Dr. Jessica Rothstein is implementing a play-based intervention to help Chicago Latine families nurture and develop infants and young children.
Dr. Jessica Rothstein, PhD, MSPH
Assistant Professor
Department of Community Health Sciences
UIC School of Public Health
Sit Down and Play: A Preventive Primary Care-Based Program To Enhance Parenting Practices
CCTS KL2 Clinical and Translational Science Scholars Program
Learn how you can get involved in translational research at ccts.uic.edu.
The University of Illinois Chicago Center for Clinical and Translational Science is supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR002003. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
00:00 Dr. Jessica Rothstein:
There aren't always one size fits all interventions. The idea is that you can use this process to make small changes or tailoring to increase the acceptability and increase the feasibility for a family, and then increase the potential for impact.
0:21 Voice Over (VO), Lauren:
Welcome to Collaborative Endeavors, a podcast about how experts from different areas of research come together to tackle big health challenges, leading to better therapies and healthier communities.
In this episode, we meet CCTS CATS Affiliate Scholar, Dr. Jessica Rothstein (ROTH-STINE) Dr. Rothstein is a social behavioral and mixed-methods researcher who seeks to reduce health inequities that emerge from experiences in early childhood. Early career work in medical anthropology and global health, coupled with time in Latin American, spurred her passion for early child development. Now, she is translating this experience closer to home, helping Chicago Latine families hone play-based skills to nurture and develop infants and young children.
1:10 Dr. Rothstein
I did my training at the Johns Hopkins Bloomberg School of Public Health in international health, and for my dissertation research, I worked in peri-urban Lima, Peru. I focused on the determinants of breastfeeding and infant formula use among infants under six months of age. And what came out of that research was an understanding of how the formula industry representatives were marketing their products to health providers, and then providers were giving unnecessary formula recommendations and prescriptions to mothers with significant negative impacts on breastfeeding outcomes. From there, I really started to develop an appreciation for the critical role that the health sector plays in shaping parents’ feeding and caregiving behaviors in either positive or negative ways. I joined UIC, the School of Public Health, in 2021. I became really interested in the racial-ethnic inequities and socioeconomic inequities in early child development that exists here in the US. Initially when I was working on my dissertation research, which focused more on child nutrition, I started noticing some delays in language development and aspects of the home learning environment that were not really conducive to optimal child development. I ended up partnering with a few developmental psychologists when I was at Johns Hopkins, and we developed a play-based intervention to support early child development. Once I got to UIC, I read about Dr. Reshma Shah's work with Sit Down and Play. I really wanted to connect with Dr. Shah and just sort of ended up cold emailing her, and we started chatting. I really started to understand the advantages of leveraging the pediatric setting to implement a responsive caregiving intervention for parents, using the fact that parents are already coming in for these frequent, regularly scheduled well child visits, and how can that time be used to also educate and provide some training around playing with children, talking with children, all those really critical things for promoting their development.
3:48 VO:
Sit Down and Play aims to to support early childhood development both domestically and internationally by leveraging routine healthcare visits during the first year of life. For those who are interested, our show notes contain a link to a 2017 journal article supported by the CCTS’s UL1 grant and co-authored by peer scientists Dr. Yoonsang Kim and Dr. Marc Atkins. I asked Dr. Rothstein to walk me through the intervention.
4:20 Dr. Rothstein
Sit Down and Play is a play-based, responsive parenting intervention. It consists mainly of interpersonal counseling, and then leveraging a really simple age-appropriate toy to use as a vehicle for facilitating parents’ positive interactions with their young children. So from two months through 24 months, there are eight well child visits, and Sit Down and Play is designed to be delivered through eight little modules. Each of those modules leverages a different age-appropriate toy. At two months it's just a simple rattle. And then at 12 months it’s a set of nesting cups; so different things that have been demonstrated to be age appropriate for the stage of development that a child is at. The session is about 10 minutes, the person delivering the intervention will talk to the parent about the benefits of play based learning, the benefits of talking and interacting with your young child- even before they can talk and really interact very much with you. And then, during that interpersonal counseling session, the person delivering the intervention demonstrates a few activities that can be that can be done with the toy. And then, a really key part is that they ask the parent to try out one of those recommended activities and gives them positive reinforcement and encouragement. The idea is that, hopefully, the parents are gaining a better understanding of just how important this interaction and play is for their child's future learning. But they're also gaining some confidence, some self-efficacy, in their ability to play with the child. They take the toy home and, in the past, they've taken home a little handout that has suggestions for games and activities related to that toy.
