Tracking implementation strategies in real-world settings: VA Office of Rural Health enterprise-wide initiative portfolio.

OBJECTIVE: To use a practical approach to examining the use of Expert Recommendations for Implementing Change (ERIC) strategies by Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) dimensions for rural health innovations using annual reports on a diverse array of initiatives. DATA SOURCES AND STUDY SETTING: The Veterans Affairs (VA) Office of Rural Health (ORH) funds initiatives designed to support the implementation and spread of innovations and evidence-based programs and practices to improve the health of rural Veterans. This study draws on the annual evaluation reports submitted for fiscal years 2020-2022 from 30 of these enterprise-wide initiatives (EWIs). STUDY DESIGN: Content analysis was guided by the RE-AIM framework conducted by the Center for the Evaluation of Enterprise-Wide Initiatives (CEEWI), a Quality Enhancement Research Initiative (QUERI)-ORH partnered evaluation initiative. DATA COLLECTION AND EXTRACTION METHODS: CEEWI analysts conducted a content analysis of EWI annual evaluation reports submitted to ORH. Analysis included cataloguing reported implementation strategies by Reach, Adoption, Implementation, and Maintenance (RE-AIM) dimensions (i.e., identifying strategies that were used to support each dimension) and labeling strategies using ERIC taxonomy. Descriptive statistics were conducted to summarize data. PRINCIPAL FINDINGS: A total of 875 implementation strategies were catalogued in 73 reports. Across these strategies, 66 unique ERIC strategies were reported. EWIs applied an average of 12 implementation strategies (range 3-22). The top three ERIC clusters across all 3 years were Develop stakeholder relationships (21%), Use evaluative/iterative strategies (20%), and Train/educate stakeholders (19%). Most strategies were reported within the Implementation dimension. Strategy use among EWIs meeting the rurality benchmark were also compared. CONCLUSIONS: Combining the dimensions from the RE-AIM framework and the ERIC strategies allows for understanding the use of implementation strategies across each RE-AIM dimension. This analysis will support ORH efforts to spread and sustain rural health innovations and evidence-based programs and practices through targeted implementation strategies.

Developmental Markers of Genetic Liability to Autism in Parents: A Longitudinal, Multigenerational Study.

Genetic liability to autism spectrum disorder (ASD) can be expressed in unaffected relatives through subclinical, genetically meaningful traits, or endophenotypes. This study aimed to identify developmental endophenotypes in parents of individuals with ASD by examining parents' childhood academic development over the school-age period. A cohort of 139 parents of individuals with ASD were studied, along with their children with ASD and 28 controls. Parents' childhood records in the domains of language, reading, and math were studied from grades K-12. Results indicated that relatively lower performance and slower development of skills (particularly language related skills), and an uneven rate of development across domains predicted ASD endophenotypes in adulthood for parents, and the severity of clinical symptoms in children with ASD. These findings may mark childhood indicators of genetic liability to ASD in parents, that could inform understanding of the subclinical expression of ASD genetic liability.

Laterality of Oral Clefts and Academic Achievement.

BACKGROUND AND OBJECTIVES: Children with isolated oral clefts have lower academic performance when compared with unaffected peers, yet few studies have examined specific attributes of clefts that may modify this risk. Oral clefts have nonrandom laterality, with left-sided clefts being more common than right-sided clefts, a pattern that may be genetically or environmentally influenced. The objective of this study was to evaluate the association between cleft laterality and academic achievement in a population-based sample of children with and without isolated oral clefts. METHODS: The study included 292 children with isolated unilateral cleft lip with or without cleft palate identified by using the Iowa Registry for Congenital and Inherited Disorders matched with 908 unaffected classmates. This group provided 1953 child-grade observations for cases and 6829 for classmates. Academic achievement was evaluated by using high-quality standardized test data on multiple academic domains as well as use of special education. RESULTS: We found that children with right-sided clefts had similar achievement scores and usage of special education services compared with their unaffected classmates. Children with left-sided clefts had lower reading scores than children with right-sided clefts by nearly 7 percentiles (P < .05). They also had lower scores on all evaluated domains by 4 to 6 percentiles and greater use of special education services by 6 percentage points than their classmates. CONCLUSIONS: Children with left-sided clefts had poorer academic performance than their classmates or children with right-sided clefts, who showed similar academic achievement compared with their unaffected classmates.

