Expanding developmental and behavioral services for newborns in primary care; Effects on parental well-being, practice, and satisfaction

Enhancing immigrant families' mental health through the promotion of structural and community-based support

Immigrant communities in the United States are diverse and have many assets. Yet, they often experience stressors that can undermine the mental health of residents. To fully promote mental health and well-being among immigrant communities, it is important to emphasize population-level policies and practices that may serve to mitigate stress and prevent mental health disorders. In this paper, we describe the stressors and stress experienced by immigrant families, using Sunset Park, Brooklyn as an example. We discuss ways to build structures and policies in support of equitable environments that promote mental health at the population level and enable families and their children to thrive.

Early parenting interventions to prevent internalising problems in children and adolescents: a global systematic review and network meta-analysis

QUESTION

We compared the effectiveness of different types of parenting interventions based on an a priori taxonomy, and the impact of waitlists versus treatment as usual (TAU), in reducing child internalising problems.

STUDY SELECTION AND ANALYSIS

We conducted a systematic review and network meta-analysis of published and unpublished randomised controlled trials (RCTs) until 1 October 2022 that investigated parenting interventions with children younger than 4 years.

EXCLUSION CRITERIA

studies with children born preterm, with intellectual disabilities, or families receiving support for current abuse, neglect, and substance misuse. We assessed the certainty of evidence using the Confidence in Network Meta-Analysis framework. We used random-effects network meta-analysis to estimate standardised mean differences (SMDs) with 95% credible intervals (CrIs).

FINDINGS

Of 20 520 citations identified, 59 RCTs (18 349 participants) were eligible for the network meta-analysis. Parenting interventions focusing on the dyadic relationship (SMD: -0.26, 95% CrI: -0.43 to -0.08) and those with mixed focus (-0.09, -0.17 to -0.02) were more effective in reducing internalising problems than TAU at the first time point available. All interventions were more effective than waitlist, which increased the risk of internalising problems compared with TAU (0.36, 0.19 to 0.52). All effects attenuated at later follow-ups. Most studies were rated as with 'high risk' or 'some concerns' using the Risk of Bias Assessment Tool V.2. There was no strong evidence of effect modification by theoretically informed components or modifiers.

CONCLUSIONS

We found preliminary evidence that relationship-focused and mixed parenting interventions were effective in reducing child internalising problems, and the waitlist comparator increased internalising problems with implications for waiting times between referral and support. Considering the high risk of bias of most studies included, the findings from this meta-analysis should be interpreted with caution. PROSPERO registration number CRD42020172251.

Impact of Screening and Co-located Parent Coaching Within Pediatric Primary Care on Child Health Care Use: A Stepped Wedge Design

Childhood adversity and toxic stress have been associated with poor mental and physical health. This study examined if Parent Connext, a program that integrates adversity screening and parent coaching by co-located specialists within pediatric primary care, had an impact on health care utilization. This stepped wedge cluster randomized controlled trial evaluated Parent Connext across six pediatric primary care practices. All practices (clusters) were in the control period during year 1. Three practices were randomized to begin the Parent Connext intervention in year 2, and three practices were randomized to begin in year 3. Medical records of all patients under age 8 treated at these practices during these 3 years were queried retrospectively for participant-level primary outcomes (sick visits, emergency department visits, hospitalizations) and secondary outcomes (well-child and immunization adherence, referrals). The study sample included 27,419 patients followed for an average 1.39 (SD = 0.66) years in the control period and 1.07 (SD = 0.60) years in the intervention period. During the intervention period, patients had significantly fewer sick visits (IRR = 0.91, p < 0.001) which aligned with our hypothesis, decreased odds of well-child visit adherence (OR = 0.88, p < 0.001) which was unexpected, and increased odds of receiving a referral (OR = 1.45, p < 0.001). The odds of an emergency department visit, hospitalization, and 2-year immunization adherence did not differ between periods. Parent Connext resulted in a significant reduction in child sick visits, highlighting the potential benefit of two-generation approaches to pediatric care for child health.

Collateral benefits from a school-readiness intervention on breastfeeding: A cross-domain impact evaluation

This study evaluated the collateral, or unanticipated, impacts of Smart Beginnings (SB), a two-site, tiered intervention designed to promote responsive parenting and school readiness, on breastfeeding intensity in a low-income sample. Impact analyses for the SB intervention were conducted using an intent-to-treat design leveraging a two-arm random assignment structure. Mothers assigned to the SB intervention group were more than three times more likely to give breastmilk as the only milk source at infant age 6 months than mothers assigned to the control group at one site, an effect not evident at the other study site. As development and growth are the two most salient domains of child health, understanding how interventions impact subsequent parenting practices across both domains is critical to address long-term economic and racial/ethnic disparities. Implications of the findings are discussed for improving the efficacy of interventions based on paediatric primary care.

Efficacy of behavioral interventions to improve maternal mental health and breastfeeding outcomes: a systematic review

BACKGROUND

Despite extensive benefits and high intentions, few mothers breastfeed exclusively for the recommended duration. Maternal mental health is an important underlying factor associated with barriers and reduced rates of breastfeeding intent, initiation, and continuation. Given evidence of a bidirectional association between maternal mental health and breastfeeding, it is important to consider both factors when examining the efficacy of interventions to improve these outcomes. The purpose of this manuscript is to review the literature on the efficacy of behavioral interventions focused on both maternal mental health and breastfeeding outcomes, examining the intersection of the two.

METHODS

This systematic review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Studies were selected if they were available in English, used primary experimental design, and used a behavioral intervention type to examine maternal mental health and breastfeeding outcomes. Articles were identified from PubMed, CINAHL, Embase, and PsycINFO from database inception to 3 March 2022. Study quality was assessed using the Cochrane Risk of Bias tool. Results were synthesized by intervention success for 1. Mental health and breastfeeding, 2. Breastfeeding only, 3. Mental health only, and 4. No intervention effect. PROSPERO CRD42021224228.

