TABLE 5.

Healthy Steps Articles Included in Piotrowski et al Review

First Author, Year	Design, Outcomes	Findings
Minkovitz, 200147; Minkovitz, 200317; Minkovitz, 200749	Controlled trial		Adjusted odds ratio (95% CI)		Child age	Article first author, yr
	6 RCT sites (n = 1987)
	9 quasi-experimental sites (n = 2909)	Quality of care outcomes
	Parent questionnaire at enrollment	Patient-centeredness
		• Providers’ helpfulness	2.09 (1.80–2.43)		30 mo	Minkovitz, 03
	Phone interview at infant age 2–4 mo	• Dissatisfied with provider support	0.37 (0.30–0.46)		30 mo	Minkovitz, 03
		• Dissatisfied with provider listening	0.67 (0.53–0.84)		30 mo	Minkovitz, 03
	Phone interview at child age 30–33 mo	• Dissatisfied with provider respect	0.79 (0.63–1.00)		30 mo	Minkovitz, 03
	6 RCT sites (n = 1593)	Up to date with immunizations at 24 mo	1.59 (1.27–1.98)		30 mo	Minkovitz, 03
	9 quasi-experimental sites (n = 2144)	Had 24 mo WCV	1.68 (1.35–2.09)		30 mo	Minkovitz, 03
		Had developmental assessment	8.00 (6.69–9.56)		30 mo	Minkovitz, 03
	Phone interview at child age 5.5 y	Discussed 5 of 6 AG topics at 2 mo, >7 of 10 AG topics at 30 mo, or >4 of 6 AG topics at 5 y	2.41 (2.10–2.75)		2 mo	Minkovitz, 01
			10.36 (8.5–12.6)		30 mo	Minkovitz, 03
			1.33 (1.13–1.56)		5 y	Minkovitz, 07
	6 RCT sites (n = 1724)	Composite measure -clinician provides support for parent	2.33 (1.82–3.03)		2 mo	Minkovitz, 01
	9 quasi-experimental sites (n = 1441)		2.70 (2.17–3.45)		30 mo	Minkovitz, 03
			1.25 (1.02–1.53)		5 y	Minkovitz, 07
	Outcomes:	• Remained at practice	1.82 (1.57–2.12)		30 mo	Minkovitz, 03
	• Receipt of intervention services (results not reported here)		1.19 (1.01–1.39)		5 y	Minkovitz, 07
		• Hospitalizations in past year	1.14 (0.84–1.54)		30 mo	Minkovitz, 03
	• Parenting practices		0.90 (0.57–1.42)		5 y	Minkovitz, 07
	• Perceptions of care	• ED use in past year	1.03 (0.89–1.20)		30 mo	Minkovitz, 03
	• Quality of care	• ED use in past year, injury-related	0.77 (0.61–0.97)		30 mo	Minkovitz, 03
	• Child behavior		1.00 (0.83–1.20)		5 y	Minkovitz, 07
	Downs & Black score (modified): 12	Discipline
		• Ever slap face or spank with object	0.73 (0.55–0.97)		30 mo	Minkovitz, 03
			0.68 (0.54–0.86)		5 y	Minkovitz, 07
		• Use harsh discipline	0.78 (0.62–0.99)		30 mo	Minkovitz, 03
			0.98 (0.74–1.30)		5 y	Minkovitz, 08
		• Use negotiation	1.16 (1.01–1.34)		30 mo	Minkovitz, 03
			1.20 (1.03–1.39)		5 y	Minkovitz, 07
		• Ignore misbehavior	1.38 (1.10–1.73)		30 mo	Minkovitz, 03
			1.24 (0.97–1.59)		5 y	Minkovitz. 07
		Parent perception of child behavior and development
		• Parent concern for behavior	1.26 (1.01–1.57)		30 mo	Minkovitz, 03
			1.35 (1.10–1.64)		5 y	Minkovitz. 07
		Aggressive behavior	0.40 (0.06–0.75)		30 mo	Minkovitz, 03
		Anxious or depressed	0.19 (–0.004–0.38)		30 mo	Minkovitz, 03
		Problems sleeping	0.20 (0.03–0.36)		30 mo	Minkovitz, 03
		Parenting practices
		• Follows routines	1.00 (0.88–1.13		2 mo	Minkovitz, 01
			1.03 (0.88–1.20)		30 mo	Minkovitz, 03
			1.02 (0.82–1.26)		5 y	Minkovitz, 07
		• Depressed parent discussed sadness with someone in practice	1.60 (1.09–2.36)		30 mo	Minkovitz, 03
		• Parent and child book sharing	1.22 (1.07–1.40)		2 mo	Minkovitz, 01
			0.96 (0.82–1.12)		30 mo	Minkovitz, 03
			1.16 (1.00–1.35)		5 y	Minkovitz, 07
		• Lowered water temp on water heater	1.03 (0.89–1.20)		30 mo	Minkovitz, 03
		• Uses covers on outlets	1.17 (0.92–1.48)		30 mo	Minkovitz, 03
		• Uses safety latches on cabinets	1.09 (0.86–1.39)		30 mo	Minkovitz, 03
Caughy, 2003;40 Caughy, 200439	Observational study of 2 HS randomized sites	Caughv 2003
		Parent discipline
	N = 378 families at 16- to 17-mo home observation (217 intervention, 161 control)	• Intervention parents were more likely to use inductive/authoritative discipline strategies compared with control group parents at 16 mo; at 34 mo, there was no difference between the 2 groups. There was no difference between groups at either 16 or 34 mo on the use of punitive strategies.
