lcc#session#39#,#advocacy# … · 2015. 12. 11. · † throughout the series iii draft of the...
Post on 17-Aug-2020
1 Views
Preview:
TRANSCRIPT
LCC#Session#39#,#Advocacy##
CanMEDS#competency:#Health#Advocate##
Dr.#Andrea#Hunter##
FACILITATOR#GUIDE#!What#will#happen#in#this#session?#!Large!group!session:!!Introducton!–!CanMEDS!2015,!Health!Advocate!role!updates!
• Dr.!Andrea!Hunter!!
How!can!physicians!best!interact!with!government!officials?!• Chris!Charlton,!MP!for!Hamilton!Mountain!
!!Case!discussions!in!small!groups!(if!time!allows)!
!Suggested(time:(60(minutes(!#Readings:##
L Behforouz!HL,!PK!Drain!and!JJ!Rhatigan.!Rethinking#the#social#history.!NEJM!Oct!2,!2014.!371!(14):!1277L1279.!(attached)!
L Canadian#Pediatric#Society#–#Are#we#doing#enough?!A!status!report!on!Canadian!public!policy!and!child!and!youth!health.!http://www.cps.ca/advocacy/StatusReport2012.pdf!!
L Canada’s#premiers#should#connect#the#dots#between#health#and#poverty!(by!Andrew!Lynk,!CPS!president)!–!Toronto!Star!July!22,!2013.!http://www.thestar.com/opinion/commentary/2013/07/22/canadas_premiers_should_connect_the_dots_between_health_and_poverty.html!
L CanMEDS#2015#–#version#III#–#Health#Advocate#role!(p.!21L22)!(attached)!!See!also!attached!list!of!resources,!for!further!reading!on!advocacy!topics/organizations!!# #
Cases:#!Case!1!–!Booster!Seats!
• A!7!year!old!child!is!late!for!an!appointment!in!your!clinic.!His!parents!apologize!but!are!quite!frustrated!as!on!their!way!to!your!office!they!were!stopped!by!the!police.!They!were!ticketed!and!fined!because!their!son!was!not!in!a!booster!seat.!They!were!not!aware!of!the!new!law!mandating!this!in!Ontario!and!tell!you!that!they!think!it!is!ridiculous.!!
• After!your!interaction!with!the!previous!family,!you!decide!to!start!asking!each!parent!whether!or!not!their!child!is!using!a!booster!seat.!You!are!surprised!to!find!out!that!of!the!next!10!children!of!the!appropriate!age,!only!3!are!in!booster!seats.!That!evening,!you!are!wondering!what,!if!anything,!you!can!do.!
• What%are%your%professional%obligations%in%responding%to%these%parents?%What%role%can%you%have%beyond%the%direct%interactions%with%your%patients%in%this%situation?%
#Tips!for!facilitators!
• remind!parents!of!legal!requirements!for!booster!seats!• consider!involvement!in!hospitalL!or!communityLbased!safety!promotion!
programs!(including!through!Hamilton!Public!Health)!• awareness!of!funding!opportunities!for!carseats/booster!seats!for!families!of!
low!income!#From#CPS#‘Are#we#doing#enough?”##Motor!vehicle!collisions!are!the!leading!cause!of!death!among!Canadian!children!over!one!year!of!age.!!Child!passenger!restraints!reduce!the!risk!of!serious!injury!by!between!40%!and!60%.In!fact,!improved!car!seat!design!and!the!increased!use!of!child!restraints!resulted!in!a!50%!drop!in!the!number!of!child!passengers!who!died!in!motorLvehicle!accidents!between!1993!and!2006.!!Although!all!provinces!and!territories!require!by!law!the!use!of!restraint!systems!for!children!up!to!about!4!years!old,!children!aged!4!to!8!years!often!graduate!prematurely!to!seat!belt!use,!increasing!their!risk!of!injury,!disability!and!death.!In!a!collision,!children!using!seat!belts!instead!of!booster!seats!are!3.5!times!more!likely!to!suffer!a!serious!injury!and!4!times!more!likely!to!suffer!a!head!injury.!Yet!while!78%!of!parents!support!the!use!of!booster!seats,!only!30%!are!using!them.!The!CPS!recommends!that!provinces!and!territories!require!children!weighing!between!18kg!and!36!kg!and!travelling!in!a!vehicle!to!be!properly!secured!in!a!booster!seat!in!the!back!seat.!Legislative!changes!should!be!complemented!by!appropriate!enforcement!measures!and!public!education!programs!to!ensure!that!parents!adopt!and!use!booster!seats!properly.!Legislation!should!be!uniform!across!Canada!to!make!it!easier!for!families!to!comply!with!regulations.!Ontario:!Meets!all!CPS!recommendations.!
!From#CPS#statement#“Preventive!health!care!visits!for!children!and!adolescents!aged!6!to!17!years:!The!Greig!Health!Record!–!Technical!Report”!
Based!on!a!systematic!review!of!randomised!controlled!trials,!there!is!strong!evidence!to!support!that!counselling!results!in!a!modest!increase!in!seatbelt!use.!Physicians!should!counsel!parents!regarding!graduation!to!seatbelts,!especially!to!avoid!premature!graduation!for!smaller!children!.!Guidelines!are!available!from!Transport!Canada,!Safe!Kids!Canada!and!the!CPS.!!! !
Case!2:!Social!Determinants!of!Health!• You!are!working!in!your!senior!resident!communityLbased!continuity!clinic.!
You!see!an!8!month!old!child!for!plateau!in!weight!gain!(weight!previously!at!50thtile!for!age,!now!at!5L10th!percentile!for!age).!!After!a!very!thorough!history!and!physical!exam,!you!find!no!concerning!findings!of!malabsorption,!increased!metabolic!needs!or!losses.!!She!was!hospitalized!at!6!months!of!age!for!RSV!bronchiolitis,!and!mom!offers!that!she!found!this!a!particularly!stressful!few!days.!As!you!are!leaving!the!room!to!review!with!your!staff,!mom!asks!if!you!have!any!formula!samples!available.!!With!some!inquiry,!you!learn!that!she!has!been!‘couchLsurfing’!with!friends!for!the!last!4!months,!has!left!her!previous!partner!and!was!laid!off!from!her!parttime!job!last!month.!
• What%are%your%next%steps?%What%resources%are%you%aware%of%that%would%assist%you%and/or%this%family%in%this%situation?%What%role%can%you%have%beyond%the%direct%interactions%with%this%family,%in%this%situation?%
!Tips#for#Facilitators:#
• See!Child!Poverty!Toolkit!(attached)!• Consider!connecting!with!shortterm!formula!supply!from!samples!or!
dietician/social!worker!if!hospitalLbased!• Realize!that!this!is!only!a!temporary!‘band!aid’!solution,!need!to!look!into!
broader!issues!within!social!determinants!of!health,!particularly!poverty!affecting!food!security!and!child!development.!
