Pediatric Annals

Future of Community Pediatric Research

I B Pless, CM, MD, FRCP(C)

Abstract

Despite the feet that I came to Montreal from Rochester in 1975 to direct a department called community pediatrie research, it is still a matter of uncertainty what "community pediatrics" means. Helpful, but also confusing, is the fact that as our research group expanded, the name we adopted was community, developmental, and epidemiologic research, also known as CDE. This granthose title was intended to ensure that all three members of the original team had a fair share of name recognition. It was necessary to compromise because, for example, from one point of view, community pediatrics does not accurately describe what is done in epidemiology, and similarly, developmental pediatrics is, in some respects, fundamentally different from the other parts of this granthose title. Our chairman at the time was somewhat annoyed by the acronym, CDE, by which the group came to be known. Whenever he fussed about it, I told him, "Be satisfied; we could easily add a few other letters before and after, such as A, B, and F, for ambulatory, behavioral, and family, and then we would become the ABCDE and F research group!" This is not too far-fetched because the feet is that at one time or another, the 10 of us who now comprise this group have engaged in research in each of these areas, as well as many others. However, the flagship of CDE remains community pediatric research, if only for historical reasons.

This introduction may seem to be a semantic self-indulgence, but how we define ourselves is an important issue. For example, when this issue of Pediatric Annals was being planned, I assumed it was a deliberate decision that I be asked to write about community pediatric research rather than ambulatory, behavioral, developmental, or epidemiological research. However, the distinctions conveyed by these words speak far more to the focus, or substance of the research, than to the methods used. Most of the divisions within this family use the same basic techniques of sampling, data collection, research design, and statistical analysis.

A distinctive element of community pediatric research, however, is that it is more intimately tied to the everyday concerns of pediatric practitioners than is most bench research. It deals with practice patterns, with how differing health service arrangements may affect clinical outcomes, and with descriptions of how pediatricians spend their time. This body of work leads to a much richer appreciation of the breadth and diversity of roles played by pediatricians. It emphasizes the need to integrate services that are not conventionally viewed as medical, but which are, nevertheless, intimately related to the health and functioning of children and their families. Although this perspective has not yet influenced pediatric training to the extent that it should, inevitably it must do so. It seems certain that pediatric education will be reformed as part of the broader (and, from the perspective of a Canadian, long overdue financing reforms) now taking place in the United States.

EXAMPLES OF COMMUNITY PEDIATRIC RESEARCH

To clarify further what is meant by community pediatric research, consider some examples of how research in this domain has affected the practices of pediatricians. These include the explosion of studies in the 1970s on pediatric nurse practitioners that paved the way for the use of paraprofessionals in many areas of child health. Pediatricians also were heavily involved in the field trials of Hemophilus influenzae type B (Hib) vaccine and in studies demonstrating the highly contagious nature of H influencie meningitis in day care, as well as other health problems associated with this increasingly popular setting. Much of the still growing body of literature on the neurocognitive…

Despite the feet that I came to Montreal from Rochester in 1975 to direct a department called community pediatrie research, it is still a matter of uncertainty what "community pediatrics" means. Helpful, but also confusing, is the fact that as our research group expanded, the name we adopted was community, developmental, and epidemiologic research, also known as CDE. This granthose title was intended to ensure that all three members of the original team had a fair share of name recognition. It was necessary to compromise because, for example, from one point of view, community pediatrics does not accurately describe what is done in epidemiology, and similarly, developmental pediatrics is, in some respects, fundamentally different from the other parts of this granthose title. Our chairman at the time was somewhat annoyed by the acronym, CDE, by which the group came to be known. Whenever he fussed about it, I told him, "Be satisfied; we could easily add a few other letters before and after, such as A, B, and F, for ambulatory, behavioral, and family, and then we would become the ABCDE and F research group!" This is not too far-fetched because the feet is that at one time or another, the 10 of us who now comprise this group have engaged in research in each of these areas, as well as many others. However, the flagship of CDE remains community pediatric research, if only for historical reasons.

