Chapter 12
Healthy Steps: The First Three Years
12. Variation in Implementation Variation in Implementation Over the course of the evaluation several hypotheses were proposed to explain potential variation in the implementation of Healthy Steps. To better inform future programs and funders, we examined two areas of potential variation in site characteristics. These related to variation in the National Program Office’s rating of the quality of implementation at each site and variation in the extent to which the site had experience implementing the program at the time the family entered care. Irrespective of whether a family received care at a “top rated” site or whether they enrolled after sites had more experience with the program, families in the intervention group within each category compared had a higher odds of receiving Healthy Steps services than control families. We found stronger effects on receipt of some services for intervention families at “top rated” sites than for those at less highly rated sites. The variation in effects between intervention children enrolled later (when sites had more experience in delivering program services) and those enrolled earlier differed for randomization and quasi-experimental sites. Children enrolled later in the program had a significantly lower odds than those enrolled earlier of receiving some Healthy Steps services and an age-appropriate well child visit at 24 months of age. However, these differential effects were seen only at QE sites. At RND sites, intervention children enrolled later had a higher odds of receiving information on community resources as well as diagnosis and referral for developmental problems. Intervention children enrolled later, at both RND and QE sites, had a significantly higher odds of being up-to-date on their vaccinations by 24 months of age. In both comparisons, the effects of raising the already high levels of service receipt to even higher levels generally did not seem to affect outcomes. These findings reinforce key informant reports, which indicated that the Healthy Steps components were made available at the start of the program and were implemented at all 15 sites.
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12. VARIATION IN IMPLEMENTATION 12.1. Introduction Over the course of the evaluation several hypotheses were proposed to explain potential variation in the implementation of Healthy Steps (HS). Key informants at the sites associated smoother implementation with strong consistent leadership to assure the structural changes needed to accommodate the program, thorough orientation and buy-in at all levels, and a welldeveloped training and orientation program. The National Program leadership and funders also developed impressions about implementation from their contacts with the sites---by and large forming similar views to those expressed above and noting variation in the “quality” of implementation. Other early childhood interventions, most recently, Early Head Start (Love et al., 2002) have noted variations in implementation due to differences in program characteristics. To better inform future programs and funders, we examined two areas of potential variation in characteristics related to implementing the program: (1) variation in the National Program Office’s (NPO’s) assessment of the quality of implementation at each site; and (2) variation in the extent to which the site had experience implementing the program at the time the family entered care. This evaluation component addresses the first question of the evaluation: 1. How did providers and local foundations implement the Healthy Steps program in their sites and what were the factors that facilitated or impeded implementation? In the first comparison, we found stronger effects on receipt of some services for intervention families at “top rated” sites. However the effect of raising the already high levels of service receipt to even higher levels did not seem to affect outcomes. In the second analysis, intervention children enrolled later had a lower odds than children who enrolled earlier of receiving some services and a higher odds of receiving others. There were few differential effects on outcomes. The findings from these two analyses reinforce key informant reports, which indicated that the HS components were made available at the start of the program and were implemented at all 15 sites.
