***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To prospect ively evaluate the impact of parental satisfaction on  childhood immunization  and the mediating role of age-appropriate well-child care . DESIGN Secondary analyses of cohort data from the National Evaluation of Healthy Steps for Young Children . Data sources included an enrollment question naire , parent interview at 2 to 4 months , and medical records . SETTING Twenty-four pediatric practice s across the United States . PARTICIPANTS A total of 4896 ( 85 % ) of the initial 5565 enrolled families who were interviewed at 2 to 4 months and had abstract ed medical records . MAIN EXPOSURE Parental satisfaction with overall pediatric care assessed at 2 to 4 months as excellent , good , or fair/poor . MAIN OUTCOME MEASURES Age-appropriate first dose of diphtheria-tetanus-pertussis ; third dose of diphtheria-tetanus-pertussis ; and measles , mumps , and rubella vaccinations ;  and up-to- date vaccinations  at 24 months ( 4 diphtheria-tetanus-pertussis , 3 polio , and 1 measles , mumps , and rubella ) . RESULTS The majority of parents were satisfied with their child 's health care ; only 4 % rated overall care as fair or poor . Children whose parents reported fair/poor satisfaction with care had a reduced odds of receiving age-appropriate first dose of diphtheria-tetanus-pertussis vaccination  ( odds ratio , 0.43 ; 95 % confidence interval , 0.28 - 0.67 ) ; third dose of diphtheria-tetanus-pertussis vaccination  ( odds ratio , 0.52 ; 95 % confidence interval , 0.36 - 0.74 ) ; and measles , mumps , and rubella vaccination  ( odds ratio , 0.58 ; 95 % confidence interval , 0.37 - 0.92 ) ; and of being up to date by 24 months ( odds ratio , 0.65 ; 95 % confidence interval , 0.43 - 0.99 ) compared with children whose parents reported excellent care , independent of sociodemographic and maternal health care utilization variables . The negative effect of fair/poor satisfaction on immunization was largely explained by reduced utilization of age-appropriate well-child care . CONCLUSION Quality assurance activities that assess parental satisfaction with care may have added value in identifying children who are less likely to receive timely preventive services BACKGROUND Healthy Steps ( HS ) was design ed to address , prospect ively , behavioral and developmental support needs of young families in pediatric clinical care setting s.  PrePare ( PP ) initiates these services prenatally , whereas HS begins services in the postnatal period . Both interventions have universal and risk-directed components . Intervention effects in the first 3 months after birth are reported here . METHODS A quasi-experimental design was used to allocate 439 participants to intervention or usual care conditions . Within the intervention group , enrollees were r and omly assigned to receive HS or PP+HS services . Early outcomes were assessed by telephone survey at 1 week and 3 months postpartum . RESULTS Mothers in either intervention condition were less likely to report depressive symptoms and more likely to describe themselves as pleased in their role as parents . Intervention families were more likely to continue breastfeeding and more likely to read to their 3-month-old . Knowledge of infant development and recognition of appropriate discipline was greater among intervention recipients . Satisfaction with pediatric care was higher among intervention recipients and the rate of health plan disenrollment was 75 % lower at 3 months among those enrolled in the prenatal intervention . No other outcome difference emerged between HS and PP+HS enrollees . CONCLUSIONS Receipt of either intervention was associated with positive effects on health , safety , and developmentally appropriate parenting , as assessed in early infancy . There were positive effects on health plan disenrollment . No additional benefit could be ascribed to prenatal institution of services . A combination of universal and risk-based support for new parents is recommended , rather than the provision of risk-based services alone The efficacy of two contrasting short term preventative interventions administered to a heterogeneous sample of new mothers during the perinatal period was evaluated . The first was infant-centered and used the Brazelton Neonatal Behavioral Assessment Scale ( NBAS ) as a method of highlighting newborn behavior to new mothers . The second was mother-centered and consisted of an in-depth interview focused on the mothers ' concerns about parenting . Mothers were r and omized into groups and were administered intervention by experienced clinicians at 3 days in the hospital and again at 14 and 30 days at home . Effects of intervention on maternal reports of parenting stress , mother-infant interactive behavior , and infant developmental quotient were evaluated at 4 months infant age . It was hypothesized that participation in the infant-centered intervention would be related to more positive maternal and infant outcomes at 4 months . It was also expected that the impact of each intervention would be moderated by differences in maternal and infant risk and parity . Hierarchical multiple regressions controlling for risk and parity yielded no significant main effects of intervention