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Johnston, B. D., Huebner, C. E., Anderson, M. L., Tyll, L. T., & Thompson, R. S. (2006). Healthy Steps in an integrated delivery system: Child and parent outcomes at 30 months. Archives of Pediatrics & Adolescent Medicine, 160(8), 793–800.

Model(s) Reviewed: PrePare supplement relative to Healthy Steps only subgroup
Manuscript screening details
Screening decision Screening conclusion
Passes screens Eligible for review
Study design details
Rating Design Attrition Baseline equivalence Reassignment Confounding factors
High Randomized controlled trial Low Established on race/ethnicity and SES (i.e., family income). Controls for baseline scores of outcomes collected at baseline. None None
Notes:

footnote73

Submitted by user on Fri, 03/15/2019 - 14:29

Study presents unadjusted program and comparison group means (columns 5 and 6). Tests of statistical significance apply to adjusted results in column 7 (means difference or odds ratio). The standard errors in Johnston et al. (2006) are adjusted for clustering within clinic.

Study characteristics
Study participants The sample included 239 mothers with children age 30 months at assessment. All women were receiving Healthy Steps services and had enrolled before 22 weeks of gestation. Study enrollment occurred between July 1998 and September 2000. Most mothers had some college experience (>90%), with over one in three also having graduate-level training. Study participants were predominately white (>75%). Over 80% of mothers had family incomes above $40,000, with over one in three family incomes exceeding $75,000.
Setting Three primary care clinics that are part of the Group Home Cooperative in the Pacific Northwest.
Intervention services The study randomly assigned mothers to receive either Healthy Steps only or Healthy Steps plus the PrePare supplement. Those in the Healthy Steps plus PrePare group received three prenatal home visits in addition to standard Healthy Steps program services following the child’s birth. Healthy Steps Specialists provided prenatal home visiting services to help parents prepare for their newborn. Specialists also screened and provided interventions for smoking, depression, and domestic violence. Following birth, Healthy Steps Specialists provided home visits, developmental and behavioral advice, a child development telephone information line, and links to community resources. The typical frequency of home visits by three months after birth is five in the standard implementation and eight with PrePare supplemental visits included.
Comparison conditions Women in the comparison group received the standard Healthy Steps program.
Staff characteristics and training Healthy Steps Specialists (HSS) underwent a five-day Healthy Steps training at Boston University, followed by one additional day of training in Seattle on how PrePare relates to Healthy Steps. HS S also underwent an additional 21 hours of training on different modules subsequent to the initial training.
Funding sources The Kaiser Foundation Health Plan; the Group Health Community Foundation; the Nesholm Family Foundation; and the Group Health Administration Employees Community Fund of Boeing, Puget Sound.
Author affiliation None of the study authors are developers of this model.

