Prescription for Play: A process and outcome evaluation of a play promotion intervention in federally qualified health centers

doi:10.21203/rs.3.rs-4492080/v1

Background

Despite the benefits of play on child development, under-resourced children are less likely to have equal access to or opportunities for play. Prescription for Play (P4P), a social impact program of The LEGO^® Group, leverages attendance at 18-to-36-month well-child checks to discuss and promote play and has the potential to effectively increase play in under-resourced families. However, limited work has investigated the feasibility and effectiveness of its implementation. As such, this research evaluated the implementation outcomes of P4P within multiple federally qualified health centers (FQHCs), which serve as important safety-net medical settings for under-resourced families.

Methods

Data were collected from six FQHCs. To understand whether P4P impacts caregiver outcomes, an interrupted time series design was used in which two separate samples of caregivers completed a researcher-designed survey before (n = 180) and after (n = 262) program implementation. A mixed-methods approach was undertaken to evaluate the process of delivering P4P using an implementation fidelity framework, in which staff surveys (n = 27), staff interviews (n = 25), and clinic observations (n = 44) were completed.

Results

Caregivers reported positive views towards play and a strong desire to play with their children before and after P4P implementation, with independent samples t-tests showing no differences between groups on survey constructs (ps > .06). Triangulation of qualitative and quantitative process data showed that P4P can be implemented as designed within varied FQHC settings and is acceptable among clinic staff, with additional implementation facilitators identified.

Conclusion

Although P4P does not appear to influence the positive views of and strong investment in play held by caregivers, this study offers important evidence that P4P can be implemented to fidelity within FQHCs, making it a feasible program to deliver in safety-net settings.

Play in early childhood fosters critical skills, like language acquisition, self-regulation abilities, physical capabilities, and social competencies [1–5], and can improve life course trajectories [6–9]. Although play is often considered synonymous with childhood, children from lower income families are less likely to have equal access to or opportunities for play. For example, due to social, emotional, and economic stressors, caregivers with lower incomes may have less time, resources, and energy to play with their children [10]. Children living in poverty are also less likely than their affluent peers to grow up in neighborhoods with safe spaces for outdoor play [11] and attend schools that offer opportunities for playful learning [12]. These play disparities can impede the developmental course of under-resourced children by preventing them from experiencing the full benefits of play [10]. Thus, play is recognized as an important equity issue [13], with calls to ensure that play be a right, rather than a privilege, granted to all children [14].

In response to these calls, numerous interventions have been developed to increase play among under-resourced children. These efforts have focused on promoting play in multiple settings, including within the home [15], in classrooms [16, 17] and Head Start programs [18], and through improvements in the built environment, such as playground upgrades and increased green spaces [19]. Despite the success of these play-based initiatives, such programs have been narrowly implemented, thereby limiting their reach. Without significant social and structural changes to promote play equity universally, there remains a need to find creative solutions to deliver play-based interventions more widely. One underutilized strategy for increasing access to play-based interventions, particularly among under-resourced families, is to leverage attendance at well-child checks (WCCs) as an opportunity to discuss and promote caregiver-directed play. The American Academy of Pediatrics (AAP) recommends that all pediatricians educate caregivers on the importance of play and encourage them to play with their children [20]. However, limited efforts have attempted to develop a standard approach for integrating play discussions and guidance into routine WCCs to bolster caregiver-led play.

One program aimed at addressing this gap is Prescription for Play (P4P). P4P is a social impact program of The LEGO^® Group designed for healthcare providers seeing 18-to-36-month-old patients for WCCs, with the goal of increasing play through caregiver education. P4P is currently being implemented nationally, with the goal of reaching diverse populations of children from all socioeconomic backgrounds. Recent preliminary data from our group shows that caregivers of children exposed to P4P report fewer developmental concerns over time compared to those whose children never received the program, providing initial support for its utility [21]. However, no work has formally investigated the process and outcomes of P4P to understand its feasibility and effectiveness. Accordingly, we evaluated the implementation process and outcomes of P4P within multiple federally qualified health centers (FQHCs). FQHCs were targeted because they provide medical services at low- or no-cost to underserved communities and are important medical homes for well-child care for under-resourced families [22, 23]. The goals of this research were (1) to explore how exposure to P4P influences caregiver attitudes and behavioral intentions towards play and (2) to assess implementation fidelity and acceptability of P4P among providers and clinic staff.

