned cesarean surgical procedures and prolonged
hospitalizations, which incur increased Medicaid costs (Mehta, 2014). Maternal health
disparities among African Americans are prevalent for both the mother and child. These
disparities include but are not limited to pre-term births, pre-eclampsia events, stillbirths, and
maternal deaths (Howell et al., 2018). In 2013, over 20,000 African American pre-term births
cost Medicaid over $100 million in hospitalization care for the mother alone (Zhang et al., 2013).
Late-term deliveries before 37 weeks of pregnancy can incur an additional $25,000 in
hospitalization costs in the first 24 months post-birth (Bird et al., 2010). It is estimated within
14 Southern states that eliminating maternal health disparities would provide Medicaid with
$100-200 million in cost savings (Mehta, 2014). Health disparity reform on poor pregnancy
outcomes for Black women would offer a significant return on investment for the federal
government.

4
Over 200 million pregnancies lead to more than 100 million newborn deliveries (Graham
et al., 2016). On a macro level, good maternal health outcomes are essential to the viability of
future generations. However, on a global scale, disparate maternal health outcomes
disproportionately occur among the most vulnerable group of women. For example, no licensed
healthcare providers attend to most birth deliveries in the low-income Malinda district in Kenya,
leading to high maternal mortality rates in that district (Lang’at et al., 2015).
In India, researchers found significant inequalities in the application of prenatal services
to poor and indigent mothers (Pathak et al., 2010). These outcomes reflect distinct international
population health system inequities for these women.
Globally, the causes of poor maternal outcomes are wide-ranging. These include various
sociological, environmental, economic, and epidemiological factors. Globally, fertility rates are
innately intertwined with maternal health because it serves as a requisite to pregnancy (Graham
et al., 2016). Therefore, due to the unmet need for contraception, high population growth rates
occur in developing countries. This increase in population leads to instability of already fragile
healthcare systems that cannot adequately prevent or treat non-communicable diseases.
Similarly, environmental transitions bring additional stressors to the health system and
socioeconomic system (Graham et al., 2016). Maternal health inequities are far-reaching and
threaten the future vitality of the world’s underserved populations.
Research, Practice, and Innovations in Maternal Health
In the United States, efforts to drastically reduce maternal mortality across all populations
and among minority populations begin with redesigning the documentation of these deaths to
gather valuable and consistent data to scope the problem effectively. The CDC National Center
for Health Statistics (NCHS) made essential changes in maternal mortality coded, published, and

5
released. Prior to 2018, NCHS had last published maternal mortality data in 2007 because states
were incrementally implementing the pregnancy status indicator on the standard U.S. vital
records for reporting deaths (Hoyert & Minino, 2020). As of 2018, all states have completed this
task. With all states reporting pregnancy-related deaths on death records, NCHS developed a
more efficient collection of maternal mortality data.
As a follow-up to the data collection and vital statistics methods for maternal deaths,
trained professionals need to review and analyze this data for actionable next steps. Maternal
Mortality Review Committees (MMRCs) complete in-depth reviews of pregnancy-related
deaths. Professionals from multiple health-related fields constitute these state-by-state
committees. An array of public health professional groups, including obstetricians, nurses,
mental health, pathologists, patient advocates, social workers, and other multidisciplinary
stakeholders, serve on these committees (Building U.S. Capacity to Review and Prevent
Maternal Deaths, 2018). MMRCs review deaths in six key areas related to death. These include
the correlation to the pregnancy, preventability, underlying causal factors, contributing factors,
actionable recommendations, and implemented recommendations. To assist MMRCs, the CDC
developed the Maternal Mortality Review Information Application (MMRIA). This foundational
technology stores this data (Division of Reproductive Health, National Center for Chronic
Disease Prevention and Health Promotion, 2020).
Quality hospital care is an effective driver to improve health outcomes. Another effort to
reduce poor pregnancy outcomes, specifically in racial/ethnic minorities, is Patient Safety
Bundles. The Alliance for Innovation in Maternal Health (AIM Program) and the Council on
Patient Safety in Women’s Health Care is interdisciplinary groups that published the Reduction
of Peripartum Racial/Ethnic Patient Safety Bundle (Howell & Zeitlin, 2017). The patient safety

6
bundles address the following and provide recommendations 1) readiness, 2) recognition, 3)
response, 4) reporting, and 5) systems learning (Howell & Zeitlin, 2017). Four themes underlie
recommendations related to decreasing racial disparities in the peripartum phase. These include
1) the failure to evaluate disparities due to inconsistent assessment, 2) the deficient recognition
of systemic and patient-level disparities, 3) understanding the scale of racial disparities, and 4)
poor communication (Howell et al., 2018).
Perinatal Quality Collaboratives (PQC) is another effort to address poor maternal
outcomes. PQCs are state-by-state networks of healthcare professional teams that work to
advance improved maternal health through proven clinical expertise and quality assurance
processes (Main, 2018). PQCs embody three critical stakeholders, including leaders from health
departments, hospitals, and clinical provider leadership.
Legislative Efforts
In July 2020, Representatives Lauren Underwood (IL-14) and Alma Adams (NC-12), founders
and co-chairs of the Black Maternal Health Caucus, convened a summit of more than 100
organizations working to address the Black maternal health crisis (Caucus, 2020).
Community Efforts
Black Mamas Matter Alliance (BMMA) is a Black women-led coalition that centers Black
mothers on advocating, leading research, and empowering Black maternal health rights. BMMA
developed a toolkit with resources to engage Black women and girls in the discussion on Black
maternal justice (Black Mamas Matter Alliance, 2020)
Uzazi’s Village is a non-profit organization that uses community-supported care models
to decrease premature birth, increase breastfeeding, improve pregnancy complications, improve
healthcare access, and increase people of color in the perinatal workforce (Payne & Ratleff,

7
2017). The National Birth Equity Collaborative creates solutions that optimize Black maternal
and infant health through training, policy advocacy, research, and community-centered
collaboration (Black Mamas Matter Alliance, 2020).
Global Efforts
On a global scale, the Sustainable Development Goals (SDG) are “a universal call to
action to end poverty, protect the planet and improve the lives and prospects of everyone,
everywhere” (Nations, n.d.). The United Nations enacted these Goals in 2015 and proposed a
15-year timeline to achieve goals. SDG #3, labeled Good Health and Well-Being, asserts
maternal health as a focus. According to the strategic framework of the SDG, globally, 98%
(significantly higher than U.S. estimates) of maternal deaths are preventable; however, mothers
in developing regions die during childbirth 14 times more than mothers in developed regions
(Kruk et al., 2016). Global and population health experts consider large-scale opportunities to
address maternal health internationally. Kruk et al. (2016) assert that future health systems must
respond to the changing variables in women’s lives. These variables include but are not limited
to urbanization, increased access to data and information, and the developing prospects of
women-centered care (p. 2297).
Urban living will bring essential benefits to expecting mothers and newborns, including
reduced travel times to health care providers, more choice in provider selection, and a greater
pool of highly skilled providers. For example, the Bangladesh Rural Advancement Committee
(BRAC), a community-based healthcare program, developed an integrated, community-based
package of essential health services to be delivered in the slums of Bangladesh (Kruk et al.,
2016). The services include antenatal checkups, nutrition education, post-partum visits,
childhood immunizations, and delivery services near the homes of expecting mothers. In

