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Journal of Pediatric Psychology 29(6) pp. 405-414, 2004
Journal of Pediatric Psychology vol. 29 no. 6 © Society of Pediatric Psychology 2004; all rights reserved
Bridging Disciplines: An Introduction to the Special Issue on Public Health and Pediatric Psychology
National Cancer Institute, Health Promotion Research Branch
All correspondence should be addressed to Bernard F. Fuemmeler, Division of Cancer Control and Population Sciences, Health Promotion Research Branch, 6130 Executive Blvd., EPN 4080, MSC 7335, Bethesda, Maryland 20892. E-mail: fuemmelb{at}mail.nih.gov. This article was managed by Ronald T. Brown.
Key words: public health; prevention; health promotion.
Public health reflects a broad variety of activities, with the ultimate goal of reducing disease mortality and morbidity and promoting health of the population as a whole. In the past, population health was measured by a relative absence of diseases, and the focus of public health research and practice was on the control of such diseases (especially communicable and infectious ones). However, more recently, a broader definition of health has been recognized. The World Health Organization views health as not just an absence of something, namely disease, but as a resource for realizing higher aspirations, satisfying needs, and coping with changes in the environment (Young, 1998
). With this conceptualization being more widely adopted, the focus of population health has broadened to include social, environmental, and behavioral factors that may jeopardize health, placing individuals at risk for disease. Consequently, there is increased interest in including behavioral science and theory in the dialogue of public health research (Muehrer et al., 2002). Public health efforts aimed at pediatric populations have focused on either preventing problematic health outcomes in children (e.g., injury, childhood obesity, social/emotional problems) or preventing health risk behaviors associated with adult-onset chronic diseases (e.g., smoking prevention to reduce cancer or heart disease).
Public health and population-based research and practice have not traditionally been the focus of pediatric psychology. Few articles submitted or published in the Journal have taken a public health focus (Kazak, 2002; La Greca, 1997; Roberts, 1992). However, recent surveys of pediatric psychologists and commentaries on the state of the field of pediatric psychology suggest the field is evolving and expanding. For instance, pediatric psychologists view primary prevention of poor health outcomes and the promotion of optimal physical and mental health in children to be of high priority (Brown & Roberts, 2000; Roberts, 1992). These sentiments are not germane solely to the pediatric psychology community; they are echoed by national health organization priorities and leaders in prevention science research calling for primary prevention and health promotion efforts to begin early in life and to include children, their families, schools, and communities (Perry, 2000; Stokols, 1996). Given the recent importance assigned to prevention of poor health outcomes and health promotion in pediatric psychology and the broader scientific community, this seems a fitting time to highlight current pediatric public health research.
In the solicitation of articles for this special issue, we sought articles in the area of pediatric psychology that are related to disease prevention, including primary and secondary prevention efforts. We also were interested in receiving articles that included studies of surveillance that pertain to pediatric populations, issues related to pediatric psychology in rural settings, delivery of and access to care in pediatric populations, economic implications of pediatric psychological services, and health disparities in pediatric populations, as well as articles addressing policy regarding the interface between pediatric psychology and public health. A broad net was cast to attract submissions from individuals of different disciplines, including pediatric psychologists, epidemiologists, health service researchers, and prevention scientists. We received a set of high-quality manuscripts, and include in this special issue articles related to injury prevention and dissemination/diffusion efforts directed at substance-abuse and obesity prevention.
Pediatric psychologists have a successful history of collaboration with other health disciplines (e.g., general pediatrics, endocrinology, oncology, nursing, etc.). It is hoped that by highlighting this set of articles in a special issue of our flagship journal, pediatric psychologists will begin to consider how their expertise in child development and health may contribute to a growing research interest in pediatric health promotion and population-based research. As an introduction to this special issue, I will first discuss some of the challenges of children’s public health and prevention research. I will then discuss how pediatric psychology and public health research might intersect. In doing so, I provide a theoretical framework based upon research findings in pediatric psychology and prevention sciences that can be used to guide researchers interested in health behavior change. Finally, I will introduce the articles in this special issue and discuss new opportunities and future directions for research in the area of public health and pediatric psychology.
