Behavioral Parent Training for Families With Young Deaf or Hard of Hearing Children Followed in Hearing Health Care.

PURPOSE: It is well established that individuals with a communication disability, including being deaf or hard of hearing (DHH), experience inequities in health services and outcomes. These inequities extend to DHH children's access to psychosocial evidence-based interventions (EBIs). Behavioral parent training is an EBI that can be used to improve caregiver and child outcomes. Despite being supported by decades of effectiveness research, this EBI is rarely accessed by, or studied with, caregivers of DHH children. The purpose of this article is to describe a program of stakeholder-engaged research adapting and assessing behavioral parent training with caregivers of young DHH children followed in hearing health care, aimed at reducing inequities in access to this EBI. METHOD: The first section briefly summarizes the literature on disruptive behavior problems in young children, with a focus on preschool-age DHH children. The evidence base for behavioral parent training is described. Next, the gaps in knowledge and practice regarding disruptive behaviors among DHH children are highlighted, and the potential integration of behavioral parent training into the standard of care for this population is proposed. CONCLUSIONS: Young DHH children who use hearing aids and/or cochlear implants experience disruptive behavior problems at rates at least as high as typically hearing children, but their access to EBIs is limited, and behavioral parent training programs tailored to this population have not been rigorously tested. Caregivers and hearing health care service providers affirm the potential benefits of behavioral parent training and were partners in adapting this EBI. This research highlights several principles and approaches essential for reducing inequities and improving the quality of life not only for DHH children and their families but also for individuals with communication disabilities more broadly: engagement of key stakeholders in research, collaboration across disciplines, and using implementation science methods and models to design for implementation, dissemination, and sustainment. Presentation Video: https://doi.org/10.23641/asha.21215900.

Study Protocol: Type 1 Hybrid Effectiveness-Implementation Trial of a Behavioral Parent Training Intervention for Parents of Young Children Who Are Deaf or Hard of Hearing.

PURPOSE: Children who are deaf or hard of hearing (DHH) and who use hearing aids or cochlear implants are more likely than their peers with typical hearing to exhibit behavior problems. Although multiple evidence-based interventions for child behavior problems exist, they are rarely delivered to children who are DHH, and no rigorous randomized controlled trials have been conducted to determine their effects with this population. This protocol describes a study aiming to test the effectiveness of an evidence-based behavioral parent training intervention adapted for parents of young children who are DHH and simultaneously to assess key implementation outcomes and multilevel contextual factors influencing implementation. METHOD: The protocol for a Type 1 hybrid effectiveness-implementation trial of a behavioral parent training intervention for parents of young children who are DHH is presented, including details of the study design, participants, assessments, and analyses. Using a stakeholder-engaged, mixed-methods approach, we will test the effects of the intervention versus treatment as usual on parenting behaviors, child behaviors, and a range of secondary effectiveness outcomes, including adherence to using hearing aids and cochlear implants as well as measures of child speech and language. We will assess the acceptability, feasibility, fidelity, and costs of the intervention from the perspectives of peer coaches who deliver the intervention, hearing health care clinicians (including audiologists and speech-language pathologists), and administrators of programs serving young children who are DHH. CONCLUSIONS: Results of this trial will inform future efforts to close the gap between prevalence of behavioral problems in young children who are DHH and access to and use of evidence-based interventions to prevent and treat them. If effective, this intervention could be widely implemented using strategies informed by the findings of this study to benefit young children who are DHH and followed in hearing health care and their families.

Parent and Provider Preferences for Parenting Intervention Delivery in Rural Appalachia: A Qualitative Analysis Guiding Adaptation.

