The Critical Value of Maternal and Child Health (MCH) to Graduate Training in Public Health: A Framework to Guide Education, Research and Practice.

INTRODUCTION: In light of persistent health inequities, this commentary describes the critical role of maternal and child health (MCH) graduate training in schools and programs of public health (SPPH) and illustrates linkages between key components of MCH pedagogy and practice to 2021 CEPH competencies. METHODS: In 2018, a small working group of faculty from the HRSA/MCHB-funded Centers of Excellence (COEs) was convened to define the unique contributions of MCH to SPPH and to develop a framework using an iterative and consensus-driven process. The working group met 5 times and feedback was integrated from the broader faculty across the 13 COEs. The framework was further revised based on input from the MCHB/HRSA-funded MCH Public Health Catalyst Programs and was presented to senior MCHB leaders in October 2019. RESULTS: We developed a framework that underscores the critical value of MCH to graduate training in public health and the alignment of core MCH training components with CEPH competencies, which are required of all SPPH for accreditation. This framework illustrates MCH contributions in education, research and evaluation, and practice, and underscores their collective foundation in the life course approach. CONCLUSIONS: This new framework aims to enhance training for the next generation of public health leaders. It is intended to guide new, emerging, and expanding SPPH that may currently offer little or no MCH content. The framework invites further iteration, adaptation and customization to the range of diverse and emerging public health programs across the nation.

Newborn Screening Programs and Sickle Cell Disease: A Public Health Services and Systems Approach.

INTRODUCTION: Despite universal newborn screening (NBS), children in the U.S. continue to experience morbidity and mortality from sickle cell disease and related causes. Recognizing that assessments of public health services and systems can improve public health system performance and ultimately health outcomes, this study examined variations in NBS program activities for sickle cell disease. METHODS: A mixed methods study included (1) a 2009 survey of NBS programs based on ten essential public health services (N=39 states with ten or more sickle cell births over a 3-year period) and (2) key informant interviews in 2011 with 13 states that had sufficient Phase 1 survey scores, black births, and variability in state legislation and geography. Key informants were from 13 NBS programs, 22 sickle cell treatment centers, and ten advocacy organizations. Analyses were conducted in 2009-2014. RESULTS: Considerable variability exists across states in program activities and roles. More programs reported activities oriented to care of individuals-ensuring access to services, coordination, and provider education; fewer reported planning and analysis activities oriented to statewide policy development and system change. Numbers of activities were not related to the number of affected births. In-depth interviews identified opportunities to enhance activities that support statewide comprehensive systems of care. CONCLUSIONS: NBS programs perform important public health roles that complement and enhance clinical services. Nationwide efforts are needed to enable NBS programs to strengthen population-based functions that are essential to ensuring quality of care for the entire population of children and families affected by sickle cell disease.

The MCH navigator: tools for MCH workforce development and lifelong learning.

Maternal and child health (MCH) leadership requires an understanding of MCH populations and systems as well as continuous pursuit of new knowledge and skills. This paper describes the development, structure, and implementation of the MCH Navigator, a web-based portal for ongoing education and training for a diverse MCH workforce. Early development of the portal focused on organizing high quality, free, web-based learning opportunities that support established learning competencies without duplicating existing resources. An academic-practice workgroup developed a conceptual model based on the MCH Leadership Competencies, the Core Competencies for Public Health Professionals, and a structured review of MCH job responsibilities. The workgroup used a multi-step process to cull the hundreds of relevant, but widely scattered, trainings and select those most valuable for the primary target audiences of state and local MCH professionals and programs. The MCH Navigator now features 248 learning opportunities, with additional tools to support their use. Formative assessment findings indicate that the portal is widely used and valued by its primary audiences, and promotes both an individual's professional development and an organizational culture of continuous learning. Professionals in practice and academic settings are using the MCH Navigator for orientation of new staff and advisors, "just in time" training for specific job functions, creating individualized professional development plans, and supplementing course content. To achieve its intended impact and ensure the timeliness and quality of the Navigator's content and functions, the MCH Navigator will need to be sustained through ongoing partnership with state and local MCH professionals and the MCH academic community.

Five-year follow-up of Community Pediatrics Training Initiative.

