From its earliest days
in the Children’s Bureau, the MCH Training Program has encouraged
cross-fertilization among academia, field practitioners, and policymakers.
The vision is of services and policymaking enhanced by research and reasoned
analysis, and of research and teaching informed by an appreciation for the
challenges of health care providers and the needs of the population being
served. Thus, collaboration is a two-way street, benefiting both faculty
and the community. Universities may also strengthen relationships with local
communities and secure additional training experiences for students.
This evaluation examined the primary methods that grantees
use to meet the requirement for collaboration, namely technical assistance,
consultation, continuing education, and the formation of collaborative
relationships with colleagues (in the grantees’ own universities
and in others) and with Title V agencies.
TECHNICAL ASSISTANCE CONSULTATION AND
Training grantees vary
in their approaches to technical assistance, consultation, and continuing
education; in the extent to which they devote time and other resources to
these activities; and even in the ways that they define them. Many grantees
make no clear distinction among these programmatic elements, and tend to
lump them together. For this evaluation, continuing education was defined
as a formal course or lecture for which continuing education units (CEUs)
or other educational credits are available to participants, and technical
assistance as the provision of technical advice covering a range of issues,
including program development, clinical services, program evaluation, and
policy and guidelines formulation. Consultation is a categor y of technical
assistance, but connotes more of a collaborative relationship. Because technical
assistance and continuing education are grant requirements, all grantees
address them in some manner, and many have quite impressive accomplishments.
Continuing education ranges from the organization of
major national and regional conferences for leaders in a profession to
specialized courses on various topics for Title V staff. It may include
community-based training or scientific presentations at professional meetings.
Technical assistance embraces information dissemination to the lay public
through radio programs and Web-based strategies, research updates for
professionals through newsletters, distance learning, and formation and
maintenance of listservs. Technical assistance also includes consultation
and program development work with community service programs,schools,and
parent organizations; service on local, state, or national committees
and task forces; and collaboration with Title V programs on needs assessments
Individual grantees report providing technical assistance,
consultation, and continuing education to persons numbering from the hundreds
to the thousands each year. Because no common definition of technical
assistance or continuing education has been provided to grantees, widely
differing types of activities are included in the annual reports. Thus,
the evaluation team has little confidence in the reliability of the numbers
reported for technical assistance and continuing education. Nevertheless,
a considerable amount of this work does occur, regardless of how it is
defined. Some of the work is highly intensive, with recipients receiving
technical assistance and/or continuing education over a period of weeks
or months. Other types of technical assistance or continuing education
are one-time activities. It appeared to the evaluation team that schools
of public health tend to provide more technical assistance to Title V
agencies than do other priorities, whereas the clinical programs tend
to provide technical assistance and continuing education to practitioners
locally and regionally.
The degree of effort devoted to technical assistance
and continuing education also varies among grantees. In some cases, technical
assistance and continuing education activities are central components
of a project, with clear and impressive outcomes, whereas in other projects,
these activities represent a minor aspect of the project. Figure 19 provides
a few examples of the technical assistance and continuing education activities
of grantees, showing their range and diversity.
One aspect of technical assistance and consultation mentioned
by several grantees as quite important is relationship-building. Grantees
commented that technical assistance is most successful when trust has
been established, and the long-term nature of many grants makes it possible
for faculty to develop ongoing personal relationships that enhance the
chances for effective collaboration.
Although grantees provide an impressive amount of technical
assistance and continuing education, many find that competing priorities
combined with the extensive time required for these activities either
limit what they can do or lead to a sense of fragmentation and tension.
Direct costs are an additional problem.
Time Constraints. If an MCH training project is
successful in developing a reputation for expertise, and if faculty seek
out opportunities to provide that expertise, the project can easily become
deluged with requests for assistance. At that point, the project must
establish some limits.
"The volume of requests is 20-fold of what can be done, especially
in evaluation. The problem is the depth of need in the community."
