Pediatricians' Involvement in Community Child Health From 1989 to 2004

Article (PDF Available)inJAMA Pediatrics 162(7):658-64 · August 2008with30 Reads
DOI: 10.1001/archpedi.162.7.658 · Source: PubMed
Abstract
To explore pediatricians' current involvement in community child health activities, to examine trends in community involvement from 1989 to 2004, and to compare perspectives and skills related to community involvement among those participating and not participating in community activities. Cross-sectional analysis of 3 American Academy of Pediatrics Periodic Surveys of Fellows. In the 1989, 1993, and 2004 surveys, 1024, 1627, and 1829 pediatricians participated, respectively (response rates: 70.3%, 65.2%, and 57.6%). Involvement, skills, and perspectives related to community child health activities. The percentage of pediatricians involved in community child health activities in the preceding year rose from 56.6% in 1989 to 59.4% in 1993 but declined to 45.1% in 2004. Pediatricians increasingly reported that these activities were volunteer rather than paid (48.6% in 1989, 57.8% in 1993, and 79.6% in 2004). More participants in community child health activities vs nonparticipants viewed their current level of involvement as "just right" (52.5% vs 24.9%), reported themselves to be very responsible for children's health (42.2% vs 24.9%), expected their community work to increase during the next 5 years (63.5% vs 54.1%), and reported higher skills in 6 areas (all P < .001). Although there has been decreased participation in community child health, most pediatricians expect their community efforts to increase. Because most community activities are volunteer, challenges to address include incorporating community involvement into employment and identifying strategies to facilitate voluntary civic engagement.
ARTICLE
Pediatricians’ Involvement in Community
Child Health From 1989 to 2004
Cynthia S. Minkovitz, MD, MPP; Karen G. O’Connor, BS; Holly Grason, MA; Anita Chandra, DrPH;
C. Andrew Aligne, MD, MPH; Michael D. Kogan, PhD; David Tayloe, MD
Objectives: To explore pediatricians’ current involve-
ment in community child health activities, to examine
trends in community involvement from 1989 to 2004,
and to compare perspectives and skills related to com-
munity involvement among those participating and not
participating in community activities.
Design: Cross-sectional analysis of 3 American Acad-
emy of Pediatrics Periodic Surveys of Fellows.
Participants: In the 1989, 1993, and 2004 surveys, 1024,
1627, and 1829 pediatricians participated, respectively
(response rates: 70.3%, 65.2%, and 57.6%).
Main Outcome Measures: Involvement, skills, and per-
spectives related to community child health activities.
Results: The percentage of pediatricians involved in com-
munity child health activities in the preceding year rose from
56.6% in 1989 to 59.4% in 1993 but declined to 45.1% in
2004. Pediatricians increasingly reported that these activi-
ties were volunteer rather than paid (48.6% in 1989, 57.8%
in 1993, and 79.6% in 2004). More participants in com-
munity child health activities vs nonparticipants viewed their
current level of involvement as “just right” (52.5% vs
24.9%), reported themselves to be very responsible for chil-
dren’s health (42.2% vs 24.9%), expected their commu-
nity work to increase during the next 5 years (63.5% vs
54.1%), and reported higher skills in 6 areas (all P.001).
Conclusions: Although there has been decreased par-
ticipation in community child health, most pediatri-
cians expect their community efforts to increase. Be-
cause most community activities are volunteer, challenges
to address include incorporating community involve-
ment into employment and identifying strategies to fa-
cilitate voluntary civic engagement.
Arch Pediatr Adolesc Med. 2008;162(7):658-664
I
N THE PAST DECADE, THERE HAVE
been frequent calls for civic en-
gagement and professionalism
among physicians generally
1-3
and
pediatricians in particular.
4-7
Ac-
cording to the American Academy of Pe-
diatrics (AAP), community pediatrics in-
corporates clinical practice and public
health principles for “promoting the health
of all children within the context of the
family, school, and community.”