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The Challenge of Children’s Public Health and Prevention Research |
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The rising costs of health care associated with improved health care technology, the limitations in reimbursement that third party payers have placed on tertiary care service delivery as well as mental health services, and the overemphasis on containing costs in the provision of health care are shaping the way in which children’s health services are being provided (Brown, 2004
). There is a growing need for primary prevention efforts that are cost-effective. Nonetheless, developing effective solutions and interventions to improve the mental and physical health of children is a complex endeavor and faces several challenges. Such challenges include 1) the lack of research on children’s developmental trajectories (i.e., how health or healthy behaviors in early childhood relate to outcomes in early, middle, and late adulthood) and how these interact with their social and environmental context, 2) the need for a better understanding of precise environmental and social contextual factors relevant to health outcomes, and 3) disciplinary insularity.
Childhood is characterized by developmental events, transitions, and reorganizations. The timing of these events can greatly influence health behaviors and health outcomes. Understanding the transactional influence of the environment and these developmental changes and trajectories is critical to developing effective health interventions (Halfon & Hochstein, 2002). Effective prevention strategies developed for older children may not be applicable for younger children. Indeed, timing tailored assessments and interventions are needed. Intervening at critical time periods during childhood may create resiliency to risk for disease at later time periods. Because of the rapid changes in children’s development, the typical cross-sectional research methodology is inadequate. Longitudinal methods are an improvement over cross-sectional studies. However, the typical method of yearly assessments may still not capture rapid changes in children’s development. One strategy for enriching an understanding of health behavior trajectories is to capture data more frequently. Ecological momentary assessment (EMA) is one methodology that may prove to be helpful in identifying key thoughts, moods, and behaviors as they occur in "real time" under natural conditions (Stone & Shiffman, 2002). EMA methods have been enhanced through such technological devices as electronic personal digital assistants and cellular telephones. Depending on the research question, this method of gathering data more frequently during a participant’s day or week may offer a promising approach to longitudinal techniques (Clayton, Scutchfield, & Wyatt, 2000).
Another challenge to developing prevention and public health efforts is that limited research has addressed how contextual variables influence the health and behavior of children. There is a growing consensus that health outcomes of children (and adults) are associated with and influenced by a variety of contextual factors including race/ethnicity, culture, socioeconomic status, and community/neighborhood structure (Flay & Petraitis, 1994). However, research on how precisely these variables relate to family and individual attitudes, beliefs, and health behaviors is lacking. As progress is made in documenting the efficacy of primary prevention interventions, efforts will be needed demonstrating the transportability of these interventions to diverse populations. This can be enhanced with more comprehensive knowledge about the context of delivery, as well as improved participation between the researchers and the community.
Finally, developing and disseminating evidence-based prevention programs for children may be hampered by a lack of communication and collaboration among individuals from different disciplines. Discipline-specific theories about how health-risk behaviors develop in children may not be comprehensive and interventions developed from specific theories are likely to fall short of producing sustainable health behavior change (Clayton, Scutchfield, & Wyatt, 2000). The challenge for disciplinary researchers is to undertake cohesive research programs that can build an understanding of basic biological, psychological, and social processes but also incorporate this knowledge into applied intervention and prevention methods. Children’s rapid development and the interaction of biological, psychological, and social milestones within their environmental context require transdisciplinary efforts and perspectives.
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Integrating Pediatric Psychology and Public Health |
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Pediatric psychology has made a venerable contribution to children’s health research. Traditionally, pediatric psychology originates from clinical and developmental psychology, with an emphasis on understanding the transactional relationships between child behavior and development and health, illness, and disability (Wright, 1967
). Over the past 30 years, pediatric psychology has forged strong collaborative ties with tertiary medical care and primary care specialists (Schroeder, 1999; Sobel, Roberts, Rayfield, Barnard, & Rapoff, 2001). In addition to identifying the primary risk and protective factors underlying mental and physical health in pediatric populations, pediatric psychologists have been at the forefront in developing and evaluating interventions targeting adherence and illness management (Delamater et al., 1990; Lemanek, Kamps, & Chung, 2001), pain management (Kazak et al., 1996; Powers, Blount, Bachanas, Cotter, & Swan, 1993), and weight management (Epstein, Wing, Penner, & Kress, 1985; Epstein, Wing, Steranchak, Dickson, & Michelson, 1980).
