More Than a Turkey Sandwich and a Bus Ticket

Should screening for homelessness be routine in the ED?

In the emergency department (ED) patient screening for a multitude of illness and risk factors occurs in the first few minutes of contact with a patient. We screen for communicable disease, falls risk, domestic abuse, eldercare, and childhood injury and abuse as part of initial assessments and triage. These assessments are important to providing care to our patients in order to prevent the spread of disease among patients and staff, to direct the proper supports to patients at risk and to provide care and resources to vulnerable populations in order to facilitate safe discharge from the department when their treatment is complete. However, homelessness is not one of the vulnerable populations we identify in routine ED screening. With the challenges faced in treating those amongst the homeless population and the prevalence of homelessness in our society, should we be doing more to screen for homelessness during our patients stay in the ED?

Significance

In order to understand if homelessness should be screened for as a risk factor in the ED, it is important to understand what unique health challenges being homeless presents. This occurs in both the concurrent illness and chronic disease that are prevalent in the homeless population as well as the specific challenges related to providing care to this vulnerable population. Persons who are homeless are more susceptible risk factors for diseases due to increased exposure to alcohol abuse, illicit drug use, nutrition deficits and smoking (Moore, Gerdtz, & Manias, 2007). Homelessness is also associated with extremely high rates of mental illness, social isolation, chronic illness including, HIV, hepatitis, heart disease and COPD (Moore et al, 2007, D’Amore et al, 2001). These compounding risk factors and disease make treating illness amongst the homeless complex not only due to the nature of disease but also because the nature of the chaotic lifestyle of being homeless. This includes inadequate financial resources for healthcare spending, unreliable food sources, inability to fund transportation to appointments, poor medication compliance and difficulty waiting for and attending outpatient appointments (Moore et al, 2007). These risk factors demonstrate some of the complexity of caring for the homeless population and reinforce the importance of tailoring healthcare programs to meet the specific needs of a population that are traditionally poorly served by a healthcare structure with rigid demands and scheduling (Moore et al, 2007).

Prevalence

On any given day in Waterloo region there are approximately 360 people who identify as homeless (Canadian Observatory on Homelessness, 2017). It is important to remember that homelessness by definition is fluid and identifying exact numbers are difficult obtain with certainty. In 2017, 2762 different people reported using emergency shelter services, and there were only 245 shelter beds available in the region on any given day, most running at capacity (Canadian Observatory on Homelessness, 2017), suggesting that actual numbers of homelessness in the community may actually be much higher than reported.

Regional trends suggest that there may be declining use of emergency shelters, but those who access the service are staying longer (Homeless Housing Umbrella Group, 2017) demonstrating a need for more long-term housing solutions in the community. A reported 16% of the homeless population identified in the region identifies as Aboriginal (Canadian Observatory on Homelessness, 2017), a disproportionate representation of the 2% of the regional population that self identify as Aboriginal (WWLHIN, 2014). Recently there has also been an increase in the number of elderly (greater than 65 years) using shelter services as well in a rise in refugee claimants in the local emergency shelter system and an increase in family units requiring assistance with housing (Homeless Housing Umbrella Group, 2017). These demographics demonstrate the variability of the homeless population in the Waterloo Region. This highlights the importance of any targeted intervention serving the homeless population have the flexibility to meet not only the complex needs of the individual, but also the varying needs across multiple social, ethnic and age demographics.

What Is Being Done?

The Government of Ontario seeks to support the homeless population through a number of initiatives aimed at preventing homeless, investing in affordable housing and providing funds for emergency shelter care, with the ultimate goal of ending homelessness in Ontario by 2025 (Government of Ontario, 2017). This includes the identifying of four priority areas including indigenous, youth and chronic homelessness, as well as transitions from institutions (including prison) (Government of Ontario, 2017). The priority focus of the Ontario Government is on providing funding for shelter and housing through the Community Homelessness Prevention Initiative (CHPI). The goal of CHPI is the “end homelessness by improving access to adequate, suitable, and affordable housing and homelessness services for people experiencing homelessness and for people at-risk of homelessness” (Ontario Ministry of Housing, 2017).

