Forward and Back is Not Enough: Applying Best Practices for Translation of Pediatric Sleep Questionnaires.

Cultural differences in the experience of sleep warrant consideration in the measurement of sleep across populations. This requires careful attention to both language and culture when translating survey measures. While forward and back translation is the most commonly used approach, it has numerous limitations if used as an isolated method. Best practice guidelines recommend a multi-step team-based approach for translating questionnaires. We present our recent experience applying best practices in a study with both Spanish and English-speaking Mexican American mothers of toddlers. This work is part of a larger project that will measure parental sleep-related beliefs and parenting practices in Mexican American parents of toddlers. We utilized a team-based approach to translation and cultural adaptation, assembling a diverse, bilingual, and bicultural team. The translation process started with items and measures that we had selected, revised as needed, or created. New items were based on constructs identified in semi-structured interviews and focus groups used to explore parental sleep-related beliefs and parenting practices in the target population. Following this, our translation process included forward and back translation, harmonization and decentering, cognitive interviewing, debriefing, adjudication, and proofreading. We outline details of our process and the rationale for each step. We also highlight how each step contributes to ensuring culturally appropriate items with conceptual equivalence across languages. To ensure inclusivity and scientific rigor within the field of sleep research, investigators must utilize best practices for translations and cultural adaptations, building on the foundation of cultural constructs often identified in qualitative work.

Mixed methods evaluation of pediatric telehealth equity for patients/families who communicate in languages other than English.

Background: Emerging research demonstrates telehealth disparities for patients who communicate in languages other than English. A better understanding of pediatric telehealth use with families who communicate in languages other than English is needed to inform interventions to promote telehealth equity. Methods: We conducted a mixed methods study of telehealth care in a children's hospital health system using electronic health record data for outpatient video telehealth encounters from April 2020 to July 2021 and qualitative interviews with clinical staff and Spanish-speaking parents of telehealth patients. Results: The 16-month study period included 102,387 telehealth encounters; 5% of which were encounters in languages other than English. 83% of languages other than English encounters were with patients/families with a preferred healthcare language of Spanish. 11% of providers conducted ≥10 languages other than English telehealth encounters. This subset of providers conducted 71% of all languages other than English encounters. We conducted 25 interviews with clinical staff (n=13) and parents (n=12). Common themes identified across interviews were: (I) technology barriers affect access to and quality of telehealth; (II) clinical staff and parents are uncertain about the future role of telehealth for patients/families who communicate in languages other than English; (III) the well-known impact of language barriers on in-person healthcare access and quality for patients who communicate in languages other than English is also evident in telehealth. Conclusions: Patients who communicate in languages other than English were underrepresented among telehealth encounters and encounters were concentrated among few providers. Promoting equitable telehealth care requires investment to address technology barriers, increase the readiness of providers and clinics to provide telehealth care in languages other than English, and continued attention to reducing the healthcare impact of language barriers.

A WIC-Based Behavior Change Intervention for Postpartum Women With Overweight and Obesity: A Pilot Feasibility Randomized Trial.

Background. Postpartum weight retention is a risk factor for obesity and is particularly important among Hispanic women who have an increased rate of obesity. Given its broad reach, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program provides an ideal setting to implement community-based interventions for low-income postpartum women. Purpose. To examine the feasibility, acceptability, and preliminary efficacy of a multicomponent intervention delivered by staff within the WIC program designed to promote behavior changes in urban, postpartum women with overweight/obesity. Method. This was a 12-week pilot trial randomizing participants to a health behavior change (Intervention) or control (Observation) group. The Intervention included monthly visits with trained WIC staff providing patient-centered behavior change counseling, with multiple touchpoints between visits promoting self-monitoring and offering health behavior change support. Results. Participants (n = 41), who were mainly Hispanic (n = 37, 90%) and Spanish-speaking (n = 33, 81%), were randomized to the Intervention (n = 19) or Observation (n = 22) group. In the Intervention group, 79% (n = 15) of eligible participants were retained for the study duration. All Intervention participants endorsed that they would participate again. Regarding physical activity, participant readiness to change and self-efficacy improved for Intervention participants. About one-quarter of women in the Intervention group (27%, n = 4) had a 5% weight loss compared with one woman (5%) in the Observation group; this difference was not statistically significant (p = .10). Conclusions. This pilot demonstrated the feasibility and acceptability of delivering a low-intensity behavior change intervention within the WIC setting for postpartum women with overweight/obesity. Findings support the role of WIC in addressing postpartum obesity.

