Faherty LJ, Lurie N, Wong CA. The COVID-19 “Return-to-Learning” Natural Experiment. JAMA Health Forum. Published online October 7, 2020. doi:10.1001/jamahealthforum.2020.1211
Across the US, more than 13 000 school districts have reopened for K-12 students during the coronavirus disease 2019 (COVID-19) pandemic using a range of remote, in-person, and hybrid models—a vast “return-to-learning” natural experiment. Without a rapid and coordinated research response1 in schools, each passing day is a missed opportunity to learn how to better protect children, families, and school personnel from COVID-19’s effects on health, well-being, and educational outcomes.2 Adapting a prior framework,1 we outline considerations for researchers seeking to partner with K-12 schools to ensure that ongoing decisions about children, schools, and COVID-19 are based on science, not speculation.
Partnering with directly affected stakeholders is critical to implementing a research response that addresses priorities and concerns of multistakeholder school communities, including parents, students, teachers, and school leaders. State and district-level scientific advisory boards should be established that include health experts and members of the school community. These boards can expeditiously develop stakeholder engagement plans3 in preparation for launching state-level or district-level studies, then oversee the research process. Virtual public meetings and online discussion boards can encourage ongoing engagement among researchers and school communities. The ABC Science Collaborative, which connects researchers and school leadership and hosts webinars for school personnel, offers an example of this approach.
Given COVID-19’s extensive health, social-emotional, and economic effects, a prioritized, manageable research agenda on child health and COVID-19 specific to K-12 schools is urgently needed. Synthesizing broader recommendations,2,4 we propose school-specific priority research questions at the organizational level of the social-ecological framework:
What are the most feasible, acceptable, and effective screening, testing, and mitigation measures in schools for different ages?
What behavioral strategies, based on behavioral change literature and prior public health campaigns, encourage adherence among children of different ages to nonpharmacologic interventions (eg, mask wearing, physical distancing)?
What learning models (eg, in-person, remote, hybrid) maximize learning and safety? How do implementation and outcomes differ across settings with varying resources?
What academic, psychosocial, and health inequities are exacerbated by school disruptions due to COVID-19? What interventions are needed to address them?
Schools can also benefit from community-level research, including research seeking to answer questions where current guidance is based on minimal data, such as, “At what level of community COVID-19 transmission do the benefits of reopening schools outweigh the transmission risks?” and “What are optimal strategies to increase access to social resources (e.g., food and housing) to protect child well-being?” In addition, stakeholder involvement created by these efforts can generate opportunities for individual-level and family-level research (eg, around severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] vaccine decision-making, given the lack of pediatric data).
This list of priority research questions should be refined and articulated as a national research agenda on COVID-19 and schools by convening a multidisciplinary expert panel of researchers, including representatives from the Centers for Disease Control and Prevention and the Department of Education. This panel could also develop study protocols for adaptation and use in local settings. District and school leaders should have considerable input on research priorities and autonomy to select the most important questions for their local contexts. An independent “boundary organization,”5 such as the National Academies of Sciences, Engineering, and Medicine (NASEM), is needed to build bridges and facilitate collaboration among stakeholders with divergent priorities and constraints.
Protecting the privacy of participants, particularly children, while developing real-world evidence is paramount. Researchers should work closely with institutional review boards to facilitate rapid reviews of study protocols. Leadership from public health, education, and medicine should be engaged to ensure that protections meet health care (eg, Health Insurance Portability and Accountability Act) and school (eg, Family Educational Rights and Privacy Act) standards. Frequent, transparent communication with stakeholders is needed about how data will be used, who will have access, and how privacy and confidentiality will be protected. Public health departments’ experience with successful communication during outbreak investigations involving schools (eg, measles) can be applied to COVID-19.
As school districts take different approaches, we will see different rates of SARS-CoV-2 transmission, absenteeism, forced school closures, and emotional distress. While randomized clinical trials are the research gold standard, more rapid study designs must be leveraged.6 These designs include crossover, non-placebo-controlled parallel, stepped-wedge, pre-post intervention with a control group, and “rapid-cycle randomization,” as well as observational studies that exploit policy variation in schools’ plans. For example, a state preparing to phase in surveillance testing in schools could coordinate with researchers to launch a stepped-wedge study, analyzing the impact of testing on infection rates, absenteeism, and emotional well-being. Additionally, qualitative data from school stakeholders (eg, parents, students, school personnel) can provide important insights on feasibility, acceptability, and implementation challenges to complement quantitative outcomes.
An effective research response requires enabling efficient, low-burden data collection, given the limited time and resources. To facilitate standardization and data comparability across settings, the boundary organization described previously should lead the development of common metrics and ensure wide dissemination through public health and educational bodies. Research funders can encourage the use of these metrics in their funding announcements. In March 2020, the Johns Hopkins COVID-19 and Mental Health Measurement Working Group began this work, disseminating 6 suggested measures of COVID-19’s mental health effects. To maximize efficiency, COVID-19–related questions could be added to ongoing data collection efforts,7 and existing research networks can make district-level data, such as school reopening policies, publicly available for broad use.
In summary, researchers and school communities can partner to:
Engage a boundary organization (eg, NASEM) to develop a research agenda that could be implemented across diverse settings, facilitate development of common metrics, streamline data collection efforts, and share lessons learned among districts, states, and decision-makers.
Form state-level and district-level scientific advisory boards comprising researchers and school leadership to adapt the research agenda to local contexts, address stakeholder concerns, and ensure that privacy protections are in place.
Although it is too late to inform fall school reopening decisions, the window of opportunity for learning as much as possible from this large natural experiment remains open if we take action now.
Corresponding Author: Laura J. Faherty, MD, MPH, MSHP, RAND Corporation, 20 Park Plaza, Suite 920, Boston, MA 02116 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Wong reported receiving grants from Verily Life Sciences outside the submitted work. No other disclosures were reported.
Additional Contributions: The authors gratefully acknowledge Sonja Rasmussen, MD, MS, University of Florida, and Julia Kaufman, PhD, RAND Corporation, for their helpful critiques of earlier drafts.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.