Abstract
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.
- AAP —
- American Academy of Pediatrics
What’s Known on This Subject:
Although community engagement is considered an important professional role of physicians, there has been declining involvement of pediatricians in community child health activities. Whether enhanced training is associated with increased involvement is unclear.
What This Study Adds:
This study reveals a continued decline in pediatricians’ involvement in community child health activities and is the first national study to identify a link between formal training and pediatricians’ community involvement.
For nearly 2 decades, pediatricians have been encouraged to engage in community child health activities to promote the well-being of children at a population level.1–5 The American Academy of Pediatrics (AAP) recognizes community pediatrics as “the practice of promoting and integrating the positive social, cultural, and environmental influences on children’s health as well as addressing potential negative effects that deter optimal child health and development within a community.”6 Pediatricians are expected to adopt a population focus, combine public health principles with clinical practice, and collaborate with community partners to improve the health and well-being of children and families.6 Corresponding efforts to promote pediatricians’ involvement in the community have included initiatives to enhance the acquisition and use of related skills during residency training through programs such as the AAP’s Community Pediatrics Training Initiative,7 the University of California–Los Angeles’ Community Health and Advocacy Training Program,8 or the Child Advocacy Curriculum at Stanford, University of California, San Francisco, and the University of Miami.9 Also, initiatives to promote involvement after clinical training have included the AAP’s Community Access to Child Health Program10,11 and the Healthy Tomorrows Partnership for Children Program, a collaboration between the federal Maternal and Child Health Bureau and the AAP.
Despite the endorsement of community engagement as an important aspect of professionalism among physicians generally,12 there has been declining involvement of pediatricians in community child health activities. In 1989, 56.6% of pediatricians reported being involved in the previous year in community child health activities, whereas the corresponding percentage in 2004 was 45.1%.13 The decline has been attributed to practice constraints with heightened focus on clinical productivity as well as demographic shifts with more pediatricians working part time14 and entering practice with greater educational debt,15 limiting opportunities for voluntary community activities. In 2004, factors associated with involvement included older age, rural practice setting, and favorable perspectives toward community pediatrics.13,16
Heightened awareness of the social determinants of health and recognition of the life-course consequences of both positive and negative experiences have strengthened calls for civic engagement and advocacy in partnership with the community among pediatricians.17,18 Solomon et al19 reported a consistent focus on community pediatrics and child advocacy training between 2002 and 2005. Whether these and other training efforts before, during, and after completion of residency have translated into increased involvement among practicing clinicians remains unclear. The objective of these analyses is to assess involvement of pediatricians in community child health activities in 2004 compared with 2010 and to identify factors (personal, practice, and community pediatrics related) associated with participation in the past year.
Methods
Periodic Surveys
The AAP conducts Periodic Surveys of Fellows on topics of importance to pediatricians 3 or 4 times per year. Each survey uses a unique random sample of members of the AAP. Periodic surveys in 2004 (number 60) and 2010 (number 77) included questions on involvement in community child health outside of their clinical practice. Both surveys included a global question asking participants to indicate whether they participated in a professional capacity in any community-based activities in the past 12 months. These surveys also included a separate question about involvement in 19 specific settings or activities related to health and fitness, schools/education, other government/public health programs, and nonprofit organizations. The surveys asked whether participation was voluntary or paid and about personal and practice characteristics and the timing of formal training in community activities that promote child health (before or during medical school, during residency, during fellowship, since completing training, or none). Respondents reported the extent to which they viewed themselves as responsible for improving the health of children (other than those in their practice) in their home or practice community (4-point Likert scale: “not at all” to “very”). Also, participants indicated how much time they were willing to spend over the next year participating in activities that promote the health of children at the local, state, or national level (“none” to “>5 hours/month”). Respondents indicated whether they had used 6 skills in the past year and their skill level (4-point Likert scale: “not at all” to “very”) for each; skills included locating and accessing resources for individual children, identifying community needs, using population-level data to understand the determinants and consequences of children’s health and illness, working as a member of an interdisciplinary team to promote children’s health in the community, speaking publicly on behalf of children’s health, and using computers/Internet to find information about child health policy and related activities.
