Methodological strategies for the elaboration of educational material: focus on the promotion of preterm infants’ development

Lemos, Rayla Amaral; Veríssimo, Maria de La Ó Ramallo

doi:10.1590/1413-81232020252.04052018

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ARTICLE • Ciênc. saúde coletiva 25 (2) • Feb 2020 • https://doi.org/10.1590/1413-81232020252.04052018 copy

Methodological strategies for the elaboration of educational material: focus on the promotion of preterm infants’ development

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This study aimed to describe and analyze the process of elaborating educational material to promote the development of preterm infants. The procedures included participative exploratory research with the target audience, integrative reviews of the literature on the subject, and systematization of contents through robust theoretical references. Popular Education in Health guided the elaboration of the educational material, and the participatory approach; the Bioecological Theory of Human Development conducted the analysis and systematization of the contents; and Simply Put guided the graphic organization of the material. The theoretical model of the development of preterm infants, and data systematization and organization, allowed the elaboration of an interactive educational material, a technology in a book format for the family. The multiple research strategies and theoretical references have provided methodological rigor, increasing the educational material’s action potential, which draws family experience closer to the updated scientific knowledge, thus enhancing child health promotion.

Key words
Health education; Child development; Premature Infant; Educational and Promotional Materials; Educational Technology

Recommended Stage*	Stage Objective	Resources used	Results/Definitions
Establishment of the conceptual framework	Measure and define the context of the tool to support each content inserted into it.	Literature review; Researchers' professional experience; Research with the target population.	References selected: Promotion of development; Functional development; Popular Education and Health;Bioecology of human development.
Definition of objectives	Establish the material's suitability.	Articulation between the needs of the population and the theoretical references adopted.	Purpose of the material: Support the family for the care and promotion of the preterm infant's development.
Definition of the target population	Establish the material's suitability and justify the relevance of the material produced.	Literature review; Researchers' professional experience; Reports of the target population.	Target population: Caregivers of preterm children with current age below three years.
Elaboration of items: Selection, Organization and Structuring of contents of the material - texts and illustrations	Establish the suitability of the material following established references.	Literature review; Analysis of existing materials on the subject; Research with the target population;Clinical observation;Expert opinion.	Material characteristics: Dialogued and interactive material; In story format, divided into chapters, with contents defined according to the needs of the target population and organized with linearity in history; Illustrations defined according the contents; Inclusion of a booklet for monitoring functional development.

