 |
|
Early Effects of the Healthy Steps for Young Children Program
Cynthia Minkovitz, MD, MPP;
Donna Strobino, PhD;
Nancy Hughart, RN, MPH;
Daniel Scharfstein, ScD;
Bernard Guyer, MD, MPH;
and the Healthy Steps Evaluation Team
Arch Pediatr Adolesc Med. 2001;155:470-479.
ABSTRACT
| |
Objective The Healthy Steps for Young Children Program (HS) incorporates early
child development specialists and enhanced developmental services into routine
pediatric care. An evaluation of HS is being conducted at 6 randomization
and 9 quasi-experimental sites. Services received, satisfaction with services,
and parent practices were assessed when infants were aged 2 to 4 months.
Methods Telephone interviews with mothers were conducted for 2631 intervention
(response rate, 89%) and 2265 control (response rate, 87%) families. Analyses
were conducted separately for randomization and quasi-experimental sites and
adjusted for baseline differences between intervention and control groups.
Hierarchical linear models assessed overall adjusted effects, while accounting
for within-site correlation of outcomes.
Results Intervention families were considerably more likely than controls to
report receiving 4 or more developmental services and home visits and discussing
5 infant development topics. They also were more likely to be satisfied and
less likely to be dissatisfied with care from their pediatric provider and
were less likely to place babies in the prone sleep position or feed them
water. The program did not affect breastfeeding continuation. Differences
in the percentage of parents who showed picture books to their infants, fed
them cereal, followed routines, and played with them daily were found only
at the quasi-experimental sites and may reflect factors unrelated to HS.
Conclusions Intervention families received more developmental services during the
first 2 to 4 months of their child's life and were happier with care received
than were control families. Future surveys and medical record reviews will
address whether these findings persist and translate into improved language
development, better utilization of well-child care, and an effect on costs.
INTRODUCTION
IN RECENT years, the general public has shown increasing interest in
early child development. Demand for further information has contributed to
the growth of news media reports, Internet sites, and parenting instruction
books regarding sleeping and feeding. However, these dissemination efforts
are only a beginning. In a recent survey of parents of children younger than
age 3 years, 79% reported wanting more information in at least 1 of 6 areas
of child rearing, and fewer than half of all parents discussed issues such
as discipline, sleep patterns, and practices to stimulate early learning with
their pediatric providers.1
Despite parental demands, pediatricians historically have focused only
a small proportion of the average preventive care visit on behavior or development.2, 3, 4 Lack of time, inadequate
training, and staffing shortages have been cited as obstacles to devoting
more time to these issues.5, 6, 7
Findings from the recent Future of Pediatric Education II (FOPE II) Project
affirm that providing optimal health care for children in the 21st century
will require renewed focus on preventive efforts, including "guiding or modifying
parental and child behavior to improve outcomes."8(p176)
The FOPE II report also suggests that nonpediatrician child health professionals
may play an increasing role in direct patient contact to meet the needs of
children and families.
A new model of pediatric care delivery that relies on a physician–child
development specialist partnership to enhance developmental services is the
Healthy Steps for Young Children Program (HS) designed by the Commonwealth
Fund, New York, NY, and an interdisciplinary team from Boston University,
Boston, Mass.9 The principal components of
HS, given in Table 1, combine
a limited number of home visits with extended developmental services provided
by the Healthy Steps specialist (HSS) during regularly scheduled well-child
office visits.10
|
|
|
|
Table 1. Programmatic Components of Healthy Steps for Young Children
Program
|
|
|
The HS is being evaluated at 15 sites across the country. (The randomization
design [RND] sites are located in Allentown, Pa; Amarillo, Tex; Florence,
SC; Iowa City, Iowa; Pittsburgh, Pa; and San Diego, Calif. The quasi-experimental
[QE] sites are located in Boston, Mass; Chapel Hill, NC/Birmingham, Ala; Chicago,
Ill; Detroit, Mich; Grand Junction, Colo/Montrose, Colo; Kansas City, Kan;
Kansas City, Mo; New York, NY; and Richmond, Tex/Houston, Tex.) The sites
include group practices (n = 8), hospital-based clinics (n = 3), and pediatric
practices in health maintenance organizations (n = 4). At each site, 2 HSSs
(or their full-time equivalents) work as a team with 4 to 8 pediatricians
and pediatric nurse practitioners; each HSS serves approximately 100 children
and their families. The HSSs—an early childhood educator, nurse, nurse
practitioner, social worker, or other professional with expertise in early
childhood development—are trained in HS by the Boston University team.
