A home-video method to assess infant gross motor development: parent perspectives on feasibility

In recent years, the necessity of multiple testing to monitor infant motor development adequately has been stated in several studies [1‐4]. The use of home videos made by parents could be a way to fulfill this need as it reduces the overall burden of traditional testing on infants and parents. The availability of the Internet and digital cameras, important conditions, seem to have been met, for 98.7% of persons between 25 and 45 years use a smartphone in the Netherlands (Statline, 2018) [5].

For this reason, we developed and validated a home-video method which enables professionals to evaluate gross motor performance with the Alberta Infant Motor Scale (AIMS) [6], a valid and reliable assessment tool for infants (0–19 months) [7‐10]. An important advantage of this assessment tool is that it evaluates spontaneous motor behavior and requires minimal handling. The home-video method allows parents to record their child’s motor behavior at home and at a convenient time, which increases the chance that the infant will show optimal motor performance [6]. Parents make a home video of their baby, guided by instructions (Additional file 3). Then, they can upload the videos from their smartphone or camera through a computer to a web application which was specifically designed for this purpose. The videos are stored after encryption, with individual encryption keys assigned to each participant. The server has been tested successfully with a high-level security scan by both the institutional security office and an independent outside security office. A Pediatric Physical Therapist (PPT) can then observe the videos and assess the infants’ gross motor development with the AIMS. Unlike a visit to an outpatient clinic, time and geographical distance are no longer barriers [9]. Figure 1 provides a detailed description of the home-video method.

Lately, the use of home videos made by parents to assess or evaluate development has been the subject of several studies [11‐15]. Libertus et al. successfully used Skype and FaceTime to assess infants’ early motor skills [13]. Using this method, the digital live connection with parents provided the opportunity to guide parents during the assessment. Although the study stated that using parents in the role of experimenter could lead to increased assessment variability, overall the conclusions on the feasibility for parents were positive. A pilot study by Ricci et al. on the feasibility of filming the General Movements Assessment (GMA is a 3-min video of the infant’s spontaneous movements in supine position) by parents at home after Neonatal Intensive Care Unit discharge showed a less positive outcome [14]. During this pilot, parents experienced major problems recording and sending accurate videos. Therefore, the clinical feasibility of providing adequate home videos made by parents could not be determined. Recently, Spittle et al. launched the Baby Moves Application for parents to record GMA [12]. The usability of the app and the engagement of 451 parents was evaluated by Kwong [15]. This population-based study included 226 infants born extremely premature or with an extremely low birthweight and a control group of 225 term born infants. Overall, positive results on the usability of the application are reported, most parents were able to successfully capture their infant’s movements with the app. All studies carried out so far focus on the practical feasibility of the use of home videos in assessments.

The uniqueness of the AIMS home-video method lies in the fact that parents have a leading role in executing the first part of the assessment, capturing gross motor performance. Apart from the instructions, parents do this on their own. Because most e-Health innovations do not make it to implementation in clinical practice [16], the feasibility of the home-video method for parents needs to be considered carefully [17, 18]. It is important to gain insight into (1) how parents evaluate the practical aspects of the home-video method, and (2) the new role they have in the assessment [17, 19]. Examining these aspects with parents of typically-developing (TD) infants is a first step in our ongoing research project. Parents of infants at risk, using the home-video method, are the ultimate target population.

Thus, the overall objective of this study was to evaluate the feasibility of the AIMS home-video method for parents of TD infants, born at full term and between the ages of 1.5 to 19 months, from the parents’ perspective. In this study, feasibility was defined according to Karsh as ‘the extent to which an innovation can be successfully used or carried out within a given setting’ [18]. According to this construct, we formulated two research questions: (1) how do parents evaluate the practical aspects of the home-video method? and (2) how do parents feel and what do they think about this new method of assessment?

Although 59 parents provided informed consent, 45 participated in the pilot study. Parents who did not send in home videos were approached by telephone to inquire about the reasons for not participating. Reasons for dropping out were: 1) the baby was unexpectedly born prematurely or pathology became evident shortly after birth (n = 2); 2) parents reported that in retrospect they were too busy to participate (n = 11); 3) frequency of filming was too high (n = 1). Participating parents were residents of 8 of the 13 different provinces in the Netherlands. In total, 45 questionnaires were returned before the start of the study. Following the period of recording the five home videos, 34 surveys were returned (T1; response rate 76%). Table 1 shows the characteristics of participating parents at T0. From this group, 10 parents were approached for an interview. In two cases, parents were unable to schedule an appointment in the allocated period; the other eight parents agreed to an interview.

After analyzing both quantitative and qualitative outcomes, the final thematic framework comprised two main themes: 1) feasibility of the home-video method, in which we combined both quantitative and qualitative data to gain insight into the extent that parents can carry out the home-video method successfully, and 2) parents’ feelings and thoughts that accompany the use of the home-video method. These results were mainly inductive qualitative outcomes.

The findings are structured according to the process of making the home video: reading the instructions, planning when to make the recording, recording the home video, uploading the home video, and receiving feedback. First, the quantitative data are presented; next, the qualitative data are used to set the context and to clarify the quantitative findings. In Table 2, the quantitative outcomes are shown and in Fig. 3 the qualitative findings are summarized and visualized.