12-2
Interpreting Odds Ratios Regression results for dichotomous outcomes, adjusting for baseline family characteristics and site, are reported in terms of odds ratios. An odds ratio of greater than 1 indicates that subjects in the intervention group were more likely to report a given characteristic than were subjects in the control group; an odds ratio of less than 1 indicates that subjects in the intervention group were less likely to report a given characteristic than were subjects in the control group. An odds ratio of 1 indicates that there was no difference between intervention and control groups. Ninety-five percent confidence intervals are estimated; when this interval does not include one, it indicates a statistically significant difference (at the 0.05 level) between the intervention and control group.
Chapter 12
Healthy Steps: The First Three Years
12.2 Variation in National Program Site Ratings The intent of the first comparison was to assess whether the variation in implementation observed by the NPO affected receipt of services by families and in turn parent and child outcomes. In this analysis, the quality ratings the NPO assigned to each site provided the measure of variation. The program ratings likely capture not only the “quality” of program implementation but also the “quality” of the site overall. The NPO used an interactive statistical technique to elicit site ratings from staff at the NPO, The Commonwealth Fund, and Boston University (Trochim, 1985; Trochim, 1997; Trochim, 1998). For purposes of both developing the site rating factors and in providing ratings, the NPO team could draw upon multiple sources of information on implementation at the sites that had been available to them throughout the project. During two monitoring visits to sites, the team met with key clinicians, staff, and funders, and observed HS activities. After each visit, a formal report was circulated to staff at the NPO offices. Prior to the second monitoring visit, each site completed a self-report form that provided information on clinical and operational issues. In addition, regular Boston University technical assistance teleconferences were monitored and summarized by NPO staff, who circulated these to staff throughout the program. The combined information from the interactive process provided a set of key site factors and quantitative rankings of the quality of implementation. The NPO analysis suggested that high quality sites were characterized by strong “buy-in” by practice staff, presence of a champion for HS, strong communication with the practice, and teamwork. Seeking to answer the question, “Is the impact of HS greater at sites with the highest NPO ratings than at the less highly rated sites?”, we assessed the difference in the effects of HS between families in care at the four “top rated” sites and those at the other 11 sites. The same co-variates were included in these analyses as were included in the overall analyses. Children in the intervention group, whether at a “top rated” site or less highly rated site had significantly higher odds than children in the control group of receiving HS services (Table 12.1). Children at the four “top rated” sites had a higher odds than children at the other sites of receiving four or more HS services and information on community resources, discussing six topics, and receiving books. With few random exceptions, there were no 12-3
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differential effects on parent and child outcomes. The effect of raising the already high levels of service receipt to even higher levels did not seem to affect outcomes. 12.3 Variation in Experience with Implementation In the second analysis, we hypothesized that as sites gained experience with the program, they might become more efficient at delivering HS services to families or that the nature or quality of the services might improve. If found, these changes might affect families in terms of receipt of services or program effects. Receipt of services and program effects were compared for families that entered care when sites had substantial experience implementing HS (after the first 100 families had been enrolled) and when they had less program experience (when 100 or fewer families had been enrolled). We included the same co-variates in these analyses as were in the overall analyses. Intervention