The NeuroSense PremmieEd Parenting Educational Intervention (PremmieSense) - a neuroprotective intervention for preterm infant-parent dyads: Reported using the TIDieR framework

The NeuroSense PremmieEd Parenting Educational Intervention (PremmieSense) - a neuroprotective intervention for preterm infant-parent dyads: Reported using the TIDieR framework | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The NeuroSense PremmieEd Parenting Educational Intervention (PremmieSense) - a neuroprotective intervention for preterm infant-parent dyads: Reported using the TIDieR framework Welma Lubbe, Kirsten A Donald This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6704844/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Preterm birth affects approximately 10% of births globally, placing infants at risk for neurodevelopmental delays, and exposing parents to stress and disrupted bonding. Parent education in neonatal intensive care units (NICUs) is a key intervention that supports neuroprotection and enhances parent-infant synchrony. While such interventions show promise, their contextual fit in low-resource settings like South Africa requires further evaluation. The NeuroSense PremmieEd Parenting Educational Intervention (PremmieSense) aims to promote neuroprotective care and strengthen parent-infant bonding during NICU admission. The intervention includes a picture-based booklet (in English and Setswana) and structured, group-based sessions delivered by trained healthcare professionals. Sessions are flexible in number and focus, tailored to maternal needs and logistical constraints within public hospital settings. Objectives: To describe the NeuroSense PremmieEd Parenting Educational Intervention (PremmieSense) using the Template for Intervention Description and Replication (TIDieR) framework, with reference to its alignment with established components of effective NICU-based interventions for parents of preterm infants and with consideration of parental expectations. Methods: The TIDieR matrix guided the structured reporting of the programme’s development, rationale, content, and delivery approach. Results: PremmieSense demonstrated feasibility and acceptability in low-resource South African NICUs. Delivered shortly after NICU admission, the programme provided practical, culturally sensitive content and was supported by trained facilitators. Parents reported improved knowledge of preterm infant behaviour (assessed via the Knowledge of Preterm Infant Behaviour (KPIB) scale), reduced stress (assessed via the Parental Stress Scale: NICU (PSS:NICU)), greater confidence, and improved responsiveness to infant cues. Despite challenges such as early discharges and limited staff, the intervention was well received and adaptable. It supported early neural synchrony, parent-infant bonding, and smoother transitions to home care. The TIDieR framework enhanced transparency and fidelity, supporting potential replication. Conclusions: This paper presents the PremmieSense parenting programme using the TIDieR matrix to promote clear reporting, replication, and implementation. Findings suggest its potential value for improving parent and infant outcomes in NICUs, especially within low-resource contexts. Trial registration: Not applicable. Programme development preterm infant parent education interventions programmes neuroprotection neural synchrony TIDiER Figures Figure 1 Figure 2 CONTRIBUTIONS TO LITERATURE Describes a context-specific parenting education programme for preterm infants in South African public-sector NICUs, addressing a gap in neuroprotective care in low-resource settings. Demonstrates how picture-based materials and group sessions, delivered in local languages, can support parent-infant bonding and reduce stress during hospitalisation. Provides a replicable, low-cost model that can be delivered by trained healthcare professionals without formal certification. Highlights the importance of co-design with parents and integration of user preferences in intervention development. Uses the TIDieR framework to enhance transparency, supporting reproducibility and adaptation in other low- and middle-income settings. INTRODUCTION Rationale for the programme In 2020, preterm birth accounted for 9.9% of all births globally, with an estimated 13.4 million preterm births ( 1 ). Southern Asia and sub-Saharan Africa account for 65% of these cases ( 1 ). While in South Africa, the preterm birth rate was 13%, making it the country with the fifth-highest rate of preterm births ( 2 ). These infants are at risk for short- and long-term adverse effects, including physiological challenges ( 3 ), medical conditions ( 4 ), sensory and behavioural challenges ( 3 ), and altered neurological and visual development ( 5 ). Adverse effects on parents include experiences of guilt, anxiety, loss and grief ( 3 , 6 ), anger and depression, hostility, and fear, in addition to high stress levels ( 7 ) and dysfunctional parenting ( 3 ). Furthermore, parents may experience shock due to the potential critical condition of both the mother and/or baby, making preterm birth a highly stressful or even traumatic event for them ( 8 ), and an experience that has the potential to impair the relationship with their baby. In addition, infant-mother separation may lead to toxic stress in infants, with negative effects on both short- and long-term developmental outcomes ( 9 ). Various in-hospital, multimodal developmental-care programmes have been developed and described in literature. Examples include programmes such as the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) ( 10 ), Implementation of Neurodevelopmental Supportive Care Programme (INDeSC) ( 11 – 13 ), Wee Care Neuroprotective NICU Program (Wee Care) ( 14 ), The Family and Infant Neurodevelopmental Education (FINE) ( 15 ), and The Consensus Committee of the Standards, Competencies and Best Practices for Infant and Family-Centered Developmental Care in the Intensive Care Unit (IFCDC Consensus) ( 16 ). NIDCAP, Wee Care and IFCDC originated in the United States and expanded to other countries, while FINE is rooted in the United Kingdom and INDeSC in South Africa. These are all complex, multi-layered, often unit- or organization-wide intervention programmes, including components such as staff training, infant support/therapy, parental support and parent education. However, a common theme across all the programmes is the family-centred approach building on the Model of Synactive Organization of Behavioral Development. This model was developed by Heidelise Als ( 10 ) to explain how an infant moves from the parental intrauterine to the parental extrauterine environment in preparation to function in the world at large. The model guides approaches to neuroprotection and development in preterm infants (see Fig. 1 ). In children born prematurely, the natural attachment process is interrupted at birth. The technologically advanced environment of the NICU, while life-saving, can inadvertently contribute to emotional and physical separation within the parent-infant dyad, potentially impairing early bonding and attachment ( 17 ). At the same time, the NICU holds critical potential to not only support infant survival ( 18 ) but, with effective NICU interventions, may also improve outcomes such as growth, early development and long-term emotional, psychosocial, and neurobehavioral health. Importantly, with the right interventions, provided at critical times, the NICU can also promote a healthy transition to parenthood by supporting parental mental health and fostering connection. Intervention programmes, specifically educational interventions, initiated in the NICU have proven potential for enhancing parent-infant relationships, supporting positive behavioural and temperament development, promoting successful breastfeeding, and contributing to early mental, neurodevelopmental and overall child growth ( 19 ). However, MacDermid ( 20 ) pointed out that education programmes are among the most poorly reported interventions, and this is even truer for parental education during the NICU stay. In order to improve understanding of the use of parent education as an intervention in the NICU, to understand current parent educational programmes, contextualize what is available, and create new, innovative educational interventions, it is critical to understand what are the components of such education programmes ( 20 ). A meta-review of systematic reviews by Puthussery et al. ( 19 ) explored the effectiveness of early intervention programmes for parents of preterm infants. Extracting from their work, the following intervention programmes included an in-hospital parent education component (one or more sessions): Creating Opportunities for Parent Empowerment (COPE), Cues Programme (CP), EI Early Intervention, Hospital to Home (H-HOPE), Mother-Infant Transaction Program (MITP) and Modified Mother Infant Transaction Programme (M-MITP), Parent-Baby Interaction Programme (PBIP), and Preventative Psychotherapy Intervention (PPI). All these interventions are delivered to individual parents, except for PPI delivery which is delivered to a group. In the South African context, the first author developed the Little Steps website in 2005 as the first accessible, evidence-based resource to support parents through their NICU journey. The content, curated from research available up to 2005 ( 21 ), was designed to meet parental educational needs in a clear, accessible and informal manner. Little Steps provided an effective tool for guiding parents through the NICU journey; however, as scientific research in the field of parenting and the importance of parenting education has evolved over the years, so too has understanding of parent education and its role in both parent and infant outcomes. Building on the foundational work established by Little Steps ( 22 – 24 ), this new programme, PremmieSense, aimed to integrate the latest scientific evidence and insights about parent education programmes in the NICU ( 25 ) and contextual input from mothers in the NICU ( 26 ) to ensure relevance and responsiveness of the educational programme specifically within the South African public sector context. METHODS Aim The aim of this paper is to describe the PremmieSense programme in detail, using the Template for Intervention Description and Replication (TIDieR) checklist (27). We describe the theoretical underpinnings and key components identified from our previous systematic review (25) and empirical study (26), as well as provide details on the programme structure and underlying parental support needs. This presentation will assist with the implementation, replication and evaluation of the programme in future. Design TIDieR is a 12-item checklist designed to enhance the quality of intervention reporting and support replicability of the intervention implementation or evaluation. It is an extension of the CONSORT 2010 statement (item 5) and the SPIRIT 2013 statement (item 11) (27). We used this matrix to report the intervention, an educational programme, and the development process, describing the rationale, development, framework, and practical provision of the PremmieSense programme. The programme outline is presented in the numerical order of the checklist in Table 1. Table 1: TIDieR items and description of the NeuroSense PremmieEd Parenting Educational Intervention (PremmieSense) Item Content Key Components of the Programme 1 Name NeuroSense PremmieEd Parenting Educational Intervention (short name: PremmieSense) 2 Why (rationale) To enhance parent education , fostering stronger parent-infant relationships, promoting positive behaviour and temperament, supporting breastfeeding, and aiding early mental, neurodevelopmental, and overall child development (19). To prevent challenges that may disrupt parent-infant bonding and secure attachment. To empower parents with essential knowledge and skills to care for their preterm infants throughout the NICU stay. To build parental confidence in interacting with their infants, including recognizing cues and providing responsive, supportive care. To create an optimal environment that facilitates neural coupling and synchrony between parents and their preterm infants, promoting healthy emotional and cognitive development. 3 What (material) Printed materials, augmented by short lectures. 4 What (procedures) Picture-based, colour printed material with concise text in English or Setswana. Structured, lecture-type group discussions to supplement the print material. 5 Who provides Healthcare professional skilled in the NICU context, knowledgeable in the neurodevelopmental supportive care model. 6 How (mode of delivery) Booklet provided for self-study. Lecture-based, small group discussion with two to four participants. 7 Where Public hospital NICU or lecture room. 8 When and how much Booklet provided on enrolment. Lecture-based sessions within one week following enrolment. At least one session. In the morning between feeding times or early afternoon. Maximum length of 60 minutes per session. 