eliminate 600 words from this document without deleting parenthetical references or headlines:
Part One: Policy Analysis
The Healthcare Policy Issue
The healthcare policy issue discussed here is infant mortality. Infant mortality rate (IMR) is a good measure of a country's healthcare system because it reflects the overall effectiveness of health services and societal well-being (Reidpath & Allotey, 2003) and provides insights into the quality of perinatal care (prenatal, birth, and postnatal care). High IMRs may indicate issues in maternal health, insufficient access to healthcare, or poor-quality medical services for pregnant women and infants. Barriers to healthcare access include cost, availability of services, providers, or nurses, and geographic disparities.
Introduction to the Problem
Although the infant mortality rate in California is one of the lowest in the United States (Centers for Disease Control, 2023), infant death remains an unacceptable outcome. In California, there are significant racial disparities in IMRs. The lowest IMRs are among Asian infants (2.7%) and white infants (3.1%), and these IMRs are declining. However, the IMRs among black infants (7.9%) and Pacific Islander infants (8.8%) are rising (California Department of Public Health, 2022). Numerous programs are in place at the state, local, and health system levels to address this problem.
The Policy Analysis Framework
This policy analysis employs the RE-AIM Framework (Seavey, Aytur, & McGrath, 2024). The RE-AIM Framework is divided into five steps. Step One of the analysis (this part), reach, examines the portion of a specific population affected by the issue and interventions proposed. Reach asks, "Whose health and behaviors need improvement?" In the case of infant mortality, the health of infants is of primary concern, but the perinatal health behaviors of mothers must be addressed to reduce the IMR. The second step, effectiveness, evaluates the outcomes of the intervention, both positive and negative. Step Two, analysis, also identifies the stakeholders to be included in the discussion, planning, and implementation. The stakeholders for this policy are primarily state Assembly members, the California Department of Public Health (CDPH), selected CDPH programs, and interested volunteer groups. Step Three, adoption, identifies the organizations or agencies that will implement the framework. The CDPH is the party that will implement this policy if approved. The specific programs involved are the California Home Visiting Program (CHVP) and the Black Infant Health Program (BIHP). Step Four, implementation, considers the quality of delivery of the intervention and resources used. The CDPH programs are tracked and analyzed for efficacy. In Step Five, maintenance, the long-term outcomes, and sustainability of the intervention are evaluated. Steps Two through Five are discussed below.
Key Stakeholders Involved in the Health Policy Process
The federal government supplies the largest percentage of funding for perinatal interventions in California through the Title V Maternal and Child Health Block Grant. In 2023 (the most recent report available), Medical paid for 40.5% of deliveries (California Department of Public Health, 2022). The Medical program is partially funded by the federal government and partially funded and administered by the state government. California Department of Public Health programs are implemented at the county level (one office per county).
The Background of the Problem
Of the 39 million California residents, about 16% are newborn to 17 years old. Sixty-five percent of the population is comprised of people of color. There were 419,214 annual births in 2023. Preterm deliveries accounted for 9.1% of newborns. There are 233 birthing facilities in the state (CDPH, 2022). Some large health systems, such as the University of California’s Preterm Birth Initiative, operate perinatal support programs (UCSF, n.d.). The recommended policy change discussed here represents the interventions that have proven most effective in reducing California's perinatal health disparities and IMRs.
Part Two: Policy Statement
The proposed policy will restore the California Home Visiting Program (CHVP) budget to reach more African American families in California. The CHVP provides at-home support for new and expecting mothers, offering guidance on infant care, feeding, and health monitoring for overburdened families at risk for adverse experiences. The intended program outcomes are reductions in child maltreatment, domestic violence, substance use disorder, and mental health-related issues. “Home visiting programs produce positive outcomes that save taxpayer dollars by reducing societal costs associated with intimate partner violence, child maltreatment, youth crime, substance use disorder, and the need for government assistance (CHVP, 2024).” These outcomes are expected to reduce maternal and infant morbidity and mortality. Since its inception in 2019, the program has served 2470 families and 1854 children from 28 weeks gestation through age 3 (CHVP, 2024).
Primary Focus of Policy Initiative
Since 2019, the CHVP has reached mostly Medical recipients (83%), of whom 57% were Hispanic, 19% were white, and only 9% were African American (CHVP, 2024). It is noteworthy, however, that the highest infant mortality rates in California are among African American infants. “During 2019-2021 (average), the infant mortality rate (per 1,000 live births) in California was highest for Black infants (8.2), followed by American Indian/Alaska Natives (5.0), Hispanics (4.2), Whites (3.2) and Asian/Pacific Islanders (2.6) (March of Dimes, 2024). The CHVP program must be explicitly expanded to reach more African American families in California.
