Systematic Review: Feasibility,Reliability, and Validity of Maternal/Caregiver Attachment and Bonding Screening Tools for Clinical Use

IntroductionInfant–caregiver attachment is crucial for an infant's immediate and long-term social–emotional development and health. Despite advocacy by the National Institute of Children's Health Quality for infant social–emotional development screening, there is a lack of identified tools for use in primary care. Therefore, we conducted a systematic review to identify caretaker–infant attachment self-report screening tools that would be feasible, reliable, and valid for use in primary care.MethodA systematic search identified 340 abstracts/articles, which were screened using inclusion and exclusion criteria. Twelve articles and six self-report attachment tools were examined for reliability, validity, and feasibility characteristics.ResultsSix caregiver–infant attachment self-report tools were identified. Establishment of feasibility, reliability, and validity are in the early stages.DiscussionPotential infant–caretaker attachment screening tools were identified for use in primary care practices. Suggestions for research and practice include informal screening, additional psychometric testing, and development of policies supporting implementation of screening.     

The Role of Lay Health Workers in Pediatric Chronic Disease: A Systematic Review

BackgroundChildren with chronic diseases represent a high-cost and resource-intensive population of children. With continued gaps in chronic disease management and persistent fragmentation in the health care system, stakeholders are seeking new strategies to address the needs of these children.ObjectiveWe sought to systematically assess the effectiveness of lay health worker interventions in improving health care utilization, symptom management, and family psychosocial outcomes for children with chronic conditions.Data SourcePubMed, PsycINFO, and Web of Science (January 1961 to February 2013).Study Eligibility Criteria, Participants, and InterventionsWe developed a strategy to search citations to identify relevant articles. Search terms included randomized controlled trial (RCT), lay worker, parent mentor, peer mentor, peer educator, community health workers, community health aids, patient advocate, patient facilitator, patient liaison, promotoras(es), care ambassadors, patient navigator, and nonprofessional. Additional studies were identified by searching the reference lists of retrieved articles and contacting clinical experts. RCTs of lay health worker interventions for children with chronic conditions were included. Studies were restricted to those concentrated on children 0–18 years of age with chronic illnesses.Study Appraisal and Synthesis MethodsAbstracts were independently screened by 2 reviewers. Articles with relevant abstracts underwent full text review and were evaluated for inclusion criteria. A structured tool was used to abstract data from selected articles. Because of the heterogeneous interventions and outcomes, we did not conduct a meta-analysis.ResultsThe search yielded 736 unique articles, of which 17 met inclusion criteria. All interventions focused on specific conditions: asthma, type I diabetes, obesity, and failure to thrive. Interventions were heterogeneous in frequency, mode, and duration of interactions between lay health workers and subjects. Several interventions were multifaceted, including both one-on-one and group interactions. Improved outcomes most commonly reported were reduced urgent care use, decreases in symptoms, fewer missed work and school days, and increased parental quality of life. One study demonstrated that lay health worker interventions were cost-effective.ConclusionsLay health workers interventions in children with chronic conditions may lead to modest improvements in urgent care use, symptoms, and parental psychosocial outcomes. Such interventions may also be cost-effective. Future research should focus on interventions targeted toward other chronic conditions such as sickle cell disease or cystic fibrosis and medically complex children whose conditions are noncategorical.     

Let Them Speak for Themselves: Improving Adolescent Self-Report Rate on Pre-Visit Screening

BackgroundAdolescent pre-visit screening on patient-generated health data is a common and efficient practice to guide clinical decision making. However, proxy informants (eg, parents or caregivers) often complete these forms, which may lead to incorrect information or lack of confidentiality. Our objective was to improve the adolescent self-report rate on pre-visit screening.MethodsWe conducted an interventional study using an interrupted time series design to compare adolescent self-report rates (percent of adolescents ages 12−18 years completing their own pre-visit screening) over 16 months in general pediatric ambulatory clinics. We collected data using a computerized clinical decision support system with waiting room electronic tablet screening. Preintervention rates were low, and we created and implemented 2 electronic workflow alerts, one each to the patient/caregiver and clinical staff, reminding them that the adolescent should answer the questions independently. We included the first encounter from each adolescent and evaluated changes in adolescent self-reporting between pre- and postintervention periods using interrupted time series analysis.ResultsPatients or caregivers completed 2670 qualifying pre-visit screenings across 19 preintervention, 7 intervention, and 44 postintervention weeks. Self-reporting by younger adolescents nearly doubled, with a significant increase of 19.3 percentage points (confidence interval [CI], 9.1−29.5) from the baseline 20.5%. Among older adolescents, the stable baseline rate of 53.6% increased by 9.2 absolute percentage points (CI, −7.0 to 25.3). There were no significant pre- or postintervention secular trends.ConclusionsTwo automated alerts directing clinic personnel and families to have adolescents self-report significantly and sustainably improved younger adolescent self-reporting on electronic patient-generated health data instruments.     