Findings details

Child development and school readiness
Rating Outcome measure Effect Sample Timing of follow-up Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes
High MCDI combines two or more words (sometimes/often versus not yet)
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 219 children Mean = 0.93 Mean = 0.89 OR = 1.05 HomeVEE calculated = 0.03 Statistically significant,
p < 0.05
High MCDI use of two-word endings (three or more versus less than three)
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 219 children Mean = 0.55 Mean = 0.55 OR = 1.09 HomeVEE calculated = 0.05 Not statistically significant, p ≥ 0.05
High MCDI vocabulary checklist
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 219 children Mean = 54.40 Mean = 52.30 Mean difference = 4.08 Not available Statistically significant,
p < 0.05
High MCDI word length of child’s 3 longest phrases
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 219 children Mean = 4.29 Mean = 4.57 Mean difference = -0.22 Not available Not statistically significant, p ≥ 0.05
High Child Behavior Checklist: Aggressive behavior subscale
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 children Mean = 8.01 Mean = 7.46 Mean difference = 0.54 Not available Not statistically significant, p ≥ 0.05
High Child Behavior Checklist: Anxious or depressed mood subscale
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 children Mean = 4.12 Mean = 3.71 Mean difference = 0.40 Not available Statistically significant,
p < 0.05
High Child Behavior Checklist: Sleep problems subscale
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 children Mean = 3.35 Mean = 2.88 Mean difference = 0.39 Not available Not statistically significant, p ≥ 0.05
Child health
Rating Outcome measure Effect Sample Timing of follow-up Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes
High 10-month well-child care visit
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 children Mean = 0.94 Mean = 0.93 OR = 1.01 HomeVEE calculated = 0.01 Not statistically significant, p ≥ 0.05
High 15-month well-child care visit
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 children Mean = 0.88 Mean = 0.89 OR = 0.99 HomeVEE calculated = -0.01 Not statistically significant, p ≥ 0.05
High 2-month well-child care visit
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 children Mean = 0.93 Mean = 0.96 OR = 0.97 HomeVEE calculated = -0.02 Not statistically significant, p ≥ 0.05
High 24-month well-child care visit
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 children Mean = 0.87 Mean = 0.76 OR = 1.17 HomeVEE calculated = 0.10 Statistically significant,
p < 0.05
High 4-month well-child care visit
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 children Mean = 0.96 Mean = 0.98 OR = 0.97 HomeVEE calculated = -0.02 Not statistically significant, p ≥ 0.05
High 6-month well-child care visit
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 children Mean = 0.94 Mean = 0.94 OR = 1.01 HomeVEE calculated = 0.01 Not statistically significant, p ≥ 0.05
High Breastfeeding duration (mo.)
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 232 mothers Mean = 13.00 Mean = 13.90 Mean difference = -0.64 Not available Statistically significant,
p < 0.05
High Ever breastfed
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 232 mothers Mean = 0.95 Mean = 0.99 OR = 0.96 HomeVEE calculated = -0.03 Statistically significant,
p < 0.05
High Immunization status up-to-date at 24 mo.
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 children Mean = 0.92 Mean = 0.88 OR = 1.03 HomeVEE calculated = 0.02 Statistically significant,
p < 0.05
Maternal health
Rating Outcome measure Effect Sample Timing of follow-up Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes
High CES-D scale
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 mothers Mean = 4.74 Mean = 3.80 Mean difference = 0.55 Not available Statistically significant,
p < 0.05
High Any illicit drug use in past year
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 mothers Mean = 0.07 Mean = 0.05 OR = 1.02 HomeVEE calculated = 0.01 Not statistically significant, p ≥ 0.05
High Clinically significant depressive symptoms
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 mothers Mean = 0.10 Mean = 0.07 OR = 0.93 HomeVEE calculated = -0.04 Not statistically significant, p ≥ 0.05
Positive parenting practices
Rating Outcome measure Effect Sample Timing of follow-up Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes
High Covers on electrical outlets
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 232 mothers Mean = 0.95 Mean = 0.91 OR = 1.06 HomeVEE calculated = 0.03 Statistically significant,
p < 0.05
High Discipline by ever slapping face or spanking with object
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 232 mothers Mean = 0.01 Mean = 0.03 OR = 0.20 HomeVEE calculated = -0.98 Not statistically significant, p ≥ 0.05
High Environment with tobacco smoke
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 mothers Mean = 0.10 Mean = 0.07 OR = 1.05 HomeVEE calculated = 0.03 Not statistically significant, p ≥ 0.05
High Followed 3 routines, 2 if no nap
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 232 mothers Mean = 0.80 Mean = 0.91 OR = 1.02 HomeVEE calculated = 0.01 Not statistically significant, p ≥ 0.05
High Has access to poison control center telephone number
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 232 mothers Mean = 0.96 Mean = 0.96 OR = 1.01 HomeVEE calculated = 0.01 Not statistically significant, p ≥ 0.05
High Health care self-efficacy
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 mothers Mean = 17.00 Mean = 17.00 Mean difference = -0.14 Not available Not statistically significant, p ≥ 0.05
High Injury prevention index
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 mothers Mean = 4.86 Mean = 4.81 Mean difference = -0.02 Not available Not statistically significant, p ≥ 0.05
High Parenting Behavior Checklist: Nurturing subscale
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 mothers Mean = 58.70 Mean = 60.20 Mean difference = -1.35 Not available Not statistically significant, p ≥ 0.05
High Parenting sense of competence
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 mothers Mean = 47.10 Mean = 47.60 Mean difference = -0.69 Not available Not statistically significant, p ≥ 0.05
High Play with child at least daily
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 232 mothers Mean = 0.97 Mean = 0.99 OR = 0.98 HomeVEE calculated = -0.01 Not statistically significant, p ≥ 0.05
High Read to child at least daily
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 232 mothers Mean = 0.88 Mean = 0.95 OR = 0.92 HomeVEE calculated = -0.05 Statistically significant,
p < 0.05
High Safety latches on cabinets
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 232 mothers Mean = 0.63 Mean = 0.71 OR = 0.87 HomeVEE calculated = -0.08 Statistically significant,
p < 0.05
High Use stair gate
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 232 mothers Mean = 0.32 Mean = 0.34 OR = 0.99 HomeVEE calculated = -0.01 Not statistically significant, p ≥ 0.05
High Watch television more than one hr. per day
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 232 mothers Mean = 0.39 Mean = 0.28 OR = 1.35 HomeVEE calculated = 0.18 Statistically significant,
p < 0.05
Reductions in juvenile delinquency, family violence, and crime
Rating Outcome measure Effect Sample Timing of follow-up Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes
High Domestic violence in past year
FavorableUnfavorable or ambiguousNo Effect
Healthy Steps sample 30 months 239 mothers Mean = 0.03 Mean = 0.01 OR = 2.09 HomeVEE calculated = 0.44 Not statistically significant, p ≥ 0.05

Outcome measure summary

Child development and school readiness
Outcome measure Description of measure Data collection method Properties of measure

CBCL: Anxious or depressed mood subscale

The CBCL is a questionnaire that assesses behavioral problems in young children. The researchers used three subscales, which used aggressive behavior (15 items with a subscale score range of 0 to 30), sleep problems (7 items with a subscale score range of 0 to 14), and symptoms related to an anxious or depressed mood (11 items with a subscale score range of 0 to 22).