Parenting a Toddler in the Era of Pervasive Screens: Interviews with Low-Income Mexican American Parents.

Screen media use starts in early childhood, despite recommendations to limit use. This study explored low-income Mexican American mothers' and fathers' beliefs, parenting practices, and perceived contextual contributors related to toddler screen use. We conducted interviews with 32 low-income Mexican American parents. Transcripts of audio recordings were analyzed to identify themes. Parents perceived numerous benefits to screen use, including learning and enjoyment, as well as seeing it as a helpful tool for parents. Reported risks included harmful mental and physical effects and a risk of use being all-consuming. Parents managed screen use with a variety of practices, including giving close attention to content, monitoring duration, and engaging in co-use. They also used screens for behavior management and in specific situations, such as to prepare for sleep. Some differences in beliefs and parenting practices exist by screen device type. Parents also reported that contextual factors, such as weather and neighborhood safety, influenced screen use. This study extends the current literature regarding child screen use, with its focus on low-income Mexican American toddlers. The findings offer interventionists and providers insight into the management of screens in the lives of this population.

Screen-related discord and dismay in low-income Mexican American families with toddlers: A qualitative study.

PURPOSE: Understanding parental experiences with managing their toddler's screen use is important to inform the design of interventions addressing early childhood screen use, yet current evidence is limited. To enhance our understanding of the context of toddler screen use, this study characterizes the screen-related discord and dismay parents experience in families with toddlers. DESIGN AND METHODS: In-depth interviews were conducted to explore everyday experiences with screen use among low-income Mexican American caregivers of toddlers (21 mothers, 10 fathers, 1 grandmother). Transcripts were content analyzed to identify prominent themes. RESULTS: Three themes were identified. Experiences of screen-related discord and dismay arose (1) between parent and child, (2) between parents, and (3) surfaced as parental internal dissonance about toddler screen use. Parent-child discord resulted from parental limit setting and child reactions to parental screen use, which often included tantrums. Parent-partner discord included patterns of agreeing to disagree and direct disagreement between partners. Parents also reported their own feelings of ambivalence and dismay as they struggled to reconcile their preferences against their toddler's actual screen use, while living in a screen-saturated world. CONCLUSIONS: Findings offer insight into types of screen-related discord and dismay low-income Mexican American parents experience as they attempt to manage their toddler's screen use. PRACTICE IMPLICATIONS: Although discord in families is normal, the screen-specific discord reported by participants warrants consideration in efforts promoting healthy screen use in families. Providers can tailor their counseling to consider the range of screen-related discord families of toddlers may experience.

Responding to a call to action for health equity curriculum development in pediatric graduate medical education: Design, implementation and early results of Leaders in Health Equity (LHE).

Introduction: Recent calls to action have urged graduate medical education leaders to develop health equity-focused curricula (HEFC) to redouble efforts to promote pediatric HE and address racism. Despite this call, examples of HEFC for pediatric residents are lacking. Such curricula could catalyze educational innovations to address training gaps. Objective: To describe the design, content, and delivery of "Leaders in Health Equity (LHE)," an innovative HEFC delivered to categorical pediatric residents using multi-modal, service-free retreats. Methods: This single institution, longitudinal curriculum study occurred between 2014 and 2020 and reports multi-level outcomes including: (1) impact on trainee's health equity related knowledge, skills and satisfaction, (2) residency impact and (3) institutional impact. Educational approaches used related to design, content and delivery are summarized and detailed. Results: Trainees (n = 72) demonstrated significant improvements in pre-post knowledge and skills related to HE content. Residents also reported increased desire for advanced HE content over the course of the 6-year study period. Residency impact on operations and resources were sustainable with the opportunity for integration of LHE content in other curricular and training areas noted. Institutional impact included catalyzing organizational HE initiatives and observing an increase in resident-led quality improvement (QI) projects focused on LHE content. Conclusions: On-going adaptation and growth of LHE content to educate increasingly prepared pediatric trainees is a critical next step and a best practice for educators in this evolving field. Developing HEFC within pediatric training programs using a longitudinal, leadership-centered approach may be an effective educational strategy in addressing pediatric health disparities.