8
response to urbanization, BRAC located its successful program in several urban areas within
Bangladesh.
Due to the data revolution and 95% cellular coverage worldwide, mobile health can
directly engage underserved women and families (Kruk et al., 2016). Increased technology will
allow individuals to have home-based self-care and diagnostic instruments when affordable
transportation to healthcare facilities is not an option. An example in South Africa is the
MomConnect program that sends health-related messages via text to pregnant and post-partum
women (Kruk et al., 2016). Another example is a mobile citizen reporting system available in
Uganda and India. This mobile service allows patients to report poor healthcare facility services,
inadequate provider care, and other negative healthcare experiences (Kruk et al., 2016).
Lastly, global health experts consider behavior economics as a venue to meet the rising
expectations of women-centered care. Improved maternal health relies on not only accessible
health care but also the pro-health choices of pregnant women. Behavioral Economists find that
people living with ongoing poverty-induced stress factors might abate their own better judgment
by selecting default options to simplify complex choices (Kruk et al., 2016). By using a
behavioral economics framework, there is an opportunity to limit suboptimal outcomes where
patient choice selection is a contributing factor. Three promising approaches to achieve this
include 1) shifting the order of options (desired options become the default), 2) altering the
outline of information, and 3) giving financial incentives for resisting pressures to select
undesirable options (Kruk et al., 2016).
Conceptual Framework Summary
Poor maternal health is an insidious problem that most impacts Black women in America
and other marginalized women in low-income nations. This problem is front and center

9
nationally and internationally. Population-focused initiatives on the global scale (e.g., SDG)
have introduced superior innovations to address poor maternal health outcomes. Global
initiatives to address maternal health are population-focused and consider broad social
determinants to address this wicked problem. In this manner, these innovations are
foundationally more holistic. The United States has exceedingly more resources than nations
such as Uganda and India. However, despite many efforts, this nation has fallen behind
significantly on maternal health innovations.

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Part Two: Problems of Practice and Solutions/Innovations
Stakeholder Perspectives & Existing Evidence (Policy, Practice, and Public Discourse)
Efforts to address Black maternal health disparities are widespread. It is a hugely current
issue that has gained much focus. Governments and organizations want to solve this problem at
the federal, state, and local levels. This investment is incredibly positive. However, with all the
investments made to reduce Black maternal health disparities, the statistics remain abhorrent.
This point leads to another problem that is unaddressed in the current matrix of solutions. This
problem includes the cyclical nature of health behaviors and disease outcomes among Black
women and their offspring.
The CDC Foundation directed that addressing social determinants of health will have a
more significant population-level impact on eradicating maternal morbidity (Building U.S.
Capacity to Review and Prevent Maternal Deaths, 2018). Health Practitioner stakeholder
interviews further informed that addressing social determinants of health is well supported in the
current maternal health discourse. Additionally, all interviewed stakeholders advise that
innovators must dually consider Black maternal health through the lens of healthcare access
combined with social determinants of health to gain a full spectrum view of where this problem
lies. Additionally, federal policy and local expert stakeholders report that programs that jointly
address reducing childhood obesity and poor Black maternal health outcomes are not in the
current solution landscape with a narrow focus on intergenerational health behaviors.
Overview of Solution/Innovation
The research evidence and stakeholder feedback culminate in a solution proposal that
entails partnering with a pre-established healthcare clinic that provides accessible care that would
not be otherwise available in a predominantly African American community. This partnership’s

11
goal would be to enhance Black maternal health services by encompassing a life course approach
addressing childhood obesity in Black girls. The life course approach would consist of medical
services and address social and environmental factors that influence childhood obesity and poor
maternal health for Black females. This approach addresses the social work grand challenge of
closing the health gap by incorporating social determinants of health (social and environmental
factors) and building on currently established healthcare access efforts. The short-term goal is to
activate Black women and girls to improve social and environmental norms that lead to poor
maternal health. The program objective is for program participants to become aware of the
specific intergenerational dynamics that influence and reinforce maladaptive health behaviors.
This awareness will lead to the development of change strategies. The mid-term goal is that
Black women and girls advance through the Stages of Change (Prochaska, 2008). The long-term
goal for this proposal will be to meet the national performance measures within the federal
Maternal and Child Health Block Grant (MCHBG) Program by utilizing intergenerational health
programming. Based on the success of this sustainability plan, the scalability plan will be that
the WGC-MH will serve as a Technical Assistance Center for Excellence in Maternal Health
Innovations. This Center for Excellence’s goal would be to assist state program recipients of
MCHBG funds in developing similar programs that provide life-course and intergenerational
approaches to the Black maternal health crisis.
Description of Solution/Innovation
This project proposes expanding a current Federally Qualified Health Center (FQHC).
FQHC’s are non-profit, public-serving community health care centers that receive funds from
federal and local governments, the private sector, and charitable donations. This expansion
would include a women and girls center that enhances Black maternal health services. The target

12
population for this project comprises Black women and girls and the health programs that serve
them. The FQHC will be a critical source of referrals to the WGC-MH. The community of focus
for this project is Washington D.C. (WDC). WDC has a significantly higher Black maternal
morbidity and mortality rate than nearby regions (Russell, Rodehau, & Quinn, 2018). WDC’s
Wards 7 and 8 are plagued explicitly with poor maternal outcomes due to significant health and
social factors. In these Wards, maternal health services are more limited than in other areas of
WDC (Russell, Rodehau, & Quinn, 2018). In Ward 7 alone, there is a population of
approximately 37,270 African American females of all ages (U.S. Census Bureau, 2019). Ward 7
has 1.5 times more households living below the poverty line than the rest of the city. Among this
population, 78% are single households, with 85% holding high school diplomas as the highest
education level (U.S. Census Bureau, 2019). The fertility rate in Ward 7 is 20% higher than in
the rest of the city (U.S. Census Bureau, 2019). Approximately ten health centers serve over
30,000 African American women and girls in Ward 7 (DC Department of Health, 2018).
The partnering FQHC will refer their current primary care patients that could benefit
from WGC-MH services. General inclusion criteria include women aged 25-44 years and young
girls as young as age 8. The FQHC will continue to provide all medical care while the referred
patient participates in WGC-MH programming. The WGC-MH and FQHC will cross-coordinate
relevant health services for each referred patient.
The WGC-MH will have a hybrid online and in-person program that provides women
and girls programming to address health, social and environmental factors that impact Black
maternal health outcomes. Adult women (age 25 and older) referred to the WGC-MH from the
partnering FQHC will sign up for the program via a website. Upon entering the interactive
website, she will create an account. Once the participant creates an account, she will book a

13
virtual session with a Health Counselor to arrange for program registration and orientation as a
new program participant. Once fully registered for WGC-MH, the woman can now begin to
invite individuals to her network. A network must include a young person (a Black girl between
ages 8-24 and at least five years younger than the participant) or other family or community
members who will participate in community engagement sessions or WGC-MH Events. Women
must be age 25 and older to sign up for the WGC-MH. Black women and girls under age 25 can
join the program in two ways:
1) invited to the network of a woman over age 25 or;
2) as a mentee for a woman who has entered the program without a young person in her network
Women over age 25 may enter the program without a young woman or girl but must be
willing to mentor a young woman or girl at least five years her minor. The WGC-MH will have
four concentrations: dietary/nutrition, exercise, community engagement, and WGC Events. The
dietary/nutrition and exercise concentrations provide the participant and her young person an
opportunity to co-develop diet and exercise plans with assistance from the participant’s Health
Counselor. These activities can be done together or separately based on the availability and
preferences of the participant and her young person. However, the participant, young person,
and the Health Counselor must agree on the joint goals of the activity (i.e., healthy meals per
week, days of exercise per week, etc.). If the participant and young person cannot complete
agreed-upon activities together, they will complete weekly in-person or virtual FaceTime check-
ins while completing the activity separately. While the participant completes registration, the
Health Counselor will coordinate with the FQHC primary care coordinator access to health
information needed for WGC-MH programming, including weight, blood pressure, pregnancy-
related trimester screenings, and other related information.