Click here to visit the Government of Ontario’s infographic on homelessness.

In Waterloo Region provincial and regional funds are used to create emergency shelter spaces, provide assistance with affordable housing, and create policy that assist those at risk of homelessness to maintain housing through its All Roads Lead to Home: The Homelessness to Housing Stability Strategy for Waterloo Region (2012). This document identifies key principles including focusing on long term sustainable housing, ensuring housing is viewed as a right, ensuring accessibility to housing, income and support of individuals and involving key stakeholders in the region (Social Planning, Policy and Program Administration, 2012).

The focus of these programs revolves around the availability of affordable housing, financial resources and community based programming that makes these services accessible to all. Although these programs thoroughly address the social and financial pathways that need to be developed or improved in the region, there is little to no discussion about the intersection of the homeless population within the previously established healthcare system.

What Can We Do Better?

The increased prevalence of these risk factors and associated health conditions with homelessness highlight the importance of healthcare systems designing programs aimed at assisting the homeless population. Provincial and regional programming for homeless populations focus almost entirely on the concepts of creating, sustaining and accessing affordable housing. There appears to be a wide gap in both provincial and regional programming in terms of the merging of healthcare services and targeting those who are homeless. Searches of both the Waterloo region public health information and Provincial Public Health Ontario discuss homelessness in terms of occurrence of disease prevalence, but little on homelessness as an individual health determinant.

As a healthcare provider in the emergency department setting, I see this as an opportunity to provide more effective and efficient care the population of homeless in our community as the homeless are traditionally high users of ED services (Moore et al, 2007) usually waiting until times of medical crisis before making contact with healthcare services (D’Amore et al, 2001). As this time of crisis can be used to intervene with homeless persons and identify priority needs in terms of housing, healthcare and financial assistance. Little research has been done into ED screening tools for homelessness and their effectiveness in identifying what can be a sometimes silent and transient condition (Moore et al, 2007). The rational for this may be the extensiveness of the programming that would be required to serve this population. D’Amore et al suggests that an effective program to serve the homeless population would include screening in the ED, assigned a case manager who could serve to coordinate all levels of care from medical needs, financial assistance, obtaining prescriptions, mental health and addictions programming and importantly connecting with available housing services (2001).

The vastness of a program such as these seems daunting from program perspective. Although many of these services exist in parts within our region. Working in the ED I am familiar with support provided by outreach workers to assist homeless persons, a multitude of social services support and resources for financial assistance, and a few regional programs that target high risk homeless mental health patients and palliative care for homeless persons as well. What our system lacks is a broader social program that can connect all of these services that intersect with our homeless patients who present to the ED.

Looking Forward

On a small scale, an ED screening tool to identify those at risk of, or currently homeless could be used within our current social and healthcare system. After identification with the screening tool, healthcare practitioners could be required to include discharge planning that included referral to one of the pre-existing community support programs. Part of the investigation into these programs would also have to include consultation with local homeless to gather input on interventions they feel would be successful. This could perhaps provide more comprehensive care to homeless persons and connect them with community support that was previously unknown to them.

Implementation of any large-scale program to adequately serve the complex needs of the homeless population as discussed previously would involve identifying key community partners that currently provide social, housing and financial support. Due to the expected cost of this type of programming, studies into the cost of homeless persons on the health care system would also be required to demonstrate efficiency. The multiple comorbidities associated with homelessness, the historical non-compliance with treatment and the evidence of repeat use of emergency services I believe would demonstrate a healthcare cost savings could be achieved by providing more comprehensive care to this vulnerable and complex population.

