What is MCH Epidemiology

1
What is MCH Epidemiology?

• 9th Annual MCH EPI Conference
• December 11, 2003
• Tempe, AZ

2
Why are we NOW asking the question?

• TrainingWhat should be taught?
• AwardsWho is an MCH epidemiologist?
• StaffingWhat is the job description?
• FellowshipsWho should be eligible?
• AssistanceWhat capabilities should agencies
  have?
• ConferenceWhat should be included?

3
Raises MORE Questions?

• What is MCH?
• What is Epidemiology?
• From whose perspective?

4
Who has the ANSWER?

• Arden Handler
• Professor Director, MCH Epidemiology Training
  Program, UIC
• Greg Alexander
• Professor Chair, Department of Maternal and
  Child Health, UAB
• Debbie Klein-Walker
• Associate Commissioner, Massachusetts Dept. of
  Public Health
• Sara Santana
• Epidemiology Director, Maricopa County Dept. of
  Public Health

5
What is the History of MCH Epidemiology?

• Arden Handler, DrPH
• 9th Annual MCH EPI Conference
• December 11, 2003
• Tempe, AZ

6
What is the History of MCH Epidemiology?

• MCH Epidemiology emerged as a distinct field for
  public health practice in the mid-late 1980s
• MCH Epidemiology emerged as a distinct field for
  public health academe in the mid-late 1990s
• MCH Epidemiology has developed in response to
  specific historical events

7
Context and History

• 1981-1989
• After implementation of the MCH Block Grant in
  1981, a hands-off approach by federal Title V
  with respect to state Title V
• In response, many states took the initiative to
  analyze their vital statistics data to address
  the problems of low birthweight and infant
  mortality - e.g., Southern Regional Task Force on
  Infant Mortality

8
Context and History

• 1986
• CDC Division of Reproductive Health/HRSA began
  to assign epidemiologists through the Maternal
  and Child Health Epidemiology Program to state
  health departments (preceded by some earlier
  efforts to place EIS officers in states to focus
  on MCH)
• The purpose was to support state efforts to
  develop their analytic capabilities, thereby
  giving state program managers the tools and
  long-term capacity to make improved decisions for
  MCH activities

9
Context and History

• 1988
• The IOM released The Future of Public Health
• Public health agencies begin to evaluate their
  capacity to implement the core functions of
  public health assessment, policy development,
  and assurance
• Switch in emphasis from personal health services
  to population approach

10
Context and History

• OBRA 1989
• In reaction to the hands-off approach of the
  1980s, increased emphasis on accountability
  including new data and reporting requirements for
  state Title V agencies
• annual application to the Secretary of DHHS
• a five-year needs assessment
• plan for meeting the Year 2000 Goals and
  Objectives for pregnant women and children
• Reporting requirements reflect the health of the
  entire maternal and child health population

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Context and History

• 1989-1994
• MCHB funds four MCH Training Programs at SPH to
  establish Enhanced Analytic Skills Programs (UIC
  uses funds to develop EASP Certificate Program)
• 1992
• Graduate Student Internship Program students
  placed in state and local health agencies to
  engage in a variety of analytic projects

12
Context and History

• Mid-1990s
• Building on the EASP approach, MCHB funds three
  academic institutions to engage in continuing
  education programs focused on increasing MCH data
  capacity in state and local health agencies

13
Context and History

• 1996
• UIC MCH faculty (Handler, Kennelly and Geller)
  evaluate the CDC/HRSA MCH Epidemiology Program in
  four domains
• Vision and planning
• Infrastructure
• Analysis and Utilization of MCH data
• Translation and Dissemination of
• MCH data

14
Context and History

• Evaluation of CDC/HRSA MCHEP leads to a
  definition of MCH Epidemiology
• The definition of MCH Epidemiology derives from
  the work of the individuals in the field
• practice rather than academe

15
Context and History

• Classic Definition of Epidemiology
• Epidemiology is the study of the distribution,
  determinants, and occurrence of disease and
  health-related conditions in populations
• But, in state and local
• health agencies, production of knowledge alone is
  not sufficient

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Context and History

• MCH epidemiology is the study of the
  distribution and determinants of MCH
  disease/health conditions for the direct and
  immediate purpose of carrying out the activities
  of the MCH planning cycle
• surveillance and monitoring, assessment, program
  planning, evaluation, policy development and
  advocacy

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Definition of MCH Epidemiology

• The systematic analysis and interpretation of
  population-based and program-specific health and
  related data in order to assess the distribution
  and determinants of the health status and needs
  of the maternal and child population, for the
  purpose of implementing effective interventions
  and promoting policy development
• (Handler, Geller and Kennelly, 1999)