14
Community engagement and WGC Events concentrations are open to other family or
community members. Participants may invite partners, fathers, sisters, brothers, and
family/community members to their network to participate in community engagement sessions
and WGC Events. Community engagement and WGC Events will be the only program
concentrations that will have an in-person modality. Community engagement sessions will
provide participants and invited family/community members to engage in sessions led by
community activists to share skills that help participants self-advocate for community
improvement initiatives. There will be two types of WGC Events:
1) Members-Only (participants and young persons) events and;
2) Community-wide events
Members-Only events will include large-scale exercise classes, cook-offs, and fashion shows, to
name a few. Community-wide events will consist of activities such as health expos and family
cooking fairs. These events will underscore community-wide collaboration to improve
community health (See Appendix A).
All women and girls who sign-up for WGC-MH will get an initial complete baseline
physical examination by FQHC staff, nutrition evaluation, and a psycho-social assessment. The
psycho-social evaluation will include assessing factors that influence health behaviors from a
mental and social perspective. Health Counselors will coordinate physical, nutrition, and psycho-
social assessments every 12 weeks to rate improvements and changes.
Each participant will sign a community commitment letter that serves as an agreement to
improve self, family, and community health and a commitment to invite a young person to the
program. If the participant does not have a young person to ask, the program will assign a young
person. After the initial set up of baseline health assessments and signing the commitment letter,

15
participants and young persons will work with Health Counselor to develop a Life Health
Improvement Plan. Program staff will transfer results from the baseline and 12-week follow-up
physicals, nutrition evaluation, and psycho-social assessments to the Life Health Improvement
Plan. The Life Health Improvement Plan will be co-developed between the participant, young
person, and Health Counselor. It will include action steps for an improved healthy pregnancy,
healthy weight, cardiac health, completion of an intergenerational health promotion project, or
participation in a community-wide project. Health Counselors and participants will track action
steps progress within the Life Health Improvement Plan.

Table 1
Competitive Analysis of Current Solutions Landscape

Design Criteria
Features
Washington, D.C.
Healthy Start
Programs
Community of
Hope Family
Health and Birth
Center
Children’s Health
Center
Adolescent
Health Center
Family Medical
Counseling
Service – Seat
Pleasant
Women and Girls
Center for
Maternal Health
Pregnancy
health services
✓ ✓ ✓ ✓
Childhood
obesity
prevention and
management
✓ ✓ ✓
Activities to
improve
intergenerational
norms
✓
Traditional
medical services
related to
medical
screenings and
evaluations
✓ ✓ ✓ ✓ ✓
Activities to
improve
community
health behaviors
✓
Counseling
services
✓ ✓ ✓ ✓
Exercise
guidance and
support
✓ ✓
Nutrition
guidance and
support
✓ ✓ ✓ ✓ ✓

16
Considerations for Existing Innovations
Four Health Centers in WDC currently provide some combination of maternal health
services, childhood obesity prevention and management, traditional medical services, counseling
services, and exercise/nutrition guidance and support. However, each of these Health Centers
offers these services in a singular capacity for maternal health or childhood obesity. These
Centers do not account for the intergenerational nature of health behaviors and disease outcomes
that lead to poor outcomes in Black maternal health.
Proposed Innovation Alignment with Theory of Change
The theory of change supporting the WGC-MH program supports community
partnerships, culturally validated intergenerational health approaches, accessibility, community
engagement in the development of renewed community health norms, and advancement through
the Stages of Change (Prochaska, 2008) leading to improved maternal outcomes health outcomes
for Black Mothers (see Appendix B). This process is not linear, with definitive points of
completion but rather cyclical and non-judgmental. Participants move fluidly through this
process allowing for setbacks and re-engagement. The goal is to integrate the change into the
intrapersonal, interpersonal, and cultural fabric of Black women, girls, families, and community
members.
Success Prospect for the Women & Girls Center for Maternal Health
What are the norms that support a static state for poor maternal outcomes among Black
women? Factors such as slavery, oppression, discrimination, and cultural annihilation
contributed to the need for a group-based identity norm in the African American community.
African American health behaviors are not one-dimensional. They are a microcosm of Black
history in America, extending from Africa through slavery, emancipation, migration,

17
assimilation, Jim Crow, civil rights, integration, and multiculturalism (Henderson, 2007).
African American social norms include unspoken rules about what this community believes is
vital for identity, a basic human psychological need.
As maladaptive social norms around health behaviors exist within the African American
community, they must be carefully disassembled and reassembled (Almond, Currie, & Hermann,
2012). The WGC-MH must operate within this conceptual foundation to increase the likelihood
of programmatic success.

18
Part Three: Project Structure, Methodology, and Action Components
Project Implementation & Analysis of Facilitators and Barriers
Implementation strategies include techniques utilized to enhance the adoption,
implementation, and sustainability of a program or initiative (Powell et al., 2015). The following
multifaceted strategies are the most significant in the WGC-MH program implementation.
Obtaining a formal commitment with a WDC Ward 7 or 8 FQHC is a foundational strategy to
implementing the WGC-MH program. This partnership will provide the avenue for engaging
with public health center consumers who live in a service area with disproportionately high
maternal morbidity and mortality rates (US Census Bureau, 2019). Another foundational
strategy of the WGC-MH includes the active participation of participants. The structure of the
WGC-MH is that Black women, girls, and community members will become aware of the
specific individual, family, and internal community dynamics that influence and reinforce
maladaptive health behaviors and then co-create change strategies. Therefore, this participation
will be vital to the pre-implementation, implementation, and sustainment phases. Pre-
implementation efforts of involvement will include interviews, surveys, and engagement events.
Ongoing feedback sessions will be conducted during the implementation phase to guide the
sustainment plan further. The WGC-MH will serve as an estimated 3-year demonstration project
to impact federal MCBHG programs in sustainability and scalability. Therefore, during a pilot
phase and full programming, participant feedback, in addition to strong evaluation support, will
be integral to program success. The feedback and evaluation support will drive any adaptations
needed for effective program outcomes.

19
EPIS (Exploration, Preparation, Implementation, & Sustainment) Model
The EPIS model is a framework that addresses the multifactorial complexities of
evidence-based practice implementation (Aarons & Hurlburt, 2011). The EPIS model highlights
facilitators and barriers that impact the probability of successful program implementation
(Palinkas, 2021). Facilitators include factors that increase the chances of programmatic success
and barriers that decrease these chances.
In the Exploration phase, stakeholders, organizations, or other service systems begin to
develop an awareness of challenges that point to the need to adopt new or innovative approaches
(Palinkas, 2021). In this phase, these entities begin to assess which evidence-based practices
best suit the identified needs (Palinkas, 2021). WGC-MH tasks completed in this phase included
research on cultural values within the target population through interviews, funding
opportunities, and legislative/policy supports. Additional tasks include health provider and
stakeholder interviews to gain perspective problem framing.
In the Preparation phase, organizations and health care systems experiment with new
practices and approaches that could lead to permanent organizational system changes (Aarons &
Hurlburt, 2011). WGC-MH tasks completed in this phase included 1) early discussions with
FQHC staff regarding partnership opportunities, 2) drafting financial plans and programmatic
outlines for feasibility considerations, 3) preliminary discussion with WDC primary care and
FQHC leadership, 4) coordination of necessary documents needed to complete funding
proposals, preparation, 5) submission of funding proposal draft, and 6) conducting marketing and
outreach events to the target community.
In the Implementation phase, organizations fully activate new evidence-based practices
(Aarons & Hurlburt, 2011). WGC-MH tasks completed in this phase will include launching the