The 2004 Periodic Survey was an 8-page, self-administered questionnaire sent to 1829 active AAP members. The original mailing and 5 follow-up mailings to nonrespondents were conducted from April through September 2004. After the first and fifth mailings, an e-mail reminder was sent to nonrespondents with e-mail addresses and a postcard reminder was sent to those without (67.9% and 32.1% of nonrespondents, respectively). A total of 1053 completed questionnaires were received (response rate of 57.6%).
The 2010 Periodic Survey was an 8-page, self-administered survey sent to 1622 active AAP members. The original and 6 follow-up mailings to nonrespondents were conducted from June through November 2010. A $2 bill was included with the first mailing, and no e-mail or reminder postcards were sent. A total of 968 completed questionnaires were received (response rate of 59.9%). In both the 2004 and 2010 surveys reported herein, involvement in community child health was the only topic of the surveys. Survey content was informed by a national advisory group with expertise in community pediatrics and was reviewed by the AAP Community Pediatrics Action Group and the Council on Community Pediatrics. Human subjects approval was obtained from the AAP Institutional Review Board and the Committee on Human Research at Johns Hopkins Bloomberg School of Public Health.
Analysis
Analysis on both surveys included postresidency pediatricians, excluding pediatricians with a Specialty Fellow designation (certified by a board other than pediatrics) in the AAP membership database. The final sample included 881 pediatricians in 2004 (83.7% of respondents) and 820 pediatricians in 2010 (84.7% of respondents). We used χ2 analysis and t tests to assess differences in responses between survey years. Additional χ2 analysis of the 2010 respondents included a comparison of personal and practice characteristics, community child health training and perspectives, and use of skills and skill level by participation in community child health activities in the past year. Logistic regression assessed the independent contributions of characteristics associated with participation in bivariate analyses (P < .05). We also assessed whether use of skills mediated the relation between formal training and participation in 2010. Analyses were conducted by using SPSS statistical software, version 11.5 (IBM SPSS Statistics, IBM Corporation, Armonk, NY).
Results
Personal and employment characteristics, formal training, perspectives, and use and level of skills were compared between participants in 2004 and those in 2010 (Table 1). A greater percentage of respondents in 2010 were female (52.2% in 2004 vs 59.2% in 2010; P = .004) and aged ≥51 years (31.5% vs 38.5%; P = .018); the samples were comparable with regard to the percentages underrepresented in medicine (eg, black, Hispanic, American Indian), those who were married, and those with children. In 2010, fewer pediatricians practiced in rural settings (12.5% vs 9.0%; P = .048) and spent ≥50% of their time in general pediatrics (71.6% vs 66.5%; P = .025), with no significant changes in employment settings and part-time status. Compared with 2004, a smaller percentage in 2010 reported any formal training in community child health (56.1% in 2004 vs 42.9% in 2010), although a larger percentage reported training before medical school (2.9% vs 4.9%) and during residency (22.0% vs 28.4%; all P < .05; training reported at multiple time points). More than three-quarters of pediatricians reported feeling moderately/very responsible for child health, and 71% reported being willing to spend at least 1 hour per month in child health activities that promote the health of children in their home or practice communities, with no differences between comparison years (P > .05). The use of 2 of 6 assessed skills, locating and accessing resources for individual children and using computers/Internet to find information about child health policy and related activities, was greater in 2010 than in 2004. In 2010, more pediatricians reported having moderate/high skill levels for those 2 areas as well as identifying community needs and being a member of an interdisciplinary team to promote children’s health in the community (all P < .05).
Personal and Practice Characteristics, Training, Perspectives, and Skills: 2004 Versus 2010
To assess potential response bias, respondents and nonrespondents were compared with regard to several demographic variables. No significant differences were found in 2004 between respondents and nonrespondents in mean age (43.7 years) and region of the country (Northeast, 24.5%; Midwest, 21.5%; South, 33.4%; and West, 20.7%). In 2004, more respondents than nonrespondents were women (53.9% vs 46.6%; P < .05). In 2010, no significant differences were found between respondents and nonrespondents in mean age (45.1 years), region of the country (Northeast, 24.1%; Midwest, 21.8%; South, 36.1%; West 18.1%), or gender (57.6% female).
