Oby: From the campus of Harvard Medical School, this is ThinkResearch, a podcast devoted to the stories behind clinical research. I'm Oby, your host. ThinkResearch is brought to you by Harvard Catalyst, Harvard University's clinical and translational science center, and by NCATS, the National Center for Advancing Translational Sciences.

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Join us today as we hear Dr. Meg Simione's journey from studying communication sciences and disorders to being a speech language pathologist who specializes in pediatric feeding and swallowing. We will also hear about what led Dr. Simione to implementation science and what that means in the broader context of her research. Dr. Simione is a clinician scientist at Mass General for children in Boston and a speech language pathologist who specializes in pediatric feeding and Swallowing Dr. Simione is also an assistant professor of pediatrics at Harvard Medical School.

Meg Simione: Hi. I'm Meg Simione. I'm a clinician scientist at Mass General for Children in Boston. I'm also a speech language pathologist who specializes in pediatric feeding and swallowing, and I'm also an assistant professor of pediatrics at Harvard Medical School. I grew up north of Boston in a small town called Lynnfield, and it's a small town that we could have goats in our backyard, but we could also easily travel into Boston and be able to enjoy all that the city had to offer.

After high school, I went to undergraduate at Boston University. And there, I studied communication sciences and disorders. And what really interested me about this field is that there was this wonderful blend of language and science, two strong interests of mine. Immediately after undergraduate, I went on to Northwestern University in the wonderful city of Chicago, and I did a master's in speech language pathology. And this is where I learned about dysphasia. And dysphasia is the study of swallowing disorders, or in pediatrics, sometimes we say feeding and swallowing.

And I learned about this through my courses and then also my clinical 1 placements that I had in a hospital, in a school setting. And when I think about what attracted me to this field of feeding and swallowing, I think it truly is my family history. I come from a large Italian family, and food was just so important. It was how we celebrated our culture. All of our holidays had such strong family food traditions. It's also how we showed love and how we cared for each other.

So this idea that there were people who struggled to eat and drink, it really intrigued me. And I wanted to learn more about that. After completing my masters, I began work as a speech language pathologist. And I worked in a variety of settings throughout my clinical career. One of my first experiences was in early intervention. Early intervention is a program for infants up to children of three years of age, and it's for children who have developmental disabilities or who have social risks.

I worked with infants and toddlers, and very importantly, their family, on helping them to develop early speech, language, and their feeding skills. And in early intervention, you provide services in what's called the least-restrictive environment. And for infants and toddlers, that's in their house. I worked in an early intervention on the North Shore, and so many of my communities were low-income communities. And it was really there that I started to understand the lived experiences of families.

So I went into houses where the family couldn't afford to heat their house. And so they had turned on their oven to try to stay warm during the winter. I worked with families who were living in shelters, and I would go in and work with the parent and the child in the shelter that they were living in. I went into families' houses where I saw that their food cabinets were empty or barely filled. I also saw many families without toys. And again, this started to get me thinking about how people's lived experience and what their life circumstances were, how that started to impact their health and their well-being.

So after working clinically for several years, I returned back to school to get a PhD in rehabilitation sciences. And I went to Mass General Hospital Institute for Health Profession. Following that, I did a two-year post-doctoral fellowship, which is this wonderful two-year experience to extend your training from your PhD before you start your own faculty or research experience. And I did my postdoc at MGH in the Department of Pediatrics.

My research started from my clinical interests that related to both feeding and nutrition and the problem that I saw in the field. And what I started to observe as I worked as a clinician is I observed disparities. If I think about my days in early intervention-- and as I mentioned, I was in the North Shore of Boston, so there were low-income communities that bordered very wealthy communities, and I saw differences in the services that children were receiving.

I saw many issues not just when I was working in early intervention, but also when I worked in hospitals and then also in outpatient clinics around access to care that these families, especially families with children with special health care needs, they had so many appointments, and the burden to the family and also the challenges that that posed to the child who was spending so much time going back and forth to hospitals or health care centers.

What I came to realize is that people's life circumstances were affecting their health and their ability to achieve their goals. And this 0 during a time where we didn't really talk much about the term "social determinants of health" or "social drivers of health" or "unmet social needs." It was something that I was seeing and that my colleagues were seeing and talking about and really trying to support families. During this time, it was really important that I was able to work collaboratively and I was able to bring in, as needed, my social work colleagues to really support families and connect them to resources in the community.

