For the past several decades, maternal and child health (MCH) experts have considered improving access to and utilization of quality prenatal care to be necessary for improving birth outcomes and reducing racial and ethnic inequities. Despite the fact that since 2000, entry into prenatal care in Contra Costa has been close to 90%, rates of preterm birth and low birth weight have risen steadily, and substantial inequities remain between racial/ethnic groups in all birth outcomes.
Contra Costa Health Services
Contra Costa Life Course Initiative – Building Economic Security Today (BEST) at WIC
For the past several decades, maternal and child health (MCH) experts have considered improving access to and utilization of quality prenatal care to be necessary for improving birth outcomes and reducing racial and ethnic inequities. Despite the fact that since 2000, entry into prenatal care in Contra Costa has been close to 90%, rates of preterm birth and low birth weight have risen steadily, and substantial inequities remain between racial/ethnic groups in all birth outcomes. In response, support is shifting away from prenatal care as an all-encompassing solution. The Life Course Perspective suggests that a complex interplay of biological, behavioral, psychological, environmental, and social protective and risk factors contributes to health outcomes across the span of a person’s life. These determinants of health include social factors such as wealth and financial stability, which are strong predictors of health and well-being and have an impact across generations. BEST, a project of Contra Costa Health Services’ Family, Maternal and Child Health (FMCH) Programs, is a Life Course Perspective-based asset development pilot project that utilizes innovative strategies to reduce disparities and inequities in health outcomes for this and future generations of low-income families by improving their financial security and stability. This summary describes BEST financial education classes at WIC.
Several outcomes were expected for staff, clients, and our local system. Staff would have increased knowledge of asset development strategies and resources, have increased skills to engage clients in improving financial behaviors, and adopt new practices for implementing knowledge and skills with their clients about asset development. Clients would have an increased understanding of the health-wealth connection, knowledge of asset development strategies and resources, and confidence and readiness to adopt improved financial behaviors. Finally, several local system changes would occur, including: stronger community partnerships will be developed and cultivated to create a supportive environment for asset development; the county health and human services system will support clients in utilizing asset development strategies; asset development strategies will be integrated into FMCH Programs’ infrastructure; awareness of the BEST project will increase; and the BEST project development process will be well-documented. The outcomes described above are all intermediate markers of success on the path to ultimately improving our clients’ financial stability and health outcomes.
BEST project activities, implemented between January 2005 and October 2010, included the following:
1. established a Life Course Planning Team, developed BEST concept, and created an evaluation plan;
2. organized staff trainings on financial asset development;
3. conducted focus groups with WIC staff and clients;
4. reviewed existing financial education curricula and resource materials;
5. developed and printed a BEST Asset Development Resource Guide for staff, and created client resource lists based on the Resource Guide;
6. selected and printed financial asset development resource materials for distribution after classes;
7. designed the BEST WIC class lesson plan, entitled “Building Your Family Financial Security;” and
8. implemented and evaluated classes.
Project outcomes included the following:
1. A total of 6,248 WIC client families attended the classes and received asset development resource materials. (The target population for BEST was WIC client families with children ages one through five. The total WIC caseload in October 2010 was 22,875. Contra Costa County has a population of 1,049,025.)
2. Over three-quarters of the 1,592 clients who completed post-tests reported that they “learned a lot” or “a little” (vs. none) about the lesson plan topics.
3. Over 90% of clients reported that the class helped them feel more confident about handling their money and understand how money could affect their health.
4. Instructors reported positive experiences teaching the classes, and that clients were very engaged in the class content.
5. We developed a local Asset Development Resource Guide that staff use to make referrals for clients to financial services.
6. Pre-and post-tests from staff trainings showed that staff knowledge and skills increased on several asset development topics.
Over the course of this project, we have learned that:
1. change takes time, and we have to be willing to have a flexible timeline;
2. we will be most successful when we start with our staff where they are in terms of their readiness for changing practices and integrating new ideas;
3. creativity and flexibility are necessary to evaluate interventions, such as this one, that are implemented with great variation;
4. focusing on financial stability as a determinant of health outcomes can open up opportunities to collaborate with new partners in the financial asset development field.