• Housing:!!Consider!local!resources!outlined:!http://www.hamilton.ca/HealthandSocialServices/SocialServices/Housing/emergencyShelters.htm!!
o Good!Shepherd,!Mary’s!place!• Food!security:!Consider!local!resources!outlined!in!
http://www.hamilton.ca/NR/rdonlyres/7F312728L445CL44E0LAA97L2C4DABD8A82D/0/FoodAccessGuide.pdf!!
o Food!banks!–!Good!Shepherd,!Neighbour2Neighour,!Hamilton!Food!Share!
o Hospital!or!community!based!social!workers!• Low!income:!Suggest!completion!of!income!tax,!and!any!special!diet!
allowance!or!OW,!ODSP!forms!that!are!applicable!o Connect!with!OW!case!worker!or!equivalent!
• Child!development:!!o Offer!options!for!free,!safe!play!spaces!for!mom!and!child!to!attend!
such!as!Ontario!Early!Years!Centres,!Healthy!Babies/Healthy!Children!!%
!! !
Case!3:!Medication!error!• You!are!the!resident!representative!on!your!hospital!patient!safety!
committee!and!one!month!you!review!2!cases!where!patients!were!inadvertently!given!excessive!doses!of!morphine!during!the!night.!!In!both!cases,!the!doses!were!given!intravenously!instead!of!orally!as!had!been!intended.!On!further!review!it!becomes!evident!that!the!orders!were!given!verbally!by!a!resident!to!the!nurse!–!in!one!case,!the!appropriate!oral!dose!was!prescribed!IV!by!a!junior!resident;!in!another,!the!ward!was!very!busy!and!the!nurse!was!not!able!to!double!check!the!dose!with!a!second!nurse!before!administering.!%
• How%could%you%address%this%issue:%%within%your%division?%Hospital%wide?%At%a%health%policy%level?%
!Tips#for#Facilitators:(
• Educate!yourself!about!the!patient!safety!practices!and!resources!at!McMaster!Children’s!Hospital!(M&M!rounds,!patient!safety!framework,!incident!reporting)%
• Discuss!these!issues!with!chief!residents!or!resident!representatives!of!morbidity/mortality!committee!for!review%
• Canadian!Patient!Safety!Institue!toolkit!including!patient!safety!competencies!at!:!http://www.patientsafetyinstitute.ca/English/toolsResources/safetyCompetencies/Pages/default.aspx!!%
! !
Case!4:!!Bullying!• 16!year!old!girl!presents!to!your!clinic!for!prolonged!fatigue!with!some!mood!
symptoms.!Preliminary!workup!indicates!no!red!flags!for!weight!loss,!fever,!inflammatory!conditions!or!selfLharm!and!normal!laboratory!screening.!History!reveals!that!she!is!going!to!sleep!at!1:30am!because!of!homework,!and!feels!a!great!deal!of!stress!due!to!their!school!work!and!high!parental!expectations.!She!has!little!time!for!physical!activity,!leisure,!and!doesn't!spend!much!time!with!friends.!She!disclosed!a!long!history!of!being!bullied!at!school!towards!the!end!of!your!visit.!!!
• What%are%your%next%steps?!!What%resources%are%you%aware%of%that%would%assist%you%and/or%this%family%in%this%situation?%What%role%can%you%have%beyond%the%direct%interactions%with%this%family,%in%this%situation?!
!Tips#for#Facilitators#
• Ensure!confidentiality!is!respected,!but!ensure!teen!safety!within!this!context!–!indicate!that!you!may!need!to!share!some!information!with!others!to!‘keep!her!safe’!
• Discuss!strategies!that!teen!(and!family)!can!begin!to!address!bullying!at!school,!involving!trusted!school!officials!(and!your!involvement,!as!needed)!
• Provide!reading!list!for!parents/teens!about!bullying!available!through!www.communityed.ca!L!see!attached!
• Some!information!about!evidenceLbased!guidelines!for!screening!for!bullying/cyberbullying!as!well!as!Electronic,!media!–!TV/Internet!within!!CPS!statement!“Preventive!health!care!visits!for!children!and!adolescents!aged!6!to!17!years:!The!Greig!Health!Record!–!Technical!Report”#http://www.cps.ca/documents/position/greigLhealthLrecordLtechnicalLreport!
• A!great!tipsheet!for!bullying!prevention!and!intervention!by!health!care!providers!available!at!http://www.stopbullying.gov/resourcesLfiles/rolesLforLhealthLprofessionalsLtipsheet.pdf!and!attached!!
#!
© 2014 Royal College of Physicians and Surgeons of Canada 21
The Draft CanMEDS 2015 Physician Competency Framework —HEALTH ADVOCATE Series III
HEALTH ADVOCATE
Definition As Health Advocates, physicians contribute their expertise and influence as they work with communities or patient populations to improve health. They work with those they serve to determine and understand needs, speak on behalf of others when needed, and support the mobilization of resources to effect change.
Description
Physicians recognize their duty to participate in efforts to improve the health and well-being of their patients, their communities, and the broader populations they serve.* Physicians possess medical knowledge and abilities that provide unique perspectives on health. Physicians also have privileged access to patients’ accounts of their experience with illness and the health care system. Improving health is not limited to mitigating illness or trauma, but also involves disease prevention, screening, health promotion, surveillance, and health protection. Improving health also includes promoting health equity, whereby individuals and populations reach their full health potential without being disadvantaged by, for example, race, ethnicity, religion, gender, sexual orientation, age, social class, economic status, or level of education.
Physicians leverage their position to support patients in navigating the health care system and to advocate with them to access appropriate resources in a timely manner. Physicians seek to improve the quality of both their clinical practice and associated organizations by addressing the health needs of the patients, communities, or populations they serve. Physicians promote healthy communities and populations by influencing the system (or by supporting others who influence the system), both within and outside of their work environments.
Advocacy requires action. Physicians contribute their knowledge of the determinants of health to positively influence the health of the patients, communities, or populations they serve. Physicians gather information and perceptions about issues, working with patients and their families† to develop an understanding of needs and potential mechanisms to address these needs. Physicians support patients, communities, or populations to call for change, and they speak on behalf of others when needed. Physicians increase awareness about important health issues at the patient, community, or population level. They support or lead the mobilization of resources (e.g., financial, material, or human resources) on small or large scales.
* In the CanMEDS framework, a “community” is a group of people and/or patients connected to one’s practice, and a “population” is a group of people and/or patients with a shared issue or characteristic.
† Throughout the Series III draft of the CanMEDS 2015 Framework and Milestones Guide, phrases such as “patients and their families” are intended to include all those who are personally significant to the patient and are concerned with his or her care, including, according to the patient’s circumstances, family members, partners, caregivers, legal guardians, and substitute decision-makers.
Health Advocate Role Expert Working Group
Chair: Jonathan Sherbino
Core members: Deirdre Bonnycastle, Brigitte Côté, Leslie Flynn, Andrea Hunter, Daniel Ince-Cushman, Jill Konkin, Ivy Oandasan, Glenn Regehr, Denyse Richardson, Jean Zigby
Advisory members: Marcia Clark, Sherissa Microys
For further information about the deliberations of the CanMEDS Health Advocate EWG in revising this Role for CanMEDS 2015, please see their February 2014 Report.
