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O C U S
ABSTRACT
Premature infants are at increased risk for poor health, feeding difficulties, and impaired mother-infant interaction,
leading to developmental delay. Social-environmental risks, such as poverty or minority status, compound these
biological risks, placing premature infants in double jeopardy. Guided by an ecological model, the Hospital-Home
Transition: Optimizing Prematures Environment intervention combines the auditory, tactile, visual, and vestibular
intervention with participatory guidance provided by a nurse and community advocate to address the impact of
multiple risk factors on premature infants development.
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Keywords
developmental intervention
ecological model
health disparities
home visitors
multiple socialenvironmental risks
premature infant development
Correspondence
Rosemary White-Traut,
PhD, RN, FAAN,
University of Illinois at
Chicago, College of
Nursing (MC 802), 845
South Damen Avenue,
Chicago, IL 60612-7350.
rwt@uic.edu
The authors and planners
for this activity report no
conflict of interest or
relevant financial
relationships. The article
includes no discussion of
off-label drug or devise use.
Rosemary White-Traut,
PhD, RN, FAAN, is a
professor and the head of
the Department of Women
Children and Family Health
Science, the University of
Illinois at Chicago, College
of Nursing, Chicago, IL.
(Continued)
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& 2009 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses
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Parenting Difficulties
High maternal anxiety and/or depression are related
to diculty in parenting, negative mother-infant
interaction, and poor child health and development
(Carter, Garrity-Rokous, Chazan-Cohen, Little, &
Briggs-Gowan, 2001; Crittenden, Kim, Watanabe,
& Norr, 2002; Feldman & Eidelman, 2003; Petterson
& Albers, 2001; Pridham, Lin, & Brown, 2001; Singer
et al., 2003). Repeated negative perceptions of
the infant can further limit a mothers capacity to
respond appropriately, thus disrupting the development of appropriate mother-infant interactions
(Coyl, Roggman, & Newland, 2002; Pridham et al.).
Over time, lack of responsivity, sensitivity, maternal
growth fostering, and contingency behaviors during interactions lead to poorer infant growth and
development (Feldman & Eidelman, 2006; Feldman
et al., 2004) and continued perception of child vulnerability (Miles & Holditch-Davis,1997).
Contingency behavior is the ability of the mother
and the infant to change their behavior based on
the partners response during an interaction. Contingency allows the infant to learn about his/her
environment and how to interact with it and to learn
about predictability and the relationship of environmental stimuli to their behavior (Blackburn, 1983).
Contingency behaviors during intervention is a favorable approach because it provides opportunities
for infants to interact with their environment, learn
about predictability and the relationship of environmental stimuli to their behavior.
Mother-Premature Infant
Interaction Difficulties
Kathleen Norr, PhD, is a
professor in the Department
of Women Children and
Family Health Science, the
University of Illinois at
Chicago, College of
Nursing, Chicago, IL.
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Multiple Social-Environmental
Risks Compound the Need for
Intervention
A strong body of research has linked maternal,
familial, and neighborhood social-environmental
risk factors with less optimal early health and development, more behavioral problems, and lower
achievement. The impact of these risk factors on infant development is magnied in premature infants
(Bendersky & Lewis, 1994; Bradley et al., 1994;
Burchinal et al., 2006; Malat et al., 2005; McGauhey,
Stareld, Alexander, & Ensminger,1991; Murry et al.,
2004). For example, premature infants reared in
poverty have three times the rate of school failure
than children from high-income families, while fullterm infants reared in poverty have only twice the
rate of school failure (McGauhey et al.). Bradley
and colleagues classic study examined performance in growth, health, and cognitive and social
development and found only 26 (11%) of 243 3year-olds born prematurely and living in poverty
functioned in the normal range for all four of these
outcomes.
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Hospital-Home Transition:
Optimizing Prematures
Environment (H-HOPE)
Intervention
To address the issues identied in previous
research, the authors developed the H-HOPE Intervention for mother-premature infant dyads. This
intervention is unique because it provides an integrated approach that addresses three gaps
identied in previous research. The target group for
the intervention is mother-premature infant dyads
at high risk of suboptimal outcomes who seldom
receive intervention. The time of the intervention
focuses on a critical transition period for the motherpremature infant dyad. The content of the intervention simultaneously addresses both the infants
and mothers needs.