For the past several decades, maternal and child health (MCH) experts have considered improving access to and utilization of quality prenatal care to be necessary for improving birth outcomes and reducing racial and ethnic inequities overall. Despite the fact that since 2000, entry into prenatal care in Contra Costa has been close to 90%, rates of preterm birth and low birth weight have risen steadily, and substantial inequities remain between racial/ethnic groups in all birth outcomes. As a result, support is shifting away from the model of prenatal care as a single all-encompassing solution. Instead, interest is increasing in frameworks that look beyond the prenatal period to a broader range of factors that may improve birth outcomes. One model that addresses health across the life span, as well as social determinants of health, is the Life Course Perspective, which suggests that a complex interplay of biological, behavioral, psychological, environmental, and social protective and risk factors contributes to health outcomes across the span of a person’s life. These determinants of health include social factors such as financial security and stability, which have an impact across generations. Wealth, or lack thereof, is a strong predictor of health and well-being. There is a “social gradient” to this effect: it runs across society, so that low-income families have worse health outcomes than those in the middle class, who in turn have worse outcomes than the upper class. This holds true in Contra Costa County, where a child born in a high-poverty area in 2000 can expect to live more than six years longer than a child born in a low-poverty area. The current recession has increased stress for low-income families striving for self-sufficiency and financial stability. In 2010, 23% of the total population and 29% of children ages 0-17 in Contra Costa lived at or below 200% of the federal poverty level. The 2010 annual unemployment rate in Contra Costa was 11.2%, an 84% increase from 2008. In addition, over the past three years, the County’s WIC caseload increased by 7% and CalFresh (food stamps) caseload increased by 88%.
The discrepancy between the services FMCH Programs was providing and the outcomes they were meant to improve prompted us to intensify our efforts to collaborate with community partners in other sectors to improve and expand available services. We conducted a Photovoice project to learn what community residents believed were the issues that FMCH Programs should be addressing to improve birth outcomes. Community residents pointed to issues related to the general state of their neighborhoods as ones that they wanted us to address. We knew that these were important and significant quality-of-life issues that needed attention. The Life Course Perspective offered us a logical and intuitive framework for addressing these social determinants of health. In 2005, FMCH Programs launched its Life Course Initiative (LCI), the goal of which is to reduce inequities in birth, infant, and maternal outcomes and improve the health of the next generation in Contra Costa County by promoting and achieving health equity, optimizing health, and shifting the paradigm of the planning, delivery, and evaluation of maternal, child, and adolescent health services. The release of “Unnatural Causes,” a documentary series designed to increase public awareness of the alarming socioeconomic and racial/ethnic inequities in health in the U.S. and their human and financial costs, also inspired us. Publications released by leading foundations and researchers during this same time also pointed out these same facts. The combination of these publications and films provided a platform to expand the LCI to collaborators outside of FMCH Programs. At about that same time, we reviewed the responses to our LCI staff training and the findings of our LCI Staff Survey and realized that financial stability across the life course, a key protective factor leading to positive health outcomes for women, children, and families in Contra Costa County, was not being addressed in any formal way by our programs. We challenged ourselves to create an intervention that would increase the financial stability and security of our clients in an effort to improve their financial status and ultimately, their health. This effort became Building Economic Security Today, or BEST.
Building Economic Security Today (BEST) is an asset development pilot project that utilizes innovative strategies to reduce disparities and inequities in health outcomes for this and future generations of low-income families by improving their financial security and stability. BEST is based on the Life Course Perspective. BEST helps families maximize their income for daily living, and preserve and increase their financial assets. Improving families’ financial status will increase their access to health care, improve their housing situations, offer opportunities to live in safer and healthier neighborhoods, increase their food security, and enhance other protective social and environmental factors. Furthermore, research shows that children learn how to manage money from their parents, so providing financial education to this generation’s parents will increase financial stability in the next.
The overall BEST project offers:
1. one-on-one support to families in two home visiting programs,
2. financial education classes for WIC clients, and
3. asset development educational materials and referrals for all clients.