OBJECTIVE: To compare community involvement of pediatricians exposed to enhanced residency training as part of the Dyson Community Pediatrics Training Initiative (CPTI) with involvement reported by a national sample of pediatricians. METHODS: A cross-sectional analyses compared 2008-2010 mailed surveys of CPTI graduates 5 years after residency graduation with comparably aged respondents in a 2010 mailed national American Academy of Pediatrics survey of US pediatricians (CPTI: n = 234, response = 56.0%; national sample: n = 243; response = 59.9%). Respondents reported demographic characteristics, practice characteristics (setting, time spent in general pediatrics), involvement in community child health activities in past 12 months, use of ≥1 strategies to influence community child health (eg, educate legislators), and being moderately/very versus not at all/minimally skilled in 6 such activities (eg, identify community needs). χ(2) statistics assessed differences between groups; logistic regression modeled the independent association of CPTI with community involvement adjusting for personal and practice characteristics and perspectives regarding involvement. RESULTS: Compared with the national sample, more CPTI graduates reported involvement in community pediatrics (43.6% vs 31.1%, P < .01) and being moderately/very skilled in 4 of 6 community activities (P < .05). Comparable percentages used ≥1 strategies (52.2% vs 47.3%, P > .05). Differences in involvement remained in adjusted analyses with greater involvement by CPTI graduates (adjusted odds ratio 2.4, 95% confidence interval 1.5-3.7). CONCLUSIONS: Five years after residency, compared with their peers, more CPTI graduates report having skills and greater community pediatrics involvement. Enhanced residency training in community pediatrics may lead to a more engaged pediatrician workforce.

Pediatricians' involvement in community child health from 2004 to 2010.

BACKGROUND AND OBJECTIVE: Pediatricians are encouraged to engage in community child health activities, yet practice constraints and personal factors may limit involvement. The objective was to compare community involvement in 2004 and 2010 and factors associated with participation in the past year. METHODS: Analysis of 2 national mailed surveys of pediatricians (2004: n = 881; response rate of 58%; 2010: n = 820; response rate of 60%). Respondents reported personal characteristics (age, gender, marital status, child ≤5 years old, underrepresented in medicine), practice characteristics (type, setting, full-time status, time spent in general pediatrics), formal community pediatrics training, and community pediatrics involvement and related perspectives. We used χ2 statistics to measure associations of personal and practice characteristics, previous training, and perspectives with involvement in the past 12 months. Logistic regression assessed independent contributions. RESULTS: Fewer pediatricians were involved in community child health in 2010 (45.1% in 2004 vs. 39.9% in 2010) with a higher percentage participating as volunteers (79.5% vs. 85.8%; both P = .03). In 2010, fewer reported formal training at any time (56.1% vs. 42.9%), although more reported training specifically in residency (22.0% vs. 28.4%; both P < .05). Factors associated with participation in 2010 included older age, not having children ≤5 years old, practice in rural settings, practice type, training, and feeling moderately/very responsible for child health. In adjusted models, older age, practice setting and type, feeling responsible, and training were associated with involvement (P < .05). CONCLUSIONS: Formal training is associated with community child health involvement. Efforts are needed to understand how content, delivery, and timing of training influence involvement.

Healthy people 2010 leading health indicators: how children with special health care needs fared.

OBJECTIVES: We compared estimates for children with and without special health care needs (SHCN) at 2 time periods for national health objectives related to the Healthy People 2010 leading health indicators (LHIs). METHODS: Data were from the 2003 and 2007 National Surveys of Children's Health. Seven survey items were relevant to the LHIs and available in both survey years: physical activity, obesity, household tobacco use, current insurance, personal health care provider, past-month depressive symptoms, and past-year emergency department visits. RESULTS: In 2003 and 2007, children with SHCN fared worse than those without SHCN with respect to physical activity, obesity, household tobacco exposure, depressive symptomology, and emergency department visits, but fared better on current insurance and having a personal health care provider. Physical activity and access to a personal health care provider increased for all children, whereas the absolute disparity in personal provider access decreased 4.9%. CONCLUSIONS: Significant disparities exist for key population health indicators between children with and without SHCN. Analyses illustrated how population-based initiatives could be used to frame health challenges among vulnerable populations.