The other thing that I noticed from my clinical practice that has really informed my research is that there was a gap between research evidence and what we knew worked and how we should be providing care and what was actually done in practice. During my PhD was an opportunity where I could really focus on very specific skills, but what I started to realize-- that as a clinician, I wanted to be just a little bit closer to clinical care. So in my postdoc, I wanted to expand my research to include clinical research. And it was an opportunity for me to focus on family-centered outcomes and then also implementation science.

As you may remember, I mentioned that as a clinician, I noticed that there was a gap between what the research told us we should be doing and how we were practicing. And so what implementation science does is it studies methods to close that gap and make sure that we are using research evidence in everyday routine clinical care. In implementation science, we can think about how we take an intervention or maybe some sort of clinical innovation and how we move that into clinical care. And it's not as easy as saying, this worked. This was effective. We should do it.

There's much more that we need to do. We need to understand, are people interested in this innovation? What's the context? Does the health care system-- are they able to provide, maybe, money to buy the innovation, or are they able to give people time to learn more about that? And in implementation science, we have these things called implementation strategies, and it's how we help people adopt new clinical innovations.

In my postdoc, I was able to really dive into implementation science and think about how we could start to move some of that evidence into practice. It was also an opportunity in my postdoc to expand my work from children who had feeding and swallowing disorders, or what we now call pediatric feeding disorders, but that I could also include children with obesity.

Now in my faculty position, I continue to focus in those areas of implementation science. I continue to work and think about family-centered outcomes, both for children with pediatric feeding disorder and also for children who have obesity. Currently, there are a few things that I'm working on in my research. One of the first big projects is that we are studying how we take research evidence and how we promote that uptake in pediatric practices. So this is my work in implementation science.

So in this particular example, we have an evidence-based effective pediatric healthy lifestyle program. And this program supports families in making behavior changes that guides clinicians in best practices. And through a series of randomized controlled trials, it was shown to be effective. And so our next step was to say, well, how do we have pediatric primary care practices adopt this program? And so we embarked on this implementation study.

We partnered with four different health care systems who agreed to adopt this program into their pediatric practices. We didn't immediately dive right into, here's a program. You need to use it. We talked with clinicians, staff, leadership. We went to different meetings, and everyone at each of the health care systems did this also. And what we asked about is, we wanted to know what they needed to adopt this program. We also asked them specifically about the program and were there any things that we needed to adapt to make it suit their environment better.

And then after that, we made some adaptations to the program. Because prior, this program had been used in a clinical trial. And interventions that we study in clinical trials may not always be ready for everyday use. So we needed to take that time to make these adaptations to make sure that it was going to work. We also developed those strategies or those implementation strategies that would help to promote the uptake. And again, we did all of that by talking to the people who were going to use the program or leadership or other staff who would be involved-- again, because we need it to make sure that it was going to suit that context.

And then after we did that, we then studied how well the program was implemented. And we did that through looking at how many children were actually exposed to this new intervention. We looked at how it was adopted, so how many clinicians actually used the program, how they used the tools of the program. We also looked at, was it implemented with fidelity, so how we intended the program to be used and those strategies that we thought would help with the uptake. Did people actually do that? We also wanted to know about, did clinicians find this program acceptable, and did families have good experiences of care with that program?

The other thing that we thought about was sustainability. And we did not want to come in, bring this program, and then when the study was over or funding was gone, we didn't want this program to go away. So we had an eye towards sustainability from the very first day and really encouraged the health care organizations to work with leadership in thinking about how they might be able to sustain that.

The other thing that we thought a lot about was, will others be able to replicate this program in their organization? And so through this process, we also built a guide that could walk people through how they, too, could implement this program. And all of this is really important because this all starts to help us take research evidence and move it into practice. As I said before, just because something is found to be effective does not mean that people will immediately adopt it.

There have been studies that say it takes upwards of 10 to 17 years to move something that's been found to be effective into practice. We really need to close that gap. We shouldn't be spending these 10 to 17 years. So implementation science really works at shortening that gap and supporting people in adopting new interventions or innovations.

