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Introduction & Table of Contents: The MCH Training Program: An Evaluation
Chapter 1: Introduction & Methodology
Chapter 2: A Statistical Snapshot of the MCH Training Program
Chapter 3: Training for Leadership
Chapter 4: Supporting Faculty in Leadership Roles
Chapter 5: Contributing to Advances in the Field
Chapter 6: Promoting Collaboration
Chapter 7: The Economics of MCH Training
Chapter 8: Recommendations
Notes
Appendix
Chapter 5: Contributing to Advances in the Field illustration of woman holding an infant that is being examined by 2 health care physicians image of mother soothing a crying infant

Although the primary mission of the MCH Training Program is to train a new generation of MCH leaders and clinicians, it also fosters improvements in the health of women and children through other means. This evaluation examined the ways in which the MCH Training Program nurtures new professional subspecialties; influences professional associations; develops innovations in treatment and services; serves as a voice for women and children—within universities, with legislative bodies and other policymakers, and with the public; and encourages research, especially applied research.

NURTURING NEW PROFESSIONAL SUBSPECIALTIES

The history of the MCH Training Program includes examples of new subspecialties that have clearly arisen as a result of MCH support, such as pediatric cardiology and adolescent health. MCH support has been pivotal for other subspecialties, including developmental/behavioral pediatrics and neurodevelopmental disabilities. MCH training projects produce trainees who form the key cadre of clinicians for such subspecialties, and project directors typically lead the movement to establish a subspecialty and define its sphere. For example, pediatricians from LEND programs collaborated to develop the subspecialty in pediatric neurodevelopmental disabilities. Additionally, the director of the LEND grant at the University of Alabama at Birmingham currently serves as the chair of the examination committee for the subspecialty certification; in that capacity, he will have great power in determining the content of national neurodevelopmental pediatrics training.

Sometimes, rather than support a subspecialty, MCH training grants help to integrate MCH issues into professional training. The requirement that all pediatricians have a residency rotation in behavioral pediatrics is attributed by one project director to MCH support. The curriculum modules developed by the social work program at the University of Maryland at Baltimore provide another example of integration of MCH into an entire field. The University of Maryland at Baltimore modules have been disseminated to all schools of social work in the United States for use in required courses.

INFLUENCING PROFESSIONAL ASSOCIATIONS

MCH training grant faculty are encouraged to work within their professional associations on behalf of women and children. Many faculty become active in their associations by holding offices or chairing committees or sections, where as others participate through giving presentations and participating in poster sessions at annual conferences. Such work leads to a greater appreciation of the needs of women and children, and helps associations address issues that need attention (e.g., family-centered care for children with special health care needs). In some professional associations, grantees constitute a critical mass of like-minded individuals who work together on policy and program issues to the benefit of women and children; they provide mutual support and diverse expertise, leading to opportunities for even greater influence. A few examples of the current leadership activities of MCH training grant faculty are shown in Figure 15.

In addition to serving in leadership positions in professional associations, MCH training grant recipients work in other capacities in those associations, for example, as journal editors, conference presenters, and as developers and disseminators of curriculum materials.

The Maternal and Child Health Bureau (MCHB) has occasionally capitalized on the leadership of MCH Training Program grant-supported faculty within professional associations by providing funding to a grantee to convene a group specifically to address a particular issue. For example, the American Academy of Pediatrics and the American Public Health Association were jointly supported to develop new child care standards, which were completed in 1992.

DEVELOPING INNOVATIONS IN TREATMENT AND SERVICES

The MCH Training Program promotes quality improvements in health services for women and children, such as through the development and promulgation of clinical practice guidelines. In addition, it fosters new services in communities. Although the development of new services is not an explicit goal of the MCH Training Program, the site visit team was impressed with the extent and range of Training Program contributions in this area. In particular, projects that train fellows appeared to be prolific in the number of community service programs initiated and creative in the innovations incorporated into those programs. Figure 16 presents a few examples of recent innovations in treatment and services supported through MCH training grants.

