Enhancing Title V Workforce Capacity to Address Complex Challenges: Impact of the National Maternal and Child Health Workforce Development Center.

INTRODUCTION: The National Maternal and Child Health Workforce Development Center provides training, coaching, and consultation to Title V programs. The flagship experience is the Cohort program, a 6-8-month leadership development program where Title V programs convene a multisector team to address a pre-selected state/jurisdictional challenge related to health systems transformation. The overall objective of this paper is to demonstrate the impact of skills developed via the Cohort program on state/jurisdictional capacities to address complex challenges. METHODS: Qualitative, post-Cohort evaluation data were analyzed using inductive and deductive coding and the "Sort and Sift, Think and Shift" method. Themes and supporting text were summarized using episode profiles for each team and subsequently organized using the EvaluLEAD methodology for identifying and documenting impact. RESULTS: Teams brought an array of challenges related to health systems transformation and 94% of teams reported achieving progress on their challenge six-months after the Cohort program. Teams described how the Cohort program improved workforce skills in strategic thinking, systems thinking, adaptive leadership, and communication. Teams also reported the Cohort program contributed to stronger partnerships, improved sustainability of their project, produced mindset shifts, and increased confidence. The Cohort program has also led to improved population health outcomes. DISCUSSION: Through working with the Center, Title V leaders and their teams achieved episodic, developmental, and transformative results through application of Center tools and skills to complex challenges. Investment in the MCH workforce through skill development is critical for achieving transformative results and solving "wicked" public health problems.

Developing State Leadership in Maternal and Child Health: Process Evaluation Findings from a Work-Based Learning Model for Leadership Development.

OBJECTIVES: Since 2013 the MCH Bureau has supported the National MCH Workforce Development Center to strengthen the Title V MCH workforce. This article describes the Center's Cohort Program and lessons learned about work-based learning, instruction, and coaching. DESCRIPTION: The Cohort Program is a leadership development program that enrolls state-level teams for skill development and work-based learning to address a self-identified challenge in their state. Teams attend a Learning Institute that teaches concepts, skills, and practical tools in systems integration; change management and adaptive leadership; and evidence-based decision-making and implementation. Teams then work back home on their challenges, aided by coaching. The Program's goals are for teams to expand and use their skills to address their challenge, and that teams would strengthen programs, organizations, and policies, use their skills to address other challenges, and ultimately improve MCH outcomes. METHODS: This process evaluation is based on evaluation forms completed by attendees at the three-day Learning Institute; six-month follow-up interviews with team leaders; and a modified focus group with staff. RESULTS: Participants and staff believe the Cohort Program effectively merges a practical skill-based curriculum, work-based learning in teams, and coaching. The Learning Institute provides a foundation of skills and tools, strengthens the team's relationship with their coach, and builds the team. The work-based learning period provides structure, accountability, and a "practice space" for teams to apply the Cohort Program's skills and tools to address their challenge. In this period, teams deepen collaborations and often add partners. The coach provides accessible and tailored guidance in teamwork and skill application. These dimensions helped teams in develop skills and address state-level MCH challenges. CONCLUSIONS FOR PRACTICE: Continuing professional development programs can help leaders learn to address complex state-level MCH challenges through integrated classroom-based skills development, work-based learning on state challenges, and tailored coaching.

System Support Mapping: A Novel Systems Thinking Tool Applied to Assess the Needs of Maternal and Child Health Title V Professionals and Their Partners.

CONTEXT: The Maternal and Child Health (MCH) workforce aims to improve health outcomes for women, children, and families. The work requires coordination and partnerships that span disciplines and service systems. As such, workforce needs assessment requires an approach that is broad, flexible, and "systems-aware." OBJECTIVE: To illustrate the use of System Support Mapping, a novel systems thinking tool that was used to guide participants through a structured assessment of their discrete responsibilities, key needs, and specific resources required for each. PARTICIPANTS: Thirty-four Title V MCH professionals and partners from 15 states or jurisdictions. MAIN OUTCOME MEASURE(S): Description and frequency of Title V MCH professionals' coded roles, responsibilities, needs, resources, and wishes. An aggregated map illustrating interconnections between identified codes is presented. RESULTS: State- and local-level MCH professionals reported a range of roles, responsibilities, needs, resources, and wishes. The most and least frequently reported roles, responsibilities, needs, resources, and wishes by state- and local-level MCH professionals are listed, as well as the most frequent connections between those responses. The most frequent responsibility reported in local maps was "link to or provide care or resources" (82%), whereas the most frequent responsibility reported in state maps was "system management" (65%). System management was indirectly connected to 3 wishes: "access to data or information," "funding or resources," and "collaboration, coordination, or support from community or other external organizations." CONCLUSIONS: System Support Mapping can be used to support needs assessment with MCH professionals. System Support Maps show not only the most and least frequently reported roles, responsibilities, needs, resources, and wishes of participants but also how those responses are connected and potentially interdependent. System Support Maps may be useful for MCH leaders determining how best to organize their teams to take on complex public health challenges and prioritize improvements that will better support their work.