4(p1092)
To
promote children’s well-being, pediatri-
cians increasingly are encouraged to en-
gage in community partnerships to ad-
dress social and environmental factors that
contribute to children’s health.
6,8
As such,
residency training places a growing em-
phasis on acquiring necessary skills in
community pediatrics, regardless of spe-
cialization.
9,10
Despite this emphasis, little
is known about the ongoing involvement
of pediatricians in community activities.
Multiple factors influence pediatri-
cians’ involvement in community activi-
ties. Prior community experiences, educa-
tion and training, and sociodemographic
characteristics have been associated with
community involvement.
11-15
However,
among practicing pediatricians, commu-
nity activities may conflict with demands
for generating revenue. Moreover, it is un-
clear how involvement is influenced by the
changing demographic characteristics of the
pediatric workforce, with more female train-
ees, more part-time employment, and
greater debt among recent graduates.
16
In-
volvement also may be influenced through
postgraduate opportunities. For example,
the AAP’s Community Access to Child
Health Program
12,17
and the Healthy To-
morrows Partnership for Children Pro-
gram, a collaboration between the Federal
Maternal and Child Health Bureau and the
AAP, are among the initiatives that encour-
age acquisition and application of new skills
among practicing pediatricians.
The objectives of this study are to de-
scribe pediatricians’ current involvement
in community child health activities, to ex-
For editorial comment
see page 695
Author Affiliations are listed at
the end of this article.
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amine trends in community involvement from 1989 to
2004, and to compare perspectives and skills related to
community involvement among those who currently do
and do not participate in community activities.
METHODS
PERIODIC SURVEYS
The AAP conducts Periodic Surveys of Fellows on topics of im-
portance to pediatricians 3 or 4 times per year. Each survey uses
a unique random sample of members of the AAP. Periodic Sur-
veys in 1989 (number 9), 1993 (number 23), and 2004 (num-
ber 60) included questions on involvement with community child
health. The 1989 survey asked respondents to indicate current
participation “in a professional capacity in any community-
based settings or activities” and included a follow-up question
to identify involvement during the past 12 months from a list of
individual activities. The 1993 and 2004 surveys included a global
question asking participants to indicate whether they partici-
pated in a professional capacity in any community-based activi-
ties in the past 12 months. These surveys also included a sepa-
rate question about involvement in listed individual activities.
All surveys asked whether participation was voluntary or paid
and about personal and practice characteristics.
The 2004 survey additionally asked respondents about their
perspectives regarding their current level of involvement in com-
munity child health activities, their view of their own respon-
sibility for child health, their willingness to spend time in child
health activities, and their expectations about whether their com-
munity work in the next 5 years would increase, decrease, or
stay the same. The 2004 respondents described their involve-
ment during the past 12 months and skill level in 6 additional
strategies to influence children’s health. Involvement re-
sponses were dichotomous (yes or no) and skills were self-
rated as “not at all skilled,” “minimally skilled,” “moderately
skilled,” or “very skilled.”
The 1989 Periodic Survey was a 6-page self-administered
questionnaire sent to 1024 active (nonretired) AAP members
from August 23 through November 16, 1989. After 5 contacts,
720 questionnaires were received (response rate, 70.3%). In ad-
dition to questions on participation in community health ser-
vices, the survey included questions on participation in inter-
national health and practice of or training in sports medicine.
The 1993 Periodic Survey was an 8-page self-administered
questionnaire sent to 1627 active members from September 15
through December 30, 1993. After 5 contacts, 1060 question-
naires were received (response rate, 65.2%). In addition to ques-
tions on participation in community health services, the sur-
vey included questions on involvement in the Healthy
Tomorrows Partnership for Children Program, as well as ques-
tions about various public education topics.
The 2004 Periodic Survey was an 8-page self-administered
questionnaire sent to 1829 active members. The original mail-
ing and 5 follow-up mailings to nonrespondents were con-
ducted from April 19 through September 14, 2004. After the
first and fifth mailings, an e-mail reminder was sent to nonre-
spondents with e-mail addresses, and a postcard reminder was
sent to those without (67.9% and 32.1% of nonrespondents,
respectively). A total of 1053 completed questionnaires were
received (response rate, 57.6%). Involvement in community
child health was the only topic of this survey. Survey content
was informed by a national advisory group with expertise in
community pediatrics and was reviewed by the AAP Commu-
nity Pediatrics Action Group and members of the Council on
Community Pediatrics.