 
Figure 15: Examples of Recent Leadership Activities of
MCH Training Program Grant Faculty
• Member, Ethics Board of American College of Obstetricians and Gynecologists
• President, Association of Teachers of Maternal and Child Health
• President, Graduate/Postgraduate Section,American Association of Dental Schools
• Board member,Academy of Eating Disorders
• Member of Governing Council,American Public Health Association
• Member of Executive Council, Society for Developmental and Behavioral Pediatrics
• Advisor,American Certified Nurse Midwives’ MCH Provider Partnerships
• Member, Board of the Perinatal Reproductive Health Association
• Past president,American Dietetic Association
• Consultant, North Carolina State Board General Anesthesia Panel for Pediatric Dentistry
• Task Force chair,American Medical Association,“Strategies to Improve Training of Primary Care Physicians in Providing Adolescent Preventive Health Services”
• Chair, Subspecialty Board of Adolescent Medicine,American Board for board-certification examination in adolescent medicine)
• Director, State-Wide School-Based Sealant Program
• Director,American Board of Psychiatry and Neurology

SERVING AS A VOICE FOR CHILDREN

MCH training grant recipients are powerful voices for children. They bring the latest research and knowledge into both local and national deci-sion-making settings, and they serve as passionate child advocates, seeking to improve the health of

 
Figure 16: Examples of Treatment and Service Innovations
• Development of guidelines for the home care of children with tracheotomies (collaborative project of four PPCs: University of Alabama at Birmingham,Tulane University, University of Florida, and University of Wisconsin-Madison)
• Establishment of a new adolescent health clinic in an urban hospital (Charles R. Drew University for Medicine and Science, HBCU)
• Development of an evidence-based positioning protocol for infants in the neonatal intensive care unit (NICU) (University of Washington, Physical Therapy)
• Organization of a conference for managed care administrators on the equipment needs of children with special health care needs, leading to an easing of restrictions and delays in securing such equipment (Oregon Health Sciences University, LEND)
• Establishment of a legal advocacy program at an inner-city hospital to assist families in accessing resources and services, such as housing and school-based health services (Boston University, Behavioral Pediatrics)
• Development and dissemination of clinical practice guidelines on attention-deficit/hyperactivity disorder (University of Washington, Nursing)
• Establishment of statewide teams to work with and train local health care providers so that children with special health care needs have a medical home (University of Washington, LEND)
• Establishment of a mechanism (i.e., sports medicine clinics) to recruit into health care services those minority, inner-city males who might not otherwise receive preseason examinations, medical care, or other health screening services (Baylor College of Medicine, LEAH)
• Development of new NICU guidelines for the Baltimore Infant and Toddler Program (University of Maryland at Baltimore, Behavioral Pediatrics)
• Development of evidence-based nutrition guidelines (University of Washington, LEND)
• Establishment of an asthma clinic for inner-city, high-risk children (University of Washington, PPC; University of Alabama at Birmingham, PPC)

the nation’s children. The emphasis in the Training Program on policy both enables and promotes such advocacy. Grantees have made contributions that have had significant, long-term effects; for example, staff from the LEND program at the University of Alabama at Birmingham worked with parents, advocates, and congressional staff in assisting to develop the legislative language for the Individuals with Disabilities Act (IDEA) of 1986, a law that continues to change the way in which persons with special needs are treated in our society. Grantees have also served on national policy development groups, such as the Institute of Medicine Forum on Adolescence (University of California at San Francisco, LEAH). Many grantees have worked in collaboration with state legislative bodies; for example, by providing expert testimony at the request of legislators. Figure 17 provides a few examples of policy work of grantees.

ENCOURAGING RESEARCH

The MCH Training Program does not directly fund research, but it does encourage research in several ways. First, in its support of interdisciplinary projects, the program enables some departments to expand their range of expertise, which often makes the departments more competitive in applying for research grants. In doctoral programs, most of the fellowship programs, and some master’s-level programs, trainees must complete a research project; the results of these projects increase the knowledge base in a given field. Such projects also train students in research methodology, leading to a new generation of researchers.

Projects examined in this evaluation that had a strong research component, especially if the focus was on applied research, frequently also had the strongest technical assistance and continuing education components. Research ensures that faculty are at the forefront of their fields, and the grant encourages faculty to convey research findings to community, state, and national audiences.