© 2014 Royal College of Physicians and Surgeons of Canada 22
The Draft CanMEDS 2015 Physician Competency Framework —HEALTH ADVOCATE Series III
Physician advocacy occurs within complex systems and thus requires the development of partnerships with patients, their families and support networks, or community agencies and organizations to influence health determinants. Advocacy often requires engaging other health care professionals, community agencies, administrators, and policy-makers.
Key concepts
• Adapting practice to respond to the needs of patients, communities, or populations served: 2.1, 2.2
• Advocacy in partnership with patients, communities, and populations served: 1.1, 1.2, 2.1, 2.2, 2.3
• Continuous quality improvement: 2.2, 2.3
• Determinants of health, including psychological, biological, social, cultural, environmental, educational, and economic determinants, as well as health care system factors: 1.1, 1.3, 2.2
• Disease prevention: 1.3, 2.1
• Fiduciary duty: 1.1, 2.2, 2.3
• Health equity: 2.2
• Health promotion: 1.1, 1.2, 1.3, 2.1
• Health protection: 1.3
• Mobilizing resources as needed: 1.1, 1.2, 1.3
• Principles of health policy and its implications: 2.2
• Potential for competing health interests of the individuals, communities, or populations served: 2.3
• Responsible use of position and influence: 2.1, 2.3
• Social accountability of physicians: 2.1, 2.3
Key competencies Enabling competencies
Physicians are able to: Physicians are able to:
1. Respond to the individual patient’s health needs by advocating with the patient within and beyond the clinical environment
1.1 Work with patients to address determinants of health that affect them and their access to needed health services or resources
1.2 Work with patients and their families to increase their opportunities to adopt healthy behaviours
1.3 Incorporate disease prevention, health promotion, and health surveillance into interactions with individual patients
2. Respond to the needs of the communities or patient populations they serve by advocating with them for system-level change
2.1 Work with a community or population to identify the determinants of health that affect them
2.2 Improve clinical practice by applying a process of continuous quality improvement to disease prevention, health promotion, and health surveillance activities
2.3 Participate in a process to improve health in the community or population they serve
n engl j med 371;14 nejm.org october 2, 2014
PERSPECTIVE
1277
Rethinking the Social History
Research has established that social environments affect
human health.1 Acknowledged social determinants of health — including racial or ethnic back-ground, occupation, and the use of alcohol and tobacco2 — also influence the effectiveness of health care delivery.3 But other social factors, such as the ability to afford medications, access to transportation, available time, and competing priorities, may influ-ence health outcomes even more. Although we believe that explor-ing these issues constitutes an essential part of the medical ex-amination, the most important and relevant social history ques-tions are rarely asked or acted on.
Applying social science prin-ciples to medicine — a practice sometimes called “social medi-cine” — enables us to contextu-alize patient care to achieve more sustainable and equitable health outcomes. Social medicine eluci-dates how patients’ environments influence their attitudes and be-haviors and how patients’ agency — the ability to act in accor-dance with their free choice — is constrained by challenging social environments.
Physicians often see patients with complex social situations as a burden — requiring extra work that is neither reimbursable nor central to our core clinical exper-tise. Unfortunately, we inculcate these attitudes in trainees, implic-itly and explicitly, perhaps because of our discomfort with hearing difficult stories or our sense of
powerlessness or incompetence in addressing these root problems. Whereas biologic pathology may present specific targets for inter-vention, social or structural pathol-ogy is difficult to treat.
Since social problems affect patients’ health and treatment effectiveness, however, we cannot afford to ignore them in assess-ments and treatment plans if we hope to improve outcomes, reduce costs, and improve patient satis-faction. Moreover, clinicians’ sim-ple acknowledgment of social forces can strengthen their ther-apeutic alliance with patients. Patients know clinicians cannot alleviate their poverty, but empa-thy and concern shown by a clini-cian who explicitly addresses it constitute powerful medicine.
So how should we teach stu-dents and clinicians to explore social determinants of health? How can we encourage health care teams to explore social fac-tors that influence health care delivery? And how should clinical teams address these issues?
To start, obtaining a more ap-propriate and comprehensive so-cial history can enable proper assessment of a patient’s social environment. Although many so-cial barriers exist between patients and providers, deliberate inquiry into the social environment allows clinicians to understand behaviors such as nonadherence to treat-ment plans, missing of appoint-ments, or failure to fill prescrip-tions not as products of ignorance or willful misbehavior but rather
as results of the complicated in-terplay of individual factors with a complex social environment.
For example, a proper social history of a “brittle diabetic” pa-tient may reveal a very limited in-come that precludes purchasing healthy foods. Social isolation may prompt excessive emotional eat-ing, limited mobility may hinder monthly visits to the pharmacy to pick up prescriptions, depres-sion or poor coping skills may thwart lifestyle modifications, family lore regarding “low sugars” may impede adherence to insulin regimens, and life with arthritic knees in a third-story walk-up in a violent neighborhood may make prescribed daily walks seriously challenging.
Adopting the social medicine framework, we revised our list of social history topics in an effort to strengthen our therapeutic al-liances, better contextualize pa-tients’ diagnostic and treatment plans, and improve health out-comes (see box). Our topics ex-tend well beyond the common “TED” (tobacco, ethanol, drug use) questions, encompassing six cate-gories: individual characteristics, life circumstances, emotional health, perceptions of health care, health-related behaviors, and access to and utilization of health care. Primary care clinicians may find that such a comprehensive history is best obtained over mul-tiple visits, but we believe it is ideal to revisit these questions annually; inpatient clinicians probably need to be more target-
BECOMING A PHYSICIAN
Rethinking the Social HistoryHeidi L. Behforouz, M.D., Paul K. Drain, M.D., M.P.H., and Joseph J. Rhatigan, M.D.
The New England Journal of Medicine Downloaded from nejm.org on December 8, 2014. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.
PERSPECTIVE
n engl j med 371;14 nejm.org october 2, 20141278
ed but could, with training, ob-tain similar relevant information. Of course, clinicians should use their judgment regarding the ap-propriate timing of these conver-sations, since patients may need to establish trust and rapport be-fore sharing intimate information.
To obtain proper social histo-ries, clinicians could be trained in basic and motivational inter-viewing techniques and chal-lenged to examine their own bi-ases, since unexplored prejudices influence our ability to obtain or act on important information. We also recommend that clinicians attempt to visit the neighbor-hoods where the majority of their patients live, since such experi-ences can enhance clinicians’ so-cial perspective and help them understand their patients’ “health homes.” Such visits might inform clinicians about people or ser-vices in their patients’ world that could be organized to help them achieve better health and about the forces working against their engagement in health-promoting or harm-reducing behaviors.
In addition to learning how to obtain this social information, clinicians need to learn how to use it — specifically, they need training in ways of developing individualized care plans that take into account patients’ per-sonal and structural barriers to good health.4 Using shared-deci-sion-making techniques and ap-propriate pedagogical and coun-seling skills, clinicians can help prioritize patients’ goals and em-power patients to make lasting changes to achieve self-identified objectives. Increasingly, through shared-savings contracts and re-imbursement for care-coordina-tion activities, clinicians will re-ceive financial incentives to make
Rethinking the Social History
Common Current Topics and Proposed Comprehensive Topics for the Patient Social History.
