ABSTRACT. A 72-hour training program for workersin child care programs (day care and Head Start) on advo cacy for health and safety was designed, implemented, and evaluated in the Southeast Region of Pennsylvania. From 142 day care sites that were involved in the study, 117 trainees were enrolled in groups of approximately 20 trainees over a two-year period. Overall attendance av eraged 88%. Trainee satisfaction with individual sessions varied from 96% to 76%. Ninety-two percent of enrolled trainees completed the course. Most completed four out of the five course assignments. A pretest and posttest of health knowledge showed significant gain in all areas covered by the training; this knowledge was retained in a follow-up test seven months after the completion of training. Changes in desired opinions related to health advocacy were limited to an increase in the number who agreed that health issues can be grasped by individuals who are not health professionals. Pretraining assessment of program compliance with accepted health and safety standards revealed widespread need for improvement. Participation in the evaluation aspect of the study alone was associated with improved compliance of programs with health and safety standards, but in a number of health and safety aspects of the program, participation in training was associated with greater improvements in compliance than evaluation alone. This finding suggests a benefit to be derived from both monitoring and training provided for health and safety aspects of child care pro grams. Changes in compliance by programs were associ ated with increased involvement of the trained advocate in health and safety activities in the program. This greater involvement was manifested by the advocates as an in crease in the combination of advocating and performing of activities and a decrease in only performing. Pediatrics 65:318—325, 1980; health advocate, child day care, health
training, health and safety evaluation.
The training program described in this paper was designed to help child care staff improve the health
Received for publication May 10, 1978; accepted Dec 3, 1978. Reprint requests to (S.S.A.) Health Service Plan of Pennsylva nia, 2010 West Chester Pike, Havertown, PA 19083.
I@EDIATRICS (ISSN 0031 4005). Copyright ©1980 by the American Academy of Pediatrics.
and safety aspects of their programs. The training program was based on the concept of advocacy. Rather than aiming to produce paraprofessional health workers or health coordinators, the program sought to train workers with a variety of roles in child care programs to be advocates for health promotion at their job sites in conjunction with their other job responsibilities. According to this model, the health advocate in a child care program is a person who increases the awareness of fellow workers, clients, and health service providers in the community about the potential of the child care program for promoting health and the need for change to fulfill this potential. This model also holds that the advocate is not the only person who implements change, but rather is the one responsi ble for seeing to it that changes are made by other staff members, by parents, and, when appropriate, by other programs in the community.
According to a 1976 US Bureau of Census report, nearly 3 million children between the ages of 3 and 13 are regularly cared for outside their own homes in day care centers (center day care) and in homes of caregivers (family day care). Recent studies of health and safety practices in such programs, re viewed by Aronson and Pizzo,' reveal widespread lack of compliance with current health and safety standards for child care programs. Although this noncompliance might be remedied by training in health and safety for program staff, no coordinated training curriculum for this purpose was available prior to the work reported in this paper.