Staff guide clients as they address financial concerns, such as applying for public benefits for which they are eligible, repairing credit, opening a bank account or prepaid debit card, and obtaining their Earned Income Tax Credit. This Model Practice application focuses on the implementation of BEST at Contra Costa County WIC. BEST WIC financial education classes were offered several times a week from June through October 2010 at all four Contra Costa WIC sites. All families with children ages one through five were required to attend the class once during this time period. The class, presented in both English and Spanish, was designed to cover the following topics: how money affects health, money values and beliefs, clients’ strengths and areas for improvement around managing money, an introduction to bank accounts and credit, setting financial goals, and asset development resources and referrals. Financial asset development resource materials were available for clients to pick up after the classes, and staff utilized the BEST Asset Development Resource Guide to make any needed referrals (see “Local Health Department and Community Collaboration”).
We conducted a brief literature review to determine whether any other local health department (LHD) had incorporated financial education into health services as a strategy for applying the Life Course Perspective or address the connection between wealth and health. We found no evidence that others had implemented projects similar to BEST. In addition, we had anecdotal information from our involvement in national-level work on integrating the Life Course Perspective into MCH practice that we were the first LHD or local MCH program to attempt such this type of project.
Projects like BEST are new for health organizations. BEST is unique in that it addresses the strongest social determinant of inequities in health, i.e. wealth, by integrating basic financial education into health services, particularly those that serve pregnant women, children, and families. This project also connects two sectors – public health and asset development – that have not traditionally worked together. BEST embodies our organization’s paradigm shift towards a Life Course approach, focusing on the cumulative effects of social factors over the course of one’s life. Through this project, we are creating opportunities for low-income families in our county to improve their quality of life and become more engaged participants in the mainstream economy.
Our primary partners in the BEST project include: 1) Contra Costa Family Economic Security Partnership (FESP), 2) Health-Wealth Connection Collaborative (HWCC), 3) Community Financial Resources (CFR), and 4) SparkPoint Centers.
Role of Stakeholders/Partners
Launching BEST has catapulted FMCH Programs into a new world of partnerships. The roles of our main partners include acting in an advisory and consulting capacity, providing financial asset development services to FMCH Programs’ clients that are referred through BEST, and working in collaboration with FMCH Programs and BEST staff to address financial stability and health, e.g. developing the BEST Asset Development Resource Guide (see below).
Contra Costa Health Services’ Family, Maternal and Child Health (FMCH) Programs is the entity that is responsible for the planning, implementation, and evaluation of BEST, and FMCH Programs’ clients are the primary audience for BEST interventions.
When we launched BEST, we became an active member of the Contra Costa County Family Economic Security Partnership (FESP). FESP is a public, private, and nonprofit collaboration dedicated to increasing the income and building the assets of low-income families and individuals in Contra Costa County. The BEST Project Coordinator sits on FESP’s Executive Committee and Coordinating Council. In addition, FESP worked with BEST staff to create the BEST Asset Development Resource Guide, copies of which were distributed to all WIC staff to be used in making referrals of clients to asset development services. BEST staff spoke with each agency listed and collected detailed information on contact information, services, languages spoken, intake procedures, and eligibility. FESP members are included as referral resources. FESP is currently collaborating with similar coalitions in neighboring Marin and Alameda Counties to create a regional online asset development resource guide, with the BEST Project Coordinator as one of FESP’s representatives in this process. FMCH Programs is a founding member of the Health-Wealth Connection Collaborative (HWCC), a cross-sector coalition of economic justice and public health organizations in the Bay Area, primarily Alameda and Contra Costa Counties. On June 23rd, 2010, HWCC hosted the first ever Health-Wealth Connection Symposium, bringing together nearly 200 participants to create a paradigm shift, learn from each other and begin cross-sector collaboration. The BEST Project Coordinator played a leadership role in the planning of this symposium. HWCC members are continuing to work together to creatively address the connection between health and wealth. Community Financial Resources (CFR), a member of both FESP and HWCC, provided the second training for our WIC staff, and has provided expert consultation as needed. Created by United Way of the Bay Area, SparkPoint Centers are one-stop financial education centers that help individuals and families who are struggling to make ends meet. The BEST Project Coordinator has built relationships with the two SparkPoint Centers in Contra Costa County, which opened recently, and participated in the planning of one of the centers. The Center Directors have trained the WIC staff on how to make appropriate referrals of their clients to the Centers.