Written Versus Verbal Food Insecurity Screening in One Primary Care Clinic

ObjectiveClinics are increasingly interested in identifying food insecurity (FI), but there are limited data on how to implement FI screening. Our objective was to determine the difference in FI disclosure rates by parents/guardians screened by a written questionnaire compared to verbally.MethodsThe study occurred in 1 pediatric primary care clinic in which we screened for FI using the 2-item Hunger Vital Sign. We used interrupted time series to evaluate the effect of changing from the clinician verbal screening to a written questionnaire. Screening results were extracted for all well-child visits from 4/2017 to 10/2018 for children age 0 to 18 years. The outcome was the proportion who screened positive for FI 9 months before and 9 months after the implementation of the written questionnaire. We estimated the difference in the level and trend of positive screens using ordinary least squares regression using Newey-West standard errors and adjusting for autocorrelation.ResultsIn 7996 well-child visits, 1141 patients (14.3%) screened positive. In bivariate analysis, there was a significant difference in the FI disclosure rates between patients screened by written questionnaire compared to verbally (16.3% vs 10.4%, P < .001). In interrupted time series, changing to the written questionnaire was associated with a significant increase in FI disclosure rates (β = .04, 95% confidence interval: 0.01, 0.07; P = .02). There was no significant change in the trend in disclosure rates.DiscussionMultiple barriers exist to effectively implementing FI screening in clinical care. Changing from a verbal to a written questionnaire resulted in an immediate and significant increase in the number of parents/guardians who reported FI.     

Engagement in a Social Needs Navigation Program and Health Care Utilization in Pediatric Primary Care

ObjectiveEvidence for social needs interventions on resource linkage has grown over the past decade. Though social and economic needs predict health care utilization, few studies have assessed social needs interventions on these outcomes. The objective of this study was to examine the association between enrollment in a clinic-based social needs program on subsequent well-child visit (WCV) attendance and emergency department (ED) use in 2 primary care clinics.MethodsA retrospective cohort study was conducted of patients in 2 clinics referred to a social risk screening and navigation program between June and August 2018. We compared health care utilization over the subsequent 12 months for those who completed a full intake and received resource navigation (enrolled) to those referred (not enrolled). Logistic regression was used to assess the association between enrollment with WCV attendance and ED visits.ResultsDuring the study period, of the 969 patients referred to the program, 761 were enrolled across the 2 clinics. At both sites, the majority of enrolled patients had high WCV attendance postintervention (Site A: 81.6%, Site B: 71.4%). High WCV attendance for nonenrolled but referred patients was significantly lower (Site A: 52.7%, Site B: 35.0%). Enrolled participants were significantly more likely to have high WCV attendance than nonenrolled patients, adjusting for preintervention utilization (Site A adjusted odds ratio [aOR]: 5.83, Site B aOR : 4.20). There were no significant differences in ED use at either clinic.ConclusionsAddressing families’ social needs through resource linkage and navigation can improve WCV attendance.     