Resident Training Experiences Providing Spanish-Language Concordant Care: Implications for Growing Health Equity Efforts Within Graduate Medical Education.

Training experiences where residents provide Spanish-language concordant care (SLCC) have not been widely described despite their increasing need and prevalence in graduate medical education. In this qualitative study, we enrolled nonnative Spanish-speaking residents (n = 21) within SLCC training clinics from 3 geographically unique programs. Participants completed semistructured interviews focused on their overall SLCC training experience. Major themes identified included (1) high levels of satisfaction in their SLCC experience, (2) concern about ongoing language barriers, (3) demonstration of high levels of cultural humility in caring for patients with limited English proficiency, and (4) identification of several valuable programmatic and clinical resources. Based on these findings, we conclude that SLCC training experiences are of significant value to trainees in becoming pediatricians able to promote health equity. Themes identified could help inform how graduate medical education programs utilize SLCC to grow health-equity based efforts to deliver more effective and compassionate care to our linguistically diverse populations.

Picture Perfect: How Attaining the Ideal Meal is Not So Easy for Parents of Young Children.

OBJECTIVE: To explore parental perspectives on the ideals and realities of family mealtimes. DESIGN: Mini-focus groups (n = 7). SETTING: Rural Colorado, US. PARTICIPANTS: Parents (n = 30) were recruited at Head Start/preschool centers. PHENOMENON OF INTEREST: Parent perspectives on mealtimes with preschool-aged children. ANALYSIS: Transcripts were analyzed using thematic analysis. RESULTS: Three categories of themes emerged: participant conceptions of ideal family meals, challenges to achieving their ideal family meal, and parental solutions. The theme of participant conceptions of ideal family meals composed family togetherness, children liking and eating the prepared food, healthfulness of food, and a nonchaotic mealtime. Challenges to achieving their ideal family meal included work schedules, disruptive child behaviors, child pickiness, snacking, and negative role-modeling. Finally, parental solutions to challenges incorporated having flexible meal timings, considering child preferences in premeal preparations, role-modeling, and numerous other parenting strategies. CONCLUSIONS AND IMPLICATIONS: While parents valued many aspects of a version of the ideal meal rooted in historical standards, families faced many challenges in trying to attain that ideal. Although parents employed various strategies to combat mealtime challenges, parental expectations for preschool-aged children's mealtime behaviors may be unrealistic for the developmental stage of early childhood. Future interventions could help parents develop age-appropriate mealtime expectations.

Managing Excessive Weight Gain in Children <2 Years of Age: Interviews with Primary Care Providers.

Background: Excessive weight gain in the first 2 years of childhood is a risk factor for future obesity. However, the current absence of clear, standardized identification and treatment guidelines may hinder primary care providers' (PCPs) ability to manage early excessive weight gain in children <2. The objective of this study was to explore PCPs' perspectives on evaluating and communicating about early excessive weight gain and to identify PCP-opined barriers to the care of children exhibiting such trends. Methods: A trained interviewer conducted 20 semistructured interviews with PCPs on identifying and communicating with families about early excessive weight gain in children <2 years old. A thematic analysis approach was used to analyze the transcripts. Results: Interviews uncovered three major themes: (1) the approach to identifying excessive weight gain in children <2 showed high variability across participants despite relative consistency in weight assessment methodology, (2) while possessing communication strategies, providers recognized multiple barriers impeding the execution of weight-related conversations with caregivers, and (3) providers perceived the need for additional support to improve their ability to respond to excessive weight gain in children <2 years old. Conclusions: Variability exists in PCP-reported methods used and barriers faced when identifying, communicating, and responding to excessive weight gain in very early childhood. Introducing guidelines and resources to help standardize the assessment and communication of excessive weight gain in children <2 could augment PCPs' strategies for managing accelerated weight-gain trajectories to mitigate rates of childhood obesity.