RESULTS

Thirty interventions reported in 33 articles were identified, representing 15 countries. Twelve studies reported statistically significant positive effect of the intervention on both maternal mental health and breastfeeding; most showing a decrease in self-report depressive and/or anxiety symptoms in parallel to an increase in breastfeeding duration and/or exclusivity. Common characteristics of successful interventions were a) occurring across pregnancy and postpartum, b) delivered by hospital staff or multidisciplinary teams, c) offered individually, and d) designed to focus on breastfeeding and maternal mental health or on breastfeeding only. Our results are not representative of all countries, persons, experiences, circumstances, or physiological characteristics.

CONCLUSIONS

Interventions that extend the perinatal period and offer individualized support from both professionals and peers who collaborate through a continuum of settings (e.g., health system, home, and community) are most successful in improving both mental health and breastfeeding outcomes. The benefits of improving these outcomes warrant continued development and implementation of such interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021224228.

Pediatric Integrated Primary Care:: A Population Health Approach to Meeting the Behavioral Health Needs of Children and Families

Addressing the behavioral health needs of the population is a growing public health concern; a significant portion of the population struggles with behavioral health challenges yet access to care is limited due to a multitude of barriers. Research has demonstrated that integration of behavioral health providers into the primary care team is an effective means of increasing care access and reducing barriers to care. While there has been an uptake in integrated primary care (IPC) in adult healthcare, there is significant opportunity for expanding IPC in pediatrics. Nemours Children's Health has developed a model IPC program to serve children and youth in Delaware and train future behavioral health professionals. Policy to support payment for IPC services and fund workforce development will be essential to sustaining the Nemours program as well as expanding this and other IPC models in order to serve more children and youth in Delaware and beyond.

Keeping our children safe: piloting a hospital-based home-visitation program in Israel

Background

Unintentional childhood injuries are a leading cause of morbidity and mortality worldwide. Attempts to prevent child home injuries have rarely been implemented in hospital settings which present an important opportunity for intervention. The SHABI (‘Keeping our Children Safe; SHomrim Al BetIchut Yeladenu’) program recruits at-risk families presenting with child injury to the Emergency Department. Medical/nursing students conduct two home visits and provide safety equipment and guidance. The objective of this study was to investigate the impact of SHABI on participating families’ home-safety.

Methods

The pilot was conducted between May 2019 and March 2020 in northern Israel, an area with high child injury rates. Eligibility included families with preschool children who incurred a home injury. Home-safety was assessed by observation through the ‘Beterem’ checklist. Parents' views, knowledge, awareness of dangers and report of home injuries were assessed at the start of each visit.

Results

352 of 773 eligible families agreed to be contacted. 135 participated, 98 completed both home visits. Significant improvement in home-safety items was observed 4 months after the first visit (14 [IQR12-16]) vs. (17 [IQR15-19]; p < 0.001), accompanied by an overall increase in home safety (Mean ± SD 71.9% ± 9.5% vs. 87.1% ± 8.6%; p < 0.001). 64% reported greater awareness of dangers, 60% affirmed home was safer, and 70% valued the equipment. No difference was found in the prevalence of injuries (14 of 98 families prior and 8 after the visit; p = 0.17). Home visitors reported benefiting from the experience of working with disadvantaged families.

Conclusion

The program, which included recruitment in a hospital emergency setting and use of healthcare students as home visitors, was successfully implemented and accompanied by significant improvement in home safety with a non-significant trend of child injury decrease.

Better safe than sorry: Evaluating the implementation process of a home-visitation intervention aimed at preventing unintentional childhood injuries in the hospital setting

Background

Child home injuries prevention interventions have rarely been implemented in hospitals. The SHABI program ("Keeping our Children Safe"; in Hebrew: "SHomrim Al BetIchut Yeladenu") recruits at-risk families arriving with child injury to the Emergency Department. Medical/nursing students conduct two home visits four months apart, providing safety equipment and guidance. One hundred thirty-five families had a first visit and 98 completed the second. Fifty percentage of families were ultra-Orthodox Jews, 11% Arab, and 28% had ≥3 preschool children. We investigated SHABI's implementation using the Consolidated Framework for Implementation Research (CFIR).

Methods

Between May 2018 and March 2021 SHABI was implemented in the Emergency Department of a hospital in Israel's northern periphery, an area with high child injury rates. The Implementation process was examined through Emergency Department medical records and tracking registries, hospital management, nurses', and home visitors' meetings notes (n = 9), and a research diary. Hospital's inner setting and SHABI's characteristics were evaluated through interviews with hospital management, nurses, and home visitors 8 months after baseline (n = 18). Home visitors' characteristics were evaluated through interviews, post-visit questionnaire on challenges encountered (n = 233), families' perceptions of SHABI and home visitors' skills through telephone interviews (n = 212); and home visitors awareness of dangers at home (n = 8) baseline and 8 months later. Qualitative data were analyzed through explanatory content analysis according to CFIR constructs. Quantitative data were analyzed using X2 and Wilcoxon test for dependent subgroups.

Results

Despite alignment between SHABI and the hospital's mission, structural hospital-community disconnect prevented implementation as planned, requiring adaptation and collaboration with the medical school to overcome this barrier. Recruitment was included in the initial patient triage process but was only partially successful. Medical/nursing students were recruited as home visitors, and following training proved competent. Children were a distraction during the visits, but home visitors developed strategies to overcome this.

Conclusions

Injury prevention programs in hospitals have significant benefits. Identifying implementation barriers and facilitators allowed implementers to make adaptations and cope with the innovative implementation setting. Models of cooperation between hospital, community and other clinical settings should be further examined.

