Impact of a Parent Education Program Delivered by Nurses and Health Care Providers in Reducing Infant Physical Abuse Hospitalization Rates in British Columbia,Canada

The Period of PURPLE Crying program® (PURPLE)

Since 2009 Prevent Shaken Baby Syndrome B.C. (PSBSBC) administers PURPLE (https://www.dontshake.ca), a universal free parent education intervention program to reduce the incidence of THI-CM, that is funded by the BC Ministry of Health. The program has undergone extensive evaluation, including randomized controlled trials and uses a multi-exposure delivery model to achieve consistent results that include materials, key messages and delivery timing (National Center on Shaken Baby Syndrome - PURPLE Crying, n.d.). The B.C. program reaches the parents of approximately 43,000 births (BC Vital Statistics Agency, 2022) annually encompassing 68 birthing hospitals, 123 public health & primary care units and numerous service agencies that support pre-natal moms, families and caregivers with infants/young children.

The program key messages emphasize that crying is a normal and healthy way for infants to communicate, and provides parents with tools and strategies for responding to crying in a positive and supportive way. PURPLE implementation online training at no cost is available to all health care and service providers who work with new families. B.C. maternity and public health nurses are required to take training as part of the onboarding process. Before discharge from maternity hospitals and at-home births, maternity nurses and midwives deliver the five-minute PURPLE education to all patients. Public health and primary care nurses engage parents in a three-minute conversation about infant crying and reinforce PURPLE messages during well baby check-ups and first immunization appointments up to four months of age. Community service providers ¹ also reinforce messages and capture those that may not be aware of PURPLE during their interactions with families, bridging the health and social service systems. For jurisdictions that do not deliver PURPLE universally, nurses can find relevant infant crying, soothing and coping information to support new parents and caregivers in their practice by accessing PSBSBC's website at https://dontshake.ca.

Study objective

The purpose of this longitudinal study, with a pre-post intervention design, was to determine if physical abuse hospitalization rates decreased in B.C. for children less than or equal to 24 months of age after implementing the PURPLE program, as was seen in THI-CM hospitalization rates post-implementation. An eight-year evaluation of the PURPLE program demonstrated that the intervention was associated with a 35% reduction in infant THI-CM hospitalizations that was significant for children less than or equal to 24 months of age. (Barr et al., 2018).

Measures

The analysis measured physical abuse hospitalization rates for the period January 1, 1999 to December 31, 2019 among children less than or equal to 24 months of age, and excluded any cases of confirmed THI-CM. Data were divided into pre-implementation period January, 1999 to December, 2008, and post-implementation period January, 2009 to December, 2019.

Data sources

Interventions

Interventions to address child physical abuse in Western culture have been directed primarily by an ecological approach. First theorized by Bronfenbrenner, this approach emphasizes that child abuse and neglect are influenced by multiple factors. These can include, the perpetrator's own development, the parent-child interaction, social systems, society, cultural beliefs and values, and interactions across these fields (Belsky, 1980; Bronfenbrenner, 1979; Leventhal, 2003; Sidebotham, 2001). Recognizing the factors and the interplay between them can help move beyond identification toward prediction and prevention of physical abuse. Primary prevention interventions are typically developed to modify known risk and protective factors.

To date, the majority of child physical abuse and neglect prevention interventions are targeted at caregivers with a history of substantiated or suspected physical abuse (Barlow et al., 2006; Vlahovicova et al., 2017). Home visitation programs for selected populations, like new mothers receiving welfare payments, can be effective in targeting high-risk populations and have shown reductions in child physical abuse (Chartier et al., 2017; Poole et al., 2014). These types of intervention programs approach physical abuse prevention by predominately focusing on improving the parent/child relationship through efforts to change parenting attitudes, practices and skills.

A systematic review of parenting education programs identified that although the programs were varied, they had similar goals including: increased parental knowledge about child development; effective parenting practices and skills; promote the use of non-violent parenting behaviours, and promotion of harmonious parent/child relationships (Barlow et al., 2006). Of parenting programs that include an intentional injury prevention component, home visitation programs are more common and more researched than universal programs (Nelson & Caplan, 2014; Poole et al., 2014).