The innovative nature of the BEST has brought FMCH Programs into several new coalitions and committees, some out of the realm of traditional public health work. This has generated more exposure and interest in BEST and created more responsibilities for staff to juggle. We have found that we need to set criteria for prioritizing new opportunities for collaboration: Is this new partnership different in some way from our existing ones? Does it help us move our paradigm shift in the right direction? Is there funding attached? Is our participation critical to the success of this collaborative’s goals?
The implementation tasks to achieve BEST’s goal and objectives have been as follows:
1. Established a Life Course Planning Team, developed the BEST concept, and created an evaluation plan: By the beginning of the third year of the LCI, we were ready to identify an intervention that would address social determinants of health. We brought together a multi-disciplinary team to determine our next steps. After several months, we determined a reasonable and realistic direction, which was BEST. The Life Course Planning Team created a logic model and evaluation plan for BEST, with the understanding that developing an evaluation plan while simultaneously developing program interventions leads to both being more precise and effective, with interventions being better designed to lead to desired project outcomes.
2. Organized staff trainings on financial asset development: The first training provided an introduction to financial asset development and building relationships with clients to address the difficulty of discussing financial issues. The second training addressed understanding the unique role of health workers in asset development, identifying client financial issues, and learning about CFR’s prepaid debit card. (See Objective 1.)
3. Conducted focus groups with WIC staff and clients, to provide us with information about the WIC clients’ challenges and barriers to financial stability and creative suggestions for how BEST could support clients. Five focus groups in English and five in Spanish were conducted with a total of 110 WIC clients, and four focus groups were conducted with 32 WIC staff.
4. Reviewed existing financial education curricula and resource materials.
5. Developed and printed a BEST Asset Development Resource Guide for staff and client resource lists based on the Resource Guide.
6. Selected and printed financial asset development resource materials for distribution after classes.
7. Designed the BEST WIC class lesson plan, entitled “Building Your Family Financial Security.”
8. Implemented and evaluated the classes.
1. Established a Life Course Planning Team, developed the BEST concept, and created an evaluation plan: January 2007 – December 2009.
2. Organized staff trainings on financial asset development: October 2008 – January 2009.
3. Conducted focus groups with WIC staff and clients: June-August 2009.
4. Reviewed existing financial education curricula and resource materials: June 2008 –April 2010.
5. Developed and printed a BEST Asset Development Resource Guide for staff, and created client resource lists based on the Resource Guide: September 2009 – April 2010.
6. Selected and printed financial asset development resource materials for distribution after classes: April 2010.
7. Designed the BEST WIC class lesson plan, entitled “Building Your Family Financial Security”: April - May 2010.
8. Implemented and evaluated the classes: June-October 2010.
Process & Outcome
Outcome 1: Staff will have increased knowledge of asset development strategies and resources, have increased skills to engage clients in improving financial behaviors, and adopt new practices for implementing knowledge and skills with their clients about asset development.
Outcome 2: Clients will have an increased understanding of the health-wealth connection, knowledge of asset development strategies and resources, and confidence and readiness to adopt improved financial behaviors.
Outcome 3: Several local system changes will occur, including: stronger community partnerships will be developed and cultivated to create a supportive environment for asset development; the county health and human services system will support clients in utilizing asset development strategies; asset development strategies will be integrated into FMCH Programs’ infrastructure; awareness of the BEST project will increase; and the BEST project development process will be well-documented.
Objective 1: In order to evaluate Outcome 1, we measured:
1. number of staff trained on asset development strategies and resources,
2. number and percent of staff who, after training, report increased understanding of asset development strategies and resources,
3. number and percent of staff who, after training, report increased skills and confidence in working with clients on asset development issues, and
4. number of staff teaching BEST WIC basic education classes.