LACK OF COMPLIANCE WITH CURRENT STANDARDS
Several authoritative groups have developed health and safety standards and recommendations for child care programs. These standards, which emphasize avoidance of known hazards and detec
Compliance of Child Care Programs with
Health and Safety Standards: Impact of
Program Evaluation and Advocate Training
Susan S. Aronson, MD, FAAP, and Leona S. Aiken, PhD
From the Departments of Community and Preventive Medicine and Pediatrics, The
Medical College of Pennsylvania, and the Department of Psychology, Temple
tion of correctable health problems, show a general consensus about the desired characteristics of facil ities and behaviors of personnel.27 Despite this consensus and the commonly stated intent of pro viders of child care services to foster safe and healthy development of children in their care, there has been limited compliance with current stan dards. Documentation of the prevalence of risk of accidental injury, lack of preparedness for emergen cies, and practices that foster the spread of infec tious disease in child care programs includes:
1. An audit of federally funded day care in nine
states reported by the Department of Health, Ed ucation and Welfare in 1974 revealed that of 453 day care centers examined, 363 did not meet federal health and safety requirements. Poisons and medi cines were found stored in places accessible to chil dren; children were exposed to broken glass, rusted, broken and insecure playground equipment, and to traffic hazards in play areas.8
2. A study of federally funded day care programs in HEW Region X revealed many examples of lack of compliance with federal standards. One fourth of the 72 day care centers and two thirds of the 72 day care homes examined failed to have the required working fire extinguisher and emergency lighting available. Almost half of the centers did not have a planned source of emergency medical care.9
To corroborate previous evaluations of compli ance with standards, the present training and eval uation project incorporated pretraining evaluation of the health and safety aspects of 142 participating child care sites. Posttraining reevaluation was per formed one year after the pretest in order to assess gains in compliance with health and safety stan dards accomplished through the training of a staff member as a health advocate in each program. Since evaluation or monitoring alone was expected to improve compliance, an additional group of pro grams was pretested and posttested with no inter vening training. Gains in these programs were ex amined and contrasted with those in the programs that received training as well as evaluation.
METHOD
Participating Programs
In all, 142 child care program sites in southeastern Pennsylvania participated on a voluntary basis in the pretest evaluation phase of the program. This number of sites represents two thirds of the 212 child care program sites in the region known to public authorities at the time of the study. At the time of entry into the study, 67% of the sites were funded by Title IV-A of the Social Security Act, 16% by Head Start, 6% by private funds, 9% by a mixture of public and private sources, and 2% by
other public funding sources. Among the sites were three multisite family day care home programs. The participating sites differed in the ages of the chil dren they served: 10% of the sites served children 0 to 18 months of age; 25%, children 19 to 35 months of age; 89%, children 3 to 6 years; 30%, children 6 to 8 years; 16%, children 9 to 11 years; and 0.6%, children 12 to 16 years of age. (The percentages add to more than 100% because some sites served more than one age group.)
Of the 142 sites participating in the pretest eva! uation, 123 had staff who completed the training and received a posttest. Of the 142 sites, 19 sites were selected as a contrast group, to receive no training for the first year and to be reevaluated before receiving any training. In type of funding, age of clientele served, date of application to partic ipate in the training program, and dates of assess ments these 19 sites were comparable to the first 54 programs that received training. Of these 19 sites, 17 were posttested as planned.
Trainees
Trainees were selected by their program admin istrators on the basis of their apparent interest in health related matters, the availability of time in their work schedules for attending the course, and the feasibility of their assuming the role of health advocate. In all, 117 individuals were enrolled in training. This number is smaller than the number of sites since 15 trainees represented multiple sites and nine pretested sites sent no individual for train ing. Of the 117 trainees enrolled, 108 (92%) com pleted the training and 88 (81%) were still acting as health advocates at the time of the one-year post training evaluation.
Most of the trainees were females between the ages of 21 and 40. Half were married. Most had some education beyond high school; of these, 35% were trained in child development, education or psychology, 28% were in social work, 16% were in nursing, 10% were in liberal arts, and 11% were in business or other fields. Half the trainees reported titles related to a position in social work while another quarter reported educational job titles.
TrainingProgram
was written in great detail. The course itself was conducted in two sections of ten trainees per section by a pediatric nurse associate assisted by a regis tered nurse, with community health and safety professionals as guest speakers.
Course content was derived from local, state, and
federal requirements and from the recommenda tions of national professional associations. Although the course included factual information on health and safety, the emphasis of training was on advo cacy per Se. The course included techniques for motivating those who plan and administer aspects of the health component in child development pro grams; finding community resources for carrying out screening tests or other routinely recommended preventive and treatment services; following medi cal problems; using health education; maintaining and using health records; assuring that adequate nutrition, dental health, and mental health prac tices are followed; maintaining emergency prepar edness, including readiness to deliver first aid; using prescribed medications safely and appropriately; transporting children safely; gathering and using information about health resources; identifying and managing children with illnesses; dealing with the health of staff; and developing written policies and procedures about all health and safety aspects of the child care program.During the course, each trainee was asked to submit five assignments: (1) a health resource file containing useful written materials and names, phone numbers, and addresses ofcommunity health resource agencies; (2) a set of health policies devel oped with co-workers for use at the day care site; (3) a weekly journal entry describing the trainee's efforts to foster change at the day care program site; (4) a day care menu for a two-week period developed with appropriate site staff; and (5) a revised job description incorporating health advo cacy tasks.