PPCT Dimensions	Aspects related to the child care and its relationships with development	References
	Positive factors for development of preterm infants
Process	Affection, interaction and continuous and participatory presence of caregivers.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131.
	Conversation, play and toys.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Hall et al., 2013³⁶36 Hall EOC, Kronborg H, Aagaard H, Brinchmann BS. The journey towards motherhood after a very preterm birth: Mothers’ experiences in hospital and after home-coming. J Neonatal Nursing 2013; 19:109e113.
	Child stimulation and skills education.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Reading, music or sport.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Provision of healthy food.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Interacting with other children at home, in the neighborhood, or at daycare.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Care based on the cues provided by the child.	Evans et al., 2014³⁷37 Evans T, Whittingham K, Sanders M, Colditz P, Boyd RN. Development are parenting interventions effective in improving the relationship between mothers and their preterm infants? Infant Behavior Development 2014; 37:131-154.
	Listening to the mother's voice;Interactions and verbalizations with the newborn in the NICU;Multisensory stimulation in the NICU by caregivers trained by the health team.	Picciolini et al., 20144Caskey et al., 201138Gerstein et al., 201539Gabis et al., 201540
	Perceiving the child's development.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131.
	Negative factors for development of preterm infants
	Ill-treatment and lack of affection.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Too much and hasty expectation about development, and/or comparison with other children.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131. Hall et al., 2013³⁶36 Hall EOC, Kronborg H, Aagaard H, Brinchmann BS. The journey towards motherhood after a very preterm birth: Mothers’ experiences in hospital and after home-coming. J Neonatal Nursing 2013; 19:109e113.
	Restrictive care for the child's independence and overprotection.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Whittingham et al., 2014⁴¹41 Whittingham K, Boyd RN, Sanders MR, Colditz P. Parenting and Prematurity: Understanding Parent Experience and Preferences for Support. J Child Fam Stud 2014; 23:1050-1061. Morais et al., 2009⁴²42 Morais AC, Quirino MD, Almeida MS. O cuidado da criança prematura no domicílio. Acta Paul Enferm 2009; 22(1):24-30. Souza et al., 2010²⁵25 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1 Pt. 1):102-106.
	Speech, thought or negative influence of persons close or external, on the child and its development.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Souza et al., 2010²⁵25 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1 Pt. 1):102-106. McGowan et al., 2014⁴³43 McGowan JE, Alderdice FA, Boylan J, Holmes VA, Jenkins J, Craig S, Perra O, Johnston L. Neonatal intensive care and late preterm infants: Health and Family functioning at three years. Early Human Development 2014; 90:201-205. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131. Pal et al., 2014⁴⁴44 Pal van der SM, Alpay LL, Steenbrugge GJ, Detmar SB. An Exploration of Parents’ Experiences and Empowerment in the Care for Preterm Born Children. J Child Fam Stud 2014; 23:1081-1089.
	Concern with current and future development (intercurrences, disabilities, side effects).	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. McGowan et al., 2014⁴³43 McGowan JE, Alderdice FA, Boylan J, Holmes VA, Jenkins J, Craig S, Perra O, Johnston L. Neonatal intensive care and late preterm infants: Health and Family functioning at three years. Early Human Development 2014; 90:201-205. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131. Hall et al., 2013³⁶36 Hall EOC, Kronborg H, Aagaard H, Brinchmann BS. The journey towards motherhood after a very preterm birth: Mothers’ experiences in hospital and after home-coming. J Neonatal Nursing 2013; 19:109e113. Pal et al., 2014⁴⁴44 Pal van der SM, Alpay LL, Steenbrugge GJ, Detmar SB. An Exploration of Parents’ Experiences and Empowerment in the Care for Preterm Born Children. J Child Fam Stud 2014; 23:1081-1089.
	Caregiver self-care in the background.	Hall et al., 2013³⁶36 Hall EOC, Kronborg H, Aagaard H, Brinchmann BS. The journey towards motherhood after a very preterm birth: Mothers’ experiences in hospital and after home-coming. J Neonatal Nursing 2013; 19:109e113.
	Caregivers' poor perception of clues given by the child during care.	Winstanley et al., 2014⁴⁵45 Winstanley A, Sperotto RG, Putnick DL, Cheriand S, Bornstein MH, Gattis M. Consistency of maternal cognitions and principles across the first five months following preterm and term deliveries. Infant Behavior Development 2014; 37:760-771.
