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1 Overall Summary CenteringParenting, a unique group post-partum care and social-support model, is ready for implementation in Calgary. Thanks to the funding provided by the Alberta Center for Child, Family, and Community Research we were able to adapt this innovative service delivery model for our Alberta context. In addition, we successfully built relationships with key stakeholder groups to prepare for the implementation of CenteringParenting in the next stage of the project: pilot testing the program. Two communities have been selected for this next stage of the research; parents, nurses, and Public Health managers from these communities were involved in various components of the first phase of this research. Support and enthusiasm for this model was high among those who were interviewed or participated in meetings. Background Early childhood development is a key determinant of health and well-being throughout the life course. 1 Parents play a pivotal role in supporting healthy development of their children. Many early health behaviours that are known to have a direct impact on later health and well-being are modifiable and controlled by parents. Examples include early nutrition and breastfeeding, child safety, oral health, parent infant interaction, early language development, and childhood immunization. Public Health Nurses, by virtue of their interactions with families during infancy and early childhood, are uniquely positioned to support parents in making the best choices for their children. The current Public Health service delivery model in Alberta provides parents with one-on-one, nurse-facilitated consultations followed by vaccination during early infancy and childhood.

2 Well-Child Clinics were originally designed to combine a number of health promotion and education activities with childhood vaccinations. However, as the number of childhood vaccinations increased in recent years, there was a reduction in the time available for other important health promotion and parenting support activities. This group of researchers, clinicians, managers, and decision-makers, aware that early childhood development is a key determinant of health and well-being throughout the life course, was keen to develop an adaptation of the current service delivery model to provide additional parenting support. A recent systematic review on early parenting interventions has identified that due to the heterogeneity of the available literature, there is a lack of strong evidence to recommend a specific parenting approach for improving child health. 2 Due to this lack of evidence, it is appropriate to look for promising practices that have been effective in other health promotion areas and have the potential for positive impact on the parenting population. The Centering Healthcare Organization, situated in the United States and led by Sharon Schindler Rising, in addition to developing the CenteringPregnancy program, has developed a promising CenteringParenting intervention. 3 CenteringParenting is designed to improve care and social support for the mother/infant dyad during the postpartum period. This innovative postnatal intervention is designed to provide women and their infants with brief one-on-one provider assessments followed by discussion and socialization with other women in a group setting. The groups provide social support for attendees and are co-facilitated by two health care professionals. Concerns of the group are addressed in the group setting. 4 Maternal topics include weight goals, role attainment, breastfeeding, maternal health, depression, and contraception.

3 Infant topics include health, development, safety, and nutrition. Family topics include sexuality, mental health, parenting, family relationships, and domestic violence. Families are involved in their own and their child s health assessments. Summary of Activities and Outcomes In this project Public Health Nurses, managers, researchers, and decision-makers all came together to adapt CenteringParenting to the Alberta context and to prepare this new service delivery model for piloting. In addition, the opinions of parents, nurses, and parenting experts were gathered to determine if there was interest in this service delivery model shift. The seed grant from the Alberta Centre for Child, Family, and Community Research provided funding to: 1. Adapt the existing CenteringParenting intervention to the Calgary context based on the needs of stakeholders, 2. Develop relationships with key stakeholders, 3. Consult with the CenteringParenting experts in the United States and, 4. Develop a grant proposal for the next stage of research, pilot/feasibility testing the intervention. Over the last year we were able to complete our planned activities. The following sections provide more detail of the specific activities and outcomes. It should be noted that while the activities are presented sequentially and independently, these activities occurred concurrently and influenced each other in an iterative nature. Adaptation of CenteringParenting Curriculum While the CenteringParenting intervention and American curriculum existed prior to our

4 commencement of this project, it was unclear at the onset if it could be wholly or partially inserted into the Alberta context. Our first activities included having the Leads of both the School Health & Well Child Services and the Perinatal and Postnatal Services examine the existing curriculum for suitability. They reported that some adaptations were required to make the intervention consistent with the practices in our clinics, the roles and scope of practice of Public Health Nurses, and our knowledge of best practice within the province. These individuals began adapting the curriculum using: parenting and well-child resources that already existed within Alberta Health Services, the expertise of the experts from the Centering Healthcare Institute, and perceptions of members of the research team which included managers, decisionmakers, and researchers. Some of the adaptations that we discussed as a research team included: the number of sessions held during the first year, the duration of the sessions, the professional backgrounds of the cofacilitators, the approach to vaccination within the group, the scope of the maternal topics to be covered, and the attendance of other children/siblings. We decided to offer six, two-hour CenteringParenting sessions during the first year of life (a balance between the four we currently offer in well-child clinics and the eight offered in the American CenteringParenting program). In addition, two Public Health Nurses will co-facilitate the sessions here in Calgary. We were initially interested in locating a Family Physician who would be interested in cofacilitating the CenteringParenting sessions with the Public Health Nurses; however we were unable to locate a practice with either sufficient numbers of post-partum women, or physicians willing to change their service delivery model. This may be something we pursue in the future. The content of the sessions and the curriculum that will be piloted is available in Appendix A.