Trade-offs
The trade-offs are largely budgetary. The 2023-24 budget for the program was $98 million. The budget for the CHVP was cut by $47.1 million in the 2023-24 budget (California State Assembly, 2024). This proposal will increase the budget to its pre-2023 spending level and increase the program's focus on reaching at-risk African American families. The funds would have to come from either increased taxes (very unlikely) or decreases in other California Human Services programs. CHVP (2024) reports that home visiting programs can reduce the need for government assistance (the amount is not provided), so the restored funds might be found in reduced expenses for government assistance such as the California Work Opportunity and Responsibility to Kids (CalWORKs) program.
Why This Policy Stands Out
Given the significant racial disparities in infant mortality, decreasing funding for a program that addresses these disparities is unreasonable. The budget for this successful program should at least be restored and, ideally, be expanded to specifically address the reduction in the infant mortality rate of African American infants and the reduction in the maternal mortality rate of African American mothers.
Political Units to Address the Issue
As part of the CDPH, the CHVP budget is controlled by the State Assembly Budget Subcommittee No. 1 on Health and Human Services and the Senate Budget and Fiscal Review Subcommittee No. 3 on Health and Human Services. The California Department of Public Health is the program administrator. The CDPH also has a specific program, Black Infant Health, which addresses issues of African American infant morbidity and mortality(CDPH, n.d.-a). National organizations, such as the March of Dimes (n.d.), and non-government groups in California, such as the California Health Care Foundation Birth Equity program (2024) and the Los Angeles County African American Infant and Maternal Mortality (AAIMM) Initiative (2024), could also advocate for CHVP budget restoration and expansion.
Part Three: Stakeholder Analysis
Through the Title V Maternal and Child Health (MCH) Services Block Grant, the United States (U.S.) government works to “improve the public health systems for mothers, children, and their families” (U.S. Department of Health and Human Services, Health Resources & Services Administration, n.d.-a). The U.S. Department of Health and Human Services (USDHHS) presents evidence of the efficacy of home visiting programs on its website (USDHHS, n.d.-b). The Department also includes the Office of Minority Health (n.d.), another potential ally of this proposed policy. The federal government’s role in providing funding gives it considerable control of programs related to infant mortality rates. The California State Legislature implements additional budget and policy control because its members control how the allocated funds are used.
All the organizations mentioned in Table 1 are potential stakeholders in policies to reduce minority infant mortality. To clarify, the California Department of Health, Center for Family Health, Maternal, Child, and Adolescent Health Division is responsible for many of the programs listed, but most of these programs have local offices. Depending upon the needs of specific communities, it may be useful to contact the local offices for support. However, the Department budget is the main focus of this policy recommendation.
Based on the stakeholder analysis summarized in Table 1, the stakeholders can be generally categorized as affecting the budget, making and approving policy decisions, or as potential coalition partners. These influences are noted in the “How could they support” and “How could they hinder” columns as “budget,” “policy,” and “coalition.” While the potential coalition partners listed have no budget control and may have limited policy control, any opposition from these organizations would be problematic. It is important, therefore, to get them on board in support of the proposed policy change.
Figures 1 and 2 illustrate California's per capita expenditure and revenue (Urban Institute, n.d.). Expenditure categories that might be affected by the proposed policy change include "public welfare" and "health and hospitals." Income tax revenue in California is more than twice the national average. The federal government also contributes almost as much to revenue as income taxes. Organizations in favor of or opposed to changes in expenses or revenues might favor or oppose the proposed policy change.
Stakeholders who might oppose the proposed changes are more difficult to identify. However, they might include other programs, especially CDPH programs, competing for funding and groups generally opposed to government spending or spending on public health. The VoteSmart website (n.d.) provides impartial summaries of interest groups. Conservative interest groups active in California include the American Conservative Union (a fiscally conservative group), the California Republican Assembly, the Christian Coalition of California, and Save California. Fiscally conservative groups include New Majority California and the Republican Liberty Caucus of California. Any of these groups might oppose policy changes related to increased spending or minority health. Before actually starting to advocate for the proposed policy changes, additional research, contact establishment, and coalition building would be necessary.