9 Tailoring Number of sessions depends on the availability of mothers to attend and availability of healthcare providers to present the sessions. Maternal needs guide the number of topics presented. 10 Modification Flexibility incorporated with consideration of individual family needs. 11 Intervention adherences Considerations on adherence of the provision of the PremmieSense programme, and a written summary. 12 How well (planned) Deviations occur when the resources and parental needs change. NICU = Neonatal Intensive Care Unit, TIDieR = Template for Intervention Description and Replication. RESULTS A parenting education programme during the neonatal unit admission period may play an important role in improving both parental and infant outcomes in the short-term as well as in the long-term, including after discharge. Parent education empowers parents to take on their parenting roles and return to the position of primary caregiver. The PremmieSense programme was initiated as soon as possible after NICU admission and demonstrated promising results. The programme is described using the TIDieR checklist ( 27 ) as a reporting matrix to ensure transparency of our educational intervention reporting ( 28 ), as shown in Table 1 . Item 1 – The name of the intervention PremmieSense is an educational intervention presented to parents while their infants are still admitted to the NICU. The education programme is based on the principles of neuroprotective care and development and aims to create sensitivity in parents about their preterm infant’s development, and as a result, empower them to fulfil the role of primary caregivers and provide sensitive and responsive parenting as early as possible during the NICU stay. Item 2 – The rationale and development An understanding of the normal physiology of the newborn infant-parent dyad and how parent education can support or restore normal physiology provides the foundation for this programme. Physiological developmental processes refer to the ‘characteristics of or appropriate to an organism’s healthy and normal functioning’ ( 29 ) and are observed in the mother-infant dyad when there is no medical interference, and the dyad is kept together to ensure zero separation while initiating immediate and continuous skin-to-skin care. Winberg ( 30 ) explained that the mother who has close body contact with her baby helps to regulate a newborn’s temperature, energy conservation, respiration regulation and acid-base balance, and improves breastfeeding. The baby also regulates the mother by increasing her attention to the newborn’s needs, breastfeeding initiation and maintenance, vagus nerve activation to ensure efficient energy use, and the release of gastrointestinal tract hormones to improve the use of ingested calories ( 30 ). In the preterm infant, this physiological development, which would be experienced in the supportive intrauterine environment and on the mother’s body, is interrupted and the immature newborn is exposed to the unsupportive extrauterine environment, where both mother and baby are deprived of normal processes to support development. Researchers have demonstrated the negative effects of infant-mother separation, leading to toxic stress with negative effects on both short- and long-term developmental outcomes ( 9 ). However, Bergman ( 31 ) reported a 25% reduction in infant mortality when immediate and continuous skin-to-skin care are practiced. The effects of some of these changes can be detected months later. A notable twenty-year follow up study by Charpak et al. ( 32 ) compared kangaroo mother care (KMC) to traditional care. The findings demonstrate that KMC has lasting positive impacts on neurodevelopment, cognitive function, and social behaviour, underscoring the long-term benefits of early skin-to-skin contact. Parental education is the first step in empowering parents to support the restoration of disrupted physiological processes. This educational intervention is designed to help parents repair the interruption in neural coupling and synchrony caused by preterm birth and the resulting separation between mother and infant—factors that contribute to stress in both parent and child. The program also seeks to reduce parental stress and enhance understanding of the infant’s needs through targeted education. The outcomes of the PremmieSense programme were formulated as follows: To enhance parent education , fostering stronger parent-infant relationships, promoting positive behaviour and temperament, supporting breastfeeding, and aiding early mental, neurodevelopmental and overall child development ( 19 ). To prevent challenges that may disrupt parent-infant bonding and secure attachment. To empower parents with essential knowledge and skills to care for their preterm infant throughout the NICU stay. To build parental confidence in interacting with their infant, including recognizing cues and providing responsive, supportive care. To create an optimal environment that facilitates neural coupling and synchrony between parents and their preterm infants, promoting healthy emotional and cognitive development. Item 3 – Informational materials Programme content. Informational materials included in the PremmieSense parenting programme consist primarily of self-explanatory, picture-based, printed materials, with concise text in either English or Setswana. The printed booklets include various topics identified in literature and supplied by mothers while in the NICU. The printed booklet contains information about the NICU and preterm infants, and the topics and sample materials are presented in Fig. 2 . The programme was presented by a healthcare professional who was familiar with the unit and had experience working in the NICU. The programme content was divided into six sections to allow for flexibility in the delivery. Depending on the needs of the group, all or only selected modules could be presented, and sessions could be split and presented based on the availability of mothers and presenters. The modules of the programme include (see Fig. 2 ): Section 1 – The NICU This section covers information on the definitions of prematurity and how the intrauterine environment should be mimicked in the NICU. It then discusses the importance of hand washing as part of infection control and uses diagrams and pictures to explain the equipment parents may see in and around their babies in the NICU. Section 2 - Parental physical and psychological changes and support provides short digestible support information which parents can consider and share with family and friends to build their support network while admitted to the NICU. Section 3 - Infant behaviour This section focuses on parent-infant interaction, starting with an explanation of the various sub-systems, calming behaviour, unpacking sleep and awake states, and concluding with stress cues parents may see in their infants. Section 4 - Infant care – handling and positive touch The first part of this section presents photos to help parents identify ways they can try to calm their babies, followed by illustrations of various positions suitable for preterm babies in the NICU, and ends with information on skin-to-skin care. Section 5 – Feeding and breastfeeding was the topic which rated the highest when identifying parental education needs. Since it can also be a more complex event, more detailed information is provided in this section. Feeding is also the one activity which the mother-infant dyad can use to apply the knowledge gathered in the previous topics. In the feeding section, information is provided about breastmilk expressing – including techniques, storing of expressed breastmilk, alternative methods to feed the preterm infant, advancing from tube-to-oral feeding, and how to assess if the infant had sufficient milk intake. Section 6 – Preparing for discharge is an important topic, especially for parents of babies who are close to discharge. However, research indicates that discharge preparation should start as soon as possible during the NICU stay. The literature has also shown that the topics to be included in discharge preparation are very similar to the topics already included in the program materials of previous sections. Therefore, this section focused on when the preterm baby could be expected to be discharged, as well as providing information on feeding advancement post discharge and information on follow-up. Programme delivery The programme was delivered in person in the NICU between feeding times, to allow mothers to attend and to spend optimal time with their babies. Mothers were informed about the study and all mothers who enrolled were provided with the educational materials in a pilot study ( 25 ). One group of mothers received only the booklet, while for another group, the booklet was augmented by brief lectures presented in a group format. Item 4 – PremmieSense procedure An important aim of the PremmieSense programme is to ensure access to information, even in resource-restricted settings, to create awareness among parents about their preterm infants’ developmental activities and how they can contribute thereto. An educational programme was selected as the intervention of choice, since education serves as a powerful, cost-effective, user-friendly tool in the NICU, and equips parents with the knowledge and confidence to get to know their infants, care for them, and actively participate in their development. Research has demonstrated that informed parents are more likely to engage in beneficial caregiving practices, such as skin-to-skin care, breastfeeding, and early developmental interventions, all of which contribute to improved infant and parental health outcomes. In healthcare settings where parental involvement is not yet well integrated as the standard of care, education can serve as a critical intervention, bridging gaps in care and ensuring that infants receive the best possible start in life. Parenting education sessions were presented by a trained facilitator, who led the group by presenting the materials for each session, and then allowed for questions and discussion within the group. The ideal is to present one session (topic) per day, every day – or at least every second day. However, due to staff restrictions in this setting, and mothers being discharged or not available to visit every day, this proved challenging. A facilitator may not always be available to provide a lecture or even bedside training in a resource-restricted setting, as care from medical and nursing staff is often triaged towards clinical-care interventions. Therefore, by providing mothers with visual materials and explanations of what they could observe in their own infants and, when possible, augmenting the material with lecture-type group discussions, mothers were empowered to take on their parenting role, activating bonding and neural-coupling that had been interrupted due to separation and stress. Item 5 – The providers The content development team comprised a professional nurse, research assistant, mother with an infant admitted to the NICU, academic expert, and master trainer of neurodevelopmental supportive care ( Little Steps for healthcare providers), who was also a qualified speech-language pathologist and audiologist. A senior researcher in the field of paediatric neuroscience, as well as an independent instructional designer completed the team. To ensure the consistent delivery of the education programme, the intervention was presented at Site A by a professional nurse familiar with the NICU context and with caring for preterm infants and also knowledgeable about the neurodevelopmental supportive-care model. She was trained in the content for this specific educational delivery by the lead researcher and provided with the same material that was given to the mothers, as well as text that could be used as a script to ensure consistent delivery across all parent groups. Importantly, the facilitator was fluent in English, Setswana and Afrikaans (the local languages of this region) and could therefore not only present the materials in all languages but could also facilitate discussions in the mother tongue of participants. At Site B, the hospital requested that social workers be trained as the educators, as they work with the preterm infant’s parents on a frequent basis. They were provided with the same training as those at Site A, spoke the three above-mentioned languages, and received the same training materials. The education focused on understanding the infant, providing appropriate interaction, integrating basic care, and being responsive rather than task-oriented. Item 6 – The delivery Mothers were presented with a printed training booklet to study in their own time, followed by a face-to-face, lecture-based group discussion at the hospital within