20
program pilot, conducting stakeholder/community/participant feedback sessions, the evaluation
team’s early assessment for any needed program design adaptations, and full program launch.
The Sustainment phase encompasses using best practices gained in the other three phases
to effectively continue using the innovation in practice (Aarons & Hurlburt, 2011). WGC-MH
tasks completed in this phase include ongoing stakeholder/community/participant feedback
sessions, program evaluation summary, fulfilling national performance measures for the federal
MCHBG program, and plans for the Maternal Health Innovations Center for Excellence.
WGC-MH program implementation barriers highlighted through the EPIS model include
1) limitations from data reliability, 2) navigating political bureaucracy, 3) non-generalizability of
related studies, 4) administrative restrictions from federal funding sources, and 5) poor evidential
support for family-centered treatment models that address childhood obesity. Facilitators
highlighted through the EPIS model include 1) recent improvements in maternal health data
sources, several recent legislative actions supporting Black maternal health innovations, 2)
increased federal funding and socio-political support for Black maternal health initiatives, and 3)
large-scale inter-organizational recommendations for Black maternal health disparity action
steps. The WGC-MH will utilize the FQHC partnership to counter-program implementation
barriers. In collaboration with a current FQHC, the WGC-MH will employ pre-established data
systems to collect data. Additionally, FQHC’s have significant experience interacting with
federal funding opportunities as well as engaging federal systems. The WGC-MH will rely upon
this expertise to neutralize the challenges that face new programs. Lastly, the WGC-MH will
expand the traditional “family participation” approach in addressing childhood obesity by
including all community members to participate in the program. The WGC-MH is an innovation

21
positioned to leverage partnerships and implementation facilitators to reduce the impacts of
implementation barriers (see Appendix C).
Analysis of Market & Alternative Strategies
Notable organizations of various platforms that have effective innovation strategies and
use technologies include:
➢ Black Girls Cook (BGC)
1
is a Baltimore-based non-profit organization designed to
empower adolescent Black girls through culinary arts and urban farming. Black Girls
Cook is available to adolescent girls throughout Baltimore, MD, between age 8 and 15,
with a high priority focus on Black girls living in food deserts and historically under-
served communities. Black Girls Cook prepares each girl to live a healthier life by
teaching cooking skills.
➢ The Center Helping Obesity In Children End Successfully (CHOICES)
2
seeks to
eradicate childhood obesity multifaceted. Through partnerships with fitness trainers,
physical and psychological health professionals, motivational speakers, and dietitians,
CHOICES is a program for families with overweight and obese children. The aim is to
provide a supportive environment for clinically diagnosed and at-risk children of obesity,
including their parents. This program is highly innovative and provides opportunities for
families to work with obese children in a pro-social manner.
➢ Media Smart Youth: Eat, Think and Be Active!
3
includes an engaging curriculum that
builds media analysis and production skills to assist young people ages 11 to 13 in

1
http://www.blackgirlscook.org/
2
https://www.choicesforkids.org/
3
https://youth.gov/federal-links/media-smart-youth

22
understanding how the complex media world around them influences their health,
especially nutrition and physical activity.
➢ Unite Fitness Retreat
4
holds a Mother/Daughter Fitness Camp. It is a structured weight
loss and fitness resort designed for all fitness levels and body types. The length of stay is
three days to 20 weeks. The retreat takes a holistic approach to health. Mothers and
daughters jointly engage in all activities. This program provides an opportunity for
mothers and daughters to develop new fitness norms together.
These programs highlight other approaches that have been effective with a narrower
focus on improving health behaviors. The unique takeaway from these programs is that they
provide a glimpse of innovative ways for the WGC-MH to scale services (up or down) to a
singular modality or pivot as needed. Progression of WGC-MH partnership development with a
WDC FQHC implementation could impact timelines. Specific implementation pivots could
include partnerships with similar programs or service providers in the WDC health care network.
These pivots could entail re-engaging the exploration phase by conducting additional interviews
with health providers and stakeholders.
Financial Plans
The WGC-MH will be a limited liability corporation (LLC) that co-operates with an
FQHC in WDC. The LLC will serve as the legal entity that ensures protection from program-
related liabilities. Additionally, the LLC status will provide the WGC-MH the necessary
professional business status to serve in a consultive role to current FQHC services that need to
augment maternal health programming support for Black women and girls in their service area.

4
https://www.unitefitnessretreat.com/mother-daughter-fitness-camp/

23
FQHC’s are non-profit, public-serving community health care centers that receive funds from
federal and local governments, the private sector, and charitable donations.
Upon ratifying the partnership with an FQHC and securing funding, the WGC-MH will
complete a 12-week program pilot phase. The objective of a pilot phase post funding is to have
the complete resources needed to run the program as designed while having a built-in phase in
which program design errors or other missteps are welcome and can be corrected. Before the
full program starts, the WGC-MH will require all full-time and contract/per-diem staff to
complete a week of training and staff program orientation. For the first year, the WGC-MH’s
program plan will have approximately 125 (target 50 in the pilot phase and up to an additional 75
in the full program) FQHC consumers sign up for the program.
Below is a brief synopsis of the budget plan for the start-up and the first full year of
programming. The total expenses for the start-up and first full-year operating (FFYO) periods
will require approximately $1 million. Specifically, Table 2 includes the 3-month start-up period
and the first full year of operation.
Table 2
Budget

Start-up (in thousands) Year 1 Op's )in thousands)
Revenue $300 $700
Expenses
Personnel $ 90 $500
Other $115 $287
Total expenses $250 $787
TOTAL + $ 95 - $87.5

The most significant expenses for the WGC-MH’s start-up activities cover personnel
expenses, technology services, communication materials, and marketing. During the FFYO, the
most significant expenses include personnel expenses, facility rental for in-person events, virtual

24
event technology services, technology services related to website maintenance, and program
evaluation.
Based on the spending requirements, the program will require moderate funding. The
WGC-MH will apply for the Kaiser Permanente health equity grant, which would provide
projected revenues to support the start-up period ($205K) and the FFYO ($787k). In terms of
long-term strategy, the WGC-MH will operate as a 3-year demonstration project. This type of
project displays a new or innovative method. The goal is to establish the feasibility and
effectiveness of a life course approach that addresses Black maternal health disparities. The long-
term goal of the WGC-MH project would be to deliver successful outcomes that drive federal
maternal health policy transformation, for which the WGC-MH can serve as a model approach.
The WGC-MH will hire an independent evaluator to monitor program effectiveness from
the start-up through the entire project period. Additionally, the WGC-MH will hire a business
manager to monitor fiscal operation efficiency and risks. The financial plan outlined below
demonstrates that the WGC-MH can be delivered with a sustainable bottom line and be scaled as
a model approach when appropriate.
Personnel/Staffing Costs
All personnel will be teleworkers and provided with all equipment and technology
required to complete job assignments. In the start-up phase of the WGC-MH, the personnel
strategies include hiring 3 FTEs, 7 PTEs, and four professional contractual staff. The 3 FTEs will
consist of a Program Director ($90,000/yr., 10+ years' experience), Assistant to Program
Director ($35,000/yr., 5+ years' experience), and Administrative Assistant ($25,000/yr., 3+ years'
experience). These will be the only FTE positions in the 3-month start-up phase and FFYO.
These full-time positions comprise the administrative team and are necessary for a program start-

25
up and the first year’s highly administrative nature. In the start-up phase, the Administrative
team will be responsible for marketing and outreach events to the community in collaboration
with FQHC support. In the FFYO, the administrative team will be responsible for the ongoing
executive leadership of the program.
The PTE positions will include a Business Manager ($35,000/yr., 7+ years’ experience),
Human Resources/Staffing Specialist ($30,000/year, 5+ years' experience), and 5 Health
Coaches/Counselors ($20,000 per year for each coach, entry-level experience). These positions
will be part-time in the 3-month start-up and FFYO because they are more program and service
delivery related and will require fewer hours in the start-up and FFYO phases. The Business
Manager will be responsible for all financial components of the WGC-MH. The Human
Resources/Staffing Specialist will complete duties related to hiring and orienting new
staff/contractors, ensuring that the professional staff for classes, and all other personnel duties.
Health Coaches/Counselors will be assigned to work with program participants to develop,
initiate and maintain their Life Health Improvement Plans.
The WGC-MH will hire professional staff, including Nurses ($70 per hour), Social
Workers ($35 per hour), Community Action Developers ($25 per hour), and Nutritionists ($25
per hour) on a contractual or per diem basis in start-up and FFYO periods. These staff will
conduct psycho-social assessments, nutrition evaluations, and community action planning
according to their expertise. These contractors will also provide individual and group sessions on
health, mental health and well-being, exercise, nutrition, and community development.
Personnel benefits, including medical insurance, dental/vision insurance, and paid leave, in the
start-up and FFYO periods will cost 30% of the salary for the 3 FTEs.

