Programs that Work
Healthy Steps for Young Children
Healthy and Safe Children
Children Ready for School
Children ages 0 to 5 exhibiting age-appropriate mental and physical development
Children experiencing good physical health
Age of Child
Early Childhood (0-8)
Type of Setting
Health Care Provider
Type of Service
Health Care Services
Type of Outcome Addressed
Evidence Level (What does this mean?)
Healthy Steps for Young Children is a national initiative that incorporates developmental specialists into primary care pediatric visits with the aim of meeting families' needs related to their young children's development and behavior. The program also aims to improve the relationships between parents and children, between parents and pediatric practices, and between pediatric practice members. The program targets families with newborns between birth and four weeks. Participating families receive up to six home visits and extended developmental services provided by a Healthy Steps Specialist (HSS) from birth to age three. The HSSs participate in the well-child office visits with the child's health care provider, answer parents' questions about child development, assess the children's developmental status, and identify family health risks. Participating families are also provided with written materials on preventative safety measures and community resources, and the families are given access to a child development telephone information line staffed by an HSS and parent groups facilitated by an HSS.
Currently, more than 50 sites nationwide, including pediatric offices and family practices, provide Healthy Steps services to families with young children starting at birth through age three.
The Women's and Children's Health Policy Center of the Johns Hopkins Bloomberg School of Public Health evaluated the impact of the Healthy Steps program in a sample of 2,235 parents utilizing care at one of 15 pediatrics practices who had a newborn between birth and four weeks old. Results from the 6 randomized sites are reported herein; data also are published from 9 quasi-experimental sites. Families were either enrolled in the hospital at birth or at the practice within the first four weeks after birth.
Families were ineligible if the newborn was going to be adopted or placed in foster care, the newborn was too ill to come to an office visit by four weeks old, the newborn's custodial parent did not speak English or Spanish, or the family intended to leave the practice within six months. Families were enrolled at six sites between September 1996 and November 1998: Allentown, PA; Pittsburgh, PA; Amarillo, TX; Florence, SC; Iowa City, IA; and San Diego, CA. At each of the six sites, approximately 400 families were randomized to receive either standard pediatric care plus Healthy Steps services or standard pediatric care only. A total of 1,133 families were randomized to receive Healthy Steps services, and 1,102 were randomized to receive standard pediatric care. At baseline, there were no significant differences in maternal characteristics or newborn's birth weight between the randomization and control families.
Outcomes were compared at two to four months, at three years, and at 5.5 years. Of the 2,235 participating families, 1,987 (89 percent) completed the two-to-four-month interview, 1,593 (71 percent) completed the three-year interview, and 1,308 (59 percent) completed the 5.5-year interview. Mothers who participated in the three-year and 5.5-year interviews were older; more educated; more likely to be white, non-Hispanic, married, and employed; and less likely to be on Medicaid than nonrespondents. There was no evidence of selective attrition based on intervention status. The percentages of nonresponders in the intervention and control groups were similar for mothers younger than 20 or older than 30; who had less than high school education; and who were black, Hispanic, or employed during the last month of pregnancy.
Minkovitz et al. (2001, 2003, and 2007) conducted analyses on the baseline sample, the three-year follow-up sample, and the 5.5-year follow-up sample. Baseline data were collected through a family demographic questionnaire at enrollment and a telephone interview at two to four months; the questionnaire and interview included questions on demographic information and on services and care received at the Healthy Steps site. The telephone interview at 30-33 months of age included questions on use of services, satisfaction with care, perceptions of child's behavior, parenting activities to promote safety and development, mother's health status, and depressive symptoms. Medical record abstraction was also completed after the child reached 32 months to collect data on well-child visits and vaccinations. The telephone interview at 61-66 months of age included questions on the child's misbehavior; perceptions of the child's health, behavior, development, and social skills; practices that promote development and safety; and experiences seeking care for the child. Analyses were conducted comparing intervention and control families controlling on baseline characteristics, including low birth weight; source of payment for care; mother's age, education, race, and employment status; father's employment status; mother's marital status; presence of the father in the household; number of siblings; and whether the family owned its own home. The researchers also controlled for enrollment site (e.g., Allentown, PA), enrollment location (hospital or office), and age of infant at the time of the interview.
