Copyright 2005 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2005
Many health problems affecting children today are based in the community and cannot be easily addressed in the office setting. Child advocacy is an effective approach for pediatricians to take.
To describe pediatric residents’ choices of advocacy topics and interventions.
Cross-sectional observational study.
Residents from 3 pediatric training programs participated in the Child Advocacy Curriculum, which featured standardized workshops and the development of individual advocacy projects. To evaluate the curriculum, project descriptions and material products were analyzed to determine individual advocacy topics, topic themes, and targets of project interventions. Differences among programs were assessed. Residents also completed an anonymous questionnaire assessing their experience with the Child Advocacy Curriculum.
Residents demonstrated a wide range of interests in selecting advocacy topics: 99 residents chose 38 different topics. The most common topic was obesity (13 residents) followed by health care access (9), teen pregnancy prevention (6), and oral health (5). Themes included health promotion and disease prevention, injury prevention, health care access, children with special health care needs, child development, at-risk populations, and the impact of media on child health. The project interventions targeted the local community most frequently (37%), followed by resident education (27%), hospital systems (21%), and public and health policy (15%). The vast majority of participating residents reported a positive experience with the Child Advocacy Curriculum.
The wide range of topics and settings in which residents developed projects illustrates residents’ extensive interests and ingenuity in applying needed advocacy solutions to complex child health issues.
Thirty years ago, Bob Haggerty coined the term new morbidity to describe the rising proportion of child health problems rooted in emotional, social, economic, and environmental conditions.1 Child injury and chronic illness replaced infectious pathogens as leading causes of childhood morbidity and mortality as a result of improved nutrition, sanitation, and medical science. Social disparities in exposure to the new morbidities make their treatment and prevention less a biomedical than a sociopolitical challenge. Across nearly all illnesses, poor health outcomes are closely associated with a declining gradient of family income.2- 4 Independent of income status, children from ethnic minorities are more likely than nonminority children to suffer from asthma, heart disease, obesity, diabetes, injury, violence, poor preventive care, and a host of other significant health risks.5,6 Other related root causes of child morbidity include limited access to care, low social capital, low caregiver literacy, and unsafe neighborhoods.7- 10 Effectively addressing the new morbidities requires training new pediatricians to perceive themselves not only as clinicians at the bedside but also as advocates in the community.
While traditional pediatric training uses a biomedical model to teach residents to improve the health of the individual patient in the hospital or office, child advocacy training requires a population-based prevention model to improve child health in the communities where children live and go to school. The pediatrician of the future must be competent in both patient-based and population-based models of care. He or she will need to move seamlessly between the “dichotomy of patient-based and population-based perspectives.”11
Recognizing the importance of advocacy training to the improvement of child health, the Pediatric Residency Review Committee of the Accreditation Council for Graduate Medical Education (Chicago, Ill) has mandated “structured educational experiences that prepare residents for the role of advocate for the health of children within the community.”12 In 2000, the Future of Pediatric Education II reported that “ . . . there is still much to do in the education of pediatricians and parents relative to the new morbidities.”11
The field of advocacy training for pediatric residents is emerging and little is known. Many authors cite the need for pediatricians to act as child advocates,11,13- 26 and others call for resident training in child advocacy.24,27- 33 There have been 1 systematic evaluation of the impact of advocacy training34 and several reports describing advocacy training.27,30,31,33,35,36 There has been no description of resident preferences for advocacy projects: what they choose to advocate for and how they choose to advocate. The goal of this study is to understand what topics and settings residents select when they have unlimited topic and intervention choices. This information can inform other programs as they develop sustainable advocacy curricula.
We conducted a collaborative descriptive study of the Child Advocacy Curriculum (CAC) instituted in the pediatric residency training programs at Stanford (Palo Alto, Calif); the University of California, San Francisco (San Francisco); and the University of Miami (Miami, Fla). We analyzed the project descriptions and material products from individual advocacy projects and anonymously surveyed residents who participated in the curriculum between July 2000 and July 2002. The institutional review board of each institution granted approval for the study protocol.
