“Translating Research Into Practice” 2002 MCH Leadership Conference UIC SPH

1. “Translating Research Into Practice”2002 MCH Leadership ConferenceUIC SPH Bernard Guyer MD MPH Johns Hopkins Bloomberg SPH April 21, 2002

2. Objectives • Describe relationship between research and practice • Value of research to improving practice • Challenges to using research • How can practice inform research

3. Specific Objectives • Use children’s immunization research as an example of practice-relevant work • Describe problem and how research used in Maryland • Baltimore Immunization Studies 1990-96 • Additional policy issues needing research

4. Measles cases (reported), U.S., 1950-1995 Measles epidemic, 1989-90

5. Child immunization coverage,U.S. Change over time

9. Baltimore Immunization Studies • Following measles epidemic of 1989,90 • Representative sample (n = 575) of poor children in inner-city • Document level of immunization coverage • Medical record data from multiple sources • Home interviews • Explain coverage patterns

10. Conceptual Framework For Failure To Immunize (1) Parental Knowledge, Attitudes Barriers to Access Failure to Immunize

11. Conceptual Framework For Failure To Immunize (2) Provider Practices, Knowledge, Policies Parental Knowledge, Attitudes Barriers to Access Failure to Immunize

12. Conceptual Framework for Failure to Immunize (3) Provider Practices, Knowledge, Policies Parental Knowledge, Attitudes Missed Opportunities Missed Visits Preventive Care @Sick Visits @Well Visits Barriers to Access Failure to Immunize

13. Immunization Coverage In Baltimore (1991) Percent Ref: Guyer B. et.al. Pediatrics, 1994;94:53-58.

14. “Access” variables didn’t explain low coverage • 41 primary care provider sites in area • 80% of children had only one provider • Averaged 8.4 preventive visits in first two years (more than enough to complete series) • Not insurance problem because 81% on medicaid (MA) • Private HMO better covered than MA

15. Provider/parent interactions • Age-appropriate DTP1 associated with • Up-to-date for 4:3:1 series at 24 months • age-appropriate MMR • Strongest predictor of AA DTP1 is early visit • Providers reluctant to give DTP1 at first preventive visit if child not previously seen

16. Missed opportunities • Occur at >1/3 of eligible visits • More likely at sick visits; don’t record if immunization status assessed at sick visits • Most common reason for missed-opp is “well child” • Eliminating missed-opp would increase inner-city UTD coverage 55%-73%

17. Actual immunization coverage & Potential w no Missed opportunities

18. Elements of the Policy Making Process • Knowledge base: • The research and information data base that derives from problem definition and measurement; necessary but not sufficient; • Social strategies: • Those broad approaches to addressing problems, e.g. financing, behavior change; • Political will: • Political consensus on social strategy and funding.

23. Wrap-up (1): Some principles • Mutual self-interest and respect: • Practitioners want to know “what works”-must get relevant results • Academics “test hypotheses” & must do publishable work; • Timeliness is important: • Academics tend to be slow- work faster; • Policy makers want instant answers- must slow down and demand quality answers

24. Wrap-up (2): Some principles • Frame answerable questions: • Agree on conceptual frameworks; • Frame testable questions • Use accurate definitions • Use effective designs: • Accept designs appropriate to questions, even if need randomization • Importance of unit of analysis • Testing components of an intervention

25. Wrap-up (3): Some principles • Follow the evidence; be skeptical: • Put aside preconceived notions • Listen to the data • “Evidence-based public health” (meta-analyses) • Strongly recommended • Recommended • Insufficient evidence

26. Wrap-up (4): Some principles • Generalizability important • Local context also important • Disseminate findings • Publish results so that others can find them • Use findings accurately in policy and practice