In Canada the Nobody's Perfect Parenting Program, a community-based program for parents of children 0–5 years targets caregivers who face health equity barriers including; young, single, socially or geographically isolated, or have low income or limited formal education, is available in all provinces and territories (Public Health Agency of Canada, 2002). Additionally, in B.C. there are a number of parenting support programs including Parent-Child Mother Goose, Triple P Positive Parenting Program and numerous organization-based programs. Evaluation of these types of programs predominately assesses improvements in parent/child relationship, effective parenting practices, changing child behaviour, and less on specific practices related to violence and maltreatment (Poole et al., 2014). Specific to nursing practice, the Nurse Family Partnership® (NFP) home visitation program is delivered by specifically trained public health nurses (Campbell et al., 2020). The focus is on girls and young women and their children who face socio-economic disadvantages and includes intensive home visits from the prenatal period to when the baby turns two years of age. Research shows that the NFP program has been effective in reducing child maltreatment (Children's Health Policy Centre, n.d.). The challenge is that this type of programming is resource intensive.

Evaluating the cost-effectiveness of universal infant physical abuse prevention programs is challenging. However, analysis of universal versus targeted prevention programs for other health topics concludes that universal behavioural interventions have positive outcomes and resource savings. For example, universal programming for diabetes prevention in relation to the allocation of resources was identified as the best way to retain health benefits for both low and high budgets (Feenstra et al., 2011). Conversely, the cost of intervention of a program to address infant sleep problems could be even lower if more widely distributed (Hiscock et al., 2007).

Universal prevention programs and PURPLE

To be most effective, universal prevention strategies should focus on reducing risk factors that are highly preventable and modifiable (Poole et al., 2014). Research on programs that target selected populations shows that the most effective are those that are highly resourced and require high levels of participant involvement but do not have the same reach as universal programs. Research has identified three advantages of universal programs (Poole et al., 2014; Rose, 2001). First, they focus on the root causes of a problem that are highly prevalent in a population. For example, PURPLE education focuses on increased infant crying as a developmental phase and it is the most common trigger for shaking behaviour. Second, behaviour can be learned and population-level strategies help to enhance the efforts of targeted interventions. For example, PURPLE education message normalizes “It's ok to put your crying baby down in a safe place and take a break”. Third, focusing on highly prevalent risks in a population has the potential to have a large impact on population attributable risk. For example, a key message of PURPLE normalizes that all babies cry, some more than others and it is, how one manages their reaction to the crying that is important.

A working group of representatives from the BC Ministry of Health, Provincial Health Services Authority and B.C. health authorities, identified a combination of universal initiatives, and selected initiatives targeted toward the needs and issues of specific populations as best practices for the prevention of violence, abuse and neglect (BC Ministry of Healthy Living and Sport, 2010). Universal prevention programs such as PURPLE can serve as a complement to other targeted programs for high-risk or selected populations as they are less resource intensive, and can result in substantial return on investment (Masters et al., 2017; Zulman et al., 2008).

Role of nurses

Nurses have been instrumental in the success of PURPLE since its implementation. Although the structural components of delivery are fixed, the nurse/parent interaction allows for nurses’ individual practice to support the unique needs of each family. B.C. health providers follow the Patient as Partners initiative with the goal being that the patient, family and caregiver voices are incorporated at all levels of the healthcare system (BC Ministry of Health, 2020). This model emphasizes the importance of partnership between patients, families, and care providers, and aims to empower patients to make informed decisions about their care. Further, PSBSBC utilizes an iterative review process for delivery which allows for modifications based on best practice, and nurses’ feedback from quality improvement since program implementation.

Limitations

Physical abuse hospitalization cases may have been underestimated, as cases are not always reported to either the police or child protection services (Afifi et al., 2015; Schilling & Christian, 2014). Abuse may not have been disclosed and therefore, may have been diagnosed as unknown or suspected by the investigating physician. Coding of physical abuse in DAD is conducted by professionally trained coders who follow guideline standards defined by the Canadian Institute of Health Information. The coding assignment is influenced by physician's chart documentation and coder interpretation, which may contribute to an underestimation of cases. Perhaps with future introduction of ICD-11, there may be better definitions and tracking of these codes. A lack of knowledge in child abuse and the social implications of misdiagnosing physical abuse (fear of potential legal implications) may have influenced physician charting (Lupariello et al., 2022). Physician documentation could be improved by providing more background detail on circumstances and risk factors (ecological approach) for physical abuse.

The number of definite physical abuse hospitalization cases in B.C. for children less than or equal to 24 months of age during the study period was small and made it challenging to conduct any descriptive or additional analyses. To have obtained numbers that allowed for meaningful analysis in order to achieve significant results would have necessitated the study period to be so long, as to not be feasible.

Finally, this study only looked at the association of physical abuse hospitalization rates decreasing in B.C. for children less than or equal to 24 months of age in relation to pre-implementation and post-implementation of PURPLE. There were other intervention programs for physical abuse prevention in B.C. within the same time period that may have had an impact on the results, however, they were outside of the study scope.