Picking up the thread of Dr. Lamberty's assertions about the need for State
MCH leaders to attend to science in the practice of their professional posts,
Dr. Edward Schor6, noted the routine and frequent
opportunities present. By reviewing a typical week's work schedule of a State
Title V Program Director, Dr. Schor highlighted several examples of how research
can and should inform public health practice and policy. Scientific data ideally
should lead to, for instance, new strategies for:
- Encouraging families to enroll their children in Medicaid and SCHIP.
- Encouraging proper sleep position across child care settings to prevent
Sudden Infant Death Syndrome (SIDS).
- Promoting fatherhood initiatives.
- Decreasing perinatal risk factors among minority women.
Given the breadth of activities consuming the workweek, it was clear from this
presentation that timely application of research required that:
- Practitioners receive updates of latest scientific evidence in usable and
digestible formats.
- Research be designed, in part, to address local needs. In particular, Dr.
Schor highlighted the limited application of national statistics on children's
health to describe the health status and needs of local communities.
Dr. Schor outlined a paradigm contrasting public health practice with public
health research in academia with regard to work activities, training, and relevance
to public health.
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| Domains |
Public
Health Practice |
Public
Health in Academia |
| Work
Activities |
- Apply knowledge.
- Work directed by legislature.
- Data used for change.
- All work applied, needs to be effective.
- Programs may need to start quickly in absence of information.
- Depend on others to implement.
|
- Create new knowledge.
- Work guided by scientific inquiry and funding.
- Data used to understand what is happening.
- All work investigative, needs to be efficacious.
- Work builds directly on prior information.
|
| Training |
- Great variability in training and socioeconomic status (SES).
|
- Highly educated and generally well paid.
|
| Relevance
to Public Health |
- Opportunity to make difference.
- Educate the public.
|
- Sometimes makes difference in public health.
- Education of professionals.
|
Notwithstanding the many differences noted between public health practitioners
and academic faculty, several similarities with subtle distinctions were noted
as well:
- Both researchers and academicians are subject to accountability; the former
through public scrutiny and accountability, and the latter by peers and academic
promotion committees.
- Both serve as educators; public health workers often are charged with educating
the public and may rely on marketing techniques to complete their assignments,
while faculty are responsible for student learning and rely on more traditional
methods of teaching.
- Both public health practitioners and academicians are users of data with
practitioners focused on data to change or evaluate programs and academicians
relying on data to explain observed phenomena.
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Partners in Prevention Study
Dr. Peter Margolis7 presented an example of a project involving researchers, policymakers and practitioners in the North Carolina area. The University of
North Carolina aligned with several stakeholders to begin the task of improving
the delivery of preventive health services to some of the State's most needy
children. The collaborative included such organizations as:
- The Children's Primary Care Research Group.
- The North Carolina Division of Medical Assistance.
- The North Carolina Office of Rural Health.
- The North Carolina Area Health Education Centers.
As backdrop, Dr. Margolis outlined some of the difficulties that exist in the
clinical practice of prevention in pediatric populations. These barriers fall
into three general areas: patient-related barriers, practitioner-related barriers,
and those related to the actual practice itself. Processes that could aid in
addressing certain of those barriers include:
- Establishing guidelines for care.
- The screening of charts and provider prompting of patients.
- Tracking systems.
- Counseling.
- More actively involving patients in their care.
Dr. Margolis next briefly described the randomized controlled trial study,
the goal of which was to evaluate the role of certain specified interventions
on increasing the rates of preventive services in pediatric and family practices.
The main hypothesis for the study was that the implementation of "office systems"
would produce dramatic results in preventive services in those practices participating. The interventions were designed to circumvent some of the identified barriers
to preventive services. The researchers measured rates of preventive services
received, the processes of care delivery, and organizational factors such as
practice, physician, and staff characteristics and culture.
The study encountered several challenges but ultimately, through the collaboration
effort, was able to demonstrate that:
- "Office systems" approaches were feasible to implement and could be effective.
- Practice-based assistance blended quality management with continuing medical
education.
- This effort could serve as a model for collaborative learning that involves
practicing physicians, policymakers and academic researchers.
This effort demonstrated that there are ways and means by which we can improve
the outcomes of care for children and collaboration.
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Longitudinal Study Research as a Collaborative Endeavor
Dr. Penny Hauser-Cram8 presented a second example of a collaboration integrating child health research and practice, citing the Early Intervention Collaborative Study, a longitudinal study of children with developmental disabilities and their families.
