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Tier 5:
Education and counseling: Individual or public educational messages and support

Tier 5 Recommendations: Education and Counseling

A.   Scale up (or continue investing) in fatherhood initiatives to increase social support within  the family and home environment.


B.   Integrate education about preconception and interconception health including mental and oral health, into hospital-based prenatal education models, group prenatal care, and home visiting programs.


C.   Integrate mental health and well-being into State Department of Education school health curriculum.

Fatherhood intuitively provides important support to mothers and children. Written and oral history of fatherhood provides evidence to support the role of men in raising children and in family development.64  With regards to birth outcomes, infants born to single mothers are more likely to have low birth weight and fathers participation in prenatal activities are associated with higher birth weights.65 Having partner support or involvement during a teenager’s pregnancy may reduce the likelihood of having a poor birth outcome.66 Fathers can influence moms to quit smoking during pregnancy,67 as well as influence the breastfeeding decision and when he is involved, mothers are more likely to breastfeed.68 Conversely, when fathers are not involved, mothers are more likely to smoke during pregnancy.69 This factor can be critical when considering that there is a 30% lower risk of sudden infant death syndrome (SIDS) if mom is not smoking.

Research demonstrates that a father’s absence can have an impact on maternal and birth outcomes, childhood obesity, education outcomes, drug and alcohol use, child abuse, teen pregnancy, crime, and incarceration. The importance of father involvement among low-income, minority fathers is also evident in the child maltreatment literature. Child abuse is associated with father absence and is one of the most common predictors. When fathers are not involved in their children’s lives the risk of neglect is also doubled.70

Fathers also influence cognitive and emotional development. When fathers are not involved, children experience more developmental delays while premature infants whose fathers spent more time playing with them had better cognitive outcomes at age 3.67 The first two years of young males lives are critical when it comes to father involvement because of the risk of experiencing “father hunger”, which can lead to mental health and behavioral problems in early years,71 whereas there are lower occurrences of psychological distress in teens whose fathers were present and involved.72

Fatherhood initiatives built on an understanding of life course theory and its implications for maternal and child health increase viability and success especially as a complimentary service in existing MCH

programs.70 Dr. Michael Lu and colleagues in their paper, “Where is the F in MCH? Father Involvement in African American Families”73 emphasize the need for a multi-level, life-course approach to strengthen the capacity of African American men to promote greater involvement in pregnancy and parenting as they become fathers. The paper explored several historical developments (slavery, declining employment for Black men and increasing workforce participation for Black women, and welfare policies that favored single mothers) that led to generations of father absence from African American families.73

Investing in fatherhood initiatives is crucial in ensuring that men are connected with their children and families, enhancing their important role as a protective factor. Father support increases social support to mothers and children, strengthening family resilience. Fatherhood initiatives priority goals are to improve the well-being of children by increasing the proportion of children growing up with involved, responsible, and committed fathers. This includes involving fathers in providing practical support during pregnancy and in raising children, as well as helping parents develop supportive and effective relationships with each other and their children.

Many fatherhood initiatives engage fathers who may have a history of incarceration; therefore specific outreach is needed to engage fathers and connecting them with needed “parenting” and “co-parenting” support. New Haven Family Alliance’s Male Involvement Network (MIN) program in New Haven74 is an example of a successful and innovative approach being implemented that engages low-income, non- custodial fathers in an effort to improve child development outcomes. The MIN is an initiative that consists of a partnership with the federally-funded New Haven Healthy Start program and The Community Foundation for Greater New Haven.  The city’s premiere MCH program and the city’s first fatherhood program took the lead in creating better outcomes for children and their mothers and fathers. This best practice model has been endorsed by the CT DSS and replicated in fatherhood programs across the state. It is a federally recognized model and has been the sustained over 17 years. The model provides a comprehensive service delivery system that helps empower fathers to become nurturing and responsible forces in their children’s lives that impacts policy and that promotes advocacy. This best practice service delivery model is comprehensive, collaborative, strategic, outcome driven and has a strong evaluation component.