Common current topicsRacial or ethnic backgroundMarital status and childrenOccupationHighest level of educationTobacco, ethanol, drugs (“TED”)Seatbelt and helmet useFirearms in the homeVictim of domestic violence
Proposed new topicsIndividual characteristics
Self-defined race or ethnicityPlace of birth or nationalityPrimary spoken languageEnglish literacyLife experiences (education, job history, military service, traumatic or life-
shaping experiences)Gender identification and sexual practicesLeisure activities
Life circumstancesMarital status and childrenFamily structure, obligations, and stressesHousing environment and safetyFood securityLegal and immigration issuesEmployment (number of jobs, work hours, stresses or concerns about work)
Emotional healthEmotional state and history of mental illness (e.g., depression, anxiety, trauma,
post-traumatic stress disorder)Causes of recent and long-term stressPositive or negative social network: individual, family, organizationalReligious affiliation and spiritual beliefs
Perception of health careLife goals and priorities; ranking of health among other life prioritiesPersonal sense of health or fears regarding health carePerceived or desired role for health care providersPerceptions of medication and medical technologyPositive or negative health care experiencesAlternative care practicesAdvance directives for cardiopulmonary resuscitation
Health-related behaviorsSense of healthy or unhealthy behaviorsFacilitators of health promotion (e.g., healthy behaviors among close social
contacts)Triggers for harmful behaviors and motivation to change (may be determined
through motivational interviewing)Diet and exercise habitsFacilitators or barriers to medication adherenceTobacco, alcohol, drug use habitsSafety precautions: seatbelts, helmets, firearms, street violence
Access to and utilization of health careHealth insurance statusMedication access and affordabilityHealth literacy and numeracy (may be ascertained with specific tools; e.g.,
“The Newest Vital Sign”)Barriers to making appointments (e.g., child care, work allowance, affordability
of copayment, transportation)
The New England Journal of Medicine Downloaded from nejm.org on December 8, 2014. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.
n engl j med 371;14 nejm.org october 2, 2014
PERSPECTIVE
1279
Rethinking the Social History
appropriate referrals to both insti-tution-based and community-based resources and to commu-nicate effectively with social workers, community health work-ers, lawyers, therapists, counselors, and other service providers.
For example, an individualized care plan for a woman with dia-betes might include referrals to a food pantry and farmer’s market for purchasing fresh produce; re-ferral to a community-based walk-ing program, where neighbors help her up and down the stairs; sending prescriptions to a phar-macy that delivers medication to her home; referral to a medicolegal group for contract assistance con-cerning her unsafe housing situ-ation; and referral to a commu-nity health center that holds group meetings where she can build re-lationships, explore new explana-tory models of disease, and learn from others’ stories of illness and coping. For the most challenging “nonadherent” patients, a struc-tured home visit by medical team members would be ideal.
Medical education curricula could be revised to incorporate this approach. Students and resi-dents could learn how to conduct structured home visits and pa-tient care mapping exercises to better understand all the places, people, and directives that pa-tients must negotiate in seeking better health. What happens, for instance, when a patient with low literacy is discharged after a hospitalization with new prescrip-tions, orders to follow up with
three subspecialists, and a refer-ral to outpatient rehab — and has to contend with the eviction notice, unpaid utility bills, and isolation that await him at home?
Trainees could learn how to assess patients’ literacy and health literacy and how to deliver infor-mation using well-established ped-agogical techniques. They could practice motivational interview-ing techniques using role playing and learn, in real clinical set-tings, how to motivate and em-power patients to engage in health-promoting behaviors. Audiotaping or videotaping of history taking, counseling, and care-planning activities can provide opportuni-ties for giving feedback and hon-ing skills. Clinicians-in-training can be taught how to enhance shared decision making, create individualized care plans, and work effectively in teams — all principles that we believe should be incorporated into the U.S. Medical Licensing Examination5 and the Accreditation Council for Graduate Medical Education and American Board of Medical Spe-cialties core training competen-cies. If we gear training toward a more comprehensive approach to understanding patients, clinicians will gain tools for developing therapeutic plans that take into account patients’ complex social environments.
We hope that the teaching and assessment of such an approach will foster a new generation of clinicians who provide more per-sonalized and appropriate care.
Attention to the social forces in our patients’ lives would allow us to provide better and less costly care to patients with the most complex conditions and situa-tions — thereby increasing satis-faction among both patients and caregivers. Failure to attend to these forces will perpetuate the cycle of poor outcomes, high costs, and dissatisfaction among our neediest patients.
William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” To be able to treat the patient, a physician must ask the right questions and know how to act on the answers.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
From the Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital (H.L.B., J.J.R.), the Divi-sion of Infectious Diseases and the Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital (P.K.D.), and Harvard Medical School (H.L.B., P.K.D., J.J.R.) — all in Boston.
1. Marmot M. Health in an unequal world. Lancet 2006;368.2081-94.2. Wilkinson R, Marmot M. Social determi-nants of health: the solid facts. Geneva: World Health Organization, 2003.3. DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol 2004;23:207-18.4. Farmer PE, Nizeye B, Stulac S, Keshavjee S. Structural violence and clinical medicine. PLoS Med 2006;3(10):e449.5. Haist SA, Katsufrakis PJ, Dillon GF. The evolution of the United States Medical Li-censing Examination (USMLE): enhancing assessment of practice-related competen-cies. JAMA 2013;310:2245-6.
DOI: 10.1056/NEJMp1404846Copyright © 2014 Massachusetts Medical Society.
The New England Journal of Medicine Downloaded from nejm.org on December 8, 2014. For personal use only. No other uses without permission.
Copyright © 2014 Massachusetts Medical Society. All rights reserved.
Advocacy(Resources(
1
Child/Pediatric Advocacy Caring for Kids New to Canada • Developed by the Canadian Paediatric Society with input from a range of experts and
organizations, Caring for Kids New to Canada has evidence-based information on assessing and screening patients, medical conditions, health promotion, child development, and much more. It also explores how issues beyond the clinical setting affect health, such as culture, social and environmental conditions, health care systems, and public policy.
www.kidsnewtocanada.ca Canadian Pediatr i c Soc i e ty
• The Canadian Paediatric Society is the national association of paediatricians, committed to working together to advance the health of children and youth by nurturing excellence in health care, advocacy, education, research and support of its membership.
Advocacy toolkit: http://www.cps.ca/en/advocacy-defense/tools-and-resources
Advocacy Centre: http://www.cps.ca/en/advocacy-defense
CMAJ Electives CMAJ
Contact: Carole Corkery, Executive Assistant to the Editor-in-Chief: carole.corkery@cmaj.ca
Refugee Health Refuge : Hamil ton Centre for Newcomer Heal th (HNCH)
• A community leader in the provision of high quality health care services to Hamilton’s newcomer population.