DATA ANALYSIS
Data analysis was conducted for questions pertaining to in-
volvement in community child health activities. Analysis on
all 3 surveys included postresidency pediatricians, excluding
residents and pediatricians with a Specialty Fellow designa-
tion in the AAP membership database. The final sample in-
cluded 637 pediatricians in 1989 (88.5% of respondents), 865
pediatricians in 1993 (81.6% of respondents), and 881 pedia-
tricians in 2004 (83.7% of respondents).
We used
2
analysis and t tests to assess differences in re-
sponses between survey years. Additional
2
and median test
analyses of the 2004 respondents included a comparison of
demographic and practice characteristics, community child
health perspectives, and skill level by participation in commu-
nity child health activities in the past year.
Analyses were conducted using SPSS statistical software, ver-
sion 11.5 (SPSS Inc, Chicago, Illinois). Human subjects ap-
proval was obtained from the AAP Institutional Review Board
and the Committee on Human Research at Johns Hopkins
Bloomberg School of Public Health.
RESULTS
RESPONDENT CHARACTERISTICS
Demographic and practice characteristics of respon-
dents were compared during the 15-year study period.
The percentage of female pediatricians increased from
29.6% in 1989 to 52.5% in 2004 (P.001), but mean age
did not vary (45.8 vs 45.3 years; P=.33). From 1993 to
2004, there was no difference in practice location (ur-
ban vs suburban vs rural), although over time fewer pe-
diatricians were in solo or 2-physician practices and more
worked in group practices. From 1993 to 2004, a grow-
ing percentage of respondents reported spending more
than 50% of their time in general pediatrics (64.8% vs
71.6%; P=.003), and there was an increase in the mean
percentage of time spent in direct patient care (71.9% to
76.9%; P=.005).
In addition, in 2004, 6.7% of respondents identified
themselves as Hispanic, 74.2% as white, 17.9% as Asian,
and 3.4% as African American (respondents were asked to
“circle all that apply”). Among the 771 respondents who
provided information regarding race and ethnicity, 85
(11.0%) were underrepresented minorities (ie, African
American, Native American, or Hispanic). Respondents had
greater representation from suburban (36.4%) and non–
inner city urban (29.3%) practices compared with inner
city urban (21.8%) or rural (12.5%) areas. Most respon-
dents (78.3%) reported full-time employment.
For assessing potential response bias in 2004, compari-
sons between respondents and nonrespondents were con-
ducted for several demographic variables. No significant
differences were found between respondents and nonre-
spondents for mean age (43.7 years) and region of the coun-
try (Northeast, 24.5%; Midwest, 21.5%; South, 33.4%; and
West, 20.7%). More respondents were women (53.9% vs
46.6%; P.05). We similarly assessed potential response
bias in 1993; no significant differences were found be-
tween respondents and nonrespondents for region of coun-
try or sex. Demographic data were no longer available for
1989 or for age in 1993.
