linda beth tiedje, phd, rn,...

November/December 2005 MCN 373

ABSTRACT

This article reviews outcomes, indicators, and challenges for building evidence-based practice in

community maternal-child health (MCH), and includes promising new design and analytical

strategies. In addition, 10 topic areas are listed, which are the foundation of community MCH evi-

dence: (1) evidence of health behavior on mortality/morbidity; (2) theoretical underpinnings of

public policy interventions; (3) evidence of growing health disparities; (4) the potential of explod-

ing information technologies; (5) data on aging, maternity, employment, and lactation; (6) data on

the changing face of HIV/AIDS; (7) data on the changing way we give birth; (8) drug safety reg-

istries; (9) antibiotic-resistant organisms; and (10) environmental pollutants and health. In addi-

tion, evidence of indirect and global influences on community MCH is reviewed and the principles

of lifestyle change and health promotion are emphasized.

Key Words: Community; Maternal-child health; Health promotion; Evidence-based practice.

Linda Beth Tiedje, PhD, RN, FAAN

It is the best and worst of times. The past 30 years ofcommunity maternal-child nursing (MCN) have seenscientific advances in improved disease surveillance, the

development of more vaccines, the availability of morebirth control options, and a burgeoning of informationtechnology. Yet we still have a long way to go: violence andabusive behavior ravage homes and neighborhoods; recordbinge drinking occurs on college campuses; a dearth ofcommunity mental health services means mental illness of-ten goes undiagnosed and untreated; obesity has achievedepidemic proportions; 40% of us engage in no physical ac-tivity; adolescent smoking continues to be a problem; andwomen and people of color are disproportionately affectedby HIV/AIDS.

Evidence-based practice, unheard of 30 years ago, isnow a familiar term, complete with outcomes and indica-tors. Yet obstetrics has been identified as the healthcarespecialty with the worst record of basing its practice onsound evidence (Rooks, 1999). A further problem in com-munity MCH is that the target population is both individu-ally and community focused. For instance, when dealingwith adolescent mothers, we need to consider both the in-dividual support system and the community response(What are school policies regarding child care? What aregovernment programs for employment/education for teenparents?). Individual and family health are nested withinand influenced by community forces, like Russian dollsneatly stacked one inside the other. Community and indi-vidual indicators and outcomes do not always divide in anorderly manner, although many databases, like theCochrane database, largely focus on individually based, notcommunity, indicators/outcomes. Throughout this articleboth individual and community indicators/outcomes willbe discussed.

Measuring OutcomesThe Institute of Medicine has recommended some qualityaims for measuring outcomes in community settings: safety,effectiveness, patient-centeredness, timeliness, efficiency,and equity, all of which seem more related to individualpractice (Institute of Medicine, Committee on Quality ofHealth Care in America, 2001). Many currently experi-mental designs are being tried to better evaluate qualityaims, interventions, and outcomes, including cost-effective-ness analysis (Paul, Phillips, Widome, & Hollenbeak,2004), the cluster or group randomized trial, and statisticalmodels in the form of general and generalized linear mixedmodels (see Vaughan, 2004, and other articles in that eval-uation issue of the American Journal of Public Health).The Institute of Medicine report (2001) also emphasizedthat more than improved outcome evaluation measures areneeded. Broad sweeping redesign is also required in health-care organizations and by professionals, and in the broaderenvironment in which they function.

Complex community indicators and outcomes make evi-dence-based practice particularly challenging in a communitycontext. Healthcare varies, as well as social, political, finan-cial, historical, and psychosocial indicators (Rycroft-Malone,

2004). This means that there are many intervention points inprotecting and developing healthy communities. Outcomes,therefore, are often multicausal and may be difficult to track.Randomized controlled trials (RCTs), the gold standard forevaluating clinical interventions with a short causal chain be-tween agent and outcome, are often not appropriate in com-munity MCH where factors are more complex. In the ab-sence of RCTs there is an urgent need to develop other out-come standards and protocols, such as plausibility designs(Victora, Habicht, & Bryce, 2004).

Beyond new evaluation standards and protocols, there isa need for more integration between public health andhealthcare delivery systems. The Institute of Medicine(2003) summarized changes that must be made:

1. Adopting a population health approach that considersmultiple determinants of health;

2. Strengthening the public health infrastructure; 3. Building partnerships between the many sectors of

health care; 4. Developing systems of accountability; 5. Making evidence the foundation of decisions; and 6. Enhancing communication within all levels of the pub-

lic health system.