Parent/caregiver report

Cronbach’s α = 0.68

CDI word length of child’s three longest phrases

The CDI assesses language development in young children. A questionnaire that included elements of the short and long forms of the CDI evaluated single-word expressive vocabulary, word combining (two words or more), use of three or more word endings, and mean length (in morphemes) of the child’s three longest phrases.

Parent/caregiver report

Not reported by author

CDI use of two-word endings (three or more versus less than three)

The CDI assesses language development in young children. A questionnaire that included elements of the short and long forms of the CDI evaluated single-word expressive vocabulary, word combining (two words or more), use of three or more word endings, and mean length (in morphemes) of the child’s three longest phrases.

Parent/caregiver report

Not reported by author

CDI vocabulary checklist

The CDI assesses language development in young children. A questionnaire that included elements of the short and long forms of the CDI evaluated single-word expressive vocabulary, word combining (two words or more), use of three or more word endings, and mean length (in morphemes) of the child’s three longest phrases.

Parent/caregiver report

Not reported by author

MacArthur CDI combines two or more words (sometimes/often versus not yet)

The CDI assesses language development in young children. A questionnaire that included elements of the short and long forms of the CDI evaluated single-word expressive vocabulary, word combining (two words or more), use of three or more word endings, and mean length (in morphemes) of the child’s three longest phrases.

Parent/caregiver report

Not reported by author

Child health
Outcome measure Description of measure Data collection method Properties of measure

Breastfeeding duration

Number of months the mother breasted her child

Parent/caregiver report

Not applicable

Ever breastfed

Percentage of mothers who had ever breastfed their child

Parent/caregiver report

Not applicable

Immunization status up-to-date at 24 months

Percentage of children who had up-to-date immunizations for their age

Review of the health plan’s standard Health Plan Employer Data and Information Set.

Not applicable

Well-child care visits at 2, 4, 6, 10, 15, 24 months of age.

Percentage of children who had a well-child visit at the reference month of age

Review of health plan records

Not applicable

Maternal health
Outcome measure Description of measure Data collection method Properties of measure

CES-D

A modified14-item version of the CES-D that assesses depressive symptoms. The researchers analyzed the modified total score ranging from 0 to 42 and a binary variable dividing the sample into those that were at or above the clinical cutoff (11) and those below it.

Parent/caregiver report

Cronbach’s α = .83

Any illicit drug use in past year

Percentage of parents who reported using illegal drugs during the past year

Parent/caregiver report

Not applicable

Clinically significant depressive symptoms

A modified14-item version of the CES-D that assesses depressive symptoms. The researchers analyzed the modified total score ranging from 0 to 42 and a binary variable dividing the sample into those that were at or above the clinical cutoff (11) and those below it.

Parent/caregiver report

Not applicable

Positive parenting practices
Outcome measure Description of measure Data collection method Properties of measure

PSOC

A 16-item assessment scored from 16 to 64 that examined parenting self-efficacy and competence

Parent/caregiver report during telephone interview

Cronbach’s α = .79

PBC: Nurturing subscale

The PBC examines how parents raise their child. This outcome is an 18-item subscale of the PBC ranging from 18 to 72.

Parent/caregiver report during telephone interview

Cronbach’s α = .79

Covers on electrical outlets

The proportion of parents who placed covers on electrical outlets in the home

Parent/caregiver report during telephone interview

Not applicable

Disciplined by ever slapping face or spanking with object

The proportion of parents who had ever disciplined their child by slapping them in the face or spanking them with an object

Parent/caregiver report during telephone interview

Not applicable

Environment with tobacco smoke

Percentage of households with current smokers

Parent/caregiver report

Not applicable

Followed three routines (two if no nap)

The proportion of parents who followed at least three routines at mealtime or sleep time

Parent/caregiver report during telephone interview

Not applicable

Has access to poison control center telephone number

The proportion of parents who reported they had access to the poison control center telephone number

Parent/caregiver report during telephone interview

Not applicable

Injury prevention index

A 5-item assessment developed for the study to access injury prevention practices. The assessment is scored by summing binary items for a score of 0 to 5.

Parent/caregiver report during telephone interview

Not reported by author

Played with child at least daily

The proportion of parents who played with their child at least once daily

Parent/caregiver report during telephone interview

Not applicable

Read to child at least daily

The proportion of parents who read to their child at least once daily

Parent/caregiver report during telephone interview

Not applicable

Safety latches on cabinets

The proportion of parents who placed safety latches on cabinets in the home

Parent/caregiver report during telephone interview

Not applicable

Uses stair gate

The proportion of parents who used a stair gate in the home

Parent/caregiver report during telephone interview

Not applicable

Watched television more than one hour per day

The proportion of parents whose children watched television for more than one hour per day

Parent/caregiver report during telephone interview

Not applicable

Reductions in juvenile delinquency, family violence, and crime
Outcome measure Description of measure Data collection method Properties of measure

Domestic violence in past year

The presence or absence of significant physical domestic violence in the preceding 12 months

Parent/caregiver report

Not applicable