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PARTICIPATION IN COMMUNITY
CHILD HEALTH OVER TIME
During the past 15 years, the percentage of pediatri-
cians involved in community child health activities in
the preceding year rose from 56.6% in 1989 to 59.4% in
1993 but declined to 45.1% in 2004 (
Table 1). There
also has been a decrease in the average number of
activities in which pediatricians are involved, either on
a volunteer or paid basis. Among those who participate
in community activities, more pediatricians in 2004
compared with preceding years reported that their com-
munity participation was voluntary (79.6% in 2004 vs
57.8% in 1993 vs 48.6% in 1989); however, the per-
Table 1. Pediatrician Participation in Community Child Health Activities
Participation
1989
(n=637)
1993
(n=865)
2004
(n=881)
P Value,
1989/1993
a
Any community activity, No. (%)
b
353 (56.6) 498 (59.4) 387 (45.1) .001 /.001
Volunteer only, No. (%)
c
171 (48.6) 284 (57.8) 297 (79.6) .001 /.001
Paid only, No. (%)
c
58 (16.5) 79 (16.1) 31 (8.3) .001/.001
Volunteer and paid, No. (%)
c
123 (34.9) 128 (26.1) 45 (12.1) .001 /.001
Volunteer community activities, mean (SD)
c
2.3 (2.0) 2.0 (1.7) 1.9 (1.3) .005/.27
Paid community activities, mean (SD)
c
1.2 (2.0) 0.8 (1.3) 0.3 (1.1) .001 /.001
Volunteer and paid community activities, mean (SD)
c
3.4 (2.7) 2.8 (2.0) 2.2 (1.6) .001 /.001
a
P values are calculated for 1989 or 1993 survey results vs 2004 survey results.
b
In 2004 and 1993, pediatricians were asked about their participation in community activities during the past 12 months; in 1989, they were asked about
current participation.
c
Based on actual number of respondents who indicated participation in specific activities.
Table 2. Pediatrician Participation by Community Child Health Activity
Activity
No. (%) of Respondents
P Value,
1989/1993
a
1989
(n=353)
1993
(n=498)
2004
(n=387)
Health and fitness
Health fairs 80 (22.7) 149 (29.9) 108 (27.9) .10/.51
Camps 71 (20.1) 101 (20.3) 54 (14.0) .03/.01
Neighborhood health centers/public health clinics
b
64 (18.1) 122 (24.5) 54 (14.0) .12/ .001
Sports team physician
c
47 (13.3) 52 (10.4) 31 (8.0) .02/ .001
School/education
School consultant
d
74 (21.0) 161 (32.3) 60 (15.5) .054/ .001
Special education program consultant 32 (9.1) NA 30 (7.8) .52/. . .
Child care center 50 (14.2) 76 (15.3) 29 (7.5) .003/ .001
School health clinic provider 15 (4.2) 41 (8.2) 28 (7.2) .08/.58
School board member NA NA 17 (4.4) . . . /. . .
Other government/public health programs
Child protection services/agencies 77 (21.8) 117 (23.5) 32 (8.3) .001/ .001
Child with special health care needs/Title V 96 (27.2) 99 (19.9) 28 (7.2) .001/ .001
Courts 64 (18.1) 88 (17.7) 23 (5.9) .001/ .001
Child-specific advisory committee (eg, IDEA, newborn screening,
Head Start, MCH, immunization)
68 (19.3) 82 (16.5) 56 (14.7) .001/.46
Board of health NA NA 13 (3.4) . . . /. . .
Nonprofit organization
Volunteer organizations (eg, AAP chapter or national activities,
March of Dimes, Rotary, Kiwanis)
e
100 (28.4) NA 89 (23.0) .10/. . .
Child advocacy (eg, Voices for Children, Children’s Defense Fund)
f
71 (20.1) 117 (23.5) 38 (9.8) .001/ .001
Homeless shelters 13 (3.7) 30 (6.0) 14 (3.6) .96/.10
Mobile health services 3 (0.8) 9 (1.8) 5 (1.3) .56/.54
Other 78 (22.1) 93 (18.7) 82 (21.2) .77/.36
Abbreviations: AAP, American Academy of Pediatrics; ellipses, not applicable; IDEA, Individuals with Disabilities Education Act; MCH, Maternal and Child Health;
NA, not asked.
a
P values are calculated for 1989 or 1993 survey results vs 2004 survey results.
b
2004 wording; in 1989 and 1993 the categories were “neighborhood health center” and “indigent care/public health clinic.”
c
1989 and 1993 wording; in 2004 the categories were “school sports team physician” and “recreational sports team physician (other than school).”
d
1993 and 2004 wording; in 1989 the categories were “public school consultant” and “private school consultant.”
e
2004 wording; in 1989 the question was asked as “volunteer organizations (eg, local chapter/national AAP activities).”
f
2004 wording; in 1989 the category was “child advocacy setting, non-AAP (eg, Healthy Mothers/Healthy Babies)” and in 1993 it was “child advocacy settings,
non-AAP.”
