Learning From Experience: Evaluating Early Childhood Demonstration Programs (1982) / Chapter Skim
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The Health Impact of Early Childhood Programs: Perspectives from the Brookline Early Education Project
The Health Impact of Early Childhood Programs: Perspectives from the Brookline Early Education Project
Pages 57-108
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From page 57... ...
Accurate numbers, however, are difficult to obtain and are often misleading. In this paper we outline some salient clinical and methodological issues that have become apparent to us in working at the Brookline Early Education Project analyzing the health impact of a comprehensive early childhood project.
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From page 58... ...
Describing Health Status Characterizing the health status of groups of children is even more difficult than characterizing individual health. Since universally acceptable scoring and weighting systems do not exist, the health evaluation of a cohort enrolled in an early childhood project can be costly to obtain and difficult to interpret.
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, and accounts of medical service utilization. Describing Health Change After defining the limits of health as a subject matter and developing the descriptors to characterize group health status, evaluators must find measures of health change.
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have demonstrated that children who have "behavior problems" at age two or three may not be the same children who have difficulty in school. It may be impossible to identify precise endpoints of health change.
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Evaluators of adult health programs may be able to measure the impact of a program on these distinct entities and thereby generalize about health status and program-induced change. In contrast, there is no single chronic organic condition of childhood common enough to scrutinize in such a fashion without a very large sample.
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In many instances this requires the use of comparison groups or control populations. Selecting Outcome Measures In documenting program effects on health, one critical issue is the precise outcomes to be measured at designated outcome points.
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From page 63... ...
One challenge for those evaluating early childhood projects is the identification of measures that can be used to provide an in-depth assessment of function to determine whether the program has diminished or minimized the effects of so-called low-severity, high-prevalence dysfunctions of childhood, which include specific learning disabilities, primary attention deficits, and various forms of psychosocial maladaptation during the school years. In delineating outcome measures, evaluators should consider the objectives of the project under scrutiny.
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In some cases a project may want to evaluate only specific target groups to demonstrate program effects. When an evaluation becomes this focused, however, either large numbers or elegant small sample designs are needed to demonstrate that intervention has been successful.
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Findings inevitably reflect the timing of an evaluation, and the implications can be -treat, especially for issues of cost-effectiveness Because of the instability of health conditions in childhood and the high degree of resiliency, the timing of evaluations significantly influences the attribution of program effects, which can be misleading from a public policy viewpoint. For example, if children in a particular program have less difficulty adjusting to the first weeks of kindergarten than nonparticipants, evaluators may feel that they have documented a measurable effect.
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From page 66... ...
Outcome measures can then be timed to assess these accordingly. Having delineated these issues for the evaluation of program effects on health, we now turn to a more detailed examination of the measurement of health status.
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From page 67... ...
On the other hand, outcome measures for a normally hearing child from a socioeconomically depressed and disorganized home might be assurance of primary health care, money for food, and an adequate after-school, supervised program. Because the health needs of children are so varied, programmers, monitors, and policy makers should keep
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Some entering an early childhood project need little more than routine preventive health care. Others, because of early negative factors, need problem-focused surveillance, while still others demand active intervention.
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can be used as a targeted index of a given program's total performance. A major problem with the literature on the relationship between perinatal trauma and later life has been the lack of uniform outcome measures.
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For this group, targeted outcome measures are appropriate (Tjossem, 1976)
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. Head Start and other early childhood programs have incorporated health components specifically for this reason (Richmond, 1966)
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From page 72... ...
Similarly in development, a child may not walk until 18 months of age but then progress normally or may walk late, talk late, and be cognitively delayed. In the Brookline Early Education Project, among a "community" of nearly 300 children, the importance of trends was underscored by an analysis of risk status during the first six months of life.
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From page 73... ...
As programs are analyzed, trends must be kept in mind. The health and developmental factors that should be followed carefully over time include health status, sensory abilities, temperament and behavior, and developmental performance.
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From page 74... ...
, which evaluators of early childhood projects might want to use as a conceptual "graduate health profile." In dealing with early diagnosis and intervention, it is essential that project planners and evaluators be fully aware of the negative outcomes likely to occur during the school years and whose effects the early projects are intended to minimize. In planning service and evaluation in an early childhood project, it is therefore helpful to identify those children who appear to be at risk for such disorders (Oberklaid and Levine, 1980)
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3. Chronic Illness and Symptoms Chronic illness affects childhood performance in multiple ways -- not the least of them being the loss of school days.
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From page 76... ...
With regard to health outcomes then, evaluations of early childhood programs should involve background characteristics of the population (e.g., premature versus term babies, child abuse versus normal environment) ; the evaluators should analyze the program variables as well as health and developmental trends; and finally, they should consider which of the 10 health outcomes their program was best suited to address; the evaluators can then move on to pose specific evaluation questions.
