Study of the Impact of Parental Note Taking on the Effectiveness of Anticipatory Guidance

The importance of communicating effectively with families and children is not unique to
medicine. In the field of child music education, research has shown that effective parental
involvement is linked to musical achievement [1]. The Suzuki method of music education in
particular emphasizes this involvement and regards an effective teacher-child-parent
relationship as fundamental to learning [2]. Parental engagement both during the music
lesion and at home is key, and parents are routinely encouraged to take notes during the
lesson so they can accurately recall the instruction for practice at home [1]. The Suzuki
method is based on the idea that this model of education can be used with any family in any
environment [3]. We are interested to learn whether a similar approach can be applied to
pediatric anticipatory guidance in an urban population.

Note taking has been shown to improve both memory and comprehension in a number of settings.
In a study of memory aids, participants taking notes exhibited higher levels of accurate
recall of information than participants using other techniques [4]. Another study
demonstrated that participants who took notes and then had the notes to review had improved
recall of information when compared to participants who were given written information to
study but did not take notes themselves [5]. Even doodling has been shown to lead to
improved memory and to aid with concentration [6]. Interestingly, patient or family note
taking for retention of medical information has not been extensively studied.

A number of studies have been done to look at interventions to improve both the delivery of
health information and the retention of the information provided. Randomized controlled
trials have looked at the impact of specific training programs for providers [7] and at
practice-wide changes in office systems [8], and have shown improvements in the amount and
quality of guidance provided. A study looking at the impact of physician advice on behavior
change found that patients who had received counseling by their physician prior to receiving
related written materials had better recall of information and were more likely to share the
materials with others when compared to patients who only received the written material with
no counseling [9]. A study on information recall of instructions given in the emergency
department for otitis media care showed that parents retained more information at one and
three days after the encounter when they received either standardized verbal or written
instructions, as opposed to the usual verbal instructions [10].

The effective delivery of health information plays a central role in pediatric primary care.
In 1990, the Federal Maternal and Child Health Bureau, along with the American Academy of
Pediatrics, launched Bright Futures, a set of health supervision guidelines for pediatric
patients aged birth to 21 [11]. The guidelines, which provide a framework for well-patient
care, emphasize a partnership between the healthcare team, the family, and the child and
highlight a number of recommended topics to be covered at routine visits [12]. This is a
standard curriculum for primary care in many pediatric residencies, including the Boston
Combined Residency Program.

For many families, the first interaction with a healthcare provider for their child occurs
during the newborn evaluation prior to discharge from the hospital. The newborn anticipatory
guidance recommended by Bright Futures is divided into the five categories of family
readiness, infant behaviors, feeding, safety, and routine newborn care [12]. Included in
these topics are recommendations for counseling on prone sleeping position, or "back to
sleep," breast feeding support, and car seat use, all of which have been shown to improve
infant health and safety [13,14,15]. Despite the recommendations for newborn anticipatory
guidance, a national survey of parents with young children showed that 38% of parents
reported never having discussed newborn care with a healthcare provider [16]. The authors of
the study comment that it is difficult to know whether a portion of these families received
information but were unable to remember it at the time of the survey. In the same study, a
perceived lack of information was correlated with decreased satisfaction with care. The
parents who reported discussing fewer anticipatory guidance topics gave their providers
lower overall ratings.

A survey of sleep position of infants seen at an urban primary care center in Washington DC
showed that 34.1% of infants were sleeping in the recommended supine position [17]. A
subsequent study of sleep position reported by parents of black infants at a WIC clinic in
Washington DC showed that 57.7% of the infants were sleeping in the supine position [13].
While there are many factors that impact parental behaviors around sleep position, the most
common reasons given for supine sleeping position in this study were concern for SIDS and
advice from a health care professional. These findings indicate that improved delivery of
anticipatory guidance may play a role in increasing the proportion of infants sleeping on
their backs.

At Boston Medical Center (BMC), a group of three nurse practitioners split full-time
coverage of the newborn nursery and are responsible for doing a great deal of the newborn
teaching with parents. Prior to discharge from the hospital, each infant is evaluated and
teaching on newborn care is done using both verbal instruction and written handouts. This
teaching, which is based on the Bright Futures recommendations, covers topics including
feeding, diaper care, bathing, dressing, umbilical cord care, circumcision care, safety,
sleeping, and crying. The providers also review warning signs that may indicate that an
infant is sick. At the time this teaching is done, each mother is given a large envelope
containing the discharge documents. On the outside of the envelope is a section designated
for taking notes, although this is not currently used by the providers or parents.

In our study, a randomized controlled trial, we will draw on the techniques promoted by the
Suzuki method of music education to see if the principles of increased parental involvement
and parental note taking can improve information retention and impact behavior change. We
hypothesize that more active parental participation in the form of note taking during the
delivery of anticipatory guidance will lead to increased knowledge, higher levels of
satisfaction with the encounter, and increased adoption of recommended parenting practices.
Our specific aims are as follows:

Specific Aim 1: To evaluate the impact of note taking during the delivery of newborn
anticipatory guidance on maternal behavior. The primary outcome of interest is maternal
practice related to infant sleep position, and the secondary outcomes of interest are
maternal practice related to breastfeeding initiation and car seat use.

Specific Aim 2: To evaluate the impact of note taking on mothers' knowledge of recommended
practices related to newborn care.

Specific Aim 3: To evaluate the impact of note taking during health information delivery on
mothers' satisfaction with the guidance received.