Evaluation Instruments
The major instrument for assessing compliance with health standards, the Health Standards Com pliance Checklist (HSCC), was a combined ques tionnaire and observation battery. It consisted of four sections: (1) a 270-item questionnaire admin istered to staff at the child development program site; (2) a set of self-administered forms to be com pleted by the staff of the site; (3) a standardized observation schedule for assessing behaviors of staff and hazards in the facility; and (4) an audit of children's medical records.
The HSCC battery was organized into 16 scales, each of which measured compliance with the stan dards for a dimension of the health and safety
component. The scales are listed in Table 1. Each scale consisted of a series of items with which a program might or might not comply. The scores represented percentage of compliance, ie, the com pliance score of a program across all items relative to the maximum compliance score for that scale. Where interview responses indicating compliance conflicted with responses to items which involved direct observation by the data collector, the obser vations of the data collector were used.
In addition to the HSCC, three other instruments were employed. A 30-item Health Opinion Scale measured views on ten aspects of health advocacy in child care. An 80-item Health Knowledge Test measured knowledge of facts about health and safety discussed in the training program. Finally, interview items on a Role Form assessed the func tioning of the designated health advocate in 68 specific health related activities required to achieve compliance with health standards. (More detailed information about these instruments is available from S. S. A.)
Immediate training related behaviors were as sessed by attendance, by responses to a brief ques tionnaire completed anonymously at the end of each session, and by completion of assignments given during the course.
Evaluation Schedule
For all experimental programs there were three points of evaluation: (1) just prior to entry into training (pretest); (2) just after training (immediate posttest); and (3) a year following the initial training (delayed posttest). The pretest and delayed posttest batteries were the same. The full HSCC battery was administered jointly to the program supervisor and health advocate at the program site by an evaluator who was not involved in the training component of the project. The Role Form was also administered separately to the program supervisor and advocate. Finally, both the supervisor and the advocate individually completed the Health Opin ion Survey, and the advocate completed the Health Knowledge Test. The immediate posttest, designed to measure the immediate effects of training, in volved only the completion of the Health Opinion Survey and Health Knowledge Test by the advo cate.
The contrast group was only measured twice with one year intervening between testing; the span of testing coincided with that of the first three training cycles.
RESULTS
ScaleMeans ScorestPretestPosttesttdfP in Scale
(two-tailed)External
planning37.4
(25.1)@49.4 (23.6)4.1122.001Special
(32.2)
n=11256.1
(34.2)
n=1125.4222.001Internal
Planning and Administration82.9
(22.5)89.6 (17.9)3.3122.01Health
Services Screening35.0
(30.5)47.0 (33.7)3.7122.001Medical
Evaluation and Treatment53.1
(36.5)74.0 (35.0)5.5122.001Medical
Records Process53.2
(22.4)65.0 (20.6)6.5122.001Medical
Records Contents31.8
(15.2)
n=12248.1
(14.5)
n=1208.5249.001Health
Policies and Procedures48.7
(21.6)67.3 (18.1)8.5122.001Health
Education64.3
(21.8)74.8 (17.8)5.4122.001Staff
Health65.5
(15.8)72.7 (13.0)5.2122.001Dental
Care61.3
(27.4)69.0 (28.0)3.1122.01Emergency,
Evaluation, and Disaster Plan49.2
(23.7)59.5 (23.1)4.7122.001First
Aid54.5
(36.5)74.2 (28.2)5.7122.001Environmental
Quality and Safety72.0
(10.6)75.0 (9.1)3.0122.01Nutrition62.5
(17.0)65.8 (13.9)2.3122.05Transportations70.4
(17.1)
n=11575.4
(13.8)
n=1162.5229.02
TABLE1. PretestversusPosttestChangeAnalysis—HSCCScaleScores*
* All sites included for which pretest and posttest data available (n = 123).
t Scale scores are expressed as percent of items in compliance relative to maximum number of applicable items. :1:Values in parentheses, SD.