The Effectiveness and Cost-effectiveness of a Parenting Intervention Integrated with Primary Health Care on Early Childhood Development: a Cluster-Randomized Controlled Trial

Developing countries require interventions that can sustainably improve early childhood development (ECD) at scale because hundreds of millions of children are at risk of poor development. This study examined the effectiveness and cost-effectiveness of a parenting intervention integrated with primary health care in terms of ECD. A cluster-randomized controlled trial was conducted in 20 urban communities in China, with 82 and 86 children aged 1-2 months enrolled in the intervention and control groups, respectively, and 71 and 69 children, respectively, followed to 14 months of age. All children in both groups received routine primary health care services. Intervention caregivers received a parenting pamphlet and two parenting training sessions during well-child clinic visits; those with children with suspected developmental delay received additional parenting guidance by telephone. Compared with controls, children receiving the intervention had similar developmental outcomes, measured with the Chinese version of the Ages & Stages Questionnaires third edition (ASQ-C), at baseline, but had significantly higher communication (adjusted mean difference = 0.26; 95% CI 0.03, 0.51), fine motor (adjusted mean difference = 0.19; 95% CI 0.01, 0.37), and overall (adjusted mean difference = 0.25; 95% CI 0.10, 0.41) ASQ-C z-scores after 12 months of the intervention. The intervention cost per child was $50.87, and the costs for increasing the communication, fine motor, and overall ASQ-C scores by one SD were $195.65, $267.74, and $203.48, respectively. Our findings indicate that the integration of a parenting intervention with existing primary health care is a cost-effective way to improve ECD.

Resilience-promoting policies and contexts for children of color in the United States: Existing research and future priorities

The health status of children in the United States varies by racial and ethnic, shaped by an interrelated set of systems that disadvantage children of color in the United States. In this article, we argue for a broad view of resilience, in both research and policy, that views resilience not just as a property of individuals but also as a characteristic of social contexts and policies. Accordingly, we describe the empirical evidence for policies and contexts as factors that can improve health among children and families that are deprived of equal opportunities and resources due to structural racism. We discuss the evidence and opportunities for policies and interventions across a variety of societal systems, including programs to promote economic and food security, early education, health care, and the neighborhood and community context. Based on this evidence and other research on racism and resilience, we conclude by outlining some directions for future research.

Connected Pediatric Primary Care for At-Risk Children

Age-specific recommendations contain extensive information that cannot be presented adequately in pediatric preventative care visits. Parental guidance is important, especially for children with social and/or medical risks, but existing evidence-based interventions tend to be resource intensive and difficult to scale. Because the use of mobile technology is now prevalent even among low-income families, the benefits of utilizing the Internet and mobile apps to improve parental guidance are active areas of research. Analyses of patient-generated data from mobile apps may help identify effective ways to use social influences, social learning, and social networks for improving population health.

Mothers' parenting knowledge and its sources in five societies: Specificity in and across Argentina, Belgium, Italy, South Korea, and the United States

In a cross-society comparison, we assessed the state of mothers' knowledge of child rearing and child development. The study included 1,077 mothers from five countries on four continents: Argentina, Belgium, Italy, South Korea, and the United States. A criteria-referenced instrument, the Knowledge of Infant Development Inventory, was used to assess parenting knowledge after being adapted for cross-society comparison using item response theory and the alignment optimization approach for testing between-sample measurement invariance. Levels of mothers' parenting knowledge varied across the five societies and were associated with different sociodemographic factors and personal and non-personal supports.

Preventive Behavioral Health Programs in Primary Care: A Systematic Review

CONTEXT

Early childhood is a critical period for socioemotional development. Primary care is a promising setting for behavioral health programs.

OBJECTIVES

To identify gaps in the literature on effectiveness and readiness for scale-up of behavioral health programs in primary care.

DATA SOURCES

PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Embase, Evidence-Based Medicine Reviews, and Scopus databases were searched for articles published in English in the past 15 years. Search terms included terms to describe intervention content, setting, target population, and names of specific programs known to fit inclusion criteria.

STUDY SELECTION

Inclusion criteria were: (1) enrolled children 0 to 5 years old, (2) primary care setting, (3) measured parenting or child behavior outcomes, and (4) clinical trial, quasi-experimental trial, pilot study, or pre-post design.

DATA EXTRACTION

Data were abstracted from 44 studies. The rigor of individual studies and evidence base as a whole were compared with the Society of Prevention Research's standards for efficacy, effectiveness, and scale-up research.

RESULTS

Gaps in the literature include: study findings do not always support hypotheses about interventions' mechanisms, trust in primary care as a mediator has not been sufficiently studied, it is unclear to which target populations study findings can be applied, parent participation remains an important challenge, and the long-term impact requires further evaluation.

LIMITATIONS

Potential limitations include publication bias, selective reporting within studies, and an incomplete search.

CONCLUSIONS

Targeting gaps in the literature could enhance understanding of the efficacy, effectiveness, and readiness for scale-up of these programs.

The Evidence Base for the Maternal, Infant, and Early Childhood Home Visiting Program Constructs

OBJECTIVES

The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program requires grantees to demonstrate program improvement as a condition of funding. The MIECHV program monitors grantee progress in federally mandated conceptual areas (ie, benchmarks) that are further subcategorized into related sub-areas or constructs (eg, breastfeeding). Each construct has an associated performance measure that helps MIECHV collect data on program implementation and performance. In 2016, MIECHV modified the constructs and associated performance measures required of grantees. Our objective was to identify whether the constructs were supported by the home visiting literature.

METHODS

We conducted an evaluation of one of the MIECHV program's benchmarks (Benchmark 1: Maternal and Newborn Health) for alignment of the Benchmark 1 constructs (preterm birth, breastfeeding, depression screening, well-child visit, postpartum care, and tobacco cessation referrals) with home visiting evidence. In March 2016, we searched the Home Visiting Evidence of Effectiveness database for all publicly available articles on studies conducted in the United States to determine how well the study findings aligned with the MIECHV program constructs.

RESULTS

Of 59 articles reviewed, only 3 of the 6 MIECHV constructs-preterm birth, breastfeeding, and well-child visits-were supported by home visiting evidence.

