Residents as health advocates: The development, implementation and evaluation of a child advocacy initiative at the University of Toronto (Toronto, Ontario)

Abstract

BACKGROUND AND OBJECTIVE:

Advocacy is an integral part of a paediatrician’s role. The Royal College of Physicians and Surgeons of Canada has identified advocacy as one of the essential Canadian Medical Education Directives for Specialists competencies, and participation in child advocacy work as an important component of paediatric residency training. The objective of the present paper was to describe the development, implementation and evaluation of the first four years of the child advocacy initiative at the University of Toronto (Toronto, Ontario).

METHODOLOGY:

Ideas for community child advocacy projects were generated through a literature review, and a link to a local elementary school was identified. Teacher and parent focus groups were conducted to identify areas for resident involvement. Workshops were then developed, implemented and evaluated by paediatric residents.

RESULTS:

Six child advocacy projects between 2001 and 2004 were conducted based on results from the focus groups. These included annual clothing drives, as well as workshops for parents and children about nutrition, safety, parenting, illness management and basic first aid. More than 95% of parents reported that the workshops were useful or very useful, more than 92% felt that they learned something new and more than 83% wanted the residents to return for further workshops. Teachers and residents gave positive informal feedback.

CONCLUSIONS:

Through the child advocacy initiative, paediatric residents had the opportunity to develop skills in advocacy, learn about the determinants of child health and become community partners in advocating for children. Such an initiative can be incorporated into the residency curriculum to help residents develop competency in advocacy.

Child advocacy is an essential component of paediatric practice. Compared with other medical specialties, advocacy is ingrained in the specialty of paediatrics, because children do not always have a political voice of their own (1). In a 1999 policy statement (2), the American Academy of Pediatrics stated that “pediatricians should interact with other members of the community to improve all settings and organizations where children spend time (eg, child care facilities, schools, youth programs)”. Because advocacy is a crucial role of the paediatrician, paediatric residency programs should include training in child advocacy.

The Royal College of Physicians and Surgeons of Canada (RCPSC) developed specific objectives for training medical specialists, known as the Canadian Medical Education Directives for Specialists (CanMEDS) (3). Six roles in addition to the central role of medical expert were identified: manager, professional, communicator, scholar, collaborator and health advocate (Figure 1). Fostering the development of these roles now forms the basis of the educational goals for all residency programs in Canada.

Figure 1.

The Canadian Medical Education Directives for Specialists (CanMEDS) roles framework. Coypright 2006 – reproduced with permission from The Royal College of Physicians and Surgeons of Canada

The RCPSC stated that as a health advocate, the physician should respond to the health needs of individual patients and communities, should identify the important determinants of health affecting their patients, and should promote the health of individual patients, communities and populations (4). Specifically, in paediatrics, the RCPSC’s educational objectives for training include an appreciation that the health care needs of children are distinct from those of adults, the promotion of active family involvement in decision-making and continuing management of the child, the ability to contribute effectively to improved health of patients and communities, and the ability to identify the important determinants of health that affect children and adolescents (5)

In the United States, the Accreditation Council for Graduate Medical Education (6) and the Ambulatory Pediatric Association (7) have developed clear objectives for advocacy training in paediatric residency. Using a survey design, over 70% of the paediatric faculty and 90% of paediatric residents in an American residency program reported interest in participating in an advocacy curriculum (8). Paediatric faculty and residents felt that the development and implementation of short- and long-term projects were the most important teaching and learning methods for child advocacy (8), while others advocated for a block rotation in child advocacy training (9). For example, in the paediatric residency program at the University of Florida (USA), each resident, along with a faculty member and community health advocate, identify, design and implement a community action initiative in a selected population of children. Residents work with public health departments, local community boards and coalitions; receive grant funding; and participate in scholarly endeavours. The department of pediatrics at Oregon Health and Science University (USA) requires all residents to complete a child advocacy project in addition to a community-based curriculum integrated throughout the three years of residency (10).

In Canada, however, a paediatric residency advocacy curriculum to enable residents to meet these educational goals is lacking. Verma et al (11) examined the views of the faculty and residents at Queen’s University in Kingston, Ontario, about teaching and evaluating health advocacy as a CanMEDS role. The study found that residents and faculty felt that they lacked understanding of the definition of a health advocate, and required guidance in developing, integrating and evaluating an advocacy curriculum in a residency program.