In this study, data were collected from 178 children with Down Syndrome, motor
impairment and developmental delay during infancy, toddlerhood, and ages 3,
5, and 10 years. Data are currently being collected at age 15 years. Although
data on a wide range of constructs relating to child development and parental
well-being have been collected, the presentation focused on a subset of variables,
specifically mastery motivation, cognitive performance, mother-child interaction
and parent stress.
The results indicated that children who had higher levels of mastery motivation
and whose mothers had more positive levels of mother-child interaction at age
3 (the time of departure from early intervention services) showed stronger cognitive
development over the middle childhood period. Discussion focused on the way
in which children who are more highly directed by adults become less self-directed
and thus diminish their problem-solving ability.
In terms of parent well-being over time, results based on parent reports indicate
that stress was within normative levels for both mothers and fathers during
the infant and toddler years. Stress of both parents increased significantly
during the middle childhood years, with levels of paternal stress exceeding
those of maternal stress. Discussion focused on the value of early intervention
and school-age programs for children with disabilities understanding the needs
of fathers and paying attention to parental adaptation during the school-age
years.
Collaboration was central to the success of this project and was essential
at several key points including the project's inception and during children's
transitions from one service system to another. Further, collaboration was beneficial
for acquiring a range of perspectives about the study results and a broad base
for dissemination of study findings. Collaboration occurred with policymakers
in the Massachusetts Department of Public Health, early intervention service
providers, public school teachers, advocacy organizations, and parents. The
parent advisors to this project had children with special needs only slightly
older than those in the study. Therefore, parents provided reflection on and
elaboration of the study findings and assisted in anticipating the important
questions to include during the next phase of the study.
The collaborative efforts taken within this project also stimulated further collaboration with agencies not initially involved. For example, the findings on the relation between mastery
motivation (measured during the preschool years) and children's later development
prompted a series of discussions with individuals in the Massachusetts Department
of Education Bureau of Early Childhood. Those discussions resulted in collaboration
in the development of a series of workshops held throughout the state for preschool
teachers which focused on ways of encouraging children's mastery motivation
and self-agency.
In conclusion, collaboration is essential to facilitate the research-to-practice
relationship. Because collaborators are good consumers of research, it is important
for stakeholders to develop a sense of ownership early in the collaborative
process. Collaboration around dissemination often results in a national and
regional approach. Regional and local meetings are important (and often overlooked)
ways of disseminating information. Dr. Hauser-Cram emphasized that collaboration,
although difficult, is necessary to ensure that meaningful questions are studied,
a range of perspectives are included, and a deeper understanding of the research
is achieved.
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Mr. Gordon Berlin9 drew on examples of the Manpower Demonstration Research Corporation's
(MDRC) research projects to highlight how "timely findings based on convincing
research methods, employed by an organization regarded as impartial, and lucid,
persistent presentation" can be used to make a difference in policy and practice.
MDRC is a research and demonstration intermediary organization that tests new
approaches to the Nation's social welfare problems.
Elements of success for the research include a clear research question, for
example, "What effect do mandates and incentives have on work, welfare, income,
and children?" Mr. Berlin indicated that the results of research are successfully
adopted into policy for several reasons, including:
- Presence of a strong study design.
- Results are reproducible across studies.
- Results are policy-relevant.
- Results receive community, agency, and political buy-in.
- Information is persistently disseminated.
Results from the MDRC's Minnesota's Family Investment Program (MFIP) study
were replicated in the study of Self Sufficiency Project (SSP), a demonstration
program in Canada that began in 1992 in New Brunswick and British Columbia.
Findings from MFIP and SSP both demonstrated rises in the rate of employment,
earnings and income rise, with a decrease in poverty.
MDRC studied, for example, how children might be affected when parents transition
from welfare to work. Negative effects may include parents' increased levels
of stress from the job and having less time available for their children. Positive
impacts on the children may include increased family incomes, reduced parental
stress from the increased income, improved home or care environments, and provision
of good role models.
For research results to have an impact on policy, the research must answer
the policy-relevant questions of what, how, and why. Research needs to have
a "real world field test" component that demonstrates that the particular program,
for example, is politically and operationally feasible. The research must be
rigorously designed, with a large sample, and high-quality data. Ownership in
the results, in the form of community support, needs to be built. In other words,
according to Mr. Berlin, "explain, explain, explain, and win the community over...Contextualize and simplify the results, and actively disseminate the results
without advocating for them." He emphasized that model development is an iterative
process and that small differences matter. Berlin specifically mentioned that
it is possible to learn from failures. Further, he noted that replication is
key.
A critical aspect of MDRC's function and process is that it internalizes the
traditional tension between operators (program managers and staff) and researchers.
