Assessing the impact of pediatric-based development services on infants, families, and clinicians: challenges to evaluating the Health Steps Program.
BACKGROUND
Begun in 1996, the Healthy Steps for Young Children Program (HS) is a new model of pediatric practice that incorporates child development specialists and enhanced developmental services for families of young children. HS is for all families, not just those at high-risk. It is expected to strengthen parents' knowledge, attitudes, and behaviors in ways that promote child health and development, and in turn, to lead to improved child outcomes, such as improved language development, increased utilization of well child care, and decreased problem behaviors, hospitalizations, and injuries. The HS evaluation is designed to assess whether HS is successful in achieving the desired outcomes, measure the program's costs, and determine the relation of the program's costs to its outcomes.


OBJECTIVE
This article is the first report of the HS evaluation. It describes the evaluation design and characteristics of the HS sites and sample for the evaluation.


METHODS
The evaluation is following a cohort of children from birth to age 3 at 15 evaluation sites across the country. The sites represent a range of organizational practice settings that include group practices, hospital-based clinics, and health maintenance organization pediatric clinics. The evaluation design relies on 2 comparison strategies. At 6 randomization design sites, 400 children were randomized to the intervention or control group. At 9 quasi-experimental design sites, a comparison location with a similar organizational setting and patient profile has been selected and up to 200 children are being followed at each of these sites. At each site, 2 developmental specialists (or their full-time equivalents) work as a team with 4 to 8 pediatricians and pediatric nurse practitioners. The specialist conducts office visits (jointly or sequentially with the pediatric clinician) and home visits, assesses children's developmental progress, provides referrals and follow-up to resources in the community, organizes and conducts parent discussion groups, coordinates early reading activities, and maintains a telephone information line for questions about child development and behavior. The evaluation relies on many data sources including self-administered provider surveys, key informant interviews, forms completed by parents at office visits, telephone interviews with parents, medical record reviews, data from each site on program costs and health services use, and an ongoing log of family contacts maintained by each developmental specialist. Analyses for this article are based on enrollment data for the Healthy Steps sample and national data on 1997 US live births. The chi2 goodness-of-fit test was used to evaluate whether the distribution of selected demographic variables, insurance, and infant's birth weight for the Healthy Steps sample was similar to the distributions for US births in 1997. In addition, comparisons were made between intervention and comparison families at the randomization and quasi-experimental evaluation sites. The chi2 test of independence was used to evaluate differences in variables across groups.


RESULTS
Throughout a 26-month period, 5565 children enrolled in the evaluation, 2963 (53.2%) children in the intervention group and 2602 (46.8%) in the comparison group. More than 10% of mothers in the Healthy Steps sample are teenagers; 18% have 11 years of education or less; 27% have completed college; 18% are black or African-American; slightly >20% are of Hispanic origin; 36% are single; and close to one-third used Medicaid for their prenatal care. Approximately 7% of infants were low birth weight. When compared with national birth data for the United States as a whole, the Healthy Steps sample seems similarly diverse. However, with the exception of maternal age, the distribution of variables was significantly different from the distribution for US births. There are no differences between intervention and comparison families at randomization sites on any of
Guyer
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B
Department of Population and Family Health Sciences, Baltimore, Maryland. Johns Hopkins University School of Hygiene and Public Health, 624 N Broadway, Baltimore, MD 21205, USA. bguyer@jhsph.edu
Hughart
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N
Strobino
D
D
Jones
A
A
Scharfstein
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D
D016009:Chi-Square Distribution; D002657:Child Development; D002662:Child Health Services; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006293:Health Promotion; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D016487:Parenting; D010290:Parents; D010372:Pediatrics; D015397:Program Evaluation / Q000379:methods; D012107:Research Design; D012959:Socioeconomic Factors; D014481:United States