What pediatricians can practice to further youth violence prevention—a qualitative study

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  1. Shari Barkin1,
  2. Gery Ryanii,
  3. Lillian Gelbergthree
  1. 1UCLA School of Public Wellness
  2. 2UCLA Section of Anthropology
  3. iiiUCLA Division of Family Medicine
  1. Correspondence to:
 Dr Shari Barkin, Wake Forest University Schoolhouse of Medicine, Department of Pediatrics, Medical Center Blvd, Winston-Salem, NC 27157, USA 
 (electronic mail: sbarkin{at}wfubmc.edu ).

Abstract

Objective—Youth violence is a public health problem world wide. However, the United States has the worst rate of youth violence amid industralized countries. This study was conducted to learn what pediatricians, community leaders, and parents think the doc's role is in youth violence prevention during the well-child exam for children.

Methods—Interviews were conducted with pediatricians, community leaders, and parents living or working in Los Angeles, California.

Results—All three groups interviewed believed that the physician should incorporate violence prevention counseling equally part of the well-child examination. The mechanism of action differed for the iii groups. Most half of pediatricians' statements focused on their role as prevention counselor, with respect to such issues as advisable field of study and gun safety. One tertiary of community leaders' statements, however, related to dr. referral to existing community resources. More than than half of parents' statements referred to the pediatrician as someone who can directly educate their child almost making positive choices.

Conclusions—Although pediatricians cannot solve the problem of youth violence alone, findings from this written report suggest that they should address this outcome with their patients and should work in tandem with existing community resources to further a solution to this growing epidemic.

  • violence
  • md
  • community perspectives

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  • violence
  • dr.
  • customs perspectives

Youth violence, defined as any person eighteen years old or younger injuring or killing some other person in this historic period group, continues to be a pregnant public health problem globe wide. In low income countries that take been exposed to on-going wars, a new generation of hardened children has emerged. Yet, the rate of homicide in many of these countries is still lower than that of the United States.one In fact, even when we compare the United States to high income countries, America has more violent deaths than any other industrialized nation.i– 4 In 1994, the homicide charge per unit for 15–19 year quondam American adolescents was twenty.3/100 000, making information technology the second leading cause of death for youth.iv– 7 Among 12–17 yr old youth, 71/m had been victims of violent crimes in 1993.5 For every child that dies as a result of trigger-happy injury, in that location are many more than that sustain non-fatal injuries.8, 9 Even though the tendency of violent crimes in the Usa has declined in most urban areas, youth violence has continued to ascension in cities such as Los Angeles.10– 13

In 1992, Surgeon General C Everett Koop recognized violence as a public health issue. Since then, health care providers accept grappled with their potential office in addressing violence prevention. The bulk of master care providers have agreed that they should address this consequence,14– 21 but it is not clear to them how to do so.

Ideally, children'due south main intendance providers should focus on primary prevention strategies. These approaches involve interventions before an injury occurs. By identifying potential hazards in the child's surroundings, pediatricians have successfully counseled families during the well-kid examination to prevent unintentional injury.22– 29 How tin can we utilize this approach to youth violence? Many have suggested that by addressing the vector of near of these violent injuries, the handgun, clinicians could subtract the number of injuries that occur.7, 15– 17, nineteen– 21 Major medical organizations such every bit the American Academy of Pediatrics and the American Medical Clan have issued guidelines that recommend counseling patients about the hazards of a gun in the home.15– 19 In addition to guns, at that place are several other risks for being either a victim or a perpetrator of violence. They include: witnessing violence on the streets, in one's family unit, or in the media; using booze, tobacco, or illicit substances; being a young male of whatsoever ethnicity; living in poverty; and being depressed.7, 30– 33

Because physicians are limited in the amount of fourth dimension they can spend with patients, and the frequency with which they collaborate with them, it is essential that the doctor'south message exist reiterated in the child's family and community. What messages can the dr. provide that parents and community leaders will reinforce? Practise they recall that doctors have a part to play during the course of a routine office visit? Our purpose was to conduct an exploratory assay of the pediatrician'due south role in youth violence prevention from the perspective of not only the doctor, but likewise the parent and the community leader. We did non interview adolescents considering we focused on the before years when children are developing their sense of normative behavior.34– 37

Methods

Through a series of interviews with pediatricians, parents, and community leaders we asked participants to elaborate on what they idea doctors potentially could do to influence youth violence primary prevention, what barriers they might run across, and what resources they might apply.