5 Following the adaptation of the intervention by the research team, input from stakeholder groups was collected to make further refinements and modifications to the CenteringParenting curriculum. Opinions of Public Health Nurses, parenting experts, and local parents were all collected and used to ensure that a viable intervention was adapted to the local context. Additional details are provided in the following section: Continued relationship building and gathering input from stakeholder groups. We feel that we have successfully adapted the CenteringParenting intervention and curriculum to our setting and we are ready for the next stages of research. Appendix A provides a copy of the family and facilitator notebooks that guide the CenteringParenting program. Continued relationship building and gathering input from stakeholder groups Including all of these stakeholders during the parenting program s development process followed an integrated knowledge exchange model. 5 This successfully ensured that the knowledge developed during the research process was guided by those who will use the results. It also helped ensure that when we implement the CenteringParenting program that all stakeholders have been included from the conception, to implementation, and through its evaluation. Prior to commencing the engagement activities, we identified the relevant stakeholder groups as: physicians and primary care networks, Public Health Nurses, current users of the Well-Child Clinics (parents), parenting experts, and Alberta Health Services program managers. We felt that it was essential to further develop relationships with these local and regional stakeholders to

6 ensure that the developing model meets their needs and expectations. Focus groups, individual interviews and meetings provided the primary means of gathering stakeholder input. Prior to asking the groups or individuals for their feedback, we provided them with an overview of the planned CenteringParenting intervention. The following sections describe the engagement activities that we undertook with each group as well as a summary of the outcomes. Physicians and Primary Care Networks Our initial proposal had focused on developing a relationship with primary care networks and their physicians in order to partner with these care providers in the implementation of the CenteringParenting model. Our hope had been to implement a model with a physician and a Public Health Nurse co-leading the facilitation of the group. We did have several physicians express some interest in the model. However, after meeting and talking with four different local primary care networks it became clear that there were currently too many barriers from their perspective to pursue this physician/nurse model at the current time. As such, we continued to identify if there was interest from other identified stakeholders, particularly Public Health Nurses, parenting experts, and parents. Public Health Nurses Data from these stakeholders was gathered through two focus groups: one in an urban setting and one in a rural setting. Twenty-one Public Health Nurses attended these two focus groups. During the focus groups the nurses discussed their perceptions of the CenteringParenting model overall as well as their feedback on all of the elements needed for the program including: location and duration of the sessions, timing, need among parents, and resources required.

7 Data from the focus groups and interviews was recorded, transcribed, and a content analysis was used to analyze it. Similar items and themes were grouped together and used to help guide the final development of the curriculum as described above. Public Health Nurses were extremely enthusiastic about the potential for a change to the CenteringParenting group well-child model. The most anticipated outcome of the program among the Public Health Nurses was the social support that the program would provide to parents. People are looking to make connections, and it was perceived that CenteringParenting would facilitate these connections for their clients. Some of the additional benefits that were perceived by nurses of the new program included: not repeating the same messages eight times in one day, the wider range of topics that could be covered compared to what is currently covered, and the benefits of normalizing parenting issues among the group, [the mothers] learn from each other, they get tips from each other. The biggest challenge that was identified by nurses was the delivery of vaccinations within the group space and within the time limits of the program. This issue had also arisen from members of the research team during the regular team meetings. We have considered this in developing the protocols for the group and will monitor this process as we proceed to the pilot stage. Parents Twelve mothers were interviewed as part of this project: six who resided in an urban setting and six from a rural/suburban setting. All interviewed mothers were clients of the current well-child Public Health clinic. Interviewed mothers came from a variety of socioeconomic and cultural

