Evidence-based community pediatrics: building a bridge from bedside to neighborhood

Utilizing the RE-AIM framework to determine effectiveness of a preschool intervention program on social-emotional outcomes

Social-emotional issues in preschoolers continue to be an area of concern across the nation. Models to determine effective implementation practices are needed. The Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework is one model that can be used to evaluate program implementation in preschool settings. The Jump Start program provided short-term intervention to children in low-income preschools from multiethnic backgrounds. The goal was to promote prosocial behaviors while minimizing problem behaviors. Various evidenced-based practices (i.e., I Can Problem Solve, play therapy, Pyramid Model) were utilized. 305 children from 73 childcare centers participated in the program. The majority of participants were from ethnic minority backgrounds and resided in high-poverty areas of the county. The RE-AIM framework was utilized to determine program outcomes. Results showed successes on each level of RE-AIM with an at-risk population. The Jump Start program significantly increased positive behaviors and decreased challenging behaviors in preschool-aged children. Results indicated medium to large effect sizes. One year following program participation, the majority of children who participated in the program were at decreased risk of special education services and expulsion.

Determinants of Health and Pediatric Primary Care Practices

More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association's Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty's negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.

Legislative advocacy: evaluation of a grand rounds intervention for pediatricians

OBJECTIVE

To evaluate the impact of a Grand Rounds Action Alert (GRAA) intervention on the behaviors, knowledge, and attitudes of pediatric grand rounds (GR) attendees; and to assess its acceptability.

METHODS

A cross-sectional, quasi-experimental study was performed at a freestanding children's hospital. GRAA on child health legislative topics were presented in the first 2 minutes of the pediatric GR session as well as posted outside. Each session included an action item, such as writing/signing letters to elected officials or informational sheets with legislator contact information. Main outcome measures included self-reported behavior, advocacy knowledge, attitudes, and acceptability.

RESULTS

One year after GRAA implementation, GR attendees with high exposure to the intervention were more likely to have written/signed a letter to a legislator compared to those with low/no exposure (60% vs 35%, P = .016). Those with high exposure were also more knowledgeable regarding financing of health care for low-income children (20% vs 5%, P = .027). Attitudes toward advocacy at baseline were positive: respondents agreed it is important to remain informed about (98%) and advocate for (94%) legislation favorable to children's health. Implementing this program was challenging, but the intervention was accepted favorably: 93% of respondents agreed that GRAA should continue.

CONCLUSIONS

GRAA facilitated participation in legislative advocacy behaviors while improving self-perceived knowledge of legislative issues relating to children's health. They were well received in a large tertiary children's hospital.

The translational research impact scale: development, construct validity, and reliability testing

Increasing emphasis is being placed on measuring return on research investment and determining the true impacts of biomedical research for medical practice and population health. This article describes initial progress on development of a new standardized tool for identifying and measuring impacts across research sites. The Translational Research Impact Scale (TRIS) is intended to provide a systematic approach to assessing impact levels using a set of 72 impact indicators organized into three broad research impact domains and nine subdomains. A validation process was conducted with input from a panel of 31 experts in translational research, who met to define and standardize the measurement of research impacts using the TRIS. Testing was performed to estimate the reliability of the experts' ratings. The reliability was found to be high (ranging from .75 to .94) in all of the domains and most of the subdomains. A weighting process was performed assigning item weights to the individual indicators, so that composite scores can be derived.

Community engagement and its impact on child health disparities: building blocks, examples, and resources

National attention to racial and ethnic health disparities has increased over the last decades, but marked improvements in minority health, especially among children, have been slow to emerge. A life-course perspective with sustained community engagement takes into account root causes of poor health in minority and low-income communities. This perspective involves a variety of primary care, public health, and academic stakeholders. A life-course perspective holds great promise for having a positive impact on health inequities. In this article we provide background information on available tools and resources for engaging with communities. We also offer examples of community-primary care provider interventions that have had a positive impact on racial and ethnic health disparities. Common elements of these projects are described; additional local and national resources are listed; and future research needs, specifically in communities around issues that are relevant to children, are articulated. Examples throughout the history of pediatrics show the potential to eliminate racial and ethnic health disparities not only for children but also for all populations across the life course.