	Traumatic experience of the initial period brings fear, insecurities, even after it is over.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131. Pal et al., 2014⁴⁴44 Pal van der SM, Alpay LL, Steenbrugge GJ, Detmar SB. An Exploration of Parents’ Experiences and Empowerment in the Care for Preterm Born Children. J Child Fam Stud 2014; 23:1081-1089.
	Caregivers' mental health problems: anxiety, depression, posttraumatic stress.	Howe et al., 2014⁴⁶46 Howe TH, Sheu CF, Wang TN, Hsu YW. Parenting stress in families with very low birth weight preterm infants in early infancy. Res Dev Disabil 2014; 35(7):1748-1756. Gray et al., 2013⁴⁷47 Gray PH, Edwards DM, O’Callaghan MJ, Cuskelly M, Gibbons K. Parenting stress in mothers of very preterm infants - Influence of development, temperament and maternal depression. Early Hum Dev 2013; 89(9):625-629. Hall et al., 2013³⁶36 Hall EOC, Kronborg H, Aagaard H, Brinchmann BS. The journey towards motherhood after a very preterm birth: Mothers’ experiences in hospital and after home-coming. J Neonatal Nursing 2013; 19:109e113. Chang et al., 2014⁴⁸48 Chang HP, Chen JY, Huang YH, Tyan JY, Yeh CJ, Su PH, Chen VCH. Prevalence and Factors Associated with Depressive Symptoms in Mothers with Infants or Toddlers. Pediatr Neonatol 2014; 55:470e479. Mehler et al., 2014⁴⁹49 Mehler K, Mainusch A, Hucklenbruch-Rother E, Hahn M, Hünseler C, Kribs A. Increased rate of parental postpartum depression and traumatization in moderate and late preterm infants is independent of the infant’s motor repertoire. Early Hum Dev 2014; 90(12):797-801. Suttora et al., 2013⁵⁰50 Suttora C, Spinelli M, Monzani D. From prematurity to parenting stress: The mediating role of perinatal post-traumatic stress disorder. Eur J Dev Psychol 2013; 11(4):478-493. Huhtala et al., 2014⁵¹51 Huhtala M, Korja R, Lehtonen L, Haataja L, Lapinleimu H, Rautava P. Associations between parental psychological well-being and socio-emotional development in 5-year-old preterm children. Early Hum Dev 2014; 90: 119-124. McManusa e Poehlmannb, 2012⁵²52 McManusa BM, Poehlmannb J. Parent-child interaction, maternal depressive symptoms and preterm infant cognitive function. Infant Behav Dev 2012; 35(3):489-498.
Person	Preterm birth defines the demand: child fragility.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Pal et al., 2014⁴⁴44 Pal van der SM, Alpay LL, Steenbrugge GJ, Detmar SB. An Exploration of Parents’ Experiences and Empowerment in the Care for Preterm Born Children. J Child Fam Stud 2014; 23:1081-1089.
	Families are not clear about Adjusted Age and Chronological Age.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Growth and weight gain are understood as proper development.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Parents of preterm infants have great personal growth.	Taubman et al., 2014⁵³53 Taubman O, Ben-Ari, Spielman V. Personal Growth Following the First Child’s Birth: A Comparison of Parents of Pre- and Full-Term Babies. Social Work Research 2014; 38(2):91-106.
Context	Microsystem
	Practices learned at the NICU are reproduced at home: the institutionalization of care.	Couto e Praça, 2009¹⁰10 Couto FF, Praça NS. Preparo dos pais de recém-nascido prematuro para alta hospitalar: uma revisão bibliográfica. Rev Esc Enferm USP 2009; 13(4):886-891. Morais et al., 2009⁴²42 Morais AC, Quirino MD, Almeida MS. O cuidado da criança prematura no domicílio. Acta Paul Enferm 2009; 22(1):24-30. Costa et al., 2009⁵⁴54 Costa SAF, Ribeiro CA, Borba RIH, Balieiro MMFG. A experiência da família ao interagir com o recém nascido prematuro no domicílio. Esc Anna Nery Rev Enferm 2009; 13(4):741-749. Whittingham et al., 2014⁴¹41 Whittingham K, Boyd RN, Sanders MR, Colditz P. Parenting and Prematurity: Understanding Parent Experience and Preferences for Support. J Child Fam Stud 2014; 23:1050-1061.
	There are gaps in the provision of health team information or educational materials. This weakens parental preparation for the discharge of the child from the NICU, hindering the organization of the home environment for the provision of care.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Whittingham et al., 2014⁴¹41 Whittingham K, Boyd RN, Sanders MR, Colditz P. Parenting and Prematurity: Understanding Parent Experience and Preferences for Support. J Child Fam Stud 2014; 23:1050-1061. Souza et al., 2010²⁵25 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1 Pt. 1):102-106. Raffray et al., 2014⁵⁵55 Raffray M, Semenic S, Galeano SO, Marín SCO. Barriers and facilitators to preparing families with premature infants for discharge home from the neonatal unit. Perceptions of health care providers. Invest Educ Enferm 2014; 32(3):379-392. McGowan et al., 2014⁴³43 McGowan JE, Alderdice FA, Boylan J, Holmes VA, Jenkins J, Craig S, Perra O, Johnston L. Neonatal intensive care and late preterm infants: Health and Family functioning at three years. Early Human Development 2014; 90:201-205. Hall et al., 2013³⁶36 Hall EOC, Kronborg H, Aagaard H, Brinchmann BS. The journey towards motherhood after a very preterm birth: Mothers’ experiences in hospital and after home-coming. J Neonatal Nursing 2013; 19:109e113. Pal et al., 2014⁴⁴44 Pal van der SM, Alpay LL, Steenbrugge GJ, Detmar SB. An Exploration of Parents’ Experiences and Empowerment in the Care for Preterm Born Children. J Child Fam Stud 2014; 23:1081-1089.