Engaging community partners in creating outreach and engagement strategies has helped increase father involvement. Partners like direct service providers, administrators, funders, policy-makers, practitioners, and consumers should come together to collaborate in a true working partnership in order to ensure that services to this population are community-based, coordinated, comprehensive and culturally competent and responsive. Engagement strategies must include engaging men “where they are” by building their strengths and addressing their needs. Based on an examination of evidenced- based national programs, the case management model should clinically informed, and address their physical, emotional, mental, economic and spiritual health needs. The relational approach and social modeling should include skill development in education, economic stability, family/child support, and mental and physical health.

Programs like NHHS and MIN implement engagement strategies that represent innovative approaches for men and fathers that incorporate lessons learned from engaging multi-sector partners, and confirm that individual, family, community, societal and policy factors play a role in barring or diminishing the involvement of fathers during pregnancy. Targeting these factors and their interaction can increase fathers’ involvement and thereby improve pregnancy outcomes.  NHHS designed and implements Barbershop Quartet workshops, an 8-week session conducted right in the neighborhood barbershops, which covers topics from preconception through interconception care. New Haven is also one of two communities piloting the “Dads and Diamond are Forever”.

The MCHB recently awarded Healthy Start programs that include provisions for projects to focus on paternal involvement. There are 101 projects across the country with two in CT: New Haven and Hartford.

The Coalition recommendation to continue investing in fatherhood initiatives to increase social support within family and home environment involves investigating more programs to which MCH programs can be aligned, integrating “father inclusion” into existing/current MCH practices, and initiating services for men to ensure their health.

Recommendation 5A - Emerging and Promising Examples

Real Dads Forever

In 1996 the Real Dads program started at Manchester Hospital. The following year a Real Dads curriculum was developed and with it the establishment of Real Dads Forever. This comprehensive and holistic curriculum incorporates the emotional, physical, social and spiritual aspects of relationships that fathers have with their children. Fathers who have been involved in Real Dads Forever groups have been referred from a number of entities including the Departments of Social Services and Children and Families, schools, churches and other agencies.


National Fatherhood Initiative (NFI)

The National Fatherhood Initiative (NFI) was established in the early 1990’s in response to statistics showing that a record number of children throughout the country were growing up in father-absent homes and to the research documenting the negative impact this has when compared to children living in two-parent families. The first decade of NFI’s work focused on research and public education. Building on its research and public education efforts,  in the early 2000’s, the National Fatherhood Initiative® began to create skill-building materials and offering training to programs throughout the country that are working with fathers.


CT Fatherhood Initiative

The John S. Martinez Fatherhood Initiative of Connecticut has been in existence for 15 years and strives to support dads by providing the skills they need to get and stay involved with their children.  It operates through 10 Department of Social Services certified fatherhood programs, which provide a range of services including intensive case management, economic stability services and group sessions.


Male Involvement Network (MIN)

This network was established in 1997 by the following New Haven based providers: the Family Alliance, the Community Action Agency, and the New Haven Healthy Start, which operates within the Community Foundation of Greater New Haven.  The model was developed to address the unique needs of low income noncustodial fathers and is funded by the Community Foundation for Greater New Haven in partnership with New Haven Healthy Start, Empower New Haven and the State of Connecticut Department of Social Services. It operates on an individual, family and community level and has 9 core intervention strategies that are used by MIN member agencies. The core intervention strategies are: 1) education; employment and career development; family and child support; health; housing; legal services; mediation, access and visitation; economic stability and self-sufficiency; and outreach and case management.