References

Canadian Observatory on Homelessness. (2017). Community Profiles – Waterloo Region, On. Retrieved from http://homelesshub.ca/community-profiles/ontario/waterloo-region

D’Amore, J., Hung, O., Chiang, W., & Goldfrank, L. (2001). The Epidemiology of the Homeless Population and Its Impact on an Urban Emergency Department. Academic Emergency Medicine (8), 1051-1055. Retrieved from https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2001.tb01114.x

Government of Ontario. (2017). Ending Homelessness What Ontario Is Doing. Retrieved from https://cdn2.hubspot.net/hubfs/316071/Resources/Case%20Studies/PCH/

PCH%20Housin g%20 Ontario.pdf

Homeless Housing Umbrella Group, (2017). Four Key Homelessness Stats for Waterloo Region. Retrieved from http://www.hhug.ca/four-key-homelessness-stats/

Moore, G., Gerdtz, M., & Manias, E. (2007). Homelessness, health status and emergency department use: An integrated review of the literature. Australasian Emergency Nursing Journal, 10, 178—185. doi:10.1016/j.aenj.2007.07.003

Ontario Ministry of Housing. (2017). Community Homelessness Prevention Initiative Program Guidelines. Retrieved from http://www.mah.gov.on.ca/AssetFactory.aspx?did=15972

Social Planning, Policy and Program Administration. (2012). All roads lead to home: The homelessness to housing stability strategy for Waterloo Region – Policy framework. Waterloo, ON: Regional Municipality of Waterloo. Retrieved from https://www.regionofwaterloo.ca/en/living-here/resources/Documents/Housing/

Homelessness-to-Housing-Stability-Strategy-Policy- Framework.pdf

Waterloo Wellington Local Health Integration Network. (2014). About US. Retrieved June 6, 2016 from http://www.waterloowellingtonlhin.on.ca/aboutus.aspx

Racial Bias in the Emergency Department

Unfortunately, I’m starting this post with some disturbing anecdotal evidence of treatment of indigenous persons when they present to the emergency department. In 2008, Brian Sinclair, an aboriginal man who presented to an ED for help and died in the waiting room, 34 hours later. Staff in the emergency department assumed that he was there to “sleep it off” and these incorrect assumptions, partially based on his being aboriginal were listed as part of the reason for his death in the courts ruling on the case (Dehaas, 2012). The judge in the case also highlighted the lack of communication between Sinclair’s support system and the healthcare system responsible for managing his multiple medical conditions including substance abuse, communication challenges, housing and a complex physical condition including bilateral leg amputations (Dehaas, 2012).

https://www.ctvnews.ca/health/death-after-34-hour-er-wait-was-preventable-judge-1.2144671

In urban settings across Canada, Aboriginal persons are more likely to use emergency departments for primary care requirements due to an inequity of access to primary care for Aboriginal people (Browne, Smye, Rodney, Tang, Mussell, & O’Neil, 2010). Creating access to appropriate and cultural relevant primary health care for Aboriginal persons in Canada is one of the goals of Health Canada for improving Aboriginal health (Health Canada, 2012). If accessible, relevant and supportive primary care initiatives focus on Aboriginal persons equal access to these services, not only will they receive more comprehensive care, but may ultimately decrease their dependence on emergency room settings that may not have sufficient resources to provide the collaborative care required to meet the complex medical and social needs of this vulnerable population.

As emergency department practitioners we also need to be aware of our own failings in providing care to Aboriginal persons. Studies have highlighted the perceived inequities that Aboriginals face when presenting to emergency departments including; feeling they are being judged on the bases of being Aboriginal, using the ED for inappropriate reasons (Browne et al, 2010), practitioners lack of knowledge of Aboriginal health, history and cultural practices, and the presence of overt racism from healthcare staff (Levin & Herbert, 2005). The Canadian Nurses Association [CNA] supports nurses efforts to provide culturally appropriate care to Aboriginal persons by providing a framework outlining six core competencies for Aboriginal nursing (Aboriginal Nurses Association of Canada, 2009) and by supporting nurses to incorporate indigenous knowledge into practice (CAN, 2014). Despite these recent efforts to improve nursing care for Aboriginal persons in Canada, there is still a demonstrated lack of understanding in health care, the impact of this lack of knowledge surrounding Aboriginal history and its relation to health is discussed in this Ted Talk by a student nurse, Dawn Tisdale.

https://www.youtube.com/watch?v=kMvn_mSsykE

As healthcare practitioners we can provided better care to our clients if we are aware of our own gaps in knowledge, and reflect on the unintentional bias we may portray in our practice. By educating ourselves Aboriginal persons experience with the healthcare system we can be better prepared to serve this vulnerable population.

