TRANSLATING RESEARCH FROM COHORT

STUDIES INTO POLICY:THE CASE OF JAMAICA

M Samms-VaughanUNIVERSITY OF THE WEST INDIES

MONA, JAMAICA

Outline of Presentation

• Review of Findings leading to Important Programme / Policy Outcomes– Jamaican Perinatal Mortality and Morbidity Survey

– Longitudinal Studies on Child Development• Jamaican Birth Cohort Studies 11-12, 15-16 yrs.

• Profiles Project cohort of 245 6 year olds followed to 9 years

• Factors supporting translation from research to policy in Jamaica

THE JAMAICAN PERINATAL MORTALITY AND MORBIDITY SURVEY

Maternal Morbidity IAntenatal Screening for STDs

• High levels of congenital syphillis though all women tested, due to delayed receipt of lab results

• Impact– Recommended more efficient methods of

management of laboratory process

• Policy Response:– On-site screening test for syphilis instituted

– Resulted in immediate treatment for mothers

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20

40

60

80

100

120

140

160

87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03

Rate

per

100

000 p

op

ula

tio

n Male Female Total

Incidence of Primary & Secondary Syphilis in Jamaica, by sex: 1987-2003

Source: National HIV/STI Control Programme, JamaicaRef: Figueroa et al. West Indian Med J 2008; 57(6):562-576

JPMMS

Maternal Morbidity II: Hypertension

• Hypertension in pregnancy identified as a major contributor to maternal illness and perinatal mortality through early delivery and prematurity

• ImpactRecommended national education

programme for mothers on danger signs of pregnancy complications (hypertension)

• Policy response:– “Act Now” Card integrated into Maternal

Health Passport

• Result:– 60% ↓ in eclampsia– (MacGillivray et al 2004)

Maternal Morbidity III: Limited Physical and Human Resources

•– 18% of observed deliveries unattended– Poor layout of labour wards– Inadequate staffing/overcrowding– Average bed occupancy : 37-93%

• Highest at Type B hospitals (86-93%)• 39% of beds at 2 Type B hospitals shared

• Policy response:– Layout of labour/delivery wards re-designed – Bed complement at 3 Type B hospitals expanded– Increased number of obstetricians and paediatricians

at specific hospitals, i.e. converted to Type B

Maternal Morbidity IV

Mothers with limited access to expert obstetric care :2 x more likely to die from pregnancy complications6 x for women with hypertension related problems

• Policy Response:Development and piloting of high risk clinic system, with focus on hypertension.High Risk Clinics now established all across the country

• Results:– 69% ↓ in eclampsia– 38% ↓ in hypertension related admissions– 54% ↓ in number of in-patient days

Maternal and Perinatal Mortality

• Highest maternal and perinatal mortality rates in regional Type B hospitals, compared with Specialist Type A and community Type C hospitals.

• Hypertension in pregnancy main cause of prematurity and growth retardation

• Policy Response: Maternal education, high risk clinicsUpgrade Type B hospitalsMonitor impact

Maternal mortality trends: 1986-2006 (ratio/100 000 live births)

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40

80

120

Total Direct Indirect Late

1986-7 1993-5 1998-0 2001-3 2004-6

• 1998 - Active maternal mortality surveillance system developed:– Maternal deaths = Class I

notifiable event

– All deaths reported on suspicion to Ministry of Health

– Significant decline in direct obstetric deaths

– Increase in indirect deaths

JPMMS

Surveillance system

Vital Registration

– Registrar General’s Dept in poor physical state – 94% live births registered– Only 9% NNDs, 12% fetal deaths registered

• Policy Response:– World Bank/GOJ Social Sector project

• New Modern Registrar General’s Department built (RGD)• Administrative changes in birth and death registration

• Challenges remain– 1998: 65% infant deaths registered– 2004-7: 30% of known maternal deaths (WHO definition)

• adequately documented• coded and registered as maternal deaths

JAMAICAN LONGITUDINAL STUDIES ON CHILD HEALTH AND DEVELOPMENT

JBCS I (1,715 children): Age 11-12JBCS II (1,565 children): Age 15-16

Profiles Project (245 children): Age 6 yearsfollowed to 9 years

Child Poverty Findings

• Low SES significant negative effects on children’s cognitive, academic and behavioural outcomes

• Profiles Project demonstrated that failure to provide interventions in the pre-school years resulted in widening disparity in academic outcome and behaviourin early primary years

• Birth cohort study demonstrated long term negative impact of inadequate EC experience, more common among low SES

• Birth cohort and Profiles Project both recommended targetted interventions to break cycle of poverty

Child Poverty Policy /Programme Impact

• Indicators identified by Profiles Project were used by the Early Childhood Commission to:

• Develop the Family Risk Screening Tool, now about to be implemented, designed to identify families who need additional social, economic or other support

• Inform the development of the Early Childhood Module now fielded every 2 years since 2008 as part of Jamaica’s national household survey

Parenting Findings and Impact

• Negative impacts on child cognitive, academic and behavioural outcome related to:– Low parental education – Low parenting education– High parental stress– Family structure– Limited stimulation of children– Limited parental participation in children’s

• Impact: • Findings brought impact of parenting to national attention• Recommended parenting become a national priority

• Policy and Programme Response• One of drivers of Jamaica’s National Parenting Policy• Informed design of parenting programmes locally• Informed Public Education Parenting messages

Violence and Aggression

• High levels of exposure to community violence and corporal punishment

• High levels of loss of fathers and other family members to homicide• Significant associations of exposure to violence with impaired

cognition, academic and behavioural outcome

• Impact• Identified factors associated with aggression • Identified protective factors