§For three scales—Special Needs, Medical Records Content, and Transportation—scores were deleted for programs
to which they did not apply, eg, programs with no special needs children or programs providing no transportation. To
test pretest to posttest change, these data were analyzed with nonrepeated measured t tests using all available data.
safety standards, as measured on the HSCC. Before
presentation of the data on compliance, there is a brief description of measures tied directly to the training, ie, attendance, ratings of trainee satisfac tion during the course, completion of course assign ments, and comparisons of the pretest and imme diate posttest data on the Health Knowledge Test and Health Opinion Survey. Three aspects of the compliance data are considered: (1) initial pretest compliance levels; (2) changes in compliance from pretest to delayed posttest in programs with trained advocates; and (3) gains in compliance levels of programs that were simply evaluated versus those in which both training and evaluation occurred. The compliance data are presented chronologically, with pretest HSCC data presented first. Changes in compliance are briefly considered in light of re
ported modifications in advocate functioning in the health component of the program, as measured on the Role Form.
Training Related Behaviors and Changes in
Knowledge and Attitudes
revision of the trainee's own job description. The completion rate for this task was only 34%.
As measured on the Health Knowledge Test (HKT), advocates acquired substantial information during the training. On the pretest, advocates achieved an average of only 52% accuracy. On the immediate posttest just after training, this value rose to 75%, a significant increase (P < .001). Inter estingly, this gain in knowledge was maintained on the delayed posttest, where the average score on the HKT was 72%.
Changes in attitudes toward health advocacy were less dramatic than changes in knowledge. Though attitudes moved significantly in the desired direction following training (P < .05), the change was limited primarily to one of the ten attitudes measured: that health issues can be grasped by individuals who are not health professionals.
Compliance with Health and Safety Standards on the Pretest
Each program received a percentage compliance score on each scale of the HSCC. These were av eraged as shown in Table 1. Average pretest corn pliance ranged between 32% and 82% and was less than 50% for six of the 16 scales. The areas of poorest compliance were as follows: Medical Rec ords Content, which measured the quality and corn pleteness of program medical records; Special Needs, which measured the adequacy of providing for children with special needs (eg, those suspected or known by the staff to have sensory deficits, physical handicaps, or emotional and learning prob lems); Health Services Screening, which measured provision of or assurance of provision of screening tests; and External Planning, which measured the routine use of appropriate outside sources for plan ning health and safety aspects of the program. For all these areas, mean compliance was below 40%. Consideration of individual items within scales highlighted still further the problems with compli ance. For example, within Special Needs, although one fourth of all programs reported having at least one child enrolled whom they suspected or knew to be hearing impaired, only 16% of those programs had sought professional evaluation and obtained a care plan for such children. In the Health Services Screening area, of the 70% of programs with chil dren for whom screening for lead poisoning was appropriate, only a third saw to it that children received such screening. In the area of External Planning, only a third of programs had an expert in child health who examined the whole health corn ponent for its adequacy. These items demonstrate that many programs failed to obtain needed experts to plan or provide health services to children in their care. (Detailed information on compliance on
each item of the scale at both the pretest and delayed posttest is available from S. Aronson.)
In other areas compliance was substantially higher. Although External Planning was poor, corn pliance with standards of Internal Planning was high (82.9% mean compliance); fully 85% of pro grams had at least one person responsible for the health and safety aspects of the program. Compli ance with Environmental Quality and Safety stan dards and with standards of providing safe trans portation for children was also high (mean compli ance levels of 72.0% and 70.4%, respectively).
