Smartphone-Based Video Antenatal Preterm Birth Education: The Preemie Prep for Parents Randomized Clinical Trial.

Importance: Preterm birth is a leading cause of infant mortality and child morbidity. Preterm birth is not always unexpected, yet standard prenatal care does not offer anticipatory education to parents at risk of delivering preterm, which leaves parents unprepared to make health care choices during the pregnancy that can improve survival and decrease morbidity in case of preterm birth. Objective: To evaluate the effect of the Preemie Prep for Parents (P3) program on maternal knowledge of preterm birth, preparation for decision-making, and anxiety. Design, Setting, and Participants: Recruitment for this randomized clinical trial conducted at a US academic medical center took place from February 3, 2020, to April 12, 2021. A total of 120 pregnant persons with a risk factor for preterm birth were enrolled between 16 and 21 weeks' gestational age and followed up through pregnancy completion. Intervention: Starting at 18 weeks' gestational age, P3 program participants received links delivered via text message to 51 gestational age-specific short animated videos. Control participants received links to patient education webpages from the American College of Obstetricians and Gynecologists. Main Outcomes and Measures: At 25 weeks' gestation, scores on the Parent Prematurity Knowledge Questionnaire (scored as percent correct), Preparation for Decision Making Scale (scored 0-100), and Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety computerized adaptive test. Analysis was based on an intention to treat. Results: A total of 120 pregnant participants (mean [SD] age, 32.5 [4.9] years) were included in the study; 60 participants were randomized to each group. Participants in the P3 group scored higher than those in the control group on knowledge of long-term outcomes at 25 weeks (88.5% vs 73.2%; estimated difference, 15.3 percentage points; 95% CI, 8.3-22.5 percentage points; P < .001). Participants in the P3 group reported being significantly more prepared than did participants in the control group for neonatal resuscitation decision-making at 25 weeks (Preparation for Decision Making Scale score, 76.0 vs 52.3; difference, 23.7; 95% CI, 14.1-33.2). There was no difference between the P3 group and the control group in anxiety at 25 weeks (mean [SE] PROMIS Anxiety scores, 53.8 [1.1] vs 54.0 [1.1]; difference, -0.1; 95% CI, -3.2 to 2.9). Conclusions and Relevance: In this randomized clinical trial, pregnant persons randomly assigned to the P3 program had more knowledge of core competencies and were more prepared to make decisions that affect maternal and infant health, without experiencing worse anxiety. Mobile antenatal preterm birth education may provide a unique benefit to parents with preterm birth risk factors. Trial Registration: ClinicalTrials.gov Identifier: NCT04093492.

Implementing an Electronic Patient-Reported Outcome and Decision Support Tool in Early Intervention.

OBJECTIVE: The aim of the study is to identify and prioritize early intervention (EI) stakeholders' perspectives of supports and barriers to implementing the Young Children's Participation and Environment Measure (YC-PEM), an electronic patient-reported outcome (e-PRO) tool, for scaling its implementation across multiple local and state EI programs. METHODS: An explanatory sequential (quan > QUAL) mixed-methods study was conducted with EI families (n = 6), service coordinators (n = 9), and program leadership (n = 7). Semi-structured interviews and focus groups were used to share select quantitative pragmatic trial results (e.g., percentages for perceived helpfulness of implementation strategies) and elicit stakeholder perspectives to contextualize these results. Three study staff deductively coded transcripts to constructs in the Consolidated Framework for Implementation Research (CFIR). Data within CFIR constructs were inductively analyzed to generate themes that were rated by national early childhood advisors for their relevance to longer term implementation. RESULTS: All three stakeholder groups (i.e., families, service coordinators, program leadership) identified thematic supports and barriers across multiple constructs within each of four CFIR domains: (1) Six themes for "intervention characteristics," (2) Six themes for "process," (3) three themes for "inner setting," and (4) four themes for "outer setting." For example, all stakeholder groups described the value of the YC-PEM e-PRO in forging connections and eliciting meaningful information about family priorities for efficient service plan development ("intervention characteristics"). Stakeholders prioritized reaching families with diverse linguistic preferences and user navigation needs, further tailoring its interface with automated data capture and exchange processes ("process"); and fostering a positive implementation climate ("inner setting"). Service coordinators and program leadership further articulated the value of YC-PEM e-PRO results for improving EI access ("outer setting"). CONCLUSION: Results demonstrate the YC-PEM e-PRO is an evidence-based intervention that is viable for implementation. Optimizations to its interface are needed before undertaking hybrid type-2 and 3 multisite trials to test these implementation strategies across state and local EI programs with electronic data capture capabilities and diverse levels of organizational readiness and resources for implementation.