Another part of my research that I'm currently working on is understanding the impacts of pediatric feeding disorder. And a lot of this work echoes back to the time when I was a clinician. I saw how challenging it was for families when they had a child who had difficulty with eating. In these series of studies, we've been examining the quality of life with children with pediatric feeding disorders. We've also been looking at, how are they able to participate in social activities? We're hearing stories about how challenging that is for children in their families.

In one of our studies, we did qualitative interviews where we interviewed families who had children with a pediatric feeding disorder. And we had a family who shared with us that she was told that they were glad that their child couldn't come to their birthday party because they were a liability because they had such difficulty eating and drinking.

We are also looking at how caregivers are impacted by having a pediatric feeding disorder. We're looking at the financial impacts. And in one of our study where we used a national database, what we found is that children with feeding difficulties were more likely to have a family who had to leave their job to care for them. They had more out-of-office expenses than children without feeding difficulties, and they really needed to utilize more community resources to provide the care for their child.

And all of this has really led for us to think about, how do we alter care to make sure we are addressing what's important to families? And it's important for us to address the challenges that they're having with feeding and drinking, but we also need to think beyond that to truly support our families and make sure that they have the best quality of life.

In another line of our research, we have been exploring how we best support families and how we can alter care to make it contextualized to their life circumstances. A lot of this work comes from the work that we have done in childhood obesity. We know that there are systemic causes of childhood obesity, and an important piece is to connect families to resources. We want to take it one step further and make sure the recommendations that we are providing are contextualized to a family's life circumstances.

And so what we are doing is we are doing surveys and interviews, and we're learning from families, clinicians, and community organizations what this might look like. How do we first identify that a family has either social risk factors or unmet social needs? And then once we do that, how do we make sure that we are referring to those services? And many large health care organizations now have community health workers or patient navigators that help with that, so that's a very important piece in this puzzle we're trying to solve.

And then we want to take it a step further. How can we adjust care? Rather than saying to a family who maybe lives in a community where it's not safe for their child to play outside, rather than just simply saying to them, well, your child should get more physical activity, go outside, and play, really contextualize that. In their community, going outside to play isn't appropriate, so talking with them about ways to increase physical activity, so maybe using different apps or maybe getting connected to an after-school program or a YMCA-- again, really contextualizing our recommendations to that family's circumstance. And we believe that that can promote better health outcomes rather than just giving generic recommendations.

Many clinicians do this now without thinking about it, but the reality is that there are many clinicians who don't do this and who aren't thinking about this. They feel like they're asking their families to do things, and then they're being met with, well, they're just not doing it. And the reality is the family might not be doing it because it might be challenging for them, or they don't have the resources they need to be able to carry out that recommendation. And so I think it's on us as health care providers and as health care systems to start to think about that.

All of this that I'm talking about have been recommended through the National Academies of Medicine. And really, there's a breadth of research that has shown that we really need to integrate social care into the work that we do.

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Ultimately, my aim is to have my research directly impact and improve health care for children. I want to do this through making sure that the evidence that we have is being used by clinicians and also making sure that the care we deliver is meaningful and family-centered and that we are putting the family and the child at the center of the decisions that we are all making. The second takeaway is that we need to better meet the needs of children and families by understanding what their needs are and addressing that in the care that we deliver. That truly is the only way that we will continue to improve health outcomes for children.

The next steps for my research is, first, we are taking that healthy lifestyle program that I earlier described, and we're adapting it to provide contextualized care. As I mentioned, we've been learning from families and clinicians and leadership what the needs are for us as we adapt the program. And so our next step is to build a care plan that guides clinicians through that process of contextualizing or adjusting the care that they deliver to children.

The second area that I'm continuing to work on is to gain that understanding of the impacts of pediatric feeding disorders, really thinking about ways that we can support clinicians to incorporate what's important to families into the care that they deliver. I think these projects really work towards my long-term goal of making sure that we are meeting the needs of children and families.

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Oby: Thank you for listening. If you enjoyed this episode, please rate us on iTunes and help us spread the word about the amazing research taking place across the Harvard community and beyond. We are always looking to connect and collaborate with the research community and would like to hear from you. Please feel free to email us at onlineeducation.catalyst.harvard.edu to inquire about being a guest on the podcast.

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