a week. In our pilot study, only two to four mothers participated at a time in lecture discussions, which allowed for good interaction and opportunities for individual questions. Item 7 – Where the PremmieSense programme was delivered The educational intervention was developed for the public healthcare sector and piloted at the NICU of a public tertiary referral hospital (Site A) as well as at a regional hospital (Site B) in the North West province of South Africa. Mothers found it most convenient when the training was presented in a quiet area within the NICU to allow them to remain close to their babies in case they were unexpectedly needed. Item 8 – When and how much Mothers were enrolled in the programme and provided with a booklet (see Fig. 2 ) as soon as possible following their infant’s admission. The programme was intended to start as early as possible during the traumatic time of NICU admission and the initial stay thereafter, in order to support and empower parents to take on their parenting role and to connect with their infants. At least one lecture-based session was presented within one week of them receiving the booklet, at a time convenient to the mothers, which was usually in the morning between two feeds or early afternoon, when they were not at their infants’ bedside. Sessions lasted a maximum of 60 minutes each and focused on the needs identified by the group attendees. Mothers could attend any or all topic discussions (refer to Item 3, Table 1 ) based on their individual needs. Item 9 – Tailoring of PremmieSense Although the sessions were designed to follow the chronological development and experience in the NICU, the programme was dynamic in nature, and sessions could follow a different organization and consist of any variety of topics, or only a few selected topics, depending on the mothers’ needs. Item 10 – Modifications of the PremmieSense programme The original programme design, informed by international literature ( 25 ), recommended a minimum of three educational sessions lasting 60–120 minutes each, delivered by trained healthcare professionals who are permanent staff in the unit. However, consistent with the findings of Helmer et al. ( 33 ), the number of sessions was reduced due to limited bed availability. High patient turnover in the NICU led to the early discharge of preterm infants to make room for more critically ill babies, often before the completion of parental education. Despite consistently high admission and occupancy rates, the short length of stay—often less than a week—meant that many mothers who were not lodging in the hospital or did not visit frequently were unable to attend the full series of sessions as intended. To enhance the accessibility and effectiveness of the education sessions, a facilitator affiliated with the unit—though not part of the clinical staff—was engaged to lead the sessions in the mothers' home language. This strategic choice helped ensure clear communication and cultural relevance. A professional nurse with prior NICU experience, fluency in English, Setswana, and Afrikaans, and expertise in neurodevelopmental supportive care was selected for this role. Her affiliation with the unit through student accompaniment further supported continuity and familiarity within the NICU environment (Site A). However, because the facilitator was not permanent staff, she was not available daily as initially planned, making it difficult to schedule training during quieter times in the unit. This required careful coordination between the facilitator’s availability and the mothers' schedules. In many cases, mothers had limited availability due to logistical constraints and personal responsibilities, which affected their attendance. Additionally, sessions longer than 60 minutes were not feasible, as mothers often became fatigued and wanted to return to their babies. At Site B, the social work department assumed the role of parent educators, and their availability was more consistent, as determined by patient load. Item 11 – Intervention adherences of the PremmieSense programme At the start of the intervention programme, the design team discussed the content and programme structure to reach consensus. The intervention was then piloted and adapted based on the results of the pilot study, after which the design team reached a consensus on the final programme content and structure. The nature and setting of the parent education programme intervention required a pragmatic approach. The facilitator required specific characteristics (among them knowledgeable about the NICU and neurodevelopmental care, fluent in mothers’ home languages, and available when mothers are available). To maintain the integrity of the programme across all the mother groups, the lead researcher trained the facilitators and provided them with a script to direct discussions. Ongoing quality assurance was ensured by reflection opportunities between the facilitators and lead researcher after group facilitation sessions, to identify challenges and possible solutions. Effectiveness of the programme was assessed by requesting participants to complete two questionnaires prior to and after the educational sessions. The first determined knowledge change using the Knowledge of Preterm Infant Behaviour (KPIB) scale ( 34 ), and the second determined whether the programme had any effect on maternal stress using the Parental Stress Scale: NICU (PSS:NICU) ( 35 ). Item 12 – The extent to which PremmieSense was delivered as planned The aim was to deliver the PremmieSense intervention to all parents of preterm infants admitted to the NICU. The plan was to present at least three facilitated, face-to-face, lecture-based, group discussion sessions – to be presented from enrolment over a period of at least one week. However, despite the NICU admission rate of 66 infants per month (Site A), babies were often discharged in less than one week of NICU admission to make room for new, more critical admissions, often full-term infants who could not participate in the intervention, in terms of the selection criteria. During the study period, it became evident that the preterm infant rates decreased, probably as a result of employing healthcare workers in the community who encouraged pregnant women to attend antenatal care, which in turn contributed to a decrease in preterm births and admissions. Although the initial plan was to train NICU staff to deliver the sessions during quieter times, increased clinical workload made this unfeasible. As a result, external healthcare professionals were trained to facilitate the programme. To ensure language accessibility, a Setswana-speaking professional nurse with NICU experience was enlisted at Site A, though her availability was limited. This required coordination with mothers’ schedules, which were often constrained by personal responsibilities. At Site B, the more consistent availability of the social work department – based on patient load – allowed for smoother session delivery. DISCUSSION Education in the NICU for parents with prematurely born children has been demonstrated and successfully used as an intervention to address the adverse effects of preterm birth in the parent-infant dyad ( 19 ). Given the time and resource constraints faced by public sector hospitals in countries such as South Africa, it is crucial to implement a feasible, effective, and sustainable intervention programme. We have established that the PremmieSense programme is feasible and demonstrated that it has potential to be sustainable. It can furthermore be delivered by healthcare providers who have experience in the NICU and are familiar with neuroprotection and neurodevelopmental care. Training is needed, though formal certification is not required. The programme is provided through a picture-based, printed booklet with concise text in the parent’s preferred language (English or Setswana in our study). This format is easy to deliver and is supplemented by face-to-face, lecture-based group discussions held at the hospital between feeding times. This approach was chosen because mothers in our previous study expressed a preference for lecture-based sessions. Additionally, since the mothers preferred the sessions to be facilitated in their mother tongue, the pool of available facilitators was limited to healthcare professionals who were both knowledgeable in neuroprotection and developmental care, familiar with the NICU environment, and fluent in the mother’s language of choice. Involving parents in infant care is recommended for optimal development. Notably, fathers who take an active role in caretaking have a positive effect on maternal-preterm infant interactive behaviour ( 36 ); however, no fathers participated in our study, due to hospital practices which discourage fathers from visiting, often due to space restrictions. In the public sector in South Africa, attention is focused primarily on mothers, with deprioritisation of paternal contact. This highlights the importance of systemic change to protect the family unit and involve fathers in NICU interventions towards an interactive family pattern, while contemplating the physical NICU space to encourage education and allow parents to support each other in practicing what they have learned ( 37 , 38 ). Although more attention is typically given to parents of extremely preterm infants, parents of moderate-to-late preterm infants, despite shorter hospital stays, also expressed significant support needs. Our programme aimed to provide timely support based on these needs. This paper focuses on presenting the developed programme according to the TIDieR template ( 27 ) to provide a clear reporting and reproducibility framework. Further studies are planned to determine the pilot impact of the programme and to investigate the extent to which the programme influences parental stress and knowledge about infant behaviour using the PSS:NICU ( 35 , 39 ) and the KPIB ( 34 ). In our study, the nurse responsible for human milk bank coordination indicated that she would be interested in presenting parenting educational sessions once the programme was fully rolled out, indicating the necessity of engaging all stakeholders to identify the most suitable candidate to take on this role. STRENGTHS AND LIMITATIONS This new PremmieSense educational intervention focuses on educational support for parents of preterm infants admitted to the NICU in a resource-limited public-sector setting in South Africa. It was developed by a design team to consider various stakeholders, including the bedside clinician, academics, instructional designer and, most importantly, the end-user, mothers of preterm infants in the NICU. It provides immediate, written, clear, and easy-to-understand material which can be consumed in a self-directed manner to make it easily accessible as soon as a baby is admitted to the NICU. The booklet is augmented by lecture-style group discussions, which provide an additional layer of peer support and a safe and relaxed environment where parents can engage with the material and ask questions, adding to the reflexive and individualized nature of the programme. A limitation of the lecture component is that it depends on the availability of healthcare professionals who are fluent in the most evident local languages to present the lecture discussion sessions; as a result, it cannot be presented when needed but rather in a scheduled manner. CONCLUSIONS This paper presents the PremmieSense programme, developed to empower parents with the knowledge they need to restore their parenting role and encouraging parents to provide responsive care for their preterm infants during their stay in the NICU. It aims to prevent adverse parent-infant bonding and attachment events and to optimize neural-coupling and synchrony. The programme is presented using a picture-based booklet with concise text and is augmented by a 60-minute lecture-based group discussion at the hospital. A knowledgeable healthcare professional with experience in the NICU and a good understanding of neuroprotective care and development can present education in a flexible manner to address individual family needs in a resource-restricted context. Abbreviations COPE Creating Opportunities for Parent Empowerment CP Cues Programme FINE The Family and Infant Neurodevelopmental Education H HOPE–Hospital to Home IFCDC Consensus The Consensus Committee of the Standards, Competencies and Best Practices for Infant and Family–Centered Developmental Care in the Intensive Care Unit INDeSC Implementation of Neurodevelopmental Supportive Care Programme KMC Kangaroo Mother Care KPIB Knowledge of Preterm Infant Behaviour scale M MITP–Modified Mother Infant Transaction Programme MITP Mother–Infant Transaction Program NICU Neonatal Intensive Care Unit NIDCAP Newborn Individualized Developmental Care and Assessment Program PBIP Parent–Baby Interaction Programme PPI Preventative Psychotherapy Intervention PSS:NICU Parental Stress Scale: NICU TIDieR Template for Intervention Description and Replication Wee Care Wee Care Neuroprotective NICU Program Declarations Ethics approval and consent to participate Ethical approval was obtained from the Health Research Ethics Committee of the University of Cape Town (UCT-647/2021), followed by approval from the North West province and the hospital management. Parents were asked to provide written informed consent to participate in the study. Consent for publication Permission to reproduce Figure 1: Als’ Model of Synactive Organization of Behavioural Development was obtained from John Wiley and Sons (2025), Licence number 6026960732177. Availability of data and materials All data generated or analysed during this study are included in this article. Competing interests The authors have no competing conflicts of interest. Funding No funding was received for this study. Acknowledgements The authors would like to thank Mrs Jessica Botha for her valuable input during the review and technical preparation of this article. We acknowledge the use of ChatGPT to suggest rephrasing of certain sections of the article to enhance clarity, improve flow, and reduce repetition. Author contributions All authors conceptualized the study, revised the manuscript, and interpreted the findings. WL conceptualized the study and prepared the manuscript for submission. KD was responsible for study supervision and critical review. All authors contributed to the intellectual content and read and approved the final manuscript. References Ohuma EO, Moller AB, Bradley E, Chakwera S, Hussain-Alkhateeb L, Lewin A, et al. National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis. Lancet. 