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The MCH Epidemiologist

• Based on this definition, the MCH epidemiologist
  uses the tools, framework and population-based
  focus of epidemiology to enhance the ability of
  state and local MCH programs to carry out the
  core functions of public health

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MCH Epidemiology Emerges as a Field

• 1995
• CDC/HRSA Annual MICHEP Conference
• 1998/1999
• Formation of the National Action Agenda /
  Alliance (NAA)
• 2000
• National MCH Epidemiology Awards begin

20
MCH Epidemiology Emerges as a Field

• 2000
• MCHB Training ProgramDoctoral Awards for
  Enhancement of Epidemiology with emphasis on
  training doctoral students to conduct data
  analysis in conjunction with state and local
  health agencies

21
MCH Epidemiology Emerges as a Field

• 2001 HRSA/CDC sponsor development of a Training
  Course in MCH Epidemiology
• 2002 Certificate Program in MCH Epidemiology
  begun at Emory
• 2002 CSTE conducts National Assessment of
  Epidemiologic Capacity in MCH
• 2002 MCH EPI Training Fellows Program (CDC)

22
MCH Epidemiology Emerges as a Field

• December, 2003
• Is MCH Epidemiology a distinct field?
• Is it different from
• reproductive epidemiology
• perinatal epidemiology
• pediatric epidemiology
• injury epidemiology
• adolescent epidemiology, etc.?
• Why? How?

23
MCH EpidemiologyWhats in a Name?

• Greg R. Alexander, RS, MPH, ScD
• Department of Maternal and Child Health
• University of Alabama at Birmingham
• December 11, 2003

24
Where to Start?

• To develop a definition of MCH Epidemiology, a
  likely starting place is to ask
• What is the role of MCH?
• What are the functions of an MCH Epidemiologist?
• What is MCH?

Department of Maternal and Child
Health University of Alabama at Birmingham
25
Background

• The initial mission of the Childrens Bureau,
  founded in 1912 and viewed as the foundation of
  MCH in the U.S., was to ...investigate and
  report upon matters pertaining to the welfare of
  children and child life among all classes of
  people...
• From its very beginning, investigation was part
  of the role of MCH.

Department of Maternal and Child
Health University of Alabama at Birmingham
26
Infant mortality and the factors related to it
were the first topics for investigation by the
Childrens Bureau!
Department of Maternal and Child
Health University of Alabama at Birmingham
27
The Role of MCH

• But, in addition to monitoring and investigating
  the health status of all children and their
  families, MCH is also involved in assessing,
  evaluating, promoting and improving health care
  and social systems.

Department of Maternal and Child
Health University of Alabama at Birmingham
28
The Concept Need for MCH Epidemiologists is Not
New!!!

• In response to a request by DHHS Region III State
  Title V Programs, an assessment was undertaken
  for MCHB in the mid-1980s to determine the need
  for a new professional the MCH/CSHCN
  Epidemiologist.
• Alexander, Greg R. The Need for Data-Related
  Personnel in Title V Programs A Position Paper
  for the Development of MCH/CSHCN Epidemiologists.
  Region III Perinatal Information Consortium
  Technical Report Series 88-06, Baltimore, 1988.

Department of Maternal and Child
Health University of Alabama at Birmingham
29
Job Description Purpose

• In order to facilitate more targeted service
  delivery and to enhance the impact of MCH/CSHN
  program efforts on the health status of mothers
  and children, this position plans, develops,
  implements and directs an ongoing comprehensive
  data collection, analysis, evaluation and
  research program in the MCH/CSHN area.

Department of Maternal and Child
Health University of Alabama at Birmingham
30
What is the Job?

• Monitors health risk status and service
  utilization in MCH populations and investigates
  determinants and distribution of poor health
  status conditions
• Conducts needs assessments and surveys
• Performs program and policy process and impact
  evaluations
• Performs performance assessments
• Provides consultation and recommendations to
  MCH/CSHN program directors in regards to setting
  program goals, priorities and future direction.

Department of Maternal and Child
Health University of Alabama at Birmingham
31
Specific Tasks and Job Functions

• Designs, implements and maintains MCH/CSHN
  management information systems to efficiently
  collect, store, analyze provide timely and
  accurate information
• Undertakes quality assurance activities,
  including analyses, reporting and training
• Undertakes managerial studies of costs, including
  productivity, cost benefit and efficiency of
  service delivery
• Inventories the service resources available to
  mothers and children
• Provides information and analyses for resource
  allocation decisions

Department of Maternal and Child
Health University of Alabama at Birmingham
32
And a Few More Things to Do

• Serves as liaison and fosters communication
  between MCH/CSHN programs and the offices of
  Biostatistics, Epidemiology, Vital Records, etc.
• Prepares MCH/CSHN program reports, scientific
  publications and presentations for information
  dissemination to professional and community
  groups
• Provides training, technical assistance and
  consultation regarding data collection, use of
  output reports, and interpretation of data
• Overall, plans, develops, implements and directs
  an ongoing, comprehensive data collection,
  evaluation and research program in the MCH/CSHN
  area.

