Personal, environmental, and family factors of participation among young children

Participação em casa e fatores pessoais e ambientais em crianças e adolescentes com síndrome de Down

Objetivo

Descrever a participação em casa atual (frequência, envolvimento) e o desejo do cuidador por mudança na participação em casa de crianças e adolescentes com síndrome de Down, bem como fatores ambientais da casa, e explorar as associações de fatores pessoais e ambientais com a participação atual e o desejo do cuidador por mudança.

Método

Oitenta e dois cuidadores (média de idade = 45 anos e 10 meses) de crianças e adolescentes com síndrome de Down (média de idade = 10 anos e 7 meses) foram entrevistados sobre a participação em casa da criança e fatores ambientais utilizando a Medida de Participação e do Ambiente ‐ Crianças e Jovens. Além disso, foram coletados fatores pessoais e ambientais das crianças. Os resultados são relatados por meio de análise descritiva e correlações (coeficientes de correlação de Spearman ou teste U de Mann–Whitney) para descrever a relação entre a participação atual e o desejo do cuidador por mudança, com fatores pessoais e ambientais, para as variáveis ordinais e nominais, respectivamente (p < 0,05).

Resultados

A participação das crianças foi maior em cuidados pessoais e menor em atividades relacionadas à escola. A maioria dos cuidadores desejava mudança nas lições de casa e nas tarefas domésticas. Maior frequência de participação foi associada ao sexo masculino, distanciamento social menos rigoroso do cuidador devido à pandemia de covid‐19 e crianças recebendo terapia. O maior envolvimento na participação foi associado a uma idade mais jovem nas crianças e a um maior apoio do ambiente. A idade mais avançada das crianças foi associada ao maior desejo por mudança do cuidador.

Interpretação

Fatores pessoais e ambientais são correlacionados com a participação de formas específicas. Devem ser realizadas estratégias criativas para promover a participação e que considerem os desejos do cuidador.

Association between environmental factors during the COVID-19 pandemic and functioning of infants with biological risk in the first year of life: Cross-sectional exploratory study

BACKGROUND

Child development can be influenced by family and environmental factors, which changed during the COVID-19 pandemic. Thus, it is important to explore how these factors are associated with the functioning of infants with biological risk in the first year of life.

OBJECTIVE

This study aimed to investigate associations between family factors, home opportunities, caregiver perception of environmental support and barriers at home and environmental factors during the COVID-19 pandemic and gross motor skills and home participation in infants with biological risk in the first year of life.

METHODS

Fifty-six infants aged two to 12 months (M = 5.80 months; ±2.44) and their mothers performed remote assessments of gross motor skills using the Alberta Infant Motor Scale (AIMS); participation and environment (phone call) by the Young Children's Participation and Environment Measure (YC-PEM); family factors (income, age and maternal education), home opportunities - The Affordances in the Home Environment for Motor Development - Infant Scale (AHEMD-IS) and environmental factors during the COVID-19 pandemic (social distancing, emotional and financial factors and physiotherapy) (online forms). Regression models were constructed, considering gross motor skills and home participation as outcome variables, with a 5 % significance level.

RESULTS

We found that older maternal age (p = 0.001), more home opportunities (p = 0.043), and less rigorous social distancing (as opposed to total social distancing [p = 0.045]) were significantly associated with better gross motor skills; and higher maternal education (p = 0.050) was associated with more involvement in home activities.

CONCLUSION

Family factors, home opportunities and social distancing were differently associated with the gross motor skills and home participation of infants with biological risk in the first year of life.

Home participation and personal and environmental factors in children and adolescents with Down syndrome

AIM

To describe current home participation (frequency, involvement) and caregiver's desire for change in home participation of children and adolescents with Down syndrome, as well as home environmental factors, and to explore the associations of personal and environmental factors with current participation and caregiver's desire for change.

METHOD

Eighty-two caregivers (mean age = 45 years 10 months) of children and adolescents with Down syndrome (mean age = 10 years 7 months) were surveyed about the child's home participation and environmental factors using the Participation and Environment Measure-Children and Youth. Furthermore, children's personal and environmental factors were collected. Results are reported using descriptive analysis and correlations (Spearman's rank correlation coefficients and Mann-Whitney U test) to describe the relationship between current participation and caregiver's desire for change, with personal and environmental factors as ordinal and nominal variables respectively (p < 0.05).