2023;402(10409):1261-71. doi:10.1016/S0140-6736(23)00878-4 World Health Organization. Born too soon: decade of action on preterm birth. Geneva: World Health Organization; 2023. Sehgal A, Stack J. Developmentally supportive care and NIDCAP. Indian J Pediatr. 2006;73(11):1007-10. doi:10.1007/bf02758309 Chawanpaiboon S, Vogel JP, Moller AB, Lumbiganon P, Petzold M, Hogan D, et al. Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis. Lancet Glob Health. 2019;7(1):e37-46. doi:10.1016/s2214-109x(18)30451-0 Leung MP, Thompson B, Black J, Dai S, Alsweiler JM. The effects of preterm birth on visual development. Clin Exp Optom. 2018;101(1):4-12. doi:10.1111/cxo.12578 Shaw RJ, Givrad S, Poe C, Loi EC, Hoge MK, Scala M. Neurodevelopmental, mental health, and parenting issues in preterm infants. Children. 2023;10(9):1565. doi:10.3390/children10091565 Moe AM, Kurilova J, Afzal AR, Benzies KM. Effects of Alberta Family Integrated Care (FICare) on preterm infant development: two studies at 2 months and between 6 and 24 months corrected age. J Clin Med. 2022;11(6):1684. doi:10.3390/jcm11061684 Ionio C, Mascheroni E, Colombo C, Castoldi F, Lista G. Stress and feelings in mothers and fathers in NICU: identifying risk factors for early interventions. Prim Health Care Res Dev. 2019;20:e81. doi:10.1017/s1463423619000021 Bergman NJ. Birth practices: maternal-neonate separation as a source of toxic stress. Birth Defects Res. 2019;111(15):1087-109. doi:10.1002/bdr2.1530 Als H. Toward a synactive theory of development: promise for the assessment and support of infant individuality. Infant Ment Health J. 1982;3(4):229-43. doi:10.1002/1097-0355 Lubbe W. Best practice guidelines for neurodevelopmental supportive care of the preterm infant [dissertation]. Potchefstroom (South Africa): North-West University; 2010. Lubbe W. Neurodevelopmental supportive care of the preterm infant: condensed guide for clinicians. 2019. Lubbe W, Van der Walt CSJ, Klopper HC. Integrative literature review defining evidence-based neurodevelopmental supportive care of the preterm infant. J Perinat Neonatal Nurs. 2012;26(3):251-9. doi:10.1097/JPN.0b013e3182650b7e Altimier L, Phillips R. The Neonatal Integrative Developmental Care Model: advanced clinical applications of the seven core measures for neuroprotective family-centered developmental care. Newborn Infant Nurs Rev. 2016;16(4):230-44. doi:10.1053/j.nainr.2016.09.030 Warren I, Mat-Ali E, Green M, Nyathi D. Evaluation of the Family and Infant Neurodevelopmental Education (FINE) programme in the UK. J Neonatal Nurs. 2019;25(2):93-8. doi:10.1016/j.jnn.2018.11.004 Browne JV, Jaeger CB, Kenner C. Executive summary: standards, competencies, and recommended best practices for infant- and family-centered developmental care in the intensive care unit. J Perinatol. 2020;40(Suppl 1):5-10. doi:10.1038/s41372-020-0767-1 Kim AR, Kim S-y, Yun JE. Attachment and relationship-based interventions for families during neonatal intensive care hospitalization: a study protocol for a systematic review and meta-analysis. Syst Rev. 2020;9(1):61. doi:10.1186/s13643-020-01331-8 World Health Organization. WHO recommendations for care of the preterm or low birth weight infant. Geneva: World Health Organization; 2022. Puthussery S, Chutiyami M, Tseng P-C, Kilby L, Kapadia J. Effectiveness of early intervention programs for parents of preterm infants: a meta-review of systematic reviews. BMC Pediatr. 2018;18(1):223. doi:10.1186/s12887-018-1205-9 MacDermid JC. Clear reporting of educational interventions facilitates innovation and implementation. J Hand Ther. 2023;36(3):499-500. doi:10.1016/j.jht.2023.07.005 Lubbe W, Bornman J. Early intervention care programme for parents of neonates. Curationis. 2005;28(5):73-82. Little Steps. Home [Internet]. 2025 [cited 2025 May 13]. Available from: https://littlesteps.co.za/ Lubbe W. Global perspectives of developmental care–South Africa: neurodevelopmental supportive care in a rainbow nation. Dev Obs. 2021;14(2). doi:10.14434/do.v14i2.33002 Lubbe W. Prematurity: adjusting your dream. Johannesburg: Little Steps; 2008. Lubbe W, Donald K, Kruger IM. Key components of parenting education interventions for preterm infant-parent dyads admitted to the NICU: a systematic review. SSRN [Preprint]. 2024 [cited 2025 May 13]. Available from: https://ssrn.com/abstract= Lubbe W, Donald K. Parental educational needs during the NICU stay: mothers’ perspectives [unpublished manuscript]. BMC Pregnancy Childbirth. 2025. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: Template for Intervention Description and Replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687. doi:10.1136/bmj.g1687 Cotterill S, Knowles S, Martindale A-M, Elvey R, Howard S, Coupe N, et al. Getting messier with TIDieR: embracing context and complexity in intervention reporting. BMC Med Res Methodol. 2018;18(1):12. doi:10.1186/s12874-017-0461-y Juvé-Udina ME, Fabrellas-Padrés N, Delgado-Hito P, Hurtado-Pardos B, Martí-Cavallé M, Gironès-Nogué M, et al. Newborn physiological immaturity: a concept analysis. Adv Neonatal Care. 2015;15(2):86-93. doi:10.1097/ANC.0000000000000162 Winberg J. Mother and newborn baby: mutual regulation of physiology and behavior—a selective review. Dev Psychobiol. 2005;47(3):217-29. doi:10.1002/dev.20094 Bergman NJ. New policies on skin-to-skin contact warrant an oxytocin-based perspective on perinatal health care. Front Psychol. 2024;15:1385320. doi:10.3389/fpsyg.2024.1385320 Charpak N, Tessier R, Ruiz JG, Hernandez JT, Uriza F, Villegas J, et al. Twenty-year follow-up of kangaroo mother care versus traditional care. Pediatrics. 2017;139(1):e20162063. doi:10.1542/peds.2016-2063 Helmer CS, Thornberg UB, Mörelius E. An early collaborative intervention focusing on parent-infant interaction in the neonatal period: a descriptive study of the developmental framework. Int J Environ Res Public Health. 2021;18(12):6656. doi:10.3390/ijerph18126656 Browne JV. Maternal–preterm infant interaction in the intensive care unit: intervention and coping style effects [doctoral dissertation]. In press 1990. Miles MS, Funk SG, Carlson J. Parental Stressor Scale: Neonatal Intensive Care Unit. Nurs Res. 1993;42(3):148-52. Holditch‐Davis D, Schwartz T, Black B, Scher M. Correlates of mother–premature infant interactions. Res Nurs Health. 2007;30(3):333–46. Craig JW, Glick C, Phillips R, Hall SL, Smith J, Browne J. Recommendations for involving the family in developmental care of the NICU baby. J Perinatol. 2015;35 Suppl 1:S5–8. doi:10.1038/jp.2015.142 Ferreira RC, Alves CRL, Guimarães MAP, Menezes KKP, Magalhães LC. Effects of early interventions focused on the family in the development of children born preterm and/or at social risk: a meta-analysis. J Pediatr (Rio J). 2020;96(1):20–38. doi:10.1016/j.jped.2019.05.002 Carter MC, Miles MS. The Parental Stressor Scale: Pediatric Intensive Care Unit. Matern Child Nurs J. 1989;18(3):187–98.s Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6704844","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":476447864,"identity":"ce39335b-8e41-44a7-9c0d-2ec551ad2c95","order_by":0,"name":"Welma Lubbe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYFAC5gYgYcFgIMHA+IBILYwgLRIgLcwGJGthkyBKg8HxxtYNPxgkErdLNx+rLmw7zMDffoD5ww98Ws4cbLvZA9Syc86xtNszgVokziQwGPbg0WJ2I7HtBg9Qy4YbOWa3ebcdZmC4wcCQwINPy/2HbTf/gLXkfysGaZEHajn4B68tjG23obawMYO0GNxgYGzGZ4v9mcS22zIGEsZAvxhL8/5L5zE8k9jMLINHi2T74WM331TYyAJD7OFnnjPWcnLHDx/++AaPFghAikMeaEyNglEwCkbBKKAEAADXulAFEREJEAAAAABJRU5ErkJggg==","orcid":"","institution":"Red Cross War Memorial Children’s Hospital, University of Cape Town","correspondingAuthor":true,"prefix":"","firstName":"Welma","middleName":"","lastName":"Lubbe","suffix":""},{"id":476447865,"identity":"9c0e747c-c642-4893-a33c-57a80eb9e688","order_by":1,"name":"Kirsten A Donald","email":"","orcid":"","institution":"Red Cross War Memorial Children’s Hospital, University of Cape Town","correspondingAuthor":false,"prefix":"","firstName":"Kirsten","middleName":"A","lastName":"Donald","suffix":""}],"badges":[],"createdAt":"2025-05-20 07:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6704844/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6704844/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85863956,"identity":"2874f528-6694-4677-b434-2035c349ef98","added_by":"auto","created_at":"2025-07-02 12:46:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":306925,"visible":true,"origin":"","legend":"\u003cp\u003eAls’ Model of Synactive Organization of Behavioural Development (10)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eReproduced with permission from John Wiley and Sons (2025), Licence number 6026960732177.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6704844/v1/cbb3d5e5eca377299b85edf4.png"},{"id":85865088,"identity":"8f3a263a-f5c9-4793-b2ea-1b92e587e4e5","added_by":"auto","created_at":"2025-07-02 12:54:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":234028,"visible":true,"origin":"","legend":"\u003cp\u003eProgramme topics and sample materials\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6704844/v1/ea404833987a6fd0ee0347f4.png"},{"id":89070121,"identity":"974bcd89-4348-487e-bbde-102496b1ce2b","added_by":"auto","created_at":"2025-08-14 10:57:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1444975,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6704844/v1/efa2880c-4b7a-4400-a3fc-106a2ce95b61.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The NeuroSense PremmieEd Parenting Educational Intervention (PremmieSense) - a neuroprotective intervention for preterm infant-parent dyads: Reported using the TIDieR framework","fulltext":[{"header":" CONTRIBUTIONS TO LITERATURE","content":"\u003cul\u003e\n \u003cli\u003eDescribes a context-specific parenting education programme for preterm infants in South African public-sector NICUs, addressing a gap in neuroprotective care in low-resource settings.\u003c/li\u003e\n \u003cli\u003eDemonstrates how picture-based materials and group sessions, delivered in local languages, can support parent-infant bonding and reduce stress during hospitalisation.\u003c/li\u003e\n \u003cli\u003eProvides a replicable, low-cost model that can be delivered by trained healthcare professionals without formal certification.\u003c/li\u003e\n \u003cli\u003eHighlights the importance of co-design with parents and integration of user preferences in intervention development.\u003c/li\u003e\n \u003cli\u003eUses the TIDieR framework to enhance transparency, supporting reproducibility and adaptation in other low- and middle-income settings.