• Policy / Programme Response:• Violence Prevention Alliance used information to guide

development of protective programmes• Corporal punishment data informed a CARICOM initiative to

promote reform in policy, legislation, public education in positive disciplinary practices

• Informed the UN Secretary General’s Study on Violence Against Children

Health and Nutrition

• Studies showed under-nutrition was no longer a significant concern• But children who were under-nourished suffered significant

cognitive and academic impact• However, childhood obesity was a problem

• Impact• Recommended revitalisation of school health system for early

identification of nutritional problems, including obesity, beginning at EC level

• Recommended specific attention to childhood obesity

• Policy / Programme Response:• School Health System was not revitalised due to limited resources• Data informed the National Strategic Plan for the Promotion of

Healthy Lifestyles in Jamaica

Screening and Early Intervention

• JBCS identified 3% - innumerate; 4% - illiterate at 11-12 years, in age appropriate class

• Profiles Project identified 35% and 10% of 6 year olds required further investigation of hearing and vision problems

• Parent/teacher reports identified few of the 13% of 11-12 year old children reporting drug use and the 12% reporting suicidal thoughts

• Impact

• Recommended screening for sensory, educational and behaviour disorders, beginning at the pre-school years

• Policy / Programme Response:

• Data informed– a UNICEF supported Situational Analysis on Screening and Early Intervention and

– National Plan for Screening, Referral and Early Intervention at ECC

– Special Education Unit at the Ministry of Education

• Early Childhood Commission now implementing a National Readiness Evaluation

• MOE implementing a national Child Find Programme

Standards - Early Childhood Institutions

• Public pre-school children performed less well academically at primary school than those from private pre-schools, regardless of social status

• Disparity in provision of ECE• Impact• Recommended minimum standards set for early childhood

centres• Use of ECERS in Jamaica led to use of this instrument to

analyse pre-school status across the Caribbean

• Policy/Programme Response• Informed Jamaica’s Early Childhood Act and Regulations,

which set standards for pre-schools• Informed Caribbean Regional Standards for Pre-Schools

Children’s Leisure Activities

• At 16 years, most common were TV viewing and listening to music (96%) • Least common was playing sport (43%) • At 12 years, >20 hours of TV/week (12 years) was associated with poorer

academic performance• Children attending church and other structured leisure activities had better

academic and behavioural outcomes

• Impact• Recommended more sport and leisure activities and less TV viewing

• Policy / Programme Response:• Broadcasting Commission of Jamaica

– Recommend limited TV viewing for children and used this in public education programme

– Informed Children’s TV programming code (2003)

• Church published the importance of attending church to children in newsletters

Gender • Girls out-perform boys in reading, spelling, arithmetic, despite

similar cognitive function• Boys exposed to more corporal punishment • Boys disengage from protective factors over time

– Organized activities, church– Leisure reading

» Boys: 12 yrs: 63%; 16 yrs: 46%» Girls: 12 yrs: 82%; 16 yrs: 74%

• Impact• Recommended more attention to development differences

between boys and girls and attention to protective factors that support boys engagement

• Policy/ Programme Response:• Informed teacher training curricula• Informed parenting programmes

Educational Outcomes• 4 PhD theses

• Numerous Masters Theses

• Academic Publications

• Technical Reports / Books

FROM RESEARCH TO POLICY AND PROGRAMMES

Research Design

• Should not be purely an academic exercise

• Should be cognisant of problems in society

• Should design study taking these into consideration

• Should ensure that findings address policy implications

Engagement with Government:Reasons for Engagement

• Understanding of unique problems and challenges

• Practical experience to inform research design and programe implementation

• Access to the health educational team/facilities

• Relationship with other government institutions

• Ability to implement policy and programmerecommendations

Engagement with Government:Models of Engagement

• Research initiated by the Government (e.g. JPMMS)– Government understanding of use of research to inform action– Clear roles for Government (policy) and University (research)

• Research initiated by the University (e.g. JAKIDS)– Government invited to be active participant– Leads to ownership of research process– Government has access to findings before publication and public discussion– Often request specific analysis– Offer available administrative data which adds to study

( JAKIDS established Cross Sectoral Steering Committee)• MoH, MoE, MoLSS, RGD, NEPA

• Identification as Expert in Field through research findings leads to placement in positions of policy impact– Chairman, Board members of Government Institutions

Dissemination of Findings (Research Marketing)

• Academic Publications– Least important in Policy implementation

• Technical Reports, Books– Used widely by undergraduate and postgraduate students– Research lives on when these students gain employment in institutions

• Oral presentations at professional meeting– Engenders professional group interest– Establishes researcher as expert among professional groups

• Oral presentations at Service Clubs (Kiwanis, Rotary)– Engenders public interest– Establishes researcher as expert among persons who have important positions in

organisations

• Media– Engenders public interest– Establishes researcher as expert in public’s opinion

• Public Meetings (Schools, community groups, churches)– Engenders public interest– Establishes researcher as expert in public’s opinion

Research Marketing Skills

• Identification of what’s important to various audiences

• Communication skills– Ability to convert research findings into language of the

various audiences

– what’s important to the Least important in Policy implementation

• Availability (Seizing every opportunity) – Media often gives short notice

– Community meetings have small populations, often required to do lots of them

Academia vs Public Service

• Personal decisions sometimes have to be made between time spent in academia vs that in public service guiding and implementing policy

Challenges

• Policy and Behaviour change are slow processes

• Some of our successes were immediate, others took a while

• Requires perseverance, persistence and patience

Publications