Implementing Healthy Steps (National Evaluation 1996 Protocol) Meets HHS Criteria

This report focuses on Healthy Steps as implemented in the 1996 evaluation. HHS has determined that home visiting is not the primary service delivery strategy and the model does not meet current requirements for MIECHV program implementation.

Last updated: July 2011

Implementation experiences

Summary of sources

Information in this section was extracted from 15 studies, including 7 RCTs/QEDs with a moderate or high rating (of these 7 studies, 2 are studies of PrePare, a program supplement) and 8 implementation studies. (Please see Studies for Implementation Experiences for a list of the studies and to link to the characteristics of the samples examined in the effectiveness studies.)

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Characteristics of model participants

Seven of the studies reviewed reported the age of the parent. In the first study, the average age of the mother was 30 years; in the second, the average age was 26 years. In the third study, 15 percent of the program participants were under 20 years old, and 53 percent were between 20 and 29 years old. Two studies reported that the average age of the mother was 32 years old. In two other studies, 17 percent of the sample were less than 19 years old, 57 percent were ages 20 to 29, and 25 percent were 30 years old or older.

One study reported on the average age of the children participating in Healthy Steps. In this study, the average age of the children was 21 months.

Of the eight studies that reported the gender of the program participants, nearly all adult participants were female (seven studies reported that 100 percent were female, and one study reported that 99 percent were female).

Eight studies reported on the race and ethnicity of the program participants. Across these studies, 6 to 25 percent of program participants were African American, and 62 to 77 percent of participants were white. In one of the studies, 17 percent of program participants identified themselves as of other or multiple races.

Across four studies that reported on the educational attainment of program participants, 85 to 97 percent had at least a high school degree, and between 20 and 79 percent of participants had a college degree.

Three studies reported on marital status. In these studies, 66 percent of program participants reported that they were married.

Four studies described the average income of program participants. Two reported that between 17 and 80 percent of families had an annual income of $40,000 or less. Two studies reported that one in three families made more than $75,000.

Twelve studies reported that participation in the Healthy Steps program was voluntary.

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Location and setting

Of the studies reviewed that described the implementation location, Healthy Steps was implemented in a diverse group of communities nationwide. In two studies, the program was implemented in Chicago; in two other studies, the implementing agencies were in Amarillo, Texas, and Florence, South Carolina. One study examined the experiences of participants in 13 states. Two studies examined 15 sites in 14 states. Five studies reported on the experiences of individuals living in the Seattle, Washington, and surrounding areas. 

Across all the studies, sites were located in rural, urban, and suburban communities.

In the studies reviewed, Healthy Steps was implemented in a variety of settings, including group pediatric practices, primary care clinics in academic medical centers, and managed care networks.

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Staffing and supervision

Nine studies described the staff that carried out the Healthy Steps program. In these studies, several types of individuals were described as key to implementation, including physicians, nurse practitioners, and Healthy Steps Specialists.

Five studies reported on the qualifications of the Healthy Steps Specialists. In four studies, Healthy Steps Specialists had a background in child development, early intervention, special education, or social work. One study reported that the Healthy Steps Specialist had a master’s-level degree.

The training provided to staff was reported in seven studies. Four studies reported that training was led by a pediatric team from Boston University School of Medicine. In these studies, the Healthy Steps Specialists received five days of training, while other direct-service staff (physicians, supervisors, and administrators) received three days of training.

None of the studies reviewed described how Healthy Steps Specialists were supervised.

Two studies reported that Healthy Steps Specialists had a caseload of between 100 and 125 families.

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Model services

All the studies reviewed described Healthy Steps as including (1) home visits offered soon after a newborn was discharged from the hospital and at key developmental stages; (2) child development and family health checkups (including formal developmental screens); (3) a child development telephone information line; and (4) written materials for parents on topics such as toilet training, discipline, and nutrition. In addition, participating practices could offer one or more of the following services: well-child visits with a clinician and Healthy Steps specialist, age-appropriate books for mothers and fathers to read to their children, parent support groups, and/or referrals for children (such as to speech or hearing specialists) and parents (such as to maternal depression counseling).


Two studies reported on the specific screenings and assessments offered to participating families. These included (1) an informal developmental checkup that was conducted every six months, (2) a temperament scale, (3) the Brazelton Neonatal Behavioral Assessment Scale, (4) the Denver II Developmental Screening Test, (5) the BABES Behavior Checklist, and (6) the MacArthur Communicative Development Inventory.

One study reported that the local programs used protocols and other program materials provided by Healthy Steps.

One study reported that the information that was handed out to parents was printed in both English and Spanish.

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Model adaptations or enhancements

Two studies reported on a supplemental service offered to families through Healthy Steps called PrePare. Those in the Healthy Steps PrePare group received prenatal home visits from Healthy Steps Specialists in addition to the standard Healthy Steps services following the child’s birth.
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Five studies reported on the dosage families enrolled in Healthy Steps received. Three studies reported on the number of home visits provided to families in the first 32 to 36 months of their child’s life. In those three studies, the average family received two home visits during that time. One study reported that 57 percent of the families had one home visit during the first four months of a child’s life. Another study reported that 83 percent of program participants received one home visit during the child’s first year, and 39 percent received more than three visits.

One study reported that the home visits were approximately 15 minutes long.

Six studies reported that they served children from birth to age 3. Of these studies, one reported that it extended its services to children slightly beyond age 3.

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Lessons learned

Several of the studies reported on lessons learned related to implementation of Healthy Steps. Lessons included:

    • Sites that experienced smoother implementation typically had (1) strong consistent leadership to assure the structural changes needed to accommodate the program, (2) thorough orientation and buy-in from staff, and (3) a well-developed training program for staff.
    • Healthy Steps Specialists recommended providing information to families about breast-feeding prenatally, because by the time they met with families (soon after mothers were released from the hospital), the families had typically decided whether or not to breast-feed.
    • Sites reported that families needed additional education about the number of well-child visits a child needs during the first year of life to assure that the families bring the children in at the age-appropriate times.
    • Sites recommended adding information to the Healthy Steps model about vaccinations, as well as using the opportunity to learn from families why they chose not to vaccinate their children.
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