Commentary
Paediatric school-based clinics in Saskatoon: Providing equitable access to paediatric care Maryam Mehtar MBBCh FRCPC M Mehtar. Paediatric school-based clinics in Saskatoon: Providing equitable access to paediatric care. Paediatr Child Health 2016;21(5):249-251. Paediatric school-based clinics (PSBCs) were established in Saskatoon (Saskatchewan) in 2007, to provide access to specialized paediatric health care as part of multidisciplinary and interdisciplinary teams, and alongside existing services. In its ninth year, the PSBCs have grown both in number and services offered, and in patient numbers – for both new patients and repeat follow-up visits. Viewing paediatric health consistently through the lens of the social determinants of health has been essential in delivering care, which require consideration and negotiation of these contexts in formulating management plans. The responsive relationships we continue to establish with our patients through the PSBCs have enabled us to work effectively with children and youth, and continue the growth of our successes. Key Words: Collaborative care; Partnerships; School-based health; Social
paediatrics
P
aediatric school-based clinics (PSBCs) were established in 2007, in response to the Health Disparity by Neighbourhood Income Study (1). The magnitude of health disparities identified in the study raised the question of whether existing traditional paediatric health care service delivery models had addressed the needs of infants, children and youth in Saskatoon’s (Saskatchewan) lowincome neighbourhoods. For example, youth in Saskatoon’s lowincome neighbourhoods were significantly more likely to give birth to a child and to be bullied, depressed and anxious. Representing the institution of health, the Department of Paediatrics assumed partial responsibility for these disparities. Subsequently, in collaboration with key partners, we began working toward addressing the needs of the most vulnerable paediatric patients in Saskatoon. Despite our medical expertise and the rapid technological advances in health care, we acknowledged that the medical care delivered to our patients had unintentionally been inconsistent (2). We recognized that the delivery of paediatric care had to be more inclusive. We needed to better address what children require to be healthy by utilizing a more collaborative framework within the community, and with meaningful engagement of patients and families. OBJECTIVES Based on the above, we focused on the following four objectives in the implementation of the PSBCs: 1. Provide access to specialized community-based paediatric care within schools, in a culturally respectful manner; as part of the continuum of the existing community-based services.
Un accès équitable aux soins pédiatriques grâce aux cliniques de santé en milieu scolaire à Saskatoon Les cliniques pédiatriques en milieu scolaire (CPMS) ont été mises sur pied à Saskatoon, en Saskatchewan, en 2007, afin de donner accès à des soins pédiatriques spécialisés fournis par des équipes multidisciplinaires et interdisciplinaires, conjointement à des services déjà en place. Les CPMS, qui existent depuis neuf ans, ont pris de l’expansion, tant pour ce qui est des services offerts que du nombre de patients, qu’il s’agisse de nouveaux patients ou de rendez-vous de suivi. Il a été essentiel de toujours concevoir la santé pédiatrique sous l’angle des déterminants sociaux de la santé lors de la prestation des soins, ce qui exige de tenir compte de ces contextes et de les négocier lors de la formulation des plans de prise en charge. Parmi les nombreuses leçons tirées de cette expérience, soulignons que ce sont les liens particuliers que nous entretenons avec nos patients au sein des CPMS qui nous permettent de travailler efficacement auprès des enfants et des adolescents et de cumuler les réussites.
