Self-compassion mediates the link between attachment security and intimate relationship quality for couples navigating pregnancy.

Millions of couples navigate the transition from pregnancy to postpartum in a given year, and this period of change and adjustment in the family is associated with elevated risk for intimate relationship dysfunction. Self-compassion has the potential to promote skills that are essential for healthy adaptation (e.g., emotion regulation, greater openness and flexibility, and more awareness of the needs of oneself and one's partner). The overarching goal of the present study was to investigate the role of self-compassion in intimate relationship quality during pregnancy. A sample of 159 couples completed semi-structured interviews and questionnaires. Parents engaging in more compassionate self-responding during pregnancy have higher-quality intimate relationships as measured across multiple facets-the degree of emotional intimacy and closeness in the relationship, adaptive conflict management and resolution, high-quality support in response to stress, and a high degree of respect and acceptance directed toward each other. Furthermore, compassionate self-responding emerged as a mediator of the link between attachment security and intimate relationship quality. Specifically, mothers who were higher in attachment anxiety reported lower levels of compassionate self-responding, which in turn undermined multiple dimensions of the intimate relationship. Furthermore, fathers who were higher in attachment avoidance practiced less self-compassion, which have deleterious consequences for the couple. These results provide implications that can inform conceptual frameworks of intimate relationship quality and clinical implications for interventions targeting the transition into parenthood.

Millones de parejas pasan por la transición del embarazo al posparto cada año, y este periodo de cambio y adaptación en la familia está asociado con un riesgo elevado de disfunción en las relaciones amorosas. La autocompasión puede promover habilidades que son fundamentales para una adaptación saludable (p. ej.: regulación emocional, mayor apertura y flexibilidad, mejor conocimiento de las necesidades propias y de las del otro integrante de la pareja). El objetivo general del presente estudio fue investigar el papel que desempeña la autocompasión en la calidad de las relaciones amorosas durante el embarazo. Una muestra de 159 parejas contestó entrevistas y cuestionarios semiestructurados. Los padres con más autorrespuestas compasivas durante el embarazo tuvieron relaciones amorosas de mejor calidad según la evaluación de diferentes aspectos: el grado de intimidad emocional y cercanía en la relación, la gestión adaptativa de conflictos y la resolución de los mismos, el apoyo de alta calidad en respuesta al estrés y un alto grado de respeto y aceptación mutuos. Además, la autorrespuesta compasiva surgió como mediadora del vínculo entre la seguridad del apego y la calidad de las relaciones amorosas. Específicamente, las madres que tuvieron una mayor ansiedad en el apego informaron niveles más bajos de autorrespuesta compasiva, lo cual, a su vez, debilitó varios aspectos de la relación amorosa. Además, los padres que tuvieron una mayor evitación en el apego practicaron menos autocompasión, lo cual tuvo consecuencias perjudiciales para la pareja. Estos resultados tienen implicancias que pueden orientar los marcos conceptuales de la calidad de las relaciones amorosas y consecuencias clínicas para las intervenciones dirigidas a la transición a la paternidad.

Successful implementation of a combined learning collaborative and mentoring intervention to improve neonatal quality of care in rural Rwanda.

BACKGROUND: Globally, neonatal mortality remains high despite interventions known to reduce neonatal deaths. The All Babies Count (ABC) initiative was a comprehensive health systems strengthening intervention designed by Partners In Health in collaboration with the Rwanda Ministry of Health to improve neonatal care in rural public facilities. ABC included provision of training, essential equipment, and a quality improvement (QI) initiative which combined clinical and QI mentorship within a learning collaborative. We describe ABC implementation outcomes, including development of a QI change package. METHODS: ABC was implemented over 18 months from 2013 to 2015 in two Rwandan districts of Kirehe and Southern Kayonza, serving approximately 500,000 people with 24 nurse-led health centers and 2 district hospitals. A process evaluation of ABC implementation and its impact on healthcare worker (HCW) attitudes and QI practice was done using program documents, standardized surveys and focus groups with facility QI team members attending ABC Learning Sessions. The Change Package was developed using mixed methods to identify projects with significant change according to quantitative indicators and qualitative feedback obtained during focus group discussions. Outcome measures included ABC implementation process measures, HCW-reported impact on attitudes and practice of QI, and resulting change package developed for antenatal care, delivery management and postnatal care. RESULTS: ABC was implemented across all 26 facilities with an average of 0.76 mentorship visits/facility/month and 118 tested QI change ideas. HCWs reported a reduction in barriers to quality care delivery related to training (p = 0.018); increased QI capacity (knowledge 37 to 89%, p <  0.001); confidence (47 to 89%, p <  0.001), QI leadership (59 to 91%, p <  0.001); and peer-to-peer learning (37 to 66%, p = 0.024). The final change package included 46 change ideas. Themes associated with higher impact changes included provision of mentorship and facility readiness support through equipment provision. CONCLUSIONS: ABC provides a feasible model of an integrated approach to QI in rural Rwanda. This model resulted in increases in HCW and facility capacity to design and implement effective QI projects and facilitated peer-to-peer learning. ABC and the change package are being scaled to accelerate improvement in neonatal outcomes.