The specialist conducts office and home visits and oversees the HS activities
given in Table 1.11, 12
At each of 6 RND sites, approximately 400 children have been randomly
assigned to intervention and control groups of 200 each. It was not possible
to randomize the intervention at all sites owing to constraints of sample
size, the need to have a separate physical area for the intervention, and
the willingness of practices to provide different services to families. At
9 QE sites, an intervention and comparison practice with a similar organizational
setting and patient profile was selected, and up to 200 children are being
followed from birth to age 3 years at each location. Children in the control
group receive routine pediatric care but have no exposure to the HSS or to
the materials specific to HS.
The HS is designed to strengthen parents' knowledge, attitudes, and
behaviors in ways that promote child health and development (Figure 1). The HS evaluation will assess whether HS succeeds in
meeting its objectives, measure the program's costs, and relate the program's
costs to its outcomes.13 This article focuses
on parent perceptions and parent practices when infants were aged 2 to 4 months.
Of note, several national efforts, including the Consumer Assessment of Health
Plans and the Child and Adolescent Health Measurement Initiative, sponsored
by the Agency for Healthcare Research and Quality, Rockville, Md, and the
Foundation for Accountability, Portland, Ore, respectively, recognize the
role of parents' experiences seeking care for their children as important
components of quality of care.
|
|
|
|
Figure 1. Conceptual framework for understanding
the effect of Healthy Steps for Young Children Program on parents and children
(domains evaluated at 2-4 months in boldfaced text).
|
|
|
We examine whether HS met parents' demand for child-rearing information
in this early period and, in turn, whether HS increased parental satisfaction
with pediatric care and encouraged positive infant parenting practices related
to safety, feeding, and infant development. Infant safety, feeding, and promotion
of early literacy were among those practices the HSS was expected to emphasize
with families of newborns. Growing scientific evidence supports their respective
roles in promoting infant health. Improper sleep position has been related
to the risk of sudden infant death syndrome,14
while breastfeeding promotes general health and growth and decreases the infant's
risk for infections,15 and sharing books with
children has been associated with early vocabulary acquisition.16
SUBJECTS, MATERIALS, AND METHODS
SAMPLE
Enrollment of families began in September 1996 at one site, followed
by staggered initiation at subsequent sites and completion of enrollment during
a 2-year period. Eligible newborns were identified either in the hospital
following birth as patients from the HS site or in the practice up to 4 weeks
of age. Children were excluded only if (1) their parents expected to move
from the area or change site of care within 6 months; (2) their mothers (or
fathers if they were the custodial parents) did not speak English or Spanish
fluently; (3) they were to be adopted or placed in foster care; or (4) they
were too ill to make an office visit within the first 4 weeks of life. In
the case of multiple births, 1 child was randomly selected for the evaluation.
Of 6287 eligible families contacted to participate in HS, 469 (7.5%)
declined to participate, and 253 (4.0%) deferred participation and did not
make a visit to the practice within 4 weeks of birth (Figure 2). The study sample includes 5565 consecutively enrolled
infants, 2235 enrolled at RND sites (51% intervention, 49% control) and 3330
at QE sites (55% intervention, 45% control).
|
|
|
|
Figure 2. Healthy Steps for Young Children
Program enrollment and 2- to 4-month family interview completion. QE indicates
quasi-experimental; deferred, families who deferred participation in Healthy
Steps and did not make a visit to the practice within 4 weeks of birth; interview
excluded, families who completed the interview outside the age range of 8
to 18 weeks and families who did not make an office visit before the interview.
|
|
|
DATA SOURCES
Data reported here were obtained from 2 sources: a brief questionnaire
completed by parents at enrollment, and a telephone interview with parents,
conducted when the infant was between 8 and 18 weeks of age. Both were available
in either Spanish or English. The questionnaire provided data on the family's
demographic characteristics.13 The interview,
conducted by trained staff at Battelle Centers for Health Research and Evaluation,
Baltimore, Md, included additional demographic data and questions about the
services and care the families received from the HS site and their overall
satisfaction with them. Parents also answered questions regarding practices
such as showing picture books to their infants and sleep position.