2. Ensure that patients and families feel empowered and comfortable in accessing the clinics for follow-up; out of choice rather than the expectation to do so by agencies such as the school or social services. 3. Provide paediatric patients and families a safe space in which to share their lived experiences for us to better understand the individual and community social contexts. 4. Entrench these PSBCs within the paediatric postgraduate curriculum and, eventually, the undergraduate clinical curriculum. FRAMEWORK In developing the PSBCs in Saskatoon’s low-income neighbourhoods, consideration had to be given to using an alternative approach to health care service delivery. Both the ‘physical’ and ‘mental’ model had to be different. Service delivery had to reflect a shift in power away from ‘the institution of health’ and into the community. The development of a different approach was based on the following components: community engagement; social determinants of health; the philosophy of social paediatrics; and evidence from other school-based centres. Community engagement: This was essential in determining existing perceptions around paediatric health care service delivery within the core neighbourhoods. Through discussions with the community, we came to understand a theme of perceived abandonment as well as pervasive distrust of the health care system. Specifically, the community perceptions of differential treatment arose from organizations coming in to conduct pilot projects, providing programs until
Royal University Hospital, Saskatoon, Saskatchewan Correspondence: Dr Maryam Mehtar, Royal University Hospital, 103 Hospital Drive, Saskatoon, Saskatchewan S7N 0W8. Telephone 306-844-1068, e-mail [email protected] Accepted for publication February 26, 2016 Paediatr Child Health Vol 21 No 5 June/July 2016
©2016 Canadian Paediatric Society. All rights reserved
249
Commentary
Table 1 Formal partnerships and contributions
Table 2 Teaching in paediatric school-based clinics
Organization
Contribution
Teaching Institution
Learners
Greater Saskatoon Catholic School Division
Clinic space, financial contribution for equipment
College of Medicine
Paediatric residents
Saskatoon Tribal Council
Human Resources - medical administrative assistant, 1 full-time equivalent
Department of Paediatrics - College Human resources – Paediatrician, of Medicine, University of 1 full-time equivalent Saskatchewan (Saskatoon, SK)
funding ran out, and the practice of service providers being present inconsistently. We began to understand that the consistent presence of providers, availability and flexibility, as well as the review of conventional practices (such as the required referral to a paediatrician through a family physician), were all important factors. Social determinants of health: The service delivery model had to reflect that we understood the influence of non-medical, social determinants on health (3,4). We had to address the significant burden of disease now attributable to the non-infectious social morbidities (5). We needed to address patients’ and families’ experiences related to social exclusion. Factors contributing to social exclusion for our patient population are compounded by multiple economic, historical and social constructs: income inequality; being of minority status; being Indigenous; being in foster care; and having a mental health disorder. Focusing on the determinants of health guided our consideration of factors such as clinic locations, and the collaboration across sectors and across health disciplines. We sought to establish relationships within the PSBCs that acknowledged and respected people’s lived experiences in a manner devoid of judgment and paternalism. Philosophy of social paediatrics: Utilizing the principles of social paediatrics (6,7) required an inclusive and holistic view of child health, beyond medical knowledge and beyond the role as a medical expert. The paediatrician’s skills as medical expert and scholar would only be successful if the skills in the domains of communicator, collaborator, advocate, leader and professional were equally matched (8). This had to apply to the skills and competencies of each service provider within the PSBCs. School-based health centres: School-based health centres, as a means of health care delivery, are well established in other countries, including the United States (9,10), providing coordinated shared care across systems. We sought to embrace and understand these factors both from within the community and from a patient perspective. The science supporting early childhood development (11), the body of evidence around the determinants of health, the increasing mental health needs of children and youth (12), and the research around adverse childhood experiences (13) have continued to inform our practice.