The Partners for Change Outcome Management System: A Both/And System for Collaborative Practice.

Systematic client feedback (SCF) is increasingly employed in mental health services worldwide. While research supports its efficacy over treatment as usual, clinicians, especially those who highly value relational practices, may be concerned that routine data collection detracts from clinical process. This article describes one SCF system, the Partners for Change Outcome Management System (PCOMS), along a normative (standardized measurement) to communicative (conversational) continuum, highlighting PCOMS' origins in everyday clinical practice. The authors contend that PCOMS represents "both/and," providing a valid signal of client progress while facilitating communicative process particularly prized by family therapists steeped in relational traditions. The article discusses application of PCOMS in systemic practice and describes how it actualizes time-honored family therapy approaches. The importance of giving voice to individualized client experience is emphasized.

Prospective Evaluation of a Multifaceted Intervention to Improve Outcomes in Intensive Care: The Promoting Respect and Ongoing Safety Through Patient Engagement Communication and Technology Study.

OBJECTIVES: Studies comprehensively assessing interventions to improve team communication and to engage patients and care partners in ICUs are lacking. This study examines the effectiveness of a patient-centered care and engagement program in the medical ICU. DESIGN: Prospective intervention study. SETTING: Medical ICUs at large tertiary care center. PATIENTS: Two thousand one hundred five patient admissions (1,030 before and 1,075 during the intervention) from July 2013 to May 2014 and July 2014 to May 2015. INTERVENTIONS: Structured patient-centered care and engagement training program and web-based technology including ICU safety checklist, tools to develop shared care plan, and messaging platform. Patient and care partner access to online portal to view health information, participate in the care plan, and communicate with providers. MEASUREMENTS AND MAIN RESULTS: Primary outcome was aggregate adverse event rate. Secondary outcomes included patient and care partner satisfaction, care plan concordance, and resource utilization. We included 2,105 patient admissions, (1,030 baseline and 1,075 during intervention periods). The aggregate rate of adverse events fell 29%, from 59.0 per 1,000 patient days (95% CI, 51.8-67.2) to 41.9 per 1,000 patient days (95% CI, 36.3-48.3; p < 0.001), during the intervention period. Satisfaction improved markedly from an overall hospital rating of 71.8 (95% CI, 61.1-82.6) to 93.3 (95% CI, 88.2-98.4; p < 0.001) for patients and from 84.3 (95% CI, 81.3-87.3) to 90.0 (95% CI, 88.1-91.9; p < 0.001) for care partners. No change in care plan concordance or resource utilization. CONCLUSIONS: Implementation of a structured team communication and patient engagement program in the ICU was associated with a reduction in adverse events and improved patient and care partner satisfaction.

Integrated Primary Medical-Behavioral Health Care for Adolescent and Young Adult Depression: Predictors of Service Use in the Youth Partners in Care Trial.

Objectives: Depression, a chronic and disabling condition, frequently has its first onset during adolescence, underscoring the value of early effective treatment and prevention. Integrated medical-behavioral health care provides one strategy for improving treatment access for adolescents and young adults (AYA). Methods: This study examined predictors of accessing treatment in a multisite randomized controlled trial evaluating an integrated collaborative care intervention aimed at improving access to evidence-based depression treatment through primary health care, compared with usual care. Results: The integrated care intervention was able to overcome barriers to care associated with an initial reluctance to pursue active treatment and older age. Service use was low in both conditions among less acculturated/non-English-speaking families. Conclusions: Results support the value of integrated medical-behavioral health care for improving rates of care. Findings highlight mechanisms by which integrated care may lead to improved rates of care and outcomes for AYA, an underserved and understudied group.

A Participatory Regional Partnership Approach to Promote Nutrition and Physical Activity Through Environmental and Policy Change in Rural Missouri.