families, whether they enrolled early or late, had a far higher odds than their counterparts in the control group of receiving HS services (Table 12.2). Intervention children had higher odds of being vaccinated on time (although the differences for up-to-date vaccination were not significant for children who enrolled earlier). Mothers of children in the intervention group had a higher odds of being satisfied with care, regardless of when their children enrolled. We found variation in the impact of HS on receipt of some services and on some outcomes between the two groups but they were not consistent between RND and QE sites. At QE sites, intervention children who enrolled later (after the first 100 children) had a significantly lower odds than children who enrolled earlier (first 100 children enrolled) of receiving several of the HS services. These services included one or more home visits, developmental assessments, and books to read. At QE sites, laterenrolled intervention children also had a lower odds than those enrolled earlier of receiving their 24-month well child visit on time. At RND sites, later-enrolled intervention children had a higher odds of receiving information on community resources as well as diagnosis and referral for developmental problems. At both RND and QE sites, intervention children in the later enrolled group also had a higher odds of being up-to-date on their vaccinations by 24 months of age. The meaning of these results is not clear. It is possible that as the HS Specialist’s workload increased at the QE sites, it became more difficult to schedule home visits, to schedule 24-month office visits, and to provide developmental assessments. HS Specialists
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Healthy Steps: The First Three Years
may have had less time to spend developing relationships with families. Also, they may have taken advantage of referrals to outside resources rather than providing the service on site. Having more experience in providing services seemed to promote up-to-date vaccination. Nonetheless, the timing of the child’s entry into the program seemed to have little influence on parent and child outcomes.
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Healthy Steps: The First Three Years
Healthy Steps Intervention Families: Significantly More Likely than Control ¡ Significantly Less Likely than Control Significant Effect Not Noted
Significant Difference in Effects Between “Top Rated” and “Less Highly Rated” Groups Table 12.1. Results of Regression Analyses Comparing Impacts on Receipt of Services and Program Effects for Families at 4 “Top Rated” Sites with Families at 11 Other Sites: Adjusted Odds Ratios and 95% Confidence Intervals
Families at 4 “Top Rated” Sites
Families at 11 “Less Highly Rated” Sites
Difference Between Groups (t statistic)
34.68
15.55
3.57
(23.69, 50.79)
(12.41, 19.47)
RECEIPT OF SERVICES Received 4 or More HS Services from Practice ( Excluding Home Visiting ) Someone Visited Parent or Child in Their Home Since 6 Months Someone in the Practice Talked with Parent or Gave them Information more than 6 topics Given Developmental Assessment by Someone in Practice Received Books to Read to Their Child from Practice Received Information About Community Resources From Someone in Practice Child Received Services (Other Than Testing) For Problem With Walking, Taking, Hearing, or Using His/Her Hands
16.21
14.74
(11.56, 22.73)
(11.92, 18.24)
14.22
8.78
(9.75, 20.76)
(7.02, 10.98)
8.87
7.51
(6.29, 12.52)
(6.12, 9.21)
75.63
20.84
(46.55, 122.88)
(16.54, 26.24)
6.46
3.59
(4.67, 8.94)
(2.94, 4.38)
0.85 (0.56, 1.29)
1.42
0.47
2.16 0.82
4.71 3.03 -1.98
(1.07, 1.89)
SATISFACTION WITH CARE Someone Went Out of Way to Help Disagree That MDs And NPs Provided “Support”To Parent Disagree That MDs And NPs “Listened” To Parent Disagree That MDs And NPs Respected Parent’s Knowledge, Knew What Was Going On with the Child, and Made Them Feel Like They Were Doing a Good Job Overall Perception Of Care At Practice ( Good / Excellent ) Overall Perception that Doctors and Nurses at the Practice Are Easy to Reach by Telephone
2.17
2.08
(1.64, 2.89) ¡0.24 (0.14, 0.39) ¡0.49 (0.31, 0.79)
(1.74, 2.48) ¡0.42 (0.32, 0.54) ¡0.74 (0.57, 0.97)
0.7
0.83
(0.45, 1.08)
(0.64, 1.09)
1.47
1.1
(0.89, 2.44)
(0.82, 1.48)
0.87
0.94
(0.58, 1.29)
(0.76, 1.16)
0.26 -1.95 -1.48 -0.69 0.99 -0.34
