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A Practice-Based Intervention to Enhance Quality of Care in the First 3 Years of Life
The Healthy Steps for Young Children Program
Cynthia S. Minkovitz, MD, MPP;
Nancy Hughart, BSN, MPH;
Donna Strobino, PhD;
Dan Scharfstein, ScD;
Holly Grason, MA;
William Hou, MS;
Tess Miller, DrPH;
David Bishai, MD, PhD;
Marilyn Augustyn, MD;
Kathryn Taaffe McLearn, PhD;
Bernard Guyer, MD, MPH
JAMA. 2003;290:3081-3091.
Context 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.
Design, Setting, and Participants 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.
Intervention Incorporation of developmental specialists and enhanced developmental services into pediatric care in participants' first 3 years of life.
Main Outcome Measures Quality of care was operationalized across 4 domains: effectiveness (eg, families received  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 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]).
Conclusion Universal, practice-based interventions can enhance quality of care for families of young children and can improve selected parenting practices.
Author Affiliations: Departments of Population and Family Health Sciences (Drs Minkovitz, Strobino, Miller, Bishai, and Guyer; Mss Hughart and Grason; Mr Hou) and Biostatistics (Dr Scharfstein), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md; Department of Pediatrics, Boston University School of Medicine, Boston, Mass (Dr Augustyn); National Center for Children in Poverty, Columbia University Mailman School of Public Health, New York, NY (Dr McLearn).
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