BACKGROUND: Rural residents are less likely than urban and suburban residents to meet recommendations for nutrition and physical activity. Interventions at the environmental and policy level create environments that support healthy eating and physical activity. COMMUNITY CONTEXT: Healthier Missouri Communities (Healthier MO) is a community-based research project conducted by the Prevention Research Center in St. Louis with community partners from 12 counties in rural southeast Missouri. We created a regional partnership to leverage resources and enhance environmental and policy interventions to improve nutrition and physical activity in rural southeast Missouri. METHODS: Partners were engaged in a participatory action planning process that included prioritizing, implementing, and evaluating promising evidence-based interventions to promote nutrition and physical activity. Group interviews were conducted with Healthier MO community partners post intervention to evaluate resource sharing and sustainability efforts of the regional partnership. OUTCOME: Community partners identified the benefits and challenges of resource sharing within the regional partnership as well as the opportunities and threats to long-term partnership sustainability. The partners noted that the regional participatory process was difficult, but the benefits outweighed the challenges. INTERPRETATION: Regional rural partnerships may be an effective way to leverage relationships to increase the capacity of rural communities to implement environmental and policy interventions to promote nutrition and physical activity.

Using LiST to model potential reduction in under-five mortality in Burkina Faso.

BACKGROUND: Under-five mortality remains high in Burkina Faso with significant reductions required to meet Millennium Development Goal 4. The Acceleration for Maternal, Newborn, and Child Health is being implemented to reduce child mortality in the North and Center North regions of Burkina Faso. METHODS: The Lives Saved Tool was used to determine the percent reduction in child mortality that can be achieved given baseline levels of coverage for interventions targeted by the Acceleration. Data were obtained from the Demographic and Health Survey 2003, the Multiple Indicator Cluster Survey 2006, and the baseline survey for the program from 2010. In addition to the scale up, scenarios were generated to examine the outcome if secular trends in intervention coverage change persisted and if intervention coverage levels remained constant. RESULTS: Scaling up all interventions to their target coverage level showed a potential reduction in under-five mortality of 22 percent, with district specific reductions in mortality ranging from 14 to 25 percent. The percent reduction in under-five mortality that might be attributable to the program was 16 percent and varied between 14 and 19 percent by district. Treatment of diarrhea with ORS and malaria with ACTs accounted for the majority of the reduction in mortality. CONCLUSIONS: These findings suggest that significant reductions in under-five mortality may be achieved through the scale-up of the Acceleration. The Ministry of Health and its partners in Burkina Faso should continue their efforts to scale up these proven interventions to achieve and even exceed target levels for coverage.

Implementing the ACHIEVE model to prevent and reduce chronic disease in rural Klickitat County, Washington.

BACKGROUND: In the United States, 133 million people live with 1 or more chronic diseases, which contribute to 7 of 10 deaths annually. To prevent and reduce the prevalence of chronic diseases, the National Association of County and City Health Officials (NACCHO) provided technical assistance and funding to 33 local health departments in Washington State, including the Klickitat County Health Department (KCHD), to implement the Action Communities for Health, Innovation, and Environmental Change (ACHIEVE) model. COMMUNITY CONTEXT: Klickitat County residents experience higher rates of obesity and overweight than people living in urban areas in the state. KCHD applied the ACHIEVE model to accomplish 2 objectives: 1) to engage the community in community health assessment, action plan development for chronic disease prevention, and implementation of the plan and 2) to work with targeted sectors to promote worksite wellness and to establish community gardens and bicycling and walking trails. METHODS: KCHD convened and spearheaded the Healthy People Alliance (HPA) to complete a community assessment, develop a community action plan, implement the plan, and evaluate the plan's success. OUTCOMES: KCHD, working with HPA, accomplished all 5 phases of the ACHIEVE model, expanded a multisector community coalition, developed Little Klickitat River Trail and 3 community gardens, and created and promoted a worksite wellness toolkit. INTERPRETATION: Assistance and training that NACCHO provided through ACHIEVE helped the KCHD engage nontraditional community partners and establish and sustain a community coalition.

Transforming the urban food desert from the grassroots up: a model for community change.

Confronted by continuing health disparities in vulnerable communities, Community Health Councils (CHC), a nonprofit community-based organization in South Los Angeles, worked with the African Americans Building a Legacy of Health Coalition and research partners to develop a community change model to address the root causes of health disparities within the community's African American population. This article discusses how the CHC Model's development and application led to public policy interventions in a "food desert." The CHC Model provided a systematic approach to engaging impacted communities in support of societal level reforms, with the goal to influence health outcomes.

Research and comprehensive cancer control coalitions.

