Maternal and Child Health Journal

, Volume 17, Issue 1, pp 136–146 | Cite as

Incorporating the Life Course Model into MCH Nutrition Leadership Education and Training Programs

  • Betsy Haughton
  • Kristen Eppig
  • Shannon M. Looney
  • Leslie Cunningham-Sabo
  • Bonnie A. Spear
  • Marsha Spence
  • Jamie S. Stang
Article

Abstract

Life course perspective, social determinants of health, and health equity have been combined into one comprehensive model, the life course model (LCM), for strategic planning by US Health Resources and Services Administration’s Maternal and Child Health Bureau. The purpose of this project was to describe a faculty development process; identify strategies for incorporation of the LCM into nutrition leadership education and training at the graduate and professional levels; and suggest broader implications for training, research, and practice. Nineteen representatives from 6 MCHB-funded nutrition leadership education and training programs and 10 federal partners participated in a one-day session that began with an overview of the models and concluded with guided small group discussions on how to incorporate them into maternal and child health (MCH) leadership training using obesity as an example. Written notes from group discussions were compiled and coded emergently. Content analysis determined the most salient themes about incorporating the models into training. Four major LCM-related themes emerged, three of which were about training: (1) incorporation by training grants through LCM-framed coursework and experiences for trainees, and similarly framed continuing education and skills development for professionals; (2) incorporation through collaboration with other training programs and state and community partners, and through advocacy; and (3) incorporation by others at the federal and local levels through policy, political, and prevention efforts. The fourth theme focused on anticipated challenges of incorporating the model in training. Multiple methods for incorporating the LCM into MCH training and practice are warranted. Challenges to incorporating include the need for research and related policy development.

Keywords

Life course Social determinants of health Health equity Nutrition Maternal and child health 

Introduction

Theoretical models and frameworks can be used to guide strategic planning of agencies, organizations and institutions. Three theoretical health models—life course perspective, social determinants of health, and health equity—have particular relevance to the field of maternal and child health (MCH). While they have distinct differences, they also are interrelated. Therefore, Health Resources and Services Administration’s Maternal and Child Health Bureau (MCHB) of the US Department of Health and Human Services considered these models for its 2010–2015 five-year strategic plan to address the priorities of the MCH population. Ultimately the models were incorporated as the MCH life course model (LCM) [1], which is consistent with the longstanding emphasis on intervention and policy in MCH and public health. Drawing from “life course” science can help inform both theory and public health professional judgment and decision-making about etiology and intervention. Therefore, the purpose of this paper is to describe a process for faculty development and then how the new MCH LCM can be used in MCH nutrition training specifically and MCH training broadly. The paper begins by describing briefly each of the models and a process of faculty development and inquiry, and then concludes with specific strategies for incorporation and projections for implications on training, practice and research.

Life course perspective is a multidisciplinary approach to understanding the mental, physical and social health of individuals [2, 3, 4]. It integrates life span (longitudinal factors across life) and life stage (specific developmental periods) concepts and proposes that biological and behavioral mechanisms determine health trajectories, or the health development of an individual over time. Factors affecting the life course include social, demographic, cultural, developmental, biological, historical and economic experiences. This model focuses on risk factors within an individual that increase vulnerability to disease, which diminish health trajectories, and protective factors that mitigate risk and enhance resilience, which improve health trajectories. Risk reduction, then, is an intervention strategy employed when protective factors are absent or insufficient. According to this model, optimal health trajectories occur when protective factors are started early and continue through key developmental periods throughout life.

The social determinants of health model proposes that health status and health inequities are determined by the conditions and environments in which people are born, grow, live, work and age [5, 6]. An individual’s physical and social environments and life circumstances are formed by the distribution of money, power and resources at local, national, and global levels and by the policies that influence the distribution of these factors [6]. The focus of this model relates to health disparities. It builds upon social ecological models and shifts the focal point from personal responsibility to the influence of the person’s environment and issues of social injustice, such as poverty and hunger, on health status [5, 7, 8, 9].

The health equity model espouses that differences in health are unnecessary, avoidable, unfair and unjust [10]. This model integrates the principles and practices of social justice, social capital, human rights and health-equity ethics, and focuses on health equity rather than health disparities. It emphasizes the influences of social, governmental and legal systems on health, as opposed to personal responsibility [5, 11].