The public health impact of behavioral parent training (BPT) is limited, especially in underserved communities such as rural central Appalachia. To improve access to BPT in this region, we completed the first two steps of the ADAPT-ITT framework for systematic adaptation of evidence-based interventions: (1) assessing community perspectives about BPT delivery, and (2) deciding upon a specific intervention and adaptations needed to increase its acceptability and accessibility in rural central Appalachian counties. Guided by a community advisory board, we conducted key informant interviews with parents (N = 21) and three focus groups with child service providers to elicit stakeholders' perspectives about child behavior problems in their communities; existing resources; and preferences regarding four characteristics of BPT delivery: interventionist, modality, dose, and location. Results of directed content analysis led to the selection of local, trusted community health workers to deliver a brief, tailored BPT with flexibility in modality and location.

Rural Adult Perspectives on Impact of Hearing Loss and Barriers to Care.

Adult hearing loss has a significant impact on communication and quality of life. In spite of effective methods of diagnosis and treatment, many rural adults face significant barriers and delays in accessing care. The purpose of this study is to characterize the impact of hearing loss and the barriers for hearing healthcare in rural adults. Using stratified purposeful sampling, the study design involved semi-structured phone interviews with adults in the Appalachian region of Kentucky between 2016 and 2017 to describe perceived susceptibility to hearing loss; knowledge of hearing loss; cues leading to help-seeking; barriers limited access to care; benefits of seeking help; and self-rated confidence in seeking treatment. Thematic qualitative analysis was performed to identify recurring content themes. Forty adults participated in the study. Participants reported susceptibility to noise induced hearing loss with infrequent hearing protection use. Participants described concern with hearing loss-related communication barriers that could affect compliance with medical care, employment performance, personal safety, and relationship communication. Rural adult expressed willingness to seek hearing healthcare but reported a lack of providers in rural areas. The cost and the lack of insurance coverage for hearing aids were the most clearly articulated obstacles influencing access to care. Hearing loss has a significant impact on adults in rural areas. A lack of providers and the overwhelming cost of treatment are barriers to care. Further research is needed to identify novel methods to support rural adults seeking affordable hearing healthcare.

Fatigue and physical activity: Potential modifiable contributors to parenting sense of competence.

OBJECTIVES: Parenting sense of competence, as measured by the Parenting Sense of Competence Scale (PSCS), is defined as one's levels of satisfaction and self-efficacy experienced in the parenting role. Previous studies have identified significant associations among PSCS scores and a host of parenting characteristics predictive of child outcomes. Existing approaches to improving parenting sense of competence focus on developing parenting knowledge and skills; however, other modifiable contributing factors to parenting sense of competence may exist. We examined associations among fatigue, physical activity, and parenting sense of competence in a community sample of female primary caregivers of young children (N=137) recruited from a university-based pediatric primary care clinic. METHODS: Participants completed measures of child disruptive behavior disorders, parent fatigue, and parent physical activity level. Parenting sense of competence was measured with the 16-item PSCS. RESULTS: Participants' mean age was 32 years (SD=8 years), and most were non-Hispanic (87%) and White (70%). Multiple linear regression analyses revealed significant independent associations of fatigue (ß=-0.19, p=.02) and physical activity level (ß=0.20 and ß=0.25, p<.05) with parenting sense of competence, controlling for child disruptive behaviors, child age, and socioeconomic status. CONCLUSIONS: In this non-clinical sample of mothers of young children, the significant relationships among fatigue, physical activity level, and parenting sense of competence could suggest potential targets for preventive intervention.

Assessment of Behavioral Problems in Children With Hearing Loss.