The paradigm of testing efficacy in pediatric psychology interventions typically involves research driven by developmental and behavioral theory conducted among small samples in clinics or single-hospital settings. The designs involve randomization at the individual level under fairly controlled settings. Alternatively, the public health paradigm has traditionally drawn from social epidemiology and descriptive research. Interventions are developed for the purpose of being delivered in larger settings across greater numbers of individuals. The level of experimental control that the researcher has over the setting may be less than what could be expected in a smaller laboratory study or tightly controlled clinical trial (Glasgow, Lichtenstein, & Marcus, 2003). For instance, in a community-based effectiveness trial, the design may involve a clustered randomized control trial in which the unit of randomization is the community or group (see Murray, 1998). Minimizing intraclass correlation (i.e., the correlation of responses within the community) in the design is impractical and thus must be accounted for in the analyses (Feng & Thompson, 2002). Further, effectiveness trials often attempt to involve the community in decisions about the intervention and how it will be carried out; thus, based on the diverse interests of the community, the level of experimental control that the researcher has may be further reduced.
Pediatric psychologists are calling for more research to be conducted on the prevention of problematic health outcomes (Holden, 2003; Roberts, 1992; Brown & Roberts, 2000). Likewise, public health researchers and prevention scientists are calling upon future research to incorporate biological, behavioral, developmental, and contextual findings into prevention trials in order to identify more comprehensive theoretical frameworks (Clayton, Scutchfield, & Wyatt, 2000; Muehrer et al., 2002). Integrating these perspectives could lead to further advancements in children’s health care as well as benefit the science of the respective disciplines. For instance, epidemiological evidence demonstrating associations between risk and outcome could stimulate new research in pediatric psychology exploring more closely the precise behavioral mechanisms driving these associations. Likewise, pediatric psychology theories describing behavior change and development could be integrated into public health research to strengthen the salience of the preventive intervention.
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Incorporating Social Ecological Frameworks into Health Behavior Interventions |
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The following section outlines a framework of how pediatric psychology models for understanding child adaptation and adjustment to illness could be integrated into a public health/prevention framework. Pediatric psychologists report being trained typically in cognitive-behavioral and family systems theory (Mullins, Hartman, Chaney, Balderson, & Hoff, 2003
). Family systems approaches to therapy draw from social ecological frameworks (Kazak, Simms, & Rourke, 2002) and ecological frameworks to assist in the formation of models of public health promotion (Black, 2002; Wilson & Evans, 2003). Ecological frameworks propose that individual behavior is a function of multiple sources of influence, such as intrapersonal, interpersonal, institutional/organizational, community, and public policy (Bronfenbrenner, 1979, 1992). Pediatric psychologists also draw from developmental psychology and consider children’s developmental stages and changes when considering adjustment and adaptation to chronic illness and health (Holmbeck, 2002). For instance, Holmbeck and Shapera’s (1999) framework incorporates the influence of developmental change and social context in developmental and health outcomes in later adolescence. Adapting and expanding the frameworks of Kazak, Segal-Andrews, and Johnson (1995) and Holmbeck and Shapera (1999) to fit a public health paradigm could offer a heuristic familiar to pediatric psychologists. Frameworks such as these could be combined with social ecological models and other theories of behavior change when public health interventions are planned.
Figure 1 provides an overview of a proposed framework to explicate primary characteristics and mediating and moderating mechanisms influencing health indicators of children. This framework proposes that child health behaviors are influenced by intra- and interpersonal mediating factors, community, school, and family modifying conditions, and the underlying sociodemographic context and developmental phase. Research on health promotion among children has highlighted the importance of psychosocial factors related to social cognitive theory (Bandura, 1977, 1986, 1994) and the theory of reasoned action (Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975). Specific components of these theories, such as self-efficacy, health behavior skills, attitudes, beliefs, and intentions, have been important targets of intervention in child health promotion interventions (Botvin, Eng, & Williams, 1980; Perry, Kelder, & Klepp, 1994; Perry, Killen, Telch, Slinkard, & Danaher, 1980).