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centage of all pediatricians engaged in volunteer activi-
ties from 1993 to 2004 was consistent (34.3% in 1993
vs 35.9% in 2004).
Although participation in many activities was stable
from 1989 to 1993, there was a decline in multiple set-
tings in 2004 across the 4 categories related to health and
fitness, school/education, other government and public
health programs, and nonprofit organizations (
Table 2).
Specifically, declines in participation were noted for
camps, neighborhood health centers, school consul-
tancy, child care centers, child protection agencies, courts,
and child advocacy organizations. Participation in health
fairs continues to be a frequently cited activity. There were
no significant changes in participation in health fairs, vol-
unteer organizations, and child-specific advisory com-
mittees (Table 2).
PARTICIPANTS AND
NONPARTICIPANTS IN 2004
Sex, marital status, having a child aged 5 years or
younger, spending half-time or more in general pediat-
rics, practice type, and full-time employment were not
associated with involvement in community child health
activities in the preceding year (
Table 3). The mean
age of participants was slightly higher. A greater per-
centage of rural physicians reported participation in
community child health activities than pediatricians
located in suburban or urban areas (61.0% vs 38.0% vs
48.0%; P.001). Finally, pediatricians who participated
reported a higher mean percentage of patients with pub-
lic health insurance than did nonparticipants (42.6% vs
38.1%; P=.003).
Perspectives on involvement varied with participa-
tion. More participants than nonparticipants reported
that their level of involvement was “just right” (52.5%
vs 24.9%; P .001) (
Table 4). Relative to results of
the 1993 survey, a greater percentage of pediatricians
in 2004 believed that their current level of activity was
inadequate (62.1% vs 35.5%; P .001).
18
More partici-
pants than nonparticipants in 2004 anticipated an
increase in their involvement during the next 5 years
(63.5% vs 54.1%; P.001) and were willing to spend 4
or more hours monthly on child health activities
(33.6% vs 10.0%; P .001), whereas more nonpartici-
pants than participants reported no willingness to
spend time (17.1% vs 2.9%; P .001). More pediatri-
cians who were currently involved in community child
health compared with those who were not felt moder-
ately or very responsible for improving child health in
their community at a population level (84.2% vs 69.4%;
P.001).
Among participants, receipt of payment for commu-
nity activities was not associated with perceived child
health responsibility. However, more who received pay
vs no pay thought their activity level was “just right”
(67.9% vs 48.6%; P =.008). In addition, those who
received pay were less likely to believe their level of
activity would increase during the next 5 years (51.3%
vs 66.1%; P=.002). Yet, those who were paid were more
willing to spend 4 or more hours per month (54.6% vs
27.7%; P .001).
SELECTED SKILLS IN COMMUNITY
CHILD HEALTH IN 2004
More pediatricians reported a moderate or high skill level
in using computers and the Internet to find information
about child health policy (60.8%) and locating commu-
nity resources for individual children (56.8%) than in
other areas, such as identifying community needs (30.0%)
or using population-level data to understand the deter-
minants of child health (28.1%) (
Table 5). More re-
spondents who participated in each activity compared with
individuals who did not reported moderate or high skills.
For example, a greater percentage of pediatricians who
spoke publicly on behalf of children’s health, compared
with pediatricians who did not, reported feeling moder-
ately or highly skilled in this area (83.2% vs 31.3%;
P .001).