This introduction may seem to be a semantic self-indulgence, but how we define ourselves is an important issue. For example, when this issue of Pediatric Annals was being planned, I assumed it was a deliberate decision that I be asked to write about community pediatric research rather than ambulatory, behavioral, developmental, or epidemiological research. However, the distinctions conveyed by these words speak far more to the focus, or substance of the research, than to the methods used. Most of the divisions within this family use the same basic techniques of sampling, data collection, research design, and statistical analysis.

A distinctive element of community pediatric research, however, is that it is more intimately tied to the everyday concerns of pediatric practitioners than is most bench research. It deals with practice patterns, with how differing health service arrangements may affect clinical outcomes, and with descriptions of how pediatricians spend their time. This body of work leads to a much richer appreciation of the breadth and diversity of roles played by pediatricians. It emphasizes the need to integrate services that are not conventionally viewed as medical, but which are, nevertheless, intimately related to the health and functioning of children and their families. Although this perspective has not yet influenced pediatric training to the extent that it should, inevitably it must do so. It seems certain that pediatric education will be reformed as part of the broader (and, from the perspective of a Canadian, long overdue financing reforms) now taking place in the United States.

EXAMPLES OF COMMUNITY PEDIATRIC RESEARCH

To clarify further what is meant by community pediatric research, consider some examples of how research in this domain has affected the practices of pediatricians. These include the explosion of studies in the 1970s on pediatric nurse practitioners that paved the way for the use of paraprofessionals in many areas of child health. Pediatricians also were heavily involved in the field trials of Hemophilus influenzae type B (Hib) vaccine and in studies demonstrating the highly contagious nature of H influencie meningitis in day care, as well as other health problems associated with this increasingly popular setting. Much of the still growing body of literature on the neurocognitive effects of low-level lead poisoning, as well as the effectiveness of various approaches to prevent or curtail exposure to lead, comes from this field.

Of great personal interest is the virtual discovery by pediatricians of the magnitude and seriousness of injuries. A related issue is the impact of the finding that adolescent suicide may be viewed as a "contagious disease." Along similar lines, much of what is now known about child abuse and other forms of intentional injury or violence has come from community pediatric research. Although not all these findings have been translated into new clinical or public health practices, many have, and investigators deserve credit for having set the stage for these changes.

ASSESSMENT OF THE FUTURE OF COMMUNITY PEDIATRIC RESEARCH

Assuming that everyone means the same thing when they use the phrase community pediatric research, my assessment in a nutshell is that so far as the future is concerned, there is good news and there is bad news. The good news arises from two elements. The first is based on an idea that came up when the Rochester Child Health studiesp 1 were under way, and Klaus Roghmann was struggling with the analysis of data from diaries from a sample of families. These contained information about stress and illness, and were obtained to try to better understand their role as determinants of health service use.p 2 The analysis proved more complicated than he anticipated, so he sought advice from Hanan Selvin, the distinguished sociologist who concluded that the only way to handle these data were with a Markov chain model. Selvin provided a lengthy explanation of this model, which he summarized as "the best predictor of a future event are events in the past."

THE GOOD NEWS

Assuming that this is true in general, it seemed then that the best way to predict the future of community pediatric research was to examine the evolution of this field since its inception. The first attempt to do so involved a manual search to count the number of times the word "community" appeared in the index to Pediatrics for the period from 1969 to 1993. When this failed, the second approach was to use Medline and expand the search to include the following related fields: ambulatory, behavioral, developmental, epidemiological, social, accident, and chronic. An important assumption in doing so was that most of the indexed papers were those that included research findings. The results of this analysis are shown in Figure 1 and the Table. This indicates that, quantitatively at least, there has been a steady growth in "community pediatric research," as reflected by publications in this particular journal. However, it appears to have been more rapid in some areas than in others. For example, for Pediatrics, in raw numbers, the two largest growth topics were "chronic" and "developmental," while the smallest were "epidemiology" and "ambulatory." Bear in mind, however; that the search looked for these specific words in the titles and abstracts, so these results could be somewhat misleading.