STUDY VARIABLES
Three sets of variables were compared between HS intervention and control
families: receipt of HS services; parents' satisfaction with their infant's
care; and parents' practices related to their infant's safety, feeding, and
development. A dichotomous variable measured the receipt of 4 or more HS components
available to families during the first few months of life, including office
visits regarding the baby's development; office visits regarding general care
of the baby; a telephone number to discuss the baby's development; a letter
to prepare for office visits; brochures regarding the baby's development;
special health booklets; and parent support groups.
Home visits, also an HS service, were examined separately because of
their importance in developing an early relationship between the HSS and the
family. Visits from someone at the practice as well as other agencies were
included because we were uncertain if parents could distinguish visits specifically
from their child's pediatric practice. All HS families were expected to have
been offered 1 home visit in the first month of the baby's life.
A dichotomous variable described whether families discussed each of
5 topics with someone at the practice related to infant health and development—calming
the baby, sleep position, routines, solid foods, and car seats. These were
among the anticipatory guidance topics identified in the HS operations and
training manuals as being important to discuss with parents of young infants.
We developed 2 scales to measure parent's perception of the care their
baby received from the study site. These scales were based on responses of
parents to questions that asked them to strongly agree, agree, disagree, or
strongly disagree with descriptions of the care their baby received from the
physicians and/or nurse practitioners.
In developing the satisfaction scales, we reviewed the content of the
items, combining those with similar content into 2 subscales. The first was
related to giving time to the family and listening to and encouraging questions
from parents, and the second, to supporting parents in the care of their child
and giving parents advice about resources or activities they might engage
in with their baby. The internal consistency of the scales for physicians
and/or nurse practitioners was assessed using the Cronbach  and the
item-to-total correlation for each item in the scale (items listed in Table 5). The total score was divided by
the number of items in the scale and a cutoff value indicating that the parents
were, on average, not satisfied with care was used to create a dichotomous
variable for each scale.
|
|
|
|
Table 5. Receipt of Services by Families at Randomization and Quasi-Experimental
Sites Between 2 and 4 Months Postpartum
|
|
|
A similar approach was used to organize items in the questionnaire regarding
the care provided by the HSS into scales covering 3 content areas: (1) listens
and shows respect to parents, (2) helps parents promote the growth and development
of their child, and (3) provides emotional support to parents. The
values for scales exceeded .80, the generally accepted level for an internally
consistent scale.
We examined parent practices relevant to 3 domains: safety, feeding,
and development. These included use of the prone sleep position at both nap
time and bedtime; continuation of breastfeeding among women who initiated
breastfeeding; showing picture books to the infant at least once a day; playing
with the infant; and following routines at bedtime, nap time, and mealtime.
These practices were among the positive parenting practices the HSS was expected
to emphasize with families of young infants. Moreover, as noted earlier in
this article, growing scientific evidence supports their roles in promoting
infant health. Other health-related interventions, not specifically targeted
by HSSs, were examined and included other safety, feeding, and development
practices.
ANALYSES
Data analysis was conducted using the SAS programming package (SAS Institute
Inc, Cary, NC). Because the RND and QE sites had different sampling structures,
analyses were conducted separately for each type of site. In bivariate analyses,
we compared the distribution of HS services received, satisfaction with care,
and parenting practices between intervention and control families. The  2 test of independence was used to evaluate differences in variables
across groups.
Hierarchical linear models were estimated to determine the overall adjusted
effect of HS, while accounting for within-site correlation of outcomes.17, 18 These models account for within-site
correlation by treating site as a random variable; these correlations arise
because families within sites are more alike than are families between sites.
Adjusted analyses controlled for site of enrollment (hospital or office),
age of the infant at interview, and potential differences in the baseline
characteristics of the mother (age, education, race/ethnicity, employment),
father (employment), family (marital status, father in household, number of
siblings, owned own home), and baby (low birth weight, source of payment for
care).