A new framework for childhood health promotion: the role of policies and programs in building capacity and foundations of early childhood health.

Although the connection between early life experiences and later health is becoming increasingly clear, what is needed, now, is a new organizing framework for childhood health promotion, grounded in the latest science. We review the evidence base to identify the steps in the overall pathway to ensuring better health for all children. A key factor in optimizing health in early childhood is building capacities of parents and communities. Although often overlooked, capacities are integral to building the foundations of lifelong health in early childhood. We outline a framework for policymakers and practitioners to guide future decision-making and investments in early childhood health promotion.

State school policies and youth obesity.

The objective of this study was to examine relations between state-level school policies and childhood obesity for youth ages 10-17 years. Secondary analysis of the 2003-2006 School Nutrition Environment State Policy Classification System, 2003-2007 Physical Education Related State Policy Classification System, and 2003 and 2007 National Surveys of Children's Health was performed. Eleven nutrition and 5 physical education (PE) domains were examined for elementary (ES), middle (MS), and high school (HS) children. Logistic regression models examined the association of policies on obesity prevalence in 2007 as well as change scores for the policy assessments. Scores for 5 of 11 nutrition domains and 4 of 5 PE domains increased between 2003 and 2006-2007. Controlling for individual, family and neighborhood factors, nutrition policies were positively associated with the odds of 2007 obesity in 3 ES and 2 MS domains and negatively associated with 1 HS domain. Adjusted positive associations also were observed between 2 ES and 1 MS PE policy domains and 2007 obesity. Controlling for covariates, nutrition policy change scores showed positive associations between increases in 1 ES and 1MS domain, and negative associations with 1 ES and 1 HS domain and 2007 obesity. PE policy change scores showed positive adjusted associations between increases in 2 ES, 2 MS and 1 HS domains and 2007 obesity. The findings indicate that state-level school health policies are associated with childhood obesity after adjusting for related factors, suggesting that states with higher obesity levels have responded with greater institution of policies.

Residency training and use of strategies to promote community child health one year after graduation.

OBJECTIVE: Training pediatricians to understand child health in the context of community and to develop skills to engage with community organizations remain priorities for residency education in the United States. Our objectives were to: 1) determine use of strategies to influence community child health by graduates of the Community Pediatrics Training Initiative (CPTI); and 2) to identify personal, practice, and residency program factors associated with use of strategies 1 year after residency. METHODS: Analysis of data from the Dyson Initiative National Evaluation included surveys of physicians ("graduates") 1 year after residency and surveys of CPTI program leaders. Graduates reported personal and practice characteristics and use of one or more strategies to influence community child health. Chi-square and logistic regression were used to examine associations between personal, practice, and programmatic factors with use of strategies. RESULTS: Of the 511 graduates (68% participation), 44% reported use of one or more strategies. After adjusting for residency site, time spent in general pediatrics, and program emphasis on individual level advocacy, we found that graduates were more likely to report using strategies if they felt responsible for improving community child health (adjusted odds ratio [aOR] 4.1, 95% confidence interval [95% CI] 2.5-6.9), had contact with a person who provides guidance about community pediatrics (aOR 1.8, CI 1.2-2.6), or trained in a program that places great emphasis on teaching population level advocacy skills (aOR 2.3, CI 1.3-4.2). CONCLUSIONS: Personal perspectives and residency education influence community involvement, even early in pediatricians' careers. Efforts are needed to understand how content and delivery of training influence community engagement over time.

Findings from an assessment of state Title V workforce development needs.