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"INTRODUCTION","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\n \u003ch2\u003eRationale for the programme\u003c/h2\u003e\n \u003cp\u003eIn 2020, preterm birth accounted for 9.9% of all births globally, with an estimated 13.4\u0026nbsp;million preterm births (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). Southern Asia and sub-Saharan Africa account for 65% of these cases (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). While in South Africa, the preterm birth rate was 13%, making it the country with the fifth-highest rate of preterm births (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e). These infants are at risk for short- and long-term adverse effects, including physiological challenges (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e), medical conditions (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e), sensory and behavioural challenges (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e), and altered neurological and visual development (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eAdverse effects on parents include experiences of guilt, anxiety, loss and grief (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e), anger and depression, hostility, and fear, in addition to high stress levels (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e) and dysfunctional parenting (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). Furthermore, parents may experience shock due to the potential critical condition of both the mother and/or baby, making preterm birth a highly stressful or even traumatic event for them (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e), and an experience that has the potential to impair the relationship with their baby. In addition, infant-mother separation may lead to toxic stress in infants, with negative effects on both short- and long-term developmental outcomes (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eVarious in-hospital, multimodal developmental-care programmes have been developed and described in literature. Examples include programmes such as the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e), Implementation of Neurodevelopmental Supportive Care Programme (INDeSC) (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e), Wee Care Neuroprotective NICU Program (Wee Care) (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e), The Family and Infant Neurodevelopmental Education (FINE) (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e), and The Consensus Committee of the Standards, Competencies and Best Practices for Infant and Family-Centered Developmental Care in the Intensive Care Unit (IFCDC Consensus) (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e). NIDCAP, Wee Care and IFCDC originated in the United States and expanded to other countries, while FINE is rooted in the United Kingdom and INDeSC in South Africa. These are all complex, multi-layered, often unit- or organization-wide intervention programmes, including components such as staff training, infant support/therapy, parental support and parent education. However, a common theme across all the programmes is the family-centred approach building on the Model of Synactive Organization of Behavioral Development. This model was developed by Heidelise Als (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e) to explain how an infant moves from the parental intrauterine to the parental extrauterine environment in preparation to function in the world at large. The model guides approaches to neuroprotection and development in preterm infants (see Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eIn children born prematurely, the natural attachment process is interrupted at birth. The technologically advanced environment of the NICU, while life-saving, can inadvertently contribute to emotional and physical separation within the parent-infant dyad, potentially impairing early bonding and attachment (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e). At the same time, the NICU holds critical potential to not only support infant survival (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e) but, with effective NICU interventions, may also improve outcomes such as growth, early development and long-term emotional, psychosocial, and neurobehavioral health. Importantly, with the right interventions, provided at critical times, the NICU can also promote a healthy transition to parenthood by supporting parental mental health and fostering connection.\u003c/p\u003e\n \u003cp\u003eIntervention programmes, specifically educational interventions, initiated in the NICU have proven potential for enhancing parent-infant relationships, supporting positive behavioural and temperament development, promoting successful breastfeeding, and contributing to early mental, neurodevelopmental and overall child growth (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). However, MacDermid (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e) pointed out that education programmes are among the most poorly reported interventions, and this is even truer for parental education during the NICU stay. In order to improve understanding of the use of parent education as an intervention in the NICU, to understand current parent educational programmes, contextualize what is available, and create new, innovative educational interventions, it is critical to understand what are the components of such education programmes (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eA meta-review of systematic reviews by Puthussery et al. (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e) explored the effectiveness of early intervention programmes for parents of preterm infants. Extracting from their work, the following intervention programmes included an in-hospital parent education component (one or more sessions): Creating Opportunities for Parent Empowerment (COPE), Cues Programme (CP), EI Early Intervention, Hospital to Home (H-HOPE), Mother-Infant Transaction Program (MITP) and Modified Mother Infant Transaction Programme (M-MITP), Parent-Baby Interaction Programme (PBIP), and Preventative Psychotherapy Intervention (PPI). All these interventions are delivered to individual parents, except for PPI delivery which is delivered to a group.\u003c/p\u003e\n \u003cp\u003eIn the South African context, the first author developed the \u003cem\u003eLittle Steps\u003c/em\u003e website in 2005 as the first accessible, evidence-based resource to support parents through their NICU journey. The content, curated from research available up to 2005 (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e), was designed to meet parental educational needs in a clear, accessible and informal manner. \u003cem\u003eLittle Steps\u003c/em\u003e provided an effective tool for guiding parents through the NICU journey; however, as scientific research in the field of parenting and the importance of parenting education has evolved over the years, so too has understanding of parent education and its role in both parent and infant outcomes. Building on the foundational work established by \u003cem\u003eLittle Steps\u003c/em\u003e (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e), this new programme, PremmieSense, aimed to integrate the latest scientific evidence and insights about parent education programmes in the NICU (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e) and contextual input from mothers in the NICU (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e) to ensure relevance and responsiveness of the educational programme specifically within the South African public sector context.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of this paper is to describe the PremmieSense programme in detail, using the Template for Intervention Description and Replication (TIDieR) checklist (27). We describe the theoretical underpinnings and key components identified from our previous systematic review (25) and empirical study (26), as well as provide details on the programme structure and underlying parental support needs. This presentation will assist with the implementation, replication and evaluation of the programme in future.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTIDieR is a 12-item checklist designed to enhance the quality of intervention reporting and support replicability of the intervention implementation or evaluation. It is an extension of the CONSORT 2010 statement (item 5) and the SPIRIT 2013 statement (item 11) (27). We used this matrix to report the intervention, an educational programme, and the development process, describing the rationale, development, framework, and practical provision of the PremmieSense programme. The programme outline is presented in the numerical order of the checklist in Table 1.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;1: TIDieR items and description of the NeuroSense PremmieEd Parenting Educational Intervention (PremmieSense)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey Components of the Programme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eName\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eNeuroSense PremmieEd Parenting Educational Intervention\u003c/p\u003e\n \u003cp\u003e(short name: PremmieSense)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eWhy (rationale)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eTo enhance parent education\u003c/strong\u003e, fostering stronger parent-infant relationships, promoting positive behaviour and temperament, supporting breastfeeding, and aiding early mental, neurodevelopmental, and overall child development (19).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTo prevent challenges\u003c/strong\u003e that may disrupt parent-infant bonding and secure attachment.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTo empower parents\u003c/strong\u003e with essential knowledge and skills to care for their preterm infants throughout the NICU stay.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTo build parental confidence\u003c/strong\u003e in interacting with their infants, including recognizing cues and providing responsive, supportive care.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTo create an optimal environment\u003c/strong\u003e that facilitates neural coupling and synchrony between parents and their preterm infants, promoting healthy emotional and cognitive development.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eWhat (material)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePrinted materials, augmented by short lectures.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eWhat (procedures)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePicture-based, colour printed material with concise text in English or Setswana.\u003c/li\u003e\n \u003cli\u003eStructured, lecture-type group discussions to supplement the print material.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eWho provides\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eHealthcare professional skilled in the NICU context, knowledgeable in the neurodevelopmental supportive care model.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eHow (mode of delivery)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eBooklet provided for self-study.\u003c/li\u003e\n \u003cli\u003eLecture-based, small group discussion with two to four participants.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eWhere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cul\u003e\n \u003cli\u003ePublic hospital NICU or lecture room.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eWhen and how much\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eBooklet provided on enrolment.\u003c/li\u003e\n \u003cli\u003eLecture-based sessions within one week following enrolment.\u003c/li\u003e\n \u003cli\u003eAt least one session.\u003c/li\u003e\n \u003cli\u003eIn the morning between feeding times or early afternoon.\u003c/li\u003e\n \u003cli\u003eMaximum length of 60 minutes per session.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eTailoring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eNumber of sessions depends on the availability of mothers to attend and availability of healthcare providers to present the sessions.\u003c/li\u003e\n \u003cli\u003eMaternal needs guide the number of topics presented.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eModification \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eFlexibility incorporated with consideration of individual family needs.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eIntervention adherences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eConsiderations on adherence of the provision of the PremmieSense programme, and a written summary.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eHow well (planned)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eDeviations occur when the resources and parental needs change.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003eNICU = Neonatal Intensive Care Unit, TIDieR = Template for Intervention Description and Replication.