Contact: www.newcomerhealth.ca
184 Hughson Street South Hamilton, ON
info@newcomerhealth.ca 905 526 0000
Legal Your Legal Rights
• Free legal information on a wide range of topics, in a variety of languages, produced by hundreds of organizations across the province.
• Topics include: Abuse and family violence, consumer law, criminal law, employment and work, family law, health and disability, housing law, immigration and refugee, legal system, social assistance and pension, American Sign Language resources, ESL resources for teachers. Available under ‘resources’
Information:
2
http://yourlegalrights.on.ca/ Community Legal Educat ion Ontar io (CLEO)
• CLEO produces clear, accurate and practical legal information to help people understand and exercise their legal rights. Our work focuses on providing information to people who face barriers to accessing the justice system, including income, disability, literacy, and language. As a community legal clinic and part of Ontario's legal aid system, we work in partnership with other legal clinics and community organizations across the province.
Browse Resources: http://www.cleo.on.ca/en/resources-and-publications
Refugee Claimants: www.refugee.cleo.on.ca
Additional Information on Refugee Hearings: http://refugeehearing.cleo.on.ca/
PLE Learning Exchange
• A network that supports organizations across Ontario in developing and delivering effective public legal education (PLE) to their communities.
Information: http://www.plelearningexchange.ca/
Medicare Canadian Doctors for Medicare
• Canadian Doctors for Medicare stepped into the national health care debate in May 2006 when a group of physicians and friends became concerned about the increased privatization in Canadian health care and the development of a two-tier health care system that would allow the wealthy to buy private insurance for private care at the expense of the vast majority of Canadians.
http://www.canadiandoctorsformedicare.ca/
Adults with Developmental Disabilities ARCH Disabi l i t y Law Centre South Asian Legal Cl in i c o f Ontar io (SALCO)
• ARCH Disability Law Centre and the South Asian Legal Clinic of Ontario (SALCO) have partnered to develop this factsheet for settlement and frontline workers. The factsheet discusses services and supports that may be available through Developmental Services Ontario (DSO).
• Adults labeled with intellectual disabilities may be able to get some services and supports through the DSO. A person can apply for supports and services if they qualify under the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act.
• Front-line workers may be able to: o 1. Tell people about these services and supports o 2. Help people gather the documents they need to apply o 3. Tell people where to get more information if the DSO does not help them
Accessing Factsheet: http://www.archdisabilitylaw.ca/node/980
3
Social Media Twit t er ac counts to watch :
CMA: @CMA_Docs OMA: @OntariosDoctors
Federal Minister of Health: @MinRonaAmbrose Ontario Minister of Health and Long-Term Care: @DrEricHoskins
Chris Charlton (NDP MP for Hamilton Mountain): @ChrisCharltonMP CMAJ: @CMAJ_News
CMAJ Blogs: @CMAJBlogs Canadian Pediatric Society: @CanPaedSociety
Caring for Kids (Canadian Pediatric Society): @CaringforKids Andre Picard (health reporter, Globe & Mail): @picardonhealth
Helen Branswell (health reporter, Canadian Press): @HelenBranswell Healthy Debate: @healthydebate
Brian Goldman (emergency physician, host of CBC's White Coat Black Art):@NightShiftMD Richard Horton (Editor-in-Chief, The Lancet): @richardhorton1
Matthew Stanbrook (CMAJ associate editor): @drstanbrook Mark Cherrington (Youth at risk worker in Edmonton): @MarkCherrington
Upstream (Social determinants of health): @UpstreamAction Jim Dunn (McMaster Research Chair on Neighbourhoods, Housing and Health):
@UrbanHealthProf Medical Reform Group: @MedReformGroup Doctors for Refugee Care @Docs4refugeehc
Ritika Goel (Toronto based family doctor, health justice activist): @RitikaGoelTO Gary Bloch (Toronto family physician focusing on poverty, sdoh) @Gary_Bloch
Tom Cooper (Director, Hamilton Roundtable for Poverty Reduction): @TomCoopster
Pharmacare 2020 (Organization advocating for better access to medications and toward a pharmacare plan in Canada/Ontario) @pharmacare2020
Canadian Health Coalition @healthcoalition Prabhat Jha (Toronto-based MD, head of Grand Challenges Canada) @countthedead Monika Dutt (Nova Scotia MD and Chair of Cdn Docs for Medicare) @monika_dutt
Canadian Doctors for Medicare @CdnDrs4Medicare Health Providers Against Poverty @hpap_ontario
Evidence Network (online resource that compiles both journal articles and Op-Ed pieces regarding Canadian health policy issues) @evidencenetwork
Irfan Dhalla (Toronto-based MD, VP of Health Quality Ontario – government agency responsible for health QI) @irfandhalla
MSF access to essential medicines campaign @MSF_access Children’s Mental Health Ontario (network of community-based children’s mental health
centres in Ontario) @kidsmentalhlth Ontario Advocate (Provincial Advocate for children and youth receiving care under the Child and
Family Services Act) @OntarioAdvocate
22
InjuryPrevention
Booster seat legislationMotor vehicle collisions are the leading cause of death among Canadian children over one year of age.66,67 Child passenger restraints reduce the risk of serious injury by between 40% and 60%.68,69 In fact, improved car seat design and the increased use of child restraints resulted in a 50% drop in the number of child passengers who died in motor-vehicle accidents between 1993 and 2006.70
Although all provinces and territories require by law the use of restraint systems for children up to about 4 years old, children aged 4 to 8 years often graduate prematurely to seat belt use, increasing their risk of injury, disability and death. In a collision, children using seat belts instead of
booster seats are 3.5 times more likely to suffer a serious injury and 4 times more likely to suffer a head injury.71 Yet while 78% of parents support the use of booster seats,72 only 30% are using them.73
The CPS recommends that provinces and territories require children weighing between 18 kg and 36 kg and travelling in a vehicle to be properly secured in a booster seat in the back seat. Legislative changes should be complemented by appropriate enforcement measures and public education programs to ensure that parents adopt and use booster seats properly. Legislation should be uniform across Canada to make it easier for families to comply with regulations.
A R E W E D O I N G E N O U G H ?2 0 1 2 E D I T I O N
Excellent: Province/territory has legislation in place requiring children to be in an approved booster seat until they reach the height of 145 cm or 9 years of age, and a weight minimum of 18 kg to 36 kg. Public education programs are in place.Good: Province/territory has legislation in place requiring children to be in an approved booster seat until they reach the height of 145 cm or an age specifi ed as less than 9 years, and a weight minimum of 18 kg to 22 kg. Public education programs are in place.Fair: Province/territory requires the use of a booster seat after children have outgrown their front-facing safety seat, but legislation is based on age and/or weight criteria without mentioning height. Public education programs are in place. Poor: Province/territory has no booster seat legislation for children weighing over 18 kg.
Booster seat legislation
Province/Territory 2009 Status 2011 Status Recommended actions
British Columbia Excellent Excellent Meets all CPS recommendations.
Alberta Poor Poor Enact booster seat legislation.
Saskatchewan Poor Poor Enact booster seat legislation.