The need for these standards was especially evident re-cently in the aftermath of Hurricane Katrina.

Indicators of Community HealthMeasurable community health indicators were recently re-leased in an annual report: America’s Health: State HealthRankings (2004). This report is a state-by-state analysis of18 indicators such as how many adults smoke, what per-centage of tax dollars go toward health, high-school gradu-ation rates, violent crime statistics, and cancer and motorvehicle accident deaths. These indicators show that after 15years of significant improvements, health progress hasstalled. One of the most critical areas is infant mortality, al-ways an indicator of overall community health. More than75 infants die each day in the United States, which meansthat on average, seven of every 1000 babies die before 1year of age. The United States ranks 29th in the world ininfant mortality. The rate is directly related to access tohealthcare, but other community-based factors such as obe-sity, smoking, infection, and stress are also associated. Inaddition, factors such as greater numbers of people withouthealth insurance, declining high-school graduation rates,and increased child poverty are causing a slowing of thesecommunity “vital signs” related to our nation’s health.

Challenges to the Use of Evidence-Based Practice in Community HealthThere are many practice challenges in using evidence-basedpractice in community MCH, some individually and somecommunity focused. First, the evidence keeps changing,which requires continual improvising as new ideas and ap-proaches emerge from research. Second, if the client/com-

374 VOLUME 30 | NUMBER 6 November/December 2005

munity becomes our report card, what does it take to get an“A” on an outcome? Do we shift the focus from the clientor community to what weight, blood glucose level, orsmoking status will help us as providers look good? And isthis the way to effective change? A final challenge involvesthe measurability of outcomes we think are important.Breastfeeding rates, the week that prenatal care is initiated,infant mortality, and the number of premature births are allimportant outcomes. Equally important and more intangi-ble are issues of patient-centeredness and self esteem, bothrelated to the provision of good MCH in the community.

Ten Areas for Building on Evidencein Community MCHDuring the past 30 years, accumulating evidence for protect-ing and developing community MCH has developed. Thefollowing 10 areas are a sampling of themany MCH topics in which a foundation ofindividually or community-based evidence ex-ists. At times the topics may seem unrelatedto MCH, but directly or indirectly they all af-fect the health of mothers, children, and fami-lies in our communities.

1. Evidence of Health Behavior on Mortality/MorbidityCauses of death in the United States are nowoften framed in terms of behaviors, not dis-eases. For example, in the United States in2000 the two leading causes of death weretobacco use (435,000 people) and poor dietand physical inactivity (400,000 people)(Mokdad, Marks, Stroup, & Gerberding,2004). Although a recent report states thatthe latter number may have been inflated,physical inactivity and poor diet still remaina significant health issue in the United States.Beyond contributing to one third of U.S. mortality, tobaccouse and poor diet/physical inactivity also influence MCH.Although evidence linking behavior to mortality/morbiditynow exists, evidence of the effectiveness of community in-terventions for tobacco cessation, poor diet, and physicalinactivity is still needed: innovative new tobacco cessationprograms, exercise programs, and home-visit-centeredweight loss programs targeting postpartum women (seeKearney & Simonelli, 2004, for a description of one suchprogram).

2.Theoretical Underpinnings of Public Policy InterventionsThe focus of public policy health interventions is on thelarger social and environmental factors that shape healthand illness, for example, understanding the connection be-tween healthy communities and health systems, health be-haviors, housing, schools, and jobs (see Diez Roux, 2001,for further evidence). In the example of smoking, interven-tions must extend beyond the individual to public policies

that restrict tobacco marketing, increase taxes on cigarettes,ensure warning labels, and limit smoking in public places.An international public health treaty proposed by the WorldHealth Organization (WHO) includes these policies, andwas recently ratified by a 40th country, Peru. Unfortunately,the U.S. State Department still needs to review the treatyand recommend it to the Senate for ratification (WHO,2004). Monitoring smoking rates after treaty implementa-tion is necessary to further build public policy evidence.

Another example of policy intervention concerns familyplanning. Family planning has come under increased scruti-ny from conservative politicians and constituents. Somepharmacists have begun restricting contraceptives andmorning-after pills to women; the Food and Drug Admin-istration is evaluating the use of RU-486 (an abortifacientcurrently on the market); and changes in the U.S. SupremeCourt could potentially affect the Roe v. Wade decision

and abortion rights for women. All of these factors remindus of the influence of public policy on the individual choic-es of women (see Hwang & Stewart, 2004, for a discussionof recent policy developments in sexual and reproductivehealth). Monitoring birth rates and abortion rates as out-comes is important in light of these changes.