CONCLUSIONS

This evaluation highlights a limited evidence base for the MIECHV Benchmark 1 constructs and a need to clarify other criteria, beyond evidence, used to choose constructs and associated performance measures. One implication of not having evidence-based performance measures is a lack of confidence that the program will drive positive outcomes. If performance measures are not evidence based, it is difficult to attribute positive outcomes to the home visiting services.

Evaluating the effects of a targeted home visiting program on maternal and child health outcomes

We evaluate the effects of home visiting targeted towards disadvantaged first-time mothers on maternal and child health outcomes. Our analysis exploits a randomized controlled trial and combines rich longitudinal survey data with unique administrative health data. In a context in which the target group has comprehensive health care access, we find no effects of home visiting on most types of health utilization, health behaviors, and physical health measures. However, the intervention has a positive effect on some maternal mental health outcomes, reducing depression reported in the survey data by eleven percentage points and prescription of psycholeptics recorded in the administrative data by seven percentage points.

Home safe home: Evaluation of a childhood home safety program

BACKGROUND

The London Health Sciences Centre Home Safety Program (HSP) provides safety devices, education, a safety video, and home safety checklist to all first-time parents for the reduction of childhood home injuries. The objective of this study was to evaluate the HSP for the prevention of home injuries in children up to 2 years of age.

METHODS

A program evaluation was performed with follow-up survey, along with an interrupted time series analysis of emergency department (ED) visits for home injuries 5 years before (2007-2013) and 2 years after (2013-2015) implementation. Spatial analysis of ED visits was undertaken to assess differences in home injury rates by dissemination areas controlling differences in socioeconomic status (i.e., income, education, and lone-parent status) at the neighborhood level.

RESULTS

A total of 3,458 first-time parents participated in the HSP (a 74% compliance rate). Of these, 20% (n = 696) of parents responded to our questionnaire, with 94% reporting the program to be useful (median, 6; interquartile range, 2 on a 7-point Likert scale) and 81% learning new strategies for preventing home injuries. The median age of the respondent's babies were 12 months (interquartile range, 1). The home safety check list was used by 87% of respondents to identify hazards in their home, with 95% taking action to minimize the risk. The time series analysis demonstrated a significant decline in ED visits for home injuries in toddlers younger than2 years of age after HSP implementation. The declines in ED visits for home injuries remained significant over and above each socioeconomic status covariate.

CONCLUSION

Removing hazards, supervision, and installing safety devices are key facilitators in the reduction of home injuries. Parents found the HSP useful to identify hazards, learn new strategies, build confidence, and provide safety products. Initial finding suggests that the program is effective in reducing home injuries in children up to 2 years of age.

LEVEL OF EVIDENCE

Therapeutic/care management study, level V.

Effectiveness of an internet-based education on maternal satisfaction in NICUs

OBJECTIVE

This study was conducted to evaluate the effect of internet-based education on the satisfaction of the mothers of the preterm neonates in the NICUs.

METHODS

This quasi-experimental study was conducted on 80 mothers of preterm neonates hospitalized in the NICUs of two hospitals in Iran during 9 months. The mothers were assigned in two groups as cases and controls. The satisfaction level of the mothers was evaluated by using WBPL-Revised¹ in both groups on the first and tenth day of the study. Mothers in the case group received the educational program available at www.iranlms.ir/myinfant for 10days. After 10days, the satisfaction level of the mothers in both groups was measured by questionnaire again.

RESULT

the satisfaction of the mothers increased in both groups after this intervention. However, comparison of the mean scores revealed that the satisfaction of the mothers in the case group increased significantly following the intervention (P<0.001).

CONCLUSION

Considering the benefits of internet-based education, its utilization in mothers education programs in NICUs is recommended.

PRACTICE IMPLICATIONS

The results of this study show nurses in the NICU is a way to improve communication and education to parents of infants hospitalized in NICU.

Redesigning Health Care Practices to Address Childhood Poverty

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Implementation of evidence-based home visiting programs aimed at reducing child maltreatment: A meta-analytic review

In recent years there has been an increase in the popularity of home visitation programs as a means of addressing risk factors for child maltreatment. The evidence supporting the effectiveness of these programs from several meta-analyses, however, is mixed. One potential explanation for this inconsistency explored in the current study involves the manner in which these programs were implemented. In the current study we reviewed 156 studies associated with 9 different home visitation program models targeted to caregivers of children between the ages of 0 and 5. Meta-analytic techniques were used to determine the impact of 18 implementation factors (e.g., staff selection, training, supervision, fidelity monitoring, etc.) and four study characteristics (publication type, target population, study design, comparison group) in predicting program outcomes. Results from analyses revealed that several implementation factors, including training, supervision, and fidelity monitoring, had a significant effect on program outcomes, particularly child maltreatment outcomes. Study characteristics, including the program's target population and the comparison group employed, also had a significant effect on program outcomes. Implications of the study's results for those interested in implementing home visitation programs are discussed. A careful consideration and monitoring of program implementation is advised as a means of achieving optimal study results.

Child Health Disparities: What Can a Clinician Do?

Pediatric primary and specialty practice has changed, with more to do, more regulation, and more family needs than in the past. Similarly, the needs of patients have changed, with more demographic diversity, family stress, and continued health disparities by race, ethnicity, and socioeconomic status. How can clinicians continue their dedicated service to children and ensure health equity in the face of these changes? This article outlines specific, practical, actionable, and evidence-based activities to help clinicians assess and address health disparities in practice. These tools may also support patient-centered medical home recognition, national and state cultural and linguistic competency standards, and quality benchmarks that are increasingly tied to payment. Clinicians can play a critical role in (1) diagnosing disparities in one's community and practice, (2) innovating new models to address social determinants of health, (3) addressing health literacy of families, (4) ensuring cultural competence and a culture of workplace equity, and (5) advocating for issues that address the root causes of health disparities. Culturally competent care that is sensitive to the needs, health literacy, and health beliefs of families can increase satisfaction, improve quality of care, and increase patient safety. Clinical care approaches to address social determinants of health and interrupting the intergenerational cycle of disadvantage include (1) screening for new health "vital signs" and connecting families to resources, (2) enhancing the comprehensiveness of services, (3) addressing family health in pediatric encounters, and (4) moving care outside the office into the community. Health system investment is required to support clinicians and practice innovation to ensure equity.