Operational issues are seen as MDRC's problem, and they are addressed before
releasing the information in order to minimize the potential for challenges
from the field that can distract attention away from the core message of the
findings. Operational details, Berlin stressed, matter at all staff levels,
including program directors, managers, and line staff.
Research conclusions must be clearly stated, and must differentiate between
outcomes and impacts. Mr. Berlin used a simple example to illustrate this point.
If Program A places 60 percent of its participants in jobs, but Program B placed
only 30 percent of participants in jobs, Program A seems to be better than
Program B. However, Program A may only have had a 10 percent differential impact
beyond what occurs normally for the control population, while Program B had
a 20 percent differential impact. Thus, the impact of Program B was greater
than that of Program A.
In conclusion, Mr. Berlin stressed that information dissemination is a key
aspect of translation from research into policy and practice. A media strategy
for release should include stories and editorials in papers, radio, TV, and
the trade press. All stakeholders should be targeted, including:
- Public interest groups.
- Governors.
- Federal, State and local legislators.
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Meeting participants convened in four working groups to outline an agenda
for enhancing the use of child health research in MCH policy and practice. Group
assignments ensured a balance of State MCH practitioners, researchers, and representatives
from national organizations. Each group completed two tasks:
- Each group discussed one of eight content areas identified as an urgent
and emerging policy and program topic.
- Using this information, barriers were identified, and each group identified
specific opportunities for action as well as key players and/or constituencies
who would need to be involved.
On reconvening in plenary session, the working groups shared the results
of their respective discussions, which identified several cross-cutting themes
and potential improvement strategies. The perspectives shared during the working
group sessions are reflected in the conclusion section.
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Dr. Maxine Hayes10 and Dr. Modena Wilson11 reflected on the day's presentations
and discussions.
Dr. Hayes highlighted issues regarding inclusivity in addressing
child health issues, placing research issues and strategies in the context of
how the health system is currently operating, and regarding the need to draw
on what is already known about child health to address contemporary questions.
She has served in leadership posts in both community health centers and State
maternal and child health programs. Given this experience, she emphasized the
need in future gatherings of child health researchers and program leaders to
bring local health agencies and community health providers, health plan medical
directors, and benefits managers into discussions about translating information
to action.
She further noted that a great deal of research on what constitutes
the appropriate content of child health services has been conducted, and that
defining research agendas to address the contemporary system structures should
follow strategic synthesis of the existing evidence in this regard. We need
not rediscover what is known; we need instead to better understand the application
of that information at the community level, and with respect to health plan
and care payment strategies. Further, Dr. Hayes recommended that we in the United
States take a page from the international child health arena—that we pursue
strategies guided by our intuition, as well as data.
With specific regard to data, Dr. Hayes pointed out that although national
level data are plentiful, these data sets are not strategically designed to
answer questions in the current context. Data routinely collected at the national
level are difficult to combine in meaningful ways to provide the multidisciplinary
perspective necessary to answer questions of child health. Moreover, these data
are too rarely applicable to community populations. Information is needed from
both public and private providers, but resources must be made available to support
such data collection and reporting. Data collection further needs to reflect
the composition of our country and communities; an example would be including
more minority populations and providers in the Pediatric Research in Office
Settings program.
Dr. Hayes proposed that a partnership of child health researchers, policymakers,
and practitioners seize the opportunity this meeting provided to envision and
pursue a well-focused research strategy. This strategy will need to view child
health broadly in terms of health needs and consequent system challenges, but
simultaneously provide results that are local and that can be applied by local
constituents to community contexts.
Dr. Wilson challenged the group to recognize that the "bridges" connecting
child health research, policy, and practice were already present, though vastly
underutilized. Constraints of time, costs, competing priorities, disparate goals
among relevant stakeholders, and a history of unsuccessful collaborations were
among the constraints identified as contributing to the "light traffic" on existing
bridges.
Citing the recent editorial by Chris Collins and Thomas Coates, Dr. Wilson
encouraged the cohabitation rather than divorce of science and health policy
to improve public health (Collins and Coates, 2000). While rigorous science should
inform public policy, researchers should understand the political implications
of their findings. She further indicated that true collaborative efforts required
that discussion among the players begin before or when relevant scientific questions
are being identified and study designs selected. Waiting until results are available
and ready to be translated to other audiences will be too late.
Dr. Wilson suggested that true collaboration among researchers, practitioners,
and policymakers would require mutual respect for two different types of questions.