PARENT KNOWLEDGE, BELIEFS, PSYCHOLOGICAL HEALTH: MATERNAL DEPRESSION Percentage of Mothers with Depressive Symptoms (Score of 11 or Higher on Modified CES-D)
1.43
1
(0.99, 2.08)
(0.8, 1.25)
1.62
PARENT KNOWLEDGE, BELIEFS, PSYCHOLOGICAL HEALTH: PARENT BEHAVIOR (Modified ) Parent Behavior Checklist: nurturing % More Nurturing (≥63) (Modified ) Parent Behavior Checklist: nurturing % Less Nurturing (≤44) (Modified) Parent Behavior Checklist: Higher Expectations ( >1 SD above mean) (Modified) Parent Behavior Checklist: Lower Expectations( >1 SD below mean)
1.15
1.08
(0.85, 1.55)
(0.89, 1.31)
0.77
0.98
(0.42, 1.4)
(0.72, 1.33)
1.03
0.97
(0.71, 1.49)
(0.79, 1.2)
0.98
1.14
(0.67, 1.43)
(0.9, 1.46)
12-6
0.35 -0.71 0.27 -0.68
Chapter 12
Healthy Steps: The First Three Years
Families at 4 “Top Rated” Sites
Families at 11 “Less Highly Rated” Sites
Difference Between Groups (t statistic)
PARENT KNOWLEDGE, BELIEFS, PSYCHOLOGICAL HEALTH: PARENT BEHAVIOR (Modified): Parent Response to Misbehavior: Severe Physical Discipline: % ever slapped child in face or spanked with object (Modified): Parent Response to Misbehavior: Discipline: % Using Harsh Discipline (≥6) (Modified): Parent Response to Misbehavir: Discipline: % Using More Reasoning (≥9)
0.64
0.76
(0.37, 1.11)
(0.55, 1.04)
0.64
0.79
(0.38, 1.06)
(0.61, 1.03)
1
1.17
(0.72, 1.4)
(0.96, 1.42)
-0.53 -0.75 -0.78
PARENT KNOWLEDGE, BELIEFS, PSYCHOLOGICAL HEALTH: PARENT PRACTICES Parent Showed Picture Books Every day or More Often Family Follows At Least 3 Routines at Bedtime, Naptime, or Mealtime Mother And Father Equally Or Father Usually Takes Child To Well Child Visits Parent Lowered Temperature on Water Heater Family Uses Covers on Electric Outlets
0.81
1.02
(0.6, 1.09)
(0.85, 1.22)
1.05
1.04
(0.78, 1.41)
(0.87, 1.24)
1.32
1.04
(0.94, 1.84)
(0.85, 1.28)
0.95
1.06
(0.71, 1.25)
(0.89, 1.27)
0.79 (0.49, 1.28)
Family Has Safety Latches on Cabinets Parent Knows a Number to Call if Concerned Child May Have Swallowed Something Harmful Current Smokers in Household Who Smoke Outside
1.32
-1.32 0.03 1.17 -0.69 -1.81
(1.01, 1.72)
0.88
1.11
(0.67, 1.17)
(0.94, 1.32)
1.5
0.99
(0.93, 2.43)
(0.76, 1.3)
0.93
1.33
(0.52, 1.66)
(0.93, 1.91)
-1.39 1.47 -1.02
CHILD OUTCOMES: HEALTH AND DEVELOPMENT Child is Very Healthy Child’s Health is Excellent Since Child Came Home from Hospital S/He Had Been Seriously Ill Age Child spoke Two-Word Sentences (did not speak 2word sentences before 24 months of age) Age Child First Walked Without Holding On Parent Very Satisfied with Child’s Eating Habits Parent Very Satisfied With Child’s Sleeping Habits Parent Very Satisfied With Child’s Bowel Habits Parent Very Satisfied With Progress Walking And Talking Very Satisfied With How Well Child Understands What Respondent Says
1.39
1.1
(0.996, 1.94)
(0.9, 1.36)
0.86
1.01
(0.66, 1.13)
(0.85, 1.2)
0.88
0.9
(0.61, 1.26)
(0.7, 1.16)
0.94
0.98
(0.69, 1.28)
(0.8, 1.19)
1.28
0.92
(0.99, 1.66)
(0.78, 1.08)
0.85
0.92
(0.72, 1.00) ¡0.76 (0.64, 0.91)
(0.71, 1.19)
1.13 (0.86, 1.48)
0.93
0.94
(0.69, 1.25)
(0.79, 1.13)
1.1
0.92
(0.74, 1.64)
(0.72, 1.18)
0.9
0.88
(0.55, 1.47)
(0.66, 1.16)
1.16 -0.98 -0.14 -0.21 2.14 0.51
2.41 -0.07 0.76 0.11
CHILD OUTCOMES: CHILD’S PROBLEM BEHAVIOR CBCL: % More Aggressive (≥14)
1.06 (0.73, 1.55)
CBCL: % More Destructive (≥8)
1.4
0.99
1.01
(0.61, 1.62)
(0.77, 1.33)
12-7
-1.21
(1.11, 1.76)
-0.06
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Healthy Steps: The First Three Years
Families at 4 “Top Rated” Sites
Families at 11 “Less Highly Rated” Sites
Difference Between Groups (t statistic)
1.35
0.86
(0.94, 1.95)
(0.68, 1.09)
2.04
CHILD OUTCOMES: INJURIES AND HEALTH CARE UTILIZATION Injured Badly Enough To See Doctor Number Of Emergency Room Visits In Past Year (1 or more ) One or More Emergency Room Visit for Injury-Related Causes in Past Year Number Of Hospitalizations ( 1 or More Times In Past Year)
0.95
1.07
(0.7, 1.27)
(0.9, 1.27)
0.91
0.75
(0.58, 1.42)
(0.57, 0.97)
1.57
0.94
(0.89, 2.77)
(0.66, 1.34)
-0.71 0.75 1.51