Despite the differences in these models, they are complementary and synergistic. Social determinants and health inequities at critical developmental periods affect the health trajectory across the life course. Furthermore, health inequities exist for social determinants, which affect health outcomes. The MCH LCM builds on the strengths and synergism of the models, but provides challenges to MCHB-funded leadership education and training programs charged with incorporating this new model in their work to support the MCH workforce infrastructure [12] through graduate training and continuing education.

The MCH LCM has particular relevance to MCH nutrition training programs, which have traditionally included some aspects of each of the models in their work focused on how clinical and public health nutrition impact critical developmental periods related to pregnancy, infancy, early and middle childhood, and adolescence. The programs have tended to focus on the MCH life cycle as opposed to life course. In addition, with obesity as a national health problem, the current programs all focus on obesity prevention and/or treatment as part of their funding mandate and, while some programs are more clinically-focused and others are more public health-focused, all incorporate both clinical and public health aspects in their training. What follows describes the process through which faculty and trainees from the programs developed a plan for faculty development in the MCH LCM and determined priority areas for implementing the LCM into training, which includes graduate and continuing education, MCH programs, and policy. Obesity was used as a specific example. This process may serve as a model for how other MCH leadership education and training programs can incorporate the MCH LCM in their work.

Aim

The purpose of this paper is to: (1) describe a process for faculty development; (2) identify specific ways to incorporate the MCH LCM in nutrition leadership education and training, using obesity as an example; and (3) discuss implications of the model on training, research, and practice.

Methods

To accomplish these aims, faculty and trainees from the six nutrition leadership education and training programs funded by the MCHB’s Division of Research, Training and Education (hereafter referred to as the Division) collaborated with MCHB staff and other stakeholders in a two-stage process of: (1) faculty development and planning about the models that inform the MCH LCM; and (2) stakeholder input to identify how the models can be used in training.

Faculty Development on Models that Inform the MCH LCM

Over a six-month period, a planning committee representing each of the MCH nutrition training programs and a facilitator met via conference calls and email to plan a one-day meeting of program faculty, trainees, funding agency representatives, and other interested stakeholders. The committee’s charge was to determine the specific content and format of the meeting, determine how attendees would prepare for the meeting, and provide input on logistics.

The committee determined that faculty development and meeting preparation would be promoted by assigning foundation literature prior to the meeting on the three models that form the basis for the MCH LCM (life course perspective, social determinants of health, and health equity), with particular attention to implications for MCH training, nutrition, and obesity. Relevant literature was identified through literature searches using PubMed, Medline, and Web of Science. Search terms included health equity, social determinants of health, life course perspective, life course theory, LCM, nutrition, obesity, MCH and combinations of these terms. Searches were confined to the period of 1995–2010.

Stakeholder Meeting on Ways to Incorporate the MCH LCM in Training

Invitations to the meeting were extended to nutrition training program faculty and trainees from the six funded projects, MCHB staff, an MCHB strategic plan consultant, a National Institutes of Health nutritionist, and a nutrition faculty member from another MCHB-funded interdisciplinary training program. The meeting included a: (1) presentation by the MCHB Division Director on the Bureau’s strategic planning process; (2) presentation by the MCHB consultant on the strengths and weaknesses and implications of the three models for strategic planning; (3) guided small group discussion on how to incorporate the models into MCH nutrition leadership training; and (4) reports of small group discussion results.

Facilitated discussion occurred in three groups, each with representation from project faculty, trainees, MCHB staff, and other stakeholders. Planning committee members served as facilitators and recorders. Each group responded to questions about how the three models could be incorporated into nutrition training grants and for both clinically- and public health-focused programs. Small group discussion notes were reported back to the larger group and collected.