In 2001, the paediatric residents’ child advocacy initiative at the University of Toronto (Toronto, Ontario) was created to enable paediatric residents to develop skills in child advocacy, learn about some of the social determinants of child health and contribute to the well-being of children in the local community. The objectives of the present paper were to describe the development of the child advocacy initiative, and to describe the implementation and evaluation of the first four years of this ongoing initiative. This initiative is an example of the type of training that can be incorporated into advocacy curricula to enable residents to develop skills in child advocacy and meet the CanMEDS objectives.

METHODS

Development of the initiative

The paediatric residency program director approached the members of the University of Toronto’s paediatric residency training committee (composed of residents, staff physicians and the residency program director), recognizing the need to increase paediatric residents’ awareness of child advocacy and to create opportunities to gain skills as a child advocate. A University of Toronto paediatric resident child advocacy team was formed and was (and continues to be) led by residents from multiple years of training with staff supervision. The residents searched the literature for existing avenues of advocacy for paediatric residents and discussed ideas for a child advocacy initiative. The advocacy team decided to focus on a local community initiative within the school system. Meetings with the Toronto District School Board helped to identify a local elementary school, and school leaders then met with representatives from the advocacy team to plan the initiative.

Resident leaders of the initiative underwent training to conduct focus groups. Separate focus groups with teachers and parents were conducted to identify potential health-related areas of interest. Parents and teachers were asked about the health issues that their children and students were facing, as well as the barriers that they had in obtaining optimal health. Health was defined as encompassing physical, emotional and social well being. A series of health-related workshops were then developed by the residents to meet the self-identified needs of the teachers and parents.

Research Ethics Board approval was not sought for the initiative, because the project was intended to be primarily an advocacy, community initiative. However, consent was obtained from the parents to participate in these workshops, and to use their evaluations for the purposes of presentation and publication. All current and future evaluative components of this initiative are and will formally be reviewed by the Research Ethics Board at The Hospital for Sick Children (Toronto, Ontario).

Implementation

Six projects were implemented between 2001 and 2004. These included an annual clothing drive and five after-school workshops. The projects were developed and run by paediatric residents with support from staff paediatricians. Residents gave mini-lectures, showed videos, and provided handouts for parents in small- and large-group formats. Parents had the opportunity to ask questions and make comments at each workshop. Residents planned related fun and educational activities for the students. Nutritious snacks were also available for the parents and children in attendance. Residents from all years of training participated on a voluntary basis and were excused from their clinical duties to participate.

Evaluation

Parents completed an evaluation form at the conclusion of each workshop. Parents reported on the usefulness of the projects, whether they learned something new and their interest in attending further workshops. Teachers, principals and residents provided informal feedback about their experience.

RESULTS

School population and demographics

The identified school is in a low-income, urban neighbourhood and has approximately 350 culturally diverse students from junior kindergarten to grade 6. Fifty per cent of the families are new immigrants, and over 30 cultures and languages are represented. The median yearly household income of families living in this area is approximately $34,000 (12).

Focus groups and needs assessment

The first focus group was comprised of 10 teachers, one resident to moderate the discussion and two residents to record the discussion. Six different parent focus groups were held, each consisting of eight to 12 parents, two residents and a translator. The common topics identified from the focus groups were nutrition, dental hygiene, clothing, safety, access to medical care, emotional or behavioural issues, development, sleep, parenting and child care.

Educational workshops

Table 1 lists the topics for the educational workshops and the target grade. The parent session of the illness management workshop was organized as six 10 min talks in a large-group setting. For the remainder of the workshops, the parents rotated in small groups through several 10 min to 15 min stations.

TABLE 1.