One measure of research accomplishment is publications. In FY 1999, the total number of faculty and trainee publications directly supported by the MCH Training Program was 1,671; 967 of these were journal articles, 61 were books, and 225 were book chapters, as shown in Figure 18. It is noteworthy that so many journal articles and books were published in just 1 year; this high publication rate demonstrates exceptional productivity, suggesting that supported faculty are indeed leaders in their fields.

The category “other publications” in Figure 18 includes materials developed for lay audiences, documenting the extent to which Training Program faculty and trainees disseminate information to a broad audience. Some of the publications of grant-supported faculty are seminal in their fields. For example, the first textbook on adolescent medicine was edited by a grantee.

FOSTERING DIVERSITY

Most MCH training projects address cultural competency in the educational curriculum; for some, it is a central component of the curriculum, and a few have developed materials on cultural competency that they have shared widely, both among MCH training projects and other groups.

Even though projects state that they address the topic of cultural competence, the survey of former trainees suggests that, at least in the past, cultural competency has not been a major strength of the projects. When asked to identify strengths of their training projects, only 2 of the 110 respondents volunteered that their training projects had enhanced their knowledge of cultural competence.

 
Figure 17: Examples of Policy Work of Grantees
• Coalition building, leading to universal newborn hearing screening in Maryland (University of Maryland at Baltimore, Behavioral Pediatrics)
• Participation and co-leadership of the Alabama Asthma Consortium, a statewide multiagency effort to devise a statewide asthma plan (University of Alabama at Birmingham, PPC)
• Organization of “Social Venture Partners,” designed to focus the philanthropic activities of biotechnology and computer millionaires on the pressing needs of children (University of Washington, School of Public Health)
• Provision of expert testimony on lead poisoning to the state legislature (Kennedy Krieger Institute/Johns Hopkins University, LEND)
• Preparation and presentation of a policy paper on the efficacy of pediatric occupational therapy to California’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) oversight committee, leading to inclusion of occupational therapy services in the state EPSDT program (University of Southern California, Occupational Therapy)
• Development of language for district court regulations defining medical records for adoptions (University of Maryland at Baltimore, Social Work)
• Sponsorship of community-based forums and consultation with teachers, leading to attitudinal shifts in the city of Birmingham on the mainstreaming of children with special health care needs (University of Alabama at Birmingham, LEND)
• Provision of technical assistance to the state legislature as the legislature drafted a bill (and passed a law) on respite care (Kennedy Krieger Institute/Johns Hopkins University, LEND)
• Leadership on state task force on Ritalin and psychotropic drug use in children, and testimony at state legislature on implementation of task force recommendations (University of Maryland at Baltimore, Behavioral Pediatrics)
• Collaboration with District of Columbia Office of Early Intervention, educating pediatricians and family practitioners on identification of children with developmental disabilities and services available to these children (Howard University, HBCU)
• Preparation and dissemination of a report on the financial benefits of nutrition services for children with special health care needs (University of Washington, LEND)

 

Like many other professional training programs, most MCH training projects are not particularly successful in recruiting and retaining trainees or faculty from diverse racial and ethnic backgrounds. Of those projects that reported the race/ethnicity of their trainees in continuation reports (421 trainees out of the total of 709 for all projects in FY 1999), 79 percent of trainees were white and the rest were minorities. However, this figure probably overstates the percentage of minority trainees because projects with poor cultural representation may have been less likely to report the race/ethnicity of their trainees. In addition, some of the minority trainees who were reported were actually international students.

Project directors who have been less successful at minority recruitment cite several reasons:

  • The limited number of minority faculty are in great demand, and the projects cannot offer a competitive salary.

  • It is difficult to attract minority trainees to some fields because those fields are poorly paid relative to others that require a comparable educational commitment.

  • The pool of trainees of diverse heritage from applicable undergraduate- or master’s-level programs is limited.

  • Minority trainees tend to require a larger stipend than the MCH training grants allow, because these students often have fewer resources.