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA parenting education programme during the neonatal unit admission period may play an important role in improving both parental and infant outcomes in the short-term as well as in the long-term, including after discharge. Parent education empowers parents to take on their parenting roles and return to the position of primary caregiver. The PremmieSense programme was initiated as soon as possible after NICU admission and demonstrated promising results. The programme is described using the TIDieR checklist (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) as a reporting matrix to ensure transparency of our educational intervention reporting (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ch3\u003eItem 1 – The name of the intervention\u003c/h3\u003e\n\u003cp\u003e PremmieSense is an educational intervention presented to parents while their infants are still admitted to the NICU. The education programme is based on the principles of neuroprotective care and development and aims to create sensitivity in parents about their preterm infant\u0026rsquo;s development, and as a result, empower them to fulfil the role of primary caregivers and provide sensitive and responsive parenting as early as possible during the NICU stay.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eItem 2 \u0026ndash; The rationale and development\u003c/h2\u003e \u003cp\u003eAn understanding of the normal physiology of the newborn infant-parent dyad and how parent education can support or restore normal physiology provides the foundation for this programme. \u003cem\u003ePhysiological developmental\u003c/em\u003e processes refer to the \u0026lsquo;characteristics of or appropriate to an organism\u0026rsquo;s healthy and normal functioning\u0026rsquo; (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and are observed in the mother-infant dyad when there is no medical interference, and the dyad is kept together to ensure zero separation while initiating immediate and continuous skin-to-skin care. Winberg (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) explained that the mother who has close body contact with her baby helps to regulate a newborn\u0026rsquo;s temperature, energy conservation, respiration regulation and acid-base balance, and improves breastfeeding. The baby also regulates the mother by increasing her attention to the newborn\u0026rsquo;s needs, breastfeeding initiation and maintenance, vagus nerve activation to ensure efficient energy use, and the release of gastrointestinal tract hormones to improve the use of ingested calories (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the preterm infant, this physiological development, which would be experienced in the supportive intrauterine environment and on the mother\u0026rsquo;s body, is interrupted and the immature newborn is exposed to the unsupportive extrauterine environment, where both mother and baby are deprived of normal processes to support development. Researchers have demonstrated the negative effects of infant-mother separation, leading to toxic stress with negative effects on both short- and long-term developmental outcomes (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, Bergman (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) reported a 25% reduction in infant mortality when immediate and continuous skin-to-skin care are practiced. The effects of some of these changes can be detected months later. A notable twenty-year follow up study by Charpak et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) compared kangaroo mother care (KMC) to traditional care. The findings demonstrate that KMC has lasting positive impacts on neurodevelopment, cognitive function, and social behaviour, underscoring the long-term benefits of early skin-to-skin contact.\u003c/p\u003e \u003cp\u003e Parental education is the first step in empowering parents to support the restoration of disrupted physiological processes. This educational intervention is designed to help parents repair the interruption in neural coupling and synchrony caused by preterm birth and the resulting separation between mother and infant\u0026mdash;factors that contribute to stress in both parent and child. The program also seeks to reduce parental stress and enhance understanding of the infant\u0026rsquo;s needs through targeted education.\u003c/p\u003e \u003cp\u003eThe outcomes of the PremmieSense programme were formulated as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eTo enhance parent education\u003c/b\u003e, fostering stronger parent-infant relationships, promoting positive behaviour and temperament, supporting breastfeeding, and aiding early mental, neurodevelopmental and overall child development (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eTo prevent challenges\u003c/b\u003e that may disrupt parent-infant bonding and secure attachment.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eTo empower parents\u003c/b\u003e with essential knowledge and skills to care for their preterm infant throughout the NICU stay.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eTo build parental confidence\u003c/b\u003e in interacting with their infant, including recognizing cues and providing responsive, supportive care.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eTo create an optimal environment\u003c/b\u003e that facilitates neural coupling and synchrony between parents and their preterm infants, promoting healthy emotional and cognitive development.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eItem 3 – Informational materials\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eProgramme content.\u003c/em\u003e Informational materials included in the PremmieSense parenting programme consist primarily of self-explanatory, picture-based, printed materials, with concise text in either English or Setswana. The printed booklets include various topics identified in literature and supplied by mothers while in the NICU. The printed booklet contains information about the NICU and preterm infants, and the topics and sample materials are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe programme was presented by a healthcare professional who was familiar with the unit and had experience working in the NICU. The programme content was divided into six sections to allow for flexibility in the delivery. Depending on the needs of the group, all or only selected modules could be presented, and sessions could be split and presented based on the availability of mothers and presenters. The modules of the programme include (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSection 1 \u0026ndash; The NICU\u003c/strong\u003e \u003cp\u003eThis section covers information on the definitions of prematurity and how the intrauterine environment should be mimicked in the NICU. It then discusses the importance of hand washing as part of infection control and uses diagrams and pictures to explain the equipment parents may see in and around their babies in the NICU.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003eSection 2 - Parental physical and psychological changes and support\u003c/em\u003e provides short digestible support information which parents can consider and share with family and friends to build their support network while admitted to the NICU.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSection 3 - Infant behaviour\u003c/strong\u003e \u003cp\u003eThis section focuses on parent-infant interaction, starting with an explanation of the various sub-systems, calming behaviour, unpacking sleep and awake states, and concluding with stress cues parents may see in their infants.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSection 4 - Infant care \u0026ndash; handling and positive touch\u003c/strong\u003e \u003cp\u003eThe first part of this section presents photos to help parents identify ways they can try to calm their babies, followed by illustrations of various positions suitable for preterm babies in the NICU, and ends with information on skin-to-skin care.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSection 5 \u0026ndash; Feeding and breastfeeding\u003c/em\u003e was the topic which rated the highest when identifying parental education needs. Since it can also be a more complex event, more detailed information is provided in this section. Feeding is also the one activity which the mother-infant dyad can use to apply the knowledge gathered in the previous topics. In the feeding section, information is provided about breastmilk expressing \u0026ndash; including techniques, storing of expressed breastmilk, alternative methods to feed the preterm infant, advancing from tube-to-oral feeding, and how to assess if the infant had sufficient milk intake.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSection 6 \u0026ndash; Preparing for discharge\u003c/em\u003e is an important topic, especially for parents of babies who are close to discharge. However, research indicates that discharge preparation should start as soon as possible during the NICU stay. The literature has also shown that the topics to be included in discharge preparation are very similar to the topics already included in the program materials of previous sections. Therefore, this section focused on when the preterm baby could be expected to be discharged, as well as providing information on feeding advancement post discharge and information on follow-up.\u003c/p\u003e\n\u003ch3\u003eProgramme delivery\u003c/h3\u003e\n\u003cp\u003eThe programme was delivered in person in the NICU between feeding times, to allow mothers to attend and to spend optimal time with their babies. Mothers were informed about the study and all mothers who enrolled were provided with the educational materials in a pilot study (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). One group of mothers received only the booklet, while for another group, the booklet was augmented by brief lectures presented in a group format.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eItem 4 \u0026ndash; PremmieSense procedure\u003c/h2\u003e \u003cp\u003eAn important aim of the PremmieSense programme is to ensure access to information, even in resource-restricted settings, to create awareness among parents about their preterm infants\u0026rsquo; developmental activities and how they can contribute thereto. An educational programme was selected as the intervention of choice, since education serves as a powerful, cost-effective, user-friendly tool in the NICU, and equips parents with the knowledge and confidence to get to know their infants, care for them, and actively participate in their development. Research has demonstrated that informed parents are more likely to engage in beneficial caregiving practices, such as skin-to-skin care, breastfeeding, and early developmental interventions, all of which contribute to improved infant and parental health outcomes. In healthcare settings where parental involvement is not yet well integrated as the standard of care, education can serve as a critical intervention, bridging gaps in care and ensuring that infants receive the best possible start in life.\u003c/p\u003e \u003cp\u003eParenting education sessions were presented by a trained facilitator, who led the group by presenting the materials for each session, and then allowed for questions and discussion within the group. The ideal is to present one session (topic) per day, every day \u0026ndash; or at least every second day. However, due to staff restrictions in this setting, and mothers being discharged or not available to visit every day, this proved challenging. A facilitator may not always be available to provide a lecture or even bedside training in a resource-restricted setting, as care from medical and nursing staff is often triaged towards clinical-care interventions. Therefore, by providing mothers with visual materials and explanations of what they could observe in their own infants and, when possible, augmenting the material with lecture-type group discussions, mothers were empowered to take on their parenting role, activating bonding and neural-coupling that had been interrupted due to separation and stress.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eItem 5 \u0026ndash; The providers\u003c/h2\u003e \u003cp\u003eThe content development team comprised a professional nurse, research assistant, mother with an infant admitted to the NICU, academic expert, and master trainer of neurodevelopmental supportive care (\u003cem\u003eLittle Steps\u003c/em\u003e for healthcare providers), who was also a qualified speech-language pathologist and audiologist. A senior researcher in the field of paediatric neuroscience, as well as an independent instructional designer completed the team.