Part 4: Measuring Success
There are numerous outcomes to consider when evaluating a policy change to reduce minority infant mortality. The best long-term measure of success would be a decrease in the IMR among African American babies. As discussed above, so many factors influence this intended outcome that it would not be wise to assess only the IMR. The IMR might only change over the years. When a trend in the data emerged, significant resources might have been invested in the wrong areas or not applied where most needed. Short-term outcomes also need to be monitored to ensure timely adjustments.
Monitoring the success of the California Home Visiting Program (HVP) in the short term can involve tracking key metrics related to program engagement, participant satisfaction, and immediate outcomes for families. Some short-term measures of success include the following. The enrollment and program retention rates can be measured by tracking the number of families enrolled, indicating the program's reach and appeal. An increased retention rate over time suggests that families find the program valuable. Interested parties might conduct surveys of participating families to gauge their satisfaction with the program, home visitors, and the perceived benefits. Survey takers might also be asked how likely they are to recommend the program to others to provide insights into program quality. Key indicators of program success include engagement levels. Track the number of scheduled visits that are completed. Higher completion rates indicate more program engagement. Ensure that families receive visits as frequently as intended according to the program's design.
Maternal health is vital to fetal and infant health. Short-term monitoring should track perinatal maternal health screenings, such as the prevalence of preeclampsia and postpartum depression. Similarly, program evaluations should track infant morbidity via completion rates of child developmental screenings. Additional monitoring outcomes include maternal breastfeeding rates, infant immunization completion, or reductions in emergency room visits. Short-term measures can assess the program's effectiveness in meeting its initial objectives and provide early indications of where improvements or successful services need to be expanded.
Part 5: Systematic Review for Policy Options
The recommended policy and funding changes for addressing this particular issue, restoring the funding for the CHVP, can be implemented incrementally or non-incrementally. The recommendation is a budget change to restore the budget to pre-2024 levels. It would also be beneficial to include additional funding for research so that program results can be shared. An additional option would be to increase program spending based on existing evidence. Increased spending could be another incremental change as the specific results of the CHVP are published.
In a brief review of literature on CINAHL published between 2000 and 2024, the following published evidence supports the effectiveness of home visitation programs in reducing infant mortality. These are all recently published and appeared in referred journals. The report from McConnell et al. (2022) was inconclusive, and there were no published reports of home visit program failures or inadequacy in reducing infant mortality. Ghoshal et al. (2024), Kahraman and Havlio?lu (2024), Scharf et al. (2020), and the United States Department of Health & Human Services, Administration for Children and Families (n.d.-b) all reported evidence of the effectiveness of home visitation programs. These results would support the continuation of the CHVP and additional research. Interestingly, McConnell et al. (2022) studied the use of home health workers, not trained nurses, in perinatal home visitation programs and found them equally effective. The use of home health workers is an area where additional research would be helpful due to the cost implications.
The existence of multiple live programs (listed in Table 1) supports the use of home visit programs to improve minority infant morbidity and mortality. Some groups opposed to increased government spending might oppose the CHVP budget. However, there is no published evidence of groups specifically opposed to decreasing minority infant mortality. Except for the United States Department of Health & Human Services, Administration for Children and Families (n.d.-b) report, the programs listed in Table 1 need to offer published evidence of their effectiveness on their websites.
Gray literature refers to information not typically published through traditional academic or commercial publishing channels, but it can still be highly influential in shaping healthcare policy decisions. Some examples of gray literature that might influence healthcare policy include government reports and publications, such as National Institutes of Health (NIH) Reports, Centers for Disease Control and Prevention (CDC) publications, World Health Organization (WHO) policy documents, Health and Human Services (HHS) reports, and Congressional Budget Office (CBO) analyses of healthcare proposals. Other sources such as think tank publications (Kaiser Family Foundation, The Commonwealth Fund, RAND Corporation) or university-affiliated research centers focused on health policy often influence policy decisions through detailed analyses and policy briefs. Nonprofit and advocacy groups, healthcare industry white papers and policy briefs, consulting companies (e.g., McKinsey & Company, Deloitte, PwC, and conference proceedings may also influence healthcare policy. Regulatory and legal filings, public comments on proposed regulations or legislation, public health data, clinical practice guidelines, working papers, or final reports from specialized task forces or coalitions may also be part of the gray literature affecting health policy. These sources provide valuable data, expert opinions, and recommendations that can inform and influence healthcare policy decisions at local, state, national, and international levels.