OBJECTIVE: To compare the prevalence of disruptive behavior problems between preschool-aged children with hearing loss and normal hearing. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary academic center. PATIENTS: Caregivers of children (2-5 yr old) with normal hearing (NH) (n = 39), hearing loss using hearing aid(s) (HA) (n = 29), or cochlear implant(s) (CI) (n = 21). INTERVENTION(S): Demographic information and a mental health history were obtained. Child behavior and language development were assessed. MAIN OUTCOME MEASURE(S): The Young Child-Diagnostic Interview Schedule for Children-IV and the MacArthur-Bates Communication Development Inventory III. RESULTS: Distributions of race, socioeconomic status, insurance status, and parental home situation (single versus two parent family) were similar across all groups. Parents of children with hearing loss were significantly more likely to report behavior problems (HA = 41%, CI = 38%) than parents of NH children (10%; p = 0.002). Children with hearing loss were significantly more likely to meet diagnostic criteria for oppositional defiant disorder (HA = 48%, CI = 48%) than NH children (23%; p = 0.02). More NH children (8%) than hearing impaired children (0%) had accessed mental health services (p = 0.08). NH children were found to have more advanced language development than hearing-impaired children (p < 0.01), but controlling for Communication Development Inventory III percentiles, the observed behavioral differences remained. CONCLUSION: Controlling for language development, children with hearing loss have higher prevalence of and impairment from disruptive behaviors than their NH peers. These children are less likely to receive appropriate behavioral interventions. Further research is warranted to investigate the impact of disruptive behaviors on speech and hearing rehabilitation. Methods to improve access to effective behavioral interventions in this population are needed.

Promotion of early pediatric hearing detection through patient navigation: A randomized controlled clinical trial.

OBJECTIVES/HYPOTHESIS: To assess the efficacy of a patient navigator intervention to decrease nonadherence to obtain audiological testing following failed screening, compared to those receiving the standard of care. METHODS: Using a randomized controlled design, guardian-infant dyads, in which the infants had abnormal newborn hearing screening, were recruited within the first week after birth. All participants were referred for definitive audiological diagnostic testing. Dyads were randomized into a patient navigator study arm or standard of care arm. The primary outcome was the percentage of patients with follow-up nonadherence to obtain diagnostic testing. Secondary outcomes were parental knowledge of infant hearing testing recommendations and barriers in obtaining follow-up testing. RESULTS: Sixty-one dyads were enrolled in the study (patient navigator arm = 27, standard of care arm = 34). The percentage of participants nonadherent to diagnostic follow-up during the first 6 months after birth was significantly lower in the patient navigator arm compared with the standard of care arm (7.4% vs. 38.2%) (P = .005). The timing of initial follow-up was significantly lower in the navigator arm compared with the standard of care arm (67.9 days after birth vs. 105.9 days, P = .010). Patient navigation increased baseline knowledge regarding infant hearing loss diagnosis recommendations compared with the standard of care (P = .004). CONCLUSIONS: Patient navigation decreases nonadherence rates following abnormal infant hearing screening and improves knowledge of follow-up recommendations. This intervention has the potential to improve the timeliness of delivery of infant hearing healthcare; future research is needed to assess the cost and feasibility of larger scale implementation. LEVEL OF EVIDENCE: 1b. Laryngoscope, 127:S1-S13, 2017.

The role of researchers in disseminating evidence to public health practice settings: a cross-sectional study.

BACKGROUND: Evidence-based public health interventions, which research has demonstrated offer the most promise for improving the population's health, are not always utilized in practice settings. The extent to which dissemination from researchers to public health practice settings occurs is not widely understood. This study examines the extent to which public health researchers in the United States are disseminating their research findings to local and state public health departments. METHODS: In a 2012, nationwide study, an online questionnaire was administered to 266 researchers from the National Institutes of Health, the Centers for Disease Control and Prevention, and universities to determine dissemination practices. Logistic regression analyses were used to examine the association between dissemination to state and/or local health departments and respondent characteristics, facilitators, and barriers to dissemination. RESULTS: Slightly over half of the respondents (58%) disseminated their findings to local and/or state health departments. After adjusting for other respondent characteristics, respondents were more likely to disseminate their findings to health departments if they worked for a university Prevention Research Center or the Centers for Disease Control and Prevention, or received their degree more than 20 years ago. Those who had ever worked in a practice or policy setting, those who thought dissemination was important to their own research and/or to the work of their unit/department, and those who had expectations set by their employers and/or funding agencies were more likely to disseminate after adjusting for work place, graduate degree and/or fellowship in public health, and the year the highest academic degree was received. CONCLUSIONS: There is still room for improvement in strengthening dissemination ties between researchers and public health practice settings, and decreasing the barriers researchers face during the dissemination process. Researchers could better utilize national programs or workshops, knowledge brokers, or opportunities provided through academic institutions to become more proficient in dissemination practices.