References

Aboriginal Nurses Association of Canada. (2009). Cultural Competence and Cultural Safety in Nursing Education: A framework for First Nations, Inuit and Metis Nursing. Retrieved from https://www.cna-aiic.ca/-/media/cna/page-content/pdf- en/first_nations_framework_e.pdf?la=en&hash=DEE45D341B96BDA653C57B7737AE 6E300C708 C42

Browne, A. J., Smye, V. L., Rodney, P., Tang, S. Y., Mussell, B., & O'Neil, J. (2010). Access to Primary Care From the Perspective of Aboriginal Patients at an Urban Emergency Department. Qualitative Health Research, 21(3), 333-348. Retrieved from https://doi.org/10.1177/1049732310385824

Canadian Nurses Association. (2014). Aboriginal Health Nursing and Aboriginal Health: Charting Policy Direction for Nursing in Canada. Retrieved from https://www.cna- aiic.ca/-/media/cna/page-content/pdf-en/aboriginal-health-nursing-and-aboriginal- health_charting-policy-direction-for- nursing-in- canada.pdf?la=en&hash=59F4641D59EBDE29D9CC573CAF19FA8706647625

Dehaas, J. (2012, December 12). Death after 34-hour ER wait was preventable: judge. CTV News. Retrieved from https://www.ctvnews.ca/health/death-after-34-hour-er-wait-was- preventable-judge-1.2144671

Health Canada. (2012). First Nations and Inuit Health Strategic Plan: A shared path to improved health. Retrieved from https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/fniah- spnia/alt_formats/pdf/pubs/strat-plan-2012/strat-plan-2012-eng.pdf

Levin, R. & Herbert, M. (2005) The Experience of Urban Aboriginals with Health Care Services in Canada. Social Work in Health Care, 39(1), 165-179, DOI: 10.1300/J010v39n01_11

Tedx Talks. (2015, June 4). Dawn Tisdale: The Impact of Residential Schools on Aboriginal Healthcare [Video File]. Retrieved from https://www.youtube.com/watch?v=kMvn_mSsykE

Seeing Beyond the Patient: Revised

An ecological framework for understanding adolescent suicidal behaviours and its implications for emergency room nurses

As a registered nurse in the emergency department, a population of patients that I encounter daily are adolescents with suicidal acts or thoughts. The nursing of this vulnerable population involves caring for families of children who have ended their own life, managing the medical needs of overdose attempts and providing safety to those adolescents who come to the emergency room with suicidal ideation. By using an ecological approach to health, nurses can have a have more comprehensive understanding of the complex nature of adolescent suicide.

Ecological Theory

Ecological theories of health take into consideration both the individual, their environments, and the effects of overlaying policy (Sallis & Owen, 2015). One of the earliest, modern multiple levels of health theory was proposed by Urie Bronfenbrenner in 1977. His model described multiple levels of influence on the individual behaviour in the micro-, meso-, exo- and macrosystems and how all of these layers of influence interact with each other (Tannenbaum, 2018). Suicide prevention can be viewed through an ecological theory by using a four-tiered model of individual, relationship, community and societal influences that recognizes the complex interplay between levels and outlines risk and protective factors related to suicidal behaviours. (Office of the Surgeon General, National Action Alliance for Suicide Prevention, 2012).

Figure 1. Examples of a Social Ecological Model and Risk and Protective Factors Related to Suicide. Office of the Surgeon General, National Action Alliance for Suicide Prevention, (2012).