Early Child Social-Emotional Problems and Child Obesity: Exploring the Protective Role of a Primary Care-Based General Parenting Intervention

OBJECTIVE

To determine whether early social-emotional problems are associated with child feeding practices, maternal-child feeding styles, and child obesity at age 5 years, in the context of a primary care-based brief general parenting intervention led by an integrated behavioral health specialist to offer developmental monitoring, on-site intervention, and/or referrals.

METHODS

A retrospective cohort study was conducted of mothers with 5-year-old children previously screened using the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) during the first 3 years of life. ASQ:SE scores were dichotomized "not at risk" versus "at risk." "At risk" subjects were further classified as participating or not participating in the intervention. Regression analyses were performed to determine relationships between social-emotional problems and feeding practices, feeding styles, and weight status at age 5 years based on participation, controlling for potential confounders and using "not at risk" as a reference group.

RESULTS

Compared with children "not at risk," children "at risk-no participation" were more likely to be obese at age 5 years (adjusted odds ratio, 3.12; 95% confidence interval, 1.03 to 9.45). Their mothers were less likely to exhibit restriction and limit setting and more likely to pressure to eat than mothers in the "not at risk" group. Children "at risk-participation" did not demonstrate differences in weight status compared with children "not at risk."

CONCLUSION

Early social-emotional problems, unmitigated by intervention, were related to several feeding styles and to obesity at age 5 years. Further study is needed to understand how a general parenting intervention may be protective against obesity.

Prenatal Psychosocial Profile: translation, cross-cultural adaptation and validation to its use in Brazil

OBJECTIVES

To translate the Prenatal Psychosocial Profile (PPP) to be used in Brazil; to perform its cross-cultural adaptation; and to evaluate its reliability and validity.

DESIGN

Methodological study.

SETTING

The study was conducted in 10 prenatal care clinics at the city of Porto Alegre/Brazil.

PARTICIPANTS

241 women pregnant women.

METHODS

The adaptation process consisted in: translation; first version synthesis; expert committee evaluation; back translation; pre-test of the PPP version in Portuguese (PPP-VP); validation; the data with the participants was collected in 2007, by trained student nurses that approached the women while they were waiting for prenatal consultation.

FINDINGS

The mean scores for all subscales were similar to the ones found by the original authors; internal consistency was verified through Cronbach׳s alpha, with values of 0.71 for the stress subscale; 0.96 for support from the partner; 0.96 for support from others; and 0.79 for self-esteem; validity was supported through factorial analysis; construct and criterion validities were also established.

CONCLUSION

PPP-VP should be used as a tool to obtain a psychosocial profile which can lead to nursing interventions that will reduce health risk behaviours during pregnancy.

Medicaid home visitation and maternal and infant healthcare utilization

BACKGROUND

The Michigan Maternal and Infant Health Program (MIHP) is a population-based home-visitation program providing care coordination, referrals, and visits based on a plan of care. MIHP is available to all Medicaid-eligible pregnant women and infants aged ≤1 year in Michigan.

PURPOSE

To assess the effects of MIHP participation on maternal and infant healthcare utilization.

METHODS

Propensity-score matching methods were used to assess differences in healthcare utilization between MIHP participants and nonparticipants using 2009-2010 Medicaid claims and administrative data obtained from the Michigan Department of Community Health. Data were analyzed between October 2011 and March 2013.

RESULTS

MIHP participants had higher odds of receiving any prenatal care compared to matched women not participating in MIHP (OR=2.94, 95% CI=2.43, 3.60) and higher odds of receiving adequate prenatal care (OR=1.06, 95% CI=1.01, 1.11). MIHP participants had higher odds of receiving an appropriately timed postnatal visit (OR=1.50, 95% CI=1.43, 1.57). Infants participating in MIHP had higher odds of receiving any well-child visits over the first year of life (OR=1.70, 95% CI=1.51, 1.93) and higher odds of receiving the appropriate number of well-child visits over their first year of life (OR=1.47, 95% CI=1.35, 1.60) compared to matched nonparticipant infants.

CONCLUSIONS

The results from Michigan provide strong evidence for the effectiveness of a Medicaid-sponsored population-based home-visitation program in improving maternal prenatal and postnatal care and infant care. This evidence is important to consider as the federal healthcare reform is implemented and states are making decisions on the expansion of the Medicaid program.

Parenting interventions for the prevention of unintentional injuries in childhood

BACKGROUND

Parent education and training programmes can improve maternal psychosocial health, child behavioural problems and parenting practices. This review assesses the effects of parenting interventions for reducing child injury.

OBJECTIVES

To assess the effects of parenting interventions for preventing unintentional injury in children aged under 18 years and for increasing possession and use of safety equipment and safety practices by parents.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, BIOSIS Preview, PsycINFO, Sociological Abstracts, Social Science Citation Index, CINAHL, ProQuest Dissertations and Theses, ERIC, DARE, ASSIA, Web of Science, SIGLE and ZETOC. We also handsearched abstracts from the World Conferences on Injury Prevention & Control and the journal Injury Prevention. The searches were conducted in January 2011.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (non-RCTs) and controlled before and after studies (CBAs), which evaluated parenting interventions administered to parents of children aged 18 years and under, and reported outcome data on injuries for children (unintentional or unspecified intent), possession and use of safety equipment or safety practices (including the Home Observation for Measurement of the Environment (HOME) scale which contained an assessment of home safety) by parents. Parenting interventions were defined as those with a specified protocol, manual or curriculum aimed at changing knowledge, attitudes or skills covering a range of parenting topics.

DATA COLLECTION AND ANALYSIS

Studies were selected, data were extracted and quality appraised independently by two authors. Pooled relative risks (RR) were estimated using random effect models.

