Date of Award

Spring 2022

Document Type


Degree Name

Master of Public Health (MPH)


Public Health


The United States’ preterm birth rate is one of the highest among high-resource countries (Fighting premature birth: The prematurity campaign 2021). Approximately 1 in 10 babies in the US is born preterm (Preterm birth 2021). There are few comprehensive community-wide interventions focused on birth outcomes and cardiovascular risk reduction. Franklin County in Maine implemented an integrated, community-level cardiovascular risk reduction program in the 1970s. This community-level intervention focused on improving the health systems (infrastructure, access, and quality), reducing risk factors (hypertension, cholesterol, and diabetes), and improving health behaviors (tobacco cessation, healthy diet, and physical activity) (Record et al., 2015). The researchers’ analysis consisted of aggregating Maine data at the county level and then comparing Franklin County to the other Maine counties. Franklin County’s community-wide intervention targeting cardiovascular risk reduction centered on reducing hospitalizations and mortality rates. They found that Maine hospitalization rates were strongly associated with household income, yielding an R2 of 0.72 and a p-value of <0.001 (Record et al., 2015). Franklin County’s hospitalization rate was found to be significantly lower than what was predicted by household income, with 17 fewer hospitalizations per 1000 population in Franklin county than would be expected given household income (Record et al., 2015). Analyses were conducted to determine the benefits of population-wide interventions in reducing risk factors and improving health. A more recent study conducted by some of the same researchers assessed mortality and smoking rates prior to and after the Franklin County Model. The goal was to determine upon completion of a community-wide intervention focused on reducing risk factors and improving health how sustainable the effects were. The researchers conducted linear regression and analysis of variance on age-adjusted mortality versus median household income, smoking vs income and county health rankings (CHR) health outcomes vs SES (Onion et al., 2019). They found that improved health outcomes decreased as intervention actions were reduced. During the period 1996 to 2000, Franklin’s income-adjusted smoking rates were an outlier in Maine, with a t-score of -3.31 (indicating lower than expected smoking rates given median household income), but by 2011 to 2015 results were similar to the predicted rates, with a t-score of -0.33 (indicated expected rates) (Onion et al., 2019). The study also found that comparing expected health outcomes such as mortality against median household incomes by county may provide a better, more effective way to identify and monitor rural population health than comparing county outcomes to the state average (Onion et al., 2019). The purpose of this Capstone project was to examine the effects of the Franklin County community-level intervention model with a focus on the birth outcomes of low birth weight and

2 preterm births. Low birth weight is defined as a newborn weighing less than 2,500 grams (5 pounds and 8 ounces) (FastStats - Birthweight 2021). Preterm birth is a newborn born before 37 completed weeks of pregnancy (Preterm birth 2021). Previous evaluations suggest that the Franklin County Model did have a positive effect on cardiovascular health outcomes at the population level, but the effect it had on birth outcomes is unknown. This study estimated the effects of a community level intervention on birth outcomes by examining births from Franklin County, Maine during 1970-1988.



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