Developing an Implementation Strategy for Post-concussion Communication With Low Health Literacy Parents in the Emergency Department

Study Overview
=================
Brief Summary
-----------------
Investigators will conduct a hybrid implementation-effectiveness evaluation of an implementation toolkit that supports communication with families post-concussion in the emergency department. Primary outcomes will be parent self-report of specific concussion management behaviors two weeks post-visit. Investigators will also explore whether successful implementation is associated with (1) improved parent knowledge and self-efficacy related to helping their child adhere to CDC guidelines for returning to daily activities, school and sports, and (2) decreased disparity in knowledge and self-efficacy between high and low health literacy parents.

Detailed Description
-----------------
Parents can play an important role in evidence-based concussion management by (1) monitoring their child's activity and level of stimulation, (2) communicating with school personnel about potential need for short-term academic accommodations, and (3) ensuring their child does not return to contact or collision sport prematurely and risk greater injury. However, not all parents follow these evidence-based guidelines, in part due to health literacy deficits, and further compounded by the poor fit and inconsistent implementation of educational materials. The initial medical encounter following a concussion provides an important opportunity for evidence-based knowledge translation to parents. Families at risk of low health literacy most often seek initial post-concussion care in emergency departments (ED) and often do not follow-up with a primary care provider or concussion specialist. Knowledge translation to parents in the ED is often inconsistent in terms of content and delivery, and existing approaches often do not meet the needs of families with low health literacy. The Agency for Healthcare Research and Quality's (AHRQ) Re-Engineered Discharge (RED) Toolkit provides an evidence-based approach to supporting the implementation of parent education that has not as yet been adapted for use post-concussion in the ED setting. Investigators will work with stakeholders to develop toolkit to support evidence-based parent education post-concussion in the ED. Guided by the Consolidated Framework for Implementation Research, investigators will adapt the AHRQ RED Toolkit to facilitate post-concussion parent education in the ED. The evidence-based parent education to be shared will be an asynchronous text-based intervention, adapted to meet learning needs of parents with low health literacy and limited English proficiency. Investigators will use parent and provider interviews to iteratively develop the implementation toolkit in consultation with an advisory board comprised of parents. The clinical trial component of the study will be a hybrid implementation-effectiveness evaluation of the educational intervention. Primary outcomes will be parent self-report of specific concussion management behaviors two weeks post-visit. Investigators will also explore whether successful implementation is associated with (1) improved parent knowledge and self-efficacy related to helping their child adhere to CDC guidelines for returning to daily activities, school and sports, and (2) decreased disparity in knowledge and self-efficacy between high and low health literacy parents. Achieving these aims will result in a scalable approach to the implementation of the developed parent education toolkit in the pediatric ED post-concussion. If parents are better able to follow evidence-based guidelines for concussion, they will better advocate and care for their children, and this should improve outcomes for all youth. More broadly, achieving these aims will provide a model for engaging low health literacy parents in adapting evidence-based educational practices for implementation in ED settings.

Official Title
-----------------
Developing an Implementation Strategy for Post-concussion Communication With Low Health Literacy Parents in the Emergency Department

Conditions
-----------------
Concussion, Brain

Intervention / Treatment
-----------------
* Behavioral: Post-concussion education for families


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion criteria: Parent/guardian of a child between the ages of 5 and 17 who presented to the Seattle Children's Hospital Emergency Department and was treated for closed head injury. Child for whom care was sought was not admitted for inpatient care Parent/guardian of child without chronic disease or with non-complex chronic disease Parent/guardian with a preferred language for medical care of English or Spanish Parent/guardian present in the ED is child's legal guardian

Ages Eligible for Study
-----------------
Minimum Age: 5 Years
Maximum Age: 17 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Sequential Assignment
Interventional Model Description: Consecutive cohort design with randomization
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Education as usual<br>Participants receive education/healthcare provider communication as usual during their visit to the ED for concussion care. | |
| Experimental: New education<br>Participants receive the newly developed educational toolkit | Behavioral: Post-concussion education for families<br>* An educational resource for families will be developed based on the CDC guidelines for returning to daily activities, school, and sports, adapted with stakeholder feedback to meet the learning needs of low health literacy parents. An implementation toolkit will be developed, adapting the AHRQ RED Toolkit, to support communication about the educational resource and other best-practices for communication with families, including low health literacy families.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in concussion management behavior | Parent self-report of specific concussion management behaviors in the home setting (monitor child's symptoms/functioning, contact medical provider when appropriate, interface with school personnel about academic accommodations, prohibit activities with risk of contact or collision until child has obtained medical clearance, discuss return to sport decision with child). | Two weeks post-visit | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in concussion management self-efficacy | Self-report survey of parent confidence in their ability to engage in specific concussion management behaviors in the home setting (monitor child's symptoms/functioning, contact medical provider when appropriate, interface with school personnel about academic accommodations, prohibit activities with risk of contact or collision until child has obtained medical clearance, discuss return to sport decision with child). | Immediately post-visit | 
| Change in concussion knowledge | Self-report survey of parent knowledge about the benefits of engaging in specific concussion management behaviors in the home setting (monitor child's symptoms/functioning, contact medical provider when appropriate, interface with school personnel about academic accommodations, prohibit activities with risk of contact or collision until child has obtained medical clearance, discuss return to sport decision with child). | Immediately post-visit, two weeks post-visit |