Putting Implementation Science into Practice: Lessons from the Creation of the National Maternal and Child Health Workforce Development Center.

Purpose This article describes how implementation science informed the design of a national training and technical assistance (TA) center, and how implementation best practices have been used to improve the quality of training and technical assistance services offered to states/jurisdictions. Description An existing tool, based on the Implementation Drivers Framework (in: Fixsen et al., Implementation research: a synthesis of the literature, University of South Florida, The National Implementation Research Network, Tampa, 2005), was adapted to assess efforts of the National MCH Workforce Development Center (the Center) against known implementation best practices. Staff identified specific examples of effective practice and gaps for inclusion in this article. Assessment Using implementation science to establish, assess and improve Center practice was both feasible and practical, requiring intentionality, dedicated time, and staff committed to deepening their understanding of implementation science. The Implementation Drivers framework proved useful for creating a shared approach to analysis and identification of opportunities for improvement of Center practice. Conclusion Policymakers and funding agencies should consider how training and technical assistance programs demonstrate knowledge and use of implementation science best practices among other evidence based practices in their work. Increasing attention to the use of implementation science can contribute to a higher quality of service among technical assistance centers, with the long term goal of improving outcomes for training and assistance recipients and the communities they serve. Establishing the link between customer satisfaction and quality of technical assistance, on the one hand, and long term outcomes, on the other, remains a challenge and an area of focus and learning for the Center.

Title V Workforce Development in the Era of Health Transformation.

Purpose The National Maternal and Child Health Workforce Development Center at UNC Chapel Hill (the Center), funded by the Maternal and Child Health Bureau, provides Title V state/jurisdiction leaders and staff and partners from other sectors with opportunities to develop skills in quality improvement, systems mapping and analysis, change management, and strategies to enhance access to care to leverage and implement health transformation opportunities to improve the health of women and children. Description Since 2013, the Center has utilized a variety of learning platforms to reach state and jurisdiction Title V leaders. In the intensive training program, new skills and knowledge are applied to a state-driven health transformation project and include distance-based learning opportunities, multi-day, in-person training and/or onsite consultation, as well as individualized coaching to develop workforce skills. Assessment The first intensive cohort of eight states reported enhanced skills in the core areas of quality improvement, systems mapping and analysis, change management, and strategies to enhance access to care which guided changes at state system and policy levels. In addition, teams reported new and/or enhanced partnerships with many sectors, thereby leveraging Title V resources to increase its impact. Conclusion The Center's provision of core workforce skills and application to state-defined goals has enabled states to undertake projects and challenges that not only have a positive impact on population health, but also encourage collaborative, productive partnerships that were once found to be challenging-creating a workforce capable of advancing the health and wellbeing of women and children.

A preliminary study of youth sport concussions: Parents' health literacy and knowledge of return-to-play protocol criteria.

PRIMARY OBJECTIVE: To preliminarily explore parents' health literacy and knowledge of youth sport league rules involving concussion education and training, and return-to-play protocols. RESEARCH DESIGN AND METHODS: This study was guided by the Knowledge, Attitude and Practice (KAP) model of health knowledge to examine parents' concussion literacy, and understanding of concussion education and training, and return-to-play protocols in youth sports. The mixed-method design involved 119 participants; that included in-person (n=8) and telephone (n=4) interviews, and web-based surveys administered through Mechanical Turk via Qualtrics (n=98). MAIN OUTCOMES AND RESULTS: Most respondents were not familiar with concussion protocols, but trusted coaches' knowledge in return-to-play rules. More than half of the respondents report that the return-to-play concussion criteria have not been clearly explained to them. The majority of respondents were not familiar with the CDC's 'Heads Up' online concussion training programme, nor were they familiar with any other educational/training tool. About one-fifth of the parents had conversations with a coach or medical staff about youth sport concussions. CONCLUSION: Parents have a general understanding of how to identify concussion symptoms, but lack knowledge of immediate steps to take following an incident other than seeking medical help.