A third public policy issue concerns obesity. A multifac-eted, public health approach is needed to address the manybehavioral, sociocultural, and environmental factors con-tributing to obesity. Decreasing obesity by focusing primar-ily on individual behavior has been ineffective (Blumenthal,2002). Banning soft drink (soda) machines in high schoolsand imposing junk food taxes are but two broader policyinterventions suggested. Ten years ago Kelly Brownell, di-rector of Yale’s Center for Eating and Weight Disorders,proposed junk food taxes, and in 2003, New York assem-blyman Felix Ortiz again proposed taxes on junk food andsedentary entertainments to fund nutrition and exerciseprograms (Leigh, 2004). Databases to monitor obesitychanges in response to these policy changes are essential.


Complex community

indicators and outcomes

make evidence-based

practice particularly challenging in

a community context.

Finally, perhaps the most important public policy issuein community MCH is healthcare for the uninsured, sincemost of the uninsured are women and children. To includethe uninsured, we cannot expand healthcare as it is cur-rently delivered to everyone the way we have always doneit: high-tech, high-cost healthcare centered on surgical andpharmaceutical tertiary fixes. Evidence indicates that ourhealthcare system is burdened by chronic diseases rooted inpoor health behaviors and an aging baby boomer genera-tion. If we continue to practice nursing as we know it, theresults will be pretty much the same as we’re getting. Ourevidence must widen to include policies that accommodatethe scope of the problem; we must look realistically atwhat needs to be done and what it is we do. To makehealthcare affordable for all, we must reframe it and sharp-en our skills as providers by working with local govern-ments, policy makers, business executives, educators, com-munity leaders, and the federal government. If we refuse tocome up with a solution to provide healthcare for the unin-sured, someone else will do it for us, and it might not be inthe best interests of those involved (O’Grady, 2004).

3. Evidence of Growing Health DisparitiesEliminating health disparities is one of two overarchinggoals for Healthy People 2010. (U.S. Department of Health

and Human Services, 2000b). Current evidence of healthdisparities in race/ethnicity include the infant mortalityrate, which among African Americans and American Indi-ans/Alaska natives is more than double that of whites. Thedeath rate from HIV/AIDS for African Americans is morethan seven times that for whites. Hispanics are almosttwice as likely to die from diabetes as are non-Hispanicwhites, and the rate of diabetes for AmericanIndians/Alaskan natives is more than twice that for whites.Although only 11% of the population is Hispanic, Hispan-ics account for 20% of the new cases of tuberculosis. Oth-er disparities also exist for gender, income, education, dis-ability, rural localities, and sexual orientation. Achievingequity in healthcare means promotion of communities thatare safe, educated, and with job opportunities and access tohealthcare—evidence indicates that real changes in healthstates begin in communities (see Figure 1 for evidence ofthe association between poverty and health).

4.The Potential of Exploding Information TechnologiesThe proliferation of cell phones, computers, and wireless-enabled laptops or PDAs is good news for the tracking ofoutcomes needed in evidence-based practice. As providers,we have not only access to more and more information,but also the ability to track outcomes of interventions. We


Perc

en

tw

ith

Fair

or

Po

or

Healt

hS

tatu

s

Less than $15,000 $15,000–24,999 $25,000–34,999 $35,000–49,999 $50,000 or more

Household Income

FIGURE 1. Relationship between household income and fair or poor health status.

25.00% –

20.00% –

15.00% –

10.00% –

5.00% –

0.00% –

Source: U.S. Department of Health and Human Services, 2004b.

also have access to more online data to track evidence onhealth-related community issues related to the environ-ment, communicable disease, business, industry, and eco-nomic development.

5. Data on Aging, Maternity, Employment, and LactationWhile the birth rate for girls 10 to 14 of age is at the lowestsince 1946, the birth rate is increasing for women ages 35 to44 (National Center for Health Statistics, 2004). Assisted re-productive technologies that were unheard of 30 years agoare now commonplace. Although breastfeeding initiationrates reached their highest recorded levels in 2002 (70.1%),up from 54.2% a decade ago, rates at 6 months were lowestfor women who worked outside the home and for womenwho participated in supplemental nutrition programs likeWomen, Infants, and Children (WIC) (Ab-bott Laboratories, Ross Products Division,2003). The U.S. Department of Healthand Human Services (2000a) has cited thelack of exclusive and prolonged breast-feeding as “a public health challenge.” Ev-idence of birth rates, rates of assisted re-productive technology, and breastfeedinginitiation rates are readily available, yet ata time when more than half of womenwith preschool children work outside thehome, there is almost no evidence aboutemployers who accommodate lactatingemployees (Wolf, 2003).