Following the meeting, a coding team of two research assistants and a faculty researcher completed a content analysis of the discussion notes. Written notes from the small group discussions were compiled, and then were analyzed using standard content analysis methodology [13]. Emergent strategies were used to code segments, which were the units of analysis that consisted of phrases or sentences that denoted a complete thought (QDA Miner software, version 3.2.3, from Provalis Research). After completing initial individual coding, the analysis team met to compare codes, determine if code definitions and terminology were consistent, and reconcile inconsistencies. The research assistants re-coded the notes, using the revised codes and coding method. Remaining differences were reconciled during a second meeting. Discussion notes then were jointly coded using this unified coding structure. An analysis of coding frequency was completed.

Results

Faculty Development

Nine publications [2, 3, 4, 6, 7, 8, 11, 14, 15] were selected as foundational readings and assigned prior to the meeting. A 3-by-4 table was developed to compare and contrast the models focusing on implications for nutrition leadership in the areas of research, practice, policy, and training and education (Table 1). The categories for implications were selected based on those identified by Pies and colleagues [16].
Table 1

Summary table for faculty development: three models that form a foundation for the MCH life course model

Component

Life course perspective

Social determinants of health

Health equities

Research

Current knowledge base:

Current knowledge base:

Current knowledge base:

Limited number of risk determinants studied with limited longitudinal scope

Real-life social conditions of families over the lifespan remain unobserved

MCH epidemiology field is just beginning to support this approach

Limited research on how population-based environmental change affects health

Limited research available has focused on small rather than large scale, population-based changes.

Uses socio-economic, political, environmental and cultural determinants to establish interventions

Limited evidence available

Research needs:

Research needs:

Research needs:

Longer term longitudinal studies across the lifespan and across generations are needed to determine the full scope of life course influences. Future research needs include:

  Appropriate ways to measure allostatic load at different developmental periods of life

  Methods to link data across social, medical, educational and other systems to create complete, longitudinal records

  Training of professionals to participate in interdisciplinary research studies

  Theory needs to be linked to research methods that can measure both positive and negative factors longitudinally

New research methods need to be developed, as randomized controlled trials and other typical research designs are not appropriate and do not effectively measure environmental change or changes in social, political and environmental factors that underlie health disparities. New research methods should focus on:

  Effects of changes to the physical environment in which people work and live

  Effective ways to quantify the outcomes of policy changes

  Methods for modeling efficacy of private vs. public ownership or administration of health programs

  Health economic analysis methods to apply to public health interventions

Future research will focus on population-based factors at the community, national and global levels. Current research methods may not capture the type of data needed. Future research methods should focus on:

  Factors and processes that affect what countries can do to address health inequities

  Measuring how social and political structures affect health within a population

  Interrelationships between individual level and social level factors on health equity

  Health policy interventions to reduce health inequities

Practice

Significant shifts in practice will be required as professionals move from theory and research on how health risks impact health trajectory toward the implementation of interventions to address risk factors.

  Clinical service providers will play a key role in reducing health risk factors

  More focus on prevention-based services that align care between hospitals, physicians, and other continuing healthcare providers will be needed to achieve optimal health

  Public health system will need to emphasize environment and policy changes to support risk factor reduction and prevention

Practice will focus on identifying, developing and implementing policies and actions on a large scale (an entire population or jurisdiction) to improve socioeconomic and physical conditions.

  Reducing the unequal distribution of resources (economic and physical) will be important

  Simulations of potential models to determine the effects of different types of actions and policies will need to be developed.

  A strong role for local, state and national government will be required to administer and/or oversee population-based initiatives and to monitor effects and progress through health surveillance systems

Professionals will utilize health policy and political structures to improve social justice within populations and jurisdictions.

  Ethics will play a central role in determining appropriate courses of action.

  Local, state, national and global governmental agencies will take the lead in identifying and addressing social inequities that impact on health status.

Policy

A policy agenda that addresses the prevention of social and individual risk factors for disease at critical points in the life span and attempts to develop a seamless social and health care system across the lifespan is needed.

Policies should:

  Avoid categorical solutions to singular problems

  Focus on integrating solutions upstream based on population needs

  Support the development of community-based protocols and additional financing to provide services where families live and work.

Public policy will be a key feature of changing the distribution of resources and altering the interaction between different levels of environmental influence. Health and social policies will need to address:

  The political, financial and institutional constraints that may be barriers to improving health among populations

  Cost-effectiveness analyses of policy effects to determine the best use of limited resources to address population-based health risk factors

  Alternative ways to analyze potential and current effects of policy change are needed to assist officials in prioritizing resources and determining the appropriate degree of government intervention.