INTERVIEW PROCEDURE

We developed a semistructured instrument with 15 questions. All interviews began with the question, "Do you recollect the clinician has a part in youth violence principal prevention, defined equally preventing violent injury in children younger than 18 years old". Because we were interested in main prevention, we focused our questions on the part of the clinician during the routine well-child test. Most questions were open ended and the interviewer probed the respondent to elaborate on responses. Interviews with pediatricians and community leaders lasted approximately an hour and were audiotaped with the respondents' consent. We interviewed informants until no new themes were mentioned.38 For parents, a group interview was conducted for 1 hour. We immune all participants the opportunity to vocalization their opinion on a question before proceeding to the next question. Interviews were transcribed verbatim from audiotapes.

Subject area RECRUITMENT

Table ane shows the details of gender and ethnicity among the three groups interviewed. A convenience sample of pediatricians were randomly selected from the 1995 Los Angeles County Resource Directory. This identified doctors working in either South Key or E Los Angeles, the two highest youth violent crime districts in Los Angeles. 8 doctors were invited to participate and six accepted. Two were unable to participate due to time constraints. A convenience sample of seven youth violence community leaders were selected equally suggested by the director of the Violence Prevention Coalition of Greater Los Angeles, a coalition of more than 200 grass roots organizations. All those invited agreed to participate. A convenience sample of parents gathered at a customs school meeting in Southward Central Los Angeles volunteered to participate in a grouping interview subsequent to the school meeting. From a gathering of 30 parents, nosotros asked for 10 volunteers who had young children and teenagers at home; 13 agreed to participate. Notably, parents who agreed to participate were more often African American and female. This reflects the composition of parents in South Central Los Angeles. Participants were compensated with breakfast or dejeuner.

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Tabular array 1

Study population (n=26)

Although we would have preferred to increase the sample size and make the process random, nosotros were nigh interested in identifying the salient themes that were associated with youth violence among these iii groups. Given the investigators limited time and monetary constraints, we decided to interview just enough participants from each group to attain theme saturation (no longer gathering new themes).

Data ANALYSIS

2 investigators independently reviewed the transcripts and identified all segments of text that pertained to three major themes: the potential doctors possess to bargain with this issue; the barriers they confront; and the resources that exist to assistance them. The two investigators compared their coding of the text and retained all statements where they agreed. Where there was disagreement, the text in question was reviewed and retained only if both investigators agreed it captured the sense of the theme. In all, the two coders identified 84 statements related to potential, 74 associated with barriers, and 41 pertaining to resourcesouth. Intercoder reliability (κ) was 0.88 for potential, 0.66 for bulwarks, and 0.72 for resources, indicating moderate to strong agreement.

To place subthemes in the data, four coders performed pile sorting tasks on each of the three themes' statements. Statements for a theme were typed on separate pieces of paper. Then four coders (three of whom were naive to the participants and the questions) independently sorted the statements into four piles, based on the perceived similarity of statements. After sorting the statements, coders described each pile in their own words. Allowing several coders to sort statements into their own categories reduced the gamble of the subthemes beingness identified only because the principal investigators establish them interesting.38

The pile-sort technique produced a statement by statement similarity matrix where the degree to which any ii statements were like was determined by the number of times the 2 statements were placed in the same pile by the four coders. The matrix was analyzed with not-metric multidimensional scaling39 and hierarchical cluster analysis.40 These qualitative analysis techniques identified groups of similar items. Combined with the qualitative descriptions provided by the coders, the two chief investigators identified half-dozen subthemes for potential, five for barriers, and four for resources.

To ensure that the newly identified subthemes could be described and identified as contained constructs, the four coders independently read each theme'due south statements and marked them equally either belonging or non belonging to the relevant subthemes. Intercoder understanding produced a crude measure of association between a subtheme and each statement. A statement was considered highly associated with a subtheme if it was marked past at least three coders, weakly associated if marked by two coders, and non associated if marked by 1 or fewer coders. The results reported below pertain to only those statements that were strongly associated with each of the subthemes. All quotations cited as examples were marked by all 4 coders, indicating consummate coder agreement.