The goal of cancer control research is "to generate basic knowledge about how to monitor and change individual and collective behavior and to ensure that knowledge is translated into practice and policy rapidly, effectively, and efficiently" (Division of Cancer Control and Population Sciences in Cancer control framework and synthese rationale, 2010). Research activities span the cancer control continuum from prevention to early detection and diagnosis through treatment and survivorship (Division of Cancer Control and Population Sciences in Cancer control framework and synthese rationale, 2010). While significant advancements have been made in understanding, preventing and treating cancer in the past few decades, these benefits have yielded disproportionate results in cancer morbidity and mortality across various socioeconomic and racial/ethnic subgroups (Ozols et al in J Clin Oncol, 25(1):146-1622, 2007). It has been a high priority since the beginning of the Comprehensive Cancer Control (CCC) movement to utilize research in the development and implementation of cancer plans in the states, tribes and tribal organizations, territories and US Pacific Island Jurisdictions. Nevertheless, dissemination and implementation of research in coalition activities has been challenging for many programs. Lessons learned from programs and coalitions in the implementation and evaluation of CCC activities, as well as resources provided by national partners, can assist coalitions with the translation of research into practice.

Validation of a Collaboration Readiness Assessment Tool for Use by Supplemental Nutrition Assistance Program-Education (SNAP-Ed) Agencies and Partners.

OBJECTIVE: To evaluate content and face validity of a collaboration readiness assessment tool developed to facilitate collaborative efforts to implement policy, systems, and environment changes in Supplemental Nutrition Assistance Program-Education (SNAP-Ed). METHODS: Evaluation of the validity of the tool involved 2 steps. Step 1 was conducted with 4 subject matter experts to evaluate content validity. Step 2 used an iterative cognitive testing process with 4 rounds and 16 SNAP-Ed staff and community partners to evaluate face validity. RESULTS: Subject matter experts found that survey items appropriately matched the content area indicated and adequately covered collective efficacy, change efficacy, and readiness. Cognitive testing with SNAP-Ed staff and partners informed modifications and resulted in adequate face validity. CONCLUSIONS AND IMPLICATIONS: The ability to measure collaboration readiness will allow agencies and community partners that implement SNAP-Ed to target areas that facilitate collaboration efforts needed for policy, systems, and environment change and collective efficacy. Further cognitive testing of the tool with other populations is needed to ensure its applicability and usefulness. Evaluation of the reliability of the tool with a broad range of SNAP-Ed programs and community agencies is also recommended.

Evaluating the impact of partnerships to improve clinical quality.

BACKGROUND: Translating research into practice and policy is a complex process that links the research enterprise and health care delivery system of the United States. The Agency for Healthcare Research and Quality (AHRQ) Partnerships for Quality (PFQ) initiative expanded the scope of research translation beyond clinical practice, highlighting the role of strategic partners. A work group of AHRQ grantees developed a framework for systematic evaluation of the impact of strategic partnerships on research translation. METHODS: The evaluation framework posits a hierarchy of impacts that cumulatively lead to observable patient outcomes. The evaluation framework captures (1) health care outcomes improvement, (2) clinical practice changes, (3) policies, procedures, and protocols, and (4) research and knowledge. After the framework and tool were subjected to face-validity critique among PFQ investigators, the concept of synergy was added. PFQ investigators pilot-tested the evaluation framework, and the PFQ tool was refined further. RESULTS: Early feedback from PFQ grantees suggested that the framework is generalizable and potentially useful to guide investigators in capturing impacts of their work that might otherwise go unrecognized or trivialized. DISCUSSION: The PFQ Evaluation Tool, a pragmatic approach for evaluating the impact of partnership-driven translation projects, provides a comprehensive evaluation of impacts, including synergistic outcomes.

A methodology for evaluating organizational change in community-based chronic disease interventions.

BACKGROUND: In 2003, the Monterey County Health Department, serving Salinas, California, was awarded one of 12 grants from the Steps to a HealthierUS Program to implement a 5-year, multiple-intervention community approach to reduce diabetes, asthma, and obesity. National adult and youth surveys to assess long-term outcomes are required by all Steps sites; however, site-specific surveys to assess intermediate outcomes are not required. CONTEXT: Salinas is a medically underserved community of primarily Mexican American residents with high obesity rates and other poor health outcomes. The health department's Steps program has partnered with traditional organizations such as schools, senior centers, clinics, and faith-based organizations as well as novel organizations such as employers of agricultural workers and owners of taquerias. METHODS: The health department and the Stanford Prevention Research Center developed new site-specific, community-focused partner surveys to assess intermediate outcomes to augment the nationally mandated surveys. These site-specific surveys will evaluate changes in organizational practices, policies, or both following the socioecological model, specifically the Spectrum of Prevention. CONSEQUENCES: Our site-specific partner surveys helped to 1) identify promising new partners, select initial partners from neighborhoods with the greatest financial need, and identify potentially successful community approaches; and 2) provide data for evaluating intermediate outcomes matched to national long-term outcomes so that policy and organizational level changes could be assessed. These quantitative surveys also provide important context-specific qualitative data, identifying opportunities for strengthening community partnerships. INTERPRETATION: Developing site-specific partner surveys in multisite intervention studies can provide important data to guide local program efforts and assess progress toward intermediate outcomes matched to long-term outcomes from nationally mandated surveys.

