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Translating Research Into Practice2002 MCH
Leadership ConferenceUIC SPH

• Bernard Guyer MD MPH
• Johns Hopkins Bloomberg SPH
• April 21, 2002

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Objectives

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

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Specific Objectives

• Use childrens 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

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Measles cases (reported), U.S., 1950-1995
Measles epidemic, 1989-90
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Child immunization coverage,U.S. Change over time
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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

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Conceptual Framework For Failure
To Immunize (1)
Parental Knowledge, Attitudes
Barriers to Access
Failure to Immunize
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Conceptual Framework For Failure
To Immunize (2)
Provider Practices, Knowledge, Policies
Parental Knowledge, Attitudes
Barriers to Access
Failure to Immunize
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Conceptual Framework for Failure to Immunize (3)
Provider Practices, Knowledge, Policies
Parental Knowledge, Attitudes
Missed Opportunities
Missed Visits Preventive Care
_at_Sick Visits
_at_Well Visits
Barriers to Access
Failure to Immunize
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Immunization Coverage In Baltimore (1991)
Percent
Ref Guyer B. et.al. Pediatrics, 19949453-58.
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Access variables didnt 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

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Provider/parent interactions

• Age-appropriate DTP1 associated with
• Up-to-date for 431 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

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Missed opportunities

• Occur at gt1/3 of eligible visits
• More likely at sick visits dont 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

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Actual immunization coverage Potential w no
Missed opportunities
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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.

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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

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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

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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

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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