RESULTS

Children's participation was highest with regard to personal care management and lowest with regard to school-related activities. Most caregivers desired change in homework and household chores. Greater frequency was associated with male sex, caregiver less rigorous social distancing due to the COVID-19 pandemic, and children receiving therapies. Greater involvement was associated with younger age in children and higher environmental support. Older age in children was associated with caregiver's greater desire for change.

INTERPRETATION

Personal and environmental factors correlated with participation in specific ways. Creative strategies to promote participation that consider caregiver's wishes should be undertaken.

F-words e ingredientes das intervenções precoces para crianças com paralisia cerebral não deambuladoras: uma revisão de escopo

Cuidados centrados na família (incluindo coaching e intervenções fornecidas pelo cuidador) e treinamento parental formal são estratégias eficazes para crianças nos níveis IV e V do GMFCS. Os ingredientes de tecnologia assistiva podem promover várias F-words (funcionalidade, saúde, família, diversão, amigos e futuro). O menor nível de evidência foi encontrado para diversão, amigos e futuro. Outros fatores (prestação de serviços, treinamento profissional, dose de terapia, modificações ambientais) são relevantes para crianças pequenas nos níveis IV e V do GMFCS. Esta revisão de escopo identificou os ingredientes de intervenções precoces para crianças com paralisia cerebral em risco de não serem deambuladoras, e os mapeou-os de acordo com a estrutura das F-words. O treinamento formal dos pais e a tecnologia assistiva se destacaram como estratégias para abordar com várias F-words.

F-words and early intervention ingredients for non-ambulant children with cerebral palsy: A scoping review

AIM

To explore the ingredients of early interventions provided to young children with cerebral palsy (CP) who are classified in Gross Motor Function Classification System (GMFCS) levels IV and V, and to identify the 'F-words' addressed by the interventions.

METHOD

Searches were completed in four electronic databases. Inclusion criteria were the original experimental studies that fitted the following PCC components: population, young children (aged 0-5 years, at least 30% of the sample) with CP and significant motor impairment (GMFCS levels IV or V, at least 30% of the sample); concept, non-surgical and non-pharmacological early intervention services measuring outcomes from any of the International Classification of Functioning, Disability and Health domains; and context, studies published from 2001 to 2021, from all settings and not limited to any specific geographical location.

RESULTS

Eighty-seven papers were included for review, with qualitative (n = 3), mixed-methods (n = 4), quantitative descriptive (n = 22), quantitative non-randomized (n = 39), and quantitative randomized (n = 19) designs. Fitness (n = 59), family (n = 46), and functioning (n = 33) ingredients were addressed by most experimental studies, whereas studies on fun (n = 6), friends (n = 5), and future (n = 14) were scarce. Several other factors (n = 55) related to the environment, for example, service provision, professional training, therapy dose, and environmental modifications, were also relevant.

INTERPRETATION

Many studies positively supported formal parent training and use of assistive technology to promote several F-words. A menu of intervention ingredients was provided, with suggestions for future research, to incorporate them into a real context within the family and clinical practice.

WHAT THIS PAPER ADDS

Family-centred care (including coaching and caregiver-delivered interventions) and formal parental training are effective strategies for children in GMFCS levels IV and V. Assistive technology ingredients (power, mobility, supported, sitting, stepping, and standing) may promote several 'F-words' (functioning, fitness, family, fun, friends, and future). The lowest level of evidence was found for fun, friends, and future. Other factors (service provision, professional training, therapy dose, environmental modifications) are relevant for young children in GMFCS levels IV and V.

F-Wörter und Interventionsinhalte in der Frühförderung nicht gehfähiger Kinder mit Cerebralparese: eine umfangreiche Literaturübersicht

Ziel

Untersuchung der Inhalte von Frühfördermaßnahmen für Kleinkinder mit Cerebralparese (CP) mit Gross Motor Function Classification System (GMFCS) Level IV und V und die Identifikation von „F‐Wörtern“, die von den Maßnahmen adressiert werden.