Park-based obesity intervention program for inner-city minority children

OBJECTIVE

To assess an intervention strategy--a 6-week obesity intervention program, Project KidFIT, at 3 Houston, Texas park centers--to address the obesity epidemic in minority children.

STUDY DESIGN

Project KidFIT is a physical fitness and nutrition education program aimed at promoting the benefits of physical activity and improving nutrition knowledge in overweight (body mass index [BMI] > or = 95th percentile) minority children.

RESULTS

A total of 120 minority children (77 boys and 43 girls; mean age, 10.1 years) were enrolled in the program. Approximately 71% of these children were at risk of overweight (BMI > or = 85th percentile), and 54% were overweight. Decreases in body weight (0.3 +/- 0.2 kg [mean +/- standard error]) and BMI (0.1 +/- 0.1 kg/m2) were detected in the overweight children, whereas increases in body weight (0.4 +/- 0.1 kg) and BMI (0.2 +/- 0.1 kg/m2) were observed in the children with normal body weight (BMI < 85th percentile but > 5th percentile). Significant improvements (P < .05) in flexibility, muscular endurance, and muscular strength were detected in all children, regardless of weight status.

CONCLUSIONS

The findings suggest that the city park-based KidFIT program might be effective at promoting stabilization for body weight and BMI and improving physical activity performance and nutrition knowledge in overweight minority children.

Implementation of an asthma intervention in the inner city

BACKGROUND

Despite availability of asthma self-management interventions for children, few have been implemented in community-based settings.

OBJECTIVE

To describe implementation of the Inner-City Asthma Intervention and factors associated with higher rates of program completion by enrollees.

METHODS

Descriptive analyses of data from multiple data sources. Two-tailed Pearson correlation coefficients and analyses of variance were used to calculate associations of descriptive variables with the retention rate (percentage of enrolled children who completed the core intervention and had more than 1 follow-up visit) and with the percentage who had allergy testing done.

RESULTS

A total of 4,174 children were enrolled at 22 sites; 2,153 (52%) completed the core intervention and had more than 1 follow-up visit. A total of 2,014 enrolled children (48%) were tested for allergies. Retention was related to type and location of site, ease of obtaining written plans, language and ethnicity of asthma counselor, and on-site allergy testing. Higher rates of allergy testing were associated with the same factors, as well as flexibility in scheduling and selective enrollment of participants.

CONCLUSIONS

Inner-city children with asthma can be enrolled in the Inner-City Asthma Intervention outside a controlled research setting. However, completion of all intervention components is difficult to achieve. We identify having an asthma counselor who is representative of the community, access to asthma action plans, and on-site allergy testing as factors that facilitate the implementation of this intervention in community-based settings.

An analysis of predictors of sustainability efforts at the Inner-City Asthma Intervention sites: after the funding is gone

BACKGROUND

The Inner-City Asthma Intervention was a national, multicenter implementation of an evidence-based intervention to reduce asthma morbidity in inner-city children that was funded by the Centers for Disease Control and Prevention. Funding was initially planned for 4 years beginning in April 2001, but because of budgetary changes funding ceased in September 2004, 6 months before the original plan. Some sites were able to sustain their asthma program when the funding ended and others were not.

OBJECTIVE

To compare characteristics of sites that were able to sustain their asthma program after the original funding ended with those that were not.

METHODS

Data were collected from the project manager at each site in an electronic survey and through telephone interview in November 2003 and August 2005. Using contingency tables, we examined the bivariate relationship between each proposed factor and our outcome measure, secured funding.

RESULTS

Of the 18 sites that completed the survey, 50% reported continued funding. All sustainable sites received funding from multiple sources, including either the hospital or the community. One site received federal funding and one site received state funding. Of the sites that presented data to multiple funders, 6 of 9 were sustained (P = .05).

CONCLUSIONS

Sustainable programs were more likely to be funded locally. Programs that used an evaluative process, including patient outcomes data, to demonstrate the importance of the program to their institution and community were more likely to obtain continued funding compared with those that did not.