Chapter 7
Healthy Steps: The First Three Years
7. Healthy Steps Program Participation
Healthy Steps Program Participation
This chapter includes reports on families’ participation in the program and their views of the services they
received. The reports from families support those of the sites. They indicate that Healthy Steps families
participated to varying degrees in the full range of services provided under the program and that families were
particularly pleased with services the HS Specialist provided.
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Chapter 7
Healthy Steps: The First Three Years
7. PROGRAM PATICIPATION
7.1. Introduction
The previous section described types of contacts between the
Healthy Steps (HS) Specialist and families, topics they discussed,
and patterns of contacts with families in relation to the goals of
the HS program. This chapter includes reports on families’
participation in the program and their views of the services they
received. The reports from families support those of the sites:
They indicate that HS families participated to varying degrees in
the full range of services provided under the program and that
families were particularly pleased with services the HS Specialist
provided.
The HS program sought to offer a number of services to families
and to tailor those services to families’ needs. Evidence from sites
indicates that the full range of services was offered to families from
the inception of the program. With time, experience, and feedback
from the families, sites adapted some of these services. The mothers’
self-reports of services they received (as was true for family contacts
and topics discussed that were documented by the HS Specialists)
reflect the services the families chose to accept at any given time out
of the full range of services offered by the sites. For example,
families could decide to participate in parent groups or not, or to
accept a home visit or not. Thus, a mother’s self-report captures not
only whether the site offered the service but whether the family took
advantage of that offer and remembered receiving the service. The
self-reports also reflect the families’ length of stay in the HS practice
and their availability to receive the services.
7.2. Receipt of Healthy Steps Services
In their 30-33 month interviews, mothers reported their
participation in a wide variety of services associated with the HS
program. Among the 3737 mothers interviewed at 30-33 months
were mothers still using the practice for their child as well as
those who withdrew their child from care sometime between nine
months of age and the time of their interview. (Mothers of
children who left the practice prior to nine months were not asked
to recall their receipt of services.) Of course, the longer the family
continued at the practice, the more services they could be
expected to receive.
Mothers reported taking advantage of some program services
more than others (Figure 7.1, Table 7.1). For example, more
than 80% of mothers said they had received child development
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Chapter 7
Healthy Steps: The First Three Years
handouts, a telephone number to call with questions on
development, books to read to their child, and developmental
assessments. Smaller percentages reported receiving information
on community resources and participating in parent groups
offered by the practice. This variation in uptake of program
services also was reflected in the HS Specialists’ records of
contacts with families and reported by HS Specialists in their key
informant interviews. The HS Specialists reported, for example,
that despite considerable effort to make parent groups accessible
by altering hours and topics offered, these activities tended to be
popular primarily with a core group of families that found them
very helpful. Similarly, not all families could be expected to need
information on community resources.
Contrary to office visits recorded by the HS Specialist in their
logs, which showed at least one office visit with the HS Specialist
for 97% of families, only 62.4% of mothers reported receiving an
office visit with a developmental specialist. It is possible that the
mother did not discern the HS Specialist as a “special person who
Figure 7.1. Question: Some doctors’ offices give services to parents that help them take better care of
their children. These services are in addition to check-ups and sick visits. Please tell me if you have
received any of these services from [HS practice]. How useful was this [service]? Would you say very
useful, somewhat useful, or not at all useful (n = 2021)
% of Mothers who Received Service
Child development handouts
89.4
Telephone number for
development questions
89.3
Books to read
85.1
Developmental assessments
83.1
Letter before visits
78.8
Special booklet to track health
77.2
Home visits
76.5
Office visit with developmental
specialist
% who Found Service Useful
(99.6%)
(99.5%)
(98.8%)
(98.6%)
(98.5%)
(98.1%)
(97.5%)
(96.9%)
(94.3%)