Part 6: Recommendations and Strategies
Reducing African American infant mortality rates (IMR) requires addressing fundamental issues of health equity, systemic racism, social justice, and public health expenses. Reducing infant mortality can lower healthcare costs, improve productivity, and create healthier workforces, contributing to economic stability and growth. The IMR of African American babies in California is more than twice the IMR for white babies (March of Dimes, 2024). Health disparities, including high infant mortality rates, place a significant economic burden on society. The medical costs associated with high-risk pregnancies, preterm births, and neonatal intensive care stays are substantial, and minority populations in California face higher rates of these complications. The home visit model has shown considerable promise in reducing infant mortality among minority populations and decreasing healthcare spending (Center for Health Care Strategies, 2022). Like other home-visiting programs, the California Home Visiting Program (CHVP) shows promise in reducing maternal and infant health disparities. Continued efforts and research are necessary to fully close the gap (Dagher & Linares, 2022).
In 2024, the California State Assembly reduced funding for the CHVP by $25 million for each of two years (2024-2026). The budget should be restored explicitly to expand the program’s reach among Black families and to support additional research. These recommended changes can improve the health of mothers and infants and save millions of dollars in medical expenses in California (Schmitt, Sneed, & Phibbs, 2006). Strategies for accomplishing these recommendations are to engage concerned community members in the issue via social media, present research results, and cost-benefit analysis, form coalitions with like-minded groups (listed in Table 1), create a public education campaign to inform key stakeholders about the issue of minority infant mortality, and provide legislative advocacy via lobbying by coalition partners and individuals to make the budget changes and providing testimony at budget hearings.
There are short- and long-term measures of success. Short-term measures include reaching more African American families during the perinatal period (tracked through the CHVP), monitoring and reporting positive changes in maternal, fetal, and neonatal health (e.g., reduced rates of preeclampsia and maternal demise, increased infant birth weight, decreased length of stay in neonatal intensive care units), and publishing research documenting the efficacy of the CHVP. Long-term measures include reducing the IMR among African Americans in California, thus closing the health equity gap and decreasing healthcare costs associated with high-risk pregnancies, preterm births, and stays in neonatal intensive care for African American babies. These outcomes are worth the investment.
Part 7: Policy Strategies
The final step is to implement the plan to restore and possibly expand the funding for CHVP so that the program can reach more minority families and ultimately reduce minority IMRs. Coalition partners are needed to achieve this end. Table 1 lists potential coalition partners and contacts, but it is just a starting point. The list will be refined as contacts are made and new potential partners are identified. A key part of this strategy will be to start following others on social media with healthcare equity interests. Participating in these online discussions will not only help identify new allies; it will also help spread the word about this project. When the coalition reaches a critical mass (to be determined), it will be time to identify a California State Assemblymember or senator to sponsor the legislation. Media efforts will then intensify, with a focus on social media and as many individuals and coalition partners as possible participating. After introducing the new bill, the coalition will organize testimony and lobbying efforts. After the bill passes, the coalition must remain active to ensure that funding is not cut again and that new research is published and promoted.
In conclusion, the key points of the message are:
African American families in California are disproportionately affected by infant mortality. The infant mortality rate (IMR) of African American babies in California (8.2/1,000) is more than twice the IMR for white babies (3.2/1,000) (March of Dimes, 2024). The California Home Visiting Program (CHVP) has improved health outcomes for racial and ethnic minorities, including reduced infant mortality (CHVP, 2024). CHVP provides at-risk families with home visits by trained professionals who offer support in areas like child development, parenting, and health care access. These interventions are particularly impactful in communities facing socioeconomic challenges, including racial and ethnic minorities (Center for Health Care Strategies, 2022). Programs like CHVP help mitigate the effects of systemic racism and improve health outcomes for Black mothers and infants (California Department of Public, n.d.). They have shown promise in reducing maternal and infant health disparities, though continued efforts and research are necessary to close the gap fully (Dagher & Linare. 2022).
Health disparities, including high infant mortality rates, place a significant economic burden on society. The medical costs associated with high-risk pregnancies, preterm births, and neonatal intensive care are substantial, and minority populations in California face higher rates of these complications. In a literature review of social determinants of health, Dagher and Linare (2022) found that reducing infant mortality can lower healthcare costs, improve productivity, and create healthier workforces, contributing to broader economic stability and growth. The authors identify multiple areas where additional research is needed to reduce racial and ethnic health disparities and to select the most efficacious interventions.
In 2024, the California State Assembly reduced funding for the CHVP by $25 million for each of two years (2024-2036). The budget should be restored explicitly to expand the program’s reach among Black families and to support additional research.