Table 3. Demographic and Practice Characteristics
for Community Child Health Activity Participants
and Nonparticipants in 2004
Characteristic
Participation in
Community Child Health
Activity in Past Year
a
P
Value
Yes
(n=387)
No
(n=481)
Demographic
Age, mean (SD), y 46.0 (10.2) 44.6 (10.0) .04
Sex
Male 200 (48.4) 213 (51.6)
.06
Female 187 (42.1) 257 (57.9)
Marital status
Married 344 (46.3) 399 (53.7)
.22Single 25 (36.6) 45 (63.4)
Widowed/separated/divorced 14 (38.9) 22 (61.1)
Youngest child 5 y 112 (45.7) 133 (54.3) .50
Underrepresented minority
b
35 (43.8) 45 (56.3) .93
Practice
Community setting
Urban, inner city 79 (43.4) 103 (56.6)
.001
Urban, non–inner city 124 (51.5) 117 (48.5)
Suburban 115 (38.0) 188 (62.0)
Rural 61 (61.0) 39 (39.0)
Percentage of time spent in
general pediatrics
50% 107 (45.3) 129 (54.7)
.93
50% 280 (45.0) 342 (55.0)
Type of practice
Solo or 2-physician 60 (50.0) 60 (50.0)
.71
Pediatric group/multispecialty/
HMO staff
177 (43.3) 232 (56.7)
Medical school 43 (43.9) 55 (56.1)
Nongovernment/government
hospital or clinic
61 (47.3) 68 (52.7)
Other
c
39 (47.0) 44 (53.0)
Employment status
Full-time 304 (45.8) 360 (54.2)
.48Part-time 71 (44.4) 89 (55.6)
Other
d
12 (35.3) 22 (64.7)
Abbreviation: HMO, health maintenance organization.
a
Data are given as number (percentage) of respondents.
b
Includes African American, Native American, and Hispanic ethnicities.
c
Includes nonprofit community health center and other.
d
Includes retired, semiretired, not in practice, and not active.
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COMMENT
The results of this study reveal an overall decrease in pe-
diatrician involvement in community child health activi-
ties from 1989 to 2004. Although this decline is consis-
tent with overall declines in civic engagement among the
general public,
19
it is particularly concerning because part-
nerships with community organizations are viewed as in-
tegral to addressing the social and community factors that
influence children’s health and inequalities.
5
The AAP rec-
ognizes community pediatrics as “an integral part of the
professional role and duty of the pediatrician.”
4(p1092)
Our findings, therefore, suggest implementation chal-
lenges. Of note, the decline in involvement is largely driven
by a decline in paid participation. For some publicly
funded programs serving children, declines in federal in-
vestments may contribute to a decline in paid opportu-
nities for pediatricians.
20,21
Efforts are needed to under-
stand whether paid positions in government and
philanthropic organizations are less available or whether
reimbursement for such activities is so low as to pre-
clude paid participation by individuals or support from
their employers. It is possible that for some activities, pe-
diatricians perceive that other systems, such as insur-
ance expansions for children with special health care
needs, have diminished the need for involvement of in-
dividual physicians. It is also possible that barriers re-
lated to insufficient time, competing family and work de-
mands, and limited knowledge and training contribute
to declining involvement.
22
In 2004, Solomon et al reported that 72% of pediatric
residency programs required involvement of trainees in
4 or more community settings.
10
As residency training
programs adopt curricula to meet training require-
Table 5. Participation in Activity in the Past Year by Moderate or High Skill in Activity in 2004
Activity
Any
Participation
a
Moderate or High Skill
P ValueAll Respondents
b
Nonparticipants
c
Participants
c
Locate resources for individual children 568/830 (68.4) 398/701 (56.8) 24/141 (17.0) 374/560 (66.8) .001
Use computers and Internet to find information
about child health policy and related activities
553/825 (67.0) 421/692 (60.8) 35/151 (23.2) 386/541 (71.3) .001
Identify community needs 249/810 (30.7) 167/557 (30.0) 38/316 (12.0) 129/241 (53.5) .001
Member of a team to promote child health 248/814 (30.5) 252/572 (44.1) 77/332 (23.2) 175/240 (72.9) .001
Speak publicly on behalf of children’s health 228/820 (27.8) 293/571 (51.3) 110/351 (31.3) 183/220 (83.2) .001
Use population-level data to understand the
determinants of child health
202/802 (25.2) 154/548 (28.1) 33/352 (9.4) 121/196 (61.7) .001
a
Data are given as number/total number of respondents (percentage) who answered the question about participation.
b
Data are given as number/total number of respondents (percentage) who participated in an activity and reported a skill level.
c
Data are given as number (percentage) of respondents.