Health policies must integrate social justice and human rights considerations with ethical issues when determining public policy needs. Policies will focus on:

  Improving social capital and fair distribution of health care resources

  Methods for measuring policy affects

Training and education

New skills will be needed in the areas of:

  Coalition building and interdisciplinary collaboration

  Health policy and advocacy

  Leadership development

  Community-based participatory research methods

  Methods to develop and implement longitudinal data systems will be needed

  Integration of the life course perspective theory into core competencies

  Interdisciplinary training approached

  Risk communication

  Translation of knowledge and research into practice, programs, policies

Training in MCH and public health will need to focus on integrating several new skill sets:

  Methods for health economic analysis and modeling

  Improved methods for assessing and monitoring the impact of social inequalities on the health status of MCH populations

  Development and implementation of data systems to monitor changes in social systems and health to determine effectiveness of interventions

  Health policy and advocacy

  Sensitive methods for assessing and monitoring the impact of policies on health behaviors and outcomes

  Health economic modeling as it relates to decisions about health and healthy lifestyles

  Interdisciplinary training methods

  Environmental impact assessments

Training will need to have a strong focus on:

  Ethics

  Social systems analysis

  Public policy development

  Macroeconomics

  The interplay between individual and social factors on health equity will be needed

  Multidisciplinary training methods

Implications for Ways to Incorporate the MCH LCM in Training Identified in the Stakeholder Meeting

Meeting attendees represented each of the nutrition training programs (13 faculty and 9 trainees), MCHB (6 staff), 1 MCHB interdisciplinary program nutritionist, 2 facilitators, and the MCHB consultant on strategic planning. Four major themes emerged, three of which were specifically related to ways the MCH LCM could be incorporated into nutrition leadership education and training (Table 2): incorporation by training grants; incorporation through collaboration; and incorporation by others. The fourth theme emerged across themes and was about challenges to incorporating the MCH LCM in training and, therefore, is not included in Table 2. Each of these themes was delineated further into categories for incorporation. Within each category, discussants suggested ways to incorporate the models into leadership education and training using obesity-related examples (See Table 2 for the categories, examples, and the analysis of coding frequencies for Themes 1–3). There were no exclusive distinctions made for how more clinically- or more public-health focused programs could incorporate the models.
Table 2

How to incorporate the life course model into MCH leadership education and training: themes and categories for incorporation with examples using obesity

Themes

Categories for incorporation

Percent of coded segments* (%, #)

Examples of ways to incorporate MCH life course, using obesity as an example

Incorporation by Training Grants (Theme 1)

Coursework

10.9%,14

Review MCH Life Course Perspective to understand the research and components of the constituent three models/theories

Review research on nutrition and environmental factors that impact obesity such as maternal weight gain, weight gain in infancy, parenting skills, child care environment, school nutrition/environment

Create academic assignments for students/trainees to identify evidence-based strategies to address childhood obesity at critical time periods that will intervene to influence trajectories

Leadership training

10.2%, 13

Ensure nutrition trainees are leaders in the field of obesity prevention and treatment by providing training in variety of areas (see specific areas below)

Skill development

7.0%, 9

Provide trainees with skills to impact changing obesity roles. For example- behavioral counseling/motivational interviewing for individual intervention, how to assess community strengths and risk, and developing coalitions that combine medical care and community intervention.

Develop data skills e.g., what data exists, when and what to collect and how to analyze existing and new data to assess nutrition, physical activity and obesity rates/changes

Design interventions (individual and community) to include planning, implementation and evaluation

Continuing education

4.7%, 6

Provide continuing education for providers in practice on obesity prevention and early intervention through the life course to impact health trajectories

Experience

3.9%, 5

Participate in clinical intervention using behavioral counseling (e.g., motivational interviewing).