Research sites

FQHCs were invited by email to apply for participation in the study. Responses were received from 243 FQHCs across the country. Organizations were narrowed according to the following eligibility criteria: (1) must average a minimum of 83 monthly WCCs for 18-36-month-old patients to achieve sample size goals, (2) have at least 40% of patient households list Spanish as the preferred language to evaluate outcomes in a language-diverse sample, (3) demonstrate a dedicated team for data processing and transfers, and (4) have ability to seek IRB approval and possess proof of Federalwide Assurance. Three eligible FQHCs were initially selected to participate. Due to lower caregiver response rates than anticipated, an additional three organizations were later recruited to achieve sample size goals. The six participating FQHCs were geographically diverse, located in urban and rural areas of California, Connecticut, Florida, Indiana, New York, and North Carolina.

Prescription for Play program

P4P offers a virtual hub to healthcare teams [24], which includes program resources and trainings, implementation toolkits, continuing medical education credits, technical assistance, and program support. P4P further provides participating clinics with kits containing age-appropriate LEGO^® DUPLO^® bricks and related educational materials as prompts to engage caregivers on the benefits of play. Providers are instructed to model play with their patients using the kit in real-time while educating their caregivers on the role of play in child development. In line with AAP recommendations [20], providers are encouraged to give caregivers a “prescription” to play daily with their child. At subsequent visits, providers are advised to continue conversations on the importance of play. For this study, healthcare teams completed the provider training through the virtual hub and began integrating P4P into their clinic workflow after receiving approval for program implementation. A member of the research team subsequently held monthly virtual calls with organization leads to provide insight and troubleshoot challenges.

Procedures

Study procedures are outlined in Fig. 1. To understand whether P4P impacts caregiver outcomes, an interrupted time series design was used. Interrupted time series designs are a quasi-experimental approach used to evaluate intervention effects by comparing outcomes before and after its implementation when randomization is not feasible [25]. In line with this approach, a baseline group of caregivers was recruited from each organization prior to P4P implementation. This baseline group of caregivers received a handout during their child’s 18-36-month WCC asking them to complete a pre-implementation phone survey on their views of and behavioral intentions towards play. After collecting pre-implementation surveys, organizations were approved to implement P4P. An additional sample of caregivers, who received P4P during their child’s 18-36-month WCC, were then recruited to complete an identical phone survey. All caregivers were required to (1) be at least 18 years old, (2) be the responsible party for the pediatric patient, and (3) have phone access to complete the survey. Phone surveys were conducted by a third-party survey vendor (Crossroads Group, Inc.) in English, Spanish, and Haitian Creole within several weeks of the completed WCC. All caregivers provided verbal consent to participate and received a $30 Amazon gift card for compensation. We aimed to collect a total of 250 pre- and post-implementation surveys (500 surveys total).

Figure 1. Study procedures

A mixed-methods approach was further undertaken to evaluate the process of implementing P4P in FQHC settings. After each organization began implementing P4P, all participating providers and clinic staff were invited to complete surveys (either online or on paper) and qualitative interviews (either in-person or virtually) to gather their insights on the acceptability of the program and the feasibility of its implementation. All providers and clinic staff provided consent prior to participation. In addition, clinic observations were performed by trained, Master’s-level members of the research team to observe P4P delivery during 18-36-month WCCs at each FQHC to assess program implementation. Team members obtained verbal permission from caregivers prior to observing their child’s WCC. All data were collected between July 2022 and December 2023.