Reducing Barriers to Autism Screening in Community Primary Care: A Pragmatic Trial Using Web-Based Screening

ObjectiveTo determine whether an intervention addressing both logistical and knowledge barriers to early screening for autism spectrum disorder (ASD) increases evidence-based screening during 18-month well-child visits and primary care providers' (PCPs’) perceived self-efficacy in caring for children with ASD.MethodsForty-six PCPs from 10 diverse practices across four counties in Washington State participated. PCPs attended a 2-hour training workshop on early recognition and care for toddlers with ASD and use of a REDCap-based version of the Modified Checklist for Autism in Toddlers–Revised with Follow-up (webM-CHAT-R/F) that provided automated presentation and scoring of follow-up questions. Data were collected at baseline and 6 months following each county's training window. PCPs’ screening methods and rates and perceived self-efficacy regarding ASD care were measured by self-report and webM-CHAT-R/F use was measured via REDCap records.ResultsAt follow-up, 8 of the 10 practices were using the webM-CHAT-R/F routinely at 18-month visits. The proportion of PCPs reporting routine M-CHAT screening increased from 82% at baseline to 98% at follow-up (16% increase, 95% confidence interval [CI] 3%–28%; McNemar exact P = .02). The proportion using the M-CHAT-R/F follow-up interview questions increased from 33% to 82% (49% increase, 95% CI 30%–68%, exact McNemar test, P < .001). Significant increases in self-efficacy were found for all seven areas assessed (Ps ≤ .008).ConclusionsThis brief intervention increased PCPs’ self-reported valid use of the M-CHAT-R/F at 18 months and their self-efficacy regarding ASD care. Combining educational information with a web-based ASD screen incorporating the M-CHAT-R/F follow-up questions may increase universal ASD screening with improved fidelity.     

Meeting the Needs of Postpartum Women: Provider Perspectives on Maternal Contraceptive Care in Pediatric Settings

ObjectiveClosely spaced, mistimed, and unwanted pregnancies are common among postpartum women and can lead to adverse maternal and perinatal outcomes. Women inconsistently attend postpartum obstetric visits, though they reliably interface with pediatric providers during the postpartum months, presenting novel opportunities to identify and address unmet family planning needs.MethodsWe conducted a qualitative study to explore pediatric provider perspectives on addressing maternal family planning in three settings: a neonatal intensive care unit, a primary care clinic, and a high-risk infant follow-up clinic.ResultsPediatric providers were generally open to incorporating postpartum family planning screening and counseling into a pediatric encounter, if given appropriate training and implementation support. Providers largely agreed that contraceptive provision to women was not feasible in their practices, and they shared ideas for utilizing the pediatric encounter to connect women with comprehensive contraceptive care.ConclusionPediatric providers perceived postpartum family planning screening and counseling, and not contraceptive provision, as potentially acceptable and feasible in their practice settings. These exploratory findings justify further investigation to assess their generalizability and to develop postpartum family planning interventions for pediatrics.     

Implementing Suicide Risk Screening in a Pediatric Primary Care Setting: From Research to Practice

ObjectiveTo describe the methodological development and feasibility of real-world implementation of suicide risk screening into a pediatric primary care setting.MethodsA suicide risk screening quality improvement project (QIP) was implemented by medical leadership from a suburban-based pediatric (ages 12–25 years) primary care practice in collaboration with a National Institute of Mental Health (NIMH) suicide prevention research team. A pilot phase to acclimate office staff to screening procedures preceded data collection. A convenience sample of 271 pediatric medical outpatients was screened for suicide risk. Patients, their parents, and medical staff reported their experiences and opinions of the screening procedures.ResultsThirty-one (11.4%) patients screened positive for suicide risk, with 1 patient endorsing imminent suicide risk (3% of positive screens; 0.4% of total sample). Over half of the patients who screened positive reported a past suicide attempt. Most patients, parents, and medical staff supported the implementation of suicide risk screening procedures into standard care. A mental health clinical pathway for suicide risk screening in outpatient settings was developed to provide outpatient medical settings with guidance for screening.ConclusionsScreening for suicide risk in pediatric primary care is feasible and acceptable to patients, their families, and medical staff. A clinical pathway used as guidance for pediatric health care providers to implement screening programs can aid with efficiently detecting and managing patients who are at risk for suicide.     

