C14.3 It Takes a Village_Ingrid Tyler

IT TAKES A VILLAGE: A realist synthesis addressing early childhood programs combining a determinants of health and community-based public health approach with individuals’ clinical primary care Presented by Dr. Ingrid Tyler, Physician, Health Promotion Chronic Disease and Injury Prevention, Public Health Ontario | Santé publique Ontario Co-authored by Feller A, Ford-Jones L, Loock C, Lynam J, Makin S, Manson H, O’ Campo P

Team Members Investigators •

•

•

•

Principal Investigator - Ingrid Tyler (MD, CCFP, MHSC, MEd, FRCPC, Associate Professor, Dalla Lana School of Public Health, University of Toronto, ON) Judith Lynam (PhD, RN Professor, School of Nursing, University of British Columbia, Vancouver, BC) Heather Manson (MD, FRCPC, MHSc, Assistant Professor at the Dalla Lana School of Public Health , Chief, Heath Promotion, Chronic Disease & Injury Prevention, OAHPP, Toronto, ON) Patricia O’Campo (Ph.D. Director, Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, ON)

PublicHealthOntario.ca

Knowledge Users •

Principal Knowledge User - Sue Makin (RN, BScN, MEd, Director, Healthy Families, Toronto Public Health, Toronto, ON)

•

Andrea Feller (MD, MS, FAAP, FACPM, Associate Medical Officer of Health, Niagara Region Public Health, Thorold, ON)

•

Lee Ford-Jones (Head, Social Pediatrics, Professor of Pediatrics, Social Pediatrics and Infectious Diseases, Hospital for Sick Children, Toronto, ON)

•

Christine Loock (MD, FRCPC, RICHER Initiative, Vancouver, BC)

2

Biological Embedding • Prenatal experiences • Early experiences • Brain plasticity • Toxic stress/fear response • Cortisol expression • Social epigenesis Clinton J. Early Childhood Development – Foundations of health and wellbeing. Presented at: Public Health Ontario Grand Rounds.

2013 Nov 05; Toronto, ON. PublicHealthOntario.ca

3

Social Pediatrics

From: Child Public Health. Blair M, Stewart-Brown S, Waterston T, Crowther R. Oxford: Oxford University Press, 2003.

PublicHealthOntario.ca

4

What is social pediatrics?

• Each child is on his/her own life and developmental trajectory based largely on experiences in early childhood1 • Adverse experiences, or toxic stress, disrupts the architecture of the brain, influencing behavioural, educational, economic, and health outcomes decades and generations later2 • It is necessary that practitioners strive to change conditions to elevate health and developmental trajectories by acting on the social determinants of health because they drive brain development by the experiences they create 1EL

PublicHealthOntario.ca

Ford-Jones, R Williams, J Bertrand. Social paediatrics and early child development: Part 1. Paediatr Child Health. 2008;13(9):755-758.

2American Academy of Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012; 129(1): e224-e231.

5

Why PHPC Integration?

• Enhances the capacity of both sectors to carry out their respective missions toward improved population health1 • Key health issues that can be addressed by integration: socioenvironmental issues (poverty, community development)2 • Addressing the complexities of paediatric care requires enhanced collaborative interdisciplinary networks with public health, primary care, and community resources3 *

1Institute of

Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health.

Washington, DC: The National Academies Press. 2012.

2Valaitis et al. Strengthening Primary Health Care through Primary Care and Public Health Collaboration: Final report to CHSRF. In Hamilton, ON: McMaster University; 2012: 1-44.

3EL Ford-Jones, R Williams, J Bertrand. Social paediatrics and early child development: Part 1. Paediatr Child Health. 2008;13(9):755-758.

PublicHealthOntario.ca

Realist Review Method • Systematic literature review method • Combines evaluative evidence with theoretical thinking about program workings • Makes explicit the theories about how a program works and then gathers evidence in a systematic way to test these underlying theories

• ‘Unpacks’ complex mechanisms and contextual elements that impact program success • Explains what works, for whom, in what circumstances, and how

• Demands active participation of stakeholders through iterative consensus-building and integrative interpretation •

*

Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2004). Realist synthesis: an introduction. ESRC Research Methods Programme. Manchester: University of Manchester.

PublicHealthOntario.ca

7

It Takes a Village Research Question • What program theory(s) and associated mechanisms underlie effective and contextually relevant early childhood programs combining a public health, community-based, determinants of health approach with individual clinical care?

Objectives of the Knowledge Synthesis • Identify integrated public health-clinical primary care (PH-CPC) programs in child health whose theoretical focus is an integration of these two approaches through a community-based, determinants of health lens; • Determine facilitators and barriers to program success under various circumstances and the various mechanisms through which these are enacted; • Test a coherent and transferable explanatory program theory to assist decision makers in developing and planning integrated approaches to child public health .

PublicHealthOntario.ca

8

What is a mechanism?

PublicHealthOntario.ca

9

Mechanisms

PublicHealthOntario.ca

10

Methodology as adapted from Pawson et al. (2005)* • Step 1: Identify the research question • Step 2: Refine the purpose of the review • Step 3: Articulate key theories to be explored • Step 4: Conduct an iterative literature review • Step 5: Quality appraisal and data extraction • Step 6: Data synthesis and conclusion • Step 7: Disseminate, implement, evaluate * Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review--a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy. 2005;10(Suppl 1):21-34.

PublicHealthOntario.ca

11

Outcomes • Allow PH practitioners, clinicians, community leaders and policy makers to better understand integrated PH-CPC programs for planning and implementation of early childhood programs and policies.

• Policy-makers will be able to better understand program success factors and failures to inform decisions on child health policy and programming in their jurisdictions which could improve the health care experience for children and their families through increased comprehensiveness, inclusiveness and engagement.

• Future research to optimize public health – primary care integration in child health will be informed.

PublicHealthOntario.ca

12

Questions?

PublicHealthOntario.ca

13