Is medical home care adequacy associated with educational service use in children and youth with autism spectrum disorder (ASD)?

BACKGROUND: The American Academy of Pediatrics (AAP) recommends medical home care for children and youth with autism spectrum disorder (ASD) for health needs. Children and youth with ASD also receive educational services for cognitive, social, and behavioral needs. We measured whether inadequate medical home care was significantly associated with current educational service use, controlling for sociodemographic factors. METHODS: We analyzed the 2016/2017 National Survey of Children's Health (NSCH) on 1,248 children and youth with ASD ages 1-17. Inadequate medical home care was operationalized as negative or missing responses to at least one medical home component. Educational service use was defined as current service use under individualized family service plans (IFSP) and individualized education programs (IEP). RESULTS: Inadequate medical home care was significantly associated with higher likelihood of current educational service use (aOR = 1.95, 95% CI [1.10, 3.44], p = 0.03). After adjustment, older children (aOR = 0.91, 95% CI [0.84, 0.99], p = 0.03), lower maternal health (aOR = 0.52, 95% CI [0.29, 0.94], p = 0.03), and children without other special health care factors (aOR = 0.38, 95% CI [0.17-0.85], p = 0.02) had significantly lower odds of current educational service use. CONCLUSIONS: Inadequate medical home care yielded higher odds of current educational service use. Child's age, maternal health, and lack of other special health care factors were associated with lower odds of current educational service use. Future research should examine medical home care defined in the NSCH and improving educational service use via medical home care.

Learning from Graduate and Undergraduate Public Health Virtual Internship Experiences with State Title V Agencies During COVID-19, Summer 2020.

BACKGROUND: Since summer 2014, the National MCH Workforce Development Center has placed students from MCH public health graduate (Centers of Excellence and Catalyst) and undergraduate (MCH Pipeline) programs, all funded by the Maternal and Child Health Bureau, in summer internships with state and territorial Title V agencies. In 2020, due to the COVID-19 pandemic the Title V MCH Internship Program was offered virtually. PARTICIPANTS AND METHODS: This manuscript includes quantitative and qualitative data from 2017 to 2020 generated by both Title V MCH Internship student interns (n = 76) and their preceptors (n = 40) with a focus on a comparison between the 2020 virtual year and the 2017-2019 years. RESULTS: Evaluation data from the 2017 to 2020 Title V MCH Internship Program from both students and preceptors revealed the implementation of a robust and successful internship program in which students increased their confidence in a variety of team, mentorship, and leadership skills while gaining direct exposure to the daily work of state Title V agencies. However, students and preceptors identified more challenges during 2020 compared to previous years. CONCLUSIONS: The COVID-19 Pandemic was both a disruption and a catalyst for change in education. While there were clearly some challenges with the pivot to a virtual Title V MCH Internship Program in summer 2020, students were able to participate in meaningful internship experiences. This success can be attributed to the ability of the internship sponsor to engage in best practices, including extensive planning and provision of ongoing support to the students. Going forward, it is recognized that virtual internships may facilitate access to agencies in distant locales, eliminating issues related to housing and transportation. When both virtual and in-person relationships are available, those responsible for internship programs, including the Title V MCH Internship, will need to weigh these type of benefits against the potential missed opportunities students may have when not able to participate in on-site experiences.

"Watch Me!" Training Increases Knowledge and Impacts Attitudes Related to Developmental Monitoring and Referral Among Childcare Providers.

OBJECTIVES: To evaluate the impact of "Watch Me!" developmental monitoring training on childcare providers' knowledge and attitudes related to monitoring developmental milestones and making recommended referrals when there is a concern about a child's development. METHODS: A pretest-posttest design using web-based surveys was used to assess the impact of "Watch Me!" training on knowledge and attitudes related to conducting five key components of developmental monitoring (tracking development, recognizing delays, talking to parents about development, talking to parents about concerns, and making referrals). Variables included belief that developmental monitoring is important and is part of childcare provider role; perceived knowledge of, access to tools for, and prioritization of developmental monitoring; and ability to list recommended referrals when there is a concern. RESULTS: Childcare providers demonstrated a significant pre-post increase in perceived knowledge and access to the tools to engage in five core components of developmental monitoring after completing "Watch Me!" training. There was also a significant pre-post increase in childcare providers' ability to list the child's doctor as an appropriate referral (39 pre-63% post), but not in the ability to list Part C/Part B programs as an appropriate referral (56 pre-58% post). CONCLUSIONS FOR PRACTICE: "Watch Me!" training may be effective at impacting targeted areas of knowledge and attitude about developmental monitoring among childcare providers in the short term.