An Ecocultural Perspective on Eating-Related Routines Among Low-Income Families With Preschool-Aged Children.

Eating-related routines, such as regular mealtimes, can protect against obesity. Little is known about eating-related routines among preschoolers or the factors that shape those routines. Ecocultural Theory and qualitative interviews with 30 caregivers of preschoolers in Colorado were used to describe eating-related routines at home and parents' perspectives on the factors that shape routines. Qualitative content analysis was used to analyze and interpret data. Consistent with clinical recommendations, parents' goals included dinner meals where adults and preschoolers eat the same food, in the same place, at the same time. However, parents' employment schedules and challenges in managing preschoolers' behavior prevented parents from consistently enacting recommended routines. Educating parents alone may not be sufficient to ensure optimal eating-related routines among preschoolers, and the household context needs to be considered. Families organized routines according to cultural values and available resources.

Beyond Nutrition Knowledge and Tools-What Do Pediatric Providers Really Need?

Nutrition counseling continues to be a concern for pediatric providers. This study aimed to extend the understanding of the perceptions of pediatric providers regarding nutrition care. Individual semi-structured qualitative interviews were conducted using a purposive sampling technique. Interviews were conducted in-person or via telephone, recorded, and transcribed. Seven themes emerged from the data and these can be used as a "how to" for medical educators. Based on the experiences and perspectives of the pediatric providers in our study, we are moving forward with the systematic development of a curriculum to improve nutrition care and counseling in pediatrics.

Use of the Delphi Technique to Obtain Community Input on Leading Contributors to Early Childhood Obesity in Latino Communities.

INTRODUCTION: In the United States, Latino children are disproportionately affected by childhood obesity and related comorbidities. Stakeholder engagement has the potential to heighten the efficacy of interventions, thereby reducing the disparate prevalence of obesity among Latino children. The objective of this study was to identify stakeholders' opinions on factors influencing early childhood obesity in Latino children aged 0 to 5 years. METHOD: This study used the Delphi technique to gather and prioritize stakeholders' opinions about the factors and barriers considered most influential in early (age 0-5 years) childhood obesity intervention or prevention within the Latino community. Three sequential phases were used. Participants included Latina women as well as staff from community organizations serving Denver metropolitan's Latino population. RESULTS: Study results revealed that stakeholders value the role of the child's primary care provider in the identification of overweight children and desire more educational support to reduce intake of nonnutritious foods. Participants further determined that obesity-related knowledge gaps and affordability of healthy foods and activities were the largest barriers to helping Latino children maintain healthy weights. CONCLUSION: Use of this stakeholder-informed data could assist in the development of future culturally tailored interventions aimed at reducing the rates of early childhood obesity in the Latino population.

Screen-Related Parenting Practices in Low-Income Mexican American Families.

