Background: A public health approach to child maltreatment prevention relies on programs that impact the underlying drivers of maltreatment and that can easily be implemented. Stress in the family, mental illness, unrealistic expectations, and lack of knowledge have all been shown to be preceding factors in maltreatment risk. To help address some of these risks, an education program consisting of the Period of PURPLE crying, a social and economic stressor questionnaire, and the Parenting Action Plan was designed for maternal caregivers of newborns at pediatric clinics. This paper explores implementation challenges and successes of the education program, and describes strategies to implement such a program for maternal caregivers of newborns in pediatric clinics.

Methods: The education program was delivered at 4 pediatric clinics serving low-income families in Houston, Texas. Each clinic received a program orientation, topic specific training for implementing staff, and technical assistance as needed. The implementation evaluation of the education program focused on responses from key informant interviews with 18 staff members from the 4 pediatric clinics. Interview data was recorded through note taking then transcribed and coded relying on the grounded theory approach using inductive reasoning for analysis.

Results: A majority of the 18 study staff interviewed across all four clinics expressed the need for and benefits of providing an education program to maternal caregivers of newborn during well-child visits. Key themes that emerged were (1) maternal caregivers were receptive to an education program for support during well-child visits and staff saw its benefits, (2) motivational interviewing was helpful in engaging caregivers in conversations, and (3) it is important to establish a workflow that can accommodate the maternal caregivers and clinic needs alike.

Conclusions: An education program in pediatric clinics is a valuable resource to support maternal caregivers and their families. This type of program can be achievable when key factors are in place including: leadership and staff buy-in by having program transparency, efficient workflow that carefully considers maternal caregivers and staff time, and willingness of the organization is invest into the program. However, there is no one-size fits-all approach to successfully implement an education program into a routine part of pediatric care. It is vital to understand the organizational and structural strengths of each implementing clinic and leverage personnel in order to implement the program components with the highest fidelity.

Key Take Away Points

  • Education to support maternal caregivers of newborns in pediatric clinics is welcomed, beneficial and achievable.
  • Buy-in from leadership and staff members of every level is key to program adoption and sustainability.
  • Planning for implementation is crucial to ensure organizational readiness to deliver a new innovation.
  • Motivational interviewing is a recommended approach when providing an education program to maternal caregivers of newborns in pediatric clinics.
  • Coordination within the clinic workflow to provide the program is important for efficient use of staff and caregiver time.
  • There is no one-size-fits-all approach to successful implementation of an education program. Careful assessment of clinic environment with considerations of recommendations will increase likelihood of success.

Author Biography

Yen H. Nong received her MPH from Columbia University, New York City in Population and Family Health and her BA in Biology from Texas A&M University, College Station. She began her career working in HIV prevention programs and research specifically among women and children. Her work brought her experiences in multiple under-served communities from Uganda to the South Bronx. She is currently a Research Associate in the Section of Public Health and Child Abuse Pediatrics at Baylor College of Medicine/Texas Children’s Hospital in Houston. In her role she conducts research around maternal mental health and supporting families through pediatric clinic settings to mitigate adverse childhood experiences and improve health outcomes for women, children and their families. She is passionate about working collaboratively across sectors to foster resilience in individuals, families and communities. Dr. Kimberly Kay Lopez earned a Bachelor of Arts in Anthropology from the University of Houston, a Master's in Public Health in Community Health Practice and a Doctorate in Public Health in Management, Policy and Community Health from The University of Texas School of Public Health-Houston. Dr. Lopez's research interests include the effects of adversities on children, families, and communities. Her areas of expertise include maternal/child health, community assessment, and qualitative research methods. Dr. Lopez works with communities and vulnerable populations to identify health issues of concern and to develop solutions from within the community. She has more than twenty-five years experience engaging community and vulnerable populations in research and advocacy and developing strategic partnerships and action-oriented collaboratives to address health disparities and improve outcomes for children and families. Currently, Dr. Lopez is leading a research initiative designed to evaluate maternal support programs for mothers of newborns and infants; conducting an assessment of the health and medical needs of children in foster care, and bringing to scale a community-based early brain/language development program in underserved communities. As Director Public Health and the Center for the Study of Adversity, Resilience, and Education, Dr. Lopez leads the application of a public health framework to inward and outward facing research and program initiatives designed to improve maternal child health outcomes. Dr. Lopez and her team design, implement and evaluate innovative strategies, programs, policies, and practices to mitigate childhood and community adversities and to promote resilience. Dr. Lopez is an Assistant Professor of Pediatrics, Section of Public Health Pediatrics at Baylor College of Medicine.. She also serves as adjunct faculty at The University of Texas School of Public Health-Division of Health Promotion and Prevention, and is a Faculty Affiliate with the Kinder Institute for Urban Research, Rice University. Dr. Mandell received her PhD from the University of Washington, Seattle in Developmental Psychology and her BA from the University of Texas, Austin. She also served as a post-doctoral fellow at the Wake Forest School of Medicine and the University of Amsterdam. Her research has spanned multiple topics in maternal and child health including understanding the relations between early experiences and later developmental outcomes, especially neurocognitive outcomes. She has extensive direct public health experience through her work on a variety of public health topics including work that has supported the Maternal Mortality and Morbidity Task Force, Healthy Texas Babies, Child Fatality Review, and the strategic plan to align prevention resources between the Department of Family Protective Services and the Department of State Health Services in Texas. She is currently an Assistant Professor at the University of Texas Health Science Center, Tyler and with Population Health, Office of Health Affairs at the University of Texas System Administration in Austin. She supports the Texas Collaborative for Healthy Mothers and Babies and is the primary investigator for the Texas Safe Babies project and the Maltreatment Risk mapping project funded by Department of Family and Protective Services.


We would like to acknowledge Angie Hayes for her assistance in getting this study started and running properly. We would also like to thank Texas Children's Pediatrics and The Center for Women and Children who were on the ground putting this study into action. We are also greatly indebted to the Texas Department of Family and Protective Services for funding this important and necessary work.