26
Other (Non-Personnel) Operating Costs
In the start-up phase of the WGC-MH, the other operating costs primarily include
technology services, communications materials, and marketing. Technology services in the start-
up phase will cost approximately $52,000. This cost will cover iPads for 50 participants and 5
Health Coaches -$400x55; laptops and printers for the administrative team -$1700x3; website
development (business analysis, design, development, project management, branding, animation,
and illustration) and ongoing website maintenance and marketing-$25,000. The WGC-MH will
provide participants with iPads to digitally track health-related goals in collaboration with their
assigned Health Coach/Counselor. The iPads will provide access to the program’s virtual
services.
Lastly, communication/marketing materials in the start-up phase will cost approximately
$12,000. This cost will include the production of business cards, program flyers/booklets, and
expenses related to participation in workshops/health fairs/symposiums. Marketing and
communication will be critical in this phase to build relationships in the WDC healthcare market
that will support the development of a strong referral network. During the FFYO period, in
addition to facility rentals to hold in-person events, other operating costs are primarily related to
technology services related to virtual platforms, ongoing website maintenance, and program
evaluation. Facility rentals will cost approximately $59,000. In-person events will happen in
rented facilities. Larger/formal events will occur in hotel conference rooms. The average rental
for hotel conference rooms is $160/hr. Small-scale events will occur at rented parks and
recreation community centers. These community centers rent at $150 for 4 hours. Technology
services to have live and pre-recorded events will cost approximately $48,000. These fees will
cover virtual break-out sessions, presentations, and a platform (Zoom, WebEx, MS Teams, or

27
Google Meet). Website maintenance includes administrative costs for ongoing website services
and will cost approximately $60,000. Lastly, during the FFYO period, an independent program
evaluator will cost roughly $33,333. An independent program evaluation will be vital to
effectively measure program outcomes and impacts, develop and improve data collection
strategies, analyze data and recommend/initiate process improvements.
Revenue Strategies/Models and Funding Types
To improve health and reduce racial, ethnic, and other health disparities, Kaiser
Permanente funds health equity grants for programs and projects that support regionally
determined critical health needs. Grant funding is available for non-profits, public agencies, and
other institutions. Projects that fit within Kaiser’s community health goals are eligible to apply
for grant funds. Regional Community Health Needs Assessments (CHNA) determine
community health goals. The objectives of the CHNA are to identify and measure community
needs and assets to engage with communities and appropriate resources to advance healthy
communities. The Kaiser CHNA emphasizes the social determinants of health. Three primary
pillars prioritize needs: 1) socioeconomic security, 2) healthcare access, and 3) mental health
awareness. The severity of need, magnitude/scale of the needs, and disparity/inequity level form
the basis for individualized priority health needs categories. It is not a surprise that in the Kaiser
MidAtlantic regions populated by a large percentage of Blacks (Baltimore, Washington, D.C.,
Southern Maryland, and Northern Virginia), the CHNA identified the following priority health
needs within the top 10 needs. These priority needs included obesity, access to care, and
maternal and child health. The Kaiser CHNA further validates the significant need for
innovations to address Black maternal health disparities and obesity.

28
I plan to utilize this project as a mechanism to apply for this funding opportunity through
Kaiser Permanente. Funding allocation would cover expanding a current FQHC in the WDC
region based on their current MidAtlantic CHNA identified priority health needs.
The Kaiser Permanente Grant is my primary choice as a revenue source. The target
population and the local focus align perfectly with the goal of the WGC-MH. Currently, the
most appropriate revenue model for the WGC-MH is funding through foundation grants. Many
corporate and independent foundations have strategically aligned their operational strategies to
provide financial support to end racial inequity. Corporations specifically have vocalized dissent
to racial injustice. One example of this is the Kaiser Permanente corporation.
The focus of the WGC-MH fits well within the business strategies and public relations
goals of several foundations. Another opportunity that strategically aligns with the WGC-MH’s
mission includes the Families USA Foundation, Inc. grant funding to identify community-based
models of care in states to improve maternal and child health, promote health equity, and reduce
disparities. Thriving Children USA provides grants to strengthen state maternal and child health
programs’ capacity to improve birth outcomes, focusing on life course approaches for collective
impact in states and communities. Lastly, Robert Wood Johnson Foundation, Merck Foundation,
and W.K. Kellogg Foundation provide grant funding to address health inequities among Black
women.
The WGC-MH will serve as an estimated 3-year demonstration project to fulfill the
national performance measures of the federal MCHBG program. These short-term targeted grant
opportunities would be ideal revenue source opportunities.

29
Detailed Revenue Plans
I project that the WGC-MH will need a $3,000,000 grant for a 3-year (36 months)
programming period to serve as a demonstration project to impact federal maternal health policy.
Each year will require $1,000,000. The first 15 months of this 36-month programming period
will include a 3-month start-up phase in which expenses will total $205,130. The remaining 12
months of FFYO expenses will total $787,451. The expenses from these 15 months will total
$992,581. This 15-month period will roll over into the 2
nd
year of programming. The WGC-MH
will have a minimal surplus after the start-up and FFYO; however, strategically allocated
resources will bolster high-quality core components and produce a strong program initiation.
The WGC-MH financial bottom line focuses on initiating programming with a lower
volume of services to strategically focus on the program design’s effectiveness in the start-up
and FFYO. Primary risks include the unknowns of first-time programming, developing clear
budget lines between FQHC services and WGC-MH services, a minimal financial surplus, and a
sustainability model dependent on highly successful program outcomes. Mitigation of primary
risks includes 1) lower volume program initiation to carefully monitor first-time programming
challenges, 2) a very detailed memorandum of agreement with the FQHC, and 3) a robust
independent program evaluation process to assure strong outcome measures that lead to
increased program impact and effectiveness (see Appendix D).
Opinion Leaders and Change Agents
The partnership between the WGC-MH and a WDC FQHC causes both to share many
opinion leaders and change agents. Key opinion leaders include the FQHC board of directors,
clinical providers, other in-house health programs, and administrative staff. These individuals
will directly influence decision-making, staffing, operations, and scheduling related to the WGC-

30
MH. These stakeholders can positively and negatively impact the adoption and implementation
of the WGC-MH program. Flexibility, planning, and negotiations will, in many cases, mediate
this impact. However, in some cases, due to the high stress and “stretched resource”
environment of public health centers, negative impacts will be inevitable. Negative impacts
could include poor implementation due to limited FQHC staffing and services.
Key change agents include federal and city governments, advocacy groups, foundations,
churches, city council members, corporate sponsors, private sector organizations, community
members, and consumers. These change agents serve as funding sources and individuals that
directly interface with health center programs throughout WDC. This interface will have a vital
influence on the adoption process of the WGC-MH within the WDC network of health centers.
However, high-quality relationships with opinion leaders and change agents will support
sustained overall program operation and long-term goal attainment of the WGC-MH.
Diversity and Inclusion
The WGC-MH will hold quarterly community forums for feedback on the program’s new
implementation in the WDC community. This event will be open to the public and will be
advertised broadly throughout citywide communication networks. Key change agents and
opinion leaders will receive direct invitations through email. This event will be in person and
will have a virtual option for attendance. The purpose of this event will be to provide information
on the WGC-MH’s activities and receive feedback and suggestions from stakeholders and public
attendees. These forums will provide equitable opportunities for each community sector
(community members, participants, change agents, and opinion leaders) to provide feedback and
ask questions on WGC-MH programming.