Adolescent Suicidal Behaviours and Health Promotion

The Waterloo Wellington Local Health Integration Network (WWLHIN) identifies promoting healthy childhood development as one of its key determinants of health to focus on in the region (Seskar-Hencic, 2011). Suicide is the second leading cause of death from age 14-35 (Statistics Canada, 2017) and for every completed suicide there may be 100-200 unreported additional attempts (Larkin & Beautrais, 2010). By using an ecological framework for understanding suicide, healthcare providers can better understand the nature of this complex illness and design protective interventions aimed at promoting resilience with considerations at all levels (Office of the Surgeon General, National Action Alliance for Suicide Prevention, 2012).

Individual Level

When examining adolescent suicidal behaviour at the level of the individual there are multiple factors that should be considered due to the complex nature of identifying those at risk. Depression, hopelessness and substance abuse are seen as the most significant risk factors associated with adolescent suicide (Ayyash-Abdo, 2002). Gender in adolescent suicidal behaviour is a paradox, although statistically more females attempt suicide, completion of suicide is more common amongst males (Langhinrichsen-Rohling, Friend, & Powell, 2009). Gender identity in adolescents is also a key determinant in identifying at-risk youth as those who belong to sexual minorities are more likely to think about or attempt suicide (Russell & Joyner, 2001). These individual factors in isolation are not known to be causative factors for suicide in adolescents but demonstrate the need for a multilevel ecological approach to understand adolescents who may be at risk (Ayyash-Abdo, 2002).

Identifying individual risk factors may be the most obvious in emergency department settings as they are easily reported and clinically assessed. The important consideration for emergency department nurses is to view the patient outside of this layer and consider the interaction with all layers of the environment. Routine health promotions strategies that target individuals, seek to change individual behaviour (McLeroy et al, 1988) and in the emergency setting this could include referral to drug cessation programs, specialized mental health treatment, or support groups for GLBTQ youth with the goal of increasing the adolescent’s individual protective behaviours.

Relationships

Interpersonal relationships with family, friends, teachers and acquaintances directly affect behaviour and health as they provide support and mediate life stress (McLeroy et al, 1988). Adolescents are particularly vulnerable on this level with almost one third of those who attempt suicide report feeling isolated or having broken up from a relationship before the attempt (Ayyash-Abdo, 2002). As adolescents have a crucial need for close friendships, the loss of these interpersonal relationships is significant, as is family dysfunction and parental psychopathologies which are both correlated with higher suicide attempts by adolescents (Ayyash-Abdo, 2002). Nurses in the emergency department should consider these risk factors when assessing adolescents at risk for suicidal behaviours. Assessment of their perception of loss and interactions with family supports could help to identify those at risk. Targeted health promotion activities such as therapy that includes parental support have shown to be of benefit in reducing depressive thoughts in adolescents and the coping abilities of the family unit (Rotheram-Borus, 2000).

Community

How organizations can support behavioural changes and targeting health promotion to create organizational change is a key concept when considering an ecological perspective on health promotion (McLeroy et al, 1988). Adolescents spend a large amount of time in the school setting and a large number of suicide prevention programs are based in schools (Ayyash-Abdo, 2002). Programs aimed at creating support in school setting for at risk groups have shown to have positive affects (Eggert, Thompson, Herting, & Nicholas, 1995). Emergency department nurse’s awareness of programs available in local school boards can be a valuable resource when referring adolescents who present with suicidal behaviours.

The community setting can refer not only the physical, but also the psychological sense of community (McLeroy et al, 1988) and to adolescents this would include traditional as well as social media as nearly one hundred percent of adolescents (age 15-24) use social media daily (Statistics Canada, 2018). Although research into social media use and suicide risk has yet to draw many sound conclusions, the presence of cyberbullying increases the risk of suicide amongst adolescents at two times the rate of those who are not (Luxton, June, & Fairall, 2012) and adolescents who engage in the social media community for more than two hours a day are found to report poorer mental well being, including suicidal thoughts (Sampasa-Kanyinga & Lewis, 2015). When adolescents present to the emergency department with suicidal behaviours, considerations for the effects of social media on the client should be considered. This may include interventions such as assessing the appropriateness of patients having access to social media accounts or the posting of suicidal messaging in group forums. Assessing a client’s history of cyberbullying is an important intervention as fifteen percent of adolescent’s report being cyberbullied within the last year (Statistics Canada, 2018).