Effectiveness of the WHO Safe Childbirth Checklist program in reducing severe maternal, fetal, and newborn harm in Uttar Pradesh, India: study protocol for a matched-pair, cluster-randomized controlled trial.

BACKGROUND: Effective, scalable strategies to improve maternal, fetal, and newborn health and reduce preventable morbidity and mortality are urgently needed in low- and middle-income countries. Building on the successes of previous checklist-based programs, the World Health Organization (WHO) and partners led the development of the Safe Childbirth Checklist (SCC), a 28-item list of evidence-based practices linked with improved maternal and newborn outcomes. Pilot-testing of the Checklist in Southern India demonstrated dramatic improvements in adherence by health workers to essential childbirth-related practices (EBPs). The BetterBirth Trial seeks to measure the effectiveness of SCC impact on EBPs, deaths, and complications at a larger scale. METHODS/DESIGN: This matched-pair, cluster-randomized controlled, adaptive trial will be conducted in 120 facilities across 24 districts in Uttar Pradesh, India. Study sites, identified according to predefined eligibility criteria, were matched by measured covariates before randomization. The intervention, the SCC embedded in a quality improvement program, consists of leadership engagement, a 2-day educational launch of the SCC, and support through placement of a trained peer "coach" to provide supportive supervision and real-time data feedback over an 8-month period with decreasing intensity. A facility-based childbirth quality coordinator is trained and supported to drive sustained behavior change after the BetterBirth team leaves the facility. Study participants are birth attendants and women and their newborns who present to the study facilities for childbirth at 60 intervention and 60 control sites. The primary outcome is a composite measure including maternal death, maternal severe morbidity, stillbirth, and newborn death, occurring within 7 days after birth. The sample size (n = 171,964) was calculated to detect a 15% reduction in the primary outcome. Adherence by health workers to EBPs will be measured in a subset of births (n = 6000). The trial will be conducted in close collaboration with key partners including the Governments of India and Uttar Pradesh, the World Health Organization, an expert Scientific Advisory Committee, an experienced local implementing organization (Population Services International, PSI), and frontline facility leaders and workers. DISCUSSION: If effective, the WHO Safe Childbirth Checklist program could be a powerful health facility-strengthening intervention to improve quality of care and reduce preventable harm to women and newborns, with millions of potential beneficiaries. TRIAL REGISTRATION: BetterBirth Study Protocol dated: 13 February 2014; ClinicalTrials.gov: NCT02148952 ; Universal Trial Number: U1111-1131-5647.

An Evaluation of the CDC's Community-Based Breastfeeding Supplemental Cooperative Agreement: Reach, Strategies, Barriers, Facilitators, and Lessons Learned.

BACKGROUND: Community-based organizations (CBOs) have an important role to play in promoting breastfeeding continuation among mothers. The Centers for Disease Control and Prevention's Nutrition, Physical Activity, and Obesity Program's Cooperative Agreement Breastfeeding Supplement funded 6 state health departments to support CBOs to implement community-based breastfeeding support activities. OBJECTIVES: Study objectives were to (1) describe the reach of the Cooperative Agreement, (2) describe breastfeeding support strategies implemented by state health departments and CBOs, and (3) understand the barriers and facilitators to implementing community-based breastfeeding support strategies. METHODS: Qualitative and quantitative data were abstracted from state health departments' final evaluation reports. Qualitative data were analyzed for common themes using deductive and inductive approaches. RESULTS: Within the 6 states funded by the Cooperative Agreement, 66 primary CBOs implemented breastfeeding support strategies and reported 59 256 contacts with mothers. Support strategies included incorporating lactation services into community-based programs, training staff, providing walk-in locations for lactation support, connecting breastfeeding mothers to resources, and providing services that reflect community-specific culture. Community partnerships, network building, stakeholders' commitment, and programmatic and policy environments were key facilitators of program success. CONCLUSION: Key lessons learned include the importance of time in creating lasting organizational change, use of data for program improvement, choosing the right partners, taking a collective approach, and leveraging resources.

Effects of the Seattle social development project on sexual behavior, pregnancy, birth, and sexually transmitted disease outcomes by age 21 years.