\u003c/p\u003e \u003cp\u003eTo ensure the consistent delivery of the education programme, the intervention was presented at Site A by a professional nurse familiar with the NICU context and with caring for preterm infants and also knowledgeable about the neurodevelopmental supportive-care model. She was trained in the content for this specific educational delivery by the lead researcher and provided with the same material that was given to the mothers, as well as text that could be used as a script to ensure consistent delivery across all parent groups. Importantly, the facilitator was fluent in English, Setswana and Afrikaans (the local languages of this region) and could therefore not only present the materials in all languages but could also facilitate discussions in the mother tongue of participants. At Site B, the hospital requested that social workers be trained as the educators, as they work with the preterm infant\u0026rsquo;s parents on a frequent basis. They were provided with the same training as those at Site A, spoke the three above-mentioned languages, and received the same training materials. The education focused on understanding the infant, providing appropriate interaction, integrating basic care, and being responsive rather than task-oriented.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eItem 6 \u0026ndash; The delivery\u003c/h2\u003e \u003cp\u003eMothers were presented with a printed training booklet to study in their own time, followed by a face-to-face, lecture-based group discussion at the hospital within a week. In our pilot study, only two to four mothers participated at a time in lecture discussions, which allowed for good interaction and opportunities for individual questions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eItem 7 \u0026ndash; Where the PremmieSense programme was delivered\u003c/h2\u003e \u003cp\u003eThe educational intervention was developed for the public healthcare sector and piloted at the NICU of a public tertiary referral hospital (Site A) as well as at a regional hospital (Site B) in the North West province of South Africa. Mothers found it most convenient when the training was presented in a quiet area within the NICU to allow them to remain close to their babies in case they were unexpectedly needed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eItem 8 \u0026ndash; When and how much\u003c/h2\u003e \u003cp\u003eMothers were enrolled in the programme and provided with a booklet (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) as soon as possible following their infant\u0026rsquo;s admission. The programme was intended to start as early as possible during the traumatic time of NICU admission and the initial stay thereafter, in order to support and empower parents to take on their parenting role and to connect with their infants. At least one lecture-based session was presented within one week of them receiving the booklet, at a time convenient to the mothers, which was usually in the morning between two feeds or early afternoon, when they were not at their infants\u0026rsquo; bedside. Sessions lasted a maximum of 60 minutes each and focused on the needs identified by the group attendees. Mothers could attend any or all topic discussions (refer to Item 3, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) based on their individual needs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eItem 9 \u0026ndash; Tailoring of PremmieSense\u003c/h2\u003e \u003cp\u003eAlthough the sessions were designed to follow the chronological development and experience in the NICU, the programme was dynamic in nature, and sessions could follow a different organization and consist of any variety of topics, or only a few selected topics, depending on the mothers\u0026rsquo; needs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eItem 10 \u0026ndash; Modifications of the PremmieSense programme\u003c/h2\u003e \u003cp\u003eThe original programme design, informed by international literature (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), recommended a minimum of three educational sessions lasting 60\u0026ndash;120 minutes each, delivered by trained healthcare professionals who are permanent staff in the unit. However, consistent with the findings of Helmer et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), the number of sessions was reduced due to limited bed availability. High patient turnover in the NICU led to the early discharge of preterm infants to make room for more critically ill babies, often before the completion of parental education. Despite consistently high admission and occupancy rates, the short length of stay\u0026mdash;often less than a week\u0026mdash;meant that many mothers who were not lodging in the hospital or did not visit frequently were unable to attend the full series of sessions as intended.\u003c/p\u003e \u003cp\u003eTo enhance the accessibility and effectiveness of the education sessions, a facilitator affiliated with the unit\u0026mdash;though not part of the clinical staff\u0026mdash;was engaged to lead the sessions in the mothers' home language. This strategic choice helped ensure clear communication and cultural relevance. A professional nurse with prior NICU experience, fluency in English, Setswana, and Afrikaans, and expertise in neurodevelopmental supportive care was selected for this role. Her affiliation with the unit through student accompaniment further supported continuity and familiarity within the NICU environment (Site A).\u003c/p\u003e \u003cp\u003eHowever, because the facilitator was not permanent staff, she was not available daily as initially planned, making it difficult to schedule training during quieter times in the unit. This required careful coordination between the facilitator\u0026rsquo;s availability and the mothers' schedules. In many cases, mothers had limited availability due to logistical constraints and personal responsibilities, which affected their attendance. Additionally, sessions longer than 60 minutes were not feasible, as mothers often became fatigued and wanted to return to their babies.\u003c/p\u003e \u003cp\u003eAt Site B, the social work department assumed the role of parent educators, and their availability was more consistent, as determined by patient load.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eItem 11 \u0026ndash; Intervention adherences of the PremmieSense programme\u003c/h2\u003e \u003cp\u003eAt the start of the intervention programme, the design team discussed the content and programme structure to reach consensus. The intervention was then piloted and adapted based on the results of the pilot study, after which the design team reached a consensus on the final programme content and structure. The nature and setting of the parent education programme intervention required a pragmatic approach. The facilitator required specific characteristics (among them knowledgeable about the NICU and neurodevelopmental care, fluent in mothers\u0026rsquo; home languages, and available when mothers are available).\u003c/p\u003e \u003cp\u003eTo maintain the integrity of the programme across all the mother groups, the lead researcher trained the facilitators and provided them with a script to direct discussions. Ongoing quality assurance was ensured by reflection opportunities between the facilitators and lead researcher after group facilitation sessions, to identify challenges and possible solutions. Effectiveness of the programme was assessed by requesting participants to complete two questionnaires prior to and after the educational sessions. The first determined knowledge change using the Knowledge of Preterm Infant Behaviour (KPIB) scale (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), and the second determined whether the programme had any effect on maternal stress using the Parental Stress Scale: NICU (PSS:NICU) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eItem 12 \u0026ndash; The extent to which PremmieSense was delivered as planned\u003c/h2\u003e \u003cp\u003eThe aim was to deliver the PremmieSense intervention to all parents of preterm infants admitted to the NICU. The plan was to present at least three facilitated, face-to-face, lecture-based, group discussion sessions \u0026ndash; to be presented from enrolment over a period of at least one week. However, despite the NICU admission rate of 66 infants per month (Site A), babies were often discharged in less than one week of NICU admission to make room for new, more critical admissions, often full-term infants who could not participate in the intervention, in terms of the selection criteria. During the study period, it became evident that the preterm infant rates decreased, probably as a result of employing healthcare workers in the community who encouraged pregnant women to attend antenatal care, which in turn contributed to a decrease in preterm births and admissions.\u003c/p\u003e \u003cp\u003eAlthough the initial plan was to train NICU staff to deliver the sessions during quieter times, increased clinical workload made this unfeasible. As a result, external healthcare professionals were trained to facilitate the programme. To ensure language accessibility, a Setswana-speaking professional nurse with NICU experience was enlisted at Site A, though her availability was limited. This required coordination with mothers\u0026rsquo; schedules, which were often constrained by personal responsibilities. At Site B, the more consistent availability of the social work department \u0026ndash; based on patient load \u0026ndash; allowed for smoother session delivery.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eEducation in the NICU for parents with prematurely born children has been demonstrated and successfully used as an intervention to address the adverse effects of preterm birth in the parent-infant dyad (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Given the time and resource constraints faced by public sector hospitals in countries such as South Africa, it is crucial to implement a feasible, effective, and sustainable intervention programme. We have established that the PremmieSense programme is feasible and demonstrated that it has potential to be sustainable. It can furthermore be delivered by healthcare providers who have experience in the NICU and are familiar with neuroprotection and neurodevelopmental care. Training is needed, though formal certification is not required.\u003c/p\u003e \u003cp\u003eThe programme is provided through a picture-based, printed booklet with concise text in the parent\u0026rsquo;s preferred language (English or Setswana in our study). This format is easy to deliver and is supplemented by face-to-face, lecture-based group discussions held at the hospital between feeding times. This approach was chosen because mothers in our previous study expressed a preference for lecture-based sessions. Additionally, since the mothers preferred the sessions to be facilitated in their mother tongue, the pool of available facilitators was limited to healthcare professionals who were both knowledgeable in neuroprotection and developmental care, familiar with the NICU environment, and fluent in the mother\u0026rsquo;s language of choice.\u003c/p\u003e \u003cp\u003eInvolving parents in infant care is recommended for optimal development. Notably, fathers who take an active role in caretaking have a positive effect on maternal-preterm infant interactive behaviour (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e); however, no fathers participated in our study, due to hospital practices which discourage fathers from visiting, often due to space restrictions. In the public sector in South Africa, attention is focused primarily on mothers, with deprioritisation of paternal contact. This highlights the importance of systemic change to protect the family unit and involve fathers in NICU interventions towards an interactive family pattern, while contemplating the physical NICU space to encourage education and allow parents to support each other in practicing what they have learned (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough more attention is typically given to parents of extremely preterm infants, parents of moderate-to-late preterm infants, despite shorter hospital stays, also expressed significant support needs. Our programme aimed to provide timely support based on these needs. This paper focuses on presenting the developed programme according to the TIDieR template (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) to provide a clear reporting and reproducibility framework. Further studies are planned to determine the pilot impact of the programme and to investigate the extent to which the programme influences parental stress and knowledge about infant behaviour using the PSS:NICU (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) and the KPIB (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). In our study, the nurse responsible for human milk bank coordination indicated that she would be interested in presenting parenting educational sessions once the programme was fully rolled out, indicating the necessity of engaging all stakeholders to identify the most suitable candidate to take on this role.