Play has long been recognized as essential to optimal child development, including contributing to healthy brain development and facilitating positive bonding with parents and caregivers; the United Nations High Commission for Human Rights declared play to be the birthright of every child. However, through our own research at the Weitzman Institute, as well as the experience of our pediatric clinical colleagues, we recognize that not every child is able to exercise their right to play. Structural factors such as toys being cost-prohibitive, as well as parents and caregivers having to juggle multiple jobs to make ends meet, may serve as barriers to play. To address these challenges, the Weitzman Institute partnered with the LEGO® Group to support its Prescription for Play (P4P) program, with an emphasis on implementation and related research in Federally qualified health centers (FQHCs) across the U.S. Developed through expert insights and previous research, P4P is a social and emotional learning initiative that promotes learning through play by providing pediatric health care professionals with free LEGO® DUPLO® brick kits and educational materials, available in both English and Spanish, to deliver to their 18- to 36-month old patients during routine well-child visits. The kits and related educational materials are provided as prompts to communicate with caregivers about the benefits of play for development of their child’s emotional, cognitive, creative, social, and physical skills. Through a virtual hub, providers and site coordinators are trained to implement and adapt the program for their site. Providers receive Continuing Medical Education credits for completing the training.
During the well-child visit, the provider delivers the DUPLO® brick kit to the patient along with educational materials for the caregiver on how to utilize the kit and examples of appropriate play activities for their child. The DUPLO® brick kit is currently offered once throughout the 18- to 36-month period per child. While distributing the kit, the provider initiates a conversation with the caregiver about the importance of play that actively involves the caregiver. If time allows, the provider models an example of a learning-through-play experience with the child. After distributing the kit, the provider documents the delivery of the P4P program within the electronic health record (EHR). Providers are encouraged to follow up with caregivers at their child’s next well-child visit to ask if and how they have been utilizing the kit or other play methods and dedicating time each day to play with their child.
Barriers and Facilitators to Success of Conducting Research on a Novel Intervention during COVID
A few key factors contributed to the success of the initial phase of the intervention:
- Clinical subject matter experts: The project team enlisted the support of pediatric clinicians to serve as subject matter experts (SMEs) and help address questions and uncertainties that partnering sites had. This nuanced understanding of clinical workflows and relatability of the project SMEs subsequently facilitated the engagement of the research team with the various sites.
- Asynchronous learning materials to support uptake: In addition, the development of a virtual resource hub, which included various trainings, manuals, and sample workflow documents, also supported successful engagement of the clinical staff in distributing the duck kits.
- Accessibility and compensation: the duck kits available at no cost, and similarly, providing appropriate compensation for implementation sites to participate in the project, also facilitated success of the initiative.
Nonetheless, there were barriers to success worth noting:
- Time constraints: While the decision to introduce the duck kits during the well-child visits was done in an effort to “meet patients where they’re at,” this proved to be more challenging to conduct in practice then initially anticipated. The time constraints of the well-child visit posed a challenge to clinicians to introduce the intervention and still get through all necessary components of the visit.
- Variations in staff motivation: The differences in motivation among site leadership and patient-facing staff also posed a challenge; in some instances, leadership was enthusiastic about participating in the initiative/study while patient-facing staff did not see the benefit; in other cases, the reverse was true.
- Negotiating funder expectations with research realities: Managing funders’ expectations is also a barrier to success that warrants further discussion. The funder eagerly anticipated results by the initially agreed upon dates. However, generating evidence takes time: challenges with identifying and recruiting appropriate sites, as well as getting participating sites and staff to provide EHR data and participate in surveys and key informant interviews, made it difficult to provide results to the funders in a timely manner.
Fortunately, the project team was able to course-correct by adopting several solutions as the initiative progressed. The identification of a clinical champion at participating sites provided a liaison for both staff on the ground, as well as the project team. In addition, the project team created open communication channels among providers from different sites, which allowed for an organic formation of a support system among participating clinicians, as well as help overcome hesitancy among newer clinicians participating in the project. The project team also recognized it was important to build trust and rapport with the clinicians and teams at the participating sites. As part of our ongoing effort to normalize community engagement and health equity in our approach to research, the project team was intentional about making time to address the needs of participating FQHCs and care teams, finding ways to support them, and ensuring that the intervention added value to patient care. Based on prior embedded research projects, we recognize the need to establish authentic connections with study populations, patients, and communities, particularly given historic and present-day transgressions of our field. Such interactions provide an opportunity to reintegrate the humanity in research so that research is seen as a resource for realizing positive social change, both in its processes and outcomes.
Lessons Learned for Future Patient/Community Engaged Research
There are several key lessons learned that will be carried forward as the P4P begins to expand in other safety-net settings beyond FQHCs, which may also be applicable to other patient and community-based research initiatives:
- Variations in clinical sites’ readiness to engage in research: Prior to commencing the study, the project team observed various in participating sites’ readiness to engage in research. The project team recognized that interest in participating in the study was not necessarily indicative of readiness to participate. Many of the FQHCs that were approached initially were unable to commit given that they were still playing catch up with patients and general clinical operations, which needed to be prioritized over research participation. Similarly, at one site, a clinician was also trained as a researcher and was able to complete the site-specific IRB protocol, whereas at other sites, such personnel did not exist, and thus, needed support from the project team to complete the protocol and related paperwork. Thus, there is a need to remain flexible and open to provide support to sites, particularly in multi-site studies, that may differ in their capacity to engage in research.
- Feasibility of study design and approach: During the initial months of the study, the project team began to encounter difficulties with data collection, including significant missing data from both patient and provider surveys. Thus, another lesson learned is keeping in mind what is feasible to collect in terms of data as participants, in this case patients, families, and clinicians, may not have the bandwidth to engage as much in the study as the project team would like them to.
- Test and tailor dissemination messages and activities for different stakeholders: The responsibility of health equity researchers to authentically engage with patients and communities does not stop when data collection is complete. Instead, health equity research obliges us to decrease the time from data collection to dissemination, return to the patients and communities from and with whom we have collected the data, report back the study findings, and correct and revise the latter when deemed necessary by patients and communities. Similarly, while the project team values the peer-reviewed publication process, we recognize that evidence may need to be disseminated in a more rapid, accessible manner.
- Project staffing: Ensuring that staff have adequate allocated time and effort to assist participating sites with troubleshooting, particularly in the earlier stages of implementation and determining best fit within current clinical workflows and processes.
With the overburdening of health systems due to the COVID-19 pandemic and the need to address neglected health conditions that fell behind over the last two and a half years, we, as health services researchers, have the responsibility to reflect on our previous practices and change the course of future research. The demand to innovate given the restrictions of the pandemic revealed new ways to conduct research and implement interventions in a way that minimizes burden and promotes program sustainability.