OBJECTIVE: To examine the long-term effects of the full Seattle Social Development Project intervention on sexual behavior and associated outcomes assessed at age 21 years. DESIGN: Nonrandomized controlled trial with long-term follow-up. SETTING: Public elementary schools serving children from high-crime areas in Seattle, Wash. PARTICIPANTS: Ninety-three percent of the fifth-grade students enrolled in either the full-intervention or control group were successfully interviewed at age 21 years (n = 144 [full intervention] and n = 205 [control]). INTERVENTIONS: In-service teacher training, parenting classes, and social competence training for children. MAIN OUTCOME MEASURES: Self-report measures of all outcomes. RESULTS: The full-intervention group reported significantly fewer sexual partners and experienced a marginally reduced risk for initiating intercourse by age 21 years as compared with the control group. Among females, treatment group status was associated with a significantly reduced likelihood of both becoming pregnant and experiencing a birth by age 21 years. Among single individuals, a significantly increased probability of condom use during last intercourse was predicted by full-intervention group membership; a significant ethnic group x intervention group interaction indicated that after controlling for socioeconomic status, single African Americans were especially responsive to the intervention in terms of this outcome. Finally, a significant treatment x ethnic group interaction indicated that among African Americans, being in the full-intervention group predicted a reduced probability of contracting a sexually transmitted disease by age 21 years. CONCLUSION: A theory-based social development program that promotes academic success, social competence, and bonding to school during the elementary grades can prevent risky sexual practices and adverse health consequences in early adulthood.

Buprenorphine and medication management in a community corrections population: a pilot study.

AIMS: This project sought to demonstrate the feasibility and acceptability of providing on-site buprenorphine treatment to individuals under community corrections supervision. METHODS: Seventeen women and 13 men were enrolled on-site over a 2-week period at a community corrections location. Study participants received open-label study medication dispensed weekly over 12 weeks, weekly medication management therapy, and returned for a 1-month follow-up. RESULTS: Participants were predominantly female (56%) and white (90%) with an average age of 31.7 ± 7.4 years. More than half (53%) had hepatitis C virus infection and 75.9% reported intravenous use of opioids in the 30 days before treatment. Rates of illicit substance use was high, as 37.9% of urines were positive for benzodiazepines, 31.7% were positive for cocaine, and 13.7% were positive for alcohol across the time in the study. Although rates of positive urines for opiate use and sex with multiple partners did not change during treatment, rates of injection drug use significantly decreased during treatment. Overall, 86.7% of participants were retained through the 1-month follow-up with low rates of adverse events. CONCLUSIONS: Acceptability and feasibility of this approach were demonstrated by the ability to enroll and randomize the target sample of participants over 2 weeks with high retention and low rates of adverse events through 1-month follow-up. This pilot study demonstrated that this population could be successfully engaged in treatment and show reductions in risky behaviors. However, more intensive interventions may be needed to reduce opiate use to reach this vulnerable population at their point of contact with the criminal justice system.

Developing clinical competencies to assess learning needs and outcomes: the experience of the CS2day initiative.

An outcomes-based education (OBE) approach was desired for the CS2day initiative, and the size and scope of the initiative compelled a consistent and cohesive framework in order to apply such an approach. A series of competency statements were developed to provide that framework. The competency statements were based on current clinical guidelines, and further refined through stakeholder interviews and expert feedback. These competency statements were utilized throughout the CS2day initiative as the foundation for needs assessments, activity planning and development, and outcomes measurement. The CS2day partners found these competencies useful in developing over 150 educational activities in the initiative. The competencies became the firm linkages between the needs and outcomes measures used for all CS2day activities, and enabled a summative evaluation to be developed for the entire initiative. This article describes the rationale for developing the competencies, the methods used to deploy them, and the tools that incorporated these competencies.

O impacto de um programa de visitas domiciliares no ambiente de cuidado de mães adolescentes e seus bebês: uma análise comparativa / The impact of a home visiting program on the care environment of adolescent mothers and their babies: a comparative analysis