But where overall compliance levels were rela tively high, there were still notable failures of com pliance on individual items of these scales. With respect to environmental quality and safety, fully one third of center programs did not have panic hardware on outside doors; in a third of programs the temperature of hot water accessible to children exceeded the scald temperature of 120 F; a quarter of programs had failed to check walls to assure there was no lead-based paint; less than a third of programs had fire resistive drapes and blankets. Finally, in the transportation area, a fifth of pro grams transporting children did not have their ye hides insured for that purpose, and four fifths of these programs did not have vehicles equipped with suitable restraints or seat belts for each child.
In sum, pretest compliance levels indicated marked deficiencies in the health and safety aspects of child development programs. In some areas, the failures of compliance pervaded a whole area, as in the provision of services for special needs children. In other areas, such as Environmental Quality and Safety and Transportation, compliance within an area was variable for individual aspects of that dimension of health or safety.
Changes in Compliance Levels in Programs with Trained Advocates
Changes in compliance from pretest to posttest are also shown in Table 1. Comparison of posttest with pretest results indicated significant gains in compliance on all scales of the HSCC. The gains were not uniform across the scales; the smallest gains were noted in the areas of Environmental Quality and Safety and Nutrition, the largest in the area of Special Needs children. The magnitude of gain on each scale was substantially negatively cor related with pretest level (r (14) = —¿.70,P < .01), ie, the scales with the lowest initial scores showed the greatest change.
Gain on each scale was tested for significance with repeated measures t tests, given in Table 1. In all cases gains were significant at conventionally accepted levels (P = .05 or better).
TABLE 2. Change in Percentage Only Child Care Programs vs ProgrCompliance
(Posttest Minus Pretest) for Evaluated ams Receiving Both Evaluation and
Training*ScaleImprovement
(@i) Test of
DifferenceEvaluated-Evaluated t valuet Significance
Only and
(n = 17) Trained' (n = 54)External
Planning18 15 —¿.36
...Special
Needs12 27 1.28
...Internal
Planning and Adminis 9 12 .52
...trationHealth
Services Screening15 28 1.99
.05Medical
Evaluation and Treat 17 31 1.67
.10mentMedical
Records Process7 17 1.15
...Medical
Records Content17 23 1.25
...Health
Policies and Procedures19 29 2.13
.05Health
Education2 14 2.55
.05Staff
Health6 11 .01
...DentalCare—11
11 1.70
.10Emergency,
Evacuation, and Dis —¿2 7 1.99
.05aster PlanFirst
Aid—7 19 4.67
.001Environmental
Quality and Safety3 4 .53
...Nutrition0
4 .03
...Transportation7
2 —¿1.09 ...
further. Such gains might have been accomplished in two ways. There might have been gains across all the items of a scale. Alternately, the gain might have been erratic, with marked improvement on some items, but failures of improvement on other items. Some scales lent themselves to an analysis of improvement patterns. For example, the Health Services Screening scale is based on the provision of ten different screening tests. Change from pretest to posttest in the percentages of programs providing each of these tests was examined. Although there was an increase in the percentage of programs pro viding each of the tests, the increases varied from test to test. The increase in percentages of programs providing a specific test ranged from 20% for vision screening and 19% for developmental and school performance screening to 9% for anemia screening. For three screening tests, lead, glucose-6-phosphate dehydrogenase, and sickle cell testing, appropriate for selected populations, gains were 15%, 11%, and 1%, respectively. On this scale, then, gains were not homogeneous on individual items of the scale.
In contrast, the Medical Evaluation and Treat ment scale showed more homogeneity in gains across items related to a variety of services. Provi sion of immunizations such as diphtheria-pertussis tetanus or diphtheria-tetanus, oral polio, rubeola, and rubella increased by 19%, 18%, 21%, and 17%, respectively. There was a 20% increase in the num ber of programs providing evaluation of suspected
medical problems and a 23% increase for evaluation of dental problems. The one discrepant figure, a gain of only 10% for provision of emergency medical care could be accounted for by the fact that 88% of programs provided this service at the pretest.