Key Evaluation Findings
The Healthy Steps program increased the receipt of services among intervention families at two to four months (Minkovitz et al., 2001). The Healthy Steps program provided services (denoted as Healthy Steps services), including parent support groups, discussion and assessment of development at office visits, discussion of caring for the infant at office visits, a telephone information line, informational materials about development and health, letters to help parents prepare for office visits, and home visits. Some or all of these services were also provided to non-intervention families if the services were part of the practices' standard of care. Significantly more intervention families than control families received four or more Healthy Steps services at office visits (75% versus 24%) and received a home visit (76% versus 32%). Intervention families were more likely to report discussing all five developmentally important topics (calming the baby, sleep position, routines, solid foods, and car seats) with their provider (44% versus 28%). Parental perceptions of care were more positive among intervention families than among control families. Intervention families were significantly more likely to report that someone at the practice went out of their way to help them (66% versus 49%). Satisfaction with care may be an important indicator in this population because it has been linked to improved adherence with medical advice (Cameron, 1996; Winefield, Murrell, and Clifford, 1995). At two to four months, there were also reported differences in some of the safety practices of intervention and control families (Minkovitz et al., 2001). Intervention families were less likely to report use of an incorrect sleeping position for their infants (11% versus 14%). There were no differences in use of car seats or lowering of water temperature at home. There were also no differences in reported feeding practices (including breast feeding and timing of solid foods) between intervention and control families.
At three years, intervention families were still receiving more services than control families (Minkovitz et al., 2003). Significantly more intervention families than control families reported receiving four or more Healthy Steps services at office visits (79% versus 21%) and reported receiving a home visit after six months (79% versus 25%). Additionally, significantly more intervention families reported discussing more than six developmentally important topics with their provider (86% versus 44%), receiving a development assessment (82% versus 43%), and receiving information about community resources (45% versus 20%).
Intervention families reported more frequent timely care than control families. Significantly more intervention families reported on-time, age-appropriate visits than control families, including visits at one month (98% versus 96%), two months (92% versus 88%), six months (87% versus 81%), 12 months (89% versus 84%), and 24 months (87% versus 77%). There was no difference in on-time visits at month four. Significantly more intervention families reported receiving vaccinations on time, including receipt of the DTP1 (94% versus 91%), DTP3 (82% versus 77%), and MMR1 (91% versus 87%) vaccinations, as well as receipt of all recommended vaccinations at 24 months (80% versus 72%).
Parents in the intervention cohort were more likely to report receiving patient-centered care at three years (Minkovitz et al., 2003). Significantly more intervention families reported that someone in the practice went out of their way to help them (68% versus 51%). Significantly more intervention families agreed that the pediatrician or nurse practitioner provided support (91% versus 81%) and agreed that the pediatrician or nurse practitioner listened to the parent (91% versus 88%). There was no difference between intervention and control families in perceptions of the providers' respect for the parent.
At three years, the care received by intervention families was more efficient in some ways than the care received by control families (Minkovitz et al., 2003). Intervention families were significantly more likely to report attending their last visit after 20 months than control families (70% versus 57%). There were no differences among intervention and control families in number of hospitalizations in the past year, emergency department use in the past year, and emergency department use for injury-related causes in the past year. Parents in the intervention and control cohorts did not differ in their use of discipline, perceptions of their child's behavior, promotion of their child's development, and use of safety practices, with the exception of use of covers on electrical outlets. Intervention parents were significantly more likely to use covers on their electrical outlets (92% versus 89%).