Capacity building for evidence-based decision making in local health departments: scaling up an effective training approach.

BACKGROUND: There are few studies describing how to scale up effective capacity-building approaches for public health practitioners. This study tested local-level evidence-based decision making (EBDM) capacity-building efforts in four U.S. states (Michigan, North Carolina, Ohio, and Washington) with a quasi-experimental design. METHODS: Partners within the four states delivered a previously established Evidence-Based Public Health (EBPH) training curriculum to local health department (LHD) staff. They worked with the research team to modify the curriculum with local data and examples while remaining attentive to course fidelity. Pre- and post-assessments of course participants (n=82) and an external control group (n=214) measured importance, availability (i.e., how available a skill is when needed, either within the skillset of the respondent or among others in the agency), and gaps in ten EBDM competencies. Simple and multiple linear regression models assessed the differences between pre- and post-assessment scores. Course participants also assessed the impact of the course on their work. RESULTS: Course participants reported greater increases in the availability, and decreases in the gaps, in EBDM competencies at post-test, relative to the control group. In adjusted models, significant differences (p<0.05) were found in 'action planning,' 'evaluation design,' 'communicating research to policymakers,' 'quantifying issues (using descriptive epidemiology),' and 'economic evaluation.' Nearly 45% of participants indicated that EBDM increased within their agency since the training. Course benefits included becoming better leaders and making scientifically informed decisions. CONCLUSIONS: This study demonstrates the potential for improving EBDM capacity among LHD practitioners using a train-the-trainer approach involving diverse partners. This approach allowed for local tailoring of strategies and extended the reach of the EBPH course.

What predicts dissemination efforts among public health researchers in the United States?

OBJECTIVES: We identified factors related to dissemination efforts by researchers to non-research audiences to reduce the gap between research generation and uptake in public health practice. METHODS: We conducted a cross-sectional study of 266 researchers at universities, the National Institutes of Health (NIH), and CDC. We identified scientists using a search of public health journals and lists from government-sponsored research. The scientists completed a 35-item online survey in 2012. Using multivariable logistic regression, we compared self-rated effort to disseminate findings to non-research audiences (excellent/good vs. poor) across predictor variables in three categories: perceptions or reasons to disseminate, perceived expectation by employer/funders, and professional training and experience. RESULTS: One-third of researchers rated their dissemination efforts as poor. Many factors were significantly related to whether a researcher rated him/herself as excellent/good, including obligation to disseminate findings (odds ratio [OR] = 2.7, 95% confidence interval [CI] 1.1, 6.8), dissemination important for their department (OR=2.3, 95% CI 1.2, 4.5), dissemination expected by employer (OR=2.0, 95% CI 1.2, 3.2) or by funder (OR=2.1, 95% CI 1.3, 3.2), previous work in a practice/policy setting (OR=4.4, 95% CI 2.1, 9.3), and university researchers with Prevention Research Center affiliation vs. NIH researchers (OR=4.7, 95% CI 1.4, 15.7). With all variables in the model, dissemination expected by funder (OR=2.0, 95% CI 1.2, 3.1) and previous work in a practice/policy setting (OR=3.5, OR 1.7, 7.1) remained significant. CONCLUSIONS: These findings support the need for structural changes to the system, including funding agency priorities and participation of researchers in practice- and policy-based experiences, which may enhance efforts to disseminate by researchers.

Training the workforce in evidence-based public health: an evaluation of impact among US and international practitioners.