MAIN RESULTS

Twenty two studies were included in the review: 16 RCTs, two non-RCTs, one partially randomised trial which contained two randomised intervention arms and one non-randomised control arm, two CBA studies and one quasi randomised controlled trial. Seventeen studies provided interventions comprising parenting education and other support services; 15 of which were home visiting programmes and two of which were paediatric practice-based interventions. Two provided solely educational interventions. Nineteen studies recruited families who were from socio-economically disadvantaged populations, were at risk of adverse child outcomes or people who may benefit from extra support, such as single mothers, teenage mothers, first time mothers and mothers with learning difficulties. Ten RCTs involving 5074 participants were included in the meta-analysis, which indicated that intervention families had a statistically significant lower risk of injury than control families (RR 0.83, 95% CI 0.73 to 0.94). Sensitivity analyses undertaken including only RCTs at low risk of various sources of bias found the findings to be robust to including only those studies at low risk of detection bias in terms of blinded outcome assessment and attrition bias in terms of follow up of fewer than 80% of participants in each arm. When analyses were restricted to studies at low risk of selection bias in terms of inadequate allocation concealment the effect size was no longer statistically significant. Several studies found statistically significant fewer home hazards or a greater number of safety practices in intervention families. Of ten studies reporting scores on the HOME scale, data from three RCTs were included in a meta-analysis which found no evidence of a difference in quality of the home environment between treatment arms (mean difference 0.57, 95% CI -0.59 to 1.72). Most of the studies reporting home safety practices, home hazards or composite home safety scores found statistically significant effects favouring intervention arm families. Overall, using GRADE, the quality of the evidence was rated as moderate.

AUTHORS' CONCLUSIONS

Parenting interventions, most commonly provided within the home using multi-faceted interventions are effective in reducing child injury. There is fairly consistent evidence that they also improve home safety. The evidence relates mainly to interventions provided to families from disadvantaged populations, who are at risk of adverse child health outcomes or whose families may benefit from extra support. Further research is required to explore mechanisms by which these interventions may reduce injury, the features of parenting interventions that are necessary or sufficient to reduce injury and the generalisability to different population groups.

Well-child care clinical practice redesign for young children: a systematic review of strategies and tools

BACKGROUND AND OBJECTIVE

Various proposals have been made to redesign well-child care (WCC) for young children, yet no peer-reviewed publication has examined the evidence for these. The objective of this study was to conduct a systematic review on WCC clinical practice redesign for children aged 0 to 5 years.

METHODS

PubMed was searched using criteria to identify relevant English-language articles published from January 1981 through February 2012. Observational studies, controlled trials, and systematic reviews evaluating efficiency and effectiveness of WCC for children aged 0 to 5 were selected. Interventions were organized into 3 categories: providers, formats (how care is provided; eg, non-face-to-face formats), and locations for care. Data were extracted by independent article review, including study quality, of 3 investigators with consensus resolution of discrepancies.

RESULTS

Of 275 articles screened, 33 met inclusion criteria. Seventeen articles focused on providers, 13 on formats, 2 on locations, and 1 miscellaneous. We found evidence that WCC provided in groups is at least as effective in providing WCC as 1-on-1 visits. There was limited evidence regarding other formats, although evidence suggested that non-face-to-face formats, particularly web-based tools, could enhance anticipatory guidance and possibly reduce parents' need for clinical contacts for minor concerns between well-child visits. The addition of a non-medical professional trained as a developmental specialist may improve receipt of WCC services and enhance parenting practices. There was insufficient evidence on nonclinical locations for WCC.

CONCLUSIONS

Evidence suggests that there are promising WCC redesign tools and strategies that may be ready for larger-scale testing and may have important implications for preventive care delivery to young children in the United States.

Family-centered care: current applications and future directions in pediatric health care

Family-centered care (FCC) is a partnership approach to health care decision-making between the family and health care provider. FCC is considered the standard of pediatric health care by many clinical practices, hospitals, and health care groups. Despite widespread endorsement, FCC continues to be insufficiently implemented into clinical practice. In this paper we enumerate the core principles of FCC in pediatric health care, describe recent advances applying FCC principles to clinical practice, and propose an agenda for practitioners, hospitals, and health care groups to translate FCC into improved health outcomes, health care delivery, and health care system transformation.

Parenting knowledge: experiential and sociodemographic factors in European American mothers of young children

Knowledge of child rearing and child development is relevant to parenting and the well-being of children. Using a sociodemographically heterogeneous sample of 268 European American mothers of 2-year-olds, we assessed the state of mothers' parenting knowledge; compared parenting knowledge in groups of mothers who varied in terms of parenthood and social status; and identified principal sources of mothers' parenting knowledge in terms of social factors, parenting supports, and formal classes. On the whole, European American mothers demonstrated fair but less than complete basic parenting knowledge; age, education, and rated helpfulness of written materials each uniquely contributed to mothers' knowledge. Adult mothers scored higher than adolescent mothers, and mothers improved in their knowledge of parenting from their first to their second child (and were stable across time). No differences were found between mothers of girls and boys, mothers who varied in employment status, or birth and adoptive mothers. The implications of variation in parenting knowledge and its sources for parenting education and clinical interactions with parents are discussed.

Community-based interventions to optimize early childhood development in low resource settings

OBJECTIVE

Interventions targeting the early childhood period (0 to 3 years) help to improve neuro-cognitive functioning throughout life. Some of the more low cost, low resource-intensive community practices for this age-group are play, reading, music and tactile stimulation. This research was conducted to summarize the evidence regarding the effectiveness of such strategies on child development, with particular focus on techniques that may be transferable to developing countries and to children at risk of developing secondary impairments.

STUDY DESIGN

PubMed, PsycInfo, Embase, ERIC, CINAHL and Cochrane were searched for studies involving the above strategies for early intervention. Reference lists of these studies were scanned and other studies were incorporated based on snow-balling.