Children with oral clefts are at greater risk for persistent low achievement in school than classmates.

OBJECTIVES: To examine trajectories in academic achievement for children with oral clefts versus unaffected classmates and explore predictors of persistently low achievement among children with oral clefts. DESIGN: Longitudinal cohort study of academic achievement in a population-based sample. SETTING AND PARTICIPANTS: Children born from 1983 through 2003 with oral clefts were identified from the Iowa Registry for Congenital and Inherited Disorders and matched to unaffected classmates by sex, school/school district and month and year of birth. MAIN OUTCOME MEASURES: Academic achievement was measured from Iowa Testing Programs data. Outcomes included achievement scores in reading, language and mathematics. RESULTS: Academic achievement data were available for 586 children with oral clefts and 1873 unaffected classmates. Achievement trajectories were stable for both groups. Children with oral clefts were more likely than their classmates to be classified into persistent low achievement trajectories, including when adjusting for socioeconomic differences: OR=1.63, 95% CI 1.23 to 2.16 for reading; OR=1.73, 95% CI 1.29 to 2.31 for language; OR=1.45, 95% CI 1.05 to 1.99 for math. Predictors of low achievement were cleft palate only (vs other cleft types), adolescent mothers, low maternal education and less frequent use of prenatal care. CONCLUSIONS: Most children have steady academic trajectories and children with oral clefts are at greater risk for persistent low achievement in school than unaffected classmates. These findings support the need for routine, early screening for academic deficits in this population. Cleft palate only, low parental education and adolescent mothers are associated with increased risk for persistent low achievement.

Academic achievement in children with oral clefts versus unaffected siblings.

OBJECTIVE: To compare academic achievement in children with oral-facial clefts (OFC) with their unaffected siblings. METHODS: 256 children with OFC were identified from the Iowa Registry for Congenital and Inherited Disorders, and 387 unaffected siblings were identified from birth certificates. These data were linked to Iowa Testing Programs achievement data. We compared academic achievement in children with OFC with their unaffected siblings using linear regression models, adjusted for potential confounders. In post hoc analyses, we explored modifiers of siblings' academic performance. RESULTS: Achievement scores were similar between children with OFC and their siblings. Children with cleft palate only were significantly more likely to use special education than their unaffected siblings. Siblings' academic achievement was inversely related to distance in birth order and age from the affected child. CONCLUSION: Children with OFC and their siblings received similar achievement scores. Younger siblings, in particular, may share a vulnerability to poor academic outcomes.

Academic achievement of children and adolescents with oral clefts.

BACKGROUND AND OBJECTIVE: Previous studies of academic achievement of children with oral clefts have mostly relied on small, clinic-based samples prone to ascertainment bias. In the first study in the United States to use a population-based sample with direct assessment, we evaluated the academic achievement of children with oral clefts relative to their classmates. METHODS: Children born with isolated oral clefts in Iowa from 1983 to 2003 were identified from the Iowa Registry for Congenital and Inherited Disorders and matched to unaffected classmates by gender, school/school district, and month and year of birth. Academic achievement was assessed by using standardized tests of academic progress developed by the Iowa Testing Programs. Iowa Testing Programs data were linked to birth certificates for all children. Regression models controlled for household demographic and socioeconomic factors. The analytical sample included 588 children with clefts contributing 3735 child-grade observations and 1874 classmates contributing 13 159 child-grade observations. RESULTS: Children with oral clefts had lower scores than their classmates across all domains and school levels, with a 5-percentile difference in the overall composite score. Children with clefts were approximately one-half grade level behind their classmates and had higher rates of academic underachievement and use of special education services by 8 percentage points. Group differences were slightly lower but remained large and significant after adjusting for many background characteristics. CONCLUSIONS: Children with oral clefts underperformed across all academic areas and grade levels compared with their classmates. The results support a model of early testing and intervention among affected children to identify and reduce academic deficits.

Application of neurodevelopmental screening to a sample of South American infants: the Bayley Infant Neurodevelopmental Screener (BINS).