Develop or participate in a weight management program at the clinic or community level

Participate in community experiences of developing programs and community-based interventions focused on environment and policy strategies to promote access to healthy foods and places for safe physical activity

Identify or participate in development of convenient and affordable opportunities to be physically active (Blueprint for Nutrition and Physical Activity, 2007)

Identify community strength/support and risk factors to develop appropriate interventions based on needs

Material development

2.3%, 3

Develop educational materials for different MCH populations around healthy weight, healthful eating and adequate physical activity incorporating life course trajectory into materials

Trainees participate in writing articles and book chapters for publication on how early nutrition, early intervention and obesity prevention can change the life course of individuals and community

Incorporate models into academia by developing materials reflective of MCH Life Course Model to be used by other educators

Incorporation Through Collaboration (Theme 2)

State/community collaboration

9.4%, 12

MCH Nutrition Training Grantees work with Title V States to increase collaborative efforts to incorporate the LCM into obesity prevention and intervention

MCH Nutrition Training Grantees incorporate models through collaboration and nutrition programming with other programs and organizations

Interdisciplinary care

7.0%, 9

Develop individual interventions involving variety of disciplines (e.g. Community weight management programs)

Stakeholder community-based planning to promote environments where healthy foods are available.

Develop programs for prevention and intervention of obesity in children with special health care needs

Collaboration with other training programs

3.9%, 5

MCH Nutrition Training Grantees work with other MCHB funded Training Grantees to develop training materials, joint training or joint clinical interventions

Work together to develop community collaborative around prevention of childhood obesity

Advocacy

1.6%, 2

Write letters to legislators

Participate in legislative days

Advocate for vending machine policies

Advocate for greenway policies

Support restaurant labeling

Be involved with child nutrition authorization guidance for healthy foods in schools

Champion physical education policies in schools

Incorporation by Others (Theme 3)

MCHB

8.6%, 11

The Maternal and Child Health Bureau incorporates the models into their strategic plans and thereby all MCH Nutrition Training Grantees will incorporate the models into their grants didactic, experiential activities and research

Advocate for change

4.7%, 6

Work with political leaders to advocate for change or for development of policies to help with prevention of obesity (e.g., school policies, reimbursement for obesity diagnosis)

Prevention

1.6%, 2

Incorporate the models into healthcare to shift our current healthcare system from treatment to prevention of obesity

* The total percent of coded segments in this table is for themes 1–3, which consisted of 75.8% of coded segments. Theme 4, anticipated challenges of incorporating the model in training, consisted of 24.2% of the coded segments, which is discussed in the body of the paper

Theme 1: Incorporation by Training Grants

Identified categories for training programs to incorporate the LCM in their work included: coursework, leadership training, skill development, continuing education, experience, and material development. One example of how to accomplish this through coursework was for trainees to review research literature on nutrition and environmental factors that impact obesity. An example of how to accomplish this through skill development was for trainees to learn and practice skills directly related to new roles in obesity prevention and treatment, such as behavioral counseling and motivational interviewing, community strengths and risk assessment, and coalition building that links medical care and community interventions (See Table 2 for additional examples for each category of incorporation).

Theme 2: Incorporation Through Collaboration

Grantees also could incorporate the LCM by collaborating with others. Identified categories for how to accomplish this were through collaborations with state- and community-based MCH programs, interdisciplinary care, collaborations with other training programs, and advocacy. An identified example of a state and community collaboration was one with state-level Title V programs to incorporate the LCM into obesity prevention and interventions and an example of interdisciplinary care was community-based planning with stakeholders to promote environments where healthy foods are available (Table 2). In many cases, some of these collaborations might be new, such as those established with faith-based entities, regional and local planning bodies, and regulatory and enforcement agencies, and would require collaborative efforts to address not only individual and family needs and priorities, but also those of the broader environments that impact health.

Theme 3: Incorporation by Others

Three categories were identified for how others could incorporate the LCM. MCHB, specifically, was identified as an entity to incorporate the model in its work, reinforcing MCHB’s stated intention to use the model as a framework for its strategic planning. The example identified here for MCHB was to incorporate the model into its grant guidance, including didactic and experiential activities of leadership education and training grants, and research priorities and emphases of research grants. The other two categories within this theme of incorporation by others focused on how others could incorporate the model through advocacy for change and prevention (Table 2).