Changes in Compliance as a Function of
Evaluation Alone vs Evaluation Plus Training
A considerable amount of information about health and safety standards might have been gleaned from participating in an administration of the HSCC. Thus, compliance levels might have been expected to improve if program staff partici pated in evaluation, but received no training. In fact, this did occur. For the 17 programs that were evaluated and reevaluated without participating in training, improved compliance was found on 12 of the 16 HSCC scales as shown in Table 2. Table 2 also presents data on the gains of 54 programs from the first three training cycles that were evaluated, received training, and reevaluated within the same time frame as were the contrast programs. Gains for programs with trained personnel exceeded those for evaluated-only programs on 13 of the 16 scales. These differences were statistically significant for five of the scales.
The first statistical contrast of programs was accomplished by a series of two-factor analyses of variance of compliance scores on each scale as a function of program group (trained vs evaluated
* Includes those trained programs evaluated concurrently with programs that were only evaluated.
t Test of differences is on adjusted changesscoreswith pretest levels partialed out, rather
TABLE3.ProgramsContentPretestversusPosttestChangeAnalysis of Role of the Health Advocate in Child Day Care
of MeasureAdvocate Self-Report
(n=90)Supervisor's
Report of Advocate Role (n=70)Pretest
Posttest P (two-tailed) Mean (C%) Mean (%)Pretest
Posttest P (two-tailed) Mean (@) Mean
(@)Activities
in which advocate is in 38.6 58.8 < .00141.2 58.5 <
.001volvedHow
advocate is involved in activ ityPerform
only32.7 18.9 < .00136.6 19.7 <
.001Advocate
only21.5 23.5 NS20.4 23.9 <
.10Mixture
of performing and ad 45.9 57.5 < .00141.6 56.4 <
.001vocating
only) and evaluation time (pretest vs posttest). Significant main effects of evaluation time at a = .05 or better for the first ten scales of the HSCC indicated that both groups of programs had gained from the first to the second testing (see Table 2 for a listing of the first ten scales). A number of signifi cant interactions of program group and evaluation time indicated differential gain might have occurred across the two groups. This possibility was tested by an analysis of adjusted change scores, which controlled for pretest differences that existed be tween the two groups of programs. Change scores (posttest minus pretest) were first predicted in a linear regression equation from the pretest scores. The residuals (observed change minus predicted change) from this regression analysis then served as measures of change that were independent of pre test level. The residuals from the 54 “¿trainedpro grams― were contrasted with those of the 17 “¿eval
uated-only―programs by t test for each scale to
assess whether adjusted gain was greater in one or the other group of programs. The outcomes of these tests are reported in Table 2. On six of the 16 scales, the gain in the trained group exceeded that in the evaluated-only group; one additional scale showed nonsignificant change in the same direction (P = .10).One further comparison was made to validate the apparent effect of evaluation. The posttest scores of the evaluated-only group were compared with the pretest scores of the 49 programs that were pretested either during or after the posttest of the evaluated-only group. The posttest scores of the evaluated-only group exceeded the pretest scores of the 49 programs on 14 of the 16 HSCC scales (P < .005 for this many differences in one direction by change alone), thus confirming the positive effects of evaluation.
Changes in Advocate Role
The Role Form, administered to both advocates and their program supervisors, was used to docu ment various aspects of the functioning of newly
trained advocates. In order to ascribe gains in corn pliance to the action of the advocate in the program, it was necessary to show that the advocate did become more involved in health and safety activi ties following training. Such changes were found. The percentage of these activities in which the advocate was involved increased from a self-re ported average of 38.6% on the pretest to 58.8% on the posttest (P < .001). (These percentages as re ported by the program supervisors were similar, 41.2% and 58.5%, respectively; P < .001 for signifi cance of gain.)