Table 4. Perspectives on Involvement and Responsibility for Child Health in 2004
Characteristic
Community Child Health Activities During the Past Year
a
P Value
Total
(n=881)
Participants
(n=387)
Nonparticipants
(n=471)
Current level of involvement
Too little 527 (62.1) 181 (46.8) 346 (75.1)
.001Just right 318 (37.5) 203 (52.5) 115 (24.9)
Too much 3 (0.4) 3 (0.8) 0
Responsibility for child health
Very responsible 278 (32.8) 163 (42.2) 115 (24.9)
.001
Moderately 367 (43.3) 162 (42.0) 205 (44.5)
A little 189 (22.3) 59 (15.3) 130 (28.2)
Not at all 13 (1.5) 2 (0.5) 11 (2.4)
Time willing to spend in child health activities, h/mo
5 92 (10.9) 75 (19.5) 17 (3.7)
.001
4-5 83 (9.8) 54 (14.1) 29 (6.3)
1-3 427 (50.5) 193 (50.3) 234 (50.6)
1 154 (18.2) 51 (13.3) 103 (22.3)
None 90 (10.6) 11 (2.9) 79 (17.1)
Expectation of community work in next 5 y
Increase 493 (58.3) 242 (63.5) 251 (54.1)
.001Stay the same 330 (39.1) 124 (32.5) 206 (44.4)
Decrease 22 (2.6) 15 (3.9) 7 (1.5)
a
Data are given as number (percentage) of respondents.
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ments for structured experiences in community and child
advocacy, it is possible that the workforce increasingly
will be equipped with related skills and capacity. Such
skills and capacity have the potential to benefit children
if the more than 70% of pediatricians willing to spend at
least an hour per month on community activities en-
gage in these activities and advocate effectively.
23
Inter-
estingly, in this study, more recent respondents report
growing expectations for involvement and a willingness
to spend time in community activities.
We found that those with recent involvement also re-
ported higher skill levels. Similarly, Nader et al
11
re-
ported that involvement in school health activities dur-
ing residency was associated with involvement later in
practice. In these analyses, participation was associated
with higher self-reported skill levels.
Several study limitations should be noted. We asked re-
spondents about involvement in selected activities in 4 do-
mains. However, comparable declines in overall involve-
ment also were reported using a global measure. Second,
this global measure (any participation without specifying
activities) asked about current involvement in 1989 and
involvement in the past 12 months in the later 2 surveys.
However, this would tend to underestimate levels of in-
volvement in 1989 and the subsequent decline. More-
over, questions regarding involvement in specific activi-
ties related to the past 12 months in all surveys. Third, it
is possible that respondents who chose to complete the sur-
vey were influenced by social desirability and overre-
ported involvement. However, this same phenomenon likely
would have influenced earlier surveys, suggesting that the
trend is comparable. Fourth, respondents did not com-
ment on the quality of experience. Although pediatricians
reported fewer activities over time, it is possible that the
quality of community experiences among those involved
was constant or enhanced. Fifth, response rates to Peri-
odic Surveys have declined over time. However, Cull et al
24
show minimal response bias with AAP survey response rates.
These data largely precede recent initiatives such as the
Anne E. Dyson Community Pediatrics Training Initia-
tive, which aims to provide residents with the skills and
knowledge related to improving the health of children in
their communities.
25
However, many residency pro-
grams, in addition to those funded through the Dyson Ini-
tiative, have had long-standing interests in equipping resi-
dents with community pediatrics skills.
25-28
Since 2002, the
Accreditation Council for Graduate Medical Education
Residency Review Committee for Pediatrics has required
“structured educational experiences with planned didac-
tic and experiential opportunities for learning...that pre-
pare residents for the role of advocate for the health of chil-
dren within the community.”