Outcome Measures

Caregiver surveys. To understand caregiver views on and behavioral intentions towards play, a survey was developed by the research team according to the Theory of Planned Behavior [26], a psychological theory linking an individual’s beliefs to their behavior. As described elsewhere [27], four constructs were assessed, including (1) attitudes, (2) subjective norms, (3) perceived behavioral control, and (4) behavioral intentions. The attitudes subscale (4-items) assessed beliefs that play is enjoyable, pleasant, helpful, and valuable. The subjective norms subscale (3-items) evaluated support and approval from others regarding play. The perceived behavioral control subscale (3-items) assessed the extent to which play is within the caregiver’s control and not prevented by others. The behavioral intentions subscale (3-items) assessed intentions to play daily. Questions were rated using a 4-point Likert scale and subscale items were averaged, with higher scores indicating more positive views of and higher behavioral intentions to play. Cronbach’s alphas ranged from .68-.78 for the pre- and .63-.79 for the post-implementation surveys. Only the behavioral intentions subscale had an alpha < .70, indicating largely adequate reliability.

Process Measures

Program evaluation measures were designed according to a previous conceptual framework for implementation fidelity [28, 29] and are publicly available [27]. In line with this framework, we assessed components of program adherence (i.e., program content and coverage) as well as potential implementation moderators, such as intervention complexity, quality of delivery, participant responsiveness, and facilitation strategies. To evaluate these implementation factors, both quantitative (surveys) and qualitative (interviews and observations) data were collected among providers and clinic staff implementing P4P.

Staff surveys. The staff survey consisted of questions assessing previous knowledge of play, views of P4P, and program fidelity.

Staff interviews. Staff interviews consisted of open-ended questions to understand staff experiences with the program and its implementation, motivation to implement the program, and views on the effect of the program on patient visits.

Clinic observations. The observation protocol involved the passive observation of clinic settings, visit procedures, and P4P delivery.

Analysis

To evaluate caregiver outcomes, demographic data for both the pre- and post-implementation respondents were summarized and compared using Fisher’s exact tests. Survey subscales were described and compared between the pre- and post-implementation surveys using independent samples t-tests.

To complete the process evaluation, data from qualitative interviews were transcribed and observation texts compiled. Both qualitative sources were then reviewed by the research team (SAB, LG, PR) for initial impressions and later assigned codes to identify major themes using a predominantly deductive approach with additional themes emerging inductively [30]. Specifically, themes related to the conceptual framework of program fidelity that informed this evaluation [28, 29] were deductively coded and included factors related to adherence and implementation moderators, with additional subthemes determined inductively. Meanwhile, items from the staff survey were descriptively summarized. Of note, because not all questions on the staff survey were relevant for the different roles held by respondents, the total number of participants responding to certain items does not reflect the total number of survey respondents (e.g., only providers answered questions relevant to how P4P fits into their practice). Finally, the research team triangulated the findings by combining different data sources to complement one another and provide further context [31]. Final themes were determined through team consensus.

Caregiver characteristics

Due to lower caregiver response rates than anticipated, most organizations (n=5) began implementing P4P earlier than anticipated to ensure timely completion of post-implementation procedures, resulting in a smaller number of pre-implementation surveys than intended. Of the 832 caregivers contacted for the pre-implementation survey, 180 (21.6%) were surveyed. Meanwhile, 262 (28.7%) of the 914 caregivers contacted for the post-implementation survey completed the measure. As shown in Table 1, the pre-implementation group had a smaller proportion of caregivers identifying as Hispanic/Latine and preferring Spanish and a larger proportion of caregivers preferring Haitian Creole compared to the post-implementation group. No other demographic differences were detected between groups.