Improving Adolescent Depression Screening in Pediatric Primary Care

ObjectiveDepression among adolescents is a leading public health problem. Although screening for adolescent depression in primary care is strongly recommended, screening rates remain low. Effective quality improvement (QI) initiatives can facilitate change. This study aims to assess the impact of a QI learning collaborative on adolescent depression screening and initial plans of care in primary care.MethodsSeventeen pediatric-serving practices in Vermont participated in a QI learning collaborative aimed at improving practitioner knowledge and office systems around adolescent depression screening. Monthly medical record reviews provided monitoring of adolescent depression screening and initial plans of care over 7 months for QI. Randomly sampled annual medical record review data allowed comparison of screening and initial plans of care after the QI learning collaborative between participating and 21 control practices.ResultsAs practices improved their office systems around adolescent depression screening and initial plans of care, data showed marked improvement in depression screening at all 17 practices, from 34% to 97% over 7 months. Adolescents at participating practices had 3.5 times greater odds (95% confidence interval [CI], 1.14–10.98, P = .03) of being screened for depression and 37.5 times greater odds (95% CI, 7.67–183.48, P < .0005) of being screened with a validated tool than adolescents at control practices, accounting for patient characteristics.ConclusionsThere were significant within practice increases in adolescent depression screening after a QI learning collaborative, as well as in comparison with control practices 1 year later.     

Improving recognition of adolescent depression in primary care

OBJECTIVE: To address the following questions: (1) What evidence (ie, psychometric data collected in pediatric primary care, patient outcome data) exists for the various methods used to identify adolescent depression in primary care? and (2) What identification practices are currently in use? DATA SOURCES: We systematically searched MEDLINE for English-language articles using specific search terms and examined relevant titles, abstracts, and articles. STUDY SELECTION: We reviewed 1743 MEDLINE abstracts. Seventy-four articles were pulled for examination, with 30 articles meeting full criteria. DATA EXTRACTION: Five studies had adequate psychometric data on various adolescent depression identification methods in primary care. Only 1 compared the diagnostic accuracy of physicians trained to ask depression questions vs physicians trained in the use of a diagnostic aid. Six studies reported on current practice. Evidence regarding sensitivity, specificity, positive predictive value, and negative predictive value was sought for question 1. Frequency of screening was sought for question 2. DATA SYNTHESIS: Review of these articles found that few health care professionals use systematic depression identification methods, despite some growing evidence for their validity, feasibility, and possible efficacy. CONCLUSION: Available evidence indicates that primary care professionals would improve their rates of depression diagnosis through training, but even more so by using adolescent symptom rating scales.     

Mind-Body Skills Groups for Adolescents With Depression in Primary Care: A Pilot Study

IntroductionThe objective of this study was to determine the acceptability and preliminary effectiveness of Mind-Body Skills Groups (MBSGs) as a treatment for depressed adolescents in primary care.MethodA single-arm clinical trial was conducted. A 10-week MBSG program was implemented in primary care. Participants completed self-report measures at baseline, postintervention, and 3 months following the MBSGs. Measures included the Children's Depression Inventory-2, Suicidal Ideation Questionnaire, Mindful Attention Awareness Scale, Self-Efficacy for Depressed Adolescents, rumination subscale of the Children's Response Style Questionnaire, and a short acceptability questionnaire.ResultsParticipants included 43 adolescents. The total depression scores significantly improved following the MBSG intervention and continued to improve significantly from posttreatment to follow-up. Mindfulness, self-efficacy, rumination, and suicidal ideation all had significant improvement following the intervention. Acceptability of the program was strong, and attendance was excellent.DiscussionPreliminary evidence suggests that MBSGs are an acceptable treatment for primary care settings and lead to improved depression symptoms in adolescents.     

Characteristics of High-Performing Primary Care Pediatric Practices: A Qualitative Study

ObjectivePerformance on pediatric quality measures varies across primary care practices. Health care quality is associated with organizational factors, but their effect is understudied in pediatric care. This study aimed to develop hypotheses regarding the relationship between organizational factors and composite scores on pediatric quality measures.MethodsUsing a positive deviance approach, semistructured interviews were conducted with pediatricians and staff (N = 35) at 10 purposively selected high-performing pediatric primary care practices in Massachusetts between September and December 2016. Practices were sampled to achieve diversity in geographic location, size, and organizational structure. Interviews aimed to identify organizational strategies (eg, care processes) and contextual factors (eg, teamwork) that may be associated with performance on quality measures. Interviews were audiotaped, transcribed, and analyzed using qualitative content analytic methods.ResultsWe identified 4 major themes (MTs): MT1, Practice Culture; MT2, Practice Structures and Quality Improvement Tools; MT3, Attitudes and Beliefs Related to Measuring Care Quality; and MT4, Perceived Barriers to Achieving High Performance on Quality Measures. MT1 subthemes included contextual factors such as teamwork, leadership, and feeling respected as an employee. MT2 subthemes included fixed characteristics such as practice size and strategies such as the use of an electronic medical record. MT3 and MT4 subthemes linked these constructs to factors external to the practices.ConclusionsThis study suggested that elements of organizational culture may play as important a role in the quality of care delivered as specific quality improvement strategies. Interventions to further test this relationship may aid practices seeking to improve the care they deliver.     