Introdução: Existem fortes evidências que associam ambiente e desenvolvimento infantil (DI) na primeira infância e justificam a relevância de estudos sobre as características do ambiente com o objetivo de compreendê-lo e, assim, intervir sobre o DI. Ambientes físico e socialmente empobrecidos, bem como a ausência de estimulação e brincadeiras, limitam a oportunidade da criança de interagir com o meio em que vive. Crianças de classes econômicas mais baixas crescem e se desenvolvem frequentemente em ambientes de privação de espaço e estimulo. Modificar esses cenários e torná-los ambientes capazes de promover o DI é um desafio. Por essa razão, o Programa Jovens Mães Cuidadoras (PJMC) é uma proposta de assistência que tem como foco a promoção de práticas parentais positivas voltadas para mães adolescentes e que vivem em situação de vulnerabilidade social. Objetivo: Avaliar os resultados do PJMC no âmbito do ambiente domiciliar de cuidado à criança, utilizando o Inventário IT-HOME. Método: Estudo de natureza exploratória, descritiva, centrada no ambiente domiciliar de 80 mães adolescentes e seus bebês acompanhados pelo PJMC, randomizadas 40 para o grupo intervenção (GI) e 40 para o grupo controle (GC). Os dados foram coletados através de avaliações periódicas (3, 6, 12 e 24 meses de vida da criança) utilizando o Inventário IT-HOME como instrumento, armazenados na plataforma REDCap e trabalhados com os softwares RStudio, versão 1.2.1335; R, versão 3.60: GUI 1.70 El Capitan Build e Excel, versão 16.16.3. Sendo assim, foram realizadas análises descritiva e comparativa dos dados com cálculo de escore geral e das sub escalas do inventário IT-HOME, para os grupos Intervenção e Controle. Os dados sociodemográficos escolaridade da mãe, assim como presença de parceiro, foram avaliados para verificar sua influência na comparação de resultados do inventário IT-HOME entre GC e GI. Resultados: Apesar da diferença entre os grupos não ser estatisticamente significativa na maioria das analises, este estudo mostrou resultados positivos da intervenção do PJMC. Desse modo, os dados sugerem que o PJMC precisa sofrer adequações na abordagem do período de 13 a 24 meses para que seja mais efetiva na manutenção da qualidade do ambiente. Outro dado importante, a presença de companheiro materno pode ter relação estatisticamente significativa com o desempenho do grupo intervenção no Inventário IT-HOME: para Escore Total e sub escore Disponibilidade de Materiais de Brinquedos e Jogos apropriados aos 6 meses; Responsividade Emocional e Verbal do Cuidador aos 12 meses; e, Oportunidade de Variação na Estimulação Cotidiana aos 24 meses de vida do bebê. Enquanto isso, escolaridade materna pode ter relação, estatisticamente significante, com o desempenho do grupo intervenção no Inventário IT-HOME para Escore Total, sub escores Responsividade Emocional e Verbal do cuidador e Disponibilidade de Materiais de Brinquedos e Jogos apropriados aos 6 meses de vida do bebê. O número de visitas recebidas teve fraca associação com a qualidade do ambiente, assim como a rotatividade de enfermeira visitadora não mostrou impacto sobre o mesmo. Conclusão: Os resultados mostram um discreto impacto das ações desenvolvidas pelo PJMC na qualidade do ambiente das famílias assistidas. Contudo, talvez sejam necessárias algumas adaptações culturais para que o Inventário IT- HOME possa apreender com fidelidade a realidade das periferias brasileiras e ser mais sensível a proposta do PJMC. Além disso, quando se trabalha com condições de vulnerabilidade severa torna-se muito desafiador medir impactos a curto prazo, pois a instabilidade da situação financeira e social muitas vezes faz com que a construção de um ambiente domiciliar favorável ao desenvolvimento infantil seja lenta e sua manutenção delicada.