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Modifying conditions may play a role in mitigating or enhancing mediating mechanisms of behavior change. The child’s social context—particularly peer norms, acceptance, and affiliation—has been found to be an important predictor of children’s health risk behaviors (La Greca, Bearman, & Moore, 2002; La Greca, Prinstein, & Fetter, 2001) and can be targeted in health behavior change intervention trials (Perry et al., 2000). The school environment and the degree to which it is oriented toward health is believed to be an important social condition that can have an impact on health behaviors and outcomes, such as smoking, diet, and physical activity (Allensworth & Kolbe, 1987; St. Leger, 1999). The structural characteristics of the neighborhoods and communities, such as safety, access to places to play, opportunity for organized group exercise activities, sidewalks, biking routes, walking trails, and less access to fast-food restaurants, may also impact health behaviors and outcomes (Huston, Evenson, Bors, & Gizlice, 2003; Saelens, Sallis, Black, & Chen, 2003; Sallis et al., 2003). Family discord also may influence the degree to which a child’s affiliating with risky peers influences his or her own health risk behaviors (Prinstein, Boergers, & Spirito, 2001). These modifying conditions, although not the primary target of behavioral interventions, may be included in intervention trials to enhance the impact that the intervention has on health behavior change.
In addition to the mediating mechanisms and modifying conditions suggested by this framework, evidence from social epidemiology has demonstrated the importance of socioeconomic position and developmental characteristics underlying health outcomes. Extant research has shown that significant socioeconomic and racial/ethnic disparities exist in children’s health status and health risk behaviors (for review, see Brown, Fuemmeler, & Forti, 2003). Poverty, lack of resources, and lack of access to quality health care may be primary factors associated with racial/ethnic disparities in health. However, the social, cultural, and political forces that contribute to the disparities also are likely to contribute to these racial and ethnic disparities observed in health outcome (Giachello & Arrom, 1997).
Development phases and changes are critical influences on health behaviors and health risk (Holmbeck & Shapera, 1999). Age-specific experiences or changes may contribute to resiliency or one’s risk of injury or disease in later adolescence and on into adulthood. During certain phases of development, the sociodemographic influences, modifying conditions, and mediating conditions may become especially relevant. For very young children, health behaviors and outcomes with relation to family cohesiveness and adaptability may be more critical than peer norms. As children move from playing at home under supervised situations to playing outside the home, the roles of neighborhood, community characteristics, and peers may become particularly influential in health behaviors. Similarly, a child’s cognitive and physical developmental level may also be important to health outcomes and behaviors. For example, children’s cognitive development may relate to their ability to assess their physical capabilities and the task demands of novel situations, ultimately influencing their risk for injury (Schwebel, Plumert, & Pick, 2000). For adolescents, an insulin resistance state, linked with the development of (type II) diabetes mellitus, can be aggravated by fat mass which occurs during pubertal growth spurts (Roemmich et al., 2002). Understanding how these social, cognitive, and biological factors relate to development and health may be important when considering how best to optimize delivery of the intervention. Mediating and moderating variables can be conceptualized as being embedded or nested in both the sociodemographic conditions noted above as well as these developmental phases.
Partnering with community members and stakeholders for the purpose of shaping public health policy may ultimately influence the impact of public health interventions (Dietz, Bland, Gortmaker, Molloy, & Schmid, 2002). The approach toward partnership with the community could take a systems theory orientation. A family systems therapist in a hospital setting partners with the hospital staff and the child/family to build a collaborative therapeutic relationship that recognizes the goals of the systems with which the child is involved (i.e., doctors and parents) and the preferred outcomes at the subsystem level (i.e., the child) (Mullins, Gillman, & Harbeck, 1991). A similar approach of collaboration employing systems theory may be used by the public health researcher or practitioner with the goal of building relationships among the community stakeholders and decision makers (e.g., school administrators, policymakers, civil engineers), families, children, and adolescents within the community (Best, Moor, et al., 2003; Best, Stokols, et al., 2003).
The framework proposed here is transdisciplinary, incorporating input from social ecology, systems therapy, behavioral theory, developmental research, and social epidemiology. It contains biological, psychological, and sociocultural contextual variables that are critical for understanding health risk behavior acquisition. The framework provides a heuristic for conceptualizing and building hypotheses related to findings from epidemiological investigations of risk factors and disease outcomes. Such a framework will prove useful in planning community- and population-based intervention trials designed to promote children’s health behaviors and prevent disease. Interventions that have incorporated multiple individual-level factors as well as contextual factors have been demonstrated to be successful in changing and maintaining health behaviors (Nader et al., 1999). A closer examination of mediators of behavior change among some of these intervention studies may serve to generate hypotheses about how to most efficiently influence health outcomes among children and families (Baranowski, Anderson, & Carmack, 1998). Also, studies on health-behavior change in children that examine the combined influence of the various levels (intrapersonal, interpersonal, social, environmental, and developmental) will be valuable in planning intervention trials.
