Promoting Community Pediatrics: Recommendations From the Community Access to Child Health Evaluation

Abstract

The American Academy of Pediatrics' (AAP) revised policy statement, “The Pediatrician's Role in Community Pediatrics,” published in this month's issue ofPediatrics,1 provides a fitting backdrop to presentation of our findings and recommendations from the evaluation of the Community Access to Child Health (CATCH) Program. The evaluation was conducted over a 20-month period by a team of investigators from the Women's and Children's Health Policy Center at the Johns Hopkins School of Public Health and the National Center for Education in Maternal and Child Health within the Public Policy Institute at Georgetown University. Both the evaluation and this supplement were funded by the Robert Wood Johnson Foundation (RWJF) to inform those concerned about the health of this country's children about characteristics of effective approaches to promoting community activism, and to provide guidance for future efforts to strengthen the effectiveness of pediatricians in building community-based programs.This supplement to Pediatrics includes three articles that present findings from the evaluation and a set of commentaries reflecting on the place of CATCH in the development of the field of Community Pediatrics. The first article uses a historical analysis to document the events, achievements, and themes that constitute the transition from a national demonstration program of community-based child advocacy projects to the establishment of a Community Pediatrics infrastructure at the AAP.2 The second article uses case study methods to identify the characteristics of successful pediatrician-led efforts to improve child health services in communities.3 The third article provides in summary form the case studies of those 12 community child health initiatives assessed in the evaluation.4 In this introduction, we summarize the findings and recommendations from the evaluation, highlighting in particular those issues and ideas not otherwise discussed in the three articles.We evaluated the CATCH program over a 7-year period, from January 1989 through December 1995. CATCH was, and continues to be, an effective program strategy for stimulating and enhancing community-based child health initiatives. The premise of CATCH—that with information, support, and tailored tools, pediatricians can be agents of change in their communities—was confirmed by our program review, key informant interviews, and visits to CATCH projects. The pediatricians with whom we met and many of their colleagues capitalize on their status in the community as physicians, their expertise, and their many programmatic and political connections to create opportunities to promote expanded and improved health and social services for children and families. Moreover, the leadership of these pediatricians is often key in overcoming political and cultural barriers to implementing system changes.As noted in the article by Minkovitz and associates, we observed that exposure to issues of community child health and direct experience in addressing system-wide problems early on in the pediatrician's education and career are pivotal in promoting their ongoing career commitment and activity in this arena. However, pediatricians who are more established in their practices and communities are most available to provide leadership for community child health activity. It appears that before adopting leadership responsibilities in the community, there may be a period of “dormancy” when pediatricians need most to attend to clinical practice and to building linkages and credibility with children's agencies and advocates in the community. Different strategies are indicated for meeting the information and support needs of pediatricians interested in community child health at different stages of their career.We found that the involvement of pediatricians in public health programs was a common theme in most study communities. Relationships with local and/or state public health professionals and agencies can be important to catalyzing and supporting the ongoing involvement of pediatricians in addressing child health problems in the community. Ongoing interaction with and support of peers—primarily, but not exclusively, health profession colleagues—also are important elements in promoting and maintaining the active involvement of pediatricians in community child health activity.The staff and leadership of the CATCH Program, over the years, provided competent stewardship and professional expertise contributing significantly to the program's success in expanding and enhancing the active involvement of pediatricians in community child health activities, garnering recognition of Community Pediatrics within the AAP organization, and improving care and services for children. Based on our review of administrative documents, key informant interviews, and our observations made in the context of this evaluation, we believe that the creative strategic thinking, professional expertise, and unfailing commitment of AAP staff involved in implementing CATCH since its inception provided the organizational fuel for institutionalizing an initiative that today benefits children and families across the county.As noted in the article by Hutchins and colleagues, however, the program has been challenged by the fact that the CATCH acronym created confusion and resentments over time, sometimes straining collegial relationships throughout the AAP and in community projects. The program name CATCH was used to denote a variety of meanings at different times, depending on the orientation of the program leadership, and on particular program development goals. In the early years in particular, the CATCH label was applied to a number of community projects established well before the program came into being. This strategy adopted by CATCH to promote visibility and understanding of the notion of Community Pediatrics was effective toward that end, but was problematic for those pediatricians who had accomplished