Methode

Recherche in vier elektronischen Datenbanken. Einschlusskriterien: experimentelle Originalstudien, die die folgenden PCC‐Komponenten erfüllten: Population: Kleinkinder (im Alter von 0–5 Jahre, mindestens 30% der Stichprobe) mit CP und erheblicher motorischer Beeinträchtigung (GMFCS‐Levels IV oder V, mindestens 30% der Stichprobe); Konzept: nicht‐chirurgische und nicht‐pharmakologische Leistungen der Frühförderung, die Ergebnisse aus einem der Bereiche der Internationalen Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit (ICF) messen; und Kontext: Studien, die zwischen 2001 und 2021 veröffentlicht wurden, in allen Konstellationen und nicht auf einen bestimmten geografischen Ort beschränkt.

Ergebnisse

87 Studien wurden in dieser Literaturübersicht berücksichtigt, mit qualitativen (n = 3), Mixed Methods (n = 4), quantitativ deskriptiven (n = 22), quantitativ nicht‐randomisierten (n = 39) und quantitativ randomisierten (n = 19) Designs. Die meisten experimentellen Studien befassten sich mit Fitness (n = 59), Familie (n = 46) und Funktion (n = 33), während es nur wenige Studien zu den Bereichen Spaß (n = 6), Freunde (n = 5) und Zukunft (n = 14) gab. Verschiedene Umweltfaktoren (n = 55) waren ebenfalls bedeutsam, z. B. das Angebot an Dienstleistungen, Berufsausbildung, Therapiedosis und Umweltanpassungen.

Interpretation

Viele Studien unterstützen Elternschulungen und den Einsatz assistiver Technologien zur Förderung verschiedener F‐Wörter. Ein „Menü“ von Inhalten der Frühförderung wurden ermittelt, mit Vorschlägen für weitere Forschung, um diese in der klinischen Praxis mit Familien umzusetzen.

Was dieser Artikel beiträgt

F-words e ingredientes de las intervenciones tempranas dirigidas a niños no ambulantes con parálisis cerebral: Una revisión exploratoria

La atención centrada en la familia (incluyendo coaching e intervenciones realizadas por los cuidadores) y el entrenamiento formal de los padres son estrategias efectivas para los niños con niveles IV y V de la GMFCS. Los ingredientes de la tecnología de apoyo pueden promover varias "F-words" (funcionamiento, estado físico, familia, diversión, amigos y futuro). Se encontró el nivel más bajo de evidencia para diversión, amigos y futuro. Otros factores (provisión de servicios, formación profesional, dosis de terapia, modificaciones del entorno) son relevantes para los niños pequeños con niveles IV y V de la GMFCS. Ingredientes de la intervención y F-words en intervenciones tempranas dirigidas a niños no ambulantes con parálisis cerebral.

Occupational performance and participation in children with developmental coordination disorders before and during Covid-19

INTRODUCTION

Developmental coordination disorder (DCD) is a neurodevelopmental disorder that affects children's occupational performance and participation. It is known that the Covid pandemic has adversely affected the whole world in many areas. We aim to investigate the occupational performance and participation of children with DCD before and during the COVID-19.

METHODS

Sixty-five children aged 5-12 years included in the study were assessed by the Canadian Measure of Occupational Performance and the Participation and Environment Measure for Children and Youth.

RESULTS

Statistically significant differences were detected in occupational performance and satisfaction scores (p < 0.01). Additionally, except for 'involvement in the home environment' (p > 0.05), there were statistically significant differences in all other areas of participation (p < 0.01).

CONCLUSION

The occupational performance and participation of children with DCD are impacted during COVID-19. In addition, it is seen that the desire of families to change regarding participation has increased due to COVID-19. It would be beneficial to include strategies to improve these areas in the rehabilitation processes.

Participation of Children With Autism During COVID-19: The Role of Maternal Participation

BACKGROUND

Little is known about participation during adverse times.

OBJECTIVES

This study described participation of children with autism aged 6 to 13 during COVID-19 pandemic and examined the extent to which child factors, mother's own participation, and environmental barriers/supports explain child participation in home and community.

METHOD

A total of 130 mothers completed the Participation and Environment Measure for Children and Youth, the Health Promoting Activities Scale, functional issues checklist, and sociodemographic questionnaire.

RESULTS

Children's participation frequency and involvement were significantly higher at home than in the community. In both settings, mothers desired change in 71% of activities. Multiple regression models indicated that child's age and mother's participation frequency significantly explained child's home involvement (R2 = 21%), where mother's participation (frequency) had a unique contribution (ΔR2 = 10.4%) at home but not in the community.

