Designing interoperable health information systems using Enterprise Architecture approach in resource-limited countries: A literature review.

BACKGROUND: Enterprise Architecture (EA) integrates business and technical processes in health information systems (HIS). Low-income and middle-income countries (LMIC) use EA to combine management components with disease tracking and health care service monitoring. Using an EA approach differs by country, addressing specific needs. METHODS: Articles in this review referenced EA, were peer-reviewed or gray literature reports published in 2010 to 2016 in English, and were identified using PubMed, Scopus, Web of Science, and Google Scholar. RESULTS: Fourteen articles described EA use in LMICs. India, Sierra Leone, South Africa, Mozambique, and Rwanda reported building the system to meet country needs and implement a cohesive HIS framework. Jordan and Taiwan focused on specific HIS aspects, ie, disease surveillance and electronic medical records. Five studies informed the context. The Millennium Villages Project employed a "uniform but contextualized" approach to guide systems in 10 countries; Malaysia, Indonesia, and Tanzania used interviews and mapping of existing components to improve HIS, and Namibia used of Activity Theory to identify technology-associated activities to better understand EA frameworks. South Africa, Burundi, Kenya, and Democratic Republic of Congo used EA to move from paper-based to electronic systems. CONCLUSIONS: Four themes emerged: the importance of multiple sectors and data sources, the need for interoperability, the ability to incorporate system flexibility, and the desirability of open group models, data standards, and software. Themes mapped to EA frameworks and operational components and to health system building blocks and goals. Most articles focused on processes rather than outcomes, as countries are engaged in implementation.

Correction to: Randomized Trial of a Training Program to Improve Home Visitor Communication around Sensitive Topics.

The article "Randomized Trial of a Training Program to Improve Home Visitor Communication around Sensitive Topics", written by Allison West, Laina Gagliardi, Amanda Gatewood, Susan Higman, Jane Daniels, Kay O'Neill and Anne Duggan, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 31 May 2018 without open access.

Randomized Trial of a Training Program to Improve Home Visitor Communication around Sensitive Topics.

INTRODUCTION: Strong communication skills are necessary to engage families, perform accurate assessments, and motivate behavior change around sensitive issues encountered in home visiting. METHODS: A two-arm, cluster-randomized trial evaluated the impact of a trans-model communications training course for home visitors. Fourteen home visiting programs in Maryland were assigned to a training intervention (n = 7 programs; 30 visitors) or wait-list control group (n = 7 programs; 34 visitors). Independent observers assessed training fidelity. Visitor's attitudes, knowledge, and confidence were assessed through surveys. Their skills were assessed through coding of video-recorded visits with standardized mothers. Data were collected at baseline, within 2 weeks post-training, and at 2 months post-training. Regression models accounted for clustering within programs and controlled for characteristics on which study groups differed at baseline. RESULTS: Independent observers rated the training highly on fidelity and acceptability. Home visitors rated it as useful, consistent with their model, and worth the effort. Immediately following the training, the training group scored higher than the control group on a range of indicators in all domains-knowledge, attitudes, confidence, and skills in using motivational communication techniques. At 2 months post-training, impacts on knowledge and attitudes persisted; impacts on confidence and observed skill were attenuated. DISCUSSION: The training course showed favorable immediate impacts on knowledge, attitudes, confidence, and skills, and long-term impacts on home visitor knowledge and attitudes. The findings underscore the need for ongoing reinforcement of skills following training.

Self-efficacy for smoking cessation counseling parents in primary care: an office-based intervention for pediatricians and family physicians.

Few pediatricians or family physicians routinely counsel parental smokers to quit smoking. Poor self-efficacy in smoking cessation counseling skills may be one barrier to counseling. Analysis of self-efficacy scores of physicians participating in the Clean Air for Healthy Children program demonstrates that pediatricians had higher self-efficacy scores for explaining the health risks of environmental tobacco smoke on children (P < .05); family physicians had higher self-efficacy scores for smoking cessation counseling knowledge (P < .05). Posttraining, both pediatricians and family physicians who participated in an office-based smoking cessation counseling program had significantly higher scores in all 4 self-efficacy domains (P < .01).

Agreement of injury reporting between primary care medical record and maternal interview for children aged 0-3 years: implications for research and clinical care.