Theme 4: Anticipated Challenges of Incorporating the Model in Training

A fourth theme emerged from the discussion on how to incorporate the models in training, but instead focused on the challenges anticipated by training programs in incorporating the model in their work. The analysis of coding frequency revealed that 24.2% of the content in the discussion notes were related to these challenges, and included how funding allocations could impact training (5.5% of coded segments, n = 7 segments), the need for research on the models to inform policies (6.2% of coded segments, n = 8 segments), and uncertainties about the feasibility and effectiveness of incorporating the model in training (12.5% of coded segments, n = 14 segments). In fact, the most commonly mentioned topics were related to “uncertainties about incorporating the model”.

Discussion

The MCH LCM was developed based on the interrelated concepts of life course perspective, social determinants of health, and health equity to help explain health and disease patterns over time. The need to apply the LCM science to research, practice, policy and training and education was apparent from the foundation readings for this project. However, key questions focused on “How do we incorporate this into training?” and “We are already incorporating these concepts, aren’t we?” The consensus was that a new strategic plan centered on integration of three perspectives to address MCH issues was critical, because of ongoing health disparities among the MCH population, and limited improvement in key US health outcomes, especially when compared to European and East Asian countries relative to infant and child health [17]. Within MCH, nutrition can be a good example of the LCM due to the inter-relationships of eating and leisure-time behaviors, environmental influences, health outcomes, and optimal growth. The LCM provides clear evidence that nutritional status, eating habits, overall dietary intake, and physical activity can positively or negatively affect multiple heath trajectories of the MCH population [18]. However, as the MCHB strategic plan develops, all training programs and other Title V-funded programs will need to enhance faculty, practitioner and student training and development, and to apply LCM concepts to clinical and public health practice and research.

Nutrition programs provide a unique opportunity to consider how the MCH LCM can be integrated in nutrition training specifically and MCH training programs more broadly. Historically, use of a life cycle approach in clinical and public health nutrition programs has focused to greater or lesser extents on interventions to reduce individual risk factors and to establish broader-level environments and policies to promote improved health overall. The MCH LCM allows clinical and public health nutrition programs to move beyond a life cycle approach focused on interventions at particular time periods to one that considers not only individual-level risk factors, but also broader-level protective factors that are addressed with interventions designed to influence health trajectories across life [19].

Faculty Development

It is important that training program faculty have a common understanding of the development and application of the three synergistic theories that form the foundation for the MCH LCM. While some of the nutrition programs incorporated one or more theories or models into their leadership education and training, none incorporated a single integrated and synergistic model. Based on verbal feedback, there was an early realization of the differential needs of program faculty and trainees to understand and use the underlying models independently, before fully understanding and appreciating the comprehensive MCH LCM. Some training programs are more clinically-oriented and focus on individual health, while others are more public health-oriented and focus on population health. Thus, the foundation readings distributed prior to the meeting provided evidence-based knowledge to address these varying levels of faculty understanding of how the models could be used in specific training environments. Programs that address faculty development also should employ evidence-based strategies, such as experiential learning, feedback and fostering of effective peer and colleague relationships, to address these needs [20].

Incorporation of the MCH LCM by Training Grants, Through Collaboration and By Others (Themes 1–3)

Many participants stated that they already taught components of health disparities, life course, and social determinants of health, but were not using an integrated or comprehensive MCH LCM approach. Discussions centered on how to accomplish this integration. Themes 1–3 displayed in Table 2 are centered about what the nutrition training programs could do individually and in collaboration with other training programs, Title V agencies and professional organizations.

While the strategies identified are broad, they can be tailored to a variety of specific conditions or situations such as failure to thrive, iron deficiency anemia, pre-pregnancy nutritional status or obesity. Due to the national spotlight on obesity and the funding mandate, it was used as an example of a specific condition to demonstrate how strategies can be applied the MCH LCM. For example, advocacy was a key area discussed for Themes 1 and 2 and Table 2 identifies different ways that a training program could incorporate advocacy into the MCH LCM related to obesity. This includes training on advocacy for both students and faculty. Training programs need to engage faculty and trainees not only in reading, writing, and reviewing policies, but also in communicating effectively with stakeholders. A MCH workforce trained to engage with national, state and local stakeholders will help to promote the political will needed to build and sustain a life course approach [1]. With advocacy, the life course agenda can continue to build through engagement of MCHB leadership education and training programs (such as adolescent health, neurodevelopmental and related disabilities, and nutrition) and other partners (such as the Association of Maternal and Child Health Programs (AMCHP), Child and Youth with Special Health Care Needs (CYSHCN), the community, consumers, families, and the National Organization of Urban MCH Leaders (City MatCH)).