Results

Nosotros were about interested in how pediatricians' perceptions of their role in youth violence prevention compares with the perceptions of customs leaders and parents. Tables 2–four depict this emphasis by listing subthemes in the order nearly oft mentioned by doctors. The qualitative assay below combines the code frequency data in tables 2–4 with typical quotes taken from respondents in the three groups. We divers a typical quote as one that all coders agreed upon as representing a subtheme. The focus group and semistructured interviews began with the question, "Should doctors counsel on youth violence prevention?" All participants stated that doctors should do and then during the routine well-child examination. Beneath, we present the results for the iii major themes.

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Table two

Distribution of subthemes across clinicians, customs leaders, and parents for the major theme: potential (Due north=199 unique statements*)

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Table iii

Distribution of subthemes across clinicians, community leaders, and parents for the major theme: barriers (North=199 unique statements*)

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Table 4

Distribution of subthemes across clinicians, customs leaders, and parents for the major theme: resource (North=199 unique statements*)

MAJOR THEME: POTENTIAL

Ane of the major themes we developed was the potential contribution clinicians could make to violence prevention during a routine well-child examination. Coders identified six potential areas of intervention: educating the family unit about youth violence; counseling the kid directly; using the unique bond formed between dr. and patient; advocating gun rubber to either the parent or the patient; referring patients and families to community programs, such as parenting classes or Boys and Girls Clubs; and educating patients through impersonal means, such every bit brochures or posters.

Of the 36 physician statements related to potential interventions, 41.7% dealt with family unit education, and 22.0% focused on direct patient education. As one doctor put it, "You lot empower the family unit to focus on the child's development—to really recall about TV and think almost spanking, and think about the type of music or the type of plays y'all may view with your child".

Community leaders agreed with doctors that teaching was an of import tool in prevention, with 41.0% and 25.6% of their 39 statements being strongly associated with family unit and direct patient education, respectively.

Community leaders and parents, however, were more likely than physicians to encounter the doctor-patient human relationship as a vehicle of potential intervention. A community leader summed up this perspective,"Everyone needs to practise their part if we're going to tackle such a large problem. I retrieve, in particular, doctors have a lot of influence on families and they should use that to address the problem of violence".

Additionally, customs leaders were more likely than doctors or parents to view the pediatrician'due south role as one of a liaison between parents and other community services. Of all the community leaders' statements, one third were related to community program referrals. An example of a community program mentioned included Boys and Girls Clubs, which promote positive peer activities as well as the importance of doing homework. One community leader envisioned the process this way, "So this child in your office is 5 years old and you take 2 minutes to bear upon the family about violence prevention. I think the only thing you could practice with a time limit like that is to offer the family a referral to a program like ours. Doctors need to know their community and refer their patients into existing programs".

MAJOR THEME: BARRIERS

Barriers refer to those obstacles that either inhibit the pediatrician'due south ability to promote youth violence prevention during a routine well-kid exam or negatively affect the effectiveness of counseling. Coders identified v subthemes: limitations of the function visit; limitations of the health care arrangement in full general; limitations of the family; living in a violent neighborhood; and a full general culture of violence in our gild.

Fifty two per cent of doctors' statements about barriers related to the limitations of the health care system and 44% related to the limitations of the role visit. Ane clinician stated, "You can't do it [counsel on youth violence prevention] in a five infinitesimal or a 15 infinitesimal function visit, fifty-fifty though y'all have good intentions. You might address information technology and bring those issues up, simply people aren't going to follow through with information technology....".

Another expressed concern about the lack of continuity in a managed care environment stating, "I just don't know what the boilerplate life span of a member in a wellness maintenance arrangement is considering if the employers were to determine to change their insurance, it may be two years or even less [that the patient stays in the same organization]".

Like doctors, parents are too acutely enlightened of role limitations. Of the 14 parent statements most barriers, 43% related to this subtheme. 1 parent expressed her concern this fashion, "In one case y'all go to the physician, you're going for one problem and then bringing up other things. And most of these doctors are in HMOs [health maintenance organizations] and they have besides many patients to sit down downwardly and talk with y'all personally".