There are, of course, several possible important biases in this sample as well as in the analytic process, and one such bias is the choice of journal. To compensate for this, another somewhat differently oriented but nevertheless pediatric "mainstream" publication, the Journal of Pediatrics, was chosen for comparison. The results for the same time period are also shown (in parentheses) in the Table. These figures dearly suggest that the latter journal published roughly half the number of papers for most of the same topics, but that the growth patterns were otherwise similar.

A second potential flaw is that the apparent growth of interest in these areas was simply a reflection of a general growth pattern in the journals as a whole; ie, that the denominator had grown. However, steps were taken to verify that the actual number of pages devoted to scientific reports in both journals had not changed substantially during this time period, albeit the total number of pages per volume had increased by about 20% because of American Academy of Pediatrics committee reports and other features added over the years. Despite these limitations, on the face of it, these findings are interesting, reasonably valid, and should help predict the future.

The other element of "good news" is perhaps of equal or even greater importance than this quantitative analysis. It is based on an assessment of the scientific quality of the work represented in these publications. This, of course, is far more difficult to judge, but it seems reasonable to observe that there is scarcely any comparison between the methods used in the mid-1960s and those that are used today. For example, in 10 randomly selected articles from one issue of Pediatrics in 1969, the designs were descriptive and rarely experimental. The statistics were comprised of frequency distributions, percentages, t tests, and test-retest reliability. In a 1993 issue, the designs were case-control and experimental trials, and the statistics were comprised of sensitivity and specificity, multivariate (logistic), Kruskal-Wallis nonparametric, survival analysis, and large data sets. Evidently, much more sophisticated work is being done now than previously. Based on this, there seems to be no reason to reject the hypothesis that the scientific quality of work in this field also will continue to improve in the future.

FACTORS RESPONSIBLE FOR THE CHANGES

One reason for the sophistication of current work may be the fact that most of those working in this field have come to recognize the central role played by epidemiology. Alongside this is the increasing accessibility, as well as increasing complexity, of this discipline and its cousin, biostatistics. With the complexity has come, perhaps dangerously, even greater accessibility through all the popular computer programs now available for personal computers. Notable among these for its take-you-by-the-hand approach (to say nothing of the fact that it is free) is Epi Info.p 3 But, as noted, there is some danger of being seduced by software, and most would-be investigators in this field acknowledge the need to collaborate with more experienced methodologists. The analogy with clinical practice is apt: just as the practicing pediatrician frequently needs the input of medical or surgical specialists, the community pediatric researcher often needs a good working relationship with a statistician, epidemiologist, or simply a more experienced investigator.

Figure 1. Trends in topics appearing in community pediatric publications from 1969 to 1993, based on Index Medicus publications.

Figure 1. Trends in topics appearing in community pediatric publications from 1969 to 1993, based on Index Medicus publications.

The movement toward greater involvement of community practitioners in child health research is essential because many profoundly important clinical and epidemiologic discoveries have begun with the observations of astute clinicians. Ultimately, effective collaboration among practitioners and academicians will prove rewarding to both, and most importantly, to children and their families.

All of these developments are now part of the training available to fellows in community pediatrics. For example, the fellowship offered in what is effectively community pediatrics at the Montreal Children's Hospital involves participation in all or most of the courses given during the 2-year McGill master of science program in epidemiology. Graduates of this program are capable of conducting population type research of great diversity and at a formidable level of sophistication. Whether trainees are called community pediatric fellows, general academic pediatric fellows, clinical scholars, or some other variation on this theme, the fact is that they all learn how to do research in which population denominators are a key component.