To describe results of a 2008 assessment of Title V workforce competencies and training needs at the state level, and examine preferences and barriers related to available education and training opportunities. A web-based survey was administered May through August, 2008 to Maternal and Child Health (MCH) and Children and Youth with Special Health Care Needs (CYSHCN) program leaders in all 50 states, and U.S. jurisdictions. Forty-nine MCH (96%) and 44 CYSHCN (86%) programs and four territories completed surveys. A major focus of the survey related to competencies in six core domains: Public Health/Title V Knowledge Base, Communication, Critical Thinking, Management Skills, Family Centered Care and Medical Home, and Leadership Development. The top training needs identified by state Title V programs fall into the global category of critical thinking, including skills in MCH data synthesis and translation, in program evaluation, and in systems thinking. The need to enhance personal rather than organizational leadership skills was emphasized. Blended learning approaches (graduate education), and national conferences with skills building workshops (continuing education) were identified as preferred training modalities. Barriers to training included lack of career opportunities, insufficient agency support, and inability to take leave (graduate education), and travel restrictions, release time limitations, costs, and limited geographic access (continuing education). Both the focus of training and preferred training modalities differed from previous MCH workforce survey findings. Given the changing needs expressed by state Title V leaders as well as their training preferences, it is important that current and future graduate education and continuing education approaches be better aligned to meet these needs and preferences.

Reducing exposure to environmental toxicants before birth: moving from risk perception to risk reduction.

In this study, we considered approaches to reducing maternal exposure to hazardous environmental toxicants, focusing on risk communication to pregnant women and providers, but also considering identification of environmental toxicants in the community and reduction of environmental toxicants. We addressed the following questions: (1) What do pregnant women and their providers know about environmental toxicants and perinatal health? and (2) What policy strategies are needed (should be considered) to move forward in risk reduction in this area? We reviewed the literature on knowledge of pregnant women and providers regarding these issues. While there is limited research on what pregnant women and their providers know about environmental toxicants and perinatal health, there is evidence of reproductive and perinatal toxicity. This article describes a wide range of policy strategies that could be implemented to address environmental toxicants in the context of perinatal health. Effective leadership in this area will likely require collaboration of both environmental health and maternal and child health leaders and organizations.

Early childhood health promotion and its life course health consequences.

OBJECTIVE: To explore whether health promotion efforts targeted at preschool-age children can improve health across the life span and improve future economic returns to society. METHODS: We selected 4 health topics to review-tobacco exposure, unintentional injury, obesity, and mental health-because they are clinically and epidemiologically significant, and represent the complex nature of health problems in this early period of life. The peer-reviewed literature was searched to assess the level of evidence for short- and long-term health impacts of health promotion and disease prevention interventions for children from before birth to age 5. This review sought to document the monetary burden of poor child health, the cost implications of preventing and treating child health problems, and the net benefit of the interventions. RESULTS: The evidence is compelling that these 4 topics-tobacco exposure, unintentional injury, obesity, and mental health-constitute a significant burden on the health of children and are the early antecedents of significant health problems across the life span. The evidence for the cost consequences of these problems is strong, although more uneven than the epidemiological data. The available evidence for the effectiveness of interventions in this age group was strongest in the case of preventing tobacco exposure and injuries, was limited to smaller-scale clinical interventions in the case of mental health, and was least available for efforts to prevent obesity among preschoolers. CONCLUSIONS: Currently available research justifies the implementation of health interventions in the prenatal to preschool period-especially to reduce tobacco exposure and prevent injuries. There is an urgent need for carefully targeted, rigorous research to examine the longitudinal causal relationships and provide stronger economic data to help policy makers make the case that the entire society will benefit from wise investment in improving the health of preschool-age children and their families.

Pediatricians' involvement in community child health from 1989 to 2004.

OBJECTIVES: To explore pediatricians' current involvement in community child health activities, to examine trends in community involvement from 1989 to 2004, and to compare perspectives and skills related to community involvement among those participating and not participating in community activities. DESIGN: Cross-sectional analysis of 3 American Academy of Pediatrics Periodic Surveys of Fellows. PARTICIPANTS: In the 1989, 1993, and 2004 surveys, 1024, 1627, and 1829 pediatricians participated, respectively (response rates: 70.3%, 65.2%, and 57.6%). MAIN OUTCOME MEASURES: Involvement, skills, and perspectives related to community child health activities. RESULTS: The percentage of pediatricians involved in community child health activities in the preceding year rose from 56.6% in 1989 to 59.4% in 1993 but declined to 45.1% in 2004. Pediatricians increasingly reported that these activities were volunteer rather than paid (48.6% in 1989, 57.8% in 1993, and 79.6% in 2004). More participants in community child health activities vs nonparticipants viewed their current level of involvement as "just right" (52.5% vs 24.9%), reported themselves to be very responsible for children's health (42.2% vs 24.9%), expected their community work to increase during the next 5 years (63.5% vs 54.1%), and reported higher skills in 6 areas (all P < .001). CONCLUSIONS: Although there has been decreased participation in community child health, most pediatricians expect their community efforts to increase. Because most community activities are volunteer, challenges to address include incorporating community involvement into employment and identifying strategies to facilitate voluntary civic engagement.