Target Group
The target group for the H-HOPE Intervention is
mother-premature infant dyads where the infant is
born between 29 and 34 weeks gestation without
serious complications. These mother-infant dyads
also have two or more social-environmental risk
factors identied in previous research as being associated with negative outcomes (Samero et al.,
1987). While otherwise healthy premature infants
born at these gestational ages are capable of
normal development, when multiple social-environmental risk factors are present, premature infants
are at high risk for suboptimal growth and developmental problems (Bradley et al., 1994; McGauhey et
al., 1991;Samero et al.). This group is especially
likely to benet from early intervention, but currently few interventions are tailored to their specic
needs.
Timing
The H-HOPE intervention is provided from 32 to
34 weeks gestational age through 4 weeks corJOGNN 2009; Vol. 38, Issue 4
Content
The content of the H-HOPE Intervention, based on
Sameros Transactional Model, integrates two
dierent, early interventions into one to provide remediation for the infant and redenition and
re-education for the mother using visits by a NurseCommunity Advocate Team (NAT) (a registered
nurse and a trained community member, called a
health advocate). Both interventions have been
documented to be eective in previous research. A
developmentally specic multisensory intervention,
the auditory, tactile, visual and vestibular intervention (ATVV) provides infant remediation (Burns et
al., 1994; Nelson et al., 2001; White-Traut & Nelson,
1988; White-Traut et al., 1987, 1997; White-Traut, Nelson, Silvestri, Vasan, Littau et al., 2002) and is easily
learned by mothers and nurses. The ATVV was developed over the last 20 years by the rst author.
Participatory guidance oered by the NAT provides
redenition and re-education for the mother
(Barnes-Boyd, Norr, & Nacion, 1996; Barnes-Boyd,
Norr, & Nacion, 2001; Nacion, Norr, Burnett, & Boyd,
2000; Norr et al., 2003).
Infant Remediation
The ATVV intervention is a 15 minute, multisensory
intervention that incorporates the interactive behaviors of mothers and infants (Figure 1). The rst
part of the ATVV intervention consists of auditory
stimulation. A soothing, female voice is presented
to the infant for a minimum of 30 seconds, using
infant-directed speech to alert the infant to the
presence of the caregiver. The infant-directed
speech continues throughout the 15 minute inter483
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Premature infant
Remediation
through a
developmentally
specific multisensory
intervention
(ATVV intervention)
H-HOPE
Redefinition
and Re-education
for mothers
offered by a nurse
and trained
community
member
(NAT participatory
guidance)
safety, and assesses the mothers stressors, supports, and signs of depression. At each home visit,
the nurse observes administration of the ATVV and
a feeding and gives participatory guidance regarding the contribution of mother and infant to the
interaction, infant behavioral state and cues, and
the mothers use of soothing behaviors (redenition
and re-education) (Sumner & Spietz, 1994). Each
mother receives two in-hospital visits and two home
visits, one within the rst 2 days after infant discharge to home and the second after the infant
has been home for 2 weeks. A telephone contact is
made after each home visit.
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H-HOPE Outcomes
Costs
Earlier hospital discharge
Fewer clinic and emergency department visits
Decreased costs for later health care and special education
Figure 2. Anticipated outcomes of the H-HOPE intervention
Implications
Prematurity extracts a high cost on infants, families,
and the nation. Approximately half a million premature infants are born each year in the United States,
and the national prematurity rate of 12.5% has not
declined over the last 20 years (Martin et al., 2006).
Moreover, there are signicant racial health disparities associated with prematurity. The rate of
premature birth among African Americans is
17.9%, while the rate of premature birth among
Whites is 11.5% (Martin et al.). Most premature infants require an expensive and lengthy hospital
stay, presenting signicant economic costs to their
families and society.
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Acknowledgments
Funded by the National Institute of Child Health and
Development and the National Institute of Nursing
Research, Grant 1 R01 HD050738-01A2 and the
Harris Foundation.
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Learning Objectives
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18. What are the three strategies that guide intervention in the Transactional Model?
a. Infant feeding, maternal remediation, and maternal teaching.
b. Infant remediation and maternal redenition
and re-education.
c. Maternal anticipatory guidance, participatory
guidance, and infant redenition.
19. The H-HOPE Intervention
a. is best provided in the home.
b. reinforces the mothers ability to decide the
best stimulus for her infant.
c. targets critical transitions for the premature
infant.
20. The H-HOPE Intervention may lead to the
following outcome:
a. decrease in the rate of premature births.
b. earlier discharges for premature infants.
c. improved school performance for premature
infants.
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