Partnering with parents in interprofessional leadership graduate education to promote family-professional partnerships.

Evidence supports the benefits to families of relationships with professionals that build on the concept of partnership, but there are few studies in the literature of strategies involving joint education for parents and professionals to enhance the capacity of parents of children with special healthcare needs to be effective interprofessional partners. Since 2007, parents of children with special healthcare needs have participated alongside graduate students from five different profession-based training programmes in a structured interprofessional leadership programme. The aims of this summative evaluation study were to elicit the influences of this training model on parents' capacity to partner with both health professionals and other parents and explore features of the training that facilitated these partnership skills. Using qualitative analysis, a semi-structured interview, guided by sensitising concepts informing leadership development, was conducted with 17 of the 23 parents who participated in the training. Transcriptions of the interviews were used for creating codes and categories for analysis. Parents described how the programme enhanced abilities to see other points of view, skills in communicating across professions, skills in conflict management, and feelings of confidence and equality with providers that influenced their relationships with their own providers and their capacity to assist other parents in addressing challenges in the care of their children. Parents reported that building concrete skills, organised opportunities to hear other viewpoints, structured time for learning and self-reflection, and learning in the context of a trusting relationship facilitated the development of partnership skills. These findings suggest that the leaders of interprofessional training programmes should involve parents and graduate students as equal partners to enhance partnership skills.

Advancing MCH Interdisciplinary/Interprofessional Leadership Training and Practice Through a Learning Collaborative.

Purpose The Interdisciplinary Leadership Learning Collaborative (ILLC), under the sponsorship of AUCD and the Maternal and Child Health Bureau, brought together six teams, composed of 14 MCHB and UCEDD training programs to enhance their leadership training. Description Using adult learning principles, interactive training methods, and skill-focused learning, the ILLC built upon the evidence-based Interdisciplinary Leadership Development Program of the University of North Carolina at Chapel Hill. The program began with a 4-day on-site intensive and then continued through monthly conference calls, a mid-term on-site workshop, and a summary virtual workshop to present programmatic accomplishments and share plans for sustainability. Coaching/consultation for the teams around particular challenges was also part of the program. Assessment All teams reported enhancements in intentional leadership training, threading of leadership concepts across clinical, didactic, and workshop settings, and new collaborative partnerships for leadership training. Teams also identified a number of strategies to increase sustainability of their intentional leadership training efforts. Conclusion for Practice The learning collaborative is a productive model to address the growing need for interdisciplinary MCH leaders.

North Carolina's Operation Medicine Drop: Results From One of the Nation's Largest Drug Disposal Programs.

INTRODUCTION: In 2013, a total of 1,085 North Carolina residents died due to unintentional poisoning; 91% of these deaths were attributed to medications or drugs (over-the-counter, prescription, or illicit). Proper disposal of unused, unneeded, and/or expired medications is an essential part of preventing these unintentional deaths, as well as averting the other adverse consequences of these drugs on the environment and population health. METHODS: Operation Medicine Drop is a medication take-back program coordinated by Safe Kids North Carolina, a county-level, coalition-based injury prevention organization. The Operation Medicine Drop program and event registration system were used to review and validate the number of events, the counties where the events were held, and the number of unit doses (pills) collected from March 2010 to June 2014. SAS version 9.4 was used to generate basic counts and frequencies of events and doses, and ArcGIS version 10.0 was used to create the map. RESULTS: From March 2010 to June 2014, Operation Medicine Drop held 1,395 events with 245 different participating law enforcement agencies in 91 counties in North Carolina, and it collected 69.6 million unit doses of medication. More than 60 local Safe Kids North Carolina community coalitions had participated as of June 2014. Every year, Operation Medicine Drop has witnessed increases in events, participating agencies, participating counties, and the number of doses collected. CONCLUSION: Operation Medicine Drop is an excellent example of a successful and ongoing collaboration to improve public health. Medication take-back programs may play an important role in preventing future overdose deaths in North Carolina.

Fostering intentional interdisciplinary leadership in developmental disabilities: the North Carolina LEND experience.