Changes occurred in the nature as well as the amount of involvement ‘¿of the advocate in health and safety activities after training. As shown in Table 3, following training, advocates increased the percentage of health and safety activities in which they were involved. This increase was accomplished by an increase in advocating and an increase in the combination of advocating and performing of activ ities, associated with a significant decrease in the percentage of activities that the advocate at tempted by performing himself. Comparison of the independent reports of advocates and their super visors reveals little discrepancy between them.
DISCUSSION
tion on how to expediently meet those standards, and motivates staff to improve compliance in their programs.
The data of the present study provide evidence that both evalution alone and evaluation coupled with training produce increased compliance with health and safety standards. Training, in addition, produced gains over and above those produced by evaluation alone.
Whenever there are gains from pretest to posttest in the absence of treatment, the question arises as
to whether confounding factors produced the effect.
Here the gain from pretest to posttest in the eval
uation-only group has been ascribed to the initial
evaluation. What else might have produced the gain? One possibility is an increase in the expertise of interviewers over the course of the study, which led to the solicitation of clearer, more readily scored data from respondents. A second is modification of the coding or scoring system by which compliance
measures were derived. A third is change in factors
unrelated to the research program that, nonethe
less, are in favor of the desired effect. Two examples
of such factors could be increased emphasis on health related issues by a major day care funding
source or increases in community resources for
health care, both of which might lend themselves to increases in compliance in the absence of any evaluation effect. Three aspects of the present data mitigate against interpretation of the evaluation effect as artifactual. First is that coding procedures were done in strict adherence to a coding manual.
Second is that the pretest scores of the five sets of
programs receiving training during a two-year pe nod were completely equivalent, ie, they were not at all time dependent. Third is the superiority of posttest scores in the evaluated-only group to the
pretest scores of other programs, when data being
compared were gathered within the same time frame. In sum then, there are substantial reasons for concluding that the evaluation effect found is not artifactual and that there is great potential benefit from monitoring of compliance with health and safety standards at program sites.
There is a further consideration that has impli cations for all reported gains for any group of pro
grams. This is that program staff may have become
“¿testwise―by virtue of the pretest and were thus able to give desired responses on the second HSCC. This is highly unlikely since the HSCC contained copious verification checks that ensured the verac
ity of responses.
Training health advocates who then worked on improving the health component of their programs increased compliance with health and safety stan dards on all dimensions to a greater or lesserdegree.
Gains were not uniform across dimensions (or scales of the HSCC) nor across individual items within
scales. There are at least three ways to look at this
variation in gain. Perhaps some of the variation within scales is explicable by the ease with which compliance may be obtained for certain items. For example, implementing vision screening using the instructions and materials supplied in the training was easier than obtaining anemia screening from a variety of local health providers used by the chil then. Another factor may be the priorities suggested in the training, eg, lead testing of susceptible pre schoolers is more urgent than sickle cell screening.
In all, these results suggest that monitoring of
child development programs with an extensive and detailed instrument such as the HSCC can be useful in producing substantial improvement in the health component of such programs. In addition, they
suggest that training, over and above monitoring, is
an effective way of improving compliance, at least in the areas in which gain was greater for trained than for evaluated-only programs.
ACKNOWLEDGMENTS
This researchwas funded by the Federal Office of Child Development Grant OCD-CB-491.
We wish to thank Herberta Strother, RN, PNA, and project health trainer, for her able implementation of the
training; Judith M. Mausner, MD, MPH, for her profes sional advice; and Frederick C. Green, MD, FAAP, and associate director of the Office of Child Development at the time of the project's inception, for his encouragement and support for the concept of the project.
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DOI: 10.1542/peds.65.2.318
1980;65;318
Pediatrics
Susan S. Aronson and Leona S. Aiken
Program Evaluation and Advocate Training
Compliance of Child Care Programs with Health and Safety Standards: Impact of
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Susan S. Aronson and Leona S. Aiken
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American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