Part One: Policy Analysis
The Healthcare Policy Issue
The healthcare policy issue discussed here is infant mortality. Infant mortality rate (IMR) is a good measure of a country's healthcare system because it reflects the overall effectiveness of health services and societal well-being (Reidpath & Allotey, 2003) and provides insights into the quality of perinatal care (prenatal, birth, and postnatal care). High IMRs may indicate issues in maternal health, insufficient access to healthcare, or poor-quality medical services for pregnant women and infants. Barriers to healthcare access include cost, availability of services, providers, or nurses, and geographic disparities.
Introduction to the Problem
Although the infant mortality rate in California is one of the lowest in the United States (Centers for Disease Control, 2023), infant death remains an unacceptable outcome. In California, there are significant racial disparities in IMRs. The lowest IMRs are among Asian infants (2.7%) and white infants (3.1%), and these IMRs are declining. However, the IMRs among black infants (7.9%) and Pacific Islander infants (8.8%) are rising (California Department of Public Health, 2022). Numerous programs are in place at the state, local, and health system levels to address this problem.
The Policy Analysis Framework
This policy analysis employs the RE-AIM Framework (Seavey, Aytur, & McGrath, 2024). The RE-AIM Framework is divided into five steps. Step One of the analysis (this part), reach, examines the portion of a specific population affected by the issue and interventions proposed. Reach asks, "Whose health and behaviors need improvement?" In the case of infant mortality, the health of infants is of primary concern, but the perinatal health behaviors of mothers must be addressed to reduce the IMR. The second step, effectiveness, evaluates the outcomes of the intervention, both positive and negative. Step Two, analysis, also identifies the stakeholders to be included in the discussion, planning, and implementation. The stakeholders for this policy are primarily state Assembly members, the California Department of Public Health (CDPH), selected CDPH programs, and interested volunteer groups. Step Three, adoption, identifies the organizations or agencies that will implement the framework. The CDPH is the party that will implement this policy if approved. The specific programs involved are the California Home Visiting Program (CHVP) and the Black Infant Health Program (BIHP). Step Four, implementation, considers the quality of delivery of the intervention and resources used. The CDPH programs are tracked and analyzed for efficacy. In Step Five, maintenance, the long-term outcomes, and sustainability of the intervention are evaluated. Steps Two through Five are discussed below.
Key Stakeholders Involved in the Health Policy Process
The federal government supplies the largest percentage of funding for perinatal interventions in California through the Title V Maternal and Child Health Block Grant. In 2023 (the most recent report available), Medical paid for 40.5% of deliveries (California Department of Public Health, 2022). The Medical program is partially funded by the federal government and partially funded and administered by the state government. California Department of Public Health programs are implemented at the county level (one office per county).
The Background of the Problem
Of the 39 million California residents, about 16% are newborn to 17 years old. Sixty-five percent of the population is comprised of people of color. There were 419,214 annual births in 2023. Preterm deliveries accounted for 9.1% of newborns. There are 233 birthing facilities in the state (CDPH, 2022). Some large health systems, such as the University of California’s Preterm Birth Initiative, operate perinatal support programs (UCSF, n.d.). The recommended policy change discussed here represents the interventions that have proven most effective in reducing California's perinatal health disparities and IMRs.
Part Two: Policy Statement
The proposed policy will restore the California Home Visiting Program (CHVP) budget to reach more African American families in California. The CHVP provides at-home support for new and expecting mothers, offering guidance on infant care, feeding, and health monitoring for overburdened families at risk for adverse experiences. The intended program outcomes are reductions in child maltreatment, domestic violence, substance use disorder, and mental health-related issues. “Home visiting programs produce positive outcomes that save taxpayer dollars by reducing societal costs associated with intimate partner violence, child maltreatment, youth crime, substance use disorder, and the need for government assistance (CHVP, 2024).” These outcomes are expected to reduce maternal and infant morbidity and mortality. Since its inception in 2019, the program has served 2470 families and 1854 children from 28 weeks gestation through age 3 (CHVP, 2024).
Primary Focus of Policy Initiative
Since 2019, the CHVP has reached mostly Medical recipients (83%), of whom 57% were Hispanic, 19% were white, and only 9% were African American (CHVP, 2024). It is noteworthy, however, that the highest infant mortality rates in California are among African American infants. “During 2019-2021 (average), the infant mortality rate (per 1,000 live births) in California was highest for Black infants (8.2), followed by American Indian/Alaska Natives (5.0), Hispanics (4.2), Whites (3.2) and Asian/Pacific Islanders (2.6) (March of Dimes, 2024). The CHVP program must be explicitly expanded to reach more African American families in California.