A DIGRESSION ON TERMINOLOGY

A digression at this point seems indicated to provide an interpretation of what, for some, may have become a somewhat confused battleground over terminology. Distinguishing between a clinician and an epidemiologist is relatively easy-clinicians are interested primarily and sometimes exclusively in patients, or numerators. (The late Archie Cochrane, the famous British epidemiologist, has been quoted as saying that "The trouble with clinicians is that they don't know how to count past two!") In contrast, epidemiologists are concerned with, and sometimes fixated on, denominators in general and finding the most appropriate denominators in particular. That distinction is easy.

Table

TABLENumber of Articles Related to Community Pediatric Research by 5-Year Publication Periods for Two Journals

TABLE

Number of Articles Related to Community Pediatric Research by 5-Year Publication Periods for Two Journals

Figure 2. A comparison of the amount of money spent on injury research with that spent on acquired immunodeficiency syndrome (AIDS) research in Canada from 1986 to 1987.

Figure 2. A comparison of the amount of money spent on injury research with that spent on acquired immunodeficiency syndrome (AIDS) research in Canada from 1986 to 1987.

However, when an attempt is made to distinguish between clinical research, clinical epidemiology, and population epidemiology-the latter being where community pediatrics usually is situated-there is often much more confusion. Clinical research has, or should have, according to one classification system, two distinguishing features. The first is that it most often involves hospitalized patients (because the term "clinical" itself derives from the Greek, clinoid, meaning "bedposts"). The second is that it involves studies that are essentially numerator-based.

In contrast, while clinical epidemiology also is concerned with denominators, for the most part these are based on hospital populations as opposed to community populations. The latter-a community-based denominator-is, of course, the main criteria for most community pediatrie research studies.

Another possibly contentious point is that most clinical studies are reasonably free of values and political considerations, whereas many community pediatrie studies have a social agenda that is either implicit or explicit. Certainly, this was the view of the editors and most of the contributors in the first edition of Child Health and the Community, and it remains true in the recently published second edition. As Haggerty wrote in the Introductionp 1:

The ultimate criterion for success of any program in child health must be how well all of the children in the community succeed in achieving their full potential, whether the impediment to be removed is physical illness, problem behaviors, school difficulties, or other problems. The boundaries of health, especially when one deals with the new morbidity, overlap with education, welfare, housing, employment, environmental concerns, and indeed, even with the moral climate of the community. Children and their families must have reasons to hope dial a better life lies ahead of them, and society needs to do its share to encourage that hope.

Thus, community pediatrie researchers share a set of beliefs and social values about what children need and are entitled to, and many of the studies performed are designed to provide evidence to support those beliefs. Whether doing so and even doing so extremely well from a scientific point of view actually helps promote the policies we are advocating is, perhaps, an entirely different matter.p 4

In summary, the future looks bright for community pediatrie research. Based on the past it seems safe to predict that there will be much more such research, that it will continue to improve scientifically, and that it will be increasingly socially relevant and responsive to newly emerging problems of children and practitioners.

THE BAD NEWS

If that is the good news, then what is the bad? On this side of the ledger, the main concerns are the same as those expressed by others in this issue. They have to do with funding, both for research training and for the research itself These concerns arise not only from the dismal state of the economy in both Canada and the United States following a decade or more of conservative leadership, but also from the continuation of what appears to be a two-class system in the world of research. It is one that remains pervasive in many medical schools. It is still the case that so-called basic research-by which is often meant laboratory research-is judged to be more scientific and is therefore more highly regarded by many department chairmen than is ambulatory or community pediatrìe research (I.B. Pless, unpublished data, 1991).

This phenomenon in which dry lab-survey research involving real people that is usually done in groups or communities-is considered less worthy than that which is done in the wet lab-on animals, cells, or subcellular elements-is reflected in the amount of funding various supporting agencies provide for these respective genres of research. One simple example would be to compare the budget of those few NIH study sections that address community pediatrie type research with all the others. A more specific example is evident on the Canadian scene. Figure 2 compares the amount of money spent on injury research to that spent on acquired immunodeficiency syndrome (AIDS) and sets this against the actual number of childhood deaths from these two problems.