Perspectives of Caregivers Experiencing Persistent Food Insecurity at an Academic Primary Care Clinic

ObjectiveFood insecurity (FI) is often transitory and instigated by changes in family circumstances or environmental events. Clinics have developed interventions to address FI, yet families may face persistent FI. Little is known about persistently food insecure families’ experiences with clinic-based interventions. The objective of this study was to evaluate the perspectives of caregivers experiencing persistent FI in a clinical setting.MethodsWe conducted 40 semistructured interviews at one academic primary care clinic between July 2019 and December 2019. The clinic routinely screened families for FI at every visit; families screening positive could meet with a care navigator and receive bags of nonperishable foods. Caregivers who received food bags at ≥3 visits, spoke English or Spanish, and were ≥18 years old were eligible to participate. Interviews were recorded, de-identified, transcribed, and systematically coded using inductive content analysis. A modified constant comparative method was used to iteratively review codes, identify emerging themes, and resolve differences through consensus.ResultsForty caregivers were interviewed; all were women; 45% were Hispanic/Latinx and 37.5% African American/Black. Three major themes emerged: 1) unmet social and medical needs and the challenges of caregiving complicate FI; 2) social supports help address FI and other social challenges that present barriers to accessing resources; and 3) caregivers provide practical recommendations for addressing persistent FI.ConclusionFamilies experiencing persistent FI described important social supports that help address FI and other social challenges that present barriers to accessing resources. Clinic-based resources were welcomed interventions, but their impact may be limited; practical recommendations were made.     

Guideline-Based Educational Intervention to Decrease the Risk for Readmission of Newborns With Severe Hyperbilirubinemia

IntroductionThe purpose of this study was to determine if educational intervention with medical providers in combination with a management tool to facilitate clinical guideline usage would (a) increase quality of care, (b) increase compliance with published guidelines, and (c) decrease hospital readmissions as a result of hyperbilirubinemia in the first week of life.MethodA quality improvement initiative was undertaken with a preintervention/postintervention design.InterventionAn educational intervention was offered to persons who provide medical care to newborns. The charts of newborns were reviewed before and after the intervention in three samples: a care quality sample (N = 244), a compliance sample (N = 240), and a readmission sample.ResultsIn the quality care sample, documentation of three quality care indicators improved significantly and one worsened significantly. In the compliance sample, the percentage of infants who were given appropriate follow-up appointments in primary care based on their hyperbilirubinemia risk at discharge improved (p = .03), and the readmission rate of newborns within the first week of life as a result of hyperbilirubinemia decreased by 50%.DiscussionAn educational intervention with a clinical tool may help change provider practice. Longer follow-up is needed to determine if the impact is sustainable.     

Screening for Adverse Childhood Experiences in Primary Care: A Quality Improvement Project

IntroductionThe American Academy of Pediatrics (AAP) advocates for the screening of Adverse Childhood Experiences (ACEs) during well-child care visits by pediatric health care providers. The evidence shows a strong correlation between children with high ACE scores and the likelihood of physical and mental health problems as adults. The purpose of this Quality Improvement (QI) project was to increase pediatric providers’ awareness on ACEs through education and increase the utilization of an ACE screening tool.MethodThis QI project used a pre-post test to evaluate the effectiveness of the educational model and the utilization of the screening tool within an urban pediatric primary care clinic.ResultsThis project demonstrated an increase in provider awareness as well as a marked increase in the utilization of the screening tool.DiscussionFour hundred eighty ACE screening tools were collected over a 12-week period. By introducing the ACE screening tool as the standard of care in the primary care office, providers can provide early interventions to mitigate the potential untoward outcomes. This QI project also demonstrated that there was a statistical and clinical significance (p value < 0.001) in the provider's knowledge pre-post the educational intervention.     