Overall, a smaller percentage of pediatricians reported involvement in community child health activities in the past 12 months (45.1% in 2004 vs 39.9% in 2010; P = .03), with decreases in each age subgroup (Table 2). There were significant decreases in community child health training among pediatricians 40 to 50 years old (53.6% in 2004 vs 37.3% in 2010), and a significant increase among pediatricians ≥51 years old (52.1% vs 69.5%; all P < .001), with no changes observed for the other age groups. Among those participating in community activities, a larger percentage in 2010 reported that their participation was voluntary rather than paid (79.5% vs 85.8%; P = .03). With regard to specific activities, among those who reported any involvement in the past 12 months, the only significant changes were fewer reporting participation as a school health clinic provider (7.2% vs 3.4%; P = .025) and more engaging in child advocacy (9.8% vs 15.7%; P = .017). Among those with any involvement, the most common settings, in both study years, were as follows: health fairs (28.8% for 2004 and 2010 combined), nonprofit volunteer organizations (eg, AAP, March of Dimes, Rotary; 25.2%), and school consultant (16.9%).
Involvement in Past 12 Months by Age Group: 2004 Versus 2010
In 2010, personal and practice characteristics associated with any involvement in community child health activities included older age, not having children aged ≤5 years, employment type, practice in rural settings, and receiving any formal training (Table 3). With regard to the timing of training, exposures before medical school, during fellowship, and since completing training were associated with involvement. Feeling responsible for child health and being willing to spend time to promote child health also were associated with involvement. In adjusted analyses, older age, practice setting and type, feeling responsible, and formal training remained associated with increased involvement (P < .05; Table 4).
Personal and Practice Characteristics, Training, and Perspectives Regarding Community Child Health Activities Among Participants and Nonparticipants in 2010
Participation in Community Child Health Activities in 2010
To further understand the role of training, we examined the use of 6 skills related to community child health in 2010 and their relation to whether respondents received any formal training (Table 5). Nearly three-quarters of pediatricians reported locating resources for individual children (74.2%) and using computers/Internet to find information about child health policy and related activities (74.0%). Among those using the skills, more than half reported having moderate/high skill levels. Formal training was associated with larger percentages of pediatricians reporting the use of 4 skills and with smaller percentages reporting the use of 2 skills (locating resources for individual children and using computers/Internet to find information about child health policy and related activities; all P ≤ .001). In turn, greater use of skills was reported by those who participated in community child health activities in the past year than by those who did not participate (P < .001 for all 6 skills). Formal training remained significant (P < .01) when use of each of the skills was added individually to the regression model, although the magnitude of the odds ratio decreased (range of odds ratios: 1.61–1.79), indicating partial mediation.
Formal Training, Skills Used, and Moderate/High Skills in Community Child Health Activities in 2010
In 2010, formal training also was associated with higher skill level for 3 of 6 skills, with findings in a comparable direction, although not significant, for the remaining 3 skills. In turn, participation was associated with higher self-reported skill levels (P < .001 for all 6 skills). The extent to which skill level mediated relations between formal training and participation was not assessed due to small sample sizes because fewer respondents reported skill levels than use of skills.
Discussion
This study reveals a continued decline in pediatricians’ involvement in community child activities in 2010 compared with 2004. In 2010, greater involvement was reported by pediatricians who were older, practiced in rural settings and in particular types of practices, had received formal training, and had a high sense of personal responsibility. Although several of these associations have previously been noted, this is the first national survey to identify relations between formal training and pediatricians’ community involvement broadly defined across an array of settings and activities. One previous study reported that exposure to 1 particular community setting in residency, schools, was associated with subsequent involvement in that same setting.20 Solomon et al21 also observed that, among pediatricians who trained at programs funded by the Dyson Community Pediatrics Training Initiative, those who trained at programs emphasizing population-level advocacy reported greater use of strategies to promote community child health.
Increased involvement with age likely reflects the need to be established in clinical practice before engagement in community activities11 and greater ability to balance personal, work, and other professional responsibilities over time. Nearly all community involvement reported by pediatricians in 2010 was voluntary and likely not conducted in association with clinical responsibilities. It may be particularly challenging for younger pediatricians, many with educational debt and/or beginning families, to volunteer in the community without focused efforts or incentives to facilitate involvement. Also, in some communities, allied health professionals may engage with community organizations as part of their work responsibilities, thus decreasing pediatricians’ opportunities.
Other factors associated with participation in community child health activities are more difficult to influence; these include practice setting and type. However, the independent association of formal training with community involvement emphasizes the importance of this modifiable factor. Not surprisingly, the use of skills partially mediated the relation between formal training and participation in the past year, suggesting that evaluations of community pediatrics training focus on skills acquisition as well as influences on attitudes and subsequent community involvement.