HUMAN SUBJECTS
Institutional Review Board approval was obtained from The Johns Hopkins
University School of Hygiene and Public Health Committee on Human Research,
Baltimore, and the institutional review boards of the parent organization
for each HS and control practice. Informed consent was obtained at the time
of enrollment and reviewed immediately prior to the interview.
RESULTS
All study families provided enrollment data for this report, and 4896
families (88%) provided parent interview data. The sample excludes 537 families
(10%) who did not complete the parent interview because they declined (2%),
could not be located (6%), or were ineligible (2%); 53 families (<1%) who
completed the interview outside the age range of 8 to 18 weeks; and 79 families
(1%) who did not report making at least 1 visit to the practice before the
interview. For 69% of families, the mother alone was the respondent to the
enrollment questionnaire; for 30%, the mother and father; and for fewer than
2%, the father alone. By design, the mother was the respondent in more than
99% of the parent telephone interviews.
Approximately 7% of infants were low birth weight, 48% had no other
siblings, and 13% were born to teenaged mothers (Table 2). Of mothers, 42% had worked during their last month of
pregnancy, and close to one third used Medicaid for their prenatal care; 16%
had not graduated from high school, but 28% had completed college; 34% were
unmarried; slightly more than 20% were Hispanic; and 24% were African American.
Just more than 88% of fathers were employed at the time of their child's birth.
Overall, respondents to the parent interview tended to have demographic characteristics
that would place them at less risk for poor outcomes than nonrespondents.
Comparing respondents, there were no statistically significant differences
between intervention and control families at RND sites on any of the maternal
demographic characteristics. However, at QE sites, mothers in the intervention
group were at less risk demographically than mothers in the control group.
|
|
|
|
Table 2. Percentage Distribution of Mother's Demographic Characteristics,
Insurance Status, and Baby's Birth Weight for Respondents and Nonrespondents
in Intervention and Control Groups at Randomization and Quasi-Experimental
Sites*
|
|
|
RECEIPT OF DEVELOPMENTALLY RELATED SERVICES
In terms of the quality of care, 48% of families received 4 or more
developmentally related services, 57% had a home visit, and 35% discussed
all 5 developmentally appropriate topics. Nevertheless, a markedly greater
percentage of intervention than control families at both RND and QE sites
reported receiving these services promoted by the HS program (Table 3). Close to 74% of intervention families vs 13% to 24% of
control families reported receiving 4 or more HS services. Moreover, among
the intervention families, 2.7% received 0 to 1 service; 23.3%, 2 to 3 services;
26.1%, 4 services; and 48.0%, 5 to 7 services. When examined as individual
services and topics, intervention families were more likely than control families
to report receiving each component of care (Table 4). Seventy-six percent of intervention families vs 32% to
35% of control families reported receipt of home visits from the practice
or another source (Table 3). Nearly
twice as many intervention families as control families discussed all 5 infant
development topics.
|
|
|
|
Table 3. Receipt of Services by Intervention and Control Families at
Randomization and Quasi-Experimental Sites*
|
|
|
|
|
|
|
Table 4. Receipt of Individual Services and Topics Discussed Among
Intervention and Control Families at Randomization and Quasi-Experimental
Sites*
|
|
|
Table 5 gives the hierarchical
analysis results for receipt of HS services. The odds of receiving 4 or more
HS services was 18 times greater among intervention families than control
families at RND sites and 26 times greater for intervention families at the
QE sites. The odds ratios for home visits from the practice or another agency
for intervention families were close to 16 at RND sites and nearly 8 at QE
sites. They were between 2 and 3 for intervention families for talking to
someone at the practice about the 5 developmentally related topics.