Department of Maternal and Child
Health University of Alabama at Birmingham
33
Job Skills Knowledge

• History, philosophy, content scope of Title V
  programs
• Research methods and study design
• Statistical analysis and statistical computing
• Data collection, informatics and data base
  management (MIS) methods
• Data report preparation, dissemination and
  display/presentation
• Needs and performance assessment methods
• Evaluation methods
• Resource inventory and allocation methods
• Financial costs analysis methods
• Quality assurance
• Consultation, technical assistance training
  skills
• Communication and leadership skills.

Department of Maternal and Child
Health University of Alabama at Birmingham
34
Main Competency Areas of MCH-EPI

• MCH Competencies (MCH population-specific disease
  development content, life-cycle, MCH history,
  legislation philosophy)
•  Biostat/Epidemiology Competencies (data
  collection, measurement, analysis, research
  methods, study design, and interpretation skills)
• Managerial-EPI Competencies
• (Fleming, Scutchfield, Tucker. Managerial
  Epidemiology. AUPHA Press, Washington, DC, 2000.)

Department of Maternal and Child
Health University of Alabama at Birmingham
35
Managerial-EPI Competencies

• Planning (planning, needs assessment, health
  status and care utilization surveillance, goal
  and performance setting)
• Directing (communication, policy development)
• Organization (organizational design, staffing,
  locational analysis, resource allocation)
• Controlling (quality assurance, program process
  outcome monitoring/evaluation and information
  systems, performance assessment, and policy
  analysis)
• Financial management (forecasting costs, cost
  effectiveness benefit, cost reduction, risk
  adjustment)
• Integrated decision-making and problem-solving
  (leadership).

Department of Maternal and Child
Health University of Alabama at Birmingham
36
Educational Preparation?

• Given the job tasks, only a few of the needed
  skills and competencies are regularly taught in
  Epidemiology departments (e.g., disease
  investigation, research design, etc.).
• Statistical analysis and computing are typically
  taught by Biostatistics.
• More typically taught in MCH and other
  departments are
• Needs assessment, planning and evaluation
• Cost and policy analysis, health services
  research (HSR),
• resource inventory and allocation,
• MIS and informatics,
• MCH content, leadership, etc.

Department of Maternal and Child
Health University of Alabama at Birmingham
37
Remaining Questions

• Is MCH-EPI different from
• Perinatal EPI,
• Pediatric or Obstetric EPI,
• Reproductive EPI, etc? 
• YES! It is more applied
• and goes well beyond
• disease determinants.

Department of Maternal and Child
Health University of Alabama at Birmingham
38
Remaining Questions

•  But, how is being a MCH-Epidemiologist different
  from being a MCH program analyst?
• In total, is MCH-EPI as much or more about HSR
  or Managerial-EPI in the MCH field than it is
  about either epidemiology or biostatistics per
  se?
• Does the term MCH-EPI accurately describe the
  job?

Department of Maternal and Child
Health University of Alabama at Birmingham
39
Remaining Questions

• Given the multiple competencies for this
  position, do we wish the term MCH-EPI to imply
  something that goes well beyond the descriptive
  meaning?

Department of Maternal and Child
Health University of Alabama at Birmingham
40
But, is it MCH-EPI?

• Arguably, do we use the name MCH-EPI because
  it sounds very professional and has a good
  connotation in our field?
• But again, given what the job may entail, is it
  really MCH-EPI?
• Or, is it MCH-Biostatistics, Mngt-EPI, MCH-HSR
  or MCH-Data Analysis for Management?

Department of Maternal and Child
Health University of Alabama at Birmingham
41
What's in a Name?What is the MCH Profession?

• Lastly, can we define MCH-EPI, if we can't yet
  define what is MCH?

Department of Maternal and Child
Health University of Alabama at Birmingham
42
What is MCH?

• MCH is the collaborative discipline within public
  health that, using the tools of all the other
  public health disciplines, focuses on assuring
  the conditions that allow each child to be
  healthy and to reach full potential.

Department of Maternal and Child
Health University of Alabama at Birmingham
43
What is MCH?

