Abstract
Difficulties with providing quality primary health care for low-income Americans have been well documented. Few studies have addressed the challenges faced by pediatric clinicians serving low-income families or whether practice-based interventions improve clinicians’ ability to provide quality preventive health services. We investigated if, over time, the Healthy Steps for Young Children program affected the practices and perceptions of clinicians in pediatric primary care practices serving low-income families compared to practices serving more affluent families. Self-administered questionnaires were completed at baseline (N=104) and at 30 months (N=91) by clinicians at 20 pediatric practices participating in the Healthy Steps program. Practices were divided into three groups: those serving families with low, middle, and high incomes. Barriers to providing care, provision of preventive developmental services, and perceptions of care were assessed at baseline and at 30 months after introducing the program. Across all income groups and over time, clinicians were more likely to report the provision of preventive developmental health services. Clinicians in low-income practices reported increased problems with both reimbursement and time barriers; clinicians in high-income practices reported increased problems with reim-bursement. At 30 months, clinicians serving low-income families reported the greatest positive changes in their perceptions about the quality of care provided by their practices. They also were more likely to strongly agree that they gave support to families and to be very satisfied with the ability of their clinical staff to meet the developmental needs of children. We found that Healthy Steps was successful in universally increasing developmental services despite the reported practice barriers for both low- and high-income practices. The Healthy Steps program enabled low-income practices to achieve similar levels of clinician satisfaction as middle- and high-income practices despite having reported lower levels at the beginning months of the program.
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References
Tippets E, Westpheling K. The Health Promotion-Disease Prevention Project: effect on medical students’ attitudes toward practice in medically underserved areas. Fam Med. 1996;28:467–471.
Minkovitz C, Mathew MB, Strobino D. Have professional recommendations and consumer demand altered pediatric practice regarding child development? J Urban Health. 1998;75:739–750.
Rabinowitz HK, Diamond JJ, Veloski J, Gayle JA. The impact of multiple predictors on generalist physicians’ care of underserved populations. Am J Public Health. 2000;90:1225–1228.
Halfon N, Hochstein M, Sareen H, O’Connor KG, Inkelas M, Olson LM, Barriers to the provision of developmental assessments during pediatric health supervision. Platform Session. Presentation at Pediatric Academic Societies annual meeting, Baltimore, MD; May, 2000. Available at: http://www.aap.org/research/periodicsurvey.
Lara M, Allen F, Lange L. Physician perceptions of barriers to care for inner-city Latino children with asthma. J Health Care Poor Underserved. 1999;10:27–44.
Komaromy M, Lurie N, Bindman AB. California physicians’ willingness to care for the poor. West J Med. 1995;162:127–132.
Li LB, Williams SD, Scammon DL. Practicing with the urban underserved: a qualitative analysis of motivations, incentives, and disincentives. Arch Fam Med. 1995;4:124–133.
Sareen H, Hochstein M, Olson L, O’Connor K, Inkelas M, Halfon N. Disparities in referral patterns by physicians providing well child care: determinants of access to community developmental and psychosocial resources. Poster Symposium. Presentation at Pediatric Academic Societies annual meeting, Baltimore, MD; May, 2000. Available at: http://www.aap.org/research/periodicsurvey.
Larme AC, Pugh JA. Evidence-based guidelines meet the real world: the case of diabetes care. Diabetes Care. 2001;24:1728–1733.
Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458–1465.
Eliason BC, Guse C, Gottlieb MS. Personal values of family physicians, practice satisfaction, and service to the underserved. Arch Fam Med. 2000;9:228–232.
DeVoe J, Fryer GE, Hargraves L, Phillips RL, Green LA. Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care? J Fam Pract. 2002;51:223–228
Green M, Palfrey JS, editors. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health; 2002.
Minkovitz C, Strobino D, Hughart N, Scharfstein D, Guyer B, the Healthy Steps Evaluation Team. Early effects of the Healthy Steps for Young Children Program. Arch Pediatr Adolesc Med. 2001;155:470–479.
American Academy of Pediatrics. Guidelines for Health Supervision III. Elk Grove Village, IL: American Academy of Pediatrics; 1997.
Lawrence P, Magee T, Bernard A. Reshaping primary care: the Healthy Steps Initiative. J Pediatr Health Care. 2001;15:58–62.
McLearn KT, Zuckerman B, Parker S, Yellowitz M, Kaplan-Sanoff M. Child development and pediatrics for the 21st century: the Healthy Steps approach. J Urban Health. 1998;75:704–722.
Guyer B, Hughart N, Strobino D, Jones A, Scharfstein D, the Healthy Steps Evaluation Team. Assessing the impact of pediatric-based developmental services on infants, families, and clinicians: challenges to evaluating the Healthy Steps Program. Pediatrics [serial online] 2000;105:e33. Available at: http://www.pediatrics.org/cgi/content/abstract/105/3/e33. Accessed September 24, 2003.
Kaplan-Sanoff M, Zuckerman B, Parker S, et al. Healthy Steps Strategies for Change: Child Development in Primary Care for Young Children. Boston, MA: Department of Pediatrics, Boston University School of Medicine; 1999.
Diggle P, Liang K, Zeger SL. Analysis of Longitudinal Data New York: Oxford University Press; 1994.
Minkovitz CS, Hughart N, Strobino D, et al. A practice-based intervention to enhance quality of care in the first 3 years of life: The Healthy Steps for Young Children Program. JAMA. 2003;290:3081–3091.
Minkovitz CS, Strobino D, Hughart N, et al. Developmental specialists in pediatric practices: perspectives of clinicians and staff. Forthcoming, Ambul Pediatr. 2003;3:295–306.
Buchbinder SB, Wilson M, Melick CF, Powe NR. Primary care physician job satisfaction and turnover. Am J Manag Care. 2001;7:701–713.
Solberg LI, Brekke ML, Kottke TE. How important are clinician and nurse attitudes to the delivery of clinical preventive services. J Family Pract. 1997;44:451–461.
Montano DE, Phillips WR. Cancer screening by primary care physicians: a comparison of rates obtained from physician self-report, patient survey and chart audits. Am J Public Health, 1995;85:795–800.
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The Healthy Steps for Young Children Program is a program of the Commonwealth Fund, local funders, and health care providers across the nation. It is cosponsored by the American Academy of Pediatrics. Funding for the Healthy Steps National Evaluation is being provided by the Commonwealth Fund, the Robert Wood Johnson Foundation, the Atlantic Philanthropic Foundation, and local funders. The views presented here are those of the authors and not necessarily those of the funders, their directors, officers, or staff.
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McLearn, K.T., Strobino, D.M., Hughart, N. et al. Developmental services in primary care for low-income children: Clinicians’ perceptions of the healthy steps for young children program. J Urban Health 81, 206–221 (2004). https://doi.org/10.1093/jurban/jth108
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DOI: https://doi.org/10.1093/jurban/jth108