Healthy Steps services were provided to intervention families through age three. Outcomes at 5.5 years were assessed to determine whether there were sustained effects of the Healthy Steps program. A significantly higher number of parents in the intervention group received anticipatory guidance and parenting education (59.3% versus 53.7%). Intervention parents reported a higher frequency of discussing four or more age-appropriate topics with their provider (53.7% versus 48.9%), but this difference was marginally significant. There were no differences between intervention and control families on other care-seeking experiences. There were also no differences between intervention and control families in care utilization, including use of the emergency department in the past year for an injury and hospitalizations in the past year.
At 5.5 years, the discipline practices, safety practices, promotion of development, and reported behavior, developmental, and social skills of the child were also assessed. There was a marginally significant difference in parents' reports of negotiating with their children. Parents in the intervention group reported often or almost always negotiating with their child more frequently than parents in the control group (58.9% versus 54.3%). There were no significant differences on use of other discipline techniques, including slapping in the face or spanking with an object, using harsh discipline, and often or almost always ignoring misbehavior. There were no differences in reported significant concern for child's development or in reported social skills. There were also no differences in behaviors that promote development, including bedtime routine and looking at or reading books in the past week. There were no differences in reported safety practices, including use of seat belt without booster seat most of the time and always wearing a bike helmet.
Pediatric clinics, primary care providers, family practices, residency training programs.
Funding for the program evaluation was provided by The Commonwealth Fund (New York), the Agency for Healthcare Research and Quality, local funders, and health care providers nationwide. The Healthy Steps program is funded individually by each site. Examples of funders include local funders, philanthropies and national funders, Medicaid, and Title V.
The cost of the Healthy Steps program is estimated at $463 per family per year (inflated to 2010 dollars) (Zuckerman et al., 2004). Costs are site-dependent and vary based on such factors as the number of families served, the number of HSSs needed, the needs of the population served, the need for administrative support, and the site's overhead rate.
The Healthy Steps for Young Children program was designed by a multidisciplinary team of pediatricians, pediatric nurse practitioners, and child development faculty at Boston University School of Medicine to meet families' needs regarding their young children's development and behavior. The Healthy Steps program incorporates developmental specialists (Healthy Step specialists) into the pediatric care team by including developmental and behavioral services at pediatric well-child visits and at home visits. Implementation of the Healthy Steps program may differ by site, as the Healthy Steps team tailors the program to fit within their clinical practice. The implementation of the program in the national evaluation discussed above is a guideline for sites. In the national evaluation, the Healthy Steps team at each site provided seven services to families (Minkovitz et al., 2001):
- Enhanced well-child care: The pediatrician/family medicine physician, nurse/physician assistant, and HSS conduct well-child visits jointly, answer questions about development, and assess family health risks. A main goal of these visits is to take advantage of teachable moments in an effort to inform and support parents about development.
- Home visits by the HSS: The program offers up to six home visits during the three years. At home visits, HSSs promote safety, support interactions between the parents and the child, and discuss topics that arise in the home, where parents may feel more comfortable bringing up sensitive topics.
- Child development telephone information line: An HSS staffs this information line to answer parents' questions regarding development and behavior.
- Child development and family health check-ups: These check-ups identify early signs of developmental or behavioral problems in the child and assess family health risks, such as depression and domestic or community violence.
- Written information materials: These materials emphasize prevention and span a variety of issues relevant to young children.
- Parent groups: These meetings are facilitated by an HSS, are intended to provide parents with social support, and are a forum for informing parents through interactive exercises.
- Links to community resources: The Healthy Steps team provides information and links parents to valuable resources within the community, such as early intervention, housing, food supports, and library activities for children.
The Healthy Steps team includes the pediatrician/family medicine physician, nurse/physician assistant, and Healthy Steps specialist. An HSS is trained as a nurse, early childhood specialist, or social worker with experience in child development. Each HSS serves approximately 100-150 families. Staff at each site were trained at three annual training sessions sponsored by the Healthy Steps training team at Boston University School of Medicine, which covers topics in child development, parenting, and clinical strategies. Program and training manuals were also provided to the Healthy Steps sites. Training and implementation materials are available through the Healthy Steps website or through the Healthy Steps program office.