-Faculty member, LEAH
Of particular concern to faculty are the opportunity
costs of their time. Although essentially all faculty acknowledge the
importance of technical assistance and continuing education, and a majority
find such work intrinsically enjoyable and rewarding, faculty also state
that these activities divert time from other work that is strongly encouraged
or required by their universities, such as research or activities that
may generate more income. Some faculty state that they feel overwhelmed
with the expectations that are placed on them, to provide quality teaching
and student mentoring, work with the community and professional associations,
conduct research, and provide clinical services, all while generating
sufficient income to cover some or all of their salaries. Other faculty,
however, emphasize that because the grant pays for faculty time, and because
technical assistance and continuing education are required components
of the grant, they enjoy some protected time that enables them to engage
in technical assistance and continuing education that their departments
or universities would otherwise discourage.
|Figure 19: Examples of Technical Assistance, Consultation,
|• Needs assessment for Title V Block Grant application
(University of Alabama at Birmingham, School of Public Health)
|• Provision of continuing education courses on evaluation
and needs assessment to Title V staff (Boston University, School
of Public Health)
|• Publication of an electronic newsletter, distributed
quarterly to MCH agencies, professionals, advocates, and legislators
via a listserv and also available on the University of Minnesota
School of Public Health’s Web site (University of Minnesota,
School of Public Health, Nutrition)
|• Provision of annual region-based workshops on topics
of special interest to local physical therapists, such as “Strategies
for Early Intervention” (University of Washington, Physical
|• Provision of 2-day workshops for community pediatricians
focused on family intervention as a way to enhance practice
(University of California at San Francisco, Behavioral Pediatrics)
|• Assistance in the promotion of Head Start in Massachusetts,
including development of a new Early Head Start program for
children ages 0 to 3 (Boston University, Behavioral Pediatrics)
|• Assistance in the writing and research of a new teen
health magazine, published by the Department of Health through
the Title V program (Baylor College of Medicine, LEAH)
|• Training for participants in the Baltimore City Infants
and Toddlers Program on writing individual service plans that
are family centered (Kennedy Krieger Institute/Johns Hopkins
|• Development of a mentoring program for nursing teams
in the area of maternity care at 12 fertility centers across
the country (Boston University, Nursing)
|• Consultation with two national committees regarding
practice parameters for autism. As a result, a resource guide
for all primary care providers in the county was produced, and
intervention guidelines are in development. (University of North
Carolina at Chapel Hill, LEND)
"Technical assistance comes at a cost. We’re committed
to technical assistance and to teaching, so the cost is to research.
Service is valued by the university, but not as much as research. Technical
assistance does not generate the overhead that the university likes,
such as from an NIH grant. As we strive to increase our research activities,
less time will be available for technical assistance and perhaps for
-Faculty member, School of Public Health
Direct Costs. The direct costs of providing technical
assistance and continuing education can sometimes be considerable. These
costs may include room rental charges, printing, and travel. The methods
of covering direct costs vary greatly among grantees. In some cases, the
grant covers all the costs of the activity—from faculty time to
providing coffee breaks for workshop or conference participants. In other
cases, the grant provides the motivation to seek out opportunities for
technical assistance or continuing education, but the activities themselves
are funded in other ways (e.g., through contracts or registration fees).
Some grantees combine methods, using the grant for some of the costs but
supplementing with other funding sources. A few grantees expressed concern
related to a perceived directive from MCHB to engage in distance learning
projects. They pointed out that certain distance learning methods, such
as those requiring satellite uplink, are quite expensive and there are
no easy ways to recoup such direct costs.
"Our grant does not directly support CE. However, I encourage
faculty to seek funds from other sources in order to fulfill the CE
requirements of the MCH training grant. Without the MCH grant, faculty
would not pursue such funding."
-Project director, School of Public Health
COLLABORATION ACROSS PROJECTS AND WITH
MCHB supports annual meetings for some
priority categories, providing grantees an opportunity to share strategies
and learn from each other.
Typically, MCHB provides supplementary funding to one
of the grantees to support the costs of the meeting, and the grantees
work together to plan the program. Those groups that regularly meet together
find the experience extremely valuable, although because the grants must
be recompeted every 5 years, and because their colleagues are likely to
be their toughest competitors, some project directors fear putting themselves
at a disadvantage by sharing too much. Thus, the competitive grant cycle
sometimes operates as a disincentive to collaboration.
The PPCs exemplify one of the most successful cross-project
collaborations. The seven grantees worked as a group over 3 years to conduct
an assessment of PPC graduates, resulting in a national report. They have
shared their annual progress reports to ensure that each is fully informed
about the others’ activities in order to facilitate borrowing of
good ideas, and they have engaged in joint continuing education projects
and quality improvement activities. Four PPC projects worked together
to develop clinical practice guidelines for pediatric tracheotomy, which
were published by the American Thoracic Society; the projects are in the
process of developing a plan to disseminate the guidelines.