Development and utility of the Family-Centered Autism Navigation interview.

LAY ABSTRACT: When a parent learns of their child's autism diagnosis, they may be overwhelmed, confused, and frustrated. Family navigation services are designed to improve access to care. While these services are a promising intervention to enhance well-being and developmental outcomes, there are limited tools that can systematically facilitate the development of a shared navigation plan that prioritizes the concerns of the family. The Family-Centered Autism Navigation semi-structured interview guide is designed for family navigators to triage and prioritize caregiver's needs to coordinate and navigate systems of care after learning of their child's autism spectrum disorder diagnosis. The goals of the Family-Centered Autism Navigation interview are to (1) identify family and child strengths; (2) identify family/caregiver concerns regarding navigation of services and systems following their child's diagnosis of autism; (3) measure change in caregiver knowledge, ability and skill as it relates to understanding, remembering, and evaluating information they receive; and (4) assist with the development of a shared navigation plan. When using the Family-Centered Autism Navigation guide, family navigators and caregivers co-create a family-centered, prioritized action plan that supports and prepares caregivers as they navigate systems of care. This short report describes the development process of the Family-Centered Autism Navigation semi-structured interview guide. We utilized brief interviews (n = 42), expert feedback (n = 13), and quality improvement strategies (n = 2 family navigators) to develop the questions and determine the usability of the Family-Centered Autism Navigation interview in practice.

Giving Voice to Parents in the Development of the Preemie Prep for Parents (P3) Mobile App.

BACKGROUND: Parents at risk for preterm birth frequently receive prematurity education when the mother is hospitalized for premature labor. Parental ability to learn and consider the information is limited because of the stress of the hospitalization. A promising approach is dissemination of information to at-risk parents before the birth hospitalization. PURPOSE: This article describes formative research used to develop smartphone-based prematurity education app for parents at-risk for preterm birth. METHODS: Stakeholders were parents with a prior preterm birth. Using stakeholder meeting transcripts, constant comparative analysis was used to reflect upon the parental voice. RESULTS: The parents named the app, Preemie Prep for Parents (P3). Parent perspectives revealed desire for information in the following 5 categories. (1) Power in knowledge and control: parents want autonomy when learning information that may influence medical decision-making. (2) Content and framing of information: they desire information from a trusted resource that helps promote prenatal health and provides neonatal intensive care information. (3) Displaying content: parents want personalization, push notifications, photographs displaying fetal development, and easy-to-understand statistics. (4) Providing information without causing harm: they desire non-value-laden information, and they do not support "gamifying" the app to enhance utilization. (5) Decision making: parents want information that would benefit their decision making without assuming that parents have a certain outlook on life or particular values. IMPLICATIONS FOR PRACTICE: These findings support the need for the P3 App to aid in decision making when parents experience preterm birth. IMPLICATIONS FOR RESEARCH: The findings highlight the need to study the effects of smartphone-based prematurity education on medical decision-making.

Magnetic Resonance Imaging: A Personalized Approach to Understanding Fatty Liver Disease.

OBJECTIVES: To assess information retention by parents/caretakers regarding nonalcoholic fatty liver disease (NAFLD) utilizing the actual image of their child's affected liver. METHODS: In this pilot study, parents/caretakers of children with newly diagnosed NAFLD were presented with an magnetic resonance (MR) image of their child's fatty liver. An adjacent image of a normal-appearing liver was used to highlight the degree of fat accumulation present in their child's liver. The appearance of the fatty liver was used as an adjunct to patient education as provided by a nurse clinician. The efficacy of this approach was determined by a set of image- and disease-specific queries. Health literacy was assessed concurrently by the Newest Vital Sign (NVS) instrument. The image- and disease-specific queries were then repeated by telephone follow-up 2 to 4 weeks after initial clinic visit. RESULTS: Parents/caretakers initially gave 100% correct responses regarding the variation of appearance of normal liver (pink) and their child's fatty liver (yellow). They also all correctly stated the fat content initially. At follow-up, their recall was 95% for the appearance of normal liver and 81% for fatty liver; recall was only 52% for fat content at follow-up. Nonvisualized elements of nonalcoholic steatohepatitis (NASH) and cirrhosis were not identified or recalled as well. Results may have been influenced by parent/caretaker health literacy competence. CONCLUSIONS: Personalized images of fatty liver were effective visualization tools for parents/caretakers to comprehend NAFLD and comprehension was not compromised by health literacy. Clear visual instruments may improve parent/caretaker comprehension of these conditions and may help to address deficiencies in health literacy.