The present study explored the experiences of parents in using a home-video method to assess their infants’ gross motor development. Overall, parents were positive about the practical feasibility of the home-video method. They reported that the recordings were easy to do and that the handling of the baby was mostly as in daily routines. Several barriers were identified in this study. The main barrier reported was time planning. A second barrier concerned technical problems with the web portal, which sometimes made uploading the home-videos time consuming. According to parents, positive factors of this home-video method were (1) that the home videos were valuable for family use, (2) that receiving feedback from a professional about infants’ motor development was welcome, and (3) that it was fun to interact with their babies in a different way and to have a moment of one-on-one-attention. Moreover, the instructions and home video recording resulted in an increased parental awareness of, and insight into, the gross motor development of their infants. The feelings and thoughts parents expressed about their new role were both positive and negative. In some cases, parents expressed their uncertainty about the motor performance of their child or about the video recordings. Parents also reported joyful feelings about the interaction they had with their baby while making the home videos. In addition, most parents appreciated the feedback on the motor development of their child which they found reassuring.

For future application, it is important to address all barriers identified in this study [19]. Time planning is mentioned most explicitly: parents were hard pressed to find a moment when they both were at home and their baby was in the proper state to show optimal motor behavior. During the study, some parents found a solution to the logistics: by positioning their phone on the table or floor, they managed to record and handle their infant at the same time.

From the results, we can conclude that a functional and user-friendly digital application is an absolute prerequisite for successful implementation of this method. This is exactly in line with the conclusions of Ricci et al. [14]. The main barrier they described was the use of an encrypted server with very high protection levels, obligated because the home videos were considered to be personal health information. In this study, the server was security tested and found to be compliant to relevant laws (NEN 7510/7512/7513 norms). The encryption of data while uploading is important to ensure safety but as a consequence the uploading was sometimes time consuming. This was also the case for the assessors while downloading and decrypting the video data. Both aspects limit feasibility and should be addressed. A satisfactory compromise between functionality and safety in the development of health care applications seems an important step towards successful implementation in practice.

In addition, in the development and use of digital communication means, the privacy of parents and infants is considered to be very important [29]. In our study, privacy issues did not emerge as a significant theme. Perhaps digital privacy is not an important issue for all parents. Ricci et al. [14] reported that, because of the problems uploading the videos, many parents offered to share the home videos on open platforms like Facebook or WhatsApp. In our study we had similar experiences. This might also be in line with the findings of Hassol and colleagues, who reported that only a minority of patients was concerned about the privacy of their electronic health care record [30]. However, a self-selection bias may have occurred in the privacy aspect. Parents with explicit ideas on privacy regarding video material of their child may have decided not to participate in the present study from the start.

Libertus and Violi, who used Skype as a means of collecting developmental data, suggested that access to the Internet and digital equipment could also be a constraint for parents’ participation in these kind of research projects [13]. In our homogeneous sample, all parents had access to the Internet and a smartphone. According to Statistics Netherlands, over 98% of persons aged 25–45 years have access to the Internet and almost 95% own a smartphone [5]. These high percentages lead us to believe this aspect unlikely to be a limiting factor for participation in our study.

Only a few studies describe the feasibility of digital screening methods for parents at home [11, 13‐15, 24]. Besides, every method has its own specific features which affect parental experiences and thus feasibility in different ways. The evaluation of the usability of the Baby Moves app shows that most parents successfully used the app to record their baby’s movements [15]. However, because the AIMS home-video method is more demanding for parents, it is questionable whether these results can be applied to the AIMS home-video method. Our positive findings on the feasibility of the AIMS home-video method are more comparable to a study on a video-based evaluation tool for children with Rett syndrome [11]. In this study, outcomes on feasibility were positive, despite the fact that parents had to follow quite extensive instructions to record multiple abilities and interactions. Furthermore, these authors reported benefits from recording the child in a familiar setting. We think this aspect also applies to a large extent to the AIMS home-video method. On most home videos, infants’ state was suitable for testing. When assessing motor development from the recordings, it was seen that the infant didn’t have to adapt to a new environment, strange people or a set appointment time, which is the case when the infant is seen in a PPT practice or hospital outpatient clinic.

Although some parents reported that their child did not always show optimal motor performance on the home videos, we speculate that this might be overstated. The importance parents placed on their child’s showing optimal motor performance on the home video might sometimes have resulted in a more negative perception of the child’s performance. For example, if an infant had shown rolling over from supine to prone for the first time just before the recordings, it is quite likely not to be shown in the home video, and parents could feel disappointed about this. For a professional assessing the home video, not seeing the infant rolling over would not necessary influence the validity of the assessment; rolling over might just not yet be in the infant’s motor repertoire.

An important finding of this study is the teaching effect the AIMS home-video method potentially has. The method requires active parental involvement which can lead to a better understanding of the infant’s motor development [31, 32]. Parents with an infant at risk for delay might especially benefit from this knowledge. It might help them to become ‘their child’s expert’ even more and as such improve equality in shared decision-making between parents and professionals [33].

The present study provides evidence that the AIMS home-video method is feasible for participating parents regarding both practical aspects and the understanding of their task. Most identified barriers reported by parents have a practical nature that can be addressed in future applications. The home-video method has the potential to become a valuable E-health addition for both research and PPT practice to monitor infants at risk of developmental motor delay in their own familiar environment.

More research is needed to explore if these findings are applicable to parents with different backgrounds and to parents of infants at risk. How will these parents experience a more explicit role in the assessment of their child’s risk for a delay in motor development? Will the active involvement of parents indeed lead to increased awareness and knowledge of motor development? In short, can the AIMS home-video method become more than just a means and become a tool to empower parents who have an infant at risk of developmental delay?