Manitoba Poor Fair Enact booster seat legislation for children weighing 22 kg to 36 kg.
Ontario Excellent Excellent Meets all CPS recommendations.
Quebec Good Good Revise legislation to provide for a child’s height (a minimum 145 cm) as well as weight.
New Brunswick Excellent Excellent Meets all CPS recommendations.
Nova Scotia Excellent Excellent Meets all CPS recommendations.
Prince Edward Island Excellent Excellent Meets all CPS recommendations.
Newfoundland and Labrador Excellent Excellent Meets all CPS recommendations.
Yukon Fair Fair Enact booster seat legislation for children weighing 22 kg to 36 kg.
Northwest Territories Poor Poor Enact booster seat legislation.
Nunavut Poor Poor Enact booster seat legislation.
A S T A T U S R E P O R T O N C A N A D I A N P U B L I C P O L I C Y A N D C H I L D A N D Y O U T H H E A L T H
23
26
Best Interests of Children and Youth
Child poverty reductionThere is ample evidence that child poverty can lead to poor health outcomes during adulthood, including cardiovascular disease and stroke, type II diabetes and mental health issues.75 Family socioeconomic status is the primary marker for health disparities among Canadian children and youth.76,77 Poor children are at greater risk of low birthweight (<2500 grams) and typically have higher rates of death and illness, lower rates of growth, and more behavioural and developmental problems.78,79 They may also achieve lower levels of education, thus increasing the likelihood of lifelong poverty.80
Despite a unanimous resolution in the House of Commons in 1989 to end child poverty by the year 2000, the gap between rich and poor has widened over the past 20 years.81 The percentage of Canadian children living in poverty in 2009 (9.5%) was only slightly lower than in 1989 (11.8%) (after-tax figures).82 In 2009, the first full year following the recession of 2008, 639,000 children still lived in poverty.83
Poverty is not a given. It can be eliminated, or at least drastically reduced. Government legislation plays a large role, as shown by the fact that Quebec and Newfoundland and Labrador, which have had poverty reduction strategies in place for a number of years, show reduced poverty rates.84
Certain groups continue to be over-represented, including Aboriginal children (1 in 4 lived in
poverty in 2008) and single-parent families (more than half of single moms with children under 6 live in poverty). Children with disabilities and children whose families have emigrated recently are also at higher risk of growing up poor.85
Internationally, Canada ranked 20th out of 30 wealthy developed nations in child poverty rates as recently as 2007,86 and has the regrettable distinction of being one of the few nations where child poverty rates were higher than overall poverty rates over the past two decades.87
The Canadian Paediatric Society is pleased to see some alleviation of child poverty in a number of provinces and territories. Manitoba and New Brunswick have passed legislation to reduce poverty levels. Prince Edward Island and all three territories are in the process of developing anti-poverty strategies.
The CPS calls upon the remaining provincial governments to set targets and timetables, and for the federal government to show leadership with a national strategy. A number of evidence-based solutions are available, including income support measures, education and job training, and quality child care programs.88,89 The CPS believes that ending child and youth poverty should receive the same focus as stimulating economic growth. Public accountability is imperative for tracking progress on this critical health issue.
A R E W E D O I N G E N O U G H ?2 0 1 2 E D I T I O N
Excellent: Province/territory has had anti-poverty legislation promoting long-term action and government accountability for at least three years, and has a poverty reduction strategy with specifi c targets.Good: Province/territory has a comprehensive poverty reduction strategy with specifi c targets. Fair: Province/territory has a poverty reduction strategy or legislation but without specifi c targets.Poor: The province territory has no anti-poverty legislation or poverty reduction strategy.
Child poverty reduction
Province/Territory 2009 Status 2011 Status Recommended actions
British Columbia Poor Poor Develop both legislation and a strategy to reduce poverty.
Alberta Poor Poor Develop both legislation and a strategy to reduce poverty.
Saskatchewan Poor Poor Develop both legislation and a strategy to reduce poverty.
Manitoba Fair Good Launched a strategy in 2009 and passed poverty reduction legislation in 2010. Develop specifi c targets for reducing child poverty.
Ontario Good Excellent Meets all CPS recommendations.
Quebec Excellent Excellent Meets all CPS recommendations.
New Brunswick Poor Excellent Meets all CPS recommendations. Launched a strategy in 2009 and passed poverty reduction legislation in 2010, with specifi c targets.
Nova Scotia Fair Fair Add specifi c targets to its strategy for poverty reduction and develop legislation to meet them.
Prince Edward Island Poor Poor Develop both legislation and a strategy to reduce poverty. The province has begun public consultations on poverty reduction.
Newfoundland and Labrador Excellent Excellent Meets all CPS recommendations.
Yukon Fair Fair Finalize strategy and develop poverty reduction legislation with specifi c targets. A framework for poverty reduction was developed in 2011.
Northwest Territories Poor Fair Develop specifi c targets for reducing child poverty. Passed poverty reduction legislation in 2010 calling for a strategy.
Nunavut Poor Poor Develop both legislation and a strategy to reduce poverty. Public consultations on poverty reduction are underway.
A S T A T U S R E P O R T O N C A N A D I A N P U B L I C P O L I C Y A N D C H I L D A N D Y O U T H H E A L T H
27
What can we do as physicians
to address this potentially
PRGLÀDEOH�ULVN�IDFWRU�DQG�
reduce disparities?
1��'R�\RX�KDYH�WURXEOH�PDNLQJ�HQGV�PHHW"
2��'R�\RX�KDYH�WURXEOH�IHHGLQJ�\RXU�IDPLO\"
3��'R�\RX�KDYH�WURXEOH�SD\LQJ�IRU�PHGLFDWLRQV"
4��'R�\RX�UHFHLYH�WKH�FKLOG�WD[�EHQHÀW"
5 �'R�\RX�KDYH�OHJDO�RU�LPPLJUDWLRQ�FKDOOHQJHV"
6��'R�\RX�KDYH�D�VDIH�DQG�FOHDQ�SODFH�WR�OLYH"
LQMXULHV��REHVLW\�DQG�KRVSLWDOL]DWLRQ�WKDQ�WKHLU�PRUH�
DIÁXHQW�SHHUV��,QIDQW�PRUWDOLW\�LV�����KLJKHU�LQ�
ORZHVW�LQFRPH�TXLQWLOH�QHLJKERXUKRRGV�
$�SUDFWLFDO�WRRO�IRU�SULPDU\�FDUH
Child Poverty
3RYHUW\�UHTXLUHV�LQWHUYHQWLRQ�OLNH�RWKHU�PDMRU�KHDOWK�
ULVNV��7KH�HYLGHQFH�VKRZV�WKDW�VRFLRHFRQRPLF�VWDWXV�
DQG�FKLOG�KHDOWK�DUH�VWURQJO\�OLQNHG�
&KLOGUHQ�OLYLQJ�LQ�SRYHUW\�DUH�PRUH�OLNHO\�WR�H[SHULHQFH�
ORZ�ELUWK�ZHLJKW��OHDUQLQJ�GLIÀFXOWLHV��PHQWDO�KHDOWK�
SUREOHPV��LURQ�GHÀFLHQF\�DQHPLD��DVWKPD��EXUQV�DQG�
There is strong and growing evidence that higher social and economic status is associated with better health. In fact, these two factors seem to be the most important determinants of health.- Public Health Agency of Canada
“
6HH�EDFN�IRU�UHVRXUFHV
Poverty Interventions for Child Health
ASK
1
2
3
4
5
6
Do you find yourself running out of money to pay for food or shelter?