Societal Factors

Societal influences on health involves the use of policies, regulations and laws that protect the health of communities (McLeroy et al., 1988). The federal government influences suicide prevention in Canada through multiple programs including; addressing suicide prevention by creating public awareness campaigns to reduce stigma, promoting suicide awareness in schools and workplaces through the Mental Health Commission of Canada’s Opening Minds campaign, creating legislation for psychological well being in the workplace, funding research into suicide prevention, and monitoring suicide trends across Canada (Government of Canada, 2016). The Canadian Public Health Agency supports children through the Community Action Program for Children which address determinants that may affect a child’s risk for suicidal behaviour later in life by providing nutrition, parental coping skills and family violence support (Public Health Agency of Canada, 2015). The Government of Canada also seeks to address health inequity in its support of suicide prevention programs for indigenous youth in Canada, as suicide rates among indigenous youth in Canada are some of the highest in the world (Government of Canada, 2013). Through the National Aboriginal Youth Suicide Prevention Strategy, the government aims to coordinate suicide prevention strategies across all levels of government, including large scale prevention and community-based treatment with an emphasis on the community identifying its own needs (Government of Canada, 2013).

Creation of public policies related to reducing cyberbullying occurs at the societal level of ecological health promotion theory and could include education programs, national policies and the development of laws aimed at targeting cyberbullying (Luxton et al, 2012). Social media and the internet can be used preventatively in order to address suicide prevention in health promotion activities aimed at targeting individuals, schools and by creating larger public health outreach campaigns (Luxton et al, 2012).

The implication for nurses working in emergency department settings is the need to be aware of federal prevention programs that may exist in their communities and methods of engaging youth at risk with these programs. As members of larger professional bodies nurses also have the opportunity to directly influence public policy. Groups such as the Canadian Nurses Association have influence on public policy in Canada and work to ensure policy takes health and well-being on all levels into account when policies are formed (CNA, n.d.).

Conclusion

Nurses in emergency departments often meet patients in a time of crisis, focusing on the individual client and their immediate needs thus failing to consider environmental determinants that affect a client’s risk. Multiple studies have demonstrated that in isolation individual risk factors do not increase risk of suicide therefor demonstrating the importance of viewing suicide and suicide prevention through a broader lens (Perkins & Hartless, 2002). Using an ecological model of health can help health care providers look beyond the individual in crisis and understand the multiple factors associated with adolescent suicide. If considerations into ecological theory are made when treating adolescents with suicidal behaviours, nurses will be better prepared to support their clients by enforcing protective behaviours and focussing on health determinants at all levels of the environment.

References

Ayyash-Abdo, H. (2002). Adolescent Suicide: An ecological approach. Psychology in the Schools, 39(4). doi: 10.1002/pits.10042

Canadian Nurses Association. (n.d.). Health in All Policies National Action Plan. Retrieved from https://www.cna-aiic.ca/-/media/nurseone/page-content/pdf-en/hiap- national_action_plan_e.pdf?la=en&hash=FB495B27139AAB8767E5A94E84033DFEE5 C4F04C

Eggert, L. L, Thompson, E. A, Herting, J. R., & Nicholas, L.J. (1995). Reducing Suicide Potential Among High‐Risk Youth: Tests of a School‐Based Prevention Program. Suicide and Life Threatening Behaviour, 25(2). https://doi.org/10.1111/j.1943- 278X.1995.tb00926.x

Government of Canada. (2013). National Aboriginal Youth Suicide Prevention Strategy (NAYSPS) Program Framework. Retrieved from https://www.canada.ca/en/indigenous- services-canada/services/first-nations-inuit-health/reports-publications/health- promotion/national-aboriginal-youth-suicide-prevention-strategy-program- framework.html

Government of Canada. (2016). Overview of federal initiatives in suicide prevention. Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy- living/overview-federal-initiatives-suicide-prevention.html