CONCLUSION

Findings imply the importance of maternal participation to child's participation at home and suggest redirecting attention for enhancing family participation as a whole.

Environment Mediates the Relationship Between Preschoolers Functioning and Involvement in Out-of-School Activities

This study aims to understand the associations between child functioning and environmental barriers and the involvement of preschool children, with and without disabilities, in out-of-school activities, namely, home and community activities. Particularly, we aimed to investigate if environmental barriers mediate the relationship between child functioning and their involvement in these activities. Parents of 116 preschool-aged children (42 children with disabilities) reported on children's involvement and environmental factors at home and in the community. Preschool teachers assessed child functioning. Multiple linear regressions and mediation analysis were performed. Results indicated significant associations between child functioning, perceived environmental barriers, and involvement at home and in the community. A significant indirect association of child functioning on involvement through the perception of environmental barriers was found in both contexts. Findings support the biopsychosocial model of participation and a focus on environmental features by practitioners designing and implementing intervention strategies.

Association between Participation of Children with Disabilities and the Child, Family, and Environmental Factors in Shanghai, China: A Cross-Sectional Study

Participation is essential to a child's health and well-being, whereas children with disabilities may lack the associated benefits because of physical restrictions. This study aims to examine the association between the participation of children with disabilities and the child, family, and environmental factors. A total of 433 children with disabilities aged 3-18 and their family caregivers were included. Three binary logistic regression models were respectively established to identify the significant factors associated with children's home, school, and community participation. Our main empirical results showed that among 433 children with disabilities, 44.3%, 47.6%, and 58.7% of them never or seldom participated in home, school, and community activities. Child and family factors were found to be dominantly associated with children's participation, and significant factors associated with the home, school, and community participation of children were different, including children's disability type, sleep problems and emotional stability, caregivers' education, mental HRQOL, rehabilitation belief, and number of children in the family. These results highlight that the participation of children with disabilities in mainland China urgently needs to be enhanced, and further research might be focused on validating the causal relationships between participation and significant child and family factors identified in this study.

The impact of parent involvement on improving participation of children born preterm: The story in the baseline

Background

Preterm birth continues to be a major public health challenge that has long term consequences on participation into adulthood. However, little is known about effective interventions to improve the participation of children born preterm.

Methods

This study gathered initial evidence on the usefulness of a goal-focused, environmental-based approach (Pathways and Resources for Engagement and Participation (PREP)) in improving the participation of children born preterm, and living in Ireland. Three school-age boys (6–7 years old) with a history of preterm birth participated in the 12-week PREP intervention. A 36-week single-subject AB design was employed and replicated across 3 different participation goals within each child and across 3 children. Activity performance was measured repeatedly, through parental involvement, using the Canadian Occupational Performance Measure (COPM), providing 9 individual outcome trajectories. Visual inspection and mixed-effects segmented regression were used.

Results

Goals were selected from various participation domains and settings. Throughout the baseline phase, once goals were set, significant improvements in activity performance were observed for all participants (t = 14.06, p < 0.001). Further clinically significant improvements (2.58 on the COPM) for all 9 participation goals were seen in overall performance during the intervention phase. These changes remained at follow-up.

Conclusions

Findings support family-centered practice and draw attention to the power of goal setting in improving participation within this context. Challenges with single-subject design with this population were also highlighted. Results demonstrate the potential impact of parent involvement when using an environmental-based approach to improve the participation of this underserved population.

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Improvement in participation in children born preterm, without physical disabilities.

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Challenges of single-subject design with this population.

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Environmental-based strategies show effectiveness in addressing participation goals.

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Environmental-based strategies may promote capacity building in parents.

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Studies focusing on the impact of goal setting and parental involvement are needed.

Motor performance and daily participation in children with and without probable developmental coordination disorder

AIM

To test the mediating role of motor performance in the relationship between individual and environmental constraints, delayed learning of activities of daily living (ADL), and daily participation in typically developing children and children with probable developmental coordination disorder (DCD).

METHOD

Parents of 370 randomly selected children aged 5 to 10 years (194 females; mean age [SD] 7y 5mo [1y 10mo]) were included in the study (321 typically developing, 49 probable DCD). Motor performance, ADL learning, and participation were assessed using the DCDDaily-Questionnaire. Individual variables included child's age and sex, and environmental variables included mother and family educational level, presence of siblings, and area of residence. Direct, indirect, and mediating effects were tested using a partial least squares-based structural equation modelling approach.