Care team and clinic characteristics

Survey respondents (N=27) were largely medical assistants (37%, n=10) and physicians (30%, n=8), with the remaining 33% (n=9) reporting a different role. Additional demographic factors (e.g., age, race) were not collected in the staff survey. Meanwhile, of the 25 interviewees, 32% (n=8) were pediatricians, 24% (n=6) were medical assistants, and 20% (n=5) were in managerial

Table 1. Pre-implementation (N=180) and post-implementation (N=262) caregiver demographics

Demographic	Pre-implementation	Post-implementation
	n (%)	n (%)	p-value
Age			.20
18-24	23 (13%)	44 (17%)
25-34	92 (52%)	143 (55%)
35-44	56 (31%)	69 (26%)
45+	7 (4%)	6 (2%)
Gender			.63
Female	173 (97%)	250 (95%)
Male	6 (3%)	12 (5%)
Race/Ethnicity			.03
White	15 (8%)	7 (3%)
Black or African American	17 (9%)	20 (8%)
Hispanic/Latine	146 (81%)	228 (87%)
Other*	2 (1%)	7 (3%)
Relationship to Child			.71
Parents	177 (98%)	256 (98%)
Grandparents	3 (2%)	3 (1%)
Extended Family Member	0 (0%)	2 (0.8%)
Non-related Caregiver	0 (0%)	1 (0.4%)
Single Parent Household			.64
Yes	52 (29%)	68 (26%)
No	126 (71%)	192 (74%)
Language			.02
English	53 (29%)	74 (28%)
Spanish	122 (68%)	188 (72%)
Haitian Creole	5 (3%)	0 (0%)

Note: A small number of caregivers did not report demographics for the following variables: Age (pre-implementation n=2), gender (pre-implementation n=1), and single parent household (pre-implementation n=2, post-implementation n=2)

*American Indian or Alaska Native, Asian or Asian American, Native Hawaiian/Pacific Islander, Other.

positions, with the remaining 24% (n=6) reporting different roles. Respondents tended to be middle-aged and older (44%, n=11), female (52%, n=13), white (56%, n=14), and Hispanic/Latine (36%, n=9). Finally, of the 44 clinic observations, half (50%, n=22) occurred during 24-month WCCs, with the remaining observations evenly split across 18- and 36-month WCCs. Most visits were conducted in Spanish (59%, n=26) and English (34%, n=15) followed by Haitian Creole (7%, n=3).

Caregiver outcomes

As shown in Table 2, average subscale scores were high for both the pre- and post-implementation surveys. No differences were found between pre- and post-implementation respondents.

Table 2. Caregiver survey outcomes

Survey construct	Pre-implementation Mean (SD)	Post-implementation Mean (SD)	p-value
Behavioral Intention	3.50 (.49)	3.53 (.45)	.57
Attitudes	3.63 (.40)	3.68 (.37)	.20
Subjective Norms	3.34 (.52)	3.43 (.50)	.06
Perceived Behavioral Control	3.24 (.54)	3.23 (.52)	.89

Process evaluation

Supporting quotes for each theme are displayed in Table 3.

Table 3. Staff interview quotes
Theme	Subtheme	Quote
Adherence	Coverage	“I find myself talking about play in other visits where I'm not giving the packet a lot more, but I think having [the play kit] and being able to just model some of the behaviors is very helpful.”
Adherence	Content	“I would talk about the different kinds of areas that we're looking at for development, fine motor skill, gross motor skills, and problem solving and social skills and how they're learning a lot of those skills as they're playing with toys. And also as [caregivers are] playing with them with the toys. Usually I'm playing with the toys a little bit with the kids back and forth at the same time.”
Implementation Moderators	Intervention complexity	“[I] thought it was well done. It wasn't too long, wasn't too short. And it was helpful.”
		“It was pretty straightforward and easy. It was fun. I guess it wasn't overwhelming,”
	Quality of delivery	“You have to know your audience. I think that as far as what goes on in the room that is what dictates what happens in the room discussions.”
	Participant responsiveness	“Our [pediatrics] population is low income, so I think having different toys and books and things, they really appreciate.”
		“The kids get happy...You go in with vaccines and stuff like that. So [the kit] gets them happy. And it makes them open up to you…[the caregivers] get a little bit more trustworthy. Like, oh, they're actually interested in us, you know, what my kid is going through and everything.”
		“Sometimes with parents I feel like sharing and speaking to them about this project, I feel like some give you their attention and some don't…Thinking of ways to kind of make it exciting.”
	Facilitation strategies
	Usefulness for developmental conversations	“I also love making comments to the parent about how the kid is playing while we're doing the exam…It's really important that they're just playing with it and you're just making some positive reinforcement about how they're using their hands or what they're doing with it…So I think it can promote discussion that way about developing and what we're looking for.” “This is a very positive message that encourages children and parents to interact, that does all the right things without necessarily making it a don't, don't, don't, don't, don't, sort of activity.”
	Organized implementation systems	“I think the one thing I got concerned about was remembering to [log in EHR] so we can track it. So part of our workflows [is] nurses do it then I check to make sure it's in. So I think that that's been helpful, but other than that, I really have no other concerns about the flow of the day.”
	Organized implementation systems	“I think the next challenge I'll have is because we only give the blocks once, right? So my next challenge is going to be remembering to check previous physicals as we get five to six months into this to make sure that I haven't already given the blocks.”