Larkin, G. L. & Beautrais, A. L. (2010). Emergency Departments Are Underutilized Sites for Suicide Prevention. Crisis, 31(1). doi 10.1027/0227-5910/a000001

Langhinrichsen-Rohling, J., Friend, J., & Powell, A. (2009). Adolescent suicide, gender, and culture: A rate and risk factor analysis. Aggression and Violent Behaviour, 14. doi 10.1016/j.avb.2009.06.010

McLeroy, K., Bibeau, D., Steckler, A., & Glanz, K. (1988). An Ecological Perspective on Health Promotion Programs. Health Education Quarterly 15(4). Retrieved from https://www.cdc.gov/violenceprevention/overview/social- ecologicalmodel.htmlhttps://www.researchgate.net/profile/Kenneth_Mcleroy/publication/ 20088489_An_Ecology_Perspective_on_Health_Promotion_Programs/links/0d1c84f972 a1e3f12d000000/An-Ecology-Perspective-on-Health-Promotion-Programs.pdf

Miller, R. [Randy Miller]. (2013, June 27). An Introduction to the Ecological Model in Public Health [Video File]. Retrieved from https://www.youtube.com/watch?v=xhUxOZRn_4E

Office of the Surgeon General, National Action Alliance for Suicide Prevention. (2012) National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. US Department of Health & Human Services, Washington DC. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK109906/

Perkins, D. F., & Hartless, G. (2002). An Ecological Risk-Factor Examination of Suicide Ideation and Behavior of Adolescents. Journal of Adolescent Research, 17(1). doi/pdf/10.1177/0743558402171001

Public Health Agency of Canada. (2015). Community Action Program for Children (CAPC). Retrieved from https://www.canada.ca/en/public-health/services/health- promotion/childhood-adolescence/programs-initiatives/community-action-program- children-capc.html

Russel, S. T., & Joyner, K. (2001). Adolescent Sexual Orientation and Suicide Risk: Evidence From a National Study. American Journal of Public Health, 91(8). Retrieved from https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.91.8.1276

Rotheram-Borus, M. J., Piacentini, J., Cantwell, C., Belin, T. R., & Song, J. (2000). The 18- Month Impact of an Emergency Room Intervention for Adolescent Female Suicide Attempters. Journal of Consulting and Clinical Psychology 68(6). doi: 10.1037//0022- 006X.68.6.1081

Sallis, J. F., & Owen, N. (2015). Ecological Models of Health Behaviour. In K. Glanz, B. Rimer, & K. Viswanath (Eds.), Health Behaviour: Theory, Research, and Practice (pp. 43-64). Retrieved from https://books.google.ca/books?id=0j4LCgAAQBAJ &printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false

Sampasa-Kanyinga, H. & Lewis, R. F. (2015). Frequent Use of Social Networking Sites Is Associated with Poor Psychological Functioning Among Children and Adolescents. Cyberpsychology, Behaviour, and Social Networking, 18(7). doi: 10.1089/cyber.2015.0055

Seskar-Hencic, D. (2011). Addressing Social Determinants of Health in the Waterloo Wellington Social Health Integration Network Area: Public Health Perspective on Local Health Policy and Programming Needs. Waterloo Wellington Local Health Integration Network. Retrieved June 5, 2018 from http://www.waterloowellingtonlhin.on.ca/~/media/sites/ww

/files/aboutus/RPT_EQUITY_20111018_PublicHealth_

SocialDeterminants.pdf?la=en

Statistics Canada. (2017). Suicide Rates: An overview. Retrieved from https://www150.statcan.gc.ca/n1/pub/82-624-x/2012001/article/11696-eng.htm

Statistics Canada. (2018). A Portrait of Canadian Youth. Retrieved from https://www150.statcan.gc.ca/n1/pub/11-631-x/11-631-x2018001-eng.htm

Tannenbaum, R. [Rachel Tannenbaum]. (2018, January 3). Bronfenbrenner’s ecological theory [Video File]. Retrieved from https://www.youtube.com/watch?v=HV4E05BnoI8