The CAC was initially developed at Stanford (L.J.C.) and subsequently adapted at the University of California, San Francisco and University of Miami. The residents were required to participate in two 3-hour workshops introducing core concepts in child advocacy, perform independent field work during the rotations, and finally give a formal presentation to their peers and faculty. The consecutive workshops reviewed the basic tools of child advocacy: translating child health problems into advocacy issues, learning the methods of community-needs assessment and asset determination, practicing application of these tools through case vignettes, and reviewing actual work conducted by pediatric child advocates. A recurring theme highlighted in the workshops was the unique and natural role of the pediatrician advocate.
Using the child advocacy tools introduced in the workshops, each resident individually selected, developed, and implemented an advocacy project that reinforced advocacy knowledge and skills. First, residents identified and described a particular community; they assessed its resources and needs by analyzing available national and regional data and met with appropriate community leaders (eg, directors of community-based organizations). Based upon this community mapping, residents collaborated with 1 or more such individuals or organizations, with facilitative support from a faculty advisor, to carry out a feasible advocacy intervention. At the conclusion of the rotation, each resident described the project to a forum consisting of peers and faculty.
The CAC, although identical in content, was implemented with some variation into existing required community rotations at each residency program. Overall, no new rotations were added; instead, residents were given new protected time in existing blocks to integrate the advocacy activities. Table 1 illustrates how CAC implementation varied between sites, including variation in faculty time and support, rotation length, etc.
The faculty directors of the curriculum (L.J.C., L.M.S., J.I.T.) were simultaneously directors or associate directors of the respective community rotations. The directors facilitated the workshops, provided direction and guidance regarding identification of community partners and subsequent collaboration, and jointly evaluated the effectiveness of the rotation.
The 3 main outcomes for this study were individual advocacy topics chosen by residents, categorization of advocacy topics by themes, and types of project interventions. We also conducted an anonymous survey of residents after they finished the rotations to determine satisfaction and perceived barriers and enablers in conducting individual projects.
The 3 CAC directors individually analyzed the project descriptions and material products (eg, handouts, slide presentations) to determine topic choices (eg, breastfeeding, immunizations) and later discussed them as a group to verify the topics. The directors, once again, independently categorized each advocacy topic into broad themes by highlighting major features and coding key terms. They then participated in multiple group discussions to conduct de novo thematic analysis and coding to complete the final categorization process; no existing taxonomy was referenced. When discrepancies arose, sequential discussions resolved differences in interpretation of the descriptions of topics and projects. The resulting taxonomy of topics and interventions reflected the range of resident experiences.
Following the rotation, residents completed an anonymous questionnaire where they evaluated the curriculum and provided demographic information. The results of this anonymous survey could not be linked to the individual advocacy projects.
Ninety-nine residents completed advocacy projects during the child advocacy curriculum: 36 residents at Stanford, 24 at the University of Miami, and 29 at the University of California, San Francisco. For resident demographics, see Table 2.
Thematic analysis yielded 8 major categories of advocacy topics (Table 3). Health promotion and disease prevention represented 42% of topics. Others topic themes were injury prevention, improving health care access, addressing children with special health care needs, optimizing child development, serving at-risk populations, and the impact of media on children. Residents demonstrated a wide range of interests in their selections with 99 residents choosing 38 specific topics. The most commonly selected advocacy topic was obesity (13 residents), followed by health care access (9), adolescent pregnancy (6), and oral health (5). Category of advocacy topic chosen by residents did not vary by residency program (P = .15).
Residents designed advocacy projects to impact 1 of 4 types of populations: community, resident, hospital system, and health policy (Figure). Type of population targeted by the project interventions did not vary by residency program (P = .16).
Target of advocacy intervention.