PERCEPTIONS OF CARE
Parents were notably pleased with their infant's care, regardless of
whether they participated in HS (Table 6). Close to 60% of families reported someone going out of their
way to help them, although the percentage was greater for intervention than
for control families at both RND and QE sites. Across groups, fewer than 8%
of families reported dissatisfaction with either help or listening from the
physician and/or nurse practitioner at their infant's pediatric practice,
although intervention families were less dissatisfied than control families.
|
|
|
|
Table 6. Perceptions of Care and Practices Among Intervention and Control
Families at Randomization and Quasi-Experimental Sites*
|
|
|
When adjustment was made for baseline characteristics and correlation
within sites, intervention families had a 2 times greater odds as control
families of reporting that someone at the practice went out of their way to
help them (Table 7). The hierarchical
analysis findings also showed decreased dissatisfaction with care among families
participating in the intervention. For each of the perceptions of care variables,
HS effects at the RND sites were similar to those at the QE sites, although
they generally were somewhat stronger at the QE sites than at RND sites.
|
|
|
|
Table 7. Families' Perceptions of Care and Parenting Practices at Randomization
and Quasi-Experimental Sites Between 2 and 4 Months Postpartum
|
|
|
Intervention parents overwhelmingly were satisfied with the care provided
by the HSS, with more than 40% specifically identifying that the HSS went
out of his/her way for them. (Control families were not asked these questions
because they did not receive care from the HSS.) Most intervention parents
(96.4%) indicated that the HSS treated them with respect, listened to them,
and answered their questions. A similar percentage (96.7%) reported that the
HSS promoted ideas and activities related to their child's health and development.
Finally, 91.3% agreed that the HSS helped them with their feelings related
to parenting.
PARENTAL PRACTICES THAT PROMOTE CHILD HEALTH AND DEVELOPMENT
Parent practices examined included safety practices, feeding practices,
and practices that promote the infant's development. Eleven percent of intervention
families and 14% of control families reported use of the prone sleep position
at both nap time and bedtime. These differences between intervention and control
groups were significant for parents at both RND and QE sites (Table 6). Other safety practices such as the use of car seats and
lowering the water temperature at home were examined, but these practices
did not differ for intervention and control families as most families followed
the safety practices.
Among women who initiated breastfeeding, differences in the proportions
of women continuing breastfeeding at 2 to 4 months postpartum were significant
only at the QE sites (Table 6).
Regarding other feeding practices, a smaller proportion of intervention mothers
at QE sites gave their infant cereal or water by 2 to 4 months of age than
did control mothers. The effect of HS was in the same direction at RND sites
but was small and not significant.
A higher percentage of intervention parents at both QE and RND sites
showed picture books to their infants at least once a day. For other parenting
practices that may promote infant development but were not emphasized by the
HS program, there were no differences in the use of routines, and a higher
percentage of parents played with their baby once a day or more at the QE
sites.
The results of the hierarchical analysis indicate that HS may have influenced
the position in which the parents placed their baby to sleep (Table 7). The odds of placing their baby to sleep on the stomach
was 25% lower among intervention families at both QE and RND sites than among
control families. A similar reduction in the percentage of intervention parents
who gave their infants water was noted at both QE and RND sites. Although
intervention mothers at the QE sites were significantly more likely than control
mothers to continue to breastfeed, the HS effect was not significant in the
adjusted analysis, suggesting that it is likely a result of initial baseline
differences between intervention and comparison families. In adjusted analyses,
HS had a modest positive effect on showing picture books to babies, feeding
the baby cereal, following routines, and playing with the baby only at the
QE sites.
COMMENT
This report provides the first opportunity to evaluate the implementation
and effects of the HS intervention. Our study results indicate that developmental
services promoted by HS clearly were being delivered to families even when
infants were 2 to 4 months of age. Differences between intervention and control
families at both the RND and QE sites were large for most services specifically
implemented as part of the program. These findings are important for 2 reasons.
First, they clearly document a different array of services provided to intervention
families—services which, based on prior surveys, parents specifically
demand for their young children. Second, many evaluations of early parenting
interventions have demonstrated substantial deviations from the intended program
and significantly lower levels of involvement than reported in this article
by parents involved in HS.19
Families overwhelmingly were pleased with their baby's care. This finding
is not surprising as the sites, including comparison sites, were chosen selectively
as excellent pediatric practices. The effects of HS on 2 of the 3 satisfaction
variables were weaker at the RND sites compared with the QE sites. This finding
may reflect the fact that the same physicians and staff were providing services
to both intervention and control families at the RND sites, while at the QE
sites, intervention and control families received services from different
providers. Other possible explanations for the stronger effects at QE sites
may include better integration of the HSS into QE practices or unobserved
differences between QE intervention and comparison sites, leading to stronger
effects.