6. Data on the Changing Face ofHIV/AIDSWhen the epidemic first emerged in theUnited States more than 20 years ago,HIV/AIDS was mostly a disease of gaymen. Today incidence and prevalence fig-ures are carefully monitored by the United Nations and in-dicate that 39.4 million people are affected by the disease,and nearly half of them are women. The virus has movedinto Asia and Eastern Europe and is spreading faster inRussia than anywhere else in the world (United NationsJoint Programme on HIV/AIDS, 2004). Although rates ofthe disease are carefully monitored, less evidence is avail-able on successful programs for prevention and treatment,particularly difficult since many of those most susceptibleto HIV/AIDS are either fatalistic or in denial.

7. Data on the Changing Way We Give BirthCesarean births hit a record 27.6% in 2003 (National Cen-ter for Health Statistics, 2004). The rate is up by a thirdsince 1996. Elective cesareans are now a topic of discus-sion, epidural anesthesia is part of a majority of births, and“natural” childbirth seems outmoded or at least unpopular.Labor support has become a vanishing skill. Althoughsome have researched barriers to and facilitators of this la-bor technology and labor support (Graham, Logan,Davies, & Nimrod, 2004), more evidence is needed aboutthe cultural factors driving these trends and their outcomes.

8. Drug Safety RegistriesThe FDA is under increased scrutiny, as is the whole drugindustry, for the development and safe marketing of drugs.Accutane was recently named one of the five drugs underscrutiny for its risks as well as its benefits in acne treat-ment. Accutane, because it can cause major fetal defects, isnot to be used during pregnancy. Yet, according to theMarch of Dimes, thousands of pregnant women have tak-en it. The need to safely monitor its usage in women whereunintended pregnancy rates approach 57% is a challenge.In February 2004, an FDA panel recommended a programto set up a registry of all Accutane prescribers: all pharma-cists who dispense it and all users. This evidence is sorelyneeded, but the program has yet to be implemented (Ru-bin, 2004).

9. Antibiotic-Resistant Organisms“Pax antibiotica” (the notion that antibiotics could cure alldisease) seems to be over. Evidence indicates that there hasbeen a development of many drug-resistant strains of or-ganisms. Evidence has also accumulated over the past 30years indicating that the overuse of antibiotics in both hu-man health and animal agriculture has contributed to anincrease of antibiotic-resistant disease (Osterberg &Wallinga, 2004). Because of this link, Tyson and Perdue,two of the leading sellers of meat for human consumption,have agreed to stop using antibiotics to fatten poultry(Brower & Leon, 2004). In addition, healthcare providersare becoming more judicious in their prescription of antibi-otics. This is an example of practice clearly being influ-enced by evidence.

10. Environmental Pollutants and HealthClean air and water, as well as environmental contaminantslike lead, are still with us as community issues that affectMCH. Evidence links lead, in particular, to children’s neu-rologic development and air pollution to asthma. Growingevidence also links short-term ozone exposure to mortality,


The focus of

public policy health

interventions is on the

larger social and environmental

factors that shape health

and illness.

especially cardiovascular and respiratory illnesses (Bell, Mc-Dermott, Zeger, Samet, & Dominici, 2004). The 95 com-munities in the ozone study represent about 40% of the to-tal U.S. population, illustrating that ozone pollution iswidespread. The rise in ozone reflects mainly increased ve-hicle emissions, and in the United States more than 100 ar-eas are not in compliance with ozone standards. All of thisevidence furnishes a strong foundation for policy changesin communities. Two Web sites furnishing easy access tofurther environmental data are the U.S. Environmental Pro-tection Agency’s site (www.epa.gov) and the Centers forDisease Control and Prevention’s site (www.cdc.gov).

Evidence of Indirect Influences on MCH

Food SafetyMad cow disease (bovine spongiform encephalopathy[BSE]) and food safety are increasing threats to the com-munity’s health. BSE attacks an animal’s nervous system,and people who eat food contaminated with BSE can con-tract a rare disease that is nearly always fatal. With cuts inmeat inspections by recent governmental decisions, we arerisking the health of not only mothers and children, but al-so everyone in the United States. Investments in food in-spection and the public health infrastructure are necessaryfor this particular kind of health protection and diseaseprevention. The evidence is irrefutable. The U.S. Depart-ment of Agriculture, the cattle industry, food processors,and beef-oriented restaurant chains need to work togetherin a seamless way to ensure food safety.