8 backgrounds. During the interviews the parents were asked about their perceptions of the CenteringParenting model, group well-child care in general, as well as specific feedback on the timing and number of sessions. Data from the interviews was recorded, transcribed, and a content analysis was used to analyze it. Many of the interviewed mothers (ten of the twelve interviewed mothers) reported a lack of social support as they became new parents, I didn t have a support network: other mothers who were feeling the same things I was feeling. These parents talked about struggling to adjust to their new parenting role, and their new responsibilities. These mothers anticipated that the CenteringParenting group would give them the social support and the information that they need, and are currently lacking, as new parents, the most valuable component is connecting with other parents was a common theme from these mothers. A few concerns were raised during the parent interviews. While most mothers did not report any concerns about discussing personal health issues in a group setting, a small number of mothers felt that the lack of privacy within the group setting might be a concern for them with regards to the mother s personal health or social issues that arise, I probably wouldn t want to discuss constipation or stuff like that. No parents reported being concerned with their infant s privacy during the group session. Another concern that arose was that two of the twelve participants reported not being group people, and that they may prefer to maintain the one-on-one model for their care, Put me in a crowd and I won t talk. I ve always been a shy person groups are just not my thing.

9 This feedback from parents, as well as other feedback not reported here, was essential in understanding the needs of current users of the well-child public health clinics and identifying a real need for a change to the service delivery model. This data was used in adapting the curriculum for CenteringParenting as well as determining whether to continue with the next stage of research, the pilot. Parenting Experts Four parenting/child development experts were interviewed as part of this project. Three were employees of Alberta Health Services and one was an employee of an academic institution. During the interviews the experts were asked about their perceptions of the CenteringParenting model, group well-child care in general, as well as specific feedback on the various elements of the curriculum. Data from the interviews was recorded, transcribed, and a content analysis was used to analyze it. Support from local parenting and child development experts is high for the proposed program. One interviewed parenting expert described her perception of the program as having, really good adult learning principles and parenting education practices as well... It s fabulous. Similar to the perceptions of the nurses and the parents the parenting experts perceived social support as a big advantage of the model, The benefits are huge in the way of connecting people. A potential challenge that was identified by the experts was getting parents to opt for the group model of well-child care. The experts described the recruitment of parents as a possible challenge. Two experts independently described their perception that the population thinks that

10 by, getting parenting help, it indicates that you have a problem, and the need for the CenteringParenting program to normalize help for all parents. It s important for us to be aware of the possible recruitment challenges prior to beginning the pilot and to adapt strategies to address this. However, one expert reported that, I really think that it s only getting them there once. Once you get them to [the group], they re hooked. I truly believe that. Developing a proposal for a pilot study During the course of the adaptation of the curriculum and stakeholder engagement activities it became clear that there was a demand for this new service delivery model from many of the stakeholders. As a result of the enthusiasm for the proposed CenteringParenting model, a proposal to pilot the program within the Public Health- Calgary Zone of Alberta Health Services was developed. It was decided to pilot the program using Public Health Nurses as the facilitators. (See Appendix B for a letter of intent describing the pilot.) Potential pilot sites were examined and staff and managers were consulted regarding the types of supplies and equipment that will be needed to run the program. Staff time for training, planning, and facilitating the program has been estimated. (See Appendix C for a preliminary budget for the pilot.) In addition, very recently we have begun plans to coordinate our CenteringParenting pilot with a second pilot being planned for late preterm infants. The researchers developing this new pilot among the late pre-term infants have contacted our research team with the hope that we will be able to collaborate with them, share our experiences and the adapted curriculum, and coordinate our research programs for the betterment of both research programs. We look forward to further exploring this collaboration.

11 Consulting with CenteringParenting experts Through teleconferences, , and phone, experts at the Centering Healthcare Organization provided consultation regarding the process and content of the group Well-Child intervention. As the original developer of CenteringParenting, Sharon Schindler Rising and her staff have been involved with numerous centers in implementing Centering programs. They have an expansive expertise in designing group parenting programs in various settings. Their advice was extremely helpful in adapting the program to the Alberta context and in troubleshooting issues with us as they arose. In addition, following our initial conversations with the American group our commitment to adapting the curriculum to the Canadian context was further solidified. It became clear early on in our project that there were differences in the way the program would be implemented here due to the differences in the scope of practice of Public Health Nurses within Alberta, the well-child service delivery model, and the universal access to our Public Health Programs. These discussions with the Centering Healthcare staff helped make the research team, as well as the CenteringParenting experts, aware that the CenteringParenting program could not simply be implemented without adaptation. Notes from all meetings and s were retained to ensure a record of the discussions and decision-making process. Summary and Discussion of New Knowledge In addition to the enthusiasm we ve felt among those clinicians, researchers, and decisionmakers involved with the planning of the program, the data collected from local nurses, parenting experts and parents has provided the research team with the encouragement to continue with the planning of CenteringParenting pilot study. Over the past year we have created a network of supporters for the project through our relationship building. These supporters are