31
Methods for Assessment of Impact
The WGC-MH will assess the program’s short-term impact by measuring health behavior
readiness for change among participants. Participants will be measured for change readiness at
several intervals before the pilot program, during, and after program completion. The University
of Rhode Island Change Assessment Scale (URICA), created by James Prochaska, Ph.D., is a
well-known measure within the literature used to apply the five Stages of Change
(McConnaughy, Prochaska, & Velicer, 1983). The URICA contains a 32-item questionnaire on a
5-point Likert scale. Originally designed to measure the change processes in psychotherapy, it
was later adapted and applied to several health behaviors (Lacey & Street, 2017).
The change readiness score obtained from the URICA can be utilized before intervention
to predict outcomes, during the intervention to indicate progress, or at the end of the intervention
to predict future health behavior outcomes. URICA scores provide information about 1)
effective approaches with participants in specific stages; 2) resistance to change can increase if
the intervention approach does not match the stage of the participant; 3) resistance to change
may occur if the participant’s family members are in different stages of change and 4) matching
the appropriate stage of change intervention approach with the participant’s stage of change can
optimize outcomes (University of Maryland Baltimore County, n.d.). (see Appendix E)
Ethical Considerations
The primary challenge from an ethical standpoint includes informed participation
consent, related explicitly to non-adult girls. Mitigation strategies for the consent will consist of
significant community engagement in the exploration and preparation phase. Specific strategies
include interviews, small-scale pilot events with the target population, marketing and outreach
events, and developing relationships with well-established community networks. Additionally,

32
early in the implementation phase, stakeholder and community participant feedback sessions will
be held. These mitigation efforts will be to develop trust and buy-in from potential and active
program participants.

33
Part Four: Conclusions, Actions, and Implications
Title V Maternal and Child Health (MCH) Block Grant
The Title V Maternal and Child Health (MCH) Block Grant Program, administered by
the Health Resources and Services Administration (HRSA), supports the health and well-being
of all mothers, children, and families across U.S. states and jurisdictions (Health Resources &
Services Administration, 2021). The goal of MCH Block Grants is 1) to ensure accessible and
quality maternal and child health services to low-income mothers and children; 2) reduce infant
mortality; 3) expand routine screenings and follow-up for treatment services to low-income
children; 4) deliver accessible prenatal, postnatal, and perinatal care to low-income pregnant
women; and 5) implement family and community-centered care to children with special
healthcare needs (Health Resources & Services Administration, 2021).
MCH Block Grant and Impact
A three-tiered framework comprised of national outcome measures (NOMs), national
performance measures (NPMs), and state-initiated evidence-based or informed strategy measures
(ESMs) provide states with flexibility in meeting the unique health needs of resident mothers,
children, and families (Health Resources & Services Administration, 2021). NPM’s are short and
mid-term measures to improve long-term maternal and child health indicators listed in the
NOMs. ESMs are actionable process measures developed by the state to impact NPMs. Within
this framework, states conduct a needs assessment every five years that establish maternal and
child health priorities (Health Resources & Services Administration, 2021). Upon completing the
needs assessment, states and jurisdictions develop State Action Plans that outline proven
methods and measures to address these priorities. Within the Action Plan, states must select 5 out
of 15 NPMs that must cover five population domains, including 1) Women\Maternal Health; 2)

34
Perinatal\Infant Health; 3) Child Health; 4) Adolescent Health and 5) Children with Special
Health Care Needs. States can develop a state-level measure to address a priority in a sixth
systems building domain. See the example of state NPM selection in Figure 1.
women and girls referred to life course preventative programming that addresses poor child and
maternal health outcomes. See Table 3 ESM for the FQHC & WGC-MH partnership:
Table 3
ESM for FQHC & WGC-MH Partnership
ESM: The number of women and adolescent girls referred during well visits to prevention-oriented life
course programming that addresses poor child and maternal health outcomes.
Goal: Increase well visit referrals to life course programming designed to improve obesity and cardiac health
among women and adolescent girls.
Data Source: Washington, DC FQHC
Significance: Approximately 700 women in the United States die a pregnancy-related death each year. The rate of
Black maternal deaths is three to four times that of white women. The top causes of pregnancy-related
deaths for Black women are cardiovascular conditions, causing this increased mortality rate. There is
an intersection between Black maternal health, cardiovascular disease development across the lifespan,
and childhood obesity. Black girls (ages 6-11) have one of the nation’s highest obesity rates. Obesity
is a precursor to cardiac disease. Black women have the highest obesity rate compared to other groups
in America. Obesity pre-disposes offspring to develop obesity.

35
Figure 1
Title V Maternal and Child Health Service Block Grant to States Program Application/Annual
Report Guidance and Forms

Implications for the WGC-MH Programming on Maternal and Child Health
Federally Qualified Health Center’s (FQHC’s) provide essential primary women’s
healthcare services to women and girls in their service areas. Additionally, FQHC’s receive
MCH Block Grant funds for services provided to women and children. The WGC-MH will
partner with an FQHC to provide a programmatic strategy addressing NPM #1: Well-woman
visit; NPM #10: Adolescent well visit; and NPM # 8: Physical Activity across the population
domains Woman/Maternal Health, Child Health and Adolescent Health in Washington, DC.
FQHC referral count to the WGC-MH program can serve as an ESM to increase the number of
The 2021-2025 District of Columbia’s Title V Block Grant Program Five-Year Maternal
and Child Health Needs Assessment Summary states, “As DC Health considers the definition of
a “well-woman,” it will be important to continue to consider programs that offer opportunities

36
for healthy eating, living and early access to prenatal care” (District of Columbia Department of
Health, 2020, p. 6). The WGC-MH design can support this area for opportunity.
The U.S. Department of Health and Human Services Secretary’s Advisory Committee on
National Health Promotion and Disease Prevention developed recommendations for the Healthy
People 2030 framework (US Department of Health and Human Services Office of Disease
Prevention and Health Promotion, 2021). The Healthy People Initiative includes national
objectives over ten years. This initiative sets measurable objectives to help organizations,
communities, and individuals commit to improving health and addressing public health priorities
(US Department of Health and Human Services Office of Disease Prevention and Health
Promotion, 2021). The Healthy People 2030 framework supports Title V national outcome
measures. It lists the emerging need to use a life course perspective in health promotion and
disease prevention efforts that address persistent disparities in maternal, infant, and child health
(US Department of Health and Human Services Office of Disease Prevention and Health
Promotion, 2021).
Project’s Future Aim: Black Maternal Health Innovations Center for Excellence
This project plans to serve as a demonstration project in the WDC area. Successful
programmatic outcomes will become the basis for a Technical Assistance Center. The Center
will consult with states with high Black maternal morbidity and mortality rates. This Center’s
goals would be to assist state program recipients of Title V MCH Block grant funds in
developing innovative human-centered design programs that provide life course and
intergenerational approaches to maternal health.