RESULTS

The model explained 44.5% of the variance of daily participation. Motor performance significantly mediated the effect of individual and environmental constraints, and ADL learning on daily participation.

INTERPRETATION

Results suggest that the effect of individual and environmental constraints and delayed learning of ADL on daily participation is mediated by motor performance in typically developing children and children with probable DCD. These findings provide further evidence that interventions to promote participation in children with probable DCD should adopt ecological, task-oriented approaches. Further studies should evaluate model generalizability with clinical samples.

Effectiveness and scalability of an electronic patient-reported outcome measure and decision support tool for family-centred and participation-focused early intervention: PROSPECT hybrid type 1 trial protocol

INTRODUCTION

Early intervention (EI) endorses family-centred and participation-focused services, but there remain insufficient options for systematically enacting this service approach. The Young Children's Participation and Environment Measure electronic patient-reported outcome (YC-PEM e-PRO) is an evidence-based measure for caregivers that enables family-centred services in EI. The Parent-Reported Outcomes for Strengthening Partnership within the Early Intervention Care Team (PROSPECT) is a community-based pragmatic trial examining the effectiveness of implementing the YC-PEM e-PRO measure and decision support tool as an option for use within routine EI care, on service quality and child outcomes (aim 1). Following trial completion, we will characterise stakeholder perspectives of facilitators and barriers to its implementation across multiple EI programmes (aim 2).

METHODS AND ANALYSIS

This study employs a hybrid type 1 effectiveness-implementation study design. For aim 1, we aim to enrol 223 caregivers of children with or at risk for developmental disabilities or delays aged 0-3 years old that have accessed EI services for three or more months from one EI programme in the Denver Metro catchment of Colorado. Participants will be invited to enrol for 12 months, beginning at the time of their child's annual evaluation of progress. Participants will be randomised using a cluster-randomised design at the EI service coordinator level. Both groups will complete baseline testing and follow-up assessment at 1, 6 and 12 months. A generalised linear mixed model will be fitted for each outcome of interest, with group, time and their interactions as primary fixed effects, and adjusting for child age and condition severity as secondary fixed effects. For aim 2, we will conduct focus groups with EI stakeholders (families in the intervention group, service coordinators and other service providers in the EI programme, and programme leadership) which will be analysed thematically to explain aim 1 results and identify supports and remaining barriers to its broader implementation in multiple EI programmes.

ETHICS AND DISSEMINATION

This study has been approved by the institutional review boards at the University of Illinois at Chicago (2020-0555) and University of Colorado (20-2380). An active dissemination plan will ensure that findings have maximum reach for research and practice.

TRIAL REGISTRATION NUMBER

NCT04562038.

Family and personal factors associated with the participation of children with special needs in leisure activities: A Turkish perspective

OBJECTIVE

The primary aims of the current study were to describe the participation patterns in leisure activities of children between the ages of 6 and 15 years with special needs and to analyze family behavior and personal factors that affect participation.

MATERIAL AND METHODS

Overall, 112 children with special needs aged 6-15 years and their families participated in the present study. Children's sociodemographic characteristics, participation patterns in leisure activities, family behavior, and quality of life were evaluated.

RESULTS

In this study, it was observed that children participated in recreational activities the most and in physical activities the least. Most of the families reported that they did not have an influence on determining the activity. The findings showed correlations between leisure activities and age, gender, and socioeconomic status (p < 0.05).

CONCLUSION

The findings suggest that (a) children's participation in activities outside the home and (b) family guidance are insufficient. Thus, rehabilitation professionals can inform families about activities appropriate for children, positive family behavior, and social support programs.

Barriers and facilitators to community participation for preschool age children born very preterm: a prospective cohort study

AIM

We compared preschool age children born very preterm with term-born controls to: (1) understand the association between very preterm birth and community participation, (2) determine if motor impairment or social risk affect participation differently between groups, and (3) understand environmental barriers and supports to participation for parents.

METHOD

Forty-eight children born very preterm (<30wks' gestation; 22 males, 26 females) and 96 controls (47 males, 49 females) were assessed at 4 to 5 years' corrected age for community participation using the Young Children's Participation and Environment Measure. Motor skills were assessed using the Movement Assessment Battery for Children, Second Edition and the Little Developmental Coordination Disorder Questionnaire.