OBJECTIVE: To assess agreement of injury reporting between primary care medical record and maternal interview. METHODS: Cross-sectional study of data from a randomized controlled trial of home visiting. The setting was Hawaii's Healthy Start Program (HSP). Subjects comprised a population-based sample of children in at-risk families with 3 years of primary care medical records and maternal interviews (n = 443). Outcome measures were percentage of children injured unintentionally and mean number of injuries per child in the first 3 years of life by primary care medical record and maternal interview. RESULTS: We identified 490 injuries: 48% by primary care medical record, 22% by maternal interview, and 30% in both sources. More children were reported injured by primary care medical record than maternal interview (51% vs 39%, P< .001). The mean number of injuries per child was 0.87 by primary care medical record and 0.51 by maternal interview (difference 0.36, 95% confidence interval 0.27-0.45, P< .001). Agreement between data sources was fair (kappa = 0.47). CONCLUSIONS: This study estimates that 25% of childhood injuries may not be reported in the medical record, highlighting the need for reconsideration of the use of medical records as the gold standard for unintentional injury data. Caution should be used when interpreting injury data from one source, especially from families with stressful life situations. Poor communication regarding injuries between social service, primary care and urgent care providers may contribute to decreased quality of primary care and missed opportunities for injury prevention.

Randomized trial of a statewide home visiting program: impact in preventing child abuse and neglect.

OBJECTIVES: To assess the impact of home visiting in preventing child abuse and neglect in the first 3 years of life in families identified as at-risk of child abuse through population-based screening at the child's birth. METHODS: This experimental study focused on Hawaii Healthy Start Program (HSP) sites operated by three community-based agencies. From 11/94 to 12/95, 643 families were enrolled and randomly assigned to intervention and control groups. Child abuse and neglect were measured by observed and self-reported parenting behaviors, all hospitalizations for trauma and for conditions where hospitalization might have been avoided with adequate preventive care, maternal relinquishment of her role as primary caregiver, and substantiated CPS reports. Data were collected through annual maternal interviews (88% follow-up each year of all families with baseline interviews); observation of the home environment; and review of CPS, HSP, and pediatric medical records. RESULTS: HSP records rarely noted home visitor concern about possible abuse. The HSP and control groups were similar on most measures of maltreatment. HSP group mothers were less likely to use common corporal/verbal punishment (AOR=.59, p=.01) but this was attributable to one agency's reduction in threatening to spank the child. HSP group mothers reported less neglectful behavior (AOR=.72, .02), related to a trend toward decreased maternal preoccupation with problems and to improved access to medical care for intervention families at one agency. CONCLUSIONS: The program did not prevent child abuse or promote use of nonviolent discipline; it had a modest impact in preventing neglect. Possible targets for improved effectiveness include the program's implementation system and model.

Randomized trial of a statewide home visiting program to prevent child abuse: impact in reducing parental risk factors.

OBJECTIVES: To assess the impact of a home visiting program in reducing malleable parental risk factors for child abuse in families of newborns identified, through population-based screening, as at-risk of child abuse. METHODS: This randomized trial focused on Healthy Start Program (HSP) sites operated by three community-based organizations on Oahu, HI, USA. From 11/94 to 12/95, 643 families were enrolled and randomly assigned to intervention and control groups. Mothers in both groups were interviewed annually for 3 years (88% follow-up each year) to measure mental health, substance use, and partner violence. HSP records were reviewed to measure home visiting services provided. Home visitors were surveyed annually to measure their perceived competence. RESULTS: Malleable parental risks for child abuse were common at baseline. There was no significant overall program effect on any risk or on at-risk mothers' desire for and use of community services to address risks. There was a significant reduction in one measure of poor mental health at one agency and a significant reduction in maternal problem alcohol use and repeated incidents of physical partner violence for families receiving > or =75% of visits called for in the model. Home visitors often failed to recognize parental risks and seldom linked families with community resources. HSP training programs were under-developed in preparing staff to address risks and to link families with community resources. CONCLUSIONS: Overall, the home visiting program did not reduce major risk factors for child abuse that made families eligible for service. Research is needed to develop and test strategies to improve home visiting effectiveness in reducing parental risks for child abuse.