Do you have trouble feeding your family?
Do you have trouble paying for medications?
Do you receive the child tax benefit?
Do you have a safe and clean place to live?
Do you have legal or immigration challenges?
7KH�,QIRUPDWLRQ�DQG�5HIHUUDO�6SHFLDOLVW�DW�WKH�&RPPXQLW\�+HDOWK�+HOS�/LQH������ÀQGV�DQVZHUV�TXLFNO\�� ���KRXUV�D�GD\��HYHU\�GD\�RI�WKH�\HDU��DQG�LQ�PRUH�WKDQ�����ODQJXDJHV��DQRQ\PRXV��XQUHFRUGHG�
:KHQ�\RX�GRQW�NQRZ�ZKHUH�WR�WXUQ��FDOO������ZZZ����RQWDULR�FD��RU�YLVLW�ZZZ�VHUYLFHFDQDGD�JF�FD�
Daily Bread Food Bank ������������ ZZZ�GDLO\EUHDG�FD
School aged children ZZZ�EUHDNIDVWFOXE�FD
Benefits and Supports ZZZ�FDQDGDEHQHÀWV�JF�FDZZZ�RQWDULR�FD�%HQHÀWV'LUHFWRU\
Community Income Tax Clinics �������������� ZZZ�FUD�DUF�JF�FD�W[�QGYGOV�YOQWU�FOQFV�RQ�HQJ�KWPO
Social Support Programs ZZZ�PFVV�JRY�RQ�FD�HQ�PFVV�SURJUDPV�VRFLDO�RGVS��ZZZ�PFVV�JRY�RQ�FD�HQ�PFVV�SURJUDPV�VRFLDO�RZ�
Ontario Drug Benefit Program ����������������������������� ZZZ�KHDOWK�JRY�RQ�FD�HQ�SXEOLF�SURJUDPV�GUXJV�
Trillium ZZZ�KHDOWK�JRY�RQ�FD�HQJOLVK�SXEOLF�SXE�GUXJV�WULOOLXP�KWPO
Service Canada ZZZ�VHUYLFHFDQDGD�JF�FD�HQJ�JRF�FFWE�VKWPO ��������������
Canada Revenue Agency ZZZ�FUD�DUF�JF�FD�EQIWV�PHQX�HQJ�KWPO��LQFOXGHV�OLQNV�RQ�XQLYHUVDO�FKLOG�FDUH� EHQHÀW�DQG�FKLOGUHQ·V�VSHFLDO�DOORZDQFHV� ��������������
Consider photocopying for your patients
RESOURCES TO ADDRESS CHILD POVERTY
OCASI-Settlement ������������ ZZZ�VHWWOHPHQW�RUJ�
Community Legal Education Ontario (CLEO) ZZZ�FOHR�RQ�FD���������������
Legal Aid Ontario ����������������������������� ZZZ�OHJDODLG�RQ�FD
Access Alliance ������������ ZZZ�DFFHVVDOOLDQFH�FD
Assaulted Women’s helpline �������������
Domestic violence women ������������ ZZZ�VFKOLIHUFOLQLF�FRP
Emergency Shelters ��������������
Toronto Homeless Services ZZZ�WRURQWR�FD�KRXVLQJ
'HYHORSHG�E\�'UV�-XOLD�0RULQLV��/HR�/HYLQ��*DU\�%ORFK��/HH�)RUG�-RQHV�DQG�WKH�6RFLDO�3HGLDWULFV�:RUNLQJ�*URXS�
About the suggested resources
The books and resources on this list are selected from the collection at the Family Resource Centre at McMaster Children’s Hospital. The selection is based on parent and child feedback, and from on-going reviews at the Family Resource Centre. The inclusion of a particular resource does not imply an endorsement of the information or suggestions in that resource. Many of our resources are general in nature, and may not apply to your situation. Your health care professional is the best source of information about your child’s health and concerns.
The Family Resource Centre’s mission is to help families and the community to become active participants in their own health and medical care. The Family Resource Centre offers resources to understand and cope with illness and hospitalization, to learn more about your child’s health, to help other family members learn how to help the patient and themselves, and to learn more about wellness, prevention and the human body.
The centre has a wide collection of books, DVDs, pamphlets and online resources about the problems and concerns that bring patients to McMaster Children’s Hospital. Services provided include:
Check-outBorrowing privileges are available to families, staff, and community members.
On-line ResourcesIn addition to books, DVDs and pamphlets, much health information is available through the
Internet. The family Resource Centre can help you to fi nd these resources, as well as information from our consumer health information database.
Audio-visual Materials
Your health-care provider may suggest that you view a particular DVD, or you may want to browse our collection.
For more information visit www.mcmasterchildrenshospital.ca
Family Resource Centre
© 2012 HHS. Rev./12
The Family Resource Centre, where knowledge grows.
Teasing and Bullying
Books for Parents1. The Bully, the Bullied, and the Bystander: From Preschool to High School,
How Parents and Teachers Can Help Break the Cycle of Violence by Barbara Coloroso, HarperResource (2009) ISBN:9780061744600
2. Bullyproof Your Child For Life: Protect Your Child from Teasing, Taunting, and Bullying for Good by Joel Haber and Jenna Glatzer, Perigee Trade (2007) ISBN:0399533184
3. Bullying - What Adults Need to Know and Do to Keep Kids Safe by Irene Van der Zande, (2011) ISBN:9780979619168
4. Girl Wars:12 Strategies That Will End Female Bullying by Cheryl Dellasega & Charisse Nixon, Fireside (2003) ISBN:0743249879
5. Parent’s Guide to Preventing and Responding to Bullying: Presented by School Bullying Council by Dr. Jason Thomas, Create Space (2011) ISBN:9781461051565
Books for Children
6. No More Teasing (Katie Woo) by Fran Manushkin, Picture Window Books (2010) ISBN:9781404860568
7. Blue Cheese Breath and Stinky Feet: How to Deal with Bullies by Catherine Depino, Magination (2004) ISBN: 1591471125
8. The Juice Box Bully: Empowering Kids to Stand Up For Others by Bob Sornson and Maria Dismondy, Ferne Press (2010) ISBN:9781933916729
9. Stand Up for Yourself and Your Friends: Dealing with Bullies and Bossiness and Finding a Better Way by Patti Kelley Criswell and Angela Martini, American
Girl (2009) ISBN:9781593694821
10. Don’t Pick On Me: Help for Kids to Stand Up to and Deal with Bullies by Susan Green, Instant Help Publishing (2010) ISBN:9781572247130
Websites http://www.aacap.org/publications/factsfam/80.htm http://www.bewebaware.ca/english/cyberbullying.html http://kidshealth.org/parent/emotions/behavior/bullies.html
Roles for Health and Safety Professionals
in Bullying Prevention and Intervention
Bullying is unwanted, aggressive behavior
among school aged children that involves
a real or perceived power imbalance. The
behavior is repeated, or has the potential
to be repeated, over time. Both kids who
are bullied and who bully others may have
serious, lasting problems.
