Building Bridges for Child Health Research, Policy and Practice: Confe
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.
|Domains||Public Health Practice||Public Health in Academia|
|Relevance to Public Health|
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.
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.
- 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.
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.
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.
- Federal, State and local legislators.
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.
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.
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
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