Practice-based intervention improves quality of care for young children

December 16, 2003

A practice-based intervention enhanced the quality of care for families of young children and improved selected parenting practices, according to an article in the December 17 issue of The Journal of the American Medical Association (JAMA).

There is growing evidence of deficiencies in the quality of health care for children, including low rates of preventive services, persistent disparities in health status, and lack of a usual source of care among ethnic and racial minorities and children in low-income families, according to background information in the article.

The Healthy Steps for Young Children Program was designed to meet the needs of families regarding their young children's early development and behavior by enhancing relationships between parents and their children, between families and the pediatric practice, and among practice members.

Cynthia S. Minkovitz, M.D., M.P.P., of the Johns Hopkins Bloomberg School of Public Health, Baltimore, and colleagues conducted a study to determine whether the Healthy Steps program increased quality of care related to developmental and behavioral services and affected parenting practices regarding discipline, perceptions of their children's behavior, and promotion of development when children were ages 30 to 33 months.

The controlled clinical trial was conducted between September 1996 and November 1998 at 6 randomization and 9 quasi-experimental sites across the United States. The study included 5,565 children enrolled at birth and followed up through age 3 years. The Healthy Steps program included incorporation of developmental specialists and enhanced developmental services into pediatric care.

Intervention families received the Healthy Steps program components, including contact with the Healthy Steps specialist, who were nurses, nurse practitioners, early childhood educators, and social workers with training and experience in child development. The specialist's main focus was on developmental, behavioral, and psychosocial aspects of care. Healthy Steps provided 7 services to intervention families: enhanced well-child care (through visits with the physician and Healthy Steps specialist); 6 home visits in the first 3 years; Healthy Steps specialist-staffed child developmental telephone line to address parents' developmental concerns; developmental assessments; written materials emphasizing prevention and health promotion; parent groups offering support and learning opportunities; and linkages to community resources through targeted referrals.

Of the 5,565 enrolled families, 3,737 (67.2 percent) responded to an interview at 30 to 33 months. Families who participated in the Healthy Steps Program had a greater odds of receiving 4 or more Healthy Steps-related services; of discussing more than 6 anticipatory guidance topics; of being highly satisfied with care provided (e.g., someone in the practice went out of the way for them); of receiving timely well-child visits and vaccinations (e.g., age-appropriate 1-month visit) and of remaining at the practice for 20 months or longer. They also had a reduced odds of using severe discipline (e.g., slapping in face or spanking with object). 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.

"Pediatric practices provide unique opportunities to favorably influence health care for young children, increase parents' satisfaction, and influence parental practices to improve child development and behavior. This evaluation of Healthy Steps demonstrates that improvement is possible and that all families benefit, not only those at high risk. Eleven of the 15 participating practices continued to provide all or some of the program components 18 months after demonstration funding ended. In addition, variants of the Healthy Steps model have been or are being implemented in additional sites across the country," the authors conclude. (JAMA. 2003;290:3081-3091. Available post-embargo at

Editor's Note: The Healthy Steps for Young Children Program is a program of The Commonwealth Fund, local funders, and health care providers across the nation. It is cosponsored by the American Academy of Pediatrics. Funding for the Healthy Steps National Evaluation is being provided by The Commonwealth Fund and local funders.


In an accompanying editorial, Neal Halfon, M.D., M.P.H., and Moira Inkelas, Ph.D., M.P.H., of the UCLA School of Public Health, Los Angeles, discuss the Healthy Steps program.

"What is important about Healthy Steps, ... is that it provides important evidence that by changing the structure and process of pediatric care, performance in the delivery of pediatric developmental services can be improved significantly," they write. "Healthy Steps is also important because it not only focuses on processes within the pediatric practice, but it changes the connections of the pediatric practice to parents outside of the office and reduces important barriers to the provision of certain services."

"Improving the health, development, and education of young children requires transformations in the health system, such as Healthy Steps has done, but also requires improvements in education, family support, and the neighborhoods in which children grow up. Given the promising results of the Healthy Steps evaluation and the emergence of other complementary interventions and approaches to improvement, it is important to consider a more integrated and population-based strategy to improving early childhood health," the editorialists write. "The tradeoffs in health care expenditures between early childhood and end of life will become even more acute and significant as the baby boom generation ages and consumes increasing proportions of the health care dollar. Investing in early childhood health care is a policy priority that we cannot neglect."
(JAMA. 2003;290:3136-3138. Available post-embargo at

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