OBJECTIVE: To evaluate the utility of the Bayley Infant Neurodevelopmental Screener (BINS), standardized in the US, for South American infants, 3-24 months of age. METHODS: Thirty-five physicians administered the BINS to 2471 South American infants recruited during routine well-child visits, 578 (23%) from Brazil and 1893 (77%) from six other South American countries. The BINS was translated into Spanish and Portuguese and participating physicians were trained to administer the BINS. Physician inter-rater agreement with training tapes was 84.4%; test-retest reliability for age item sets ranged from 0.80 to 0.93 (Pearson's r). Infants were classified into being at low, moderate, or high risk for developmental delay or neurological impairment based on their total BINS score. The sample was stratified by infant's age, sex and language (Spanish and Portuguese). The BINS scores were compared to the scores of the US infant sample used to standardize the BINS. RESULTS: Female infants performed higher than male at 16-20 months and 21-24 months; male infant scores were more variable at 5-6 months. Scores on only two items were significantly different between Spanish and Portuguese speaking participants. South American scores were typically significantly higher than the US sample, and a lower proportion of infants were classified as being at high risk in the South American sample than in the US standardization sample. CONCLUSION: Overall, the results of this study indicate that the BINS is feasible and appropriate for neurodevelopmental screening in South America. Further studies are needed to confirm the BINS utility in South America, including its use with a clinical sample.

Population-based exploration of academic achievement outcomes in pediatric acute lymphoblastic leukemia survivors.

OBJECTIVE: Examine academic achievement among pediatric acute lymphoblastic leukemia survivors diagnosed during the years 1993-2008. METHOD: A deterministic linkage of the Iowa Cancer Registry and Iowa Testing Programs databases was performed and yielded 147 survivors. Achievement data, in the form of Iowa Percentile Rank scores, were obtained and analyzed by grade and content domain. RESULTS: Children diagnosed before age 5 evidenced more underachievement than those diagnosed later (p = .05). Underachievement was noted in mathematics in grades 8 and 11 (p's < .05), in addition to a longitudinal decrease in scores from grades 4 through 11 (p = .01). No differences were found in academic achievement between males and females. CONCLUSIONS: Utilization of a population-based approach with a nationally recognized, standardized instrument indicates that academic underachievement is subtle yet exists, most notably in mathematics.

Development and testing of an evidence-based practice questionnaire for school nurses.

Understanding the unique needs of school nurses is crucial for developing strategies to increase use of evidence-based health care practices in schools. This article describes the development and evaluation of an instrument designed to identify the needs of school nurses and variables associated with use of evidence-based practice in the school setting, that is, the School Nurse Evidence Based Practice Questionnaire (SN-EBP). After questions were drafted, reviewed, pilot-tested, and revised, data were collected from 386 school nurses for psychometric testing. The initial version consisted of 91 content items in five sections. Principal components analysis with promax rotation identified 17 factors in the five sections of the questionnaire, with Cronbach's alpha coefficients for the sections ranging from .62 to .89. The questionnaire showed good discrimination between known groups on key factors. The SN-EBP was reduced to 69 content items and demonstrated sufficient reliability and validity to warrant further use. It is the only scale available for use in identifying needs and variables associated with use of evidence-based practice in this population.

Use of evidence-based practice in school nursing: prevalence, associated variables, and perceived needs.

BACKGROUND: Research on the adoption of evidence-based practice (EBP) in health care has been focused mainly on hospital settings and primary care; little is known about EBP adoption and implementation among school nurses in the United States (US). OBJECTIVES: The objectives of this study were to (1) describe the prevalence of EBP use among school nurses, (2) describe demographic, individual, and organizational factors associated with EBP use, and (3) identify resources needed to enhance EBP use. METHODS: A survey designed for this study was mailed to all school nurses in Iowa in the US, with a response rate of 56.8% (n= 386). Descriptive statistics and t-tests were used to indicate and compare the variables of interest. Multiple regression and analysis of variance (ANOVA) methods were used to identify variables explaining the variance in the use of EBP. RESULTS: Information sources, professional membership, and district size explain 22% of the variance in current use of EBP. Identified resources needed to increase the use of EBP included networking opportunities, predeveloped EBP guidelines, and education on outcome evaluation. CONCLUSIONS: This study indicates important information on variables that affect current practice in school nursing and also shows requested resources for increasing EBP use. These results can be used to develop translation strategies to increase the use of EBP in the school setting. Because only 22% of the variance was explained, further research is needed to identify additional variables.