Partners in PSBCs
Establishing partnerships were essential. We continually respond to the needs of our patients by adding more services through dialogue with the community and our partners, and by reviewing reasons for accessing the PSBCs. The Saskatoon clinics were established through a formal partnership representing the collaborative work of individuals from three organizations (Table 1). This collaboration is based on a respectful and equitable relationship, with all three organizations having an 250
Family medicine residents Undergraduate students College of Nursing
Nursing students
Sask Polytech
Recreation therapy students Nursing students
First Nations University of Saskatchewan Social work students
equal voice in service delivery and structure. Regular ongoing communication among the organizations has been essential. Ultimately, the establishment of schools as the vehicle through which to deliver multidisciplinary and interdisciplinary paediatric health care services to Saskatoon’s core neighbourhoods was informed by the work of individuals within these organizations through community consultation and engagement. Most of the service providers are funded through their respective organizations. Working alongside education enables us to address mental health, behavioural and developmental problems experienced by children and youth, and the complex issues of school disengagement and school dropout as it relates to health and wellbeing. The interdisciplinary/multidisciplinary nature of our PSBCs enable improved communication and comprehensive treatment plans and supports that can be established across sectors. Schools serve as a natural confluence for sectors that influence health and wellbeing of patients who access our clinics – health, education, social services, law enforcement and justice. Because many of our patients are dually involved with social services and the justice system, we can jointly advocate for patients, students and their families. Transportation, previously a barrier to accessing services, is provided to and from the PSBCs by school staff or other agencies. No additional costs are involved. Partnering with the Saskatoon Tribal Council was essential. Saskatoon’s core neighbourhood population reflects the income inequality and social exclusion that disproportionately affect Indigenous people. Creating a culturally safe and respectful model could only be accomplished if representation occurred at the outset and on an equal footing in the organizational structure. As paediatricians, we provide services to diverse patient populations. We have a social responsibility in advocating that standards of care are consistently upheld for all paediatric patients, and that patients have equitable access to appropriate and timely health care services. PSBCs in Saskatoon have enabled us to demonstrate this in a tangible manner. We have the added responsibility of role-modelling these principles by teaching undergraduate and postgraduate learners early in their training about alternative models of care while exposing them to working with diverse patient populations in a culturally respectful manner (Table 2). Of equal importance are the informal partnerships that exist with other organizations and individuals (Table 3). Individuals who work in the PSBCs contribute their respective skills and training. The contribution of each organization is valued equally, irrespective of the skillset. Current clinicians are outlined in Table 4. Clinical services include in-clinic visits, case-conferences and multidisciplinary team meetings. Knowledge translation across sectors contribute to improved collaboration between agencies and the improved understanding of patients needs.
Paediatr Child Health Vol 21 No 5 June/July 2016
Commentary
Table 3 Informal partnerships and contributions
Table 4 Clinical services
Organization/services
Contribution
Saskatoon Public School Division
Clinic space, transportation
Clinician
Clinical services, days/week in PSBCs open five days per week
Saskatchewan Lung Association
Respiratory therapist: education for patients and families, spirometry
Paediatrician
4.5 days per week
Psychologist
Optometry
Eye See Eye Learn Program, vision screening and dispensing
4 days per week, individual and family therapy
Clinical social worker
3 days per week (children 12 years of age)
Optometry
1 day per week
Respiratory therapist
0.5 day/week (children and adults)
Child and adolescent psychiatrist
2 days per week
Paediatric nephrology team
0.5 day per month
Mental Health and Addictions Clinical social worker Services, Saskatoon Health Region Youth outreach worker/case manager Registered doctoral psychologist
Therapeutic interventions
Child and adolescent psychiatry
Consultations in school
Outcomes
Current demonstrable outcomes include increased community engagement and PSBC utilization, decreased absenteeism and improved behavioural health. Future quantitative and qualitative assessment will include shared health and academic outcomes including attendance, academic performance, the impact of bullying, and the impact of PSBCs on chronic mental health conditions such as depression and anxiety.
Conclusion
Through our PSBCS, we continue to have the privilege of working with patients and families who, despite difficult lived experiences and social circumstances, continue to place their trust in us as health care providers. Our responsibility lies in nurturing their resiliency through the exploration of their strengths as we seek to References
1. Lemstra M, Neudorf C, Opondo J. Health disparity by neighbourhood income. Can J Public Health 2006;97:435-9. 2. Committee on Psychosocial Aspects of Child and Family Health. The new morbidity revisited: A renewed commitment to the psychosocial aspects of pediatric care. Pediatrics 2001;108:1227-30. 3. Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management, 2010. 4. Marmot M, Wilkinson R, eds. Social Determinants of Health, 2nd edn. London: Oxford University Press; 2005. 5. Satcher D, Kaczorowski J, Topa D. The expanding role of the pediatrician in improving child health in the 21st century. Pediatrics 2005;115(4 Suppl):1124-8. 6. Guyda H, Razack S, Steinmetz N. Social Paediatrics. J Can Paed Soc 2006;11:643-5. 7. Spencer N, et al. Social Paediatrics. J Epidemiol Community Health 2005;59:106-8.