Researchers were characterized as favoring tightly defined scientific questions
and relying on longitudinal, costly, randomized study designs to provide the
most precise scientific answers. Policymakers, on the other hand, were characterized
as preferring questions relevant to a particular locale or subgroup of the population;
as such, policymakers might prefer a quasi-experimental design and value generation
of more timely results to inform the question at hand. Dr. Wilson highlighted
the need for researchers to remain autonomous but not isolated, and to seek
the participation of community members and policymakers in identifying appropriate
research questions. In turn, the general public, press, and policymakers share
in the responsibility for translating findings and disseminating results.
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During this meeting, a number of challenges were explored with respect to both
enhancing the knowledge base related to child health and to translating what
becomes known in ways that positively affect MCH policy and practice. Of particular
concern to participants were research topics and challenges related to children's
oral health and mental/behavioral health, and the wide range of issues specific
to the population of children with special health care needs. Thorny research
challenges for priority attention also were identified, including school
health; Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Service; and care coordination services.
Each of the stakeholder professions and organizations represented at the meeting
has a role to play in ensuring that current knowledge about child health and
child health services is embraced by practitioners and policymakers. These
same groups and individuals further can contribute to development of new methods
for studying the particularly complex research challenges specific to child
health service delivery systems.
Researchers face many obstacles in developing studies that are practice- or
policy-relevant. Many such barriers can be traced back to the rigors of the
scientific method. The field of child health, like many others, is complex,
involving a broad range of ideas, activities, and individuals. This complexity
makes it very difficult to define the specific questions that need to be answered.
Within the community of child health, there is lack of consensus on the key
research questions, indicators, and outcomes.
Also, the scientific paradigm often limits the pace of knowledge acquisition,
with findings becoming available long after policies have been voted on or programs
have been put into place. Further, the simultaneous involvement of multiple
agencies or implementation of multiple interventions presents methodological
challenges in systems level research.
Strategies to address the concerns identified above that emerged from the day's
discussions involve:
- Enhanced communication venues.
- Alleviation of structural barriers.
- Research methods development.
Conferees noted that the child health research agenda needs to be formed collaboratively
and to be focused, concentrating the energies of Government agencies, foundations,
and researchers. The specific knowledge-base issues addressed should be prioritized
with end-users in mind. To ensure that studies with the right ingredients/formula
are undertaken, review panels need to include all relevant stakeholders. Given
especially the current political culture emphasizing devolution of accountability
from the national to more local levels, State and community child health leaders
and families should be viewed and used as key participants in these processes.
Moreover, making all of the above a reality requires modifying the structures
and processes of the academic paradigm. Faculty incentives in schools of public
health and graduate training programs need to value the application of research
to practice. As students enter doctoral and other programs of advanced study,
their curriculum must emphasize these priorities as well. It will be especially
important that academic deans embrace the goal of enhanced links between science
and practice in children's health. In addition, agencies funding doctoral training
can contribute by creating incentives and programs to foster development of
a new type of academic researcher. Matching students with professionals in public
health practice as research mentors and targeting dissertation grants to practice-related
research topics were proposals in this regard.
Dissemination of knowledge once acquired is fundamental to a forward agenda.
Practitioners and policymakers experience information overload, and a lack
of consensus regarding the locus of responsibility for translation persists.
The creation of "translation centers" might circumvent certain thorny issues,
with groups of end-users consulting on the most useful/helpful means to communicate
the findings. National professional organizations can play a key role. Requirements
for inclusion of translation and dissemination plans as deliverables in research
projects was identified as an important tool of funding organizations. Finally,
joint conferences among national groups, professional organizations, and others
should be pursued on a frequent and ongoing basis to enable enhanced interaction
of child health research, policy, and practice over time.
The goal of this meeting was to enhance child health research and practice
collaboration and integration. Participating organizations and individuals expressed
interest in implementing the strategies identified. Their commitment will be
evidenced as the convening organizations develop specific concrete action steps
to implement the recommendations articulated.
6Edward Schor, M.D., Medical Director, Family
and Community Health, Iowa Department of Public Health.
7Peter Margolis, M.D., Ph.D.,
University of North Carolina Healthcare System.
8 Penny Hauser-Cram, Ed.D., Associate
Professor of Developmental Psychology at the Lynch School of Education at Boston
College.
9Gordon L. Berlin , Senior Vice President for Work, Community, and Economic
Security at the Manpower Demonstration Research Corporation (MDRC), New York,
NY.
10Maxine Hayes, M.D. is the Health Officer for the State of Washington.
11Modena Wilson, M.D. is the Director of Committees and Sections at the American Academy
of Pediatrics.
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Current as of September 2001
Internet Citation:
Building Bridges for Child Health Research, Policy and Practice. Conference Summary. September 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/bridgesch/bridge1.htm
540 Gaither Road Rockville, MD 20850