Core Adaptive Model (CAM©) for Fatherhood Programs

The National Healthy Start Association (NHSA) has long recognized the important role fathers have, with or without marriage, to their children. This recognition has led to the Association’s current initiative, Where Dads Matter that has brought together representatives from Healthy Start projects who have joined with the NHSA to ensure the fatherhood remains a visible priority that is reflected in the work done by Healthy Start projects throughout the country. NHSA has set three fatherhood-related goals to accomplish within the next few years, including: 1) create an “attitude of inclusion” action plan; 2) establish a baseline for marketing materials in order to measure the impact of promotion resources and activities; and 3) measure, by developing a research design, the impact of male involvement on the family.


National Responsible Fatherhood Clearinghouse

This national clearinghouse is a federally funded program through the Department of Health and Human Service Administration (HRSA) Administration for Children and Families’(ACF) Office of Family Assistance (OFA). It is a resource for fathers, those working with fathers and those who support and advocate for strong fathers and families. Services include: a national toll free line (1-877-4DAD411) for dads and practitioners; the website; print materials on responsible fatherhood; a responsible fatherhood media campaign; utilization of social media; and virtual trainings.

Recommendation 5B: Integrate education about preconception and interconception health including mental and oral health, into hospital-based prenatal education models, group prenatal care, as well as home visiting programs.

The evolution and validation of the positive impact that education provided about preconception and interconception has had on birth outcomes is evidenced historically in various models currently utilized in practice. As a standard within practice, the education model should include mental health and oral health and integration into hospital-based prenatal education models, group prenatal care and home visiting programs to maximize opportunities for optimal outcomes.

Education opportunities will emerge across the lifecourse as the needs of families become more evident. The needs of fragile families are multifaceted and varied. Many times these needs are challenging to meet but the value of the long-term impact of education on these topics should not be underestimated. Providing an opportunity for interaction between patients and clinician increases patient’s knowledge and enhances and strengthen patient relations that can result in better outcomes.

Recommendation 5B: Emerging and promising examples

National Healthy Start Association

The federal Healthy Start initiative began in 1991 when the US Department of Health & Human Services’ Resources and Services Administration (HRSA) funded 15 sites in locations where the infant mortality rates were 1.5 - 2.5 times the national average. Twenty three years later, on September 2, 2014, the Department of Health & Human Services announced its latest round of Healthy Start grants that have expanded to 87 organizations throughout the country, including two in Connecticut.


The New Haven Healthy Start (NHHS) project operates under the auspices of The Community Foundation for Greater New Haven.  It has been in operation for over 17 years exemplifying successful implementation measured by federal National Performance Measures. Its longevity and leadership is reflected in its role as consultant to other Healthy Start programs and its leadership role in the National Healthy Start Association, which is the membership association for the federal Healthy Start programs. With the new grant (2014-2019), NHHS will increase its emphasis on addressing social determinants of health for areas with high concentrations of maternal and child health disparities; work collaboratively with other New Haven based organizations to strengthen family resiliency; participate in New Haven’s community-wide trauma coalition designed to address and to reduce the impact of adverse childhood experiences; and support father engagement, preconception health for men, and establish The Men’s Consortium.


The other Connecticut site is  Hartford which operates through the State Department of Public Health. This latest competitive round of federal grant awards is Hartford’s second cycle of funding, which will allow for a continuation of the work started under the previous grant that includes: 1) ensuring that Black-African American pregnant women enter prenatal care early and receive adequate prenatal care services; 2) increasing interconception care among program participants; 3) increasing the number of women who are screened for perinatal depression; 4) increasing outreach and enrollment in health coverage under the Affordable Care Act;  and 5) increasing the number of program participants who have a medical home.


Over the years Healthy Start has made significant contributions around the causes of infant mortality particularly for minority populations that continue to have disproportionately high rates of adverse perinatal outcomes. This federal initiative has been addressing issues that were been given a high priority ranking by the Coalition and therefore offers opportunities to benefit from their work.  Common areas of focus are: addressing the social and economic factors contributing to negative birth outcomes; increasing awareness around the benefits of the preconception/interconception health and health care; acknowledging the impact of trauma on women and their families; and recognizing the importance of fathers in the lives of their children.