Paediatr Child Health Vol 21 No 5 June/July 2016
provide equitable medical care. Our role as safe, responsive and trusted adults is critical in the lives of children and youth whose social circumstances are often fluid and beyond their control. If, from a developmental perspective, children learn though their early relationships about relationships later in life, perhaps as paediatric health care providers we can provide positive relationships within their life course that empower our patients to continue to do so later in life with their adult health care providers. Acknowledgements: The author thanks Gary Beaudin and
Dr Bill Bingham.
8. Frank JR, Snell L, Sherbino J, eds. The Draft CanMEDS 2015 Physician Competency Framework – Series IV. Ottawa: The Royal College of Physicians and Surgeons of Canada; March, 2015. 9. Kaplan DW, Calonge BN, Guernsey BP, Hanrahan MB. Managed care and school-based health centers. Use of health services. Arch Pediatr Adolesc Med 1998;152:25-33. 10. Klein JD, Slap GB, Elster AB, Cohn SE. Adolescents and access to health care. Bull N Y Acad Med 1993;70:219-35. 11. The Science of Early Childhood Development (2007). National Scientific Council on the Developing Child. (Accessed October 2015). 12. Waddell C, McEwan K, Shepherd CA, Offord DR. A public health strategy to improve the mental health of Canadian children. Can J Psychiatry 2005;50:226-33. 13. Felitti VJ, Anda RF, Nordenberg D, et al. The relationship of adult health status to childhood abuse and household dysfunction. Am J Prevent Med 1998;14:245-58.
251
Paediatric school-based clinics in Saskatoon: Providing equitable access to paediatric care Maryam Mehtar MBBCh FRCPC M Mehtar. Paediatric school-based clinics in Saskatoon: Providing equitable access to paediatric care. Paediatr Child Health 2016;21(5):249-251. Paediatric school-based clinics (PSBCs) were established in Saskatoon (Saskatchewan) in 2007, to provide access to specialized paediatric health care as part of multidisciplinary and interdisciplinary teams, and alongside existing services. In its ninth year, the PSBCs have grown both in number and services offered, and in patient numbers – for both new patients and repeat follow-up visits. Viewing paediatric health consistently through the lens of the social determinants of health has been essential in delivering care, which require consideration and negotiation of these contexts in formulating management plans. The responsive relationships we continue to establish with our patients through the PSBCs have enabled us to work effectively with children and youth, and continue the growth of our successes. Key Words: Collaborative care; Partnerships; School-based health; Social
paediatrics
P
aediatric school-based clinics (PSBCs) were established in 2007, in response to the Health Disparity by Neighbourhood Income Study (1). The magnitude of health disparities identified in the study raised the question of whether existing traditional paediatric health care service delivery models had addressed the needs of infants, children and youth in Saskatoon’s (Saskatchewan) lowincome neighbourhoods. For example, youth in Saskatoon’s lowincome neighbourhoods were significantly more likely to give birth to a child and to be bullied, depressed and anxious. Representing the institution of health, the Department of Paediatrics assumed partial responsibility for these disparities. Subsequently, in collaboration with key partners, we began working toward addressing the needs of the most vulnerable paediatric patients in Saskatoon. Despite our medical expertise and the rapid technological advances in health care, we acknowledged that the medical care delivered to our patients had unintentionally been inconsistent (2). We recognized that the delivery of paediatric care had to be more inclusive. We needed to better address what children require to be healthy by utilizing a more collaborative framework within the community, and with meaningful engagement of patients and families. OBJECTIVES Based on the above, we focused on the following four objectives in the implementation of the PSBCs: 1. Provide access to specialized community-based paediatric care within schools, in a culturally respectful manner; as part of the continuum of the existing community-based services.