Trade-offs
The trade-offs are largely budgetary. The 2023-24 budget for the program was $98 million. The budget for the CHVP was cut by $47.1 million in the 2023-24 budget (California State Assembly, 2024). This proposal will increase the budget to its pre-2023 spending level and increase the program's focus on reaching at-risk African American families. The funds would have to come from either increased taxes (very unlikely) or decreases in other California Human Services programs. CHVP (2024) reports that home visiting programs can reduce the need for government assistance (the amount is not provided), so the restored funds might be found in reduced expenses for government assistance such as the California Work Opportunity and Responsibility to Kids (CalWORKs) program.
Why This Policy Stands Out
Given the significant racial disparities in infant mortality, decreasing funding for a program that addresses these disparities is unreasonable. The budget for this successful program should at least be restored and, ideally, be expanded to specifically address the reduction in the infant mortality rate of African American infants and the reduction in the maternal mortality rate of African American mothers.
Political Units to Address the Issue
As part of the CDPH, the CHVP budget is controlled by the State Assembly Budget Subcommittee No. 1 on Health and Human Services and the Senate Budget and Fiscal Review Subcommittee No. 3 on Health and Human Services. The California Department of Public Health is the program administrator. The CDPH also has a specific program, Black Infant Health, which addresses issues of African American infant morbidity and mortality(CDPH, n.d.-a). National organizations, such as the March of Dimes (n.d.), and non-government groups in California, such as the California Health Care Foundation Birth Equity program (2024) and the Los Angeles County African American Infant and Maternal Mortality (AAIMM) Initiative (2024), could also advocate for CHVP budget restoration and expansion.
Part Three: Stakeholder Analysis
Through the Title V Maternal and Child Health (MCH) Services Block Grant, the United States (U.S.) government works to “improve the public health systems for mothers, children, and their families” (U.S. Department of Health and Human Services, Health Resources & Services Administration, n.d.-a). The U.S. Department of Health and Human Services (USDHHS) presents evidence of the efficacy of home visiting programs on its website (USDHHS, n.d.-b). The Department also includes the Office of Minority Health (n.d.), another potential ally of this proposed policy. The federal government’s role in providing funding gives it considerable control of programs related to infant mortality rates. The California State Legislature implements additional budget and policy control because its members control how the allocated funds are used.
All the organizations mentioned in Table 1 are potential stakeholders in policies to reduce minority infant mortality. To clarify, the California Department of Health, Center for Family Health, Maternal, Child, and Adolescent Health Division is responsible for many of the programs listed, but most of these programs have local offices. Depending upon the needs of specific communities, it may be useful to contact the local offices for support. However, the Department budget is the main focus of this policy recommendation.
Based on the stakeholder analysis summarized in Table 1, the stakeholders can be generally categorized as affecting the budget, making and approving policy decisions, or as potential coalition partners. These influences are noted in the “How could they support” and “How could they hinder” columns as “budget,” “policy,” and “coalition.” While the potential coalition partners listed have no budget control and may have limited policy control, any opposition from these organizations would be problematic. It is important, therefore, to get them on board in support of the proposed policy change.
Figures 1 and 2 illustrate California's per capita expenditure and revenue (Urban Institute, n.d.). Expenditure categories that might be affected by the proposed policy change include "public welfare" and "health and hospitals." Income tax revenue in California is more than twice the national average. The federal government also contributes almost as much to revenue as income taxes. Organizations in favor of or opposed to changes in expenses or revenues might favor or oppose the proposed policy change.
Stakeholders who might oppose the proposed changes are more difficult to identify. However, they might include other programs, especially CDPH programs, competing for funding and groups generally opposed to government spending or spending on public health. The VoteSmart website (n.d.) provides impartial summaries of interest groups. Conservative interest groups active in California include the American Conservative Union (a fiscally conservative group), the California Republican Assembly, the Christian Coalition of California, and Save California. Fiscally conservative groups include New Majority California and the Republican Liberty Caucus of California. Any of these groups might oppose policy changes related to increased spending or minority health. Before actually starting to advocate for the proposed policy changes, additional research, contact establishment, and coalition building would be necessary.