CT Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program

The Patient Protection and Affordable Care Act passed in March 2010 included funding to establish the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. MIECHV is administered by the Health Resources and Services Administration (HRSA) within the US Department of Health and Human Services. The goals of the MIECHV Program are to “strengthen and improve the programs and practices carried out under Title V, improve coordination of services for at-risk communities, and identify and provide comprehensive services to improve outcomes for families who reside in at-risk



In order to be eligible for MIECHV funding, states needed to conduct a statewide needs assessment. Connecticut’s needs assessment was completed and submitted in September 2010. Through this needs assessment the state’s high needs communities were identified. In addition to identifying the high needs communities, the legislation defined eight categories of priority populations of families living in a high needs communities. Based on the targeted communities and priority populations within each community, the Department of Public Health with guidance from the Home Visiting Advisory Committee, invited selected high need communities to participate in the MIECHV program by selecting one (or more) of evidence based MIECHV approved home visiting programs through the

Home Visiting Evidence of Effectiveness study. Through formula (non-competitive) and competitive grant awards, Connecticut currently has the following MIECHV programs operating in the state:


  • ChildFirst in Ansonia/Derby, Bloomfield, Bristol, Danbury, East Hartford, Killingly, Meriden, Plainfield, Putnam, Torrington/Winchester, and Windham

  • Early Head Start Home-based Option in Ansonia/Derby

  • Nurse Family Partnership (NFP) in New London

  • Parents as Teachers in Bloomfield, Bridgeport, East Hartford, East Haven/West Haven, Griswold, Killingly, Manchester, Meriden, New Britain, Norwich, Plainfield, Sprague, Torrington/Winchester, Vernon and Windham.


MIECHV and the home visiting programs funded through this initiative provide resources and lessons learned through program implementation, the experiences of the home visitors and families visited, and the data collection required for funding.

Recommendation 5C: Encourage local school districts to integrate mental health and well-being into school health curriculum.

The World Health Organization defines health as “a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity.”75   This definition shows that health is comprehensive and multi-faceted. By this truth, it is inherent that mental health and well-being be incorporated into school health education. It is particularly important in school health as those are the stages of life that can strongly impact a person’s health beliefs and behaviors, which has a strong impact on their future health choices and outcomes.61


The Connecticut Department of Education provides guidelines and recommendations for local school districts on developing and implementing evidence-based curricula to meet national and state standards.76 Connecticut General Statutes section 10-16b58 mandates that all public schools include in their program of instruction “health and safety, including, but not limited to, human growth and development, nutrition, first aid, disease prevention, community and consumer health, physical, mental and emotional health.”77 Given this information, the Department of Education is in a unique position to encourage the integration of mental health and well-being as a key component of school health education.

Recommendation 5C: Promising and emerging examples

Healthy and Balanced Living Curriculum Framework, Hartford, CT

The Healthy and Balanced Living Curriculum Framework was developed by the Connecticut Department of Education as a framework for local school districts to use when developing health education curricula.  It incorporates the concepts of mental, emotional and social health as applied to benchmarks for what children should be expected to learn about their health by different grade years. This is an established framework that Connecticut schools can adopt, utilize and build on.78


Scarsdale Public Schools Health Curriculum, New York

Scarsdale Public Schools utilizes a comprehensive health education curriculum that incorporates various facets of mental and social health and well-being.  It includes objectives tailored for different levels of learning and understanding at different grade levels, with associated outcomes. Some included topics are stress management, social skills, self-esteem, healthy relationships, wellness, family life and sexual health (including parenting), and various subtopics within the topics of mental health, emotional health and social health.79


Maryland State Health Curriculum

The Maryland State Health Curriculum includes “Mental and Emotional Health” as one of six standards. Within this standard they include a topic area on mental illness, depression and suicide.80

Refer to Appendix D for additional Tier 5 strategies supported by Coalition members.

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