Community leaders and parents were far more likely than physicians to mention that children live in tearing neighborhoods, posing a major obstacle to effective clinician counseling. Thirty three per cent of community leaders' statements and 36% of parents' statements related to this subtheme, compared with only 11% of clinicians' statements. I community leader described the situation like this, "...[the business organisation] is whether or not they [children] were going to get shot going to and from their homes, whether or not they would be safe in their homes".

Parents expressed their business organisation in a slightly different way, "It's not every street [that is violent]. Your street tin be safe and the next couple of blocks tin can exist rubber, but it might be a couple of blocks over...".

Customs leaders and, to some extent, parents, perceived a culture of violence as being i of the central barriers. Over 60% of community leaders' statements and 28.6% of parents' statements pertained to this subtheme. We considered a culture of violence as more pervasive than just the physical violence in any particular neighborhood, defining it as an expectation or a norm of behavior. One customs leader described information technology similar this, "It doesn't matter 'cause your life doesn't mean and then much anymore. Violence becomes so commonplace and society seems distant and common cold. There's no empathy there. And then the child becomes isolated and past the end, the child is fearless because they expect to be killed themselves".

MAJOR THEME: RESOURCES

Another major theme we developed was resources currently bachelor for the md to facilitate counseling during the routine well-child examination. Coders identified 3 subthemes: the unique dr.-patient human relationship; the ability of the clinician to provide customs referrals, such as to a parenting class or to a peer social social club; and those resources that the health intendance organization can provide the clinician in counseling. Twenty eight per cent of clinicians' statements, 32% of customs leaders' statements, and 71% of parents' statements noted that the unique doc-patient relationship was a valuable resource and provided an important opportunity for intervention. One doctor summarized the relationship by saying, "I think that pediatrics lends itself very well to trying to modify a lot of these behaviors [those that pb to youth violence]. In then far as the pediatrician has the unique position to observe the kid's development and the family's development, the dynamics that occur between the child and the caregivers from birth through life".

A customs leader put it this way, "Mayhap the doctor would be one of the best people to bring this upward considering the families are going to have a relationship with their doctors".

Parents mentioned this subtheme most often. One parent stated, "It all depends on the doc—if the physician knows the child real well . . .he can accept that personal one-on-i feeling with the child that tin make the departure".

Twenty seven per cent of physicians' statements and 32% of customs leaders' statements were related to the doctor's ability to refer patients to existing community services. A community leader noted, "You could human action as a resources. You see a kid with a cleaved leg, you have to refer him to the next person that takes care of the bones. Just say that yous come across a kid that has a problem with violence, you meet a kid that looks like he is a gang member or looks like he is heading that way; you might want to refer to the side by side person that might be able to reach that person [kid] or help him as far every bit a community youth plan".

A pediatrician reiterated this subtheme, "A professional person who is highly resourceful, talented, can admission the community through referrals, only like that, considering he'south got the title and name and can focus correct on the intervention".

Give-and-take

Although the rate of violence in the Usa is down, the rate of youth violence continues to be unduly high in urban areas such equally Los Angeles.2– 6, 10– 13 Prior studies have suggested that the doctor taking care of children could influence this problem, but none of these studies examined the function of the doc from other than the their own perspective.14, 20, 21 From a community health perspective, efforts of the doctor to accost youth violence might be limited because the medico is only one point of intervention. For this reason, we chose to interview two other important groups of people who influence the lives of America'due south youths, parents and customs leaders. The nature of this report was exploratory; therefore, nosotros focused on a small number of respondents, with the goal of generating new ideas rather than testing them out. The qualitative information we gathered from in depth interviews provided rich contextual information on three themes related to the function of the medico in part based youth violence primary prevention: potential interventions; barriers impeding these interventions; and resources facilitating such interventions.

The most important point is that all three groups interviewed believed that the medico should comprise counseling on this topic as part of the well-child examination. Thus, in improver to counseling their patients on other areas of injury prevention, clinicians are being requested to counsel on youth violence prevention.