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Studies in This Special Issue |
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The topics addressed by the studies selected include childhood injury, the development of a culturally sensitive substance-abuse prevention program, and the diffusion of an obesity prevention program. These articles were selected because each represents an important piece of work that could be helpful in bridging the gap between pediatric psychology and public health. It is hoped that they will stimulate thought about what the next step in research could be and how pediatric psychology and those in public health could work to collaborate on the difficult task of improving child health and well-being.
Injury Prevention
Of concern in pediatric populations are the alarmingly high rates of injury. Among pediatric populations, injury (accidental injury and injury due to violence) is the number-one reason for emergency department visits and the leading cause of death (Centers for Disease Control and Prevention, 2002). The circumstances leading to these injuries include motor vehicle accidents, drowning, poisoning, firearm use, sports, and falls. Failure to use common safety devices (e.g., seat belts, bicycle helmets) has been identified as one reason for unintentional injury. Other factors are psychological and behavioral, such as parental stress and parental monitoring, which have been associated with these high rates of injury, especially among young children. Further, children’s individual perceptions regarding their risk of injury or their skill ability may also be an important factor in injury causation, especially during adolescent years, when risk perception and physical abilities are changing rapidly.
Morrongiello and her colleagues (this issue) describe results from a two-part study designed to move beyond epidemiological association to more closely examine what is occurring in the home between parents and children that leads to increased or reduced risk of childhood injury. The first study assesses child-related factors that are associated with minor injury, and the second study examines naturally occurring strategies used by parents to prevent their child from being injured. These studies address questions about what exactly is occurring among young boys that places them at greater risk compared with young girls and, if parental monitoring decreases risk of injury, what kind of parenting/monitoring strategies are most effective and for what age groups. These studies by Morrongiello et al., as well as others, provide important useful evidence that could dovetail into community- and population-based injury prevention interventions.
The study by Kontos (this issue) examines the association between cognitive and behavioral factors in sports-related injury among a sample of young adolescents. Specifically, the study was designed to examine the relationship in soccer-related injury among risk taking, perceived risk of injury, estimation of ability to play soccer, and previous injury in both boys and girls. This study has important implications for injury prevention in adolescents and demonstrates that the importance of risk perception and an accurate estimation of one’s ability in sports may be important factors relevant to the development of effective prevention programs to reduce sports injury.
These studies help to bridge the gap between pediatric psychology and public health, as they exemplify how epidemiological evidence of associations can be used to guide the development of research programs to gather more detailed data about the underlying processes that may be occurring. In general, greater attention is needed that addresses more precisely the biological, developmental, cognitive, behavioral, and social factors that set the occasion for injury occurrence in order for more effective prevention strategies to take place (Damashek & Peterson, 2002; Schwebel et al., 2000).
Culturally Sensitive Health Promotion and Prevention Programs
Alcohol and substance abuse are particularly problematic among youth. Over the last decade, rates of current and episodic heavy drinking have remained fairly high, with little observed change. In 2001, results from the National Youth Risk Behavior Survey found that nearly one half of youth reported current drinking (at least one drink on at least one occasion in the last 30 days) and nearly one third reported episodic drinking (at least five drinks on at least one occasion in the last 30 days). Overall, boys were found to report significantly greater alcohol use (current and episodic) than girls, and Hispanic and white students reported significantly greater use (current and episodic) than did their African American peers (Grunbaum et al., 2002). Although African Americans report lower levels of substance use, they may represent a group who are potentially at higher risk for early initiation, as they may be less likely to receive prevention messages.