37
Next Steps and Prototype Dissemination
I have met to discuss opportunities for an FQHC partnership with WDC healthcare
leadership and stakeholder organizations. Currently, this project is in the end phase of its initial
development and ready for public sharing. The next steps include presenting the project to major
healthcare organization Speakers Bureaus and City Women’s Council meetings to disseminate
the WGC-MH Prototype. Additionally, as meetings continue with WDC primary care
leadership, the WGC-MH will participate in local radio events, health fairs, and symposiums for
additional prototype dissemination (See Appendix F).
Alternative Next Steps
The WDC Department of Health uses Title V funding to support community-based
organizations and health care institutions in implementing programs that support maternal and
child health (DC Department of Health, n.d.). Should an FQHC partnership not occur over the
next year, this project will leverage other community partnerships developed through marketing
and community engagement to initiate a WGC-MH non-profit community-based organization.
Partnerships are essential and foundational to the implementation of the WGC-MH. In this
scenario, the WGC-MH non-profit organization will diversify referral opportunities from
multiple community servicing sites, including local hospitals, primary care offices, schools,
community centers, and spiritual communities, to name a few. This alternative action will
require aggressive marketing and engagement over the next year.

38
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45
Appendices
Appendix A
Prototype
The prototype includes that WGC-MH user experience guide with the Interactive User Journey
Map. The prototype was developed in collaboration with Victor Joseph, Product Designer,
Nigeria, Africa
5
. Mr. Joseph specializes in human-centered design in the creation of user-
centered digital products. The human-centered design focus is integral in developing a detailed
user Journey Map that accounts for meaningful experiences, accessibility and ease of use for
target users.
https://www.figma.com/proto/04c9kG6WnYqY1t6I5X7vkA/Women-and-Girls-Center-for-
Maternal-Health?page-id=0%3A1&node-
id=148%3A976&viewport=241%2C48%2C0.14&scaling=min-zoom&starting-point-node-
id=148%3A976

5
https://victorjoseph.cc/#

46

Appendix B
Conceptual Framework

47
Appendix C
Women and Girls Center-MH EPIS Framework Implementation Timeline
Task Description
PLAN
START
PLAN
END
EXPLORATION
Seek initial funding opportunities for project 3/1/2020 4/1/2020
Complete research on values of target population
4/1/2020 6/1/2020
Conduct ethnographic interviews of the target
population
6/1/2020 8/1/2020
conduct interviews of health providers, stakeholders
8/1/2020 10/1/2020
Review legislation/policies that support or lack
support for Black maternal health initiatives
10/1/2020 12/1/2020
PREPARATION
Begin a discussion with FQHC regarding
partnership
12/1/2020 2/1/2021
Develop initial financial plans for programming
2/1/2021 5/1/2021
Begin to develop specific details for programming
3/1/2021 6/1/2021
Connect with FQHC and WDC Primary Care
Leadership
6/1/2021 9/1/2021
Draft and establish MOA with FQHC
9/1/2021 12/1/2021
Coordinate Funding Proposal documents and data 11/1/2021 1/1/2022

48
Prepare & submit Draft Request for Proposal
details (including project description budget, work
plan and staffing)
12/1/2021 3/1/2022
Funding
3/1/2022 6/1/2022
Marketing and Outreach Events to the community
(Health Fairs, etc.)
5/1/2022 9/1/2022
IMPLEMENTATION
Launch limited-service WGC (pilot) 6/1/2022 9/1/2022
Stakeholder, community, participant feedback
sessions
07/1/2022 5/30/2025
Evaluation Team assessment for
adaptation/program design adjustment
10/1/2022 12/1/2024
Launch full-service WGC
10/1/2022 6/30/2025
SUSTAINMENT
Stakeholder, community, participant feedback
sessions
TBD TBD
Program Evaluation Summary TBD TBD
Federal MCHBG program national performance
measure metric
TBD TBD
Develop Plans for Maternal Health Innovations
Center for Excellence
TBD TBD

49
Appendix D
Budgets

50

Name: Women and Girls Center
FY 2023 Operating Budget (Oct 2022-Sept 2023)
Category ------------ $'s (000's) ------------ ---------------- Comments ---------------
REVENUE
Kaiser Health Equity Grant $700,000
Kaiser Advancing Health
Equity Grants. Three year
grant period for $3,000,000
($1,000,000 allotted for first
15 months -start-up and FFYO)
Total REVENUE $700,000
EXPENSES
Personnel Exp
Wages/Salaries
Program Director 90,000 1 FTE
Asst to Program
Director $35,000 1 FTE
Administrative
Assistant $25,000 1 FTE
Business Manager 35,000 .5 FTE
Human
Resources/Staffing 30,000 .5 FTE
Health
Coaches/Counselor
s 240,000 .5 FTE x12
add additional 7 HC's in FFYO. Each coach will earn approx. $20,000
as a part time employee. These individuals will have entry level
experience in fitness, health & wellness settings. Each HC will be
assigned approx. 10 participant/family units (total of 125
participant/family units in FFYO)
Sub-Total $455,000
Benefits (@ _30_%) $45,000 30% for 3 FTE's
Total Pers. Exp 500,000
Other Operating Exp
Contractors (Indep) $22,880
Hourly Rates: Nurses $70,
SW's $35, Nutritionist $25,
Community Action Developers
$25. Avg 2.5 hours per week
except SW 4 hours
There will be 1 contractor hired in each discipline to provide the
weekly session for their expertise. Weekly contractor expenses
equal $440 x 52 working weeks in a year.
Facility Rentals $59,490
Bi-monthly large/formal
events for 2 hours=$240.00 (6
large events during
FFYO=$1440); Monthly small
scale events=$150 (12 small
events during FFYO=$1800);
Monthly Pass to gym for
125pp x$37.50
participants=$4687.50 (12
months during FFYO at
$56,250 per month)
In-person events will be held at rented Facilities. Larger/formal
events will be held in hotel conference rooms. Average rental for
hotel conference rooms at $160/hr. Small scale events will be held
at rented parks and recreation community centers. These
community centers rent at $150 for 4 hours. Participants will
receive a 30 days pass to parks and recreation gyms at $37.50 per
person.
Live & Pre-recorded
Virtual Events $48,000
6 large event during
pilot=$8000.00
Large scale events will be live with a live virtual participation
option. These events will also be recorded. Large scale events with
presentations, breakouts, virtual platform (Zoom, Webex, MS
Teams, or Google Meet), day of registration and exhibit sites avg
$8000 per event
Tech/Computers $90,000
Website on-going maitenance
and marketing-$5000/mo.
X12=$60,000; Ipad-
$400x75=$30,000 (additional
75 participant/family units in
FFYO to total 125 in program);
Tel/Utilities $648
Zoom-12 mos.=$228; monthly
cell phones x3 FTE's= $420
Zoom for business teleconferencing=$19.00/month; cell phone
service for FTE's=$35.00/month per FTE
Comm &
Mat'ls/Marketing $5,000
Advertising and materials for
open houses and welcome
meetings for stakeholders,
community members, etc.
Trng/Prof Dev $5,000
Professional staff will be
contracted and required to
Prof Srvc's * $5,000
Professional services related
to ongoing production of
professional materials for
Office Supplies $2,500 Standard office supplies
Program Evaluator $33,333 10% of grant funding
Ancillary Fees $15,600
$300 per week to assist with
childcare coverage,
transportation and incentive
Total Other Op Exp $287,451
Total EXPENSES 787,451
SURPLUS/DEFICIT -87,451

51
Appendix E
University of Rhode Island Change Assessment Scale
6

6
University of Maryland Baltimore County. (n.d.). Health and Addictive Behaviors: Investigating Transtheoretical
Solutions. Retrieved from The Habits Lab at UMBC: TTM Measures: https://habitslab.umbc.edu/ttm-measures

University of Rhode Island Client ID#
Change Assessment Scale (URICA): Date: / /
Psychotherapy Version Assessment Point:

EACH STATEMENT BELOW DESCRIBES HOW A PERSON MIGHT FEEL WHEN STARTING
THERAPY OR APPROACHING PROBLEMS IN THEIR LIVES. PLEASE INDICATE THE EXTENT TO
WHICH YOU TEND TO AGREE OR DISAGREE WITH EACH STATEMENT. IN EACH CASE, MAKE
YOUR CHOICE IN TERMS OF HOW YOU FEEL RIGHT NOW, NOT WHAT YOU HAVE FELT IN THE
PAST OR WOULD LIKE TO FEEL. FOR ALL STATEMENTS THAT REFER TO YOUR “PROBLEM”,
ANSWER IN TERMS OF PROBLEMS RELATED TO WHY YOU ARE IN THERAPY. THE WORDS
“HERE” AND “THIS PLACE” REFER TO YOUR TREATMENT CENTER.