Introduction: There are strong evidences associating home environment and child development (CD) in early childhood and justifying the relevance of studies about the characteristics of the environment in order to understand it and, thus, intervene on CD. Physically and socially impoverished environments, as well as the absence of stimulation and plays, limit the child's opportunity to interact with the environment in which they live. Children of lower economic classes often grow and develop in environments with a lack of space and stimulation. Change these scenarios and make them capable of promoting CD is challenging. For this reason, the Young Mothers Caregivers Program (YMCP) is a proposal for assistance focusing on the promotion of positive parenting practices to teenage mothers who live in a situation of social vulnerability. Objective: To evaluate the results of the YMCP within the home environment of child care, using the IT-HOME Inventory. Method: An exploratory and descriptive study centered on the home environment of 80 teenage mothers and their Children monitored by the YMCP, from which 40 of them are selected for the intervention group (IG) and the other 40 for the control group (CG). The data were collected through periodic evaluations (3, 6, 12 and 24 months of the child's life) using the IT-HOME Inventory as an instrument, stored on the REDCap platform and analysed with RStudio software, version 1.2.1335; R, version 3.60: GUI 1.70 El Capitan Build and Excel, version 16.16.3. Descriptive and comparative data analysis were performed calculating the general score and the subscales of the IT-HOME inventory, for the Intervention and Control groups. The mother's sociodemographic data, like education and partners presence, were evaluated to verify their influence on the comparison of the results of the IT-HOME inventory between CG and IG. Results: Although the difference between the groups is not statistically significant in most cases, this study has shown positive results of YMCP intervention. Nevertheless, the analysis suggest that the YMCP needs improvements in its approach regarding children from 13 to 24 months in order to be more effective in maintaining the quality of the environment. Another important fact, the presence of a partner may have a statistically significant relationship with the performance of the intervention group in the IT-HOME Inventory: for Total Score and sub-score Availability of Materials for Toys and Games appropriate at 6 months; Caregiver's Emotional and Verbal Responsiveness at 12 months; and, Opportunity for Variation in Daily Stimulation at 24 months. Meanwhile, mothers education level may have a statistically significant relationship with the performance of the intervention group in the IT-HOME Inventory for the Total Score, sub-score Emotional and Verbal Responsibility of the caregiver and Availability of Toys and Games Materials appropriate to 6 months babies. The number of the program visits had a weak link with the quality of the environment, as well as the turnover of the visiting nurses which has not shown any impact on it. Conclusion: The results show a small impact of the actions developed by the PJMC on the quality of the assisted families' environment. However, some cultural adaptations may be necessary so that the IT-HOME Inventory can reliably assimilate the reality of the Brazilian peripheries and be more sensitive to the YMCP's proposal. In addition, when working with conditions of severe vulnerability, it becomes very challenging to measure the impacts in the short term, as the instability of the financial and social situation often slow down the construction of a home environment favorable to child development and difficult its maintenance.

Measuring progress of collaborative action in a community health effort / Medición del progreso de las actividades de colaboración en una iniciativa de salud comunitaria

OBJECTIVE: To measure the progress made by the collaborative actions of multisectorial partners in a community health effort using a systematic method to document and evaluate community/system changes over time. METHODS: This was a community-based participatory research project engaging community partners of the Latino Health for All Coalition, which based on the Health for All model, addresses health inequity in a low-income neighborhood in Kansas City, Kansas, United States of America. Guided by three research questions regarding the extent to which the Coalition catalyzed change, intensity of change, and how to visually display change, data were collected on community/system changes implemented by the community partners from 2009-2012. These changes were characterized and rated according to intensity (event duration, population reach, and strategy) and by other categories, such as social determinant of health mechanism and sector. RESULTS: During the 4-year study period, the Coalition implemented 64 community/system changes. These changes were aligned with the Coalition's primary goals of healthy nutrition, physical activity, and access to health screenings. Community/system efforts improved over time, becoming longer in duration and reaching more of the population. CONCLUSIONS: Although evidence of its predictive validity awaits further research, this method for documenting and characterizing community/system changes enables community partners to see progress made by their health initiatives.

OBJETIVO:Medir el progreso alcanzado por las actividades de colaboración de los socios multisectoriales en una iniciativa de salud comunitaria mediante el empleo de un método sistemático para verificar y evaluar los cambios en la comunidad y los sistemas con el transcurso del tiempo. MÉTODOS: Se trata de un proyecto comunitario de investigación participativa en el que colaboraron los socios comunitarios de la Coalición Salud para Todos los Latinos, que, con base en el modelo de Salud para Todos, aborda las desigualdades en materia de salud en un vecindario de bajos ingresos de Kansas City, en el estado de Kansas (Estados Unidos). Adoptando como guía tres preguntas de investigación referentes a en qué medida la Coalición catalizó los cambios, qué intensidad alcanzaron y cómo mostrarlos gráficamente, se recogieron datos sobre los cambios en la comunidad y los sistemas introducidos por los socios comunitarios del 2009 al 2012. Estos cambios se describieron y evaluaron según su intensidad (la duración del acontecimiento, el porcentaje de población expuesta y la estrategia) y según otras categorías, tales como el mecanismo implicado como determinante social de la salud y el sector afectado. RESULTADOS: Durante el período de estudio de cuatro años, la Coalición había introducido 64 cambios en la comunidad y los sistemas. Estos cambios estaban alineados con las principales metas de la Coalición: nutrición sana, ejercicio físico y acceso a los tamizajes de salud. Las iniciativas de la comunidad y los sistemas mejoraron con el transcurso del tiempo, eran más duraderas y llegaban a una parte más importante de la población. CONCLUSIONES:Aunque se requieren investigaciones adicionales para establecer datos probatorios de su validez predictiva, este método para verificar y caracterizar los cambios en la comunidad y los sistemas permite a los socios comunitarios observar el progreso alcanzado por sus iniciativas en pro de la de salud.