A practice-based intervention to enhance quality of care in the first 3 years of life: the Healthy Steps for Young Children Program.
BACKGROUND
There is growing concern regarding the quality of health care available in the United States for young children, and specific limitations have been noted in developmental and behavioral services provided for children in the first 3 years of life.


OBJECTIVE
To determine the impact of the Healthy Steps for Young Children Program on quality of early childhood health care and parenting practices.


METHODS
Prospective controlled clinical trial enrolling participants between September 1996 and November 1998 at 6 randomization and 9 quasi-experimental sites across the United States. Participants were 5565 children enrolled at birth and followed up through age 3 years.


METHODS
Incorporation of developmental specialists and enhanced developmental services into pediatric care in participants' first 3 years of life.


METHODS
Quality of care was operationalized across 4 domains: effectiveness (eg, families received > or =4 Healthy Steps-related services or discussed >6 anticipatory guidance topics), patient-centeredness (eg, families were satisfied with care provided), timeliness (eg, children received timely well-child visits and vaccinations), and efficiency (eg, families remained at the practice for > or =20 months). Parenting outcomes included response to child misbehavior (eg, use of severe discipline) and practices to promote child development and safety (eg, mothers at risk for depression discussed their sadness with someone at the practice).


RESULTS
Of the 5565 enrolled families, 3737 (67.2%) responded to an interview at 30 to 33 months (usual care, 1716 families; Healthy Steps, 2021 families). Families who participated in the Healthy Steps Program had greater odds of receiving 4 or more Healthy Steps-related services (for randomization and quasi-experimental sites, respectively: odds ratio [OR], 16.90 [95% confidence interval [CI], 12.78 to 22.34] and OR, 23.05 [95% CI, 17.38 to 30.58]), of discussing more than 6 anticipatory guidance topics (OR, 8.56 [95% CI, 6.47 to 11.32] and OR, 12.31 [95% CI, 9.35 to 16.19]), of being highly satisfied with care provided (eg, someone in the practice went out of the way for them) (OR, 2.06 [95% CI, 1.64 to 2.58] and OR, 2.11 [95% CI, 1.72 to 2.59]), of receiving timely well-child visits and vaccinations (eg, age-appropriate 1-month visit) (OR, 1.98 [95% CI, 1.08 to 3.62] and OR, 2.11 [95% CI, 1.16 to 3.85]), and of remaining at the practice for 20 months or longer (OR, 2.02 [95% CI, 1.61 to 2.55] and OR, 1.75 [95% CI, 1.43 to 2.15]). They also had reduced odds of using severe discipline (eg, slapping in face or spanking with object) (OR, 0.82 [95% CI, 0.54 to 1.26] and OR, 0.67 [95% CI, 0.46 to 0.97]). Among mothers considered at risk for depression, those who participated in the Healthy Steps Program had greater odds of discussing their sadness with someone at the practice (OR, 0.95 [95% CI, 0.56 to 1.63] and OR, 2.82 [95% CI, 1.57 to 5.08]).


CONCLUSIONS
Universal, practice-based interventions can enhance quality of care for families of young children and can improve selected parenting practices.
Minkovitz
Cynthia S
CS
Department of Population and Family Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md 21205, USA. cminkovi@jhsph.edu
Hughart
Nancy
N
Strobino
Donna
D
Scharfstein
Dan
D
Grason
Holly
H
Hou
William
W
Miller
Tess
T
Bishai
David
D
Augustyn
Marilyn
M
McLearn
Kathryn Taaffe
KT
Guyer
Bernard
B
D002657:Child Development; D002662:Child Health Services / Q000458:organization & administration*; D002675:Child, Preschool; D006266:Health Education; D006293:Health Promotion / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D010043:Outcome and Process Assessment, Health Care; D016487:Parenting; D010372:Pediatrics / Q000458:organization & administration*; D015397:Program Evaluation; D011446:Prospective Studies; D011787:Quality of Health Care; D014481:United States