[Place Table 3 here]

Adherence. Adherence is the extent to which a program is delivered as designed as measured by program content, coverage, frequency, and duration. Using information gathered through the interview, survey, and observational measures, two subthemes related to adherence, namely coverage (i.e., whether the target population was reached) and content (i.e., whether intervention components were implemented as planned), were found.

Coverage. According to survey data, 68% (n=15/22) of respondents reported occasionally, rarely, or never incorporating discussions about the importance of play into WCCs before completing P4P trainings. After completing the P4P training, this number reversed, with 58% (n=14/24) of survey respondents reporting that they now always discuss the importance of play in early childhood, which was supported in interview conversations. In addition, 33% (n=7/21) of survey respondents reported inviting other providers from their organization to complete the P4P training to expand its reach.

Content. Nearly all survey respondents somewhat or strongly agreed that they were excited about P4P (92%, n=24/26), found the program valuable (96%, n=25/26), and believe play is important to children’s development (96%, n=25/26). Most providers further demonstrated alliance with program goals. In 98% (n=43) of observations, providers successfully gave out the P4P kit, during which 60% (n=26) modeled play. Ninety-five percent of providers (n=42) discussed the importance of play to some degree and nearly two-thirds (61%, n=27) delivered a specific “prescription for play” to caregivers. These observations were consistent with interviews, with most respondents describing success in implementing the program as designed. However, staff surveys indicated more variability in adherence to program content, with only 45% (n=10/22) of respondents reporting that they model play using the kits at least most of the time.

Implementation moderators. Several implementation moderators that promoted program adherence, including intervention complexity, quality of delivery, participant responsiveness, and facilitation strategies, were identified across data sources.

Intervention complexity. Providers indicated that P4P fit nicely into their existing visits, with 89% (n=16/18) of survey respondents agreeing that the P4P content is relevant to their practice. In interviews, staff described the P4P training as a low-lift that enhanced their knowledge, further noting that the intervention itself was not time-consuming and complemented their workflows. Observations confirmed this by demonstrating that P4P took an average of 2.9 minutes to deliver, with the core messaging largely being built into standard anticipatory guidance.

Quality of delivery. In interviews, providers described tailoring their discussions about the benefits of play using education provided in the P4P training. From observations, the most frequently discussed topics during visits included encouragement to use simple toys and/or have screen-free time (n=28) and the role of play in language acquisition and speech development (n=28). Additional topics discussed included the relationship between play and brain development (n=24), social-emotional skills (n=23), and emotional regulation (n=14). However, several providers reported challenges with translating the training recommendations into practical play-based recommendations for caregivers upon interview and desired more practical guidance and sample scripts.

Participant responsiveness. A key facilitator to P4P implementation was its positive reception by families. In interviews, staff reported the toy was appreciated as a free resource. Observations further showed that children were often eased or comforted by the playfulness the program brought. Providers noted that this allowed them to better evaluate their patients’ developmental status because children were more likely to display physical evidence of developmental milestones, like stacking blocks, speaking, or interacting socially, when comfortable. Meanwhile, some providers expressed challenges with engaging caregivers in discussions about play upon interview, which may relate to different approaches in program delivery. Indeed, caregivers were seen to engage more actively in P4P when providers modeled play during observations. In 25% (n=11) of observations, families did not play with the P4P kit, and of those visits, 82% (n=9) did not have providers model play, which may have impacted caregiver engagement.