Currently, there exist a number of effective substance-abuse prevention and intervention strategies for youth; however, dissemination and diffusion of these programs remain problematic (Weinberg, Rahdert, Colliver, & Glantz, 1998). One method of facilitating dissemination and adoption may be to tailor the interventions to particular populations. The current zeitgeist purports that health promotion and prevention programs may be more effective if they are designed to be sensitive to the cultural populations in which they are delivered. However, there has been very little research on what makes a research program "culturally sensitive" and whether culturally sensitive interventions produce greater changes in outcome behaviors than do programs not identified as culturally sensitive (Resnicow et al., 2002). In a brief report, Komro and her colleagues (this issue) describe methods they are using to adapt evidence-based intervention strategies for culturally diverse inner-city populations. By following the recommendation of Resnicow, Braithwaite, Ahluwalia, and Baranowski (1999) on adapting interventions for diverse populations, Komro et al. demonstrate how "surface" and "deep" structural changes can enhance their program’s cultural relevance. The report helps to bridge the gap between pediatric psychology and public health by providing an excellent example of how, conceptually, culturally sensitive programs can be developed. Such a model could be followed by pediatric psychologists who are developing intervention or prevention programs to be delivered in primary care settings servicing multiethnic populations.
Dissemination of Obesity Prevention Programs
Finally, the current epidemic of obesity in the United States cannot be understated. Recent data indicate that the prevalence of youth characterized as overweight has increased (from 11% in 1988–1994 to 15% in 1999–2000), constituting an estimated 9 million children (Ogden, Flegal, Carroll, & Johnnson, 2002). Intervention programs for children who are already overweight and obese show some promise (Epstein, Myers, Raynor, & Saelens, 1998; Jelalian & Saelens, 1999). However, there are few obesity prevention programs for children, and the dissemination of existing evidence-based programs has been minimal (Hill & Trowbridge, 1998).
Wiecha and colleagues (this issue) describe the efforts they are undertaking to evaluate the dissemination and diffusion of an obesity prevention program with demonstrated efficacy and cost-effectiveness developed for children of middle-school age. Unlike research on efficacy, there is no "gold standard" (e.g., randomized controlled trial) for evaluating diffusion or whether or not a program is likely to be adopted by community stakeholders. This article provides one example of how to evaluate whether or not adoption is likely by asking teachers to report on their acceptability of the program and the degree to which they perceive the program to be feasible. Diffusion of innovation theory was used to help formulate the assessment of program acceptability and adoption. A majority of teachers endorsed items that in previous evaluations have been related to program adoption (e.g., consistent with current values, relative advantage, broad applicability, and observability). This investigation is only the first step. As pediatric psychologists forge ahead with research testing efficacy and effectiveness of their program for improving the health of children, there will also be a need to examine whether such a program can be easily implemented and adopted into practice. Pediatric psychologists can collaborate with those in public health and the health promotion arena to develop a consensus for methods assessing and reporting on the likely adoption, implementation, and sustainability of evidence-based programs.
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How Can Pediatric Psychologists Contribute to the Public Health Agenda? |
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The field of pediatric psychology is poised to translate research on behavior change in both primary and tertiary care settings into broader systems. As presented in this article, frameworks and models familiar to pediatric psychologists can be feasibly integrated into public health frameworks. Using such frameworks and the embedded theories to analyze public health problems and develop, plan, and implement effective interventions and policies to promote health will enhance public health research and practice. Likewise, successfully partnering with community stakeholders and decision makers will enhance the impact that public health prevention efforts may have on the community. Systems theory is a method familiar to pediatric psychologists and could be helpful in facilitating this partnership. Pediatric psychologists who are trained to be consultants and collaborators are familiar with working and conducting research within a transdisciplinary setting. Transdisciplinary efforts will offer great promise for improving children’s health as well as improving public health science and research. Previously, the Editor’s vale dictum stated that "relatively few papers were published that focused explicitly on prevention" and "physicians and researchers outside of psychology do not typically send their work to us; as a result we probably lose the opportunity to publish a subset of papers that are more truly multidisciplinary" (Kazak, 2002
). It is hoped that this special issue is only the beginning of research on child health promotion and public health practice and that it will stimulate additional growth of research in this field. |
Acknowledgments |
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The views expressed in this article are those of the author and do not necessarily reflect the official policy of the National Institutes of Health, the National Cancer Institute, or any other component of the United States Department of Health and Human Services. The author would like to thank Drs. Larry Mullins and Audie Atienza and the anonymous reviewers for providing their helpful critique of earlier versions of this manuscript.
Received November 26, 2003; revision received February 3, 2004; accepted March 12, 2004
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