Evaluating a statewide home visiting program to prevent child abuse in at-risk families of newborns: fathers' participation and outcomes.

This study sought to describe fathers' participation in a statewide home-visiting program to prevent child abuse and to assess program impact on their parenting. This randomized trial followed 643 at-risk families for 3 years. Data were collected through program record review, staff surveys, and annual maternal interviews. Participation in visits varied by the parents' relationship and paternal employment, violence, and heavy drinking at baseline. Overall, the program had no apparent impact on fathers' accessibility to the child, engagement in parenting activities, and sharing of responsibility for the child's welfare. The program promoted parenting involvement for nonviolent fathers in couples who lived together but also for violent fathers in couples with little contact at baseline; it decreased the father's accessibility to the child in couples who lived apart but saw each other frequently at baseline. Infrequent participation in visits and differential program impact on violent versus nonviolent fathers demonstrate the need to consider family context in developing, implementing, and studying home-visiting models.

Medical homes for at-risk children: parental reports of clinician-parent relationships, anticipatory guidance, and behavior changes.

BACKGROUND: Family-centeredness, compassion, and trust are 3 attributes of the clinician-parent relationship in the medical home. Among adults, these attributes are associated with patients' adherence to clinicians' advice. OBJECTIVES: The objectives were (1) to measure medical home attributes related to the clinician-parent relationship, (2) to measure provision of anticipatory guidance regarding injury and illness prevention, (3) to relate anticipatory guidance to parental behavior changes, and (4) to relate medical home attributes to anticipatory guidance and parental behavior changes. METHODS: A cross-sectional study of data collected among at-risk families when children were 1 year of age, in a randomized, controlled trial of a home-visiting program to prevent child abuse and neglect, was performed. Modified subscales of the Primary Care Assessment Survey were used to measure parental ratings of clinicians' family-centeredness, compassion, and trust. Parental reports of provision of anticipatory guidance regarding injury and illness prevention topics (smoke alarms, infant walkers, car seats, hot water temperature, stair guards, sunscreen, firearm safety, and bottle propping) and behavior changes were recorded. RESULTS: Of the 564 mothers interviewed when their children were 1 year of age, 402 (71%) had a primary care provider and had complete data for anticipatory guidance items. By definition, poverty, partner violence, poor maternal mental health, and maternal substance abuse were common in the study sample. Maternal ratings of clinicians' family-centeredness, compassion, and trust were fairly high but ranged widely and varied among population subgroups. Families reported anticipatory guidance for a mean of 4.6 +/- 2.2 topics relevant for discussion. Each medical home attribute was positively associated with parental reports of completeness of anticipatory guidance, ie, family-centeredness (beta = .026, SE = .004), compassion (beta = .019, SE = .005), and trust (beta = .016, SE = .005). Parents' perceptions of behavior changes were positively associated with trust (beta = .018, SE = .006). Analyses were adjusted for potential confounding by randomized, controlled trial group assignment, receipt of >or=5 well-child visits, and baseline attributes. CONCLUSIONS: Among at-risk families, we found an association between parental ratings of the medical home and parental reports of the completeness of anticipatory guidance regarding selected injury and illness prevention topics. Parents' trust of the clinician was associated with parent-reported behavior changes for discussed topics.

Hawaii's healthy start home visiting program: determinants and impact of rapid repeat birth.