Part 4: Measuring Success
There are numerous outcomes to consider when evaluating a policy change to reduce minority infant mortality. The best long-term measure of success would be a decrease in the IMR among African American babies. As discussed above, so many factors influence this intended outcome that it would not be wise to assess only the IMR. The IMR might only change over the years. When a trend in the data emerged, significant resources might have been invested in the wrong areas or not applied where most needed. Short-term outcomes also need to be monitored to ensure timely adjustments.
Monitoring the success of the California Home Visiting Program (HVP) in the short term can involve tracking key metrics related to program engagement, participant satisfaction, and immediate outcomes for families. Some short-term measures of success include the following. The enrollment and program retention rates can be measured by tracking the number of families enrolled, indicating the program's reach and appeal. An increased retention rate over time suggests that families find the program valuable. Interested parties might conduct surveys of participating families to gauge their satisfaction with the program, home visitors, and the perceived benefits. Survey takers might also be asked how likely they are to recommend the program to others to provide insights into program quality. Key indicators of program success include engagement levels. Track the number of scheduled visits that are completed. Higher completion rates indicate more program engagement. Ensure that families receive visits as frequently as intended according to the program's design.
Maternal health is vital to fetal and infant health. Short-term monitoring should track perinatal maternal health screenings, such as the prevalence of preeclampsia and postpartum depression. Similarly, program evaluations should track infant morbidity via completion rates of child developmental screenings. Additional monitoring outcomes include maternal breastfeeding rates, infant immunization completion, or reductions in emergency room visits. Short-term measures can assess the program's effectiveness in meeting its initial objectives and provide early indications of where improvements or successful services need to be expanded.
Part 5: Systematic Review for Policy Options
The recommended policy and funding changes for addressing this particular issue, restoring the funding for the CHVP, can be implemented incrementally or non-incrementally. The recommendation is a budget change to restore the budget to pre-2024 levels. It would also be beneficial to include additional funding for research so that program results can be shared. An additional option would be to increase program spending based on existing evidence. Increased spending could be another incremental change as the specific results of the CHVP are published.
In a brief review of literature on CINAHL published between 2000 and 2024, the following published evidence supports the effectiveness of home visitation programs in reducing infant mortality. These are all recently published and appeared in referred journals. The report from McConnell et al. (2022) was inconclusive, and there were no published reports of home visit program failures or inadequacy in reducing infant mortality. Ghoshal et al. (2024), Kahraman and Havlio?lu (2024), Scharf et al. (2020), and the United States Department of Health & Human Services, Administration for Children and Families (n.d.-b) all reported evidence of the effectiveness of home visitation programs. These results would support the continuation of the CHVP and additional research. Interestingly, McConnell et al. (2022) studied the use of home health workers, not trained nurses, in perinatal home visitation programs and found them equally effective. The use of home health workers is an area where additional research would be helpful due to the cost implications.
The existence of multiple live programs (listed in Table 1) supports the use of home visit programs to improve minority infant morbidity and mortality. Some groups opposed to increased government spending might oppose the CHVP budget. However, there is no published evidence of groups specifically opposed to decreasing minority infant mortality. Except for the United States Department of Health & Human Services, Administration for Children and Families (n.d.-b) report, the programs listed in Table 1 need to offer published evidence of their effectiveness on their websites.
Gray literature refers to information not typically published through traditional academic or commercial publishing channels, but it can still be highly influential in shaping healthcare policy decisions. Some examples of gray literature that might influence healthcare policy include government reports and publications, such as National Institutes of Health (NIH) Reports, Centers for Disease Control and Prevention (CDC) publications, World Health Organization (WHO) policy documents, Health and Human Services (HHS) reports, and Congressional Budget Office (CBO) analyses of healthcare proposals. Other sources such as think tank publications (Kaiser Family Foundation, The Commonwealth Fund, RAND Corporation) or university-affiliated research centers focused on health policy often influence policy decisions through detailed analyses and policy briefs. Nonprofit and advocacy groups, healthcare industry white papers and policy briefs, consulting companies (e.g., McKinsey & Company, Deloitte, PwC, and conference proceedings may also influence healthcare policy. Regulatory and legal filings, public comments on proposed regulations or legislation, public health data, clinical practice guidelines, working papers, or final reports from specialized task forces or coalitions may also be part of the gray literature affecting health policy. These sources provide valuable data, expert opinions, and recommendations that can inform and influence healthcare policy decisions at local, state, national, and international levels.