\u003c/p\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eSTRENGTHS AND LIMITATIONS\u003c/h2\u003e \u003cp\u003eThis new PremmieSense educational intervention focuses on educational support for parents of preterm infants admitted to the NICU in a resource-limited public-sector setting in South Africa. It was developed by a design team to consider various stakeholders, including the bedside clinician, academics, instructional designer and, most importantly, the end-user, mothers of preterm infants in the NICU. It provides immediate, written, clear, and easy-to-understand material which can be consumed in a self-directed manner to make it easily accessible as soon as a baby is admitted to the NICU. The booklet is augmented by lecture-style group discussions, which provide an additional layer of peer support and a safe and relaxed environment where parents can engage with the material and ask questions, adding to the reflexive and individualized nature of the programme. A limitation of the lecture component is that it depends on the availability of healthcare professionals who are fluent in the most evident local languages to present the lecture discussion sessions; as a result, it cannot be presented when needed but rather in a scheduled manner.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis paper presents the PremmieSense programme, developed to empower parents with the knowledge they need to restore their parenting role and encouraging parents to provide responsive care for their preterm infants during their stay in the NICU. It aims to prevent adverse parent-infant bonding and attachment events and to optimize neural-coupling and synchrony. The programme is presented using a picture-based booklet with concise text and is augmented by a 60-minute lecture-based group discussion at the hospital. A knowledgeable healthcare professional with experience in the NICU and a good understanding of neuroprotective care and development can present education in a flexible manner to address individual family needs in a resource-restricted context.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOPE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCreating Opportunities for Parent Empowerment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCues Programme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFINE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Family and Infant Neurodevelopmental Education\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHOPE\u0026ndash;Hospital to Home\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIFCDC Consensus\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Consensus Committee of the Standards, Competencies and Best Practices for Infant and Family\u0026ndash;Centered Developmental Care in the Intensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eINDeSC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eImplementation of Neurodevelopmental Supportive Care Programme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKangaroo Mother Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKPIB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKnowledge of Preterm Infant Behaviour scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMITP\u0026ndash;Modified Mother Infant Transaction Programme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMITP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMother\u0026ndash;Infant Transaction Program\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNeonatal Intensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNIDCAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNewborn Individualized Developmental Care and Assessment Program\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePBIP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eParent\u0026ndash;Baby Interaction Programme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePreventative Psychotherapy Intervention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSS:NICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eParental Stress Scale: NICU\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTIDieR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTemplate for Intervention Description and Replication\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWee Care\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWee Care Neuroprotective NICU Program\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Health Research Ethics Committee of the University of Cape Town (UCT-647/2021), followed by approval from the North West province and the hospital management. Parents were asked to provide written informed consent to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePermission to reproduce Figure 1:\u0026nbsp;Als’ Model of Synactive Organization of Behavioural Development was obtained from John Wiley and Sons (2025), Licence number 6026960732177.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Mrs Jessica Botha for her valuable input during the review and technical preparation of this article.\u0026nbsp;We acknowledge the use of ChatGPT to suggest rephrasing of certain sections of the article to enhance clarity, improve flow, and reduce repetition.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors conceptualized the study, revised the manuscript, and interpreted the findings. WL conceptualized the study and prepared the manuscript for submission. KD was responsible for study supervision and critical review. All authors contributed to the intellectual content and read and approved the final manuscript.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOhuma EO, Moller AB, Bradley E, Chakwera S, Hussain-Alkhateeb L, Lewin A, et al. National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis. Lancet. 2023;402(10409):1261-71. doi:10.1016/S0140-6736(23)00878-4\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Born too soon: decade of action on preterm birth. Geneva: World Health Organization; 2023.\u003c/li\u003e\n\u003cli\u003eSehgal A, Stack J. Developmentally supportive care and NIDCAP. 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Available from: https://ssrn.com/abstract=\u003c/li\u003e\n\u003cli\u003eLubbe W, Donald K. Parental educational needs during the NICU stay: mothers\u0026rsquo; perspectives [unpublished manuscript]. BMC Pregnancy Childbirth. 2025.\u003c/li\u003e\n\u003cli\u003eHoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: Template for Intervention Description and Replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687. doi:10.1136/bmj.g1687\u003c/li\u003e\n\u003cli\u003eCotterill S, Knowles S, Martindale A-M, Elvey R, Howard S, Coupe N, et al. Getting messier with TIDieR: embracing context and complexity in intervention reporting. BMC Med Res Methodol. 2018;18(1):12. doi:10.1186/s12874-017-0461-y\u003c/li\u003e\n\u003cli\u003eJuv\u0026eacute;-Udina ME, Fabrellas-Padr\u0026eacute;s N, Delgado-Hito P, Hurtado-Pardos B, Mart\u0026iacute;-Cavall\u0026eacute; M, Giron\u0026egrave;s-Nogu\u0026eacute; M, et al. Newborn physiological immaturity: a concept analysis. Adv Neonatal Care. 2015;15(2):86-93. doi:10.1097/ANC.0000000000000162 \u003c/li\u003e\n\u003cli\u003eWinberg J. Mother and newborn baby: mutual regulation of physiology and behavior\u0026mdash;a selective review. Dev Psychobiol. 2005;47(3):217-29. doi:10.1002/dev.20094\u003c/li\u003e\n\u003cli\u003eBergman NJ. New policies on skin-to-skin contact warrant an oxytocin-based perspective on perinatal health care. Front Psychol. 2024;15:1385320. doi:10.3389/fpsyg.2024.1385320\u003c/li\u003e\n\u003cli\u003eCharpak N, Tessier R, Ruiz JG, Hernandez JT, Uriza F, Villegas J, et al. Twenty-year follow-up of kangaroo mother care versus traditional care. Pediatrics. 2017;139(1):e20162063. doi:10.1542/peds.2016-2063\u003c/li\u003e\n\u003cli\u003eHelmer CS, Thornberg UB, M\u0026ouml;relius E. An early collaborative intervention focusing on parent-infant interaction in the neonatal period: a descriptive study of the developmental framework. Int J Environ Res Public Health. 2021;18(12):6656. doi:10.3390/ijerph18126656 \u003c/li\u003e\n\u003cli\u003eBrowne JV. Maternal\u0026ndash;preterm infant interaction in the intensive care unit: intervention and coping style effects [doctoral dissertation]. In press 1990.\u003c/li\u003e\n\u003cli\u003eMiles MS, Funk SG, Carlson J. Parental Stressor Scale: Neonatal Intensive Care Unit. Nurs Res. 1993;42(3):148-52.\u003c/li\u003e\n\u003cli\u003eHolditch‐Davis D, Schwartz T, Black B, Scher M. Correlates of mother\u0026ndash;premature infant interactions. Res Nurs Health. 2007;30(3):333\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003eCraig JW, Glick C, Phillips R, Hall SL, Smith J, Browne J. Recommendations for involving the family in developmental care of the NICU baby. J Perinatol. 2015;35 Suppl 1:S5\u0026ndash;8. doi:10.1038/jp.2015.142\u003c/li\u003e\n\u003cli\u003eFerreira RC, Alves CRL, Guimar\u0026atilde;es MAP, Menezes KKP, Magalh\u0026atilde;es LC. Effects of early interventions focused on the family in the development of children born preterm and/or at social risk: a meta-analysis. J Pediatr (Rio J). 2020;96(1):20\u0026ndash;38. doi:10.1016/j.jped.2019.05.002\u003c/li\u003e\n\u003cli\u003eCarter MC, Miles MS. The Parental Stressor Scale: Pediatric Intensive Care Unit. Matern Child Nurs J. 1989;18(3):187\u0026ndash;98.s\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Programme development, preterm infant, parent education interventions, programmes, neuroprotection, neural synchrony, TIDiER ","lastPublishedDoi":"10.21203/rs.3.rs-6704844/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6704844/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePreterm birth affects approximately 10% of births globally, placing infants at risk for neurodevelopmental delays, and exposing parents to stress and disrupted bonding. Parent education in neonatal intensive care units (NICUs) is a key intervention that supports neuroprotection and enhances parent-infant synchrony. While such interventions show promise, their contextual fit in low-resource settings like South Africa requires further evaluation.\u003c/p\u003e\n\u003cp\u003eThe NeuroSense PremmieEd Parenting Educational Intervention (PremmieSense) aims to promote neuroprotective care and strengthen parent-infant bonding during NICU admission. The intervention includes a picture-based booklet (in English and Setswana) and structured, group-based sessions delivered by trained healthcare professionals. Sessions are flexible in number and focus, tailored to maternal needs and logistical constraints within public hospital settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eTo describe the NeuroSense PremmieEd Parenting Educational Intervention (PremmieSense) using the Template for Intervention Description and Replication (TIDieR) framework, with reference to its alignment with established components of effective NICU-based interventions for parents of preterm infants and with consideration of parental expectations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe TIDieR matrix guided the structured reporting of the programme’s development, rationale, content, and delivery approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e PremmieSense demonstrated feasibility and acceptability in low-resource South African NICUs. Delivered shortly after NICU admission, the programme provided practical, culturally sensitive content and was supported by trained facilitators. Parents reported improved knowledge of preterm infant behaviour (assessed via the Knowledge of Preterm Infant Behaviour (KPIB) scale), reduced stress (assessed via the Parental Stress Scale: NICU (PSS:NICU)), greater confidence, and improved responsiveness to infant cues. Despite challenges such as early discharges and limited staff, the intervention was well received and adaptable. It supported early neural synchrony, parent-infant bonding, and smoother transitions to home care. The TIDieR framework enhanced transparency and fidelity, supporting potential replication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThis paper presents the PremmieSense parenting programme using the TIDieR matrix to promote clear reporting, replication, and implementation. Findings suggest its potential value for improving parent and infant outcomes in NICUs, especially within low-resource contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"The NeuroSense PremmieEd Parenting Educational Intervention (PremmieSense) - a neuroprotective intervention for preterm infant-parent dyads: Reported using the TIDieR framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 12:46:10","doi":"10.21203/rs.3.rs-6704844/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"93fb7bca-d605-4e1a-8de3-ba34b208943c","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-14T10:47:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-02 12:46:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6704844","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6704844","identity":"rs-6704844","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}