Community-based advocacy projects represented more than one third of projects and consisted of a wide range of methods and outcomes. Examples of projects included interactions with youth groups on various topics (eg, conducting focus groups at a juvenile incarceration facility, developing a tobacco cessation program). Schools composed a common community site (eg, dental screening day at 1 school, obesity screening at 5 preschools). Less common were larger-scale, communitywide interventions (eg, publication of “Instructions for Effective Time Out” in a newsletter that reaches more than 13 000 parents of young children).
The second most frequently selected intervention was educational and targeted physicians (27%). A subset resulted in modifications in the resident curriculum (eg, a required palliative care curriculum at Stanford, required participation in prenatal visits and breastfeeding promotion classes for parents at the University of Miami). Other projects involved development and presentation of conferences to improve resident and faculty knowledge (eg, impact of media violence on children, availability of emergency contraception). Laminated reference cards or new web-based resources were frequently introduced and distributed during conferences.
Hospital system change was achieved by residents who modified and improved the settings in which they worked (21%). Examples of such projects included introduction of the Baby Friendly Hospital Initiative at one site and making condoms available in a hospital clinic. Other residents helped develop infrastructure to ensure availability of State Children’s Health Insurance Program applications throughout one public hospital. Another project involved the translation and distribution of shaken baby syndrome information in 3 languages.
Policy change on a wider scale was addressed by 15% of the advocacy projects. Interventions included writing letters to government representatives, testifying at local hearings and at the state capitol, and writing editorial columns for local newspapers. Residents at one program helped reestablish county-based funding for the public hospital pediatric ward through public testimony and meetings with members of the county board of supervisors.
Residents expressed overall satisfaction with the CAC. In response to the question “Did you enjoy the curriculum?” 93 (94%) of 99 participants responded very positively or positively, 4 provided neutral comments, and 2 expressed frustration. Typical responses included, “I like feeling that I can make an impact on even a small project,” and “It is critical that Pedi residents be taught how to access resources and make changes on many levels for kids. It is a difficult task and well worthwhile.” Both neutral and negative comments cited time constraints, for example, “It was difficult to fit project into framework and timeline.” In addition to these responses, residents at Stanford had the opportunity to evaluate each rotation on a 4.0 scale, allowing comparison of all intern-year rotations. The Community Pediatrics and Advocacy rotation received a 3.66, ranking it fourth highest of 18 total rotations.
The CAC was collaboratively and successfully developed and implemented in 3 distinct residency programs. After participating in standardized workshops, 99 residents completed a wide range of advocacy projects that were categorized into 8 themes. Interventions addressed 4 types of communities: resident and faculty physicians, hospital systems, local communities of families and children, and larger-scale communities (eg, cities, counties, regions). Our evaluation showed that advocacy training is not a “one topic fits all” educational encounter but a more personal experience. Although some clustering occurred around specific topics, 3 or fewer residents selected each of the remaining topics. We hypothesize that residents drew from their clinical or other personal experiences to develop projects about which they felt strongly. We believe that the CAC provides both generic tools and individual approaches that encourage initiative and also provides experiences that will approximate postresidency advocacy opportunities. Tracking graduates and describing their further involvement in advocacy projects may describe a more long-term impact of our curriculum.
Comparisons among programs did not demonstrate significant statistical differences in advocacy topics or targets of interventions. These results suggest that pediatric residents share common attitudes and concerns. On the other hand, we did witness instances where the political climate surrounding a residency program influenced the development of advocacy interventions. The announcement of the annual county budget calling for closure of the county’s pediatric ward galvanized residents to partner with local child advocacy groups and engage politicians to successfully reconsider budget allocation. Similarly, new passage of statewide legislation to permit pharmacists to dispense emergency contraception inspired the education of health professionals and community health promotion.
Given the limited time and energy of residents during their first 2 years of training, a promising outcome of our collaboration was that many residents developed advocacy projects that engaged communities beyond the health care setting. The projects reflected a strong motivation to move beyond the familiar and the traditional to ensure positive change for pediatric populations in their communities. As stated by Christoffel, “public health advocacy is intended to reduce death or disability in groups of people . . . and is not confined to clinical settings.”37 Developing effective partnerships with community-based organizations, however, requires innovative training and clear commitment: an appreciation of the population-based perspective of health11,24,37- 39 and skills in needs and resource assessment30 and coalition building,21,24- 26,28- 30,33,38,40 all of which were provided by the CAC.