OBJECTIVES: To (1) examine whether the Information-Motivation-Behavioral Skills Model predicts maternal screen-related parenting practices and (2) evaluate the relationship of American Academy of Pediatrics (AAP)-recommended parenting practices with child television (TV) use behaviors. METHODS: In this cross-sectional study, 312 Spanish-speaking and/or English-speaking female primary caregivers of Mexican descent with a child 3 to 5 years of age were recruited from safety-net pediatric clinics. Participants completed a phone interview and screen media diary. Measures included maternal screen-related beliefs, self-efficacy, parenting practices (time restriction, TV in the child's bedroom, allowing viewing while eating meals and while eating snacks), and child viewing behaviors (amount of TV viewing, frequency of eating while viewing). Two path analytic models were estimated. RESULTS: Positive general beliefs about TV viewing and positive functional beliefs were negatively associated with maternal self-efficacy to restrict TV time (ß = -0.14, P < .05; ß = -0.27, P < .001). Greater self-efficacy to restrict time was associated with more maternal restriction of time (ß = 0.29, P < .001). Greater positive functional beliefs were associated with less self-efficacy to restrict TV viewing with snacks (odds ratio = 0.56; 95% confidence interval, 0.38-0.81). High self-efficacy to restrict viewing with snacks was associated with less allowing of viewing while snacking (ß = -0.16, P < .01). Time restriction, TV in the child's bedroom, and allowing viewing while snacking were associated with child TV viewing behaviors. CONCLUSIONS: Providers should consider maternal beliefs, including beliefs regarding the functional use of screens, and self-efficacy to engage in AAP-recommended parenting practices, when counseling on screen use in this population.

HEROs: Design of a Mixed-Methods Formative Research Phase for an Ecocultural Intervention to Promote Healthy Eating and Activity Behaviors in Rural Families With Preschoolers.

OBJECTIVE: To describe the mixed-methods formative research phase in the development of the Healthy Environments Study (HEROs), a technology-based, interactive family intervention to promote healthy eating and activity behaviors for young children in the home environment. DESIGN: A mixed-method iterative approach, using ecocultural theory as a framework, will guide the development of both quantitative and qualitative formative research assessments. SETTING: Rural eastern Colorado. PARTICIPANTS: Low-income families (n = 200) with preschool-aged children enrolled at 6 Head Start/preschool centers. MAIN OUTCOME MEASURES: Quantitative and qualitative methodologies will garner insights into 4 key topic areas: (1) food behaviors and environments (Remote Food Photography Method, parent focus group, and survey), (2) physical activity behaviors and environments (parent interview and survey), (3) mobile device use (parent survey and interview), and (4) daily life (ecocultural family interview and teacher/staff group discussions). ANALYSIS: Results will be interpreted in combination to allow for a holistic understanding of participant behaviors, beliefs, attitudes and values related to each of the 4 topic areas. Collectively, outcomes will provide a comprehensive picture of preschoolers' daily life and inform intervention design and strategies to enhance preschoolers' eating and activity behaviors in the home environment.

The Familias Saludables partnership: Engaging the Latino community to address early childhood obesity.

Darcy A Thompson is an Associate Professor of pediatrics at the University of Colorado School of Medicine. Her main research seeks to address early childhood obesity in low-income children. She works in the Lifestyle Medicine clinic at Children's Hospital Colorado, a clinic focused on caring for children with obesity and related comorbidities. She is also an Associate Medical Director for the Research Institute at Children's Hospital Colorado. Her training includes a Master of Public Health degree, a medical degree (Yale University) and the Robert Wood Johnson Clinical Scholars Fellowship (University of Washington). Deborah (Deb) A Federspiel has been leading child health advocacy and community health improvement initiatives in support of Children's Hospital Colorado's mission for the past 15 years. Her professional background includes experience developing and managing teams, programs and operations, as well as building partnerships and coalitions to drive key strategic initiatives and advance positive change on behalf of children and families. An active member of a number of community advisory committees and nonprofit boards, she has worked in the Colorado nonprofit sector since 1999. She has a Bachelor of Science in business administration from the University of Dayton.

Beliefs About Child TV Viewing in Low-Income Mexican American Parents of Preschoolers: Development of the Beliefs About Child TV Viewing Scale (B-TV).