29
In addition, medical school
curricula increasingly are exposing students to commu-
nity engagement through structured curricular activi-
ties.
30-32
In 2007, the Association of American Medical Col-
leges adopted a new standard to support service learning
activities among medical students.
33
In conclusion, although pediatricians have a strong sense
of responsibility for promoting children’s health, they re-
port declining current involvement in community activi-
ties, particularly with regard to paid opportunities. The
declining involvement reported among practicing pedia-
tricians in conjunction with heightened exposures to com-
munity health training during residency may contribute
to the growing percentage who perceive their current level
of involvement to be inadequate. However, these same pe-
diatricians also expect greater involvement in the next 5
years. Whether acquisition of new skills during resi-
dency translates to increased participation in community
activities may depend on whether activities are struc-
tured to meet the realities of the busy lives of pediatri-
cians and whether opportunities are sufficiently valued by
employers to encourage involvement as part of profes-
sional responsibilities.
Accepted for Publication: December 19, 2007.
Author Affiliations: Department of Population, Family
and Reproductive Health, Johns Hopkins Bloomberg
School of Public Health, Baltimore, Maryland (Drs Minko-
vitz and Chandra and Ms Grason); Division of Health Ser-
vices Research, American Academy of Pediatrics, Elk
Grove Village, Illinois (Ms O’Connor); RAND Corpora-
tion, Arlington, Virginia (Dr Chandra); Department of
Pediatrics, University of Rochester School of Medicine
and Dentistry, Rochester, New York (Dr Aligne); Mater-
nal and Child Health Bureau, Health Resources and Ser-
vices Administration, Rockville, Maryland (Dr Kogan);
and Goldsboro Pediatrics, Goldsboro, North Carolina
(Dr Tayloe).
Correspondence: Cynthia S. Minkovitz, MD, MPP, De-
partment of Population, Family and Reproductive Health,
Johns Hopkins Bloomberg School of Public Health, 615
N Wolfe St, Room E4636, Baltimore, MD 21205 (cminkovi
@jhsph.edu).
Author Contributions: Dr Minkovitz had full access to all
the data in the study and takes responsibility for the in-
tegrity of the data and the accuracy of the data analysis.
Study concept and design: Minkovitz, O’Connor, Grason,
and Aligne. Acquisition of data: O’Connor. Analysis and in-
terpretation of data: Minkovitz, Grason, Chandra, Aligne,
Kogan, and Tayloe. Drafting of the manuscript: Minkovitz
and Chandra. Critical revision of the manuscript for impor-
tant intellectual content: Minkovitz, O’Connor, Grason,
Chandra, Aligne, Kogan, and Tayloe. Statistical analysis:
Minkovitz, Chandra, and Kogan. Obtained funding: Minko-
vitz and Grason. Administrative, technical, or material sup-
port: Minkovitz, O’Connor, Grason, Aligne, and Tayloe.
Study supervision: Minkovitz.
Financial Disclosure: None reported.
Funding/Support: This study was funded by the Mater-
nal and Child Health Bureau, Health Resources and Ser-
vices Administration.
Disclaimer: The views expressed in this article are those
of the authors and do not represent policies of the AAP.
Additional Information: These analyses were con-
ducted as part of the Dyson Initiative National Evalua-
tion and informed by the AAP Periodic Survey No. 60
Workgroup: Dr Aligne, Ms Grason, David E. Heppel, MD
(Maternal and Child Health Bureau, Health Resources and
Services Administration); Dr Kogan; Dr Minkovitz; Ms
O’Connor; Judith S. Palfrey, MD (Children’s Hospital Bos-
ton, Boston, Massachusetts); Dr Tayloe; and Thomas F.
Tonniges, MD (Boys Town National Research Hospital,
Omaha, Nebraska).
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 162 (NO. 7), JULY 2008 WWW.ARCHPEDIATRICS.COM
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Additional Contributions: Lynn Olson, PhD, performed
a thoughtful review of the manuscript.
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