    On the other hand, some projects have worked

    hard and been successful at recruiting faculty and trainees from diverse backgrounds. Two projects (Howard Universit y and Drew University for Medicine and Science) have developed high school programs to introduce minority students to various health professions in an effort to encourage them to study science in college and consider a health field as a career. A few universities have similar programs, but not as a part of the MCH training grant; both Baylor College of Medicine and the University of Alabama at Birmingham, for example, sponsor summer high school programs for minority students. Such programs reflect an understanding of the need to interest students in health careers very early and a commitment to building a pipeline of future trainees of diverse heritage.

    "The LEAH program at the Baylor College of Medicine has increased the percent of minority candidates from 13 percent in its first year of funding to 38 percent in its fourth year of funding."
-Project director, LEAH

Figure 18: Publications Produced by Supported Faculty and Trainees, FY 1999

Abstracts (204)
Reports (94)
Other Publications (120)
Journal Articles (967)
Book Chapters (255)

One approach to minority trainee recruitment used by some projects is to develop close relationships with local HBCUs, Hispanic-serving institutions, and tribal colleges and universities. Project personnel visit these schools and meet with career counselors, participate in career fairs, and provide written information about their programs. In some cases, faculty give guest lectures at the institution, or joint faculty appointments are established. Another approach that several projects have employed is to develop short-term undergraduate practicum placements which are used to recruit minority students into graduate programs.

A few MCH training projects have worked to establish relationships with practicing minority professionals, with one goal being to encourage the professionals to return to school for graduate training. Another successful approach is an MCH certificate program, such as the one at the School of Public Health at Boston University, in which practitioners can take a limited number of courses to enhance their knowledge while obtaining the certificate. This contact provides the faculty an opportunity to support minority practitioners and encourage them to enter a graduate program. The behavioral pediatrics program at Boston University has developed a special fellowship program for midcareer minority professionals as a way to enhance services to minority children and to ensure greater cultural competency within the training project. Additionally, one faculty member founded and developed a new organiza-tion—the New England Regional Nurse Midwives of Color—to assist nurse midwives. MCH faculty provide support to the organization through seminars on advancing one’s nursing career, individual mentoring of nursing students to help them complete their programs, and encouragement for nurse midwives of color to become active in public health.

image of a young boy getting his ear examined by a health care physician

The communication disorders project at Howard University views its mission as the training of racially and ethnically diverse faculty in order to correct the existing shortage of doctoral-trained individuals in the field of communication disorders. The nutrition project at the University of Minnesota also focuses on improving diversity among faculty; it has developed a relationship with a historically black university in which a doctoral-level student or junior faculty member from Morgan State University spends 3 months at the University of Minnesota to receive nutrition training that would not otherwise be available; upon return to Morgan State University, the individual continues to be mentored by facult y at the University of Minnesota.

One interviewee commented, “It is critical for universities to work on minority recruitment, but it is pointless to do it just enough to fail.” By this the interviewee suggested that half-hearted efforts at minority recruitment will not be successful.

A few project administrators who have been relatively successful in their minority recruitment stress the importance of attitudes; they have found that a true commitment to diversity and to ensuring success on the part of minority trainees and faculty have led to real improvements in recruitment.

"We have the highest proportion of African-American students of any school of public health in the U.S. mainland. Minority students tell their friends that the environment in the department is supportive to them and a good place to obtain a degree."

-Faculty member, School of Public Health

The commitment of the university as a whole to diversity is also a factor in a project’s success at minority recruitment. Some universities are not as welcoming to minority students or faculty and, in fact, this is the complaint of some trainees who were interviewed for this evaluation. They stated they had been subjected to hurtful comments and that more support for minority students is needed at the university. Where lack of diversity is a university-wide problem, projects must work with greater diligence to recruit and retain faculty and trainees from diverse backgrounds and advocate for university-wide reform.

SUMMARY

MCH Training Program faculty and former trainees have led many of the nation’s efforts to improve the health of women and children. Leadership within professional associations has been a primary stimulus for change. These strong associations often define quality of care and are key to effective national advocacy. Faculty and trainees have also improved the health of women and children through community work that has created new health services and improved existing ones. The research that faculty and trainees conduct provides the information base on which to build better systems of care and make improvements in clinical care. Many projects have developed innovative and creative approaches to enhancing racial and ethnic diversity, but achieving diversity remains a challenge for a majority of MCH training projects.

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