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Some of the questions are likely to apply universally to early childhood programs, while others would be relevant only in a program that had targeted a specific health outcome. (See Table 2.)
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? One possible outcome measure entails "documentation of engagement in a primary care source." Our experience at the Brookline Early Education Project (where 97 percent of families have maintained such a source)
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2. Hearing A series of international conferences have recommended periodic screening of children for hearing loss (Joint Committee on Infant Hearing Screening, 1971, 1972)
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In addition, anemia is a marker of other nutritional needs. In early childhood programs, screening for anemia can serve as a possible indicator of poor health status or of family needs for nutrition education (Folman, 1977)
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have indicated that the level of immunization within a community can be greatly enhanced by close and tenacious monitoring at either the clinic or the school level. Physical Examination Completion of periodic physical examinations can serve as an outcome measure related to child health practices for a given program.
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However, with the Early and Periodic Screening, Diagnosis, and Treatment Program (Frankenburg and North, 1974) , the Education for All Handicapped Children Act (Palfrey et al., 1978)
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Prevention Early childhood programs may be able to demonstrate prevention in a number of important areas, including health care neglect, child abuse and neglect, accidents, and malnutrition. These are primarily areas in which family involvement is needed and in which a clear goal must be set in order to identify effects.
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From page 85... ...
The seven systems described below are based on our own experience in planning and implementing an evaluation for the Brookline Early Education Project. Comparison Studies In health-related studies of outcome that use a comparison group, statistically significant differences should emerge when one compares a treatment with a nontreatment group.
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Or is it likely These issues are critical to the design of such evaluations. Once they are dealt with, one can proceed with the selection of the precise outcome measures desired.
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In the Brookline Early Education Project, it was necessary to develop clusters of morbidity so that ~ For they could he measurable in sufficient quantity. example, among the 300 children studied, there were not enough premature infants or infants born with jaundice.
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A careful account of what has occurred in a project can in itself serve as one dimension of evaluation. Early in the history of the Brookline Early Education Project we were asked a key question of interest to public policy makers: "What are you finding, and what are you doing about it?
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From page 89... ...
The Longitudinal Study of Findings as used in the Brookline Early Education Project was a useful method of auditing program documentation; it has, however, like other methods, had some shortcomings. First, the study .
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From page 90... ...
The necessity and/or time requirements for a nurse or physician may depend on the yield of medical findings in a particular project, although this will vary from site to site. The Longitudinal Study of Findings can help answer one question that is particularly germane: What would have happened to this group of children if the program did not exist?
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From page 91... ...
It is not sufficient to describe programs and changes: Convincing arguments should be made that the changes related causally to program effects and that the particular findings related in the case were unlikely to be self-limited or transient. A case argument study should try to prove the fact that alternative services in the community could not deal as well with this particular child's health issues.
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As part of standardized interviews, parents can be asked about their overall levels of satisfaction with the health aspects of an early education project. Listed below are examples of useful questions: · Did you feel that the doctors (or nurses)
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In the Brookline Early Education Project we undertook a process study of local pediatricians to determine the impact of the project's early-school health services on the practicing community (Hanson and Levine, 1980)
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The assumption underlying the selection of tracers is that they somehow typify the overall health status of a child. Sometimes there can be an inherent circularity in this, particularly when the objectives are too close to the tracer.
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As indicated in the table, a given prototype may be appropriate for one question or one project but not for another. For instance, when we wanted to know the prevalence of hearing defects, an outcome study with or without a comparison group and a longitudinal study of findings were both appropriate, while case arguments, process studies, and tracer studies were not.
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From page 97... ...
The scope of child health is very wide, and evaluators of early childhood programs should plan carefully before they launch a health evaluation, defining the variables they want to use (particularly background and outcome) , the questions they want to answer, and then select the one or two evaluation prototypes that are most likely to yield answers.
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(1975) A review of the research on general health status indices.
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Progress Toward a Free, Appropriate Public Education. A Report to Congress on the Implementation of Public Law 94-142: The Education for All Handicapped Children Act.
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(1972) From Birth to Seven: The Second Report of the National Child Development Study.
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Journal of School Health 50:577-580. Harvard Child Health Project Task Force (1977)
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Joint Committee on Infant Hearing Screening (1971) Joint committee statement on infant hearing screening.
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(1974) Health care of poor children.
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(1978) A Guide to Early Childhood Developmental Screening.
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(1974) The Brooklyn Early Education Project: model for a new education priority.
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(1973) Visuo-motor skills and reading ability: a longitudinal study.
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Gains. Abridged version of Project Report 76-21 prepared for the Office of Child Development, U.S.
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(1979) Parent Support and Education: An Analysis of the Brookline Early Education Project.
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