INTRODUCTION: The Prevention Research Center in St. Louis developed a course on evidence-based public health in 1997 to train the public health workforce in implementation of evidence-based public health. The objective of this study was to assess use and benefits of the course and identify barriers to using evidence-based public health skills as well as ways to improve the course. METHODS: We used a mixed-method design incorporating on-site pre- and post-evaluations among US and international course participants who attended from 2008 through 2011 and web-based follow-up surveys among course participants who attended from 2005 through 2011 (n = 626). Respondents included managers, specialists, and academics at state health departments, local health departments, universities, and national/regional health departments. RESULTS: We found significant improvement from pre- to post-evaluation for 11 measures of knowledge, skill, and ability. Follow-up survey results showed at least quarterly use of course skills in most categories, majority endorsement of most course benefits, and lack of funding and coworkers who do not have evidence-based public health training as the most significant barriers to implementation of evidence-based public health. Respondents suggested ways to increase evidence-based decision making at their organization, focusing on organizational support and continued access to training. CONCLUSION: Although the evidence-based public health course is effective in improving self-reported measures of knowledge, skill, and ability, barriers remain to the implementation of evidence-based decision making, demonstrating the importance of continuing to offer and expand training in evidence-based public health.

Designing for dissemination among public health researchers: findings from a national survey in the United States.

OBJECTIVES: We have described the practice of designing for dissemination among researchers in the United States with the intent of identifying gaps and areas for improvement. METHODS: In 2012, we conducted a cross-sectional study of 266 researchers using a search of the top 12 public health journals in PubMed and lists available from government-sponsored research. The sample involved scientists at universities, the National Institutes of Health, and the Centers for Disease Control and Prevention in the United States. RESULTS: In the pooled sample, 73% of respondents estimated they spent less than 10% of their time on dissemination. About half of respondents (53%) had a person or team in their unit dedicated to dissemination. Seventeen percent of all respondents used a framework or theory to plan their dissemination activities. One third of respondents (34%) always or usually involved stakeholders in the research process. CONCLUSIONS: The current data and the existing literature suggest considerable room for improvement in designing for dissemination.

Policy perceptions related to physical activity and healthy eating in Mississippi.

OBJECTIVE: Determine the public perceptions about policies related to physical activity and healthy eating to inform efforts to change policy for these important public health issues. DESIGN: Cross-sectional, structured phone interview survey. SETTING: Ten counties in Mississippi (5 counties with the highest and 5 with the lowest obesity prevalence). PARTICIPANTS: : Random sample of 2800 adults. MAIN OUTCOME MEASURE: Level of support for each individual policy and summary of support for 10 policies related to healthy eating and activity and 4 related to local funding for infrastructure for physical activity. RESULTS: This survey showed strong policy support among Mississippi residents for a diverse set of policies aimed at promoting healthy eating and physical activity behaviors. This was particularly true for those in counties with the highest levels of obesity. Support for policies related to healthy eating and activity was highest for the following: requiring at least 30 minutes of physical activity or physical education everyday for children in kindergarten through 12th grade (93%) and lowest for the following: taxing soda and soft drinks and using the money for public education campaigns to fight obesity in children (65%). Support for the use of local government funds to build and maintain infrastructure for physical activity was high across all categories, ranging from 86% (recreation centers) to 74% (swimming pools). The levels of support for each policy varied according to several demographic characteristics; in general, support for nearly every policy was greater among African Americans, females, and those in counties with higher levels of obesity. Logistic models predicting level of support for healthy eating and physical activity found significant associations with several demographic factors.

Oral diabetes medications: an update for home health clinicians.

Diabetes has become an epidemic in the United States and home healthcare clinicians are taking care of more patients with diabetes than ever. It takes an interdisciplinary team to provide the complicated care needed to keep patients with diabetes out of the hospital. Understanding the oral diabetes medications available is crucial for clinicians in improving outcomes for patients.

Tools for implementing an evidence-based approach in public health practice.