Community Health Workers in Schools: A Systematic Review

BackgroundCommunity health workers (CHWs) are trusted community members who provide health education and care. However, no consensus exists regarding whether community health worker-based interventions are effective within the school setting.ObjectiveTo determine outcomes and best practices of school-based community health worker interventions.Data SourcesPubMed, CINAHL, and SCOPUS databases.Study Eligibility CriteriaThis systematic literature review examined articles that described an intervention led by community health workers, targeted children and/or parents, and took place primarily within a Kindergarten-12^th grade school setting. Articles were excluded if they described an intervention outside the United States.ParticipantsCommunity health workers, children, and/or their parentsInterventionsSchool-based community health worker programsResultsOf 1875 articles identified, 13 met inclusion criteria and were included in the final analysis. Of these, 5 described a statistically significant primary outcome. Seven articles provided details regarding community health worker recruitment, training, and roles that would enable reproduction of the intervention.LimitationsThis review focused on interventions in the United States. Bias of individual studies had a wide range of scores (9–21). Heterogeneity of studies also precluded a meta-analysis of primary outcomes.Conclusions and Implications of Key FindingsThe utilization of Community health workers in school-based interventions for children and/or parents is promising. This review identified a lack of detail and uniformity in program presentation, specifically with Community health worker recruitment, training, and roles. A standardized reporting mechanism for Community health worker interventions in schools would better allow for reproducibility and scalability of existing studies.     

Enhancing the Electronic Health Record to Increase Counseling and Quit-Line Referral for Parents Who Smoke

ObjectiveTo assess the impact of an electronic health record (EHR) modification and brief clinician training on tobacco smoke exposure (TSE) management in pediatric primary care.MethodsWithin a teaching hospital-based, urban primary care setting, we modified the EHR to include TSE screening prompts, decision support, educational literature, and simplified referral to the state quit line (QuitWorks). A brief training was conducted for the 48 clinic physicians (34 residents and 14 attendings). We collected cross-sectional, independent, random samples of EHR data from well-child visits for children ≤12 years old seen 3 months before (2024 visits) and 3 months after (1895 visits) the intervention and pooled client data from QuitWorks to evaluate TSE screening, counseling, and quit-line referrals. A needs assessment questionnaire examined preintervention attitudes and practice around TSE management; follow-up questionnaires explored satisfaction and subjective changes in skills.ResultsThe baseline needs assessment revealed that although most clinicians agreed that it is appropriate for pediatricians to conduct TSE screening, counseling, and referral during well-child visits, only about half screened, 42% counseled, and 28% routinely offered to refer smoking parents. In pre–post analyses of 117 and 112 EHR-documented positive screens, the intervention was associated with a 16-fold greater likelihood of counseling among positive screens (adjusted odds ratio 16.12; 95% confidence interval 7.28, 35.68). Referrals to QuitWorks increased from 1 before to 31 after the intervention.ConclusionsImplementation of EHR modifications and a brief training to support TSE management was associated with higher rates of counseling and quit-line referrals for parents who smoke.     

Addressing the Social Needs of Spanish- and English-Speaking Families in Pediatric Primary Care

ObjectiveTo describe the social needs of families working with Health Leads (HL) at 18 pediatric practices in 9 US cities and how reported social needs and success addressing them varied according to parents’ preferred health care language.MethodsWe evaluated the social needs of English and Spanish speakers who received assistance from HL from September 2013 to August 2015. The study sample included 11,661 households in the 4 regions where HL provided support within pediatric primary care practices. We used multivariable regression stratified by region to assess the association between language and successful resource connections.ResultsReported social needs differed by language. Spanish speakers most frequently reported needs related to food (eg, food stamps, Special Supplemental Nutrition Program for Women, Infants, and Children, and food pantries). English speakers most frequently reported child-related needs (eg, childcare vouchers, Head Start, and school enrollment). The association between household language and the odds of a successful resource connection varied by region.ConclusionsOur findings highlight the importance of considering language barriers and community context when addressing unmet social needs as part of primary care.