African American Fathers' Occupational Participation: "Keeping the Mothers in a Positive Vibe".

Infant mortality is a major public health issue in the United States that disproportionally affects African Americans. Evidence suggests reducing stress on African American women and engaging African American fathers may improve health and social outcomes for families. This study sought to understand the experiences of African American fathers through a positivistic lens and to inform future interventions that support father engagement. A descriptive, qualitative study using the Person, Environment, Occupation-Performance (PEO-P) model as a framework for analysis was conducted involving 45 fathers participating in four focus groups and one member-checking group. An initial content analysis was followed by constant comparative methods to identify categories related to the PEO-P model. Transcripts revealed a range of factors that enable or inhibit fathers' occupational performance and engagement including environmental barriers such as societal expectations and perceptions. Occupational therapy practitioners may utilize population health approaches to support African American fathers' occupational engagement.

Online survey examining practitioners' perceived preparedness in the early identification of autism.

The purpose of this study was to examine the perceived preparedness of practitioners in the early identification of children ages birth to 6 yr with autism spectrum disorder (ASD). Both occupational therapists and occupational therapy assistants were included in this survey study. The online survey instrument consisted of 29 questions within six sections capturing participant demographics, delivery of occupational therapy services, action when autism is suspected, service delivery experience, resource sharing, and barriers to conducting autism screening. The results of the study provide baseline information concerning identified skills, practices, and barriers among 1,396 practitioners. Additionally, opportunities are revealed for professional development necessary to support practitioners in the early identification of children at risk for ASD through surveillance and screening among children ages birth to 6 yr.

"I cried because I didn't know if I could take care of him": toward a taxonomy of interactive and critical health literacy as portrayed by caregivers of children with special health care needs.

Although the contributions of reading ability and numeracy skills in successful navigation of health-related systems are understood, the skills that comprise interactive and critical health literacy are not fully explicit. Using a phenomenological approach and the conceptual frame of health literacy as an asset, we conducted focus group interviews with 35 caregivers of children who had significant medical needs. Caregiver quotes were coded and categorized and then compared to the Revised Blooms Taxonomy. The purpose of the analysis was to better understand the interactive and critical health literacy skills caregivers use when coordinating their children's care. The findings support a dynamic constructivist perspective of health literacy such that caregiver skill changed relative to the children's health conditions. In addition, a taxonomic code of cognitive and communicative skills emerged from the data. This taxonomy may be useful in developing instrumentation to measure interactive and critical health literacy as well as in identifying a potential foci of interventions aimed at improving interactive and critical health literacy.

Maternal health after the birth of a medically complex infant: setting the context for evaluation of co-occupational performance.

OBJECTIVE: Physical and psychological health indicators of mothers who gave birth to medically complex infants were examined to explore potential risk factors for the development of chronic conditions and to develop a scholarly base that supports the inclusion of maternal health in the scope of early intervention practice. METHOD: Ten mothers completed the Perinatal Posttraumatic Stress Disorder Questionnaire and the State Trait Anxiety Form Y-1. Nine women completed 24-h Holter recording. Frequency of symptoms of posttraumatic stress disorder (PTSD) and anxiety were determined. High frequency heart rate variability was examined for indicators of autonomic dysregulation. RESULTS: Nine of 10 women reported symptoms associated with PTSD, and 2 of these women reported more severe symptoms. Two women demonstrated indicators of autonomic dysregulation. CONCLUSION: Further research examining psychological and physical characteristics in mothers of infants at high risk is important to determine whether these women are at greater risk for chronic health conditions.

Readability levels of individualized family service plans.

This descriptive study examined the readability levels of Individualized Family Service Plans (IFSPs). The readability of 85 de-identified IFSP documents developed by seven agencies that serve families and children enrolled in a county early intervention program was analyzed using Flesch Kincaid grade levels and Flesch reading ease scores. The average Flesch Kincaid grade level of the entire IFSP documents was 8.0, indicating that the text was written at the 8th grade reading level. The Flesch reading ease mean score for all of the IFSP documents was 58.6, indicating that the text was written at a moderate level of ease to read. The highest Flesch Kincaid grade level scores and lowest reading ease scores were found in sections that require descriptive documentation of IFSP activities and ideas, justification for services provided outside of the natural environment, the way in which outcomes would be met, and a description of the activities provided in the natural environment. The lowest Flesch Kincaid grade level and the highest reading ease level were found in the section involving gross motor development. There were no agencies that prepared IFSP documents at or below the recommended 5th grade reading level. The findings from this study indicated that on average the entire IFSP documents and most sections of the documents were written above a 5th grade reading level. Overall there were no agencies that wrote the IFSP documents at or below the recommended 5th grade reading level. Analysis of readability levels when preparing IFSP documents is recommended to optimize accessibility and usability.

