Minkovitz Cynthia S, Hughart Nancy, Strobino Donna, Scharfstein Dan, Grason Holly, Hou William, Miller Tess, Bishai David, Augustyn Marilyn, McLearn Kathryn Taaffe, Guyer Bernard
Department of Population and Family Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md 21205, USA.
JAMA. 2003 Dec 17;290(23):3081-91. doi: 10.1001/jama.290.23.3081.
There is growing concern regarding the quality of health care available in the United States for young children, and specific limitations have been noted in developmental and behavioral services provided for children in the first 3 years of life.
To determine the impact of the Healthy Steps for Young Children Program on quality of early childhood health care and parenting practices.
DESIGN, SETTING, AND PARTICIPANTS: Prospective controlled clinical trial enrolling participants between September 1996 and November 1998 at 6 randomization and 9 quasi-experimental sites across the United States. Participants were 5565 children enrolled at birth and followed up through age 3 years.
Incorporation of developmental specialists and enhanced developmental services into pediatric care in participants' first 3 years of life.
Quality of care was operationalized across 4 domains: effectiveness (eg, families received > or =4 Healthy Steps-related services or discussed >6 anticipatory guidance topics), patient-centeredness (eg, families were satisfied with care provided), timeliness (eg, children received timely well-child visits and vaccinations), and efficiency (eg, families remained at the practice for > or =20 months). Parenting outcomes included response to child misbehavior (eg, use of severe discipline) and practices to promote child development and safety (eg, mothers at risk for depression discussed their sadness with someone at the practice).
Of the 5565 enrolled families, 3737 (67.2%) responded to an interview at 30 to 33 months (usual care, 1716 families; Healthy Steps, 2021 families). Families who participated in the Healthy Steps Program had greater odds of receiving 4 or more Healthy Steps-related services (for randomization and quasi-experimental sites, respectively: odds ratio [OR], 16.90 [95% confidence interval [CI], 12.78 to 22.34] and OR, 23.05 [95% CI, 17.38 to 30.58]), of discussing more than 6 anticipatory guidance topics (OR, 8.56 [95% CI, 6.47 to 11.32] and OR, 12.31 [95% CI, 9.35 to 16.19]), of being highly satisfied with care provided (eg, someone in the practice went out of the way for them) (OR, 2.06 [95% CI, 1.64 to 2.58] and OR, 2.11 [95% CI, 1.72 to 2.59]), of receiving timely well-child visits and vaccinations (eg, age-appropriate 1-month visit) (OR, 1.98 [95% CI, 1.08 to 3.62] and OR, 2.11 [95% CI, 1.16 to 3.85]), and of remaining at the practice for 20 months or longer (OR, 2.02 [95% CI, 1.61 to 2.55] and OR, 1.75 [95% CI, 1.43 to 2.15]). They also had reduced odds of using severe discipline (eg, slapping in face or spanking with object) (OR, 0.82 [95% CI, 0.54 to 1.26] and OR, 0.67 [95% CI, 0.46 to 0.97]). Among mothers considered at risk for depression, those who participated in the Healthy Steps Program had greater odds of discussing their sadness with someone at the practice (OR, 0.95 [95% CI, 0.56 to 1.63] and OR, 2.82 [95% CI, 1.57 to 5.08]).
Universal, practice-based interventions can enhance quality of care for families of young children and can improve selected parenting practices.
美国幼儿可获得的医疗保健质量日益受到关注，且已注意到为3岁以下儿童提供的发育和行为服务存在特定限制。
确定“幼儿健康起步计划”对幼儿期医疗保健质量和育儿实践的影响。
设计、地点和参与者：1996年9月至1998年11月期间，在美国6个随机化地点和9个准实验地点进行的前瞻性对照临床试验。参与者为5565名出生时登记入组并随访至3岁的儿童。
在参与者生命的前3年，将发育专家和强化发育服务纳入儿科护理。
护理质量在4个领域进行衡量：有效性（例如，家庭接受≥4项与健康起步相关的服务或讨论>6个预期指导主题）、以患者为中心（例如，家庭对所提供的护理感到满意）、及时性（例如，儿童及时接受健康儿童检查和疫苗接种）和效率（例如，家庭在该医疗机构就诊≥20个月）。育儿结局包括对儿童不当行为的反应（例如，使用严厉的管教方式）以及促进儿童发育和安全的实践（例如，有抑郁症风险的母亲与医疗机构中的某人讨论她们的悲伤情绪）。
在5565个登记家庭中，3737个（67.2%）在30至33个月时接受了访谈（常规护理组1716个家庭；健康起步组2021个家庭）。参与健康起步计划的家庭接受4项或更多与健康起步相关服务（随机化地点和准实验地点的比值比[OR]分别为：16.90[95%置信区间[CI]，12.78至22.34]和OR，23.05[95%CI，17.38至30.58]）、讨论超过6个预期指导主题（OR，8.56[95%CI，6.47至11.32]和OR，12.31[95%CI，9.35至16.19]）、对所提供的护理高度满意（例如，医疗机构中的某人特意为他们提供帮助）（OR，2.06[95%CI，1.64至2.58]和OR，2.11[95%CI，1.72至2.59]）、及时接受健康儿童检查和疫苗接种（例如，适龄儿童1个月时的检查）（OR，1.98[95%CI，1.08至3.62]和OR，2.11[95%CI，1.16至3.85]）以及在该医疗机构就诊20个月或更长时间（OR，2.02[95%CI，1.61至2.55]和OR，1.75[95%CI，1.43至2.15]）的几率更高。他们使用严厉管教方式（例如，打耳光或用物体打屁股）的几率也更低（OR，0.82[95%CI，0.54至1.26]和OR，0.67[95%CI，0.46至0.97]）。在被认为有抑郁症风险的母亲中，参与健康起步计划的母亲与医疗机构中的某人讨论她们悲伤情绪的几率更高（OR，0.95[95%CI，0.56至1.63]和OR，2.82[95%CI，1.57至5.08]）。
基于医疗机构的普遍干预措施可以提高幼儿家庭的护理质量，并改善某些育儿实践。