12 present within the two pilot communities, within Alberta Health Services at both zone and provincial levels, and within the wider academic community. Due to the support we ve had during this development stage we feel prepared and ready for the implementation of the CenteringParenting program. Based on the exploratory data that we ve collected in this early stage of the research, we anticipate that the CenteringParenting program will have a positive impact on parents, nurses, and the health system once implemented. We anticipate that the program with develop social support among the new parents who are attending, as well as improved health and parenting outcomes for mothers and children. In addition, we hope that the inclusion of social support within this group model may make it a more appealing model of service delivery to many new parents than the traditional one-on-one model. While the traditional model will always be available to meet the needs of parents who require or prefer this model, the data we ve collected here indicates a real need for additional social support during the post-partum period. We also anticipate that the Centering model will provide Public Health Nurses with the opportunity to have more diversity and to allow them to work to the full scope of their practice. It is also hoped that CenteringParenting will be as, or more, efficient than the current one-onone service delivery model. This group model has the potential for a transformational shift in the way in which Well-Child Clinics in Public Health are conducted in the Alberta Health Services healthcare system. Plans and Next Steps

13 Over the next two years we plan to submit our grant proposal for phase 2, the pilot feasibility study, to funding agencies. We are currently identifying possible funding sources and modifications to the basic grant proposal based on individual requirements of the agencies. If funding is secured we will implement the pilot in two Calgary communities. We have secured stakeholder support to implement the pilots. (See Appendix B for a letter of intent describing the pilot.) Following completion of the pilot, if deemed feasible we will make further refinements based on what we learn from the pilot and use this to develop Phase 3, a grant proposal for a multi-site randomized controlled trial (RCT). The RCT will be important to quantify both maternal and infant outcomes and to assess generalizability of the program. As well, we will continue to pursue collaboration with physician colleagues and stakeholders at future sites and locations for the full RCT. Table 1 describes the research plan for the next two years. The budget for the first year of research will be $49, and $26, for the second year and a full description is available in Appendix C. Plans to attract new funding We are pleased that Alberta Health Services is providing in-kind funding for the provision of service and space for CenteringParenting and that any new funding will support the research needs and not the basic program needs. We feel this will facilitate support for the research. Our collaborations with academic colleagues related to CenteringParenting for the late preterm population provides us with an opportunity to work together to identify broader funding sources including Alberta Innovates: Health Solutions, the Max Bell Foundation and others.

14 Table 1: CenteringParenting Research Pilot Plan Study Item Anticipated Timeline Duties Seeking funding for Phase 2 June 2012 July 2012 Biweekly meetings (conference calls) to integrate with other research programs and finalize proposal submissions Ethics approval, hiring study staff, facilitator training Aug 2012 Dec 2012 Prepare for study initiation, finalizing space and equipment, implement key research process pieces, training of staff Advertisement and recruitment Jan 2013 Mar 2013 Recruitment of families for pilot onset, ensuring eligibility Intervention delivery, data collection, and entry Apr 2013 Apr 2014 Intervention onset, scheduling groups, entering data, completing Ethics updates Final interviews and data entry Apr 2014 June 2014 Qualitative interviews with staff and participants, final questionnaire completion Data analysis June 2014 Dec 2014 Interview transcription, thematic content and quantitative analysis, verification, etc. Proposal development for Phase 3, full trial of Centering Parenting intervention Jan 2015 Apr 2015 Seek other funding agencies, examine funding requirements, update literature review Dissemination activities Dec 2014 June 2015 Abstracts, articles, reports, presentations

15 References 1 Health Canada (2001). The population health template: key elements and actions that define a population health approach. Ottawa: Health Canada Population and Public Health Branch, Strategic Policy Directorate. Health Canada. 2 Gagnon, A.J., & Bryanton, J. (2009). Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database of Systematic Reviews, Massey, Z., Rising, S.S., & Ickovics, J. (2006). Centering pregnancy group prenatal care: promoting relationship-centered care, Journal of Obstetric, Gynecological, and Neonatal Nursing, 35, Reid, J. (2007). Centering pregnancy: A model for group prenatal care. Nursing for Women s Health, 11, Canadian Institutes of Health Research (2009). More About Knowledge Translation at CIHR. Retrieved from on May 27, 2012.

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