(94.1%)
62.4
Information on community
resources
48.2
22
Parent groups
0
20
40
7-3
60
80
100
Books to read to child
Office visit with developmental specialist
Developmental assessment
Child development handouts
Letter before visits
Parent Groups
Telephone number for development questions
Home visit since 6 months of age
Special booklet to track health
Information on community resources
Chapter 7
Healthy Steps: The First Three Years
Table 7.1. Percentage of Intervention Mothers Who Received Services, and Received Information On or
Discussed Topics Considered Part of the Healthy Steps Program
2-4 Months
N = 2631
%
N
30-33 Months
N=2021
%
N
71.0
87.4
88.8
65.6
48.1
1868
2286
2318
1714
1258
77.0
89.4
77.2
78.8
62.4
1397
1647
1401
1439
1133
94.3
2425
89.3
1609
6.2
NA
NA
NA
163
NA
NA
NA
22.0
85.1
48.2
83.1
406
1568
835
1464
65.4
1714
76.5
1403
78.1
15.5
3.8
2.7
1337
265
65
46
26.8
31.1
21.0
21.2
375
436
294
297
84.2
1438
NA
NA
95.3
83.9
41.4
1627
1424
707
NA
NA
NA
NA
NA
NA
53.6
91.3
913
1559
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
96.9
93.4
91.9
72.7
36.7
1357
1305
1285
1012
132
49.0
66.5
87.3
91.8
68.4
72.2
NA
NA
NA
NA
NA
NA
NA
NA
NA
1275
1734
2284
2394
1788
1878
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
83.3
70.8
82.7
82.3
76.7
57.2
90.5
91.7
77.0
83.3
NA
NA
NA
NA
NA
1504
1278
1515
1501
1404
1027
1662
1688
1404
1519
HS services (excluding home visits)
4 or more HS services
Handouts about Baby’s Development
Special Booklet to Keep track of Child’s Health Information
Letter Before Well Child Visits
Office Visit with Special Person who Teaches Parents about
Child’s Development
Telephone number to call with questions about child’s
development
Parent group
Books to read to your child
Information on community cervices
Developmental assessment by someone in practice
Home visits
Home Visits (% any from practice) within first 2-4 months
and since 6 months of age (measured at 30-33 months)
Number of Home Visits from Practice
1
2
3
4 or more
Services Provided at Home Visits
Show you activities that you could do with baby to help
her/him grow and learn
Check the progress of the baby
Provide emotional support or help you cope with stress
Show you how to take care of the baby, like how to bathe
him/her
Show you how to make your house safe
Tell you about the kinds of things baby will be doing in the
next few weeks
Help you with understanding child’s development
Help with child’s behavior
Help with safety in the home
Help with family issues or concerns
Offered any home visit that decided not to take
HS topics discussed or given information on by anyone in
the practice
How to bathe baby (2-4 months only)
How to calm baby (2-4 months only)
Sleep positions for baby (2-4 months only)
Always using an infant car seat (2-4 months only)
When to give solid foods (2-4 months only)
Importance of regular routines (2-4 months/30-33 months)
Sleep problems (30-33 months)
Discipline (30-33 months)
Language development (30-33 months)
Toilet training (30-33 months)
Sibling rivalry (30-33 months)
Home safety (30-33 months)
Child’s development (30-33 months)
Child’s temperament (30-33 months)
Ways of helping child learn (30-33 months)
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Chapter 7
Healthy Steps: The First Three Years
teaches about development” but viewed the HS Specialist in
broader terms or thought of the HS Specialist simply as one of her
child’s providers.
At 30-33 months, the majority of mothers (76.5%) reported
receiving a home visit in the time since their child was six months
old. Of those who received a home visit, 73.3% received two or
more visits. The topics most frequently discussed during home
visits were help with understanding their child’s development
(96.9%), their child’s behavior (93.4%), and safety in the home
(91.9%). Family issues and concerns (72.7%) were raised as well.
Slightly more than one-third of mothers (36.7%) had been offered
a home visit that they declined to take. The reasons mothers most
often cited for declining the home visit were inconvenience
(22.0%), didn’t need the visit (18.9%), preferred to go to the office
or did not want anyone to come to their home (11.4%), could not
take time off from school or work (9.9%), and miscellaneous other
reasons (37.8%) such as marital problems, illness, being busy,
living far away, and scheduling problems.
During the course of their participation, mothers reported
receiving information or discussing a wide range of topics
considered part of the HS program. The two topics reported most
often were the child’s development (91.7%) and home safety
(90.5%). These were followed by the importance of routines
(83.3%), ways of helping their child learn (83.3%), discipline
(82.7%), and language development (82.3%). Their child’s
temperament (77.0%), toilet training (76.7%), and sleep problems
(70.8%) were next, followed by sibling rivalry (57.2%). This
latter topic would likely not be of concern to all families as about
half of the children in this sample had no siblings at baseline.