We experienced many “thorns among the roses” as we implemented this curriculum. Challenges common to all 3 sites revolved around resident time limitations, faculty time limitations, and varied motivation from the residents. Finding time in a resident schedule was not easy and promises to remain an unremitting challenge; at all sites, obligations including overnight call and clinical commitments interfered with community events. The study was performed prior to the institution of new residency program work-hour rules, which have since restricted the scheduling of off-site experiences.
The second challenge was providing the faculty resources required for proper oversight of the large number of active projects. We developed 2 methods to mitigate this problem. Early in the institution of the CAC, we learned to actively direct residents in establishing attainable goals with discreet end points, allowing project completion of the advocacy project by the rotation’s conclusion. Residents initially considered large and unfeasible projects, so we often needed to limit the scope without extinguishing the enthusiasm. This experience is familiar to others.24,28,33,37,40 The second method to manage the large number of projects was to create mutually beneficial community partnerships. Mentorship by community-based faculty was critical to the success of this curriculum.
Finally, individual resident enthusiasm varied, as it does with other rotations. Unlike other rotations, the CAC’s success was based in large part on the resident’s participation. For instance, some residents were passive, waiting for telephone calls from community groups, but others were more active and able to successfully engage community partners. The residents who did not get organized quickly enough had a difficult time completing the rotation’s goals.
Despite the CAC being successfully implemented and evaluated in 3 residency training programs, our experiences may not be generalizable because it is not a regional or national sample. Selection bias may play a role as residents with certain interests gravitate toward particular programs. In addition, the time frame of our study provided a cross-sectional snapshot of residents’ interests: as the threats to child well-being evolve over time, we would expect resident interests to change. Another limitation was our inability to examine topic and project choice by resident demographic data: the demographic data was obtained anonymously for the resident group as a whole and therefore could not be linked to individual projects, precluding us from delving into the subject of advocacy topic and project choice in an in-depth manner.
Our study determined the feasibility of implementing a collaboratively developed educational curriculum; thus we did not perform formal evaluations of the community experience. Although several community-based organizations have expressed high satisfaction with the projects, we believe that long-term involvement is critical to maintain community trust and support. To this end, academic medical centers must ensure sustainability of these efforts by supporting faculty involvement. Finally, the qualitative analysis was conducted by study authors who were not blinded to the study method and aims.
Pediatric residents at 3 training programs participated in the Child Advocacy Curriculum, where they selected and carried out a wide variety of advocacy projects with the most common theme being health promotion. Residents chose the local community as the most common target for advocacy interventions. Our study demonstrates that pediatric residents, given the appropriate tools for child advocacy, and despite of limited time, will successfully conduct projects that are not limited to health care settings but involve a larger community. Increased insight into residents’ interests will lead to a better understanding of topics that captivate tomorrow’s pediatricians and reveal their willingness to advocate in many settings.
Correspondence: Lisa Chamberlain, MD, MPH, Division of General Pediatrics, 750 Welch Rd, Suite 325, Palo Alto, CA 94304 (firstname.lastname@example.org).
Accepted for Publication: March 10, 2005.
Funding/Support: This study was supported by grants from the David and Lucile Packard Foundation, Los Altos, Calif; the William Randolph Hearst Foundation, San Francisco, Calif (Dr Chamberlain); and the Anne E. Dyson Community Pediatrics Training Initiative, University of Miami, Miami, Fla.
Chamberlain LJ, Sanders LM, Takayama JI. Child Advocacy TrainingCurriculum Outcomes and Resident Satisfaction. Arch Pediatr Adolesc Med. 2005;159(9):842-847. doi:10.1001/archpedi.159.9.842