Un accès équitable aux soins pédiatriques grâce aux cliniques de santé en milieu scolaire à Saskatoon Les cliniques pédiatriques en milieu scolaire (CPMS) ont été mises sur pied à Saskatoon, en Saskatchewan, en 2007, afin de donner accès à des soins pédiatriques spécialisés fournis par des équipes multidisciplinaires et interdisciplinaires, conjointement à des services déjà en place. Les CPMS, qui existent depuis neuf ans, ont pris de l’expansion, tant pour ce qui est des services offerts que du nombre de patients, qu’il s’agisse de nouveaux patients ou de rendez-vous de suivi. Il a été essentiel de toujours concevoir la santé pédiatrique sous l’angle des déterminants sociaux de la santé lors de la prestation des soins, ce qui exige de tenir compte de ces contextes et de les négocier lors de la formulation des plans de prise en charge. Parmi les nombreuses leçons tirées de cette expérience, soulignons que ce sont les liens particuliers que nous entretenons avec nos patients au sein des CPMS qui nous permettent de travailler efficacement auprès des enfants et des adolescents et de cumuler les réussites.
2. Ensure that patients and families feel empowered and comfortable in accessing the clinics for follow-up; out of choice rather than the expectation to do so by agencies such as the school or social services. 3. Provide paediatric patients and families a safe space in which to share their lived experiences for us to better understand the individual and community social contexts. 4. Entrench these PSBCs within the paediatric postgraduate curriculum and, eventually, the undergraduate clinical curriculum. FRAMEWORK In developing the PSBCs in Saskatoon’s low-income neighbourhoods, consideration had to be given to using an alternative approach to health care service delivery. Both the ‘physical’ and ‘mental’ model had to be different. Service delivery had to reflect a shift in power away from ‘the institution of health’ and into the community. The development of a different approach was based on the following components: community engagement; social determinants of health; the philosophy of social paediatrics; and evidence from other school-based centres. Community engagement: This was essential in determining existing perceptions around paediatric health care service delivery within the core neighbourhoods. Through discussions with the community, we came to understand a theme of perceived abandonment as well as pervasive distrust of the health care system. Specifically, the community perceptions of differential treatment arose from organizations coming in to conduct pilot projects, providing programs until
Royal University Hospital, Saskatoon, Saskatchewan Correspondence: Dr Maryam Mehtar, Royal University Hospital, 103 Hospital Drive, Saskatoon, Saskatchewan S7N 0W8. Telephone 306-844-1068, e-mail [email protected] Accepted for publication February 26, 2016 Paediatr Child Health Vol 21 No 5 June/July 2016
©2016 Canadian Paediatric Society. All rights reserved
249
Commentary
Table 1 Formal partnerships and contributions
Table 2 Teaching in paediatric school-based clinics
Organization
Contribution
Teaching Institution
Learners
Greater Saskatoon Catholic School Division
Clinic space, financial contribution for equipment
College of Medicine
Paediatric residents
Saskatoon Tribal Council
Human Resources - medical administrative assistant, 1 full-time equivalent
Department of Paediatrics - College Human resources – Paediatrician, of Medicine, University of 1 full-time equivalent Saskatchewan (Saskatoon, SK)
funding ran out, and the practice of service providers being present inconsistently. We began to understand that the consistent presence of providers, availability and flexibility, as well as the review of conventional practices (such as the required referral to a paediatrician through a family physician), were all important factors. Social determinants of health: The service delivery model had to reflect that we understood the influence of non-medical, social determinants on health (3,4). We had to address the significant burden of disease now attributable to the non-infectious social morbidities (5). We needed to address patients’ and families’ experiences related to social exclusion. Factors contributing to social exclusion for our patient population are compounded by multiple economic, historical and social constructs: income inequality; being of minority status; being Indigenous; being in foster care; and having a mental health disorder. Focusing on the determinants of health guided our consideration of factors such as clinic locations, and the collaboration across sectors and across health disciplines. We sought to establish relationships within the PSBCs that acknowledged and respected people’s lived experiences in a manner devoid of judgment and paternalism. Philosophy of social paediatrics: Utilizing the principles of social paediatrics (6,7) required an inclusive and holistic view of child health, beyond medical knowledge and beyond the role as a medical expert. The paediatrician’s skills as medical expert and scholar would only be successful if the skills in the domains of communicator, collaborator, advocate, leader and professional were equally matched (8). This had to apply to the skills and competencies of each service provider within the PSBCs. School-based health centres: School-based health centres, as a means of health care delivery, are well established in other countries, including the United States (9,10), providing coordinated shared care across systems. We sought to embrace and understand these factors both from within the community and from a patient perspective. The science supporting early childhood development (11), the body of evidence around the determinants of health, the increasing mental health needs of children and youth (12), and the research around adverse childhood experiences (13) have continued to inform our practice.