Also, based on anecdotal reports of variation in the implementation of the classes, we decided to qualitatively assess staff’s implementation of and feedback about the classes. Quantitative data were collected from training sign-in sheets, pre- and post-tests administered by BEST staff, and the WIC data system. Qualitative data were collected through observations of classes and interviews of the WIC staff teaching the classes. Data collected from two BEST staff trainings indicate that staff have increased their knowledge and skills around asset development strategies. The first staff training was conducted by Strategies for 40 FMCH Programs staff, including WIC staff. Pre-and post-tests from the training showed that staff knowledge and skills increased on several asset development topics, including addressing obstacles to communicating with clients about financial issues, helping families obtain asset development resources, and helping families increase their knowledge of financial issues. The second staff training was conducted by CFR for 34 FMCH Programs staff, including WIC staff. Based on the pre- and post-tests, we found that the training increased the percentage of staff who felt comfortable talking about financial issues with clients, understood how CFR’s prepaid debit card works and could be beneficial to clients, could identify specific life situations that may indicate underlying financial issues for clients, and could identify local financial resources. We found a very slight decrease in the percentage of staff who could describe how to engage clients in talking about financial issues, though this represented only three staff. Observations of the BEST WIC classes and interviews with the class instructors also suggested that we made progress in terms of staff adoption of new asset development practices, though instructors’ teaching styles varied widely, and the lesson plan was modified by each instructor to accommodate the needs of their class participants (confirming our anecdotal information).
Five WIC staff taught the classes at four sites across the county. In only two out of the 11 classes observed did the instructor cover all of the topics mentioned in the lesson plan. Eight out of the 11 classes covered only one or two of the topics. One class did not cover any of the BEST lesson plan. During interviews with the five instructors, all of them acknowledged that the most positive aspect of teaching BEST was giving WIC clients tools to help improve their financial situations. The greatest challenge that instructors faced was completing the entire BEST lesson plan in 30 minutes. Another challenge that some instructors faced was persuading clients to open up about their finances, which is usually a private topic. Finally, through the interviews, we found that an unexpected outcome for staff was that though clients were the intended audience for information about asset development resources in the community, the instructors have also gained and utilized this knowledge. The results of the above evaluation have been shared with staff from WIC and other County agencies, project funders (public and private), community partners, professional conference audiences, and organizations around the nation interested in our work. We hope to implement BEST classes again, as the WIC class schedule allows, modifying the format where possible to address staff feedback. Changing a long-standing paradigm and embarking on a project that brings in an entirely new field is a slow, complicated process that calls for teaching and learning many new concepts and gaining buy-in from staff at all levels. There are peaks and valleys in this staff buy-in, and ensuring that staff is comfortable moving forward often requires a slower pace of implementation. We have learned that change takes time, and we have to be willing to have a flexible timeline, and that we will be most successful when we start with our staff where they are in terms of their readiness for changing practices and integrating new ideas.
Objective 2: In order to evaluate Outcome 2, we measured the following:
1. number of clients who attended BEST WIC financial education classes,
2. number and percent of clients demonstrating an increase in knowledge of the health-wealth connection,
3. number and percent of clients demonstrating an increase in knowledge of asset development strategies and resources after participating in the class, and
4. number and percent of clients reporting an increase in confidence dealing with financial issues.
These quantitative data were collected from the WIC data system and client post-tests administered by instructors at the end of the classes. We also qualitatively assessed WIC staff’s opinions on the effectiveness of the classes for clients (through interviews of the WIC staff teaching the classes), and the engagement of clients in the classes (through direct observations of BEST classes). The data collected on the client outcomes above suggest that the BEST WIC financial education classes were successful. A total of 6,248 WIC client families attended the classes and received asset development resource materials. Of these families, 1,592 (26%) completed class post-tests. Of those who completed post-tests, 54% were in English classes and 46% in Spanish classes. When asked how much they learned in the class about their values and beliefs about money, 76% responded that they learned a lot and 20% responded that they learned a little. In addition, 54% responded that they learned a lot and 25% a little about getting a bank account, 52% learned a lot and 25% a little about credit, and 70% learned a lot and 18% a little about resources to help them with their finances. Also, 95% reported that the class either definitely or somewhat helped them feel more confident about handling their money, and 93% said that the class helped them understand how money could affect their health. While observing the classes, we noted that though the lesson plan covered several financial topics, a few of those topics captured the attention and interest of clients more than others. These topics included: “Needs” versus “wants,” budgeting, and utility assistance programs. We also recognized that there were some topics discussed in the classes that were not part of the lesson plan.
