Chapter 1
Healthy Steps: The First Three Years
Introduction
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Chapter 1
Healthy Steps: The First Three Years
1. INTRODUCTION
The Healthy Steps (HS) program, a universal practicebased intervention, served more than 4,000 families with
newborn children at 24 sites throughout the United States
since it began in 1995. The program emerged in response
to concerns about (1) addressing the developmental needs
of young children through better pediatric practices and
(2) meeting the needs of parents given the changing
demands of society.
Healthy Steps was particularly innovative because it
incorporated a new developmental specialist into pediatric
practice. This and an array of developmental services for
mothers, fathers, and their children made HS an
innovation in quality improvement in pediatric health care.
Although the original demonstration program ended in
2001, HS program services are continuing at twelve of the
original twenty-four demonstration sites; ten sites have
“spin off” services; and new HS programs are being
established.
Healthy Steps shares its origins with programs like Early
Head Start and other early childhood programs that
strengthen early preparation for learning. It provided
services that are consistent with many assumptions of
early childhood interventions and their framework for
change. This set of assumptions, as characterized by
Shonkoff and Phillips (National Research Council and
Institute of Medicine, 2000), incorporates specific
assertions about the nature of development and influences
on development. These include the importance of young
children’s relationships with their primary caregivers, and
the impact of multiple risk factors and sources of stress on
caregivers, which in turn affect their abilities to recognize
and meet the needs of their children.
The assumptions also reflect an understanding that
interventions to enhance children’s development and wellbeing can be designed to affect children directly (as is the
case, for example, in programs that provide early
preschool services) or indirectly through services to parents
(as is the case in many home visiting programs). They
also emphasized the importance of recognizing that
expectations about family and child outcomes must be
based on a deep understanding of children’s individual
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differences, the degree to which the caregiving
environment within the family is changeable, and the
match between the resources and goals of the intervention
(National Research Council and Institute of Medicine,
2000).
In some respects, HS fits within the very large “tent” of
early childhood intervention programs. In particular, HS
services reflect an understanding of the importance of the
caregiver-child relationship in all aspects of development,
the importance of enhancing caregivers’ emotional and
other support as a means of promoting children’s wellbeing, and a focus on aspects of the caregiving
environment that are likely to be amenable to change.
Nevertheless, Healthy Steps differs from other early
childhood intervention programs in two particularly
significant ways.
The first is that HS was designed to change pediatric care
– to expand the services offered as part of standard
pediatric primary care – as well as to enhance the
capabilities of parents and promote the health and
development of very young children. HS is thus both
unique and a pioneering effort in early childhood
intervention in its use of the pediatric primary care system
to deliver parenting and developmental services to
families.
The pediatric practice is the first major
institution with which newborns and their mothers and
fathers interact.
Second, HS services were offered to families in
participating practices regardless of risk status or
identified developmental disability or difficulty. Universal
early intervention programs are rare; programs typically
are targeted at specific populations based on risk (e.g.,
economic hardship, age of parent, low birth weight, or
other characteristics) or specific disorders or disabilities of
the child. The HS program, however, was based on an
understanding that all parents have concerns and
questions about their children’s health, behavior and
development. It was designed to capitalize on parents’
contacts with the pediatric practice, which provide
opportunities to promote their knowledge and capabilities
using “teachable moments” and other intervention
methods.
The specific goals of the HS program were to promote
improvements in:
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The clinical capacity and effectiveness of pediatric
primary care to better meet the needs of families
with young children;
The knowledge, skills and confidence of mothers
and fathers in their childrearing abilities; and
The health and development of young children.
Fifteen of the 24 sites that implemented HS during the
evaluation period participated in an independent national
evaluation to assess the extent to which the HS program
achieved these goals. Two of these sites also participated
in a direct observation study evaluating the program’s
effects on the home environment, mother-child interaction
and child development. Of the remaining nine sites, often
referred to as affiliate sites, six additional sites were
involved in a more limited evaluation. Two of the
remaining sites implemented their own formal evaluations,
which are not yet completed, and one site participated in a
local evaluation.
There were many partners involved in the HS program of
which The Commonwealth Fund was the leader and
primary sponsor. The Commonwealth Fund sought to
create, implement, and evaluate a demonstration project of
consistently high quality, at sites stretching from coast to
coast, and involving a broad demographic range of
families. This required teamwork among four major
institutional entities and a host of local collaborators.
The Commonwealth Fund originated the program,
providing a vision for the national project, support
for the nationwide institutions, and partnership
with the local funders;
Boston University School of Medicine designed the
program, trained site staff, and provided technical
assistance to the sites;
ICF Consulting directed and coordinated the
program’s implementation; and
Johns Hopkins Bloomberg School of Public Health,
evaluated the project.
In tandem with these were local funding partners at each
of the 24 sites. A National Advisory Committee provided
guidance and feedback to the project and its evaluation.
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Healthy Steps: The First Three Years describes the results of
the national evaluation of the HS program. The 15-site
national evaluation involved a sample of 5,565 children
(including both intervention and control children) enrolled
at birth and followed for three years. At six sites,
newborns were assigned randomly to the intervention or
control group; at nine sites, a quasi-experimental design
was used and a comparison location was selected.
The report also includes a summary of results for the
evaluation at six affiliate sites and the embedded direct
observation study. The six affiliate sites met the same
requirements as the sites selected for the national
evaluation but did not have a comparison population. As
the national and affiliate evaluations were limited to selfreported measures and some of the effects of HS on
parents and children were expected to be subtle, direct
observation of mothers and children at two sites was
conducted to enhance the ability of the evaluation to
measure changes in parent and child functioning.
Chapters 2 and 3 provide a detailed description of the HS
program, including its history, the larger research, policy,
and practice context in which the program originated, and
the core elements of the program.
Chapters 4 and 5 focus on the evaluation, describing the
conceptual framework that guided the evaluation; the
evaluation goals, objectives, design, and analysis strategy;
the diversity of the sample; and the demographic
characteristics of the key samples for analysis.
Chapters 6 and 7 focus on program implementation. They
describe implementation from the perspective of the lead
physicians, site administrators, and HS Specialists at the
15 national evaluation sites; summarize the services that
the HS Specialists reported providing to families; and the
services that families in the program reported receiving.
Chapter 8 examines the impact of the program on the
attitudes and practices of clinicians and practice staff.
Chapter 9 summarizes the program’s impact on the nature
and kinds of services that families in the program received
compared to families in the control group. In Chapter 10,
the conceptual framework for examining the effects of HS
on families provides the overall structure for summarizing
program effects on parents and children.
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Chapter 11 examines how HS affected subgroups of
families: low, middle, and high income; teen, young adult,
and older mothers; and first-time vs. second or greatertime mothers.
Chapter 12 examines the extent to which variation in
aspects of implementation affected receipt of services and
program outcomes.
Chapter 13 summarizes evaluation results at the six
affiliate sites and Chapter 14 presents results of the direct
observational study at the two randomization sites.
Chapter 15 describes program costs and potential benefits.
Chapter 16 addresses program sustainability.
Chapter 17 concludes the report with a summary of key
program effects, the context for understanding program
effects and costs, and the implications of evaluation results
for practice, research, and policy.
The report is comprehensive and somewhat technical. It is
intended to serve as a resource document for a
multidisciplinary audience that includes program
participants and funders, practitioners, researchers and all
others interested in learning about the evaluation of the
HS program and its findings.
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