Pediatricians' perspectives regarding community child health: training, involvement, and expectations according to age.

OBJECTIVE: There are increasing opportunities for pediatricians to promote children's health through community involvement during and after residency training. Little is known about whether younger relative to established pediatricians have different experiences regarding community activities. In this study we examined whether pediatricians' training, perspectives, and involvement in community activities vary by age. METHODS: Eight hundred seventy-six pediatricians participated in a national, random-sample, mailed periodic survey of US members of the American Academy of Pediatrics in 2004 (response rate: 58%). Chi2 statistics and median tests were used to measure associations of age (< or = 34, 35-39, 40-50, and > or = 51 years) with training, perspectives, and involvement. RESULTS: Younger pediatricians reported more training in community child health during and before residency but were less likely to be involved currently (37.9% for < or = 34 years, 44.4% for 35-39 years, 46.2% for 40-50 years, 48.3% for > or = 51 years). They were more likely to report that their current involvement was too little versus just right or too much (81.3%, 73.5%, 60.7%, and 47.1%, respectively). Younger pediatricians were more willing to spend > or = 1 hour/month on community child health activities (95.0%, 91.2%, 89.7%, and 85.4%, respectively). Younger versus older pediatricians were more likely to sense moderate or greater responsibility for improving children's health in their community (83.6%, 77.2%, 76.7%, and 70.2%, respectively) and expected their community work to increase during the next 5 years (80.0%, 67.5%, 59.7%, and 40.1%, respectively). Age findings persisted when adjusted for gender. CONCLUSIONS: Although practice constraints may limit community involvement, younger pediatricians anticipated growing participation in community activities. Longitudinal studies are needed to determine whether such expectations are realized.

Healthy Steps for Young Children: sustained results at 5.5 years.

OBJECTIVE: We sought to determine whether Healthy Steps for Young Children has sustained treatment effects at 5.5 years, given early findings demonstrating enhanced quality of care and improvements in selected parenting practices. METHODS: Healthy Steps was a clinical trial that incorporated developmental specialists and enhanced developmental services into pediatric care in the first 3 years of life. A total of 5565 children were enrolled at birth and followed through 5.5 years. Healthy Steps was evaluated at 6 randomization and 9 quasi-experimental sites. Computer-assisted telephone interviews were conducted with mothers when Healthy Steps children were 5.5 years of age. Outcomes included experiences seeking care, parent response to child misbehavior, perception of child's behavior, and parenting practices to promote development and safety. Logistic regression was used to estimate overall effects of Healthy Steps, adjusting for site and baseline demographic characteristics. RESULTS: A total of 3165 (56.9%) families responded to interviews (usual care: n = 1441; Healthy Steps: n = 1724). Families that had received Healthy Steps services were more satisfied with care (agreed that pediatrician/nurse practitioner provided support, 82.0% vs 79.0%; odds ratio: 1.25 [95% confidence interval: 1.02-1.53]) and more likely to receive needed anticipatory guidance (54.9% vs 49.2%; odds ratio: 1.33 [95% confidence interval: 1.13-1.57]) (all P < .05). They also had increased odds of remaining at the original practice (65.1% vs 61.4%; odds ratio: 1.19 [95% confidence interval: 1.01-1.39]). Healthy Steps families reported reduced odds of using severe discipline (slap in face/spank with object, 10.1% vs 14.1%; odds ratio: 0.68 [95% confidence interval: 0.54-0.86]) and increased odds of often/almost always negotiating with their child (59.8% vs 56.3%; odds ratio: 1.20 [95% confidence interval: 1.03-1.39]). They had greater odds of reporting a clinical or borderline concern regarding their child's behavior (18.1% vs 14.8%; odds ratio: 1.35 [95% confidence interval: 1.10-1.64]) and their child reading books (59.4% vs 53.6%; odds ratio: 1.16 [95% confidence interval: 1.00-1.35]). There were no effects on safety practices. CONCLUSIONS: Sustained treatment effects, albeit modest, are consistent with early findings. Universal, practice-based interventions can enhance quality of care for families with young children and can improve selected parenting practices beyond the duration of the intervention.