RESULT

Overall, 76 articles corresponding to 53 studies, 24 of which were randomized controlled trials, were identified. Sixteen of those studies were from low- and middle-income countries. Play and reading were the two commonest interventions and showed positive impact on intellectual development of the child. Music was evaluated primarily in intensive care settings. Kangaroo Mother Care, and to a lesser extent massage, also showed beneficial effects. Improvement in parent-child interaction was common to all the interventions.

CONCLUSION

Play and reading were effective interventions for early childhood interventions in low- and middle-income countries. More research is needed to judge the effectiveness of music. Kangaroo Mother Care is effective for low birth weight babies in resource poor settings, but further research is needed in community settings. Massage is useful, but needs more rigorous research prior to being advocated for community-level interventions.

Understanding Interventions and Outcomes in Mothers of Infants

The first two years after an infant's birth is a time of transition for mothers as changes in roles, responsibilities, expectations, and behaviors occur in response to the demands of caring for newborn infants and young children. Mothers play pivotal roles in overall child development and health and may benefit from nursing intervention that assists in the transition to motherhood. A review of the intervention literature related to the promotion of effective mothering was performed in order to examine the range of interventions and evidence of their usefulness for maternal-child and pediatric nursing practice. Five broad categories of interventions appropriate for nursing practice were identified through the literature review. Home visiting, skin-to-skin contact, individual, infant-focused education/counseling, and theory-based group intervention have a specific applicability for the promotion of mothering in particular populations of mothers. Based on the evidence, nurses can incorporate selected strategies into nursing care to promote effective mothering during the first years of a child's life.

Healthy Steps: a systematic review of a preventive practice-based model of pediatric care

The preventive role of anticipatory guidance in pediatric practice has gained increasing importance over the last two decades, resulting in the development of competing models of practice-based care. Our goal was to systematically evaluate and summarize the literature pertaining to the Healthy Steps Program for Young Children, a widely cited and utilized preventive model of care and anticipatory guidance, Medline and the bibliographies of review articles for relevant studies were searched using the keywords: Healthy Steps, preventive care, pediatric practice and others. Other sources included references of retrieved publications, review articles, and books; government documents; and Internet sources. Relevant sources were selected on the basis of their empirical evaluation of some component of care (e.g., child outcomes, parent outcomes, quality of care). From 21 identified articles, 13 met the inclusion criteria of empirical evaluation. These evaluations were summarized and compared. 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. It is recommended that the Healthy Steps program be more widely disseminated to relevant stakeholders, and further enhanced by improved linguistic and cultural sensitivity and long term evaluation of cost effectiveness.

Parenting interventions and the prevention of unintentional injuries in childhood: systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of parenting interventions in preventing unintentional injury and increasing parental safety practices.

DATA SOURCES

A range of medical and social science electronic databases were searched. Abstracts from the first to seventh World conferences on injury prevention and control and the journal Injury Prevention were hand searched.

REVIEW METHODS

Randomized controlled trials (RCTs), non-randomized controlled trials (non-RCTs) and controlled before and after studies, providing parenting interventions to parents of children aged 0-18 years and reporting injuries, safety equipment or safety practices were included. Studies were selected, data extracted and quality appraised independently by two reviewers. Pooled relative risks were estimated using random effect models.

RESULTS

Fifteen studies (11 RCTs) were included, 11 of which were home visiting programmes and two of which were paediatric practice-based interventions. Thirteen studies recruited families at risk of adverse child health outcomes. Intervention arm families had a significantly lower risk of injury (RR 0.82, 95% CI 0.71-0.95), as measured by self-report of medically or non-medically attended injury. Several studies found fewer home hazards, a home environment more conducive to child safety, or a greater number of safety practices in intervention arm families.

CONCLUSIONS

Parenting interventions, most commonly provided within the home, using multi-faceted interventions appear to be effective in reducing unintentional child injury. Further research is required to explore the mechanisms by which parenting interventions reduce injury, the features of interventions that are necessary to reduce injury, and their generalizability to different population groups.

Parenting interventions for the prevention of unintentional injuries in childhood

BACKGROUND

Parent education and training programmes can improve maternal psychosocial health, child behavioural problems and parenting practices. This review assesses the effects of parenting interventions for reducing child injury.

OBJECTIVES

To assess the effects of parenting interventions for preventing unintentional injury as well as increasing possession and use of safety equipment and parental safety practices.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, Biological Abstracts, Psych INFO, Sociofile, Social Science Citation Index, CINAHL, Dissertation Abstracts, ERIC, DARE, ASSIA, Web of Science, SIGLE and ZETOC. We also handsearched abstracts from the World Conferences on Injury Prevention & Control and the journal Injury Prevention. The searches were conducted in May 2005.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (non-RCTs) and controlled before and after studies (CBAs), which evaluated parenting interventions administered to parents of children aged 18 years and under, and reported outcome data on injuries (unintentional or unspecified intent), and possession and use of safety equipment or safety practices. Parenting interventions were defined as those with a specified protocol, manual or curriculum aimed at changing knowledge, attitudes or skills covering a range of parenting topics.

DATA COLLECTION AND ANALYSIS

Studies were selected, data were extracted and quality appraised independently by two authors. Pooled relative risks (RR) were estimated using random effect models.

MAIN RESULTS

Fifteen studies were included in the review: 11 RCTs (one included a CBA within the same study), one non-RCT, one study contained both randomised and non-randomised arms and two CBAs. Two provided solely educational interventions. Thirteen provided interventions comprising parenting education and other support services; 11 of which were home visiting programmes and two of which were paediatric practice-based interventions. Thirteen studies recruited families at risk of adverse child health outcomes. Nine RCTs were included in the primary meta-analysis, which indicated that intervention families had a significantly lower risk of injury (RR 0.82, 95% CI 0.71 to 0.95). Several studies found fewer home hazards, a home environment more conducive to child safety, or a greater number of safety practices in intervention families.