This study describes the effects of interdisciplinary leadership training on a retrospective cohort (2001-2009) of the University of North Carolina MCH Leadership Education in Neurodevelopmental and Related Disabilities (UNC-CH LEND) program, including LEND graduates who were selected to participate in a focused Interdisciplinary Leadership Development Program (ILDP) in addition to their LEND training. Specifically, the study examined graduates' reports of the relationship between LEND training and their attitudes/beliefs about interdisciplinary practice, as well as their reported use of interdisciplinary skills in their post-fellowship practice settings. Using a post-test design, participants in the LEND and ILDP programs were contacted to complete an on-line survey. Using a Conceptual Model guided by EvaluLEAD, respondents were asked to rate the influence of the UNC-LEND training program on their attitudes/beliefs and skills using a 5-point Likert scale, as well as through open-ended descriptions. The 49 LEND respondents represented a 56% overall response rate from years 2001-2009. ILDP participants reported greater agreement with interdisciplinary attitudes/beliefs and more frequent use of interdisciplinary skills than did the non-participants. Graduates of LEND as well as ILDP reported the influence of training through a range of qualitative responses. Response examples highlight the influence of LEND training to promote outcomes at the individual, organizational and systems level. Findings from this study illustrate that MCHB funded LEND training has a strong influence on the future employment and interdisciplinary practices of graduates for the MCH workforce as well as services for individuals with developmental disabilities, their families and systems of care.

Effects of interdisciplinary training on MCH professionals, organizations and systems.

We studied the effects of the Interdisciplinary Leadership Development Program (ILDP) on MCH trainees from five MCHB-funded training programs at the UNC-Chapel Hill from the years 2001-2008. Specifically, we examined attitudes/beliefs about interdisciplinary practice and the frequency of use of interdisciplinary skills; identified effects of interdisciplinary training on career choices; and, examined the ways in which graduates used their interdisciplinary skills to effect change in MCH organizations and systems, up to 8 years after completion of training. Using a post-test design, participants in the ILDP were contacted to complete a web-based survey. Non-participating LEND and public health graduates were recruited for comparison. Guided by EvaluLEAD, we designed questions that asked graduates to rate the influence of their programs on their attitudes/beliefs and skills (on 5-point Likert scales), and to describe those influences in some detail in open-ended questions. The 208 respondents represented 59.6 % of the graduates from 2001 through 2008. Model-predicted mean levels of frequency of use of interdisciplinary skilIs was associated with ILDP participation (p = 0.008) and nearly so for interdisciplinary attitudes/beliefs (p = 0.067). There is an association between four domains of systems changes and frequency of skill use: develop/improve a program (3.24 vs. 2.74, p < 0.0001); improve the way an organization works (3.31 vs. 2.88, p < 0.0001); develop/improve a partnership (3.22 vs. 2.83, p < 0.0003); and, develop a policy (3.32 vs. 2.98, p < 0.0013). Graduates used interdisciplinary training to improve outcomes for families and to effect change in MCH systems. MCH leaders should disseminate, more broadly, rigorous assessments of the training intended to develop leadership competencies that underpin effective interdisciplinary practice.

Looking at graduates of Title V MCHB-funded training programs through the lens of the MCH pyramid.

OBJECTIVES: To examine the distribution of professional responsibilities as reflected in each level of the MCH Pyramid for 208 graduates of five Maternal and Child Health Bureau (MCHB)-funded training programs-Leadership Education in Neurodevelopmental and Related Disabilities, nutrition, pediatric dentistry, public health, and social work-at the University of North Carolina at Chapel Hill. METHODS: Graduates completed a web-based survey, 1-8 years after graduation. For each program, we constructed means of the reported percentages of total work time spent in infrastructure-building, population-based, enabling, and direct health care services. RESULTS: Although generally consistent with the goals of the training programs, the percentages of time spent in each level of the Pyramid varied substantially among the five programs. For example, for a clinically focused program like pediatric dentistry, 80.2 % of time is spent in direct care services in contrast to 14.8 % for public health graduates. For each program, however, graduates report responsibilities among the different levels of the Pyramid. CONCLUSIONS: Reporting job responsibilities within the MCH Pyramid provides a more informative picture of the contributions of training program graduates than do conventional metrics such as institutional or agency appointments. The fact that graduates from all five programs engage multiple roles is consistent with the MCHB workforce training goal to develop leaders in the field of MCH. Given the central role of the MCH Pyramid in planning and reporting for the MCH Services Block Grant, MCH training programs should include metrics such as graduates' roles according to the MCH Pyramid to assure that training goals are more closely aligned with workforce needs.