"It has been beneficial to collaborate with the other six PPCs.
It has forced us to have a larger focus to our work and to deal more
effectively with medically fragile children. We e-mail one another with
questions and issues."
-Faculty member, Pediatric Pulmonary Center
Behavioral pediatrics grantees also work collaboratively.
For example, at the annual grantee meeting, fellows present research that
is critiqued by fac-ulty from across all projects. Mentoring relationships
among fellows and faculty from other sites have emerged from these meetings.
Over the past 2 years the LEND projects have developed a draft self-assessment
instrument, which they will be able to use to reflect upon and enhance
their programs. This tool has been pilot tested and will be made available
A different form of collaboration sometimes occurs when
there are multiple MCH training grants at one institution. For example,
the University of Washington currently has five MCH training grants in
different fields. The five grant projects have developed ways to support
each other (e.g., through reciprocal clinical placements for trainees)
and to collaborate on mutually beneficial activities (e.g., a common leadership
training seminar, joint research, and joint regional technical assistance).
When projects are able to establish collaborations of this type, there
appears to be a value added to MCH: a greater university-wide impact,
a faster dispersal of new ideas (e.g., on ways to recruit minority students),
and the benefit of shared resources. Some universities with multiple grants
that were visited through this evaluation were not as successful at bridging
departmental and other barriers in order to collaborate.
A few projects expand their influence locally or regionally
by establishing working relationships with other, nonfunded universities.
For example, faculty sometimes hold joint appointments at the university
that houses the MCH training grant and at a different university in the
same city or region. Other projects develop joint degree programs, such
as the clinically based programs that encourage (or in some cases, require)
fellows to obtain an M.P.H. degree through a collaborative arrangement
with another university. Figure 20 provides four examples of collaborations
developed by grantees.
A final form of collaboration is that of consultation
provided to other, nonfunded universities. This occurs in a variety of
ways; some of the consultation is relatively passive, such as sharing
information on MCH innovations at meetings or on Web sites. Other times,
it is intensive and one-on-one. Examples are provided in Figure 21.
COLLABORATION WITH TITLE
One of the most uneven
forms of collaboration among grantees is with state Title V programs. Some
MCH training projects and Title V offices have established strong relationships,
leading to a variety of collaborative activities, whereas others have not
succeeded in establishing a relationship of any kind. Universities and Title
V offices with strong collaborative relationships describe the relationships
as mutually productive and valuable: The Title V offices receive state-of-the-art
assistance while the MCH training projects have the opportunity to influence
policy and also to develop a better understanding of the issues confronting
practitioners. There are several reasons for the variance that exists:
Both Title V programs and MCH training projects are frequently
unaware of the possibilities for collaboration. Faculty in several training
projects expressed a desire to forge relationships with the state, but
seemed to have difficulty doing so. They believe that MCHB should encourage
state programs to seek them out. At the same time, some Title V staff
have stated that they find it difficult to learn about services that might
be available from the MCH training projects. Staff in Title V programs
may not even real ize that projects in their state are funded by MCHB.
|Figure 20: Examples of University-Based Collaborations
|• The nutrition project at the University of Minnesota
and the LEND project at the University of Iowa have established
a formal collaborative relationship.The nutrition training project
serves as the official academic unit sponsoring nutrition trainees
for the LEND project, and University of Minnesota nutrition
trainees may complete the 8-week LEND program to fulfill the
block field experience requirement.There is also an exchange
of faculty between the two universities.
|• Because of the lack of medical schools in several
northwestern states, the University of Washington serves as
a regional training center. Medical students and residents train
in their home states for the first 2 years, then complete their
clinical training at the University of Washington.The PPC and
LEND programs participate in a medical consultation service
for physicians in the region and in a visiting professor program
for the other states, providing continuing education, technical
assistance, and consultation, and conducting research.
|• Boston University’s behavioral pediatrics training
project and occupational therapy training project led the development
of Boston’s University Partnership Program, through which
several universities in Boston collaboratively promote research
and education on infant and toddler development. Courses provided
through the partnership are open to students from all the participating
|• The Pediatric Conclave, developed by the Center for
Leadership in Pediatric Physical Therapy Education at the University
of Washington, brings pediatric physical therapy faculty from
other universities in the northwest region and other MCH Training
Program–funded physical therapy training programs together.The
faculty meet annually to exchange ideas around pediatric and
maternal and child health curricular issues and to develop strategies
for improving the training
of all physical therapists to meet the needs of the MCH population.