Dr. Shah has conducted a few studies at UI Health demonstrating acceptability and effectiveness of this intervention. However, I learned that the implementation of Sit Down and Play at UI Health had really been done using volunteers- there are a lot of residents or med students around that are interested in helping out with things like this. I also learned that it had only been implemented in English at UI Health. I was really interested in sort of how this intervention could be adapted in two ways. So first, how could it be adapted, culturally tailored to meet the needs of the Latino population in Chicago. So not only translating it to Spanish, but also making other adaptations, so it would be acceptable and satisfactory for the Latino population. I was also really interested in how it could be delivered in a way that did not rely on volunteers, because if you're working in a community clinic, a federally qualified health center, those areas are not going to have access to student volunteers in the same way that a large teaching hospital like UI Health does. I ended up partnering with Esperanza Health Centers, which is an FQHC in Chicago that provides fully bilingual care, primarily to the Latino population, so regardless of immigration or insurance status. That's where my current research questions really emerged.
I've continued working with Dr. Shah and with the pediatric team at one of the Esperanza Clinics. To date, we've accomplished that first goal that I mentioned: culturally tailoring this intervention. We completed formative research over the past year, which was really successful, and now I'm interested in that second question: how can we integrate this into the routine workflow so that it's available for all of the patients that come in, and not just relying on volunteers. We have done some preliminary work trying to figure out how the pediatric medical assistants or MAs could deliver this intervention, figuring out, you know, after the child and the parent are roomed, and the MA weighs them and talks to them a little bit, but there’s that waiting period before the pediatrician comes into the exam room. We've identified that as a good opportunity for delivering the Sit Down and Play intervention. My goals moving forward are to really understand how the MAs could deliver the intervention, try to assess fidelity when they are asked to deliver this, and then move on to doing more of a pilot trial to understand the impact, both on the families receiving the intervention and the impact of delivering the intervention on potential job satisfaction and how they feel about playing this role in the patient families’ lives.
9:45 VO:
Dr. Rothstein shared some of their findings to date, particularly the families’ response to the expanded Sit Down and Play intervention.
9:56 Dr. Rothstein
We found that, overall, the families were really satisfied with receiving this information at the pediatrician's office and were really satisfied with the different kinds of toys given for the different age groups. There were some barriers to playing and talking, especially with the youngest children, time is a huge thing; parents just feeling like they don't have enough time to really, you know, sit down and play for half an hour or an hour. So, one change that we're making is incorporating into the counseling session an emphasis on how even just playing for five or ten minutes with your child is super beneficial.
We've also added in a whole set of recommendations that do not involve the toy, so things that can just sort of be done on the go to encourage that positive parent child interaction. Another big thing we found was that the handouts were not very effective. I think that's partly because giving a handout to someone that's then leaving with a six-month-old, it’s just kind of hard to keep track of things. But also, people are really used to getting information through images or through their phones, people are just not really into reading a lot of text at this point. And so, we have eliminated the handouts and created a Sit Down and Play website, which we, in the future, will share with parents. And this has a lot of advantages: we can incorporate more images and perhaps someday even videos demonstrating how to play these games and activities. The website can be accessed at any time. It can easily switch from English to Spanish. Parents can share it with their other family members or their friends.
12:03 VO:
Dr. Rothstein described the existing frameworks that have aided in the development of her expanded implementation approach, including PRISM- a Practical, Robust Implementation and Sustainability Model for Integrating Research Findings into Practice- and TIPs: Trial of Improved Practices.