	N = 233 families at 34- to 37-mo home observation (34 intervention, 99 control)	• Intervention vs control mean scores (SD) for inductive/authoritative: 0.10 (0.07) vs –0.12 (0.08) at 16 mo, P < .05
	Child age: birth to 37 mo	Caughv 2004
		Parent outcomes
	In-home observation and parent interview	• No differences in parent outcomes between intervention and control at 16 mo. At 34 mo, intervention group parents were more likely to interact sensitively and appropriately with their child compared with control parents.
	Parenting outcomes	Child outcomes
	• Sensitive parent-child interaction- Nursing Child Assessment by Satellite Training	No differences in child outcome at 16 or 34 mo between intervention and control.
	• Appropriate Parent Interaction-Parent/Caregiver Involvement Scale (P/CIS)
	• Optimal home environment—Home Observation for Measurement of the Environment Inventory
	Child outcomes
	• Child attachment—Attachment Q-Sort
	• Problem behaviors—Child Behavior Checklist
	• Self-regulation—Toy Clean Up Task
	Discipline outcomes
	• Inductive/authoritative discipline strategies (eg, timeouts) vs punitive discipline strategies (eg, spanking)—Parental Responses to Child Misbehavior
	Downs & Black score (modified): 11
Huebner, 2004,41; Johnston, 200443; Johnston, 200642	Quasi-experimental comparison	Outcome		Adjusted rate ratio (95% CI)
	Enrolled: N = 439 women (301 intervention; 136 comparison)	Child Health and Development (Johnston 2006)
	Integrated delivery system	24-mo well-visit attendance		1.0 9 (0.97–1.22)
	Three intervention clinics	Immunization up to date at 24 mo		1.06 (1.02–1.09)
	Two comparison clinics	Language development
	Intervention: HS + prenatal component or HS alone	• Combines 2 words at 24 mo		1.02 (0.94–1.12)
	Child age: 0–30 mo	• Two-word endings, ≥3 vs <3		1.10 (0.82–1.50)
	Parent survey at 3 mo and 30 mo	Maternal Depression
	Outcomes	• Clinically significant symptoms		1.21 (0.80–1.82)
	• At 3 mo-	• Discussed sadness with provider		1.45 (0.95–2.21)
	• Parental knowledge of development	Breastfeeding duration >6 mo		1.18 (1.11–1.26)
	• Parenting practices	Parenting Practices
	• Parental satisfaction with quality of provider	Reads with child		1.03 (0.96–1.10)
	• At 30 mo-	Plays with child		1.01 (0.99–1.02)
	• Child health and development	TV viewing >1 h/d		0.75 (0.62–0.90)
	Child behavioral problems	Follows 3 routines		1.12 (1.03–1.22)
	• Nurturing parenting style	Injury prevention index (5 vs <5 score)		1.19 (1.09–1.28)
	• Parenting self-efficacy	Spanking with object/slapping in face		0.46 (0.29–0.73)
	• Health care self-efficacy	Continuous outcomes (Johnston 2006)		Adjusted linear coefficient (95% CI)
	Maternal depressive symptoms	Child behavior problems
	Parenting Practices	• Aggressive behavior score, continuous		0.83 (0.37 to 1.30)
	Downs & Black score (modified): 12	• Sleep problems score, continuous		0.09 (−0.29 to 0.48)
		• Anxious or depressed mood score, continuous		0.03 (−0.44 to 0.50)
		Parenting competence score, continuous		−0.92 (−1.40 to −0.44)
		Health care self-efficacy score, continuous		0.04 (−0.28 to 0.36)
		Parenting nurturing scale, continuous		−0.06 (−0.42 to 0.31)
		Outcome (Johnston 2004)		Adjusted rate ratio (95% CI) or linear regression coefficient (95% CI) when indicated
		Parental knowledge
		• of infant development, linear regression		0.02 (0.00– 0.03)
		• of safe sleep positions		1.01 (0.98 – 1.04)
		• of appropriate discipline		1.08 (1.04 – 1.11)
		Parenting practices
		• Home safety score, linear regression		0.10 (0.02– 0.17)
		• Breastfeeding at 3 mo		1.14 (1.09–1.20)
		• Tobacco-free home		0.97 (0.94–0.99)
		• Safe sleep		1.02 (0.98–1.05)
		• Reading with child		1.12 (1.04–1.22)
Minkovitz, 2003a		Clinician perspectives		Intervention group providers odds ratio (95% CI) 30-mo vs baseline
	Cross-sectional survey	Practice barriers
	N = 118 clinicians at baseline (80 intervention surveys, 70 control surveys)	• Limited staff to address needs of families		0.43 (0.08–2.40)