Facilitation strategies. Several subthemes related to facilitation strategies inductively emerged relating to the usefulness of the program for developmental conversations and the importance of organized systems for implementation.

Usefulness for developmental conversations. Providers appeared more willing to carry out the intervention if they recognized the importance of play in development and how P4P could be used as a complementary tool to support development. For example, providers reported often using the kit to observe how their patients engaged with the bricks to understand their developmental stage.

Organized implementation systems. Established processes, like electronic health record (EHR) tracking, workflows, and storage plans, facilitated P4P implementation. Those with established implementation systems and strategies were observed to be more likely to model play and discuss multiple benefits of play. In contrast, interviewees reported challenges with implementation when organizational systems were not clear, with others noting concerns about remembering to track kit distribution in the EHR. The importance of these organizational systems was further reflected in open-ended comments in the staff survey, with respondents expressing several challenges they faced in delivering P4P kits when organizational systems were not in place, like “Making sure each patient who qualifies for a kit gets identified” and “Running out of P4P kits.”

This study is the first to conduct a process and outcome evaluation of P4P across multiple FQHCs. Contrary to expectations, P4P did not alter caregiver views and behavioral intentions towards play. However, results consistently demonstrated that P4P can be implemented as designed within safety-net settings and is viewed as acceptable among providers and clinic staff, making it a feasible program to deliver among under-resourced families.

Results show that, even before exposure to P4P, caregivers report positive views of and a high investment in playing with their child. This finding is consistent with prior qualitative research among low-income families demonstrating that parents view play favorably and report a strong desire to encourage their child’s developmental skills through play [32]. Given that caregivers enter the program already liking and wanting to play with their child, it is unsurprising that P4P did not impact these particular outcomes as there was already little room for improvement. Nevertheless, it is encouraging that caregiver beliefs and motivations align with the goals of P4P. Developing a program that is acceptable to its target audience is necessary for any healthcare intervention to be effective [33], with behavior change theories purporting that individuals are more likely to follow intervention recommendations when they agree that the issue being addressed is important and are intrinsically motivated to engage in the suggested behavior [34, 35]. The P4P program thus has a high likelihood of being acceptable to caregivers and is well-positioned to influence their play behaviors. With regard to program acceptability, clinic observations in our sample showed that caregivers positively received the program overall, which was further corroborated during staff interviews. However, we did not evaluate whether the positive feelings and motivations towards play reported by caregivers translated to actual play behaviors. Thus, future work is needed to understand if the messaging of P4P promotes increased play behaviors between caregivers and their children to better understand program effectiveness.

This research provides further support for the fidelity and feasibility of delivering P4P in FQHC settings. Completion of the P4P training increased the number of providers integrating play conversations into their standard practice, with a majority of these providers successfully discussing the key role play has in child development while modeling play using the P4P kit. Importantly, given the competing demands and time constraints faced by providers during routine WCCs [36, 37], the simplicity of the program was viewed as an important strength, with the average length of the intervention taking less than 3 minutes to deliver. Although this timing may be concerning for providers who are already overburdened with long checklists to complete during short visits, providers were widely observed to integrate P4P messaging into their usual anticipatory guidance, meaning that part of these 3 minutes often included conversations providers would typically have as part of standard well-child care. It is also worth noting that observer effects may have led providers to spend more time discussing P4P than they would have if research staff were not present [38], which may have artificially inflated the length of intervention delivery beyond what would be expected under normal circumstances. Regardless, most providers reported feeling that P4P was easy to implement without being overwhelmed by additional demands on time.