	Conflicts at home and absence of one of the spouses.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131.
	Family problems with physical functioning, including feeling tires, headaches, weakness and stomachache.	McGowan et al., 2014⁴³43 McGowan JE, Alderdice FA, Boylan J, Holmes VA, Jenkins J, Craig S, Perra O, Johnston L. Neonatal intensive care and late preterm infants: Health and Family functioning at three years. Early Human Development 2014; 90:201-205. Howe et al., 2014⁴⁶46 Howe TH, Sheu CF, Wang TN, Hsu YW. Parenting stress in families with very low birth weight preterm infants in early infancy. Res Dev Disabil 2014; 35(7):1748-1756. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131.
	Problems with social functioning, restricted social role, including a sense of isolation.	McGowan et al., 2014⁴³43 McGowan JE, Alderdice FA, Boylan J, Holmes VA, Jenkins J, Craig S, Perra O, Johnston L. Neonatal intensive care and late preterm infants: Health and Family functioning at three years. Early Human Development 2014; 90:201-205. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131.
	Problems with communication, including lack of understanding of the family situation by others, difficulty in talking about the child's health condition and communication with health professionals.	McGowan et al., 2014⁴³43 McGowan JE, Alderdice FA, Boylan J, Holmes VA, Jenkins J, Craig S, Perra O, Johnston L. Neonatal intensive care and late preterm infants: Health and Family functioning at three years. Early Human Development 2014; 90:201-205.
	Problems with daily activities, including activities that need time and energy, such as domestic chores.	McGowan et al., 2014⁴³43 McGowan JE, Alderdice FA, Boylan J, Holmes VA, Jenkins J, Craig S, Perra O, Johnston L. Neonatal intensive care and late preterm infants: Health and Family functioning at three years. Early Human Development 2014; 90:201-205. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131.
	Family problems, including communication, stress and difficulty in making decisions and solving problems.	McGowan et al., 2014⁴³43 McGowan JE, Alderdice FA, Boylan J, Holmes VA, Jenkins J, Craig S, Perra O, Johnston L. Neonatal intensive care and late preterm infants: Health and Family functioning at three years. Early Human Development 2014; 90:201-205. Howe et al., 2014⁴⁶46 Howe TH, Sheu CF, Wang TN, Hsu YW. Parenting stress in families with very low birth weight preterm infants in early infancy. Res Dev Disabil 2014; 35(7):1748-1756. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131.
	Daycare or health services/professionals that favor good caregiver attitudes.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Hall et al., 2013³⁶36 Hall EOC, Kronborg H, Aagaard H, Brinchmann BS. The journey towards motherhood after a very preterm birth: Mothers’ experiences in hospital and after home-coming. J Neonatal Nursing 2013; 19:109e113. Guillaume et al., 2013⁵⁶56 Guillaume S, Michelin N, Amrani E, Benier B, Durrmeyer X, Lescure S, Bony C, Danan C, Baud O, Jarreau PH, Zana-Taïeb E, Caeymaex L. Parents’ expectations of staff in the early bonding process with their premature babies in the intensive care setting: a qualitative multicenter study with 60 parents. BMC Pediatrics 2013; 13:18.
	Toys, games and challenging contexts.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Mesosystem
	Relationships with services that serve children can be positive and conducive to development, or negative and limiting.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Pal et al., 2014⁴⁴44 Pal van der SM, Alpay LL, Steenbrugge GJ, Detmar SB. An Exploration of Parents’ Experiences and Empowerment in the Care for Preterm Born Children. J Child Fam Stud 2014; 23:1081-1089.
	Exosystem
	Preterm infants received more visits from health professionals or went more often for visits, attendance and specialized support of health services.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. McGowan et al., 2014⁴³43 McGowan JE, Alderdice FA, Boylan J, Holmes VA, Jenkins J, Craig S, Perra O, Johnston L. Neonatal intensive care and late preterm infants: Health and Family functioning at three years. Early Human Development 2014; 90:201-205.