Associations between state economic and health systems capacities and service use by children with special health care needs.

To examine the relationship between measures of state economic, political, health services, and Title V capacity and individual level measures of the well-being of CSHCN. We selected five measures of Title V capacity from the Title V Information System and 13 state capacity measures from a variety of data sources, and eight indicators of intermediate health outcomes from the National Survey of Children with Special Health Care Needs. To assess the associations between Title V capacity and health services outcomes, we used stepwise regression to identify significant capacity measures while accounting for the survey design and clustering of observations by state. To assess the associations between economic, political and health systems capacity and health outcomes we fit weighted logistic regression models for each outcome, using a stepwise procedure to reduce the models. Using statistically significant capacity measures from the stepwise models, we fit reduced random effects logistic regression models to account for clustering of observations by state. Few measures of Title V and state capacity were associated with health services outcomes. For health systems measures, a higher percentage of uninsured children was associated with decreased odds of receipt of early intervention services, decreased odds of receipt of professional care coordination, and increased odds of delayed or missed care. Parents in states with higher per capita Medicaid expenditures on children were more likely to report receipt of special education services. Only two state capacity measures were associated explicitly with Title V: states with higher generalist physician to population ratios were associated with a greater likelihood of parent report of having heard of Title V and states with higher per capita gross state product were less likely to be associated with a report of using Title V services, conditional on having heard of Title V. The state level measure of family participation in Title V governance was negatively associated with receipt of care coordination and having used Title V services. The measures of state economic, political, health systems, and Title V capacity that we have analyzed are only weakly associated with the well-being of children with special health care needs. If Congress and other policymakers increase the expectations of the states in assuring that the needs of CSHCN and their families are addressed, it is essential to be cognizant of the capacities of the states to undertake that role.

The UNC-CH MCH Leadership Training Consortium: building the capacity to develop interdisciplinary MCH leaders.

This article describes the UNC-CH MCH Leadership Consortium, a collaboration among five MCHB-funded training programs, and delineates the evolution of the leadership curriculum developed by the Consortium to cultivate interdisciplinary MCH leaders. In response to a suggestion by the MCHB, five MCHB-funded training programs--nutrition, pediatric dentistry, social work, LEND, and public health--created a consortium with four goals shared by these diverse MCH disciplines: (1) train MCH professionals for field leadership; (2) address the special health and social needs of women, infants, children and adolescents, with emphasis on a public health population-based approach; (3) foster interdisciplinary practice; and (4) assure competencies, such as family-centered and culturally competent practice, needed to serve effectively the MCH population. The consortium meets monthly. Its primary task to date has been to create a leadership curriculum for 20-30 master's, doctoral, and post-doctoral trainees to understand how to leverage personal leadership styles to make groups more effective, develop conflict/facilitation skills, and identify and enhance family-centered and culturally competent organizations. What began as an effort merely to understand shared interests around leadership development has evolved into an elaborate curriculum to address many MCH leadership competencies. The collaboration has also stimulated creative interdisciplinary research and practice opportunities for MCH trainees and faculty. MCHB-funded training programs should make a commitment to collaborate around developing leadership competencies that are shared across disciplines in order to enhance interdisciplinary leadership.

The relationship between state capacity measures and allocations to children and youth with special needs within the MCH Services Block Grant.

OBJECTIVES: To examine the association between state economic, political and health services capacity and state allocations for Title V capacity for Children and Youth with Special Health Care Needs (CSHCN). METHODS: Numerous datasets were reviewed to select 13 state capacity measures: per capita Gross State Product (economic); governor's institutional powers and legislative professionalism (political); percent of Children with Special Health Care Needs, percent of uninsured children, percent of children enrolled in Medicaid, state health funds as a percent of Gross State Product, ratio of Medicaid to Medicare fees, percent of children in Medicaid enrolled in managed care, per capita Medicaid expenditures for children, ratios of pediatricians/family practitioners and pediatric subspecialists per 10,000 children, and categorical versus functional state definition of CSHCN (health). Five measures of Title V capacity were selected from the Title V Information System, four that reflect allocation decisions by states and the fifth a state assessment of the role of families in Title V decision-making: ratio of state/federal Title V spending; per capita state Title V spending; percent of state Title V spending on CSHCN; state per child spending on CSHCN; and, state Title V Family Participation Score. OLS regression was used to model the association between state and Title V capacity measures. RESULTS: The percentage of the state's gross state product (GSP) accounted for by state health funds and the per capita GSP were positively associated with the per capita expenditures on all children. The percentage of CSHCN in the state was negatively associated with the ratio of state to federal support for Title V and the per child expenditures on CSHCN. Lower family participation scores were associated with having a hybrid legislature; however, higher family participation scores were found in states using a functional definition of special needs. CONCLUSIONS: Measures of state economic, political and health services capacity do not demonstrate consistent and significant associations with the Title V capacity measures that we explored. States with greater economic capacity appear to devote more financial resources to Title V. Our finding that per capita CSHCN expenditures are negatively associated with the percentage of CSHCN in the state suggests that there is an upper limit on what states devote to CSHCN. Our current understanding of what state factors influence Title V capacity remains limited.