This problem of second-class citizenship is compounded by the perception-or conviction-that many pediatricians have about where children stand in the scheme of things in our society. It is not only that health-care research is often judged to be secondclass, but also that children are often viewed as less important than adults. So those doing child health research face what is, in effect, a form of double jeopardy: they must compete not only with the bench scientists, but also with those whose work is focused on the diseases of adulthood-cancer, heart, stroke, etc. As funds continue to shrink, the concern is that shortsighted people will be tempted to conclude that what we do is less essential than what others do.

CONCLUSION

Taking the good news with the bad, it seems that on the whole the future for community pediatric research looks bright. One reason for this is that over the last 20 years, there has been a growing involvement of community pediatricians in research in this area. Rochester pioneered this tradition, beginning with the studies of Breese et al5 on streptococcal illness. Over the Haggerty years, it expanded into a network and spanned work at the benches and in the trenches. In part as a result of the success of this collaboration in Rochester, the American Academy of Pediatrics initiated the Pediatrie Research in the Office Setting (PROS)6 network, which in recent years, has completed a number of outstanding studies. Among the topics pursued are: an age-gender registry, secondary sexual characteristics of young females, immunizations among children in practice, management of acute asthma, gastroenteritis outcomes, febrile infant assessment, and child behavior.

Apart from the quantity and quality of research, there are a number of challenging new issues that are likely to be addressed in the future. Stress and coping, although an old topic, has many new facets and many old ones that remain unresolved. These include a closer examination of the effects of divorce or single-parenthood on child rearing. In a different vein, there is bound to be a burst of work examining the effects of managed care arrangements on the use of child health services and ultimately on health status. The manner in which this and other practice arrangements can be made to better serve the needs of children who live in poverty or who have a chronic disorder is a persisting challenge. Other old but still challenging issues include ways to improve immunization status, how to deal better with colic, and above all, finding ways to stem the epidemic of violence.

Novice researchers in this field (or any other for that matter) are urged to pay tribute to their dedicated trainers. Without them there would be no future worth thinking about for community pediatric research. This is a young field of investigation, and most of the pioneers are still alive. Their struggle in getting such research launched was greater than that of most other research trainers for many reasons, some of which have been presented in this article. It is not often appreciated that research trainers have much in common with horse trainers. Both need to know when to push the beast to get him started, when to reign him in a bit, what feeding he responds to best, how to treat his various, often mysterious ailments, and most importantly, how to coax him to the finish line as quickly as possible. Both, too, share in the occasional chore of having to sweep up the droppings.

REFERENCES

1. Haggerty RJ, Roghmann KJ, Pless IB. Introduction. In: Haggerty RJ, Roghmann KJ, Pless IB, eds. Child Health and the Community. 2nd ed. New Brunswick, NJ: Transaction Publishers; 1993.

2. Roghmann KJ, Haggerty RJ. The stress model for illness behavior In: Haggerty RJ, Roghmann KJ, Pless IB, eds. Child Health and the Community. 2nd ed. New Brunswick, NJ: Transaction Publishers; 1993:142.

3. Dean AG, Dean JA, Burton AH, Dicker RC. Epi Info, Version S: A Ward Processing. Database, and Statistics Program for Epidemiology on Microcomputers. Atlanta, Ga: Centers for Disease Control; 1990.

4. Pless IB, Pekeles G. Applications of health care research to child health services: a problematic relationship. Israel J Med Sci. 1981;17:192-200.

5. Breese BB, Disney FA. Factors influencing the spread of beta hemolytic streptococcal infections within family groups. Pediatrics. 1956;17:834-839.

6. Wasserman RC, Slora EJ. PROS update. Child Health Care Update. 1994;10:4.

TABLE

Number of Articles Related to Community Pediatric Research by 5-Year Publication Periods for Two Journals

10.3928/0090-4481-19941201-07

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