Partners in PSBCs
Establishing partnerships were essential. We continually respond to the needs of our patients by adding more services through dialogue with the community and our partners, and by reviewing reasons for accessing the PSBCs. The Saskatoon clinics were established through a formal partnership representing the collaborative work of individuals from three organizations (Table 1). This collaboration is based on a respectful and equitable relationship, with all three organizations having an 250
Family medicine residents Undergraduate students College of Nursing
Nursing students
Sask Polytech
Recreation therapy students Nursing students
First Nations University of Saskatchewan Social work students
equal voice in service delivery and structure. Regular ongoing communication among the organizations has been essential. Ultimately, the establishment of schools as the vehicle through which to deliver multidisciplinary and interdisciplinary paediatric health care services to Saskatoon’s core neighbourhoods was informed by the work of individuals within these organizations through community consultation and engagement. Most of the service providers are funded through their respective organizations. Working alongside education enables us to address mental health, behavioural and developmental problems experienced by children and youth, and the complex issues of school disengagement and school dropout as it relates to health and wellbeing. The interdisciplinary/multidisciplinary nature of our PSBCs enable improved communication and comprehensive treatment plans and supports that can be established across sectors. Schools serve as a natural confluence for sectors that influence health and wellbeing of patients who access our clinics – health, education, social services, law enforcement and justice. Because many of our patients are dually involved with social services and the justice system, we can jointly advocate for patients, students and their families. Transportation, previously a barrier to accessing services, is provided to and from the PSBCs by school staff or other agencies. No additional costs are involved. Partnering with the Saskatoon Tribal Council was essential. Saskatoon’s core neighbourhood population reflects the income inequality and social exclusion that disproportionately affect Indigenous people. Creating a culturally safe and respectful model could only be accomplished if representation occurred at the outset and on an equal footing in the organizational structure. As paediatricians, we provide services to diverse patient populations. We have a social responsibility in advocating that standards of care are consistently upheld for all paediatric patients, and that patients have equitable access to appropriate and timely health care services. PSBCs in Saskatoon have enabled us to demonstrate this in a tangible manner. We have the added responsibility of role-modelling these principles by teaching undergraduate and postgraduate learners early in their training about alternative models of care while exposing them to working with diverse patient populations in a culturally respectful manner (Table 2). Of equal importance are the informal partnerships that exist with other organizations and individuals (Table 3). Individuals who work in the PSBCs contribute their respective skills and training. The contribution of each organization is valued equally, irrespective of the skillset. Current clinicians are outlined in Table 4. Clinical services include in-clinic visits, case-conferences and multidisciplinary team meetings. Knowledge translation across sectors contribute to improved collaboration between agencies and the improved understanding of patients needs.