		• Problems with reimbursement		1.86 (0.76–4.53)
	N = 99 clinicians at 30-mo follow-up (69 intervention surveys, 70 control surveys)	• Inadequate time with families		1.87 (0.76–4.56)
		Discussed family psychosocial risk factors		0.64 (0.33–1.25)
	Child age: birth-3 y	Satisfied with ability of clinical staff to meet needs of families		4.05 (1.15–14.2)
	Provider and staff surveys	Perceptions of HSS
	Outcomes included the following:	• Talks to parents about child behavior/development		7.58 (2.08–27.67)
	• Perspectives on HSS	• Shows parents activities and gives information about what to do with their child		5.85 (1.89–18.09)
	• Perspectives on HS program	• Provides parents with support, helps with stress, and refers for parent emotional problems		5.84 (1.80–19.01)
	Results shown are for quasi-experimental group only; changes from baseline to 30 mo	• Discusses temperament and/or sleep problems		5.64 (1.40–22.68)
	Downs & Black score: N/Aa
Kizner, 200444	Observational study	Resident perceptions of HSS (N = 29 residents)
	N = 37 residents (37 intervention; no comparison)	• 69%: HSS assisted with resident learning of anticipatory guidance
	Child age: birth to 3 y	• 69%: HSS facilitated resident knowledge of common responses to behavioral and developmental concerns
	Survey of resident physicians involved with JS	• 69%: HSS helped patients receive information efficiently
	Outcomes included:	• 62%: HSS did not interfere with resident-parent relationship
	• Perceptions of HSS	• 66%: Enjoyed working with the HSS
	• Perception of HS program	• 76%: Would consider using HSS in their future practice
	Downs & Black score: N/Aa	• 35%: HSS improved clinic efficiency
		Resident perceptions of Healthy Steps Program (N = 29 residents)
		• 90%: HS did not help improve resident knowledge of family violence
		• 97%: HS did not help improve resident awareness of mental illness
		• 69%: HS did not help the resident establish community contacts and referrals
Niederman, 200750	Controlled trial	Intervention children had greater continuity of care for well-child visits compared with control children (52% vs 28% with scores indicating excellent continuity). This was measured for intervention and control group children at 1 site (n = 263) using the Continuity of Care Index of Bice and Boxerman. The score is 0 to1, with 0 indicating that all visits were made with different providers and 1 indicating that all visits were made with 1 provider.
	N = 363 children (71 intervention, 292 control)
	Child age: birth to 3 y
	Chart review
	Outcomes included the following:	There were no statistically significant differences between intervention and control children for
	• Continuity of care	• longitudinality of care
	• Longitudinal care	• quality of care (immunizations, anemia and lead screening)
	• Quality of care	• behavioral, developmental, or psychosocial diagnoses
	• Rates of diagnoses
	Downs & Black score (modified): 9
McLearn, 200445	Cross-sectional survey of clinicians (physicians and NPs) at 20 HS program sites	Does not compare intervention versus control clinicians; compares clinician perceptions by income level of patients served
	N = 104 clinicians at baseline
	N = 120 clinicians at 30 mo
	Outcome: perspectives on HS program
	Downs & Black score: N/A
McLearn, 200446	Observational study	Does not compare intervention versus control families; compares outcomes for intervention group families by income level
	N = 1910 families (1910 families; no comparison)
	Child age: 1–33 mo; assessments at 2–3 and 30–33 mo
	Parent survey
	Outcomes:
	• Quality of care
	• Parent experiences and satisfaction with care
	Downs & Black score: N/Aa

AG, anticipatory guidance; WCV, well-child visit.

^aDowns and Black checklist was only used for studies that reported parent or child outcomes and included an intervention and comparison group.