The timing of training in this national sample varied. Residency was the most frequently cited, as might be expected because programs are required to provide “structured educational experiences … that prepare residents for the role of advocate for the health of children within the community.”22 However, only 28% of pediatricians reported receiving training during residency, perhaps reflecting vague language of the Residency Review Committee requirement,8 difficulty implementing the requirement given competing priorities, and varied respondent ages. The recently revised guidelines that went into effect in 2013 are more proscriptive and recommend that 2 out of 5 ambulatory months include elements of community pediatrics and child advocacy.23 Solomon et al19 found that >70% of residency programs reported offering training in schools (1 of 14 types of community-based settings queried in a survey of program directors) and >73% reported moderate to heavy emphasis of child advocacy training during residency recruitment. The percentage of pediatricians reporting formal training may increase over time if efforts are sustained; the Pediatric Milestones Project has recently been developed to guide resident assessment and educational outcomes in the next accreditation system. Under systems-based practice, the Milestones Working Group included the subcompetency “Advocate for the promotion of health and prevention of disease and injury in the population.”24 Among the initial 21 subcompetencies that programs are required to report on, is, under systems-based practice, “advocate for quality patient care and optimal patient care systems.”25
Several limitations are noted. First, respondents may overestimate their extent of community involvement, although we have no reason to suspect differential reporting by survey year. Second, the surveys had response rates of 58% to 60%; these are consistent with other national surveys of physicians, and respondent bias has not been not observed.26 A combination of Web-based and mailed administration might increase participation but also might increase response bias.27 Third, we lacked information regarding previous experiences that might influence community engagement and information regarding the types or quality of training received. Fourth, although we identified associations between formal training and participation, we were not able to assess causality. Analyses from the longitudinal evaluation of the Dyson Community Pediatrics Training Initiative will capture some of the additional factors of interest and provide enhanced understanding of how training during residency influences participation in community activities.
Pediatricians’ involvement in community child health activities has taken on new importance with implementation of the Affordable Care Act. For example, pediatricians skilled in identifying community needs and working as members of interdisciplinary teams may be particularly well suited to collaborate with nonprofit hospitals, now required to engage in community health planning.28 Others skilled in using population-level data may contribute to discussions regarding implementation of health insurance exchanges to be certain that children with special health care needs have continuous, adequate, affordable coverage.29 Pediatricians skilled in speaking publicly on behalf of children’s health also can contribute to critical discussions regarding their state’s essential health benefits selection process to advocate for a robust set of dental benefits30 and to ensure implementation of Bright Futures Guidelines for Health Supervision and provision of preventive services for infants, children, and adolescents without patient/family cost-sharing. The ability of pediatricians to work beyond the clinical setting and play these important roles is congruent with recommendations put forth in recent reports calling for the integration of primary care and public health to improve population health.31,32
Conclusions
The association of formal training with community involvement is intriguing and suggests that a continued commitment to community pediatrics training efforts is needed to support such involvement amid the realities of current practice environments. Including core advocacy skills for all residents and concurrently providing enhanced experiences for those who wish to include enhanced related skills as part of their “individualized curriculum” may be warranted. Residency programs are currently restructuring curricula to create experiences consistent with learners’ needs and career paths. As these changes occur, it will be important to assess the impact of enhanced community exposure on skills and future community involvement. Efforts are needed to understand how content, delivery, and timing of training influence involvement and, ultimately, to understand how pediatricians’ involvement contributes to population health outcomes.
Footnotes
- Accepted September 23, 2013.
- Address correspondence to Cynthia S. Minkovitz, MD, MPP, Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, E4636, Baltimore, MD 21205. E-mail: cminkovi{at}jhsph.edu
Dr Minkovitz conceptualized and designed the study, carried out the analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Grason, Dr Solomon, and Dr Kuo critically reviewed the analyses and reviewed and revised the manuscript; Ms O’Connor led data collection, coordinated data use, critically reviewed the analyses, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded by the American Academy of Pediatrics’ National Center for Medical Home Implementation Medical Home Capacity Building for Children with Special Health Care Needs Cooperative Agreement through the Health Resources and Services Administration, Maternal and Child Health Bureau (grant U43MC09134).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found on page 1123, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2013-3096.
References
- Copyright © 2013 by the American Academy of Pediatrics
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