Paediatr Child Health Vol 21 No 5 June/July 2016
Commentary
Table 3 Informal partnerships and contributions
Table 4 Clinical services
Organization/services
Contribution
Saskatoon Public School Division
Clinic space, transportation
Clinician
Clinical services, days/week in PSBCs open five days per week
Saskatchewan Lung Association
Respiratory therapist: education for patients and families, spirometry
Paediatrician
4.5 days per week
Psychologist
Optometry
Eye See Eye Learn Program, vision screening and dispensing
4 days per week, individual and family therapy
Clinical social worker
3 days per week (children 12 years of age)
Optometry
1 day per week
Respiratory therapist
0.5 day/week (children and adults)
Child and adolescent psychiatrist
2 days per week
Paediatric nephrology team
0.5 day per month
Mental Health and Addictions Clinical social worker Services, Saskatoon Health Region Youth outreach worker/case manager Registered doctoral psychologist
Therapeutic interventions
Child and adolescent psychiatry
Consultations in school
Outcomes
Current demonstrable outcomes include increased community engagement and PSBC utilization, decreased absenteeism and improved behavioural health. Future quantitative and qualitative assessment will include shared health and academic outcomes including attendance, academic performance, the impact of bullying, and the impact of PSBCs on chronic mental health conditions such as depression and anxiety.
Conclusion
Through our PSBCS, we continue to have the privilege of working with patients and families who, despite difficult lived experiences and social circumstances, continue to place their trust in us as health care providers. Our responsibility lies in nurturing their resiliency through the exploration of their strengths as we seek to References
1. Lemstra M, Neudorf C, Opondo J. Health disparity by neighbourhood income. Can J Public Health 2006;97:435-9. 2. Committee on Psychosocial Aspects of Child and Family Health. The new morbidity revisited: A renewed commitment to the psychosocial aspects of pediatric care. Pediatrics 2001;108:1227-30. 3. Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management, 2010. 4. Marmot M, Wilkinson R, eds. Social Determinants of Health, 2nd edn. London: Oxford University Press; 2005. 5. Satcher D, Kaczorowski J, Topa D. The expanding role of the pediatrician in improving child health in the 21st century. Pediatrics 2005;115(4 Suppl):1124-8. 6. Guyda H, Razack S, Steinmetz N. Social Paediatrics. J Can Paed Soc 2006;11:643-5. 7. Spencer N, et al. Social Paediatrics. J Epidemiol Community Health 2005;59:106-8.
Paediatr Child Health Vol 21 No 5 June/July 2016
provide equitable medical care. Our role as safe, responsive and trusted adults is critical in the lives of children and youth whose social circumstances are often fluid and beyond their control. If, from a developmental perspective, children learn though their early relationships about relationships later in life, perhaps as paediatric health care providers we can provide positive relationships within their life course that empower our patients to continue to do so later in life with their adult health care providers. Acknowledgements: The author thanks Gary Beaudin and
Dr Bill Bingham.
8. Frank JR, Snell L, Sherbino J, eds. The Draft CanMEDS 2015 Physician Competency Framework – Series IV. Ottawa: The Royal College of Physicians and Surgeons of Canada; March, 2015. 9. Kaplan DW, Calonge BN, Guernsey BP, Hanrahan MB. Managed care and school-based health centers. Use of health services. Arch Pediatr Adolesc Med 1998;152:25-33. 10. Klein JD, Slap GB, Elster AB, Cohn SE. Adolescents and access to health care. Bull N Y Acad Med 1993;70:219-35. 11. The Science of Early Childhood Development (2007). National Scientific Council on the Developing Child. (Accessed October 2015). 12. Waddell C, McEwan K, Shepherd CA, Offord DR. A public health strategy to improve the mental health of Canadian children. Can J Psychiatry 2005;50:226-33. 13. Felitti VJ, Anda RF, Nordenberg D, et al. The relationship of adult health status to childhood abuse and household dysfunction. Am J Prevent Med 1998;14:245-58.
251