Exurbs and Urban SprawlExurbs, the outer suburbs of inner cities, are flourishing.The acceleration of the suburbs began 30 years ago, andthey now are growing at twice the rate of the cities theysurround. In addition to the increased costs of deliveringservices like water and electricity to these less-dense areas,there is evidence that sprawl discourages connected and liv-able communities where citizens get involved (Brown,

2004). A growing body of evidence also suggests that ur-ban sprawl is associated with less physical activity, obesity,and hypertension, due to the inconvenience of walking anddecreased physical activity in such places (Ewing, Schmid,Killingsworth, Ziot, & Raudenbush, 2003). The implica-tions of this evidence for the design of healthy communitiesare clear.

Global Evidence: Flu Pandemics andClimate Change

Reframing Infectious DiseaseSince September 11, 2001, terrorism has changed the pro-vision of public health services. Initially, smallpox and an-thrax were the foci, often draining scarce resources fromMCH services and family planning. The new healththreats, although not necessarily terrorist connected, in-volve preparing for a flu pandemic, which potentially couldaffect up to 30% of the global population. “All vaccinemakers, regulatory agencies and health authorities need towork together to create and test vaccines” based on this ev-idence (Stohr, 2004). Multiple vaccine suppliers are needed,including government producers if necessary. In addition,prevention of a flu pandemic involves taking a global viewof the crisis. International experts are urging President Bushto facilitate U.S. government agencies to work with Chinaand its neighbors to develop safe ways to raise and slaugh-ter poultry and swine each year, and to keep migratorybirds away from livestock (Garrett, 2004).

Global WarmingThe United States is the world’s largest emitter of CO2, oneof the gases implicated in global warming. Thirty yearsago, global warming was first proposed as a theoreticalpossibility. Now we are experiencing first-hand its effects;for example, human influence has at least doubled the riskof heat waves of the magnitude of the one in Europe in2003 (Stott, Stone, & Allen, 2004). Policy changes requir-ing that more of our energy come from clean, renewablesources and putting a national limit on emissions are a


There is an urgent need to

develop other evaluation

standards in community

circumstances when

randomized controlled trials

are not appropriate.

start. Like many community interventions, outcomes arelong term and difficult to track. Nonetheless, acting to pre-vent climate change is a health-promoting activity. We mustrespond to the important as well as the immediate.

ConclusionTwo principles should guide us in the future collection ofevidence for practice of MCH in the community:

1. The power of healthier mothers and children lies inthe power of lifestyle change. If evidence indicates thatbehaviors like smoking and diet/inactivity are killingpeople, eating up healthcare dollars, and creating un-healthy pregnancy and women’s health outcomes, weneed to help people make necessary lifestyle changesand monitor the outcomes. The power of lifestylechange/health promotion, although discovered by re-searchers and pilot projects over the last 30 years, is inits infancy.

2. Health promotion must also be built into nationalhealth policy in the way that smoke-free restaurants/barsand seatbelt use have been over the past 30 years.Again, tracking the outcomes of such policy changes isessential. In both lifestyle change and health-promotionactivities, we are still struggling to implement commu-nity interventions to improve MCH.

Developing the health promotion focus in communitymaternal-child nursing in addition to public policy also in-volves a return to our home visit roots. Early intervention-ists from speech therapists to social workers have now dis-covered home visits; they think they have invented them.Lillian Wald’s provision of visiting nurse and school nurseservices to the poor of New York City in the early 1900s isour heritage, and it is time we reclaim it. Home visit re-search demonstrates that visits made to vulnerable andpoor women with the goal of improving mother-infant in-teraction or use of community resources are cost-effectiveand successful (Koniak-Griffin et al., 2003; Kearney, York,& Deatrick, 2000). The issue with this evidence-basedpractice is its dissemination.

In summary, Hippocrates, nearly 2700 years ago, estab-lished a health standard central to the provision of evi-dence-based maternal-child health services in our 21st cen-tury communities: “The function of protecting and devel-oping health must rank even above that of restoring itwhen it is impaired.” <

Linda Beth Tiedje, PhD, RN, FAAN, is an Adjunct Associ-ate Professor, Department of Epidemiology, School of Hu-man Medicine, Michigan State University, East Lansing,and an Editorial Board Member of MCN. She can bereached via e-mail at [email protected].

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