These conversations arose primarily from client interest, and included topics such as how to communicate with family members about money and how to choose the right kind of bank account. During the classes, each instructor mentioned that educational materials were available. At the end of all the classes observed, clients picked up some of these materials before leaving. In their interviews, class instructors stated that clients were engaged during the classes because money is a basic need, and finances affect all members of the family. They stated that the classes provided clients with asset development resources and tools that they may not find anywhere else, and gave clients hope that they could improve their current financial situations. They also felt that the classes helped clients understand their own beliefs about money, as well as their partners’ and families’ values around money. Instructors reported that the topics that generated the most client interest were:
1. taking charge of money and creating a budget for their family,
2. “needs” versus “wants”, and
3. local financial resources (the most popular resource handouts were for utility assistance programs, CFR’s prepaid debit card, a budgeting worksheet, and an online financial education course).
Finally, the instructors observed some cultural variation between the English- and Spanish-speaking classes. They perceived Spanish-speaking clients to be more eager to learn during class, yet not as comfortable participating in discussions about family finances. One instructor commented on how English-speaking clients seemed to already know the basics of what the class was teaching and therefore enjoyed participating in class discussion. The results of the above evaluation have been shared with staff from WIC and other County agencies, project funders (public and private), community partners, professional conference audiences, and organizations around the nation interested in our work. We hope to implement BEST classes again, as the WIC class schedule allows, and focusing on topics in which clients showed particular interest. In the meantime, we will continue distributing financial asset development resource information to clients at WIC sites.
Objective 3: In order to evaluate Outcome 3, we have documented several of the system changes listed above. This documentation includes tracking logs, coalition minutes, and basic project files, collected and maintained by staff of BEST and its community partners. Following are a few examples of local system changes to come out our work on BEST:
1. Due to the cutting-edge nature of the LCI and BEST, they have received much national and local interest. Since October 2007, we have made 57 presentations to over 2,800 health and human service professionals and students about the LCI and BEST, and their grounding in the Life Course Perspective and social determinants of health.
2. Technical assistance is provided on a regular basis, by phone and e-mail, to local health departments and other health and social justice organizations across the country who would like to implement similar interventions.
3. As a result of BEST, we have created and maintained new partnerships, particularly through collaboratives addressing economic security and health, including the Contra Costa Family Economic Security Partnership (FESP) Executive Committee and Coordinating Council, and Health-Wealth Connection Collaborative (HWCC). In particular, the partnership with FESP helped us develop the BEST Asset Development Resource Guide. (See “Local Health Department and Community Collaboration” section for details.)
4. Several other County and community-based organizations have requested print or electronic (in order to print for themselves) copies of our BEST Asset Development Resource Guide. The results of the evaluation have been shared with staff from WIC and other County agencies, project funders (public and private), community partners, professional conference audiences, and organizations around the nation interested in our work.
We recognize that we have taken a significant risk as our work has expanded into uncharted territory. However, due to the growing body of evidence on the connection between health and wealth, and recent efforts to bring this evidence to larger audiences, such as California Newsreel’s documentary series, “Unnatural Causes,” we have received support and encouragement from our organization to implement this project. Furthermore, we believe that by increasing the financial security of our clients, over time we will see an impact in the larger community – having more resources enables residents to spend their money locally and support the communities in which they live. Contra Costa WIC is currently implementing a project to address interconception depression and anxiety. A key component of this project is the administration of a perinatal depression screening tool with all WIC clients. One of the screening tool questions ask women who report feeling down to state their reasons for feeling down, and the most commonly chosen reason is “money issues” (chosen by 63% of the women screened). These data highlight the need to continue BEST services at WIC, and FMCH Programs and our many community partners and committed to ensuring that this happens. In addition, FMCH Programs has made a long-term commitment to integrating the Life Course Perspective into its work with children and families, and BEST is one the primary vehicles for doing so.
BEST currently receives the majority of its funding from the California Department of Public Health’s Maternal, Child and Adolescent Health Program and federal matching funds. Traditionally these have been relatively stable sources of funding, but they are now vulnerable due to the instability of federal, State, and County budgets. Consequently, to truly sustain and expand this project over the next few years, we must bring in more outside funding, and we continue to build new partnerships with organizations in multiple sectors and seek cross-sector grant funding.
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