One parental practice that may have been influenced by HS was the position
in which the baby was placed to sleep. Intervention families were somewhat
less likely to put their baby to sleep on the stomach, the incorrect position,
than were control families. Despite major media campaigns throughout the United
States, there remains considerable room to improve parenting practices regarding
infant sleep position.14 This finding is particularly
hopeful in that HS seems to have been successful at both RND and QE sites
alike in promoting change in this behavior.
The results suggest that the program did not affect the percentage of
women continuing to breastfeed during the first few months. It may be that
the HSSs' contacts with families came too late to influence mothers' decisions
regarding continuation of breastfeeding. In addition to maternal sociodemographic
and employment factors measured in our study, prenatal and postnatal breastfeeding
education and support programs and health system factors have been shown to
positively influence continuation rates.15, 20, 21
Few of the HSSs were specifically trained to provide these services. It also
is possible that differences in breastfeeding rates may be seen for women
who continue breastfeeding beyond the first few months. Similarly, while there
were differences between groups in the percentage of parents who had showed
picture books to their baby or gave their infants cereal during the first
2 to 4 months of life, these differences were found only at the QE sites;
they likely reflect unobserved factors not related to the program. Hierarchical
analyses, however, did identify reduction in parents giving their babies water
at both RND and QE sites; future analyses of HSS contact logs will reveal
whether intervention families were more likely to discuss related feeding
practices than control families.
Our findings are tempered by several limitations. First, the pediatric
practices were selected, in part, because they were thought to deliver excellent
pediatric services. Our results may underestimate the impact of HS to the
degree that such an intervention may improve pediatric care to an even greater
extent at sites not providing as high quality care as those participating
in the evaluation. On the other hand, our results also may overestimate the
impact that HS might have in other practices if they are unable to incorporate
new providers and services into their existing practice structures owing to
limited interest of clinicians and/or limited administrative expertise.
Second, the results were observed when families had no more than 4 months'
experience with the program. This suggests that the level of services received
by families is quite intensive. Yet families may be less likely to report
such positive experiences with care as their children's ages and their interaction
with the HSS is reduced. Alternatively, because their relationship with the
HSS is well established early, findings may persist and become even stronger
at older ages.
Third, use of a telephone interview resulted in an advantaged sample,
as indicated by education, race, insurance coverage, and work status. Whether
disproportionate inclusion of advantaged families overestimates or underestimates
the effect of HS is unclear. More advantaged families may preferentially choose
to receive services to promote their children's development, or they may believe
that such services are not necessary. Future subgroup analyses by income will
address issues of preferential uptake and impact.
Among recommendations of the FOPE II Task Force was the need to "collaborate
with families and other child health professionals to identify and address
challenges and barriers to the health and well-being"8(p207)
of children. It is likely that meeting the needs of parents regarding their
children's early development will require modification of existing clinical
practices. In the current environment, it is unlikely that physicians will
be able to extend the length of visits or provide more direct services to
families without relying on other professional staff. The HS represents a
new multidisciplinary approach to meet the needs of families with young children.
Whether the introduction of a new child health professional into routine pediatric
care provides added value to children and families will depend in part on
whether the benefits are greater than, equal to, or less than the costs.
AUTHOR INFORMATION
Accepted for publication December 7, 2000.
The HS (http://www.healthysteps.org) is a program of the
Commonwealth Fund, New York, local funders, and health care providers across
the nation. It is cosponsored by the American Academy of Pediatrics, Elk Grove,
Ill. Funding for the Healthy Steps National Evaluation is being provided by
the Commonwealth Fund and local funders.
The views presented here are those of the authors and not necessarily
those of the Commonwealth Fund, its directors, officers, or staff.
| Healthy Steps Evaluation Team
Department of Population and Family Health Sciences,
The Johns Hopkins University School of Hygiene and Public Health, Baltimore,
Md: Mary Benedict, DrPH, MSW; Janice Genevro, PhD, MSW; Holly Grason,
MA; Ashraful Huq, MBBS, MPH; William Hou, MSc; Alison S. Jones, PhD; Tess
Miller, DrPH; Eleanor Szanton, PhD.