In order to be considered bullying, the
behavior must be aggressive and include:
•An Imbalance of Power: Kids who
bully use their power—such as physical
strength, access to embarrassing
information, or popularity—to control
or harm others. Power imbalances
can change over time and in different
situations, even if they involve the same
people.
•Repetition: Bullying behaviors happen
more than once or have the potential to
happen more than once.
Health and safety professionals and
volunteers are disturbed about the physical
and psychosocial harm experienced by
many youth as a result of bullying by their
peers.
There is no one single cause of bullying
among children. Rather, individual, family,
peer, school, and community factors can
place a child or youth at risk for bullying his
or her peers.
Effects of Bullying
Bullying can be a sign of other serious
antisocial and violent behavior. Youth who
frequently bully their peers are more likely
than others to
•Abusealcoholandotherdrugsinadolescence and as adults
•Getintofights,vandalizeproperty,anddrop out of school
•Engageinearlysexualactivity•Havecriminalconvictionsandtraffic
citations as adults
•Beabusivetowardtheirromanticpartners, spouses, or children as adults
Youth who are the targets of bullying
behavior may experience:
•Depressionandanxiety,increasedfeelings of sadness and loneliness,
changes in sleep and eating patterns,
and loss of interest in activities they used
to enjoy. These issues may persist into
adulthood.
•Healthcomplaints•Decreasedacademicachievement-GPAandstandardizedtestscores-andschoolparticipation. They are more likely to
miss, skip, or drop out of school.
1
Commitments by Professional
AssociationsandAlliancesProfessional associations in health care
and safety are firm advocates for change
whenever evidence suggests that the
well-beingofchildrenisimminentlyatrisk. Persuaded by research about the
nature and prevalence of bullying, several
associations have issued policy directives
that
• Instructprimarycareproviderstobevigilant in detecting signs of bullying
behaviorsandvictimization;andinterveneearly in situations of peer bullying to limit
adverse influences on children (see the
AmericanMedicalAssociation2002PolicyResolution,theNationalAssociationofSchoolNurses2003IssueBrief,andtheMedscapeNurses,2003).
•Describescreeningstrategiestoidentifyrisk factors for violence among youth
(e.g., family history and stresses, care
and support networks, and reported
exposure to or instigation of malicious
behavior).
•Recommendappropriatetreatment,referral, and management protocols for
children exhibiting antisocial and deviant
behaviors, including encouraging parents
to adopt prevention measures (see
AmericanAcademyofPediatrics1999PolicyStatement).
Challenging New Roles
in Prevention
Early intervention in detecting risky
behaviors by young adolescents is an
essential starting point. Reversing the
behavior patterns of intimidation, exclusion,
and bullying that threaten our youth,
however,willtakemorethanacase-by-caseapproach.Itwilltakecommunity-widestrategies and nontraditional approaches
to prevention to change cultures that
tend to accept, or at least tolerate, such
behaviors within peer groups, schools, and
communities.
Advocacy and Policymaking
•Beproactiveinengagingyouthindiscussionsaboutsolutionstobullying;encourageyouth-leddialogueandsupportgroups.
•Overseetheimplementationofanti-bullying policies and practices to dispel
misconceptions about bullying and
ineffective practices.
•Takepoliticalactiontoincreaseresourcesfor prevention and ensure the sustained
funding of effective bullying intervention
and prevention programs.
Early Detection and Effective Intervention
•Routinelymonitorforandintervenequickly when risk factors are evident for
children who bully and those who are
bullied;askscreeningquestionsduringwellness exams and patient visits.
•Convenemultidisciplinary,community-based coalitions to improve coordination
in the assessment, intake, and referral
of children for treatment, counseling,
and other community services (see
Commission for Prevention of Youth
Violence2000report).
Roles for Health and Safety Professionals in Bullying Prevention and Intervention 2
•Assistparentsandcaregiversinresponding to signs of bullying and in
accessing a network of support and
resourceswithattentiongivento“at-risk”youth.
Community-Wide Prevention Efforts
•Consistentlyapplydisciplinecodesthatare more therapeutic than punitive.
•Makeschools,after-school,andyouthservicesprograms“safezones”wherechildren will be assured of adequate adult
supervision.
•Supportthedevelopmentofsafeschoolpolicies and plans that specifically
addressbullyingbehaviorsandbias-motivated harassment or prejudices.
•Partnerwithschoolstoimplementcomprehensive bullying prevention
programs.
•Assistinevaluatingtheimpactofinterventions locally and advocate for
quality research nationally.
•Promotetrainingandcontinuingeducationin bullying prevention strategies in health
safety and medical fields and as part
of clinical supervision and guidance in
teaching programs.
References and Resources The American Medical Association issued two policy resolutions, Bullying Behavior Among Youth(D-60.993,2001)andBullying
Behaviors Among Children and Adolescents(H-60.943,2003),thatunderscoretheseriousnessofbullyingandrecommendactionstobetakenbyAMA,physicians,parentsandcaretakers,andcoalitionsinterestedinaddressingbullying.RetrievedAugust12,2005,from http://www.ama-assn.org/aps(PolicyFinder)
The National Association of School NursesreleasedanIssueBriefin2003aboutPeerBullying,whichdescribestheroleforschoolhealthnurses.RetrievedAugust12,2005,fromhttp://www.nasn.org/briefs/bullying.htm
The Commission for the Prevention of Youth Violence,consistingofnineofthenation’slargestmedicalandmentalhealthassociations,issuedacommitmentfrommedicine,nursing,andpublichealthinaDecember2000reportentitled,Medicine, Nursing,
and Public Health: Connecting the dots to prevent violence.RetrievedAugust12,2005,fromhttp://www.ama-assn.org/violence
The American Academy of Pediatrics, after a year of study by the Taskforce on Violence, issued a Policy Statement in January
1999thatdescribes,TheRoleofthePediatricianinYouthViolencePreventioninClinicalPracticeandattheCommunityLevel,foundin Pediatrics(Volume103,Number1,p173-181).RetrievedAugust12,2005,fromhttp://www.aap.org/policy/re9832.html
Muscari, M.(2003).WhatcanIdotohelpachildwhoisbeingbullied?Medscape for Nurses: Ask the Experts.RetrievedAugust12,2005,fromhttp://medscape.com/viewarticle/451381.
Nansel, T.R., Overpeck, M.D., Haynie, D.L., Ruan, W.J., & Scheidt, P.C. (2003).Relationshipsbetweenbullyingandviolenceamong US youth. Archives of Pediatric Adolescent Medicine,157,348-353.
Roles for Health and Safety Professionals in Bullying Prevention and Intervention 3
top related