Reflections on the contributions of self-advocates to an interdisciplinary leadership development program for graduate students in health affairs.

BACKGROUND: To advance equity and to enhance leadership skills, self-advocates with intellectual/developmental disabilities are now part of the cohort of trainees in the University of North Carolina LEND, which means that they fully participate in the Interdisciplinary Leadership Development Program, a collaboration among programs in public health, social work, and LEND, which meets monthly. OBJECTIVE: Given this important new participation by self-advocates, this study analyzes the reflections of graduate students on the contributions of self-advocates to their leadership training. METHODS: At the conclusion of the program each year, graduate students respond to a questionnaire about how self-advocates influenced the content and interactions/discussions of the monthly workshops and are asked to provide specific examples to explain their perceptions. The 12 MCH leadership competencies were used to guide the coding of the comments for this qualitative, directed content analysis. RESULTS: Forty-six of 58 students (79.3%) from two consecutive cohorts responded for this cross-sectional study. Interactions with self-advocates prompted comments on 8 of the 12 leadership competencies, including interdisciplinary team building (29% of the comments); developing others through teaching and mentoring (22%); and self-reflection (18%). CONCLUSIONS: The inclusion of self-advocates throughout an interdisciplinary leadership development program for graduate students in health affairs can strengthen MCH leadership competencies for all participants as they enter an increasingly interdisciplinary workforce.

The effects of graduated driver licensing on hospitalization rates and charges for 16-and 17-year-olds in North Carolina.

OBJECTIVE: To mitigate the high risk of motor vehicle crashes for young beginning drivers, over 40 states and the District of Columbia have implemented graduated driver licensing (GDL) systems that gradually and systematically ease teen drivers into higher risk driving conditions. Evaluations of GDL programs using motor vehicle crash data have demonstrated marked declines in crashes. The objective of this study is to examine the association between the implementation of the North Carolina GDL program and the rate of hospitalization, as well as hospital charges, for 16-and 17-year-old drivers. METHODS: Data were obtained from the North Carolina Hospital Discharge Database for the 26 months before and 46 months after the December 1, 1997, implementation of the GDL program. ARIMA interrupted time series analyses were used to model monthly hospitalization rates, controlling for the hospitalization rates of 25-to 54-year-old drivers. ARIMA analyses were also used to determine whether changes occurred in monthly total hospital charges. RESULTS: Among the 568 16-year-old hospitalized drivers, GDL was associated with a 36.5% decline in the hospitalization rate per population and a 31.2% decline in the total monthly driver hospitalization charges. Although a 12% reduction in the rate of hospitalizations was observed among the 615 17-year-old drivers, the analysis lacked sufficient power to be statistically reliable. No consistent change was observed in the 16-year-old driver total monthly hospital charges. CONCLUSIONS: The North Carolina GDL program was associated with a marked decline in the rate of hospitalizations and hospital charges for 16-year-old drivers. Following the implementation of GDL, over $650,000 in hospital charges have been averted each year for 16-year-old drivers. Analyses suggest these reductions were primarily the result of reduced exposure rather than an improvement in teen driving.

Should School Boards Discontinue Support for High School Football?

A pediatrician is asked by her local school board to help them decide whether to discontinue their high school football program. She reviews the available evidence on the risks of football and finds it hopelessly contradictory. Some scholars claim that football is clearly more dangerous than other sports. Others suggest that the risks of football are comparable to other sports, such as lacrosse, ice hockey, or soccer. She finds very little data on the long-term sequelae of concussions. She sees claims that good coaching and a school culture that prioritizes the health of athletes over winning can reduce morbidity from sports injuries. In this paper, 3 experts also review the evidence about sports risks and discuss what is known and not known about the science and the ethics of high school football.