	Micro and Mesosystem
	The family (family, friends, neighbors, grandparents) or health care (services and professionals) support network is crucial to sustaining the child's care and development.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Lundqvist et al., 2014³⁵35 Lundqvist P, Hellström-Westas L, Hallström I. Reorganizing Life: A Qualitative Study of Fathers’ Lived Experience in the 3 Years Subsequent to the Very Preterm Birth of Their Child. J Pediatric Nursing 2014; 29:124-131. Hall et al., 2013³⁶36 Hall EOC, Kronborg H, Aagaard H, Brinchmann BS. The journey towards motherhood after a very preterm birth: Mothers’ experiences in hospital and after home-coming. J Neonatal Nursing 2013; 19:109e113. Chang et al., 2014⁴⁸48 Chang HP, Chen JY, Huang YH, Tyan JY, Yeh CJ, Su PH, Chen VCH. Prevalence and Factors Associated with Depressive Symptoms in Mothers with Infants or Toddlers. Pediatr Neonatol 2014; 55:470e479. Pal et al., 2014⁴⁴44 Pal van der SM, Alpay LL, Steenbrugge GJ, Detmar SB. An Exploration of Parents’ Experiences and Empowerment in the Care for Preterm Born Children. J Child Fam Stud 2014; 23:1081-1089. Custódio et al., 2014⁵⁷57 Custódio ZAO, Crepaldi MA, Linhares MBM. Redes sociais de apoio no contexto da prematuridade: perspectiva do modelo bioecológico do desenvolvimento humano. Estudos Psicologia 2014; 31(2):247-255.
	Exosystem
	Lack of spaces for interaction, violence and drug trafficking in public spaces and neighborhoods hinder development.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Sharing experiences of other caregivers who live or lived in the same condition is positive for caregivers.	Hall et al., 2013³⁶36 Hall EOC, Kronborg H, Aagaard H, Brinchmann BS. The journey towards motherhood after a very preterm birth: Mothers’ experiences in hospital and after home-coming. J Neonatal Nursing 2013; 19:109e113. Pal et al., 2014⁴⁴44 Pal van der SM, Alpay LL, Steenbrugge GJ, Detmar SB. An Exploration of Parents’ Experiences and Empowerment in the Care for Preterm Born Children. J Child Fam Stud 2014; 23:1081-1089.
	Macrosystem
	Urban violence and lack of public welfare, culture and leisure policies hinder development.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
Time	Micro and Mesotime
Time	The family recognizes possible particularities in the continuum of the development of the preterm infant, such as delays.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906. Pal et al., 2014⁴⁴44 Pal van der SM, Alpay LL, Steenbrugge GJ, Detmar SB. An Exploration of Parents’ Experiences and Empowerment in the Care for Preterm Born Children. J Child Fam Stud 2014; 23:1081-1089.

Thematic Classification	Aspecto do cuidado	Referência
Interests and concerns of the family	Development of the preterm infant.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Causes of preterm birth or risk pregnancy.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Feeding of the preterm infant.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Knowledge of specific tests that the child must be submitted to.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Positioning and ways to carry the child.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Most common diseases in preterm infants.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Knowing the experience of other caregivers.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
Functional Development	Functional development is considered a natural consequence and result of teaching.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Preterm infants have lower scores than the normative population in functional performance evaluation tests and independence to perform activities of daily living in three main areas of functional development: self-care, mobility and social function even with age adjustment.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Cumulative effects of various environmental and biological factors influence the functional development of preterm infants.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.
	Premature infants have a less stimulating environment quantity and quality towards functional development. Functional development may be related to the care practices and the context in which the subjects are inserted.	Lemos e Veríssimo, 2015³⁴34 Lemos RA, Veríssimo MLOR. Development of premature children: caregivers’understanding according to the Bioecological Theory. Rev Esc Enferm USP 2015; 49(6):898-906.

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[1] Collaborations

Both authors participated in all phases of the preparation of this paper, including design and outline, analysis and interpretation of data, as well as drafting of the paper.