CHAPTER II: WHAT MAKES CHILDREN HEALTHY?
The Committee members used the population health framework to give shape to the issues surrounding children's health. Many witnesses supported this approach and reiterated the evidence about what makes children healthy. This framework, advanced by a federal, provincial and territorial advisory group in 1994, proposes that all governments develop strategies that focus on five categories of health determinants. These include: social and economic environment, physical environment, personal health practices, individual capacity and coping skills, and services needed for health. Within the population health framework, witnesses ascribed major roles to families, communities and governments as the segments of society that interface between children and these broad determinants.
A. FAMILIES, COMMUNITIES AND GOVERNMENTS
1. Children and Families
The families of children were seen to be the most significant factor affecting their overall health. According to witnesses, families came in many forms but all were responsible for nurturing and supporting children. Ensuring healthy child development was for many synonymous with ensuring healthy family development. Witnesses observed the growing diversity of family forms and patterns of functioning. Most witnesses acknowledged the primary role of the nuclear family but, stressed how the extended family continues to benefit children. They talked about the importance of positive parenting in ensuring child health while emphasising the need to be realistic about who acts as a parent to the child. (CICH 71:62, CPHA 72:8, NCPC 8:5, SLA 9:9, CRRU 10:9, CAFRP 12:13, KF 12:19)Of the individuals involved in parenting roles, those who filled a mothering role received the most specific recognition, with witnesses pushing for measures that would improve availability of time for women who carry the double burden of childcaring and parentcaring, frequently in addition to paid employment. Some also stressed that more than one parent needed to be fully involved, that any increase in family time for children meant having fathers more available. (CICH 71:10, SLA 9:8, KF 12:19)
2. Children and Communities
Communities were seen as having the ability to mobilise and to respond to the needs of children and their families. While witnesses saw families as the crucial variables in child health, they warned that they could not accomplish everything on their own. Attempts to address the concept of community led to varied results with some arguing for a broad societal context and others seeing a particular geographical area such as a municipality or physical neighbourhood. The understanding of what constituted a healthy community was expressed as the creation of public will, with a community actively taking on the well-being of children as part of its usual endeavours, and in terms of civic vitality, as one of the environmental indicators used to measure progress for children. Witnesses asserted that there was a dynamic and reciprocal arrangement whereby a healthy community led to healthy children and healthy children along with their families created and supported a healthy community. (CICH 71:3, CIAR 71:25, CPHA 72:9, NCPC 8:5, NCPC 8:11, CCSD 9:18, P123 9:26, PHT 11:9, GUHD 12:7)Different sectors in a community were viewed as having different roles. Witnesses talked about formal systems of health and social service delivery and informal systems such as extended family and neighbourhood support. For some this involved direct participation by health professionals in the community; for others, it meant using electronic venues like the Brighter Futures Network to link expert knowledge with community wisdom. Schools were highlighted as a key element in the process, as community leaders. Several witnesses mentioned the role that the corporate sector was playing or could play in furthering child health initiatives. Corporate funding was viewed as conveying the message that children are a major resource for future economic stability, that such investment makes good sense. But some argued that corporate involvement must go beyond funding to ensure that employees, male and female, have access to workplace policies that enable them to combine their family responsibilities and their careers. (SLA 9:8, CRRU 10