RESULTS

Children born very preterm participated less frequently than term-born children (difference in means=-0.28, 95% confidence interval [CI] -0.54 to -0.03, p=0.029). Social risk was associated with lower frequency (interaction p<0.001) and involvement (interaction p=0.05) in community activities for children in the very preterm group only. Parents of children born very preterm perceived more barriers (odds ratio=4.32, 95% CI 1.46-12.77, p=0.008) and environmental factors to be less supportive of participation than parents of controls (difference in medians=-6.21, 95% CI -11.42 to -1.00, p=0.02).

INTERPRETATION

Children born very preterm may benefit from ongoing support to promote participation, especially in families of higher social risk.

Parental Adherence to Home Activities in Early Intervention for Young Children With Delayed Motor Development

OBJECTIVE

The purpose of this study was to investigate the relationship between characteristics of home activities and coaching practices with the adherence of parents of children with motor delays to home activities provided by physical therapists and occupational therapists in early intervention.

METHODS

An online survey study was developed and distributed to physical therapists and occupational therapists across the United States. A survey flier was posted online in parent support groups, physical and occupational therapy groups, newsletters, and organizations supporting parents of children with disabilities.

RESULTS

A total of 720 respondents participated in the survey, and 446 participants from 49 states met the inclusion criteria and were included in the analysis. Parents indicated that physical therapists and occupational therapists applied the 5 coaching practices (joint planning, observation, practice, reflection, and feedback). However, parents (63%) reported more time was needed on coaching. Parents stated that therapists' modeling the activities was the most helpful teaching technique that enhanced their adherence to home activities. Coaching practices, appropriateness of the home activities to daily routines and home environment, provision of home activities enjoyed by the child, and parent self-efficacy were all significantly associated with adherence to home activities.

CONCLUSIONS

Parents' adherence to home activities is affected not only by the type of coaching used by the therapists but also by the characteristics of the home activities provided for young children with delayed motor development.

IMPACT

The results of this study provide additional evidence supporting individualization of home activities to promote parents' continuous provision of learning opportunities to promote their children's development. There was also support of the therapists' use of the 5 coaching practices in early intervention to support the parent's application of home activities when the therapists are not present.

LAY SUMMARY

This study explored the use of home activities from the parents' perspective and provided valuable recommendations to therapists to improve parents' adherence to the recommended home activities in early intervention.

Early intervention service intensity and young children's home participation

Background

Young children with developmental disabilities and delays spend significant amounts of time at home, show decreased participation in home-based activities, and receive home-based early intervention services to improve participation in activities. Yet, knowledge about the relationship between EI service use and children’s home participation in activities remains poorly understood but needed for program improvement. The purpose of this study was to understand the relationships between EI service use and children’s home participation.

Methods

In a cross-sectional design, data were gathered from caregivers (N = 139) who enrolled in a pilot trial of the Young Children’s Participation in Environment Measure (YC-PEM) electronic patient-reported outcome (e-PRO), as implemented within 1 month of their child’s next EI progress evaluation. A series of path analytic models were used to estimate EI service intensity as a predictor of parent-reported young children’s home participation 1) frequency, 2) level of involvement, and 3) desired change, adjusting for family and child social and functional characteristics. Models included caregiver perceptions of home environmental support to test its indirect (i.e., mediation) effects on the relationship between EI service intensity and each of the three home participation dimensions.

Results

All three models fit the data well (comparative fit index = 1.00). EI service intensity was not a significant predictor of participation frequency. However, EI service intensity had a significant direct effect on a child’s participation according to level of involvement and desired change, explaining between 13.3–33.5% of the variance in home participation. Caregiver perceptions of environmental support had a small yet significant indirect effect on the relationship between EI service intensity and level of involvement and desired change; these models explained between 18.5–38.1% of the variance in home participation.

Conclusions

EI service intensity has important links with involvement in and desired change for home-based activities. Caregiver perceptions of environmental support appears to be a factor in the relationship between EI service intensity and home participation. Results warrant longitudinal replication with a control group, which would be possible with the implementation of the YC-PEM e-PRO in a routine EI clinical workflow.

Trial retrospectively registered

NCT03904797.