THERE ARE FIVE POSSIBLE RESPONSES TO EACH OF THE ITEMS IN THE QUESTIONNAIRE:

1=Strongly Disagree
2=Disagree
3=Undecided
4=Agree
5=Strongly Agree

CIRCLE THE NUMBER THAT BEST DESCRIBES HOW MUCH YOU AGREE OR DISAGREE WITH
EACH STATEMENT.

Strongly
Disagree
Disagree Undecided Agree Strongly
Agree
1. As far as I’m concerned, I
don’t have any problems that
need changing.
1 2 3 4 5
2. I think I might be ready for
some self-improvement.
1 2 3 4 5
3. I am doing something about
the problems that had been
bothering me.
1 2 3 4 5
4. It might be worthwhile to work
on my problem.
1 2 3 4 5
5. I’m not the problem one. It
doesn’t make much sense for
me to be here.
1 2 3 4 5
6. It worries me that I might slip
back on a problem I have
already changed, so I am
here to seek help.
1 2 3 4 5
7. I am finally doing some work
on my problems.
1 2 3 4 5
8. I’ve been thinking that I might
want to change something
about myself.
1 2 3 4 5

52

Strongly
Disagree
Disagree Undecided Agree Strongly
Agree
9. I have been successful in 1 2 3 4 5
working on my problem but I’m
not sure I can keep up the effort
on my own.

10. At times my problem is difficult,
but I’m working on it.
1 2 3 4 5
11. Trying to change is pretty much
a waste of time for me because
the problem doesn’t have to do
with me.
1 2 3 4 5
12. I’m hoping this place will help
me to better understand myself.
1 2 3 4 5
13. I guess I have faults, but there’s
nothing that I really need to
change.
1 2 3 4 5
14. I am really working hard to
change.
1 2 3 4 5
15. I have a problem and I really
think I should work on it.
1 2 3 4 5
16. I’m not following though with 1 2 3 4 5
what I had already changed as
well as I had hoped, and I’m
here to prevent a relapse of the
problem.

17. Even though I’m not always 1 2 3 4 5
successful in changing, I am at
least working on my problem.

18. I thought once I had resolved 1 2 3 4 5
the problem I would be free of it,
but sometimes I still find myself
struggling with it.

19. I wish I had more ideas on how
to solve my problem.
1 2 3 4 5
20. I have started working on my
problems but I would like help.
1 2 3 4 5
21. Maybe this place will be able to
help me.
1 2 3 4 5

53

Strongly
Disagree
Disagree Undecided Agree Strongly
Agree
22. I may need a boost right now to
help me maintain the changes
I’ve already made.
1 2 3 4 5
23. I may be part of the problem,
but I don’t really think I am.
1 2 3 4 5
24. I hope that someone here will 1 2 3 4 5
have some good advice for me.

25. Anyone can talk about
changing; I’m actually doing
something about it.
26. All this talk about psychology is
boring. Why can’t people just
forget about their problems?
1 2 3 4 5

1 2 3 4 5

27. I’m here to prevent myself from
having a relapse of my
problem.
28. It is frustrating, but I feel I might
be having a recurrence of a
problem I thought I had
resolved.

29. I have worries but so does the
next person. Why spend time
thinking about them?
30. I am actively working on my
problem.
31. I would rather cope with my
faults than try to change them.
1 2 3 4 5

1 2 3 4 5

1 2 3 4 5

32. After all I had done to try and
change my problem, every now
and then it comes back to haunt
me.
1 2 3 4 5
1 2 3 4 5

1

2

3

4

5

54
URICA – Readiness Score
7

Calculating and Understanding the Readiness Score
Uses of The Readiness Score
The readiness score derived from the URICA can be used prior to treatment to predict outcomes. However, when the
scores from the URICA are being used to indicate progress during treatment or as end-of-treatment predictors of
drinking outcomes, action and maintenance subscale scores and not the readiness score should be used. Remember,
though, that these subscale scores represent attitudes and activities related to the stages of change and not precisely
state status. The shifts in subscale scores are associated with the shifting people go through during the process of
change, which is not a linear, single variable. For further information, please refer to DiClemente, C.C., Schlundt,
D., & Gemmell, L. (2004). Readiness and stages of change in addiction treatment. The American Journal on
Addictions, 13, 103-119.
Calculating The Readiness Score:
Calculating the Readiness Score is done by calculating the means for precontemplation responses, contemplation
responses, action responses and the struggling to maintain responses. Once means are found for each of the stage
subscales, the mean from the precontemplation is subtracted from the summation of the other three stages. Below
you will find grids showing which questions are used to calculate each of the subscale totals, the number to divide
by to obtain the mean and the formula below each grid to calculate the readiness score. Remember, if you alter the
order of the questions from the order already used in our versions of the URICA, you must adjust the grid to account
for changes in numbering to be certain the questions are correctly linked to the stages.
Cut-Off Scores:
Cut-off scores can be created for the readiness score but it is important to consider your population and how
conservative you want to be. Cut-off scores are essentially arbitrary and you should be thinking about the stages as
least ready, middle and most ready.
For the general population, the following cut-off scores may be appropriate:
8 or lower classified as People in Precontemplation
8-11 classified as People in Contemplation
11-14 classified as People in Preparation or Action
For intensive service populations, it may be more appropriate to use only score in the range of 12-14 to classify
those in preparation and action.
URICA 32 Item Versions

Precontemplation Contemplation Action Maintenance
Question
Numbers
1 2 3 6
5 4 (omit)* 7 9 (omit)*
11 8 10 16
13 12 14 18

7
https://habitslab.umbc.edu/urica-readiness-score/

55
23 15 17 22
26 19 20 (omit)* 27
29 21 25 28
31 (omit)* 24 30 32
Total:
Divide by: 7 7 7 7
Mean:
*For the questions that say “Omit” do not include them in your summation of scores for each
stage subscale.
To obtain a Readiness to Change score, first sum items from each subscale and divide by 7 to get
the mean for each subscale. Then sum the means from the Contemplation, Action, and
Maintenance subscales and subtract the Precontemplation mean (C + A + M – PC = Readiness).

56
Appendix F
Logic Model

Abstract (if available)

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Creator Blyther, Alexia Danielle (author)

Core Title The Women and Girls Center for Maternal Health intergenerational approaches to address the Black maternal health crisis

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2021-12

Publication Date 05/18/2022

Defense Date 11/18/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Black maternal health,community health norms,cultural health promotion,cultural norms,intergenerational health behaviors,life course approaches,maladaptive social norms,maternal health,maternal health crisis,OAI-PMH Harvest,self-efficacy in the Black community health,social determinants of health,Women and Girls Center for Maternal Health

Language English

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