• MCH is the professional and academic field that
  focuses on the determinants, mechanisms and
  systems that underlie, promote and maintain the
  health, safety, well-being, and appropriate
  development of children and their families in
  communities and societies, in order to enhance
  the future health and welfare of society and
  subsequent generations.

Department of Maternal and Child
Health University of Alabama at Birmingham
44
So, what is MCH Epidemiology?
Department of Maternal and Child
Health University of Alabama at Birmingham
45
What to conclude, after

• Asking all these questions
• Reviewing tasks and competencies
• Drawing mental diagrams of the proportion
  overlap of MCH, EPI, Biostatistics, HSR
  Management skills
• And, also considering the practical need to have
  a respected name to call this position and this
  conference?

Department of Maternal and Child
Health University of Alabama at Birmingham
46
MCH Epidemiology MCH
Department of Maternal and Child
Health University of Alabama at Birmingham
47
MCH EpidemiologyDefinition and Challenges

• Deborah Klein Walker, EdD
• Massachusetts Department of Public Health
• December 11, 2003

48
More Past History

• AMCHP set up network of MCH state data contacts
  to facilitate MCH Title V activities related to
  data activities (1996)
• AMCHP was an initiator (with CDC, HRSA City
  Match) of the National Action Agenda

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MCH Information and Analyses Needed

• Needs assessment
• Health monitoring of populations
• Health outcomes research
• Performance measures
• Financing and cost benefit studies
• Evaluation (experimental and quasi-
• experimental designs)

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MCH Information and Analyses Needed (continued)

• Program planning
• Policy development
• Education and advocacy
• Measurements of behavior and
• development
• Qualitative studies
• Informatics applications

51
MCH Information and Analyses Needed (continued)

• Community-based and systems
• intervention research
• Determinants of disease, health
• behaviors and outcomes
• Efficacy and effectiveness studies

52
Methods from Social, Behavioral and Education
Sciences Needed

• Example 1 sensitivity and specificity consists
  of measurement errors (reliability and validity)
  and design errors (internal and external
  validity)
• Example 2 measures of implementation
  (independent variables) needed in evaluations and
  intervention studies

53
Epidemiology Is Evolving

• Epidemiology focus and scope changes with setting
  academic or practice
• Epidemiology changes with context and nature of
  disease or outbreak from traditional
  communicable diseases to new social problems
  (e.g. violence)

54
Epidemiology for Future

• If epidemiology is the diagnostic discipline of
  public health, then it must be concerned with
• Usefulness in the definition of health problems
• Determination of principles to guide programs and
  services
• Evaluation for accomplishments
• (John Gordon, HSPH, 1949)

55
Need Applied Epidemiology

• Applied epidemiology synthesizes and applies the
  results of etiologic studies to set priorities
  for intervention it evaluates public health
  interventions and policies it measures the
  quality and outcomes of medical care and it
  effectively communicates epidemiological findings
  to health professionals and the public.
• (Ross Brownson Diana Petitti, 1998)

56
One Answer

• Consider MCH Epidemiology as a subfield of
  traditional epidemiology and acknowledge that
  many other skills (e.g., program evaluation) and
  disciplines (e.g. psychology, sociology) are
  needed to accomplish the MCH agenda of improving
  the health of all women, children and youth

57
Another Answer

• Expand and establish the definition of MCH
  Epidemiology as the broader set of skills and
  approaches needed to accomplish the MCH public
  health agenda BUT this may be difficult to do for
  just MCH and not the entire field of epidemiology

58
In Any CaseRecommendations

• Continue the dialog that recognizes a
  multidisciplinary approach is needed to meet all
  the information and analysis needs for the MCH
  population(s)
• Consider changing the MCH Epi Conference to the
  MCH Information, Statistics, Research and
  Evaluation Conference

59
Recommendations

• Convene a consensus conference on public health
  population-based methods and the role/definition
  of epidemiology in the future include scientists
  and practitioners from all the Public Health
  Service Agencies (CDC, SAMSHA, HRSA) what are
  the data analysis and methods needed for public
  health practice in the future? Is epidemiology
  necessary but not sufficient?

60
What is MCH Epidemiology?

• 9th Annual MCH EPI Conference
• December 11, 2003
• Tempe, AZ

61
Who will start todays Discussion?

• Karen Bell
• Associate Director, Emorys Womens and
  Childrens
• Barbara Ferrier
• Deputy Director, Boston Public Health Commission
• Michael Kogan
• Director, MCHBs Office of Data and Information
  Management
• Garland Land
• Director, MDHSSs Center for Health Information
  Mgt and Evaluation
• Annette Phelps
• Director, FDOHs Division of Family Health
  Services
• Cheryl Prince
• MCH Epidemiologist, Hawaii State Department of
  Health