7.3. Mothers’ Views of Healthy Steps Services They
Received
Mothers held very positive views of the HS program as reflected
in their opinions of HS services and their appreciation of the care
they received from the HS Specialist. Mothers participating in the
30-33 month interview were asked to rate the services they had
received from their child’s practice. From 94.1% to 99.6% of
mothers perceived the services as useful or very useful, depending
on the service in question (Figure 7.1).
Mothers reported being highly satisfied with the care provided by
the HS Specialist. More than half of mothers (61.5%) reported
that someone in the practice went out of the way to help them or their
child; for the majority (65.5%) of these families, this person was
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Chapter 7
Healthy Steps: The First Three Years
the HS Specialist. Overall, 93% of mothers found the HS
Specialist to be helpful or very helpful.
Mothers were asked about twelve specific services that HS
Specialists were expected to provide. These were combined into
one scale representing overall receipt of HS services.
Approximately 97% of mothers agreed or strongly agreed that they
received the services (detailed in Fig. 7.2) from the HS Specialist.
Mothers agreed most about receiving progress checks as well as
counseling on learning activities for the child, expected behaviors,
and safety proofing the house. They agreed least about receiving
help with organizing daily routines, referrals for emotional
problems, and help with making child care arrangements.
Mothers were asked specifically about nine areas of care provided
by the HS Specialists. These areas of care were combined into a
composite scale representing mother’s satisfaction. On this scale,
almost all mothers (99.3%) were satisfied or very satisfied with the
care they received from the HS Specialist in the nine areas
presented in Figure 7.3.
Mothers’ willingness to pay for the kinds of services they
received also reflected their satisfaction with the program.
They were asked how much they would be willing to pay one
time for a package of services offered at their child’s doctor’s
office that included well child visits with a child development
specialist, home visits with the HS Specialist, a telephone
information line about child development, parent groups,
brochures on child health and development, letters before well
child visits about what to expect at the next visit, and a book
designed to keep information about that child’s health care and
development. Almost half of mothers (48.3%) were willing to
make a one-time payment of $100 or more.
7-6
Willingness to Pay for Enhanced
Services by Families in the
Healthy Steps Program
%
N
One-Time Amount
1774
Not Willing to Pay
2.2
40
$15
5.4
95
$25
12.9
229
$50
22.2
394
$75
9.0
160
$100
21.3
377
$125 or more
27.0
479
247 mothers did not report willingness to
pay
Chapter 7
Healthy Steps: The First Three Years
Figure 7.2. Question: I would like you to tell me how strongly you agree or disagree that
you received the following services from the HS Specialist? (N=2021)
Strongly Agree (%)
Showed you activities that you
could do with child to help
him/her grow and learn
Agree (%)
44
52.4
Checked child's progress
42.2
55.6
Told you about the kinds of
behaviors you can expect to see
in child in the next few months
52.5
44.1
Told you about ways to make
your house safe for child
53.2
44.2
Always followed through with
what s/he said s/he would do
53.2
44.8
Never made you feel as if your
feelings or concerns about child
were wrong
40.2
Let you consider options for you
and child that were best for both
of you
37.2
49.3
60.3
Helped you know what to do
when child upsets you or does
something wrong
31.1
62.1
Helped you to understand child's
temperament
32.8
61
Helped you organize the daily
routines for child
26.4
Referred you for help with
emotional problems
23.4
Helped you find good child care
arrangements
44.9
40.1
16.9
0
52.8
20
Source: 30-33 Month Interview
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40
60
80
100
Chapter 7
Healthy Steps: The First Three Years
Figure 7.3. Question: Now I am going to ask you how satisfied you are with the
care you receive from the HS Specialist. [Are you] very satisfied, satisfied,
dissatisfied, very dissatisfied? (N=2021)
Very Satisfied (%)
Written information the HS Specialist
gave you about the child's health and
development
Satisfied (%)
76.9
22.4
Friendliness and caring of the HS
Specialist
86.3
13.3
Attention the HS Specialist paid to
what you had to say
85.7
13.4
Opportunity you had to ask questions
of the HS Specialist
82.4
16.7
Explanations the HS Specialist gave
you about child's health and
development
77.6
21.5
How capable the HS Specialist was in
working with you to promote child's
health and development
76.5
22.4
Support you received from the HS
Specialist regarding your role as a
parent
75.5
23.3
Amount of time the HS Specialist
spent with you
75.2
23.3
Information from developmental
assessments the HS Specialist did
69.9
0
20
Source: 30-33 Month Interview
7-8
40
28.6
60
80
100