Anticipated Challenges to Incorporation (Theme 4)

The fourth theme identified in the guided small group discussion, anticipated challenges to incorporation, emphasized that while participants embraced the concepts of the MCH LCM, they also were concerned how this would be implemented. The biggest concern was uncertainty about the effectiveness and feasibility of incorporating the models into training and practice, both at the clinical and community levels. Due to limited research and novelty of the MCH LCM, no methodology for incorporation into training and practice has been established; however, this paper proposes a process used by MCH nutrition training programs that can be adapted by similar MCH disciplines. Policy and funding were identified as other concerns and, again, the limited research to support developing policies regarding use of the model was noted. One example of developing research to support policy development is the relationship between MCH LCM and racial disparities, particularly on how to achieve health equity between African American and White birth outcomes [21, 22]. Additionally, the Policy Research Initiative in Canada provides an example of how the life course framework can be applied to develop policies [23]. Specifically, life course was applied as an analytic framework to assist in policy development designed to improve the economic and social inclusion of Aboriginal peoples. Similarly, such a framework could be used in the US to examine racial, ethnic, gender and class disparities in relation to health status. Finally, because programs and policies drive resources, participants at the stakeholder meeting voiced their concern about how funding would be allocated for incorporating the MCH LCM in nutrition training grants and other Title V programs.

Implications for Translation of Research into Practice

Use of the MCH LCM in training has direct implications for research and practice. For example, future research on the LCM must explore how individual health trajectories are influenced by environmental factors at the family, community and national levels beginning preconceptionally and extending to future generations. Wethington [18] provides clear ideas for nutrition interventions to investigate dietary behaviors (particularly during periods when food preferences are formed) and how the environments of families with limited access to healthy foods (food deserts) impact life trajectories of children and adolescents. However, overall, future research will require interdisciplinary developmental science because of the need to link underlying mechanisms with epidemiological observations [24, 25, 26]. Moreover, life course epidemiology, a field equipped to help understand disease etiology by investigating the most plausible hypothesis for a set of exposures, is by its nature longitudinal and will require less conventional analytical techniques [27, 28, 29]. Finally, because of the limitations of observational studies, experimental study designs will also be warranted to translate findings into practice. At a minimum, training programs have a role in helping trainees know how to critique, analyze, and interpret such research and have an opportunity to collaborate in generating research findings.

Advances in life course-related research provide outcomes for translation of the MCH LCM into practice. For example, Lu and Halfon’s research [3] informed the programs and services for a 15-year Life Course Initiative at Contra Costa Health Services, a local health department in California [30]. This initiative is designed to improve birth, infant and maternal outcomes and improve the health of the next generation. As state and local MCH programs begin to integrate the MCH LCM into practice, collaborations with non-traditional partners in other sectors, such as economics, housing, transportation, environment, and social services, will be important [30]. The work of Contra Costa Health Services serves as a model for other local MCH programs interested in integrating the MCH LCM into practice. It also demonstrates how practitioners will look toward MCH research and training programs to inform their practices.

It will be important for training programs to provide opportunities for trainees and faculty to develop and understand these new research skills and methodologies and to use the findings from research to inform policies and evidence-based practice. Learning how to function as part of an interdisciplinary team will be required to truly integrate the MCH LCM from research to practice.