In line with previous research examining facilitators of intervention uptake in primary care settings [39], several additional implementation moderators were found to support P4P delivery, including adequate training, the relevance and customizability of the program, patient responsiveness, and the presence of established implementation procedures (e.g., workflows). Perhaps most importantly for long-term program success [39–42], we also found high provider and staff buy-in, with the vast majority of respondents reporting that they found the program both enjoyable and valuable. Importantly, when these implementation strategies and facilitators were not present, challenges with program delivery were noted. For example, patient engagement was observed to be lower when providers did not adhere to recommendations to model play with their patients, and providers reported poorer adherence to the program when their organization did not have a system to support its implementation. Thus, the success of P4P appears to be enhanced when participating organizations provide the infrastructure to support its implementation and the program guidelines are adhered to during delivery.

This research had several limitations. First, response rates to the caregiver survey were low and may be subject to social desirability or selection bias. For example, it could be that only caregivers with a strong interest in play elected to participate in surveys, which may have led to more positive views of and higher behavioral intentions towards play in our sample than is true of the larger caregiver population. Second, providers and families may have experienced an observer effect during clinic observations and altered their behaviors to appear more favorable to program fidelity and acceptability. Indeed, results from anonymous staff surveys showed that implementation fidelity was lower than that shown in observations. Finally, several aspects of this research limit its generalizability, including that it was conducted in FQHCs with a caregiver sample largely comprised of Hispanic/Latine patients who identified as women and reported Spanish as their preferred language. Thus, these findings may not replicate in other health care systems or among other populations of caregivers. Despite these limitations, this study had several notable strengths, including the use of a quasi-experimental design to assess program outcomes in a language-diverse sample of caregivers as well as a mixed-methods process evaluation that incorporated a comprehensive implementation fidelity framework [28, 29] to assess program delivery across multiple, geographically diverse FQHCs.

Although future work is needed to better quantify the effectiveness of P4P on caregiver outcomes, this research provides important evidence that P4P can be implemented during WCCs in safety-net settings. Unlike previous play-promotion interventions developed for under-resourced families [15–19], P4P has the potential to reach a larger number of children through routine well-child care. Estimates suggest that over half of children, including those who are uninsured or come from families with low incomes, attend their 18-36-month WCCs [22, 23], giving P4P a unique opportunity to help fill the gaps in play disparities by encouraging play in all families through pediatric and primary care offices across the country.

Ethics approval and consent to participate

All study procedures were approved by the Community Health Center, Inc. Institutional Review Board (#1196).

Consent for publication

All participants provided verbal consent prior to participating in the study procedures.

Availability of data and material

The datasets supporting the conclusions of this article will be made available upon reasonable request to the corresponding author.

Competing interests

This work was funded by The LEGO Group, who sponsors the Prescription for Play program. The LEGO Group was not involved in the research activities described in this manuscript. The LEGO Group had no influence in the data analysis, reporting, or writing of this manuscript. The results reported herein do not necessarily reflect the views held by the LEGO Group.

Funding

This work was funded by a grant through The LEGO Group.

Authors' contributions

ML oversaw funding acquisition. MO, SAB, LG, and PR were involved with study conceptualization, methodology, and data curation and analysis. MO prepared visualizations of the data. RLET supervised all research activities. HCC, RWG, SA, KN, JE, and JLS contributed to project administration and supervision of data collection at their organizations. RLET wrote the original draft and all authors critically reviewed and edited the final version. All authors approved of the submitted version of the manuscript.

Acknowledgements

The authors would like to acknowledge the contributions of the participating organizations, clinic staff, and caregivers, without whom this research would not be possible.

Author’s information

Not applicable.

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Competing interest reported. This work was funded by The LEGO Group, who sponsors the Prescription for Play program. The LEGO Group was not involved in the research activities described in this manuscript. The LEGO Group had no influence in the data analysis, reporting, or writing of this manuscript. The results reported herein do not necessarily reflect the views held by the LEGO Group.

Prescription for Play: A process and outcome evaluation of a play promotion intervention in federally qualified health centers

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Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Methods

Research sites

Prescription for Play program

Procedures

Outcome Measures

Process Measures

Analysis

Results

Discussion

Declarations

References

Additional Declarations

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Version 1