A number of child health initiatives in recent years have sought to promote greater use of preventive and developmental services in pediatric primary care—particularly for children in low-income families, whose unmet health care needs have been a persistent national problem.
One program in particular, Healthy Steps for Young Children, has yielded significant improvements. As detailed in a pair of recent papers published in the Journal of Urban Health, the program's value was affirmed by the clinicians providing Healthy Steps services as well as the families receiving them—including, notably, the neediest families. A national experiment designed by the Boston University School of Medicine and The Commonwealth Fund, Healthy Steps incorporates enhanced preventive, developmental, and behavioral services into primary care for children from birth to age 3. The program's most distinctive feature is the addition of child development specialists (in some instances a nurse or nurse practitioner, in others a social worker or early childhood educator) to pediatric practices to assist with monitoring development, promoting good health practices, making home visits, and responding to parental concerns about infant and toddler development and behavior.
According to Kathryn Taaffe McLearn, the lead author on both studies, Healthy Steps can "begin to narrow the income gaps in utilization of preventive-health services, timely well-child care, and satisfaction with care for families with young children." McLearn, formerly of the National Center for Children in Poverty at Columbia University's Mailman School of Public Health, co-wrote both articles with colleagues at the Center and at Johns Hopkins University's Bloomberg School of Public Health.
In "Narrowing the Income Gaps in Preventive Care for Young Children: Families in Healthy Steps" (Journal of Urban Health, Dec. 2004), the researchers focused on families of different socioeconomic status and their satisfaction with the care received from Healthy Steps. They examined an initial sample of 2,963 families enrolled at 15 pediatric practices in 14 states across the country, with data aggregated according to income group: low-income (less than $20,000), middle-income ($20,000 to $49,999), and high-income (more than $50,000).
Across the three income groups, over 70 percent of parents reported receiving multiple developmental services, and most were satisfied with the care provided to their child. The odds of a low-income family receiving four or more Healthy Steps services, getting a home visit, discussing five or more childrearing topics with a provider, or securing information about community resources did not differ from the odds of a high-income family receiving the same benefits. However, while low- and middleincome group parents largely reported similar levels of satisfaction with the care received as high-income parents, some disparities persisted. Low- and middle-income families were less likely to receive a developmental assessment or books to read to their children. This is particularly disturbing, say the authors, as previous studies have shown that developmental screening of low-income children can help reduce the kinds of problems that require later care.
The researchers also evaluated the impact of Healthy Steps on clinicians, as discussed in "Developmental Services in Primary Care for Low-Income Children: Clinicians' Perceptions of the Healthy Steps for Young Children Program" (Journal of Urban Health,
June 2004). For this study, physicians and nurse practitioners at 20 practice sites completed self-administered questionnaires at the initiation of the program and again some 30 months later. The sample was divided into three groups of clinicians based on the median income (low, middle, or high) of their patients' families.
Across all income groups, clinicians reported that they were significantly more likely to provide multiple child development services to families at the 30-month mark than at the beginning of the Healthy Steps program. In particular, clinicians serving low-income families reported positive and sizeable changes in their perceptions about the quality of care they provided. They were more likely than those clinicians serving middle- or high-income families to strongly agree that they gave support to families and were very satisfied with the ability of their clinical support staff to meet the developmental needs of children. In fact, clinicians in pediatric primary care practices serving low-income families indicated a greater positive change over time in their perceptions about the quality of care they provided than did their colleagues serving higher-income populations.
The study's authors attributed these finding in part to the fact that clinicians in low-income practices reported the lowest rates of satisfaction with the care they were providing at the beginning of the program, compared with middle- and high-income practices. In effect, the Healthy Steps implementation allowed low-income practices to achieve the same level of clinician satisfaction as higher-income practices. Interviews with parents confirmed the value of the Healthy Steps program: more than 75 percent of parents reported receiving four or more developmental services and more than 61 percent reported that someone in the practice went out of their way to help then.
Healthy Steps was "successful in universally increasing developmentally oriented services across all income levels," say the researchers. The results, they argue, should be of interest to policymakers considering targeted or universal strategies to reduce inequities in health care utilization for low-income children and families. The findings from these studies suggest that a universal approach such as Healthy Steps can help to ease the disparities in access to and quality of care between different income groups.Facts and Figures
- Developmental services in practices serving lowincome families increased markedly following introduction of Healthy Steps. In practices serving families with incomes below $20,000, use of telephone information lines increased from 37 percent prior to the intervention to 87 percent after; office visits with someone who teaches parents about child development increased from 39 percent to 88 percent; and home visits increased from 30 percent to 92 percent.
- Low-income children receiving Healthy Steps services were as likely as high-income parents (median family income of $45,000 or more) to adhere to age-appropriate well child visits at one, two, four, 12, 18, and 24 months.
- In practices serving low-income families, the percentage of Healthy Steps pediatricians and other clinicians who perceived that practice staff worked as a team increased from 29 percent to 75 percent.