Increasing disease rates, limited funding, and the ever-growing scientific basis for intervention demand the use of proven strategies to improve population health. Public health practitioners must be ready to implement an evidence-based approach in their work to meet health goals and sustain necessary resources. We researched easily accessible and time-efficient tools for implementing an evidence-based public health (EBPH) approach to improve population health. Several tools have been developed to meet EBPH needs, including free online resources in the following topic areas: training and planning tools, US health surveillance, policy tracking and surveillance, systematic reviews and evidence-based guidelines, economic evaluation, and gray literature. Key elements of EBPH are engaging the community in assessment and decision making; using data and information systems systematically; making decisions on the basis of the best available peer-reviewed evidence (both quantitative and qualitative); applying program-planning frameworks (often based in health-behavior theory); conducting sound evaluation; and disseminating what is learned.

A survey tool for measuring evidence-based decision making capacity in public health agencies.

BACKGROUND: While increasing attention is placed on using evidence-based decision making (EBDM) to improve public health, there is little research assessing the current EBDM capacity of the public health workforce. Public health agencies serve a wide range of populations with varying levels of resources. Our survey tool allows an individual agency to collect data that reflects its unique workforce. METHODS: Health department leaders and academic researchers collaboratively developed and conducted cross-sectional surveys in Kansas and Mississippi (USA) to assess EBDM capacity. Surveys were delivered to state- and local-level practitioners and community partners working in chronic disease control and prevention. The core component of the surveys was adopted from a previously tested instrument and measured gaps (importance versus availability) in competencies for EBDM in chronic disease. Other survey questions addressed expectations and incentives for using EBDM, self-efficacy in three EBDM skills, and estimates of EBDM within the agency. RESULTS: In both states, participants identified communication with policymakers, use of economic evaluation, and translation of research to practice as top competency gaps. Self-efficacy in developing evidence-based chronic disease control programs was lower than in finding or using data. Public health practitioners estimated that approximately two-thirds of programs in their agency were evidence-based. Mississippi participants indicated that health department leaders' expectations for the use of EBDM was approximately twice that of co-workers' expectations and that the use of EBDM could be increased with training and leadership prioritization. CONCLUSIONS: The assessment of EBDM capacity in Kansas and Mississippi built upon previous nationwide findings to identify top gaps in core competencies for EBDM in chronic disease and to estimate a percentage of programs in U.S. health departments that are evidence-based. The survey can serve as a valuable tool for other health departments and non-governmental organizations to assess EBDM capacity within their own workforce and to assist in the identification of approaches that will enhance the uptake of EBDM processes in public health programming and policymaking. Localized survey findings can provide direction for focusing workforce training programs and can indicate the types of incentives and policies that could affect the culture of EBDM in the workplace.

Barriers to evidence-based decision making in public health: a national survey of chronic disease practitioners.

OBJECTIVE: Existing knowledge of evidence-based chronic disease prevention is not systematically disseminated or applied. This study investigated state and territorial chronic disease practitioners' self-reported barriers to evidence-based decision making (EBDM). METHODS: In a nationwide survey, participants indicated the extent to which they agreed with statements reflecting four personal and five organizational barriers to EBDM. Responses were measured on a Likert scale from 0 to 10, with higher scores indicating a larger barrier to EBDM. We analyzed mean levels of barriers and calculated adjusted odds ratios for barriers that were considered modifiable through interventions. RESULTS: Overall, survey participants (n=447) reported higher scores for organizational barriers than for personal barriers. The largest reported barriers to EBDM were lack of incentives/rewards, inadequate funding, a perception of state legislators not supporting evidence-based interventions and policies, and feeling the need to be an expert on many issues. In adjusted models, women were more likely to report a lack of skills in developing evidence-based programs and in communicating with policy makers. Participants with a bachelor's degree as their highest degree were more likely than those with public health master's degrees to report lacking skills in developing evidence-based programs. Men, specialists, and individuals with doctoral degrees were all more likely to feel the need to be an expert on many issues to effectively make evidence-based decisions. CONCLUSIONS: Approaches must be developed to address organizational barriers to EBDM. Focused skills development is needed to address personal barriers, particularly for chronic disease practitioners without graduate-level training.