Issues to Consider
The Healthy Steps for Young Children national evaluation included a fairly large sample size of 2,235 families at six pediatric practices. The families were randomly assigned to intervention (standard care plus receipt of Healthy Steps services) or control (standard care only). The national evaluation found that the Healthy Steps program led to significantly more services delivered during the first three years, but in general was associated with only mixed gains in health outcomes during the first three years and no improvements in health outcomes by 5.5 years; this may be attributable to ceiling effects. This program is listed as "promising," because there is evidence that it improves some health behaviors, but the evidence that it promoted health outcomes per se is weak. The greater services delivered in the first three years included significantly higher frequencies of on-time vaccinations, developmental assessments, and discussing age-appropriate developmental topics with a provider. The evaluation also found that families receiving intervention services were more satisfied with the care received during the first three years. The program did not have an impact on the number of emergency room visits or hospitalizations. Although the program had an impact on certain intermediate outcomes during the first three years, lasting impacts on health outcomes were not seen at 5.5 years.
Additional evaluations of the Healthy Steps program have been conducted, including quasi-experimental sites in the national evaluation. These evaluations found improvements at two to four months and at three years in parenting practices and delivery of services and, in some cases, found differences in health outcomes, such as on-time immunizations. An evaluation of impact by income level found no differences in some measures of care utilization at three years (including on-time well-child visits) or in perceptions of care. This study included only families receiving Healthy Steps services and did not include a control group. The national evaluation presented here is the only study of the Healthy Steps program that meets the Promising Practices Network (PPN) evidence criteria, including study design, effect size, and statistical significance.
For a complete listing of Healthy Steps sites, visit http://www.healthysteps.org/
Margot Kaplan-Sanoff, Ed.D.
Associate Professor of Pediatrics
Director, Healthy Steps National Office
Boston University School of Medicine
Vose Hall #419
72 E. Newton Street
Boston, MA 02118
617 414-7915 (fax)
Cameron, C., "Patient Compliance: Recognition of Factors Involved and Suggestions for Promoting Compliance with Therapeutic Regimens,"
Journal of Advanced Nursing,
Vol. 24, No. 2, 1996, pp. 244-250.
Kaplan-Sanoff, M., "Healthy Steps: Delivering Developmental Services for Young Children Through Pediatric Primary Care," Infants and Young Children: An Interdisciplinary Journal of Special Care Practices, Vol. 13, No. 3, 2001, pp. 69-76.
Minkovitz, C. S., D. Strobino, K. B. Mistry, D. O. Scharfstein, H. Grason, W. Hou, N. Ialongo, and B. Guyer, "Healthy Steps for Young Children: Sustained Results at 5.5 Years," Pediatrics, Vol. 120, No. 3, 2007, pp. e658-e668.
Minkovitz, C. S., N. Hughart, D. Strobino, D. Scharfstein, H. Grason, et al., "A Practice-Based Intervention to Enhance Quality of Care in the First 3 Years of Life: The Healthy Steps for Young Children Program," Journal of the American Medical Association, Vol. 290, No. 23, 2003, pp. 3081-3091.
Minkovitz, C., D. Strobino, N. Hughart, D. Scharfstein, B. Guyer, and the Healthy Steps Evaluation Team, "Early Effects of the Healthy Steps for Young Children Program," Archives of Pediatric and Adolescent Medicine, Vol. 155, No. 4, 2001, pp. 470-479.
Winefield, H. R., T. G. Murrell, and J. Clifford, "Process and Outcomes in General Practice Consultations: Problems in Defining High Quality Care," Social Science and Medicine, Vol. 41, No. 7, 1995, pp. 969-975.
Zuckerman, B., S. Parker, M. Kaplan-Sanoff, M. Augustyn, and M. C. Barth, "Healthy Steps: a Case Study of Innovation in Pediatric Practice," Pediatrics, Vol. 114, No. 3, 2004, pp. 820-826.