12:27 Dr. Rothstein
The PRISM framework, at its core, emphasizes that you need to understand both the patient's perspectives and the staff perspectives on an intervention. So far, what we've tried to do is understand the patient's perspective. That involved the formative research that we did over the past year or so, and I actually drew on a methodology that I had previously used in the international setting, which is called TIPS or Trial of Improved Practices. And this is the idea that you want to learn from people's experiences testing out an intervention to understand whether it's acceptable and to understand what changes need to be made. So rather than just gathering people around, for example, and having a focus group and asking them questions, we used a sample of families at the Esperanza California clinic and delivered the intervention and then followed up with them a few weeks later to understand if they had been playing with the toy and following some of the recommendations and how they felt about the counseling session, how they felt about the handout, and things like that.
What does it look like if we wanted to really ask the medical assistants to implement Sit Down and Play? We did do some interviews with the doctors and talked a lot with the MAs that we collaborated with during that first phase of formative research. They feel very positively about sit down and I think almost all of the MAs that we were working with at the one clinic, they are parents themselves. And most of them are Latina. The general understanding is that they would be really excited for this to become one of their responsibilities. At the same time, there are just challenges, of course, in terms of ensuring that in integrating something new into their routine doesn't slow down the pediatricians’ workflow. That's, definitely a challenge to work around and something that we're having discussions about. We do think that incorporating the website is something that could speed things up a little bit and we've talked with them about what kind of training they would need- refresher trainings and things like that. So that's sort of where the implementation science components come in. That's really the idea with TIPs, the Trial of Improved Practices, that there aren't always one size fits all interventions. Maybe we have a core evidence base for the content and general delivery mechanism, but interventions are always going to be more effective if they are acceptable and culturally congruent. The idea is that you can use this process to make small changes or tailoring to increase the acceptability and increase the feasibility for a family, and then increase the potential for impact.
15:52 VO:
Dr. Rothstein acknowledged the mentor team supporting her development under the CATS Affiliate award and spoke about her aspirations for the future.
16:02 Dr. Rothstein
Dr. David Dubois, he's a professor in my division, community health sciences, and he's the associate dean of research at the School of Public Health. And he really has a lot of experience in the design and conduct of experimental and quasi experimental intervention trials. Most of his research has been related to adolescent health, so slightly different population, but in terms of the methodological approaches that he's used, I'm really going to be looking to him to support my training in intervention research design and to help guide decisions related to study design and data collection and statistical analysis. And then Dr. Kate Zinsser, she is an associate professor in the department of community and applied developmental psychology at UIC. And so, she's an applied developmental psychologist, and she has a lot of training and expertise in social emotional development. She has used observational measurement techniques in her work. I will be looking to her to deepen my understanding of child development, you know, it's not an area that I was initially trained in. And in terms of not just child development theory but also measurement. I feel really strongly that investing in early child development is one of the most effective and efficient ways to reduce racial and ethnic health and educational inequities over the long term. (27:00) I really want to strengthen my implementation science skills, and I hope to be a leader in the implementation and evaluation of early child development interventions in pediatric care. I would like to continue my focus on the Latino population here in Chicago. I'm excited to carry out this study and then hopefully, with the support and the training that comes through this CATS experience, achieve research independence by developing those skills.
18:16 Voice Over:
Collaborative Endeavors is written and produced by me, Lauren Rieger, on behalf of the Center for Clinical and Translational Science (AKA the CCTS) at the University of Illinois Chicago. To learn more about Dr. Jessica Rothstein and the CCTS’s KL2 CATS and CATS affiliate program, visit the links in our show notes. The CCTS is supported by the National Institutes of Health’s National Center for Advancing Translational Science through their Clinical and Translational Science Award. Opinions expressed by guests of the show are their own and do not necessarily represent the views of myself, the CCTS or our funding agencies. You can find more episodes of Collaborative Endeavors on Apple Podcasts, Spotify, Amazon Music & Google Podcasts. While we do not monetize this podcast, we do love positive feedback! If you like what you hear, go ahead and give us a 5 star rating to help spread the word.