"People who work in state MCH offices frequently do not
know about the training grants and do not know what types of
assistance they could and should be asking for."
-Associate dean, School of Public Health
• Some projects are focused in areas that are
of little help that the states perceive to be directly relevant to them.
Training projects should support the states, but not every
training grantee is able to do so. The grantee may not have the
skills or what the state needs. Some are researchers, not practically
oriented. When I was [a state] MCH director, I found that many
[Training Program] grantees did not even know what I was talking about
with respect to MCH state needs.
-Associate dean, School of Public minimal interest
to state offices or otherwise Health
- Projects that are considered to be
regional resources may have particular difficulty in establishing relationships
with states other than the one in which they are located, due to logistics,
travel constraints, or other factors.
- Many of the grants are quite modest, and it may be
unrealistic to expect them to serve as resources for Title V programs
in addition to the other requirements they must meet.
"We can't always respond to a technical assistance request
because our activities must be justified from a time-manage-ment perspective.
We have to be able to link our consultative activities to training
-Faculty member, School of Public Health
In some cases, the expectations of a state Title V office
and an MCH training project regarding reimbursement for technical assistance
differ. Some training projects contend that they are unable to provide
any services to states without reimbursement for costs, whereas Title
V staff may believe that one of the functions of the MCH training projects
is to provide technical assistance to them free of charge. These differing
views have occasionally created tension between state Title V offices
and MCH training projects.
"We have attempted to obtain small grants for technical assistance
and consultation from the Title V program, but have met
with resistance. They believe that the money in the grant should cover
these activities. Due to increasing revenue pressures,
the LEND project is now forced to do things through contracts that we
could formerly provide for free."
- Faculty member, LEND
Figure 22 provides examples of collaboration between
Title V programs and MCH Training Program projects.
The MCH Training Program
projects generate an impressive amount of technical assistance and
continuing education, often overcoming time and financial constraints
and competing priorities with their universities. Even the most modest
grants provide evidence of considerable work in these areas. Cross-project
collaboration is also fairly strong, with some training priorities
generating a national cadre of professionals who together have the
strength to be effective in generating improvements in health services
for women and children. Some projects have strong relationships with
their Title V programs, but many do not. Those projects that work
collaboratively with a Title V program typically find the relationship
to be rewarding in a variety of ways.
|Figure 21: Examples of Consultation with Nonfunded
|• The occupational therapy project at Boston University
formed the Pediatric Occupational Therapy Educators Network
to disseminate MCH and pediatric-related information to non–MCH-affiliated
occupational therapy programs around the nation.
|• The communication disorders project at Howard University
provides consultation with Purdue University, the University
of Iowa, and the University of Vermont on how to conduct culturally
appropriate research with diverse populations.
|• LEAH faculty at the University of California at San
Francisco teach core adolescent health courses to MCH students
at the University of California, Berkeley, and faculty at Baylor
College of Medicine teach an elective course to master’s
students at the University of Houston-Texas School of Public
|Figure 22: Examples of Collaborations Between Title
and MCH Training Program Projects
|• State Title V staff serve as adjunct faculty (University
of North Carolina at Chapel Hill, School of Public Health and
Virginia Commonwealth University, LEND)
|• State staff co-teach in exchange for free tuition
for other staff in the Title V program (Boston University, School
of Public Health)
|• Trainees complete field placements in Title V agencies
(University of Minnesota, Nutrition)
|• The Colorado Department of Health co-funds two positions
at the LEND project (Colorado Health Sciences University, LEND)
|• The director of the Texas Department of Health, Division
of Children with Special Health Care Needs, serves on the Advisory
Board to the LEAH project at Baylor College of Medicine (Baylor
College of Medicine, LEAH)
|• The state Title V director and MCH Training Program
epidemiologist serve as faculty and support student research
(University of Puerto Rico, School of Public Health)
|• The directors of the New York and New Jersey Children
with Special Health Care Needs programs serve on the PPC advisory
committee (Mount Sinai/Albert Einstein University, PPC)