Limitations

This project was undertaken before a single document describing the MCH LCM was published. Therefore, it relied heavily on research literature about the key models that informed the final MCH LCM [1]. To address this concern, the programs’ project officer and other key MCHB staff were kept apprised of the process throughout. In addition the MCHB strategic planning consultant who participated in the stakeholder meeting was one of the lead authors of the final MCH LCM document [1]. Another limitation is that the project was specific for nutrition leadership education and training programs. Therefore, its findings and recommendations may not have direct implications for other MCH leadership education and training programs, although some may be able to draw examples from those related to obesity generated by the discussants. Additionally, there was no formal evaluation of change in faculty knowledge or understanding of LCM as a result of the faculty development activities. Finally, while attendees at the stakeholder meeting included some key stakeholders, due to budgetary constraints, all potential stakeholders were not present, such as parents and families and state Title V agencies.

Conclusions

Four major themes emerged, three of which identified how nutrition training programs could incorporate the MCH LCM in their work: (1) incorporation by training grants themselves; (2) incorporation through collaboration with others; and (3) and incorporation by others. The fourth theme was about anticipated challenges of incorporating the model. Interdisciplinary work across the areas of research, training, practice, and policies will prove challenging as the MCH LCM is incorporated into MCHB strategic planning and leadership education and training programs. The process described in this paper of faculty development and stakeholder input identified multiple ways to incorporate the LCM into MCH training and practice, particularly through coursework, leadership training and experiential activities. Furthermore, challenges, such as the need for research and related policy development, were identified. By learning about the three synergistic and complementary theoretical models that form the foundation for the MCH LCM, MCH nutrition leadership education and training faculty now have a better appreciation for their own faculty development needs and how to consider incorporating the MCH life course in their research, teaching and mentoring. Further work should assess and address faculty development priorities, evaluate how the MCH LCM is incorporated in training programs, including those more clinically-oriented and those more public health-oriented, and evaluate the degree to which the MCH LCM and its foundation models are consistent with the MCH Leadership Competencies [31].

Notes

Acknowledgments

This project was partially supported by grants from Health Resources and Services Administration’s Maternal and Child Health Bureau for Leadership Education and Training in Nutrition to the following institutions: Baylor College of Medicine, Indiana University, University of Alabama at Birmingham, University of California, Los Angeles, University of Minnesota, and University of Tennessee at Knoxville. Special thanks for thoughtful reviews and comments are extended to Holly Grason, Sue Lin, and Denise Sofka of Health Resources and Services Administration, Karyl Rickard and Deborah Abel of Indiana University, and Diane Anderson from Baylor College of Medicine. Additional thanks to Elizabeth (Lizzy) Miller, MCH nutrition trainee at the University of Tennessee, Knoxville, who assisted with content analysis, and to Margaret Tate, Consultant, who helped facilitate work of this collaborative project.

Glossary of terms

Life course perspective

Multidisciplinary approach to understanding the mental physical and social health of individuals, which incorporates both life span and life stage concepts that determine the health trajectory

Health trajectory

Health development over a lifetime that can be positively or negatively impacted by protective and risk factors

Social determinants of health

Model that proposes that health status is determined by the physical and social environment formed by the distribution of money, power and resources at global, national and local levels and by the policies that influence the distribution of these factors

Health equity

Model that integrates the principles and practices of social justice, social capital, human rights and health-equity ethics, and focuses on health equity rather than health disparities, and states that differences in health are unnecessary, avoidable, unfair and unjust

Life course model

Model that explains that social, environmental, health equity and other factors affect health development over a lifetime

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Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Betsy Haughton
    • 1
  • Kristen Eppig
    • 1
    • 5
  • Shannon M. Looney
    • 1
    • 6
  • Leslie Cunningham-Sabo
    • 2
  • Bonnie A. Spear
    • 3
  • Marsha Spence
    • 1
  • Jamie S. Stang
    • 4
  1. 1.Department of NutritionUniversity of TennesseeKnoxvilleUSA
  2. 2.Department of Food Science and Human NutritionColorado State UniversityFort CollinsUSA
  3. 3.Department of PediatricsUniversity of Alabama at BirminghamBirminghamUSA
  4. 4.School of Public Health, Division of Epidemiology and Community HealthUniversity of MinnesotaMinneapolisUSA
  5. 5.Maternal and Child Health Trainee Alumnus, Department of NutritionUniversity of TennesseeKnoxvilleUSA
  6. 6.Maternal and Child Health Trainee, Department of NutritionUniversity of TennesseeKnoxvilleUSA

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