much on their own. Our site-visit interviews also revealed an important need on the part of community project participants to create their own labels, and thus to promote local “ownership.”Notwithstanding these struggles, funding for CATCH from the RWJF provided pediatricians interested in community child health activity visibility and credibility within the AAP. CATCH served as a vehicle for bringing additional pediatricians interested in community health into the formal structure and processes of the AAP. Today, the CATCH Program is a major unit within a Department of Community Pediatrics (established in 1995).Our review of the CATCH Program demonstrates the effectiveness and potential impact of pediatrician involvement in child health programming and advocacy in communities. We believe that the impact of such involvement could be strengthened with the expansion of the cadre of practicing pediatricians oriented toward and skilled in such activity. As physician needs in this regard change at various stages in their careers, specific strategies are recommended as follows: create an early community experience for medical students; promote mentoring and learning experiences related to Community Pediatrics for pediatric residents; foster exposure to community child health activity for practicing pediatricians in the early phase of their career; and target efforts to promote children's health by focusing support on pediatricians established in their careers.Our evaluation also highlights the need to support community child health activities more broadly by fostering supportive environments in communities nationwide. Creative partnerships between public health, community pediatricians, and academia should be fostered and supported, and minority leaders encouraged in their participation. Collaborations among private philanthropic entities and professional organizations also are recommended to promote and provide for flexible funding supporting child health activities at the local level.Our review emphasizes the processes of CATCH in promoting pediatricians' involvement in community child health activities. Particular mechanisms developed in the early years of CATCH were found to perhaps have diminished in their effectiveness. We believe these internal efforts can be strengthened by folding CATCH processes into the larger domain of Community Pediatrics. In keeping with the longstanding vigor of the CATCH Program leadership, the Department of Community Pediatrics is involved in continuous quality improvement processes, taking steps consistent with our recommendations submitted to the RWJF and in an oral presentation to the AAP Executive Committee and the Board of Directors in the spring of 1998.The CATCH acronym provided easy recognition and identity within and outside of the AAP structure and, as an identifiable, free-standing project, facilitated relationships with a range of funding sponsors. Although the CATCH title served important purposes early on and is a comfortable name for some, it may create more problems at this juncture than it solves. Given that a Department of Community Pediatrics is now established in the AAP, most staff activities undertaken in the department supporting pediatric community activism can be subsumed aptly under the rubric of core departmental functions, and the acronym CATCH can be restricted more appropriately to projects and activities associated specifically with planning grants.During the period covered in our study, the AAP relied primarily on meetings and newsletters to reach pediatricians. Efforts now are underway for Internet-based information and communication, which may be more productive in the current context. Additional strategies may need to be developed, such as plenary presentations related to Community Pediatrics at national AAP meetings and section and committee communications. The AAP communication strategies may benefit from more information about skills needed by local pediatricians to advance children's health. The Department of Community Pediatrics may wish to hire staff to address these needs or might consider developing a pool of consultants with particular skills such as negotiating with Medicaid, sustaining school-based health centers, and working with managed care organizations to provide outreach for special populations of children such as children in foster care or homeless children. Consultant pools could be drawn from current CATCH projects and thus could serve the additional purpose of providing and strengthening peer support networks.As the AAP adopts new programs in Community Pediatrics, evaluations should be planned that provide timely assessment of the value of allocating resources to new endeavors. Prospective rather than retrospective models should be adopted to promote efficiency and reduce bias. The database currently in development in the Department of Community Pediatrics may facilitate such future efforts.Finally, and looking to the future, the Department of Community Pediatrics should work with the Residency Review Commission and the American Board of Pediatrics to strengthen community-based activities during residency training. This strategy may involve inclusion of questions related to community child health in the board examinations, as well as development of models and guidelines for didactic and longitudinal experiential training during residency related to Community Pediatrics, including advocacy, and public health problem-solving skills and strategies.It is clear from the AAP policy statement (“The Pediatrician's Role in Community Pediatrics”) and from the spirit of the commentary written by Tonniges5 that CATCH is a significant component of the AAP's evolving philosophy of strengthening the role of practicing pediatricians in advocating and working for a better system of health care for children in this country. We believe that the findings from this evaluation have played a part in focusing this evolution. We trust that these efforts will improve the health and well-being of children and their families everywhere.