Secondly, our findings suggest that the uniqueness of the dr.-patient relationship is seen as a key resource. Nonetheless, the mechanism of activeness differed for the three groups. Pediatricians saw their function as a prevention counselor, focusing on family teaching that would accost issues of appropriate bailiwick and gun safety. Customs leaders' statements centered around the doctor's ability to refer families to existing customs resources, specifically to clubs that offer young people the take chances to interact with positive peer groups and potent adult mentors. Parents saw the physician as an educator, a person who could directly educate their child to make positive choices that would pb to less violence. Therefore, our data suggest that the pediatrician'southward function should assimilate these 3 perspectives. Perhaps this could be washed if the physician, afterward establishing rapport with the patient, could teach the child some basic skills to stay safe. Some studies have examined the need for preteens and teens to acquire special skill sets to deflect the potential lethality of adolescence in today's world.41– 43 Additionally, if the physician recognizes that the patient is exposed to violence in the community or family unit, an appropriate referral into an existing community program could be made.

Several prior studies have been limited in that they merely examined pediatricians' specific behavior regarding whether they should counsel about gun violence prevention to children of all ages. Because our written report was exploratory, it identified common themes across three major groups and did non limit counseling to merely firearm safe. Respondents from this study broadened the concept of youth violence prevention to include a discussion of discipline, direct patient education on making positive choices, and advisable referrals into community based programs.

However, the data strongly suggest that we must be practical in suggesting a role for the doctor in this area. Parents and doctors recognized that time constraints curtail the amount of counseling that tin occur during an role visit. Customs leaders (and some parents) saw that the broader result of a violent civilization stands in the way of the clinician making a meaningful deviation. And parents' statements brought up the reality, that fifty-fifty if the physician counsels on youth violence prevention, the children return to a neighborhood where violence occurs routinely.

Although these barriers cannot be overcome easily, physicians can piece of work in tandem with existing resources in the customs to maximize their influence. Our data suggest that familiarizing clinicians with their customs resources could permit for appropriate referrals. This fits efficiently within the medical model. Equally 1 community leader stated, "If you suspension your leg, you get sent to a bone dr.. If you live in a bad neighborhood, you should go sent to a community program to bargain with all the things that happen because of that".

Our study had limitations. Although we gathered enough interviews to achieve theme saturation, we collected fewer statements from parents than nosotros did from doctors and community leaders. This was due to interviewing parents in a grouping environment, as opposed to the other interviews that were conducted i-on-one. It is likely that this limited the breadth of parents' statements and might have even altered the kind of responses nosotros gathered. Future studies should exist conducted to examine parents' thoughts regarding the physician'due south part in role based violence prevention to verify our findings.

We interviewed a pocket-size convenience sample of pediatricians, parents, and community leaders; this makes generalizing the findings to a larger population hard. Moreover, our report was conducted in Los Angeles, California and might but apply to urban American communities. Also, nosotros defined a community leader as 1 who actively runs an existing community plan designed for immature people. We did not interview other individuals who could also influence a child's choices, such equally teachers or preachers. Lastly, we did not interview adolescents considering nosotros narrowed the scope of our report. In the future, it might be wise to repeat this study with adolescents. Acknowledging these limitations, nosotros still believe that our findings allow for some important insights into the community'due south perspective of the pediatrician's part in violence prevention.

Implications for prevention

Pediatricians, parents, and community leaders believe that the doctor has a potential role to play in youth violence prevention. Yet, because doctors accept such a curt time to counsel on the prevention of youth violence, they could magnify their influence if they strengthened their connection to existing community resources. Past providing a message that can be reinforced by people and programs in the community, the physician could get an important link in the chain of youth violence prevention. This exploratory study offers some new ideas with the intention to test them out on larger numbers of participants. Afterwards, future studies could be directed at developing integrated programs that permit for ease of collaboration between the health care provider, the parent, and the customs leader.

Acknowledgments

Dr Barkin's work on this project was supported by the UCLA Robert Forest Johnson Clinical Scholar's program and National Enquiry Service Award 1 T32 HS00046–01 from the Agency for Health Care Policy and Research. The views expressed are those of the authors and do not necessarily reflect those of the Robert Wood Johnson Foundation or the Agency for Health Care Policy and Inquiry.

Dr Gelberg is a Robert Wood Johnson Generalist Doc Faculty Scholar.

The authors would like to acknowledge Cathy Carpenter, David Kroes, and Jeff Frumkin for their hard work in aiding to analyze the data.

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