Battelle Centers for Public Health Research and Evaluation,
Baltimore: Diane Burkom.
|
|
From the Women's and Children's Health Policy Center, Department of
Population and Family Health Sciences, The Johns Hopkins University School
of Hygiene and Public Health; Baltimore, Md. Presented in part at the Pediatric
Academic Societies Annual Meeting, Boston, Mass, May 13, 2000.
Corresponding author and reprints: Cynthia Minkovitz, MD, MPP, Department
of Population and Family Health Sciences, The Johns Hopkins University School
of Hygiene and Public Health, 624 N Broadway, Baltimore, MD 21205.
REFERENCES
| |
1. Young KT, Davis K, Schoen C, Parker S. Listening to parents: a national survey of parents with young children. Arch Pediatr Adolesc Med. 1998;152:255-262.
FREE FULL TEXT
2. Foye H, Chamberlin R, Charney E. Content and emphasis of well-child visits. Am J Dis Child. 1977;131:793-797.
ABSTRACT
3. Reisinger KS, Bires JA. Anticipatory guidance in pediatric practice. Pediatrics. 1980;66:889-892.
FREE FULL TEXT
4. Osborn LM, Reiff MI. Teaching and well child care. Clin Pediatr (Phila). 1983;22:505-508.
5. Bennett FC, Guralnick MJ, Richardson HB, Heiser KE. Teaching developmental pediatrics to pediatric residents: effectiveness
of a structured curriculum. Pediatrics. 1984;74:514-522.
FREE FULL TEXT
6. Camp BW, Gitterman B, Headley R, Ball V. Pediatric residency as preparation for primary care practice. Arch Pediatr Adolesc Med. 1997;151:78-83.
ABSTRACT
7. Minkovitz C, Mathew B, Strobino D. Have professional recommendations and consumer demand altered pediatric
practice regarding child development? J Urban Health. 1998;75:739-750.
FULL TEXT
|
ISI
| PUBMED
8. Task Force on the Future of Pediatric Education. The Future of Pediatric Education, II: organizing pediatric education
to meet the needs of infants, children, adolescents, and young adults in the
21st century: a collaborative project of the pediatric community. Pediatrics. 2000;105(1 Pt 2):157-212.
9. Zuckerman B, Kaplan-Sanoff M, Parker S, Young KT. The Healthy Steps for Young Children Program. Zero Three. 1997;June/July:20-25.
10. The Healthy Steps for Young Children Program [brochure]. New York, NY: The Commonwealth Fund; 1999.
11. Kaplan-Sanoff M, Zuckerman B, Parker S, et al. Healthy Steps, Strategies for Change, Child Development
in Primary Care for Young Children. Boston, Mass: Boston University School of Medicine; 1999.
12. McLearn KT, Zuckerman B, Parker S, Yellowitz M, Kaplan-Sanoff M. Child development and pediatrics for the 21st century: the Healthy
Steps approach. J Urban Health. 1998;75:704-722.
FULL TEXT
|
ISI
| PUBMED
13. Guyer B, Hughart N, Strobino D, Jones A, Scharfstein D and the Healthy Steps Evaluation Team. Assessing the impact of pediatric-based developmental services on infants,
families, and clinicians: challenges to evaluating the Healthy Steps Program. Pediatrics [serial online]. 2000;105:e33. Available at: http://www.pediatrics.org/cgi/content/full/105/3/e33. Accessed January 15, 2001.
14. American Academy of Pediatrics Task Force on Infant Positioning and
SIDS. Positioning and sudden infant death syndrome (SIDS): update. Pediatrics. 1996;98(6 Pt 1):1216-1218.
15. American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 1997;100:1035-1039.
FREE FULL TEXT
16. High P, Hopmann M, LaGasse L, et al. Child-centered literacy orientation: a form of social capital? Pediatrics [serial online]. 1999;103:e55. Available at: http://www.pediatrics.org/cgi/content/full/103/4/e55. Accessed January 15, 2001.