Child advocacy educational workshops

Workshop	Target grade	Topics for parent sessions	Content of student sessions
Nutrition	Junior kindergarten to grade 3	Healthy and affordable examples of meals	Prepared healthy snacks
		Maps of local grocery stores and comparative prices	Identified healthy foods
		Dental care
Safety	Junior kindergarten to grade 3	Playground safety	Discussed safe street crossing
		Traffic safety	Discussed tricycle/bicycle fun and safety
		Water safety
		Sun safety
		Burn and poison prevention
Parenting	Junior kindergarten to grade 3	Behaviour management	Played interactive games
		Common sleeping problems and solutions	Performed songs
		Immunizations – schedules, benefits and myths, new vaccines
Illness management	Junior kindergarten to grade 6	Fever	Read stories about going to the doctor
		Vomiting and diarrhea
		Head injury
		Coughs and colds
		Influenza
		Chicken pox
Basic first aid	Junior kindergarten to grade 6	Burns and wounds	Was held in conjunction with the school
		Seizures	book fair
		Choking
		Basic artificial respiration
		Activating emergency medical services

The annual clothing drive was advertised at The Hospital for Sick Children, and residents and staff members donated lightly used clothing. Teachers and students at the school helped to display the clothing and distribute it to parents. Adult clothing was donated to a local community centre.

Workshop evaluation

Parents completed evaluation forms for three workshops. There were seven, 24 and 26 evaluations returned for workshops on parenting, illness management and basic first aid, respectively (the total number of parents attending each workshop was not documented). Overall, more than 95% of the parents who responded reported that the workshops were very useful or useful. All of the parents believed that they had learned something new from the parenting and illness management workshops. More than 92% of the parents believed that they had learned something new about basic first aid. More than 83% of the parents surveyed were interested in attending another workshop. Teachers and residents provided informal feedback stating that they thought that the initiative was an important and useful learning experience.

DISCUSSION

Hennen (13) recognized that social accountability in medical education requires education through community-related activities, clinical outreach programs and community-partnered research activities, and that this learning must extend beyond medical school and be sustained in residency. There is debate about how to best implement such advocacy training in a paediatric residency program. Previously described curricular components important for successful training in child advocacy include a structured, coordinated experience with clear goals and objectives; exposure to community health outside of the traditional hospital; experiential, hands-on learning that fosters community networking and sustained partnerships; and the acquisition of knowledge about the local community and the societal factors that influence health (8,9). Berman (14) expanded on these community-based goals to include involvement in the legislative process by attempting to pass legislation and by working proactively with policymakers as a recognized expert in child health.

This child advocacy initiative was developed and implemented by the paediatric residents (supervised by staff paediatricians) at the University of Toronto and meets many of the curricular objectives identified in the literature. It incorporates hands-on learning in a community-centred format. Through identifying the needs of the children in the local community, and by developing and conducting workshops, residents had the opportunity to develop knowledge about community and societal factors that influence child health, to develop skills to communicate and collaborate with families and school leaders, and to understand their role as an advocate for children in the child’s setting. Residents worked collaboratively with the school and parents to perform a needs assessment using focus group methodology. Residents also learned about determinants of health, such as income, education, child care and employment, physical environment and health services, through the health issues identified in the focus groups. Hopefully, residents carry this knowledge into practice. Residents were given the opportunity to develop skills in other CanMEDS roles including scholar, collaborator, communicator and medical expert. Such an initiative can be incorporated into residency programs to allow residents to develop the knowledge, skills and attitudes necessary for competency in child advocacy.

More formal and complete evaluation of this initiative from parents, teachers and residents would be useful. A better understanding of what residents thought that they learned from the experience would serve to improve and expand on the existing program. Although workshops were not standardized, staff paediatricians and senior residents were present to evaluate the content and provide additional expertise during the sessions. Preparing paediatric residents for advocacy at a health policy level is also very important and is a future goal of the University of Toronto’s paediatric resident child advocacy team. The Canadian Paediatric Society has created an advocacy toolkit as a resource to assist paediatricians in affecting change through policy at provincial and government levels (15).

Currently, these workshops are ongoing and have expanded to become a part of the academic half-day. A new initiative to help students write and publish their own health magazine has been established with the school.

SUMMARY

The development, implementation and evaluation of a child advocacy initiative in a local public school was an excellent opportunity for paediatric residents to attain educational goals in child advocacy. Future directions include formalizing an advocacy curriculum for paediatric residents and developing methods to formally evaluate competency attainment by residents. In addition to evaluating the process or acceptance of an initiative, the evaluation of the uptake or outcome of these initiatives is needed.