Objectives Parental beliefs about child television viewing may affect the way parents regulate child television viewing. Despite this, little research has focused on the development of measures of parental beliefs about child television viewing, particularly among ethnic minority parents and parents of young children. This study's objective was to develop and test a culturally-based measure of parental beliefs about television viewing in low-income Mexican American mothers of preschoolers. Methods Using a cross-sectional study design, 22 items reflecting parental beliefs about influences of TV on children were developed and assessed for psychometric properties in a sample of 312 low-income Mexican American mothers of preschoolers. Results Using exploratory factor analysis, we identified four factors reflecting four domains of parental beliefs: positive general beliefs, positive sleep-related beliefs, positive functional beliefs, and negative general beliefs. Internal reliabilities were acceptable (Cronbach's alpha = 0.70-0.89) for all factors except negative general beliefs (Cronbach's alpha = 0.61). Positive sleep-related beliefs and Positive Functional Beliefs were correlated with children's average daily hours of TV (r = 0.16, p < .01; r = 0.22, p < .001, respectively) and with mother's average daily hours of TV (r = 0.14, p < .05; r = 0.22, p < .001, respectively), providing initial support for construct validity. Conclusions for Practice The Beliefs about Child TV viewing scale measures four domains of parental beliefs regarding child TV viewing, and has good initial reliability and validity for three factors. Future use will allow investigators to conduct more in-depth evaluations on the influence of parental beliefs on the way parents shape their child's use of the TV.

Parent Perceptions of Mobile Device Use Among Preschool-Aged Children in Rural Head Start Centers.

OBJECTIVE: To describe child use and parents' beliefs and comfort with young children's use of mobile devices in low-income, rural communities. METHODS: This was a descriptive, cross-sectional study. The survey, which consisted of 18 multiple-part questions, was distributed to families at 5 Head Start/preschool centers in Colorado. RESULTS: In total, 192 surveys were returned (28.5% response rate). Most children (92%) used a smartphone or tablet at some frequency and most parents (90%) had downloaded apps specifically for their child. Education and ethnicity were related to parents' technology beliefs. Parent comfort with technology was positively associated with greater child use of technology (P < .001). CONCLUSIONS AND IMPLICATIONS: Mobile device use was relatively high in this sample. Mobile devices appear to be a feasible platform to offer nutrition and physical activity education for this audience. Ensuring parent comfort with technology and apps will be important.

Mobile Device Use Among Rural, Low-Income Families and the Feasibility of an App to Encourage Preschoolers' Physical Activity: Qualitative Study.

BACKGROUND: As mobile devices are becoming ubiquitous, technology-based interventions provide a promising strategy to positively influence health behaviors of families with young children. However, questions remain about the feasibility and acceptability of intervention delivery via mobile apps in low-income, rural settings and among families with preschoolers. OBJECTIVE: The aims of this study were to understand the content and context of mobile device use for preschoolers; explore parent beliefs on this topic, including the acceptability of intervention delivery via mobile devices; and test a prototype of an app to encourage preschoolers' physical activity with both parents and children. METHODS: Parents (n=29) were recruited from 5 preschool centers in eastern, rural Colorado to complete a semistructured telephone interview regarding preschoolers' mobile device use. A second sample of parents (n=31) was recruited from the same preschool centers to view the app prototype independently and provide feedback. A third sample of preschool children (n=24) was videotaped using the app in small groups to measure engagement and record their responses to the app. RESULTS: Five key content areas emerged from the telephone interviews: (1) mobile devices are an important part of families' everyday routines, and parents have parameters governing their use; (2) parents often use mobile devices as a tool for behavior management; (3) parents clearly distinguish between mobile device use for learning versus entertainment; (4) parents have an overarching desire for balance in regard to their child's mobile device use; and (5) parents were generally supportive of the idea of using mobile apps for intervention delivery. From the app prototype testing with parents, participants reacted positively to the app and felt that it would be useful in a variety of situations. Testing with preschoolers showed the children were highly engaged with the app and a majority remained standing and/or actively moving through the entire length of the app. CONCLUSIONS: Mobile devices are already integrated into most families' daily routines and appear to be an acceptable method of intervention delivery in low-income families in rural Colorado. The physical activity app represents an innovative way to reach these families and, with further improvements based on participant feedback, will provide children with a unique opportunity to practice key movement skills.