Community pediatrics: a consistent focus in residency training from 2002 to 2005.

OBJECTIVE: To assess changes in community pediatrics training from 2002 to 2005. METHODS: Pediatric residency program directors were surveyed in 2002 and 2005 to assess resident training experiences in community pediatrics. Program directors reported on the following: provision of training in community settings; inclusion of didactic and practical teaching on community health topics; resident involvement in legislative, advocacy, and community-based research activities; and emphasis placed on specific resources and training during resident recruitment. Cross-sectional and matched-pair analyses were conducted. RESULTS: A total of 168 program directors participated in 2002 (81% response rate), and 161 participated in 2005 (79% response rate). In both years, more than 50% of programs required resident involvement with schools, child care centers, and child protection teams. Compared with 2002, in 2005, more programs included didactic training on legislative advocacy (69% vs 53%, P < .01) and offered a practical experience in this area (53% vs 40%, P < .05). In 2005, program directors reported greater resident involvement in providing legislative testimony (P < .05), and greater emphasis was placed on child advocacy training during resident recruitment (P < .01). CONCLUSIONS: In the last several years, there has been a consistent focus on legislative activities and child advocacy in pediatric residency programs. These findings suggest a strong perceived value of these activities and should inform efforts to rethink the content of general pediatric residency training in the future.

Achieving safe motherhood: applying a life course and multiple determinants perinatal health framework in public health.

Safe motherhood has begun to be identified as a priority for the health of American women. We argue that safe motherhood can be achieved through application of a life course and multiple determinants framework. This framework, with its focus on the preconception period, poses a dilemma in that it links together periods of life and domains of activities that have traditionally not been linked with maternal health. The interests of women and children have often been juxtaposed in the making of policy. Further, the domains of women's health, maternal and child health, and family planning have often clashed over policy priorities and funds. This framework shows that the research literature now links them inextricably to better health outcomes, albeit indirectly; there are no intervention studies that have demonstrated the empirical efficacy of this approach. Thus, although this framework creates a strong rationale for the linkages described, it also demands attention to a set of implementation strategies that will overcome existing barriers. Through a focus on one maternal factor, obesity, we discuss how a range of strategies grounded in the framework can be undertaken to address maternal morbidity and mortality. We then examine selected strategies at each level of the multiple determinants life course framework and emphasize how public policies and public and private sector professional practice can be reexamined to improve outcomes for women in all time periods and aspects of reproductive potential, which in turn might enhance outcomes for their offspring, both at birth and beyond. Our intent is to influence how policy makers, public health professionals, clinicians, and researchers approach safe motherhood.

The association between women's health information use and health care visits.

OBJECTIVE: To determine the effect of the type of information sources used on health services use. METHODS: Population-based random-digit dialing survey of 498 women, between December 1999 and January 2000, on use of health information sources and health visits. RESULTS: After adjustment for sociodemographic and medical factors, use of print health media and computer-based resources was associated with 1.9 and 1.6 more visits, respectively compared to non-use (Regression coefficients 1.9; [95% confidence interval {CI} 0.1, 3.7] and 1.6; [95% CI 0.3, 3.0]). CONCLUSIONS: Print health media and computer-based sources are associated with a higher number of health care visits.

The FIMR evaluation: objectives, concepts, frameworks, and methods.

FIMR is now a widespread strategy that has been adopted by more than 200 communities nationwide. Examining the impact of FIMR programs in a rigorous fashion presented a formidable challenge. A complex multiphase study design and innovative outcome measures were developed for the nationwide evaluation of FIMR. Data were collected from multiple respondents in nearly 200 communities across the United States. The results of this evaluation are an important contribution to the literature on the value of FIMR. However, while our study represents a substantial improvement over past research, limitations persist. Future work in this area will need to creatively address these limitations in order to better understand the effect of FIMR programs in communities.