OBJECTIVE: Healthy People 2010 calls for reductions in rapid repeat births (RRBs), defined as births occurring within 24 months after a previous birth for women of all ages, and prevention of repeat births during adolescence, regardless of the birth interval. Home visiting has been promoted as a mechanism to prevent child abuse and neglect and to improve pregnancy outcomes. This study aims to assess the impact of home visiting in preventing RRB and its malleable determinants and assesses the influence of RRB on the mother and the index child. We hypothesized that maternal desire to have a RRB, access to a family planning site, and use of birth control would be significant malleable determinants and that the effects of the program in preventing RRB would be mediated through its influence on these variables. We also hypothesized that the occurrence of RRB would result in increased stress and family dysfunction, resulting in adverse maternal and child outcomes such as severe maternal stress, maternal neglect of the index child, decreased maternal warmth toward the index child, and increased behavior problems of the index child. METHODS: The Healthy Start Program (HSP) is a home visiting program to prevent child abuse and neglect and to promote child health and development among newborns of families identified as being at risk for child maltreatment. This study was a randomized, controlled trial of Hawaii's HSP, in which eligible families were randomly assigned to home-visited and control groups. A total of 643 families at risk for child abuse were enrolled between November 1994 and December 1995. Data to measure RRB and malleable determinants were collected through structured maternal interviews and observation of the home environment. We measured RRB through maternal self-report by asking about a subsequent birth in follow-up interviews at 1, 2, and 3 years. To measure the malleable determinants, we measured the mother's desire for a RRB at baseline and at the 1-year interview and determined whether she had access to a family planning site. The mother was also asked which contraceptive methods she had ever used in the past and which methods, if any, she used in the year following the index child's birth. We measured 3 maternal parenting outcomes at the year 3 follow-up interview, ie, parenting stress, neglectful behavior toward the index child, and warmth toward the index child. We used odds ratios with 95% confidence intervals (CIs) to measure the strength of associations. Multiple logistic regression was used to assess 1) program effects on RRB and its malleable determinants, 2) the impact of the malleable determinants on RRB, and 3) the association between RRB and adverse maternal and child outcomes. RESULTS: Each year, 88% of the sample completed a follow-up interview; 81% completed all 3 follow-up interviews. There was no program impact on RRB for mothers overall (HSP: 21%; control: 20%; adjusted odds ratio [AOR]: 1.05; 95% CI: 0.69-1.58). HSP and control groups did not differ significantly in any of the malleable determinants of RRB. When we combined the 2 study groups, malleable determinants had significant effects on RRB. Mothers with a desire to have a child within 2 years after the index birth were significantly more likely to have a RRB, whether this desire was expressed at baseline (AOR: 2.48; 95% CI: 1.32-4.64) or at the year 1 interview (AOR: 2.86; 95% CI: 1.57-5.22). Lack of access to a family planning site at baseline was not associated with RRB, but there was a trend toward a greater likelihood of RRB among those lacking a site at 1 year (AOR: 1.61; 95% CI: 0.93-2.79). Women who had never used birth control before the index birth were more likely to have a RRB (AOR: 1.89; 95% CI: 1.20-2.98), and there was a trend toward a greater likelihood of RRB among women who did not use birth control in the year following the index child's birth (AOR: 1.67; 95% CI: 0.98-2.82). At the 3-year follow-up interview, mothers with a RRB were more likely to have adverse maternal and child outcomes. There was greater likelihood of severe maternal parenting stress (AOR: 2.29; 95% CI: 1.17-4.48), neglectful behavior toward the index child (AOR: 2.42; 95% CI: 1.41-4.18), and poor warmth toward the index child (AOR: 2.84; 95% CI: 1.71-4.42). In families with a RRB, the index child was more likely to exhibit internalizing behavior (AOR: 1.64; 95% CI: 1.04-2.58) and there was a trend toward higher odds of externalizing behavior (AOR: 1.56; 95% CI: 0.98-2.49). CONCLUSIONS: Overall, 20% of the mothers in our sample of at-risk families had a RRB, which was far greater than the national average of 11%. RRB was associated with a greater likelihood of adverse consequences for both the mother and the index child. The lack of program effects can be traced to shortcomings in the program's design and implementation system. HSP contracts required only that family planning be introduced any time during a family's first year of enrollment. Because conception can occur very soon after the index birth, a better design would be to introduce family planning counseling early in a family's enrollment in home visiting. Another shortcoming was that, although fathers could be included in counseling, they took part in only approximately one-fifth of home visits. It is possible that program effects were attenuated in families in which the father wanted a child. In conclusion, the Hawaii HSP did not reduce RRB or alter its malleable determinants. RRB was associated with adverse outcomes for both the mother and the index child. This is particularly relevant for this population of families that are already at risk for child maltreatment, for which we have found parenting stress to be associated with abusive parenting behavior by the mother. Our findings support and broaden the rationale for the Healthy People 2010 objective to reduce RRB. We think our findings are valuable for guiding the future development of home visiting in general and this widely replicated paraprofessional model in particular.