ROVIDING QUALITY PEDIATRIC care for young children involves matching the needs and expectations of families with the organizational structure and clinical practices of pediatric providers. There is growing evidence of deficiencies in the quality of health care for children, including low rates of preventive services, 1 persistent disparities in health status, 2 and lack of a usual source of care among ethnic and racial minorities and children in low-income families. 3 Specific limitations have been noted in the quality of care related to developmental and behavioral services for children in the first 3 years of life, 4-7 particularly regarding gaps between recommended and actual care received. 8,9 In a national survey, only 23% of 2017 parents of young children discussed discipline and early learning with their child's clinician, and over half Author Affiliations are listed at the end of this article.

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Throughout a 26-month period, 5565 children enrolled in the evaluation, 2963 (53.2%) children in the intervention group and 2602 (46.8%) in the comparison group. More than 10% of mothers in the Healthy Steps sample are teenagers; 18% have 11 years of education or less; 27% have completed college; 18% are black or African-American; slightly >20% are of Hispanic origin; 36% are single; and close to one-third used Medicaid for their prenatal care. Approximately 7% of infants were low birth weight. When compared with national birth data for the United States as a whole, the Healthy Steps sample seems similarly diverse. However, with the exception of maternal age, the distribution of variables was significantly different from the distribution for US births. There are no differences between intervention and comparison families at randomization sites on any of

A resurgence of measles in the past decade has focused attention on the limitations of current immunization programs, particularly for inner-city, low-income populations. As part of a larger study of immunization rates, we discussed perceptions of disease severity and vaccine efficacy, as well as the prioritization of the tasks of parenthood, with 40 parents of infants living in inner-city Baltimore to discover their beliefs about immunization. Vaccines were considered only partly successful; susceptibility to chickenpox after vaccination was repeatedly cited as evidence of vaccine failure. Fever was seen as a primary indicator of illness; thus, vaccines were believed to cause, rather than prevent, illness. Immunization was not considered a high-priority parental responsibility. These findings suggest future interventions be aimed at changing parental perceptions of vaccines as ineffective and of fever after immunization as an indicator of illness. Finally, immunizations should be made easily available, even during clinic visits for a child's illness.

Family demographics strongly correlate with vaccination status; however, they are generally not modifiable. This study's findings encourage providers to operate a tracking system, to remain current on immunization recommendations, to use all clinical encounters to screen and vaccinate children, and to ensure the availability and convenience of vaccination services.

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Early in-office visits seem to make DTP1-AA vaccination more likely. These rates may be amenable to intervention by increasing early visits and reducing DTP1-AA missed opportunities. Introduction of the hepatitis B vaccine to the recommended series may place more emphasis on early visits and result in increased DTP1-AA rates and, ultimately, higher vaccination coverage rates.