at 4 months . However , significant interactions of intervention with parity and risk were observed , indicating that intervention was beneficial for specific groups of mothers . These data suggest that early intervention should be tailored to the needs of individual groups of mothers . J Dev Behav Pediatr 16:158–166 , 1995 . Index terms : parent-infant intervention , Brazelton Neonatal Behavior Assessment Scale , intrauterine growth retardation , parenting stress , mother-infant interaction Persistent unmet preventive and developmental health care needs of children in low-income families are a national concern . Recently , there have been efforts to promote developmental services as part of primary care for all young children . However , there is limited research to determine whether the neediest families are well in universal interventions . In our study , we assessed if disparities persist in utilization of developmental services , well child care , and satisfaction with care among low- , middle- , and high-income families participating in Healthy Steps for Young Children . Healthy Steps is a national experiment that incorporated developmental services into primary care for children from birth to 3 years of age . In the United States , 15 pediatric practice s participated in this prospect i ve study . At birth , 2,963 children were enrolled between September 1996 and November 1998 and followed through 33 months of age . The utilization of developmental services , satisfaction with care , and receipt of age-appropriate well child visits were measured at 30–33 months and adjusted for demographic and economic covariates . We found that the adjusted odds of low-income families did not differ from high-income families in receipt of four or more  Healthy Steps services  , a home visit , or discussing five or more child rearing topics . Low- and middle-income families had reduced adjusted odds of receiving a developmental assessment and books to read . The adjusted odds of low- and middle-income families did not differ from high-income families in being very satisfied with care provided or receiving age-appropriate well child visits . A universal practice -based intervention such as Healthy Steps has the potential to reduce income disparities in the utilization of preventive services , timely well child care , and satisfaction with care OBJECTIVE To investigate how introducing  early child-development specialists ( Healthy Steps Specialists ) and enhanced developmental services into routine pediatric care affects perspectives of clinicians and staff . METHODS Self-administered question naires were completed at baseline and at 30 months by clinicians , clinical staff , and non clinical staff at pediatric sites participating in the evaluation of the Healthy Steps for Young Children Program . The evaluation included 6 r and omization and 9 quasi-experimental sites .  Barriers to providing well-child care , visit length , perceptions of care provided , and topics discussed with parents were assessed . RESULTS Over time , despite persistent barriers to delivering high- quality services , clinicians were more likely to report being satisfied with their clinical staff 's ability to meet developmental and behavioral needs of children . Moreover , clinicians were more likely to report discussing the importance of routines with control rather than with intervention families , suggesting a reliance on Healthy Steps Specialists . There was no effect on visit length . Thirty months after introducing Healthy Steps Specialists and enhanced services , nearly all clinicians agreed or strongly agreed that the  Healthy Steps Specialists talked with parents about their child 's development , showed them activities to do with their child , and provided emotional support . Involvement of the Healthy Steps Specialist in these activities was reported more by clinicians than by clinical staff and least by non clinical staff . CONCLUSIONS Clinicians acknowledged the activities performed by and contributions of the developmental specialists . Differences in perspectives of personnel may reflect different interactions among families , developmental specialists , and practice staff BACKGROUND Healthy Steps ( HS ) for Young Children strengthens the healthcare system as a source of developmental and behavioral support for parents . This series of papers presents a study of HS as implemented within a large health maintenance organization that tested the benefit of beginning intervention services during pregnancy with an extension program called " PrePare " ( PP ) . METHODS The design was a quasi-experimental comparison of intervention families with families receiving usual care .  