AUTHORS' CONCLUSIONS

Parenting interventions, most commonly provided within the home using multi-faceted interventions may be effective in reducing child injury. The evidence relates mainly to interventions provided to families at risk of adverse child health outcomes. Further research is required to explore mechanisms by which these interventions reduce injury, the features of parenting interventions that are necessary or sufficient to reduce injury and the generalisability to different population groups.

Healthy Steps for Young Children program in pediatric residency training: impact on primary care outcomes

OBJECTIVE

Incorporating Healthy Steps for Young Children into pediatric practice has been shown to have positive effects for children and families. Although this model of care has also been integrated into several pediatric and family medicine training programs, published reports to date have focused only on residents' perceptions of their interactions with the model of care. In this study, we report the impact on primary care outcomes after integrating Healthy Steps for Young Children into residency training.

METHODS

Continuity of care, longitudinal care in the practice, quality of primary care services, and rates of behavioral, developmental, and psychosocial diagnoses were measured for 3 cohorts: (1) Healthy Steps-enrolled children, (2) non-Healthy Steps-enrolled children who were followed at the same site of care, and (3) non-Healthy Steps-enrolled children who were receiving primary care at a similar residency training site within the same training program. All data were extracted from patient charts at the 2 practice sites.

RESULTS

Continuity of care was significantly better for Healthy Steps-enrolled children compared with non-Healthy Steps-enrolled children at the Healthy Steps site for both total visits and health maintenance visits. Longitudinal care and quality of primary care services did not differ within or between sites. The rates of documentation of behavioral, developmental, or psychosocial diagnoses did not differ between Healthy Steps-enrolled and non-Healthy Steps-enrolled children at the Healthy Steps for Young Children site but were significantly different between the Healthy Steps and the non-Healthy Steps for Young Children sites; the effect was driven wholly by differences in psychosocial diagnoses.

CONCLUSIONS

Multiple indices that measure health service outcomes suggest benefits of incorporating Healthy Steps for Young Children into pediatric residency training. Most important, continuity of care in residents' practices significantly improved, as did the residents' documentation of psychosocial issues in children.

Healthy Steps for Young Children: sustained results at 5.5 years

OBJECTIVE

We sought to determine whether Healthy Steps for Young Children has sustained treatment effects at 5.5 years, given early findings demonstrating enhanced quality of care and improvements in selected parenting practices.

METHODS

Healthy Steps was a clinical trial that incorporated developmental specialists and enhanced developmental services into pediatric care in the first 3 years of life. A total of 5565 children were enrolled at birth and followed through 5.5 years. Healthy Steps was evaluated at 6 randomization and 9 quasi-experimental sites. Computer-assisted telephone interviews were conducted with mothers when Healthy Steps children were 5.5 years of age. Outcomes included experiences seeking care, parent response to child misbehavior, perception of child's behavior, and parenting practices to promote development and safety. Logistic regression was used to estimate overall effects of Healthy Steps, adjusting for site and baseline demographic characteristics.

RESULTS

A total of 3165 (56.9%) families responded to interviews (usual care: n = 1441; Healthy Steps: n = 1724). Families that had received Healthy Steps services were more satisfied with care (agreed that pediatrician/nurse practitioner provided support, 82.0% vs 79.0%; odds ratio: 1.25 [95% confidence interval: 1.02-1.53]) and more likely to receive needed anticipatory guidance (54.9% vs 49.2%; odds ratio: 1.33 [95% confidence interval: 1.13-1.57]) (all P < .05). They also had increased odds of remaining at the original practice (65.1% vs 61.4%; odds ratio: 1.19 [95% confidence interval: 1.01-1.39]). Healthy Steps families reported reduced odds of using severe discipline (slap in face/spank with object, 10.1% vs 14.1%; odds ratio: 0.68 [95% confidence interval: 0.54-0.86]) and increased odds of often/almost always negotiating with their child (59.8% vs 56.3%; odds ratio: 1.20 [95% confidence interval: 1.03-1.39]). They had greater odds of reporting a clinical or borderline concern regarding their child's behavior (18.1% vs 14.8%; odds ratio: 1.35 [95% confidence interval: 1.10-1.64]) and their child reading books (59.4% vs 53.6%; odds ratio: 1.16 [95% confidence interval: 1.00-1.35]). There were no effects on safety practices.

CONCLUSIONS

Sustained treatment effects, albeit modest, are consistent with early findings. Universal, practice-based interventions can enhance quality of care for families with young children and can improve selected parenting practices beyond the duration of the intervention.

Expanding developmental and behavioral services for newborns in primary care: implications of the findings

BACKGROUND

In two other papers in this issue, the rationale, development, implementation, experimental design, approach to evaluation, and early results of a program to deliver developmental and behavioral services to all infants in primary care practice were described. Positive effects were seen for parental satisfaction, including decreased disenrollment, provider satisfaction, parenting practices, and health outcomes.

METHODS

In the present article, the results are reviewed and implications of our findings for the delivery of care, families, healthcare systems, and further research are discussed.

RESULTS

Findings that have broad implications are as follows: (1) developmental and behavioral services can be delivered successfully in practice using dedicated professionals to deliver and integrate services; (2) the "planned care model" was useful in program implementation for making "the right thing to do, the easy thing to do"; (3) the added focus on satisfaction and cost helps to develop the "business case" for broad scale implementation; (4) bonding of parents to organizations has marketing implications; (5) the program provides positive effects for all parents, not just high-risk parents; and (6) several research questions emerge, including persistence of effects on health outcomes, costs, and utilization.

CONCLUSIONS

The authors conclude that study results have implications for preventive services, families, child healthcare in office practice, healthcare systems, and healthcare policy. In this ongoing study, examination of intervention effects at 30 months of age shoud be informative. Further research is warranted as it remains to be seen whether or not these interventions can become viable ongoing programs.

Expanding developmental and behavioral services for newborns in primary care: program design, delivery, and evaluation framework

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 randomly 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.