The pipeline training program in maternal and child health: interdisciplinary preparation of undergraduate students from underrepresented groups.

The Preparing Academically Successful Students in Maternal and Child Health (MCH PASS) training program provided financial support and specialized training to occupational therapy (OT) and speech-language pathology (SLP) undergraduate students from underrepresented groups in maternal and child health. The project assisted undergraduate trainees to matriculate into graduate programs in their respective fields and facilitated application into long-term maternal and child health training programs. Sixteen trainees (8 OT and 8 SLP) participated in an undergraduate training program with an emphasis on interdisciplinary teaming, family mentoring, leadership development, public health and population-based research. Instruction occurred in community and classroom settings through didactic instruction and small group discussions. Fifteen of the trainees applied to and were accepted in graduate programs in their respective fields. Two trainees applied to a long-term MCH training program. Students reported increased knowledge about programs that serve women and children, the effects of poverty on health, interdisciplinary teaming and the daily routines of families who have a child with a special health care need. The MCH PASS program provided a unique opportunity for undergraduate students in OT and SLP to learn about public health with an emphasis on maternal and child health. The specialized preparation enabled students to understand better the health concerns of underserved families whose children have special health care needs.

Pilot study investigating infant vagal reactivity and visual behavior during object perception.

OBJECTIVE: The authors examined whether changes in vagal tone were related to infant visual attention during auditory and visual events paired (synchronous) and not paired (asynchronous) in time. They predicted that infants would demonstrate greater visual attention to the synchronous slideshow and that vagal tone would decrease with visual attention. METHOD: Nineteen infants, 3.5 months old, watched computer-generated synchronous or asynchronous slideshows of auditory and visual stimuli. Visual behavior and vagal tone data were collected. Vagal tone reflects physiological responses during attention or exposure to mild stressors. Repeated-measures analysis of variance examined differences in vagal tone across conditions. RESULTS: Visual behavior did not differ between the synchronous and asynchronous slideshow conditions. Vagal tone was significantly lower during the asynchronous slideshow. CONCLUSION: Infants may discriminate synchronous from asynchronous stimuli without changing visual behavior. Implications related to play with toys or objects are discussed.

Exploring ordinary childhood occupations through community partnerships.

The purpose of this paper is to discuss an innovative assignment, The Occupational Outline and Disability Status Report, and to describe how a community-academic partnership was formed. Community-academic collaborations provide students with the opportunity to observe children in natural environments. This partnership facilitates the development of clinical reasoning skills necessary for pediatric practice in community settings. Through observation of ordinary childhood occupations at a children's museum and a written assignment, students identify the significance of play and social participation while hypothesizing about the influence of impairments on performance.

Maternal attitudes and self-definition as related to perceptions of infant temperament.

Maternal childbearing attitudes and self-definition as related to maternal perceptions of infant temperament were investigated in a pilot study. Maternal attitudes, self-definition, and perceptions of infant temperament were determined through mothers' self-report. Results indicated that maternal attitudes-including self-confidence and feelings toward infants and children-were positively related to maternal perceptions of infant temperament. That is, mothers who reported low self-confidence and negative feelings toward infants and children in general also rated their infants' temperament as more negative. In addition, maternal work experience involving children was inversely related to maternal perceptions of infant temperament, in that those mothers who had more work experience with children rated their infants as being more difficult. The findings are consistent with Sameroff's transactional model of development (Sameroff & Chandler, 1975) wherein both the psychological and behavioral aspects of mother and infant create the milieu for further development.

The psychobiological theory of attachment: a viable frame of reference for early intervention providers.

Psychobiological Attachment Theory (PAT) (Kraemer, 1992) provides a way of thinking about caregiver-infant relationships for use in clinical practice. This manuscript describes how the theory translates into a frame of reference that can be used in practice within the context of natural environments. A discussion of the theoretical base, function/dysfunction criteria, postulates regarding change, and presentation of an evaluation guide, provides a practical tool for use in early intervention practice.