CHILD OUTCOMES: AGE-APPROPRIATE WELL CHILD CARE 1 Month Well Child Visit (Visit within 41 days of birth) 2 Month Well Child Visit (Visit between 42 days (1.5 months) and 92 days(3 months), inclusive) 4 Month Well Child Visit (Visit between 93 days (3 months) and 151 days (5 months), inclusive) 6 Month Well Child Visit (Visit between 152 days (5 months) and 213 days (7 months), inclusive) 9 Month Well Child Visit (Visit between 244 days (8 months) and 305 days (10 months), inclusive) 12 Month Well Child Visit (Visit between 336 days (11 months) and 397 days (14 months), inclusive) 15 Month Well Child Visit (Visit between 427 days (14 months) and 488 days (17 months), inclusive) 18 Month Well Child Visit (Visit between 519 days (17 months) and 580 days (20 months), inclusive) 24 Month Well Child Visit (Visit between 701 days (23 months) and 762 days (28 months), inclusive)
4.94
1.71
(2.11, 11.55)
(1.15, 2.52)
2.51
1.86
(1.68, 3.75)
(1.5, 2.3)
2.07
1.42
(1.44, 2.97)
(1.17, 1.72)
1.89
1.39
(1.35, 2.64)
(1.16, 1.66)
2.08
1.55
(1.55, 2.8)
(1.31, 1.83)
1.86
1.77
(1.28, 2.72)
(1.44, 2.18)
1.69
1.83
(1.26, 2.27)
(1.53, 2.2)
2.73
2.74
(2.03, 3.66)
(2.28, 3.3)
1.83
1.66
(1.23, 2.71)
(1.34, 2.06)
2.23 1.29 1.78 1.59 1.71 0.23 -0.48 -0.04 0.42
CHILD OUTCOMES: AGE-APPROPRIATE VACCINATIONS DTP 1 DTP 3 MMR 1
2.15
1.71
(1.33, 3.47)
(1.35, 2.18)
1.99
1.36
(1.46, 2.7)
(1.15, 1.61)
1.78
1.45
(1.2, 2.64)
(1.16, 1.82)
0.83
2.12 0.89
CHILD OUTCOMES: CHILD UP-TO-DATE ON VACCINATIONS Up To Date At 24 Months (4 DTP, 3 OPV/IPV, 1MMR)
1.78
1.36
(1.27, 2.49)
(1.07, 1.74)
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1.25
Chapter 12
Healthy Steps: The First Three Years
Healthy Steps Intervention Families: Significantly More Likely than Control ¡ Significantly Less Likely than Control Significant Difference Not Noted Significant Difference in Effects Between Experience Groups Table 12.2. Receipt of Developmental Services and Healthy Steps Program Effects for Children Enrolled When the Site Had More Experience or Less: Adjusted Odds Ratios and 95% Confidence Intervals MORE EXPERIENCE More than 100 children enrolled at time of entry
LESS EXPERIENCE Less than or equal to 100 children enrolled at time of entry
Difference Between Groups (t statistic)
RECEIPT OF SERVICES
Received 4 or More HS Services from Practice (Excluding Home Visiting) Randomization 17.75 16.11 Quasi-Experimental Pooled
(12.66, 24.88)
20.95
26.02
(15.33, 28.62)
(18.64, 36.33)
18.58
20.64
(14.86, 23.24)
(16.37, 26.02)
Someone Visited Parent or Child in Their Home Since 6 Months (30-33 Months) Randomization 11.6 15.62 Quasi-Experimental Pooled
(8.47, 15.89)
0.51
(11.56, 22.46)
(11.22, 21.75)
16.02
21.99
(12.12, 21.17)
(16.31, 29.65)
13.11
17.99
(10.69, 16.07)
(14.48, 22.34)
-1.37 -0.88 -1.68 -2.22 -2.88
Someone in the Practice Talked with Parent or Gave them Information More than 6 Topics @ 30-33 Months Randomization 8.54 8.58 -0.02 Quasi-Experimental Pooled
(6.03, 12.11)
(6.01, 12.24)
11.39
13.55
(8.23, 15.77)
(9.47, 19.4)
9.49
10.66
(7.51, 11.99)
(8.31, 13.68)
Given Developmental Assessment by Someone in Practice Randomization 6.79 7.46 Quasi-Experimental Pooled
(4.89, 9.44)
7.45
11.01
(5.61, 9.89)
(7.94, 15.28)
6.87
9.16
(5.56, 8.49)
(7.27, 11.54)
Received Books to Read to Their Child from Practice Randomization 32.88 Quasi-Experimental Pooled
(5.35, 10.4)
(22.52, 48.01)
25.85 (18.05, 37.02)
24.09
37.74
(17.26, 33.6)
(25.85, 55.09)
26.1
30.09
(20.46, 33.29)
(23.28, 38.89)
Received Information About Community Resources From Someone in Practice Randomization 4.19 2.93 Quasi-Experimental Pooled
(3.11, 5.63)
-0.78 -0.45 -2.09 -2.11 1.11 -2.33 -1.01 2.26
(2.18, 3.94)
4.97
4.94
(3.81, 6.48)
(3.73, 6.54)
4.55
3.96
(3.74, 5.53)
(3.24, 4.84)
12-9
-0.84
0.04 1.35
Chapter 12
Healthy Steps: The First Three Years
MORE EXPERIENCE More than 100 children enrolled at time of entry
LESS EXPERIENCE Less than or equal to 100 children enrolled at time of entry
Difference Between Groups (t statistic)
Child Diagnosed or Referred for Problem with Walking, Talking, Hearing, or Using His/Her Hands Randomization ¡ 0.62 3.02 1.34 Quasi-Experimental
(0.91, 1.99)
1.79 (1.23, 2.6)
Pooled
1.51 (1.15, 1.97)
(0.39, 0.98)
1.37 (0.9, 2.09)
0.91
1.25 3.11
(0.67, 1.24)
PARENT KNOWLEDGE, BELIEFS, PSYCHOLOGICAL HEALTH: SATISFACTION WITH CARE
Someone Went Out of Way to Help Randomization
Quasi-Experimental Pooled
1.98
2.15
(1.50, 2.60)
(1.63, 2.83)
2.00
2.25
(1.58, 2.54)
(1.74, 2.91)
1.99
2.24
(1.67, 2.38)
(1.86, 2.69)
Disagree that MDs and NPs Provided “Support” to Parent 6 Randomization ¡ 0.41 ¡ 0.47 Quasi-Experimental Pooled
(0.26, 0.65)
(0.3, 0.74)
(0.18, 0.39)
(0.27, 0.56)
(0.24, 0.43)
(0.32, 0.56)
¡ 0.27 ¡ 0.32
Disagree that MDs and NPs “Listened” to Parent Randomization ¡ 0.61 (0.38, 0.97)
Quasi-Experimental
¡ 0.55 (0.37, 0.8)