17. Byrk AS, Raudenbusch SW. Hierarchical Linear Models: Application and Data
Analysis Methods. Newbury Park, Calif: Sage Publications; 1992.
18. Goldstein H. Multi-Level Statistical Models. New York, NY: Halstead Press; 1995.
19. Gomby DS, Culross PL, Behrman RE. Home visiting: recent program evaluations—analysis and recommendations. Future Child. 1999;9:4-26, 195-223.
ISI
| PUBMED
20. Evers S, Doran L, Schellenberg K. Influences on breastfeeding rates in low income communities in Ontario. Can J Public Health. 1998;89:203-207.
ISI
| PUBMED
21. Kuan LW, Britto M, Decolongon J, Schoettker PJ, Atherton HD, Kotagal UR. Health system factors contributing to breastfeeding success. Pediatrics [serial online]. 1999;104:e28. Available at: http://www.pediatrics.org/cgi/content/full/104/3/e28. Accessed January 15, 2001.
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Healthy Steps for Young Children Program in Pediatric Residency Training: Impact on Primary Care Outcomes
Niederman et al.
Pediatrics 2007;120:e596-e603.
ABSTRACT
| FULL TEXT
Healthy Steps for Young Children: Sustained Results at 5.5 Years
Minkovitz et al.
Pediatrics 2007;120:e658-e668.
ABSTRACT
| FULL TEXT
Parental Satisfaction With Early Pediatric Care and Immunization of Young Children: The Mediating Role of Age-Appropriate Well-Child Care Utilization
Schempf et al.
Arch Pediatr Adolesc Med 2007;161:50-56.
ABSTRACT
| FULL TEXT
Healthy Steps in an Integrated Delivery System: Child and Parent Outcomes at 30 Months
Johnston et al.
Arch Pediatr Adolesc Med 2006;160:793-800.
ABSTRACT
| FULL TEXT
Maternal Depressive Symptoms at 2 to 4 Months Post Partum and Early Parenting Practices
McLearn et al.
Arch Pediatr Adolesc Med 2006;160:279-284.
ABSTRACT
| FULL TEXT
Thirty-Six-Month Outcomes for Families of Children Who Have Disabilities and Participated in Early Intervention
Bailey et al.
Pediatrics 2005;116:1346-1352.
ABSTRACT
| FULL TEXT
A Randomized Trial of Practice-Based Education to Improve Delivery Systems for Anticipatory Guidance
Rosenthal et al.
Arch Pediatr Adolesc Med 2005;159:456-463.
ABSTRACT
| FULL TEXT
Validity of Maternal Report of Acute Health Care Use for Children Younger Than 3 Years
D'Souza-Vazirani et al.
Arch Pediatr Adolesc Med 2005;159:167-172.
ABSTRACT
| FULL TEXT
Healthy Steps: A Case Study of Innovation in Pediatric Practice
Zuckerman et al.
Pediatrics 2004;114:820-826.
ABSTRACT
| FULL TEXT
The National Survey of Early Childhood Health
Blumberg et al.
Pediatrics 2004;113:1899-1906.
ABSTRACT
| FULL TEXT
Assessing Development in the Pediatric Office
Halfon et al.
Pediatrics 2004;113:1926-1933.
ABSTRACT
| FULL TEXT
Access to the Medical Home: Results of the National Survey of Children With Special Health Care Needs
Strickland et al.
Pediatrics 2004;113:1485-1492.
ABSTRACT
| FULL TEXT
Measuring the Quality of Children's Health Care: A Prerequisite to Action
Dougherty and Simpson
Pediatrics 2004;113:185-198.
ABSTRACT
| FULL TEXT
A Practice-Based Intervention to Enhance Quality of Care in the First 3 Years of Life: The Healthy Steps for Young Children Program
Minkovitz et al.
JAMA 2003;290:3081-3091.
ABSTRACT
| FULL TEXT
Optimizing the Health and Development of Children
Halfon and Inkelas
JAMA 2003;290:3136-3138.
FULL TEXT
Child Development in Pediatrics: Beyond Rhetoric
Zuckerman et al.
Arch Pediatr Adolesc Med 2001;155:1294-1295.
FULL TEXT
|