Part 6: Recommendations and Strategies
Reducing African American infant mortality rates (IMR) requires addressing fundamental issues of health equity, systemic racism, social justice, and public health expenses. Reducing infant mortality can lower healthcare costs, improve productivity, and create healthier workforces, contributing to economic stability and growth. The IMR of African American babies in California is more than twice the IMR for white babies (March of Dimes, 2024). Health disparities, including high infant mortality rates, place a significant economic burden on society. The medical costs associated with high-risk pregnancies, preterm births, and neonatal intensive care stays are substantial, and minority populations in California face higher rates of these complications. The home visit model has shown considerable promise in reducing infant mortality among minority populations and decreasing healthcare spending (Center for Health Care Strategies, 2022). Like other home-visiting programs, the California Home Visiting Program (CHVP) shows promise in reducing maternal and infant health disparities. Continued efforts and research are necessary to fully close the gap (Dagher & Linares, 2022).
In 2024, the California State Assembly reduced funding for the CHVP by $25 million for each of two years (2024-2026). The budget should be restored explicitly to expand the program’s reach among Black families and to support additional research. These recommended changes can improve the health of mothers and infants and save millions of dollars in medical expenses in California (Schmitt, Sneed, & Phibbs, 2006). Strategies for accomplishing these recommendations are to engage concerned community members in the issue via social media, present research results, and cost-benefit analysis, form coalitions with like-minded groups (listed in Table 1), create a public education campaign to inform key stakeholders about the issue of minority infant mortality, and provide legislative advocacy via lobbying by coalition partners and individuals to make the budget changes and providing testimony at budget hearings.
There are short- and long-term measures of success. Short-term measures include reaching more African American families during the perinatal period (tracked through the CHVP), monitoring and reporting positive changes in maternal, fetal, and neonatal health (e.g., reduced rates of preeclampsia and maternal demise, increased infant birth weight, decreased length of stay in neonatal intensive care units), and publishing research documenting the efficacy of the CHVP. Long-term measures include reducing the IMR among African Americans in California, thus closing the health equity gap and decreasing healthcare costs associated with high-risk pregnancies, preterm births, and stays in neonatal intensive care for African American babies. These outcomes are worth the investment.
Part 7: Policy Strategies
The final step is to implement the plan to restore and possibly expand the funding for CHVP so that the program can reach more minority families and ultimately reduce minority IMRs. Coalition partners are needed to achieve this end. Table 1 lists potential coalition partners and contacts, but it is just a starting point. The list will be refined as contacts are made and new potential partners are identified. A key part of this strategy will be to start following others on social media with healthcare equity interests. Participating in these online discussions will not only help identify new allies; it will also help spread the word about this project. When the coalition reaches a critical mass (to be determined), it will be time to identify a California State Assemblymember or senator to sponsor the legislation. Media efforts will then intensify, with a focus on social media and as many individuals and coalition partners as possible participating. After introducing the new bill, the coalition will organize testimony and lobbying efforts. After the bill passes, the coalition must remain active to ensure that funding is not cut again and that new research is published and promoted.
In conclusion, the key points of the message are:
African American families in California are disproportionately affected by infant mortality. The infant mortality rate (IMR) of African American babies in California (8.2/1,000) is more than twice the IMR for white babies (3.2/1,000) (March of Dimes, 2024). The California Home Visiting Program (CHVP) has improved health outcomes for racial and ethnic minorities, including reduced infant mortality (CHVP, 2024). CHVP provides at-risk families with home visits by trained professionals who offer support in areas like child development, parenting, and health care access. These interventions are particularly impactful in communities facing socioeconomic challenges, including racial and ethnic minorities (Center for Health Care Strategies, 2022). Programs like CHVP help mitigate the effects of systemic racism and improve health outcomes for Black mothers and infants (California Department of Public, n.d.). They have shown promise in reducing maternal and infant health disparities, though continued efforts and research are necessary to close the gap fully (Dagher & Linare. 2022).
Health disparities, including high infant mortality rates, place a significant economic burden on society. The medical costs associated with high-risk pregnancies, preterm births, and neonatal intensive care are substantial, and minority populations in California face higher rates of these complications. In a literature review of social determinants of health, Dagher and Linare (2022) found that reducing infant mortality can lower healthcare costs, improve productivity, and create healthier workforces, contributing to broader economic stability and growth. The authors identify multiple areas where additional research is needed to reduce racial and ethnic health disparities and to select the most efficacious interventions.
In 2024, the California State Assembly reduced funding for the CHVP by $25 million for each of two years (2024-2036). The budget should be restored explicitly to expand the program’s reach among Black families and to support additional research.