Pooled
¡ 0.57 (0.43, 0.76)
¡ 0.39 ¡ 0.42 0.76
-0.51 -0.82 -1.07 -0.52 -1.59 -1.5 -0.78
(0.49, 1.17)
0.8
-1.72
(0.55, 1.15)
0.79
-1.91
(0.6, 1.04)
Disagree that MDs and NPs Respected Parent’s Knowledge, Knew What Was Going On with the Child, and Made Them Feel Like Thy Were Doing a Good Job 8 Randomization 0.96 1.09 -0.52 Quasi-Experimental Pooled
(0.62, 1.48)
(0.71, 1.65)
(0.47, 0.96)
(0.44, 0.95)
¡ 0.67
¡ 0.65
0.78
0.81
(0.59, 1.02)
(0.61, 1.07)
Overall Perception of Care at Practice (good/excellent ) Randomization 1.05 1.34 Quasi-Experimental Pooled
(0.65, 1.69)
0.14 -0.28 -0.86
(0.82, 2.2)
1.31
1.12
(0.87, 1.97)
(0.74, 1.7)
1.19
1.18
(0.87, 1.62)
(0.86, 1.62)
0.64 0.04
Overall perception that Doctors and Nurses at the Practice Are Easy to Reach by Telephone Randomization 0.93 1.13 -1 Quasi-Experimental Pooled
(0.67, 1.29)
(0.81, 1.58)
0.84
0.79
(0.62, 1.14)
(0.58, 1.09)
0.89
0.95
(0.72, 1.11)
(0.76, 1.2)
12-10
0.34 -0.52
Chapter 12
Healthy Steps: The First Three Years
MORE EXPERIENCE More than 100 children enrolled at time of entry
LESS EXPERIENCE Less than or equal to 100 children enrolled at time of entry
Difference Between Groups (t statistic)
PARENT KNOWLEDGE, BELIEFS, PSYCHOLOGICAL HEALTH: MATERNAL DEPRESSION CES-D 11 Or Higher Randomization 1.02 1.34 -1.39 Quasi-Experimental Pooled
(0.71, 1.45)
(0.95, 1.88)
1.02
1.03
(0.75, 1.39)
(0.74, 1.43)
1.02
1.19
(0.81, 1.29)
(0.95, 1.51)
-0.05 -1.16
PARENT KNOWLEDGE, BELIEFS, PSYCHOLOGICAL HEALTH: PARENT BEHAVIOR
(Modified) Parent Behavior Checklist: % More Nurturing (> 63) Randomization 1.06 1.18 Quasi-Experimental Pooled
(0.78, 1.44)
1.08
1.09
(0.84, 1.4)
(0.84, 1.43)
1.06
1.14
(0.87, 1.29)
(0.93, 1.39)
(Modified) Parent Behavior Checklist: % Less Nurturing (< 44) Randomization 1.17 0.82 Quasi-Experimental Pooled
(0.73, 1.89)
-0.65
(0.88, 1.6)
-0.07 -0.65 1.22
(0.49, 1.38)
0.81
0.9
(0.52, 1.26)
(0.56, 1.44)
0.98
0.89
(0.71, 1.35)
(0.63, 1.25)
-0.42 0.5
(Modified) Parent Behavior Checklist: Higher Expectations (>1 SD above mean) Randomization 0.92 1.01 -0.48 Quasi-Experimental Pooled
(0.66, 1.29)
(0.73, 1.41)
1.03
0.92
(0.78, 1.38)
(0.67, 1.25)
1
0.97
(0.8, 1.24)
(0.78, 1.21)
0.70 0.22
(Modified) Parent Behavior Checklist: Lower Expectations (> 1 SD below mean) Randomization 1.13 0.78 1.63 Quasi-Experimental Pooled
(0.78, 1.62)
(0.53, 1.16)
1.1
1.36
(0.79, 1.54)
(0.97, 1.9)
1.1
1.09
(0.86, 1.4)
(0.85, 1.39)
-1.16 0.10
PARENT KNOWLEDGE, BELIEFS, PSYCHOLOGICAL HEALTH: PARENTING BEHAVIOR
(Modified): Parent Response to Misbehavior: % slapped child in face or spanked with object Randomization 0.9 0.75 0.60 Quasi-Experimental Pooled
(0.54, 1.5)
0.66 (0.42, 1.02)
(0.44, 1.28)
0.69
(0.43, 1.11)
0.74
0.71
(0.53, 1.02)
(0.5, 1.01)
-0.19 0.16
(Modified): Parent Response to Misbehavior: % Using Harsh Discipline (>6) Randomization 0.63 0.91 -1.38 Quasi-Experimental Pooled
(0.4, 1)
(0.59, 1.4)
0.86
0.73
(0.6, 1.23)
(0.49, 1.1)
0.74
0.78
(0.56, 0.97)
(0.59, 1.05)
12-11
0.68 -0.38
Chapter 12
Healthy Steps: The First Three Years
MORE EXPERIENCE More than 100 children enrolled at time of entry
LESS EXPERIENCE Less than or equal to 100 children enrolled at time of entry
Difference Between Groups (t statistic)
(Modified): Parent Response to Misbehavior: Discipline: % Using More Reasoning (> 9) Randomization 1.23 1.1 0.61 Quasi-Experimental Pooled
(0.89, 1.7)
(0.8, 1.51)
0.97
1.27
(0.75, 1.26)
(0.95, 1.69)
1.06
1.2
(0.87, 1.29)
(0.97, 1.48)
-1.71 -1.07
PARENT KNOWLEDGE, BELIEFS, PSYCHOLOGICAL HEALTH: PARENT PRACTICES
Parent Showed Picture Books Every Day or More Often Randomization 0.92 0.96 Quasi-Experimental Pooled
(0.69, 1.21)
0.99
0.98
(0.77, 1.26)
(0.75, 1.27)
0.95
0.97
(0.79, 1.14)
(0.8, 1.17)
Family Followed at Least 3 Routines at 30-33 Months Randomization 0.9 1.02 Quasi-Experimental Pooled
(0.68, 1.2)
-0.28
(0.73, 1.27)
0.06 -0.17 -0.71
(0.76, 1.35)
0.99
1.24
(0.78, 1.25)
(0.96, 1.61)
0.96
1.15
(0.8, 1.15)
(0.95, 1.39)
-1.6 -1.73
Mother and Father Equally or Father Usually Take Child to Well Child Visits Randomization 1.11 1.18 -0.35 Quasi-Experimental
Pooled
(0.81, 1.52)
1.13
(0.74, 1.32)
(0.84, 1.51)
1.05
1.17
(0.85, 1.3)
(0.95, 1.45)
Parent Lowered Temperature on Water Heater Randomization 1.19 Quasi-Experimental Pooled
(0.9, 1.57)
Pooled
0.81
0.88 (0.69, 1.14)
0.96
1.1
(0.81, 1.15)
(0.92, 1.32)
(0.7, 1.61)
Pooled
2.05
1.2
0.85 (0.58, 1.24)
1.14
1.2
(0.86, 1.5)
(0.9, 1.61)
(0.89, 1.51)
-1.22 -0.65 -1.27 -2.34
1.07
1.59 -0.32 0.5
(0.82, 1.39)
1.05
0.9
(0.84, 1.33)
(0.7, 1.15)
1.11
0.98
(0.93, 1.32)
(0.82, 1.17)
12-12
-0.93
(1.24, 3.4)
(0.82, 1.76)
Family Has Safety Latches on Cabinets Randomization 1.16 Quasi-Experimental
1.45
-0.8
(1.1, 1.91)
(0.63, 1.03)
Family Uses Covers on Electric Outlets Randomization 1.06 Quasi-Experimental
(0.87, 1.61)
0.99
1.19 1.27
Chapter 12
Healthy Steps: The First Three Years
MORE EXPERIENCE More than 100 children enrolled at time of entry
LESS EXPERIENCE Less than or equal to 100 children enrolled at time of entry
Difference Between Groups (t statistic)
Parent Knows a Number to Call if Concerned Child May have Swallowed Something Harmful Randomization 1.2 1.56 -0.94 Quasi-Experimental Pooled
(0.76, 1.88)
0.9
(0.68, 1.41)
(0.62, 1.32)
1.06
1.13
(0.8, 1.41)
(0.85, 1.52)
Current Smokers in Household Who Smoke Outside Randomization 1.14 Quasi-Experimental Pooled
(0.96, 2.54)
0.98
(0.67, 1.94)
1.01
0.39 -0.38 0.38
(0.6, 1.71)
1.03
1.76
(0.62, 1.71)
(0.97, 3.2)
1.1
1.34
(0.77, 1.58)
(0.91, 1.97)
-1.65 -0.91
CHILD OUTCOMES: HEALTH AND DEVELOPMENT
Child Is Very Healthy Randomization Quasi-Experimental Pooled
1.05
1.33
(0.76, 1.44)
(0.97, 1.81)
1.13
1.26
(0.86, 1.5)
(0.94, 1.69)
1.09
1.27
(0.89, 1.35)
(1.03, 1.57)
-1.33 -0.67 -1.28
Child’s Health Is Excellent Randomization Quasi-Experimental Pooled
0.99
0.82
(0.76, 1.3)
(0.63, 1.06)
1.16
0.89
(0.92, 1.47)
(0.7, 1.14)
1.08
0.86
(0.91, 1.29)
(0.72, 1.03)
Since Child Came Home from Hospital S/He Had Been Seriously Ill Randomization 0.85 0.79 Quasi-Experimental Pooled
(0.59, 1.23)
1.29 1.94 2.26 0.37
(0.54, 1.14)
0.88
1.06
(0.62, 1.26)
(0.74, 1.51)
0.87
0.92
(0.68, 1.12)
(0.71, 1.18)
-0.92 -0.32
Age Child Spoke Two-Word Sentences (did not speak 2-word sentences before 24 months of age) Randomization 0.78 0.99 -1.29 Quasi-Experimental Pooled
(0.56, 1.08)
(0.73, 1.36)
1.14
0.92
(0.88, 1.47)
(0.7, 1.22)
0.98
0.95
(0.8, 1.19)
(0.78, 1.17)
1.39 0.26
Age Child First Walked without Holding On (walked before 12 months of age) Randomization 1.23 1.26 -0.18 Quasi-Experimental Pooled
(0.95, 1.59)
(0.98, 1.63)
0.84
0.86
(0.68, 1.04)
(0.68, 1.08)
0.99
1.02
(0.84, 1.17)
(0.86, 1.2)
12-13
-0.20 -0.24
Chapter 12
Healthy Steps: The First Three Years
MORE EXPERIENCE More than 100 children enrolled at time of entry
LESS EXPERIENCE Less than or equal to 100 children enrolled at time of entry
Parent Very Satisfied with Child’s Eating Habits Randomization 0.83 Quasi-Experimental Pooled
(0.76, 1.26)
(0.65, 1.00)
(0.69, 1.10)
¡ 0.80 ¡ 0.83
(0.70, 0.97)
Parent Very Satisfied with Child’s Sleeping Habits Randomization 0.88 Quasi-Experimental Pooled
(0.67, 1.15)
Pooled
0.87 0.92
¡ -0.64 –1.16
0.82
0.47
(0.63, 1.07)
0.83
0.86 (0.67, 1.10)
0.86
0.85
(0.73, 1.03)
(0.71, 1.01)
(0.64, 1.14)
-1.10
(0.78, 1.09)
(0.66, 1.05)
Parent Very Satisfied with Child’s Bowel Habits Randomization 0.85 Quasi-Experimental
0.98
(0.65, 1.07)
Difference Between Groups (t statistic)
0.88
–0.25 0.18 -0.17
(0.66, 1.17)
1
0.94
(0.79, 1.28)
(0.72, 1.21)
0.94
0.94
(0.78, 1.13)
(0.78, 1.13)
0.49 0.04
CHILD OUTCOMES: HEALTH AND DEVELOPMENT
Parent Very Satisfied with Progress Walking and Talking Randomization 1.03 1.65 Quasi-Experimental Pooled
(0.69, 1.53)
(1.07, 2.54)
(0.52, 0.99)
(0.63, 1.3)
¡ 0.72
0.91
0.84
1.16
(0.66, 1.07)
(0.88, 1.52)
-1.91 -1.25 -2.17
Very Satisfied with How Well Child Understands What Respondent Says Randomization 1.14 1.37 -0.66 Quasi-Experimental Pooled
(0.72, 1.81)
(0.86, 2.17)
0.69
0.68
(0.47, 1.01)
(0.45, 1.03)
0.86
0.91
(0.65, 1.15)
(0.67, 1.23)
CHILD OUTCOMES: CHILD’S PROBLEM BEHAVIOR CBCL: % More Aggressive (> 14) Randomization 1.48 0.96 Quasi-Experimental Pooled
(1.05, 2.09)
(0.66, 1.39)
(1.06, 1.98)
(0.95, 1.88)
¡ 1.45 1.44
1.14
(1.15, 1.81)
(0.89, 1.46)
CBCL: % More Problems Sleeping (> 6) Randomization 1.43 Quasi-Experimental Pooled
1.34
(0.99, 2.06)
1.3
-0.31
2.11 0.45 1.76 0.45
(0.9, 1.89)
1.24
1.18
(0.9, 1.71)
(0.84, 1.67)
1.3
1.23
(1.03, 1.65)
(0.96, 1.57)
12-14
0.03
0.27 0.44
Chapter 12
Healthy Steps: The First Three Years
MORE EXPERIENCE More than 100 children enrolled at time of entry
LESS EXPERIENCE Less than or equal to 100 children enrolled at time of entry
Difference Between Groups (t statistic)
CHILD OUTCOMES: INJURIES AND HEALTH CARE UTILIZATION
Injured Badly Enough to See a Doctor Randomization 1.13 Quasi-Experimental Pooled
(0.79, 1.62)
0.97
0.93
0.99
(0.67, 1.27)
(0.71, 1.38)
1
0.98
(0.79, 1.26)
(0.77, 1.25)
Number of Emergency Room Visits in Past Year (1 or more ) Randomization 1.19 1.23 Quasi-Experimental Pooled
(0.9, 1.57)
0.75
(0.67, 1.39)
-0.34 0.14 -0.21
(0.93, 1.62)
0.84
1.02
(0.67, 1.06)
(0.8, 1.3)
0.97
1.13
(0.81, 1.15)
(0.94, 1.35)
-1.37 -1.5
One or More Emergency Room Visit for Injury-Related Causes in Past Year Randomization 0.96 0.91 0.2 Quasi-Experimental Pooled
(0.62, 1.49)
(0.59, 1.41)
(0.46, 0.95)
(0.46, 0.99)
¡ 0.66
¡ 0.67
0.78
0.79
(0.59, 1.03)
(0.6, 1.05)
-0.06 -0.06
Number of Hospitalizations (1 0r More Times in Past Year @ 30-33 Months) Randomization 1.5 1.11 1.04 Quasi-Experimental Pooled
(0.91, 2.46)
(0.66, 1.87)
0.81
1.25
(0.48, 1.38)
(0.74, 2.11)
1.08
1.1
(0.76, 1.54)
(0.76, 1.57)
-1.42 -0.07
CHILD OUTCOMES: AGE-APPROPRIATE WELL CHILD CARE
1 Month Well Child Visit (Visit within 41 days of birth) Randomization 1.88 1.5 Quasi-Experimental Pooled
(0.97, 3.66)
0.57
(0.82, 2.73)
3.13
2.62
(1.6, 6.13)
(1.37, 5.02)
2.42
1.89
(1.51, 3.86)
(1.23, 2.92)
0.41 0.85
2 Month Well Child Visit (Visit between 42 days (1.5 months) and 92 days (3 months),
inclusive)
Randomization Quasi-Experimental Pooled
2.74
1.9
(1.82, 4.14)
(1.32, 2.73)
2.03
1.86
(1.5, 2.76)
(1.37, 2.53)
2.22
1.79
(1.74, 2.83)
(1.42, 2.26)
(1.04, 2)
(1.12, 2.15)
1.5 0.48 1.47
4 Month Well Child Visit (Visit between 93 days (3 months) and 151 days (5 months), inclusive) Randomization 1.44 1.56 -0.39 Quasi-Experimental Pooled
1.72
1.58
(1.3, 2.26)
(1.19, 2.1)
1.59
1.5
(1.29, 1.96)
(1.22, 1.86)
12-15
0.48 0.42
Chapter 12
Healthy Steps: The First Three Years
MORE EXPERIENCE More than 100 children enrolled at time of entry
LESS EXPERIENCE Less than or equal to 100 children enrolled at time of entry
Difference Between Groups (t statistic)
6 Month Well Child Visit (Visit between 152 days (5 months) and 213 days (7 months),
inclusive)
Randomization Quasi-Experimental Pooled
1.88
1.47
(1.36, 2.61)
(1.08, 2.01)
1.41
1.44
(1.09, 1.81)
(1.11, 1.87)
1.54
1.44
(1.27, 1.88)
(1.18, 1.75)
1.28 -0.17 0.61
9 Month Well Child Visit (Visit between 244 days (8 months) and 305 days (10 months),
inclusive)
Randomization Quasi-Experimental Pooled
1.23
1.1
(0.9, 1.68)
(0.81, 1.48)
2.15
1.87
(1.73, 2.67)
(1.5, 2.33)
1.78
1.55
(1.49, 2.12)
(1.3, 1.85)
0.65 1.08 1.31
12 Month Well Child Visit (Visit between 336 days (11 months) and 397 days (14
months), inclusive)
Randomization
Quasi-Experimental Pooled
1.85
1.68
(1.27, 2.69)
(1.17, 2.4)
1.85
1.85
(1.4, 2.46)
(1.37, 2.49)
1.82
1.76
(1.46, 2.28)
(1.4, 2.21)
0.43 0.01 0.26
15 Month Well Child Visit (Visit between 427 days (14 months) and 488 days (17
months), inclusive)
Randomization
Quasi-Experimental Pooled
1.61
1.17
(1.18, 2.19)
(0.87, 1.57)
2.22
2.14
(1.75, 2.82)
(1.67, 2.74)
1.94
1.65
(1.61, 2.34)
(1.37, 1.99)
1.8 0.27 1.49
18 Month Well Child (Visit between 519 days (17 months) and 580 days (20 months),
inclusive)
Randomization Quasi-Experimental Pooled
2.17
2.01
(1.61, 2.93)
(1.5, 2.71)
3.35
3.42
(2.61, 4.32)
(2.63, 4.43)
2.73
2.74
(2.26, 3.31)
(2.26, 3.33)
0.44 -0.12 -0.02
24 Month Well Child Visit (Visit between 701 days (23 months) and 762 days (28
months), inclusive)
Randomization
Quasi-Experimental Pooled
1.91
2.84
(1.34, 2.71)
(1.94, 4.15)
1.16
1.68
(0.86, 1.55)
(1.22, 2.31)
1.41
2.09
(1.13, 1.76)
(1.65, 2.66)
12-16
-1.78 -2.16 -2.91
Chapter 12
Healthy Steps: The First Three Years
MORE EXPERIENCE More than 100 children enrolled at time of entry
LESS EXPERIENCE Less than or equal to 100 children enrolled at time of entry
CHILD OUTCOMES: AGE-APPROPRIATE VACCINATIONS DTP 1 Randomization 2.15 1.89 Quasi-Experimental Pooled
(1.37, 3.38)
Difference Between Groups (t statistic)
0.48
(1.24, 2.87)
1.91
1.59
(1.34, 2.73)
(1.12, 2.26)
1.95
1.66
(1.48, 2.58)
(1.27, 2.16)
0.83 0.98
DTP 3 Randomization Quasi-Experimental Pooled
1.55
1.42
(1.15, 2.09)
(1.06, 1.91)
1.67
1.39
(1.33, 2.11)
(1.1, 1.75)
1.6
1.38
(1.34, 1.92)
(1.15, 1.66)
0.49 1.37 1.39
MMR 1 Randomization Quasi-Experimental Pooled
1.37
1.52
(0.93, 2.02)
(1.04, 2.23)
1.66
1.54
(1.21, 2.27)
(1.12, 2.13)
1.54
1.52
(1.21, 1.96)
(1.19, 1.94)
CHILD OUTCOMES: CHILD UP-TO-DATE ON VACCINATIONS Up-to-Date at 24 Months (4 DTP, 3 OPV/IPV, 1 MMR) Randomization 1.88 1.26 Quasi-Experimental Pooled
(1.31, 2.69)
(0.91, 1.76)
1.84
1.1
(1.29, 2.64)
(0.79, 1.53)
1.9
1.22
(1.48, 2.44)
(0.97, 1.53)
12-17
-0.44 0.38 0.08
2.00 2.59 3.22