Within the intervention , families were assigned r and omly to begin receiving Healthy Steps services prenatally ( PP+HS ) or shortly after birth ( HS ) . We used a systems model , PRECEDE/PROCEED , for planning , implementation , and process evaluation . Outcomes examined when the infants were aged 3 months included changes in family social support and capacity for parenting , parenting behaviors , and satisfaction and loyalty to the health plan . RESULTS The sample of 439 families was distributed as follows : usual care ( n=136 ) , prenatal initiation of services ( PP+HS ; n=151 ) , and postnatal Healthy Steps ( HS ; n=152 ) . Information about program implementation , including provider satisfaction , is provided for the early phases of the study ( through age 3 months ) . The intervention was delivered with fidelity and with minimal disruption to the practice styles of pregnancy providers , most of whom considered the program valuable to their patients . Relative to families in the comparison group , families in the intervention group received more  usual care services  and more  intervention-specific services .  CONCLUSIONS The pregnancy and newborn phases of the intervention were embedded successfully within the existing healthcare delivery system . The program was considered valuable for parents by providers and parents . Participating families received more services and a greater variety of services than families in usual care . Whether these differences result in beneficial outcomes for families or the health plan are topics of the subsequent papers OBJECTIVE The Healthy Steps for Young Children Program ( HS ) incorporates early child development specialists and enhanced developmental services into routine pediatric care . An evaluation of HS is being conducted at 6 r and omization and 9 quasi-experimental sites .  Services received , satisfaction with services , and parent practice s were assessed when infants were aged 2 to 4 months . METHODS Telephone interviews with mothers were conducted for 2631 intervention ( response rate , 89 % ) and 2265 control ( response rate , 87 % ) families . Analyses were conducted separately for r and omization and quasi-experimental sites and adjusted for baseline differences between intervention and control groups . Hierarchical linear models assessed overall adjusted effects , while accounting for within-site correlation of outcomes . RESULTS Intervention families were considerably more likely than controls to report receiving 4 or more developmental services and home visits and discussing 5 infant development topics . They also were more likely to be satisfied and less likely to be dissatisfied with care from their pediatric provider and were less likely to place babies in the prone sleep position or feed them water . The program did not affect breastfeeding continuation . Differences in the percentage of parents who showed picture books to their infants , fed them cereal , followed routines , and played with them daily were found only at the quasi-experimental sites and may reflect factors unrelated to HS . CONCLUSIONS Intervention families received more  developmental services  during the first 2 to 4 months of their child 's life and were happier with care received than were control families . Future surveys and medical record review s will address whether these findings persist and translate into improved language development , better utilization of well-child care , and an effect on costs Background . Begun in 1996 , the Healthy Steps for Young Children Program ( HS ) is a new model of pediatric practice that incorporates child development specialists and enhanced developmental services for families of young children . HS is for all families , not just those at high-risk . It is expected to strengthen parents ' knowledge , attitudes , and behaviors in ways that promote child health and development , and in turn , to lead to improved child outcomes , such as improved language development , increased utilization of well child care , and decreased problem behaviors , hospitalizations , and injuries . The HS evaluation is design ed to assess whether HS is successful in achieving the desired outcomes , measure the program 's costs , and determine the relation of the program 's costs to its outcomes . Objective . This article is the first report of the HS evaluation . It describes the evaluation design and characteristics of the HS sites and sample for the evaluation . Methods . The evaluation is following a cohort of children from birth to age 3 at 15 evaluation sites across the country . The sites represent a range of organizational practice setting s that include group practice s , hospital-based clinics , and health maintenance organization pediatric clinics . The evaluation design relies on 2 comparison strategies . At 6 r and omization design sites , 400 children were r and omized to the intervention or control group . At 9 quasi-experimental design sites , a comparison location with a similar organizational setting and patient profile has been selected and up to 200 children are being followed at each of these sites . At each site , 2 developmental specialists ( or their full-time equivalents ) work as a team with 4 to 8 pediatricians and pediatric nurse practitioners . The specialist conducts office visits ( jointly or sequentially with the pediatric clin 
    Output:
    
Results indicated that the Healthy Steps program has been rigorously evaluated and shown to be effective in preventing negative child and parent outcomes and enhancing positive outcomes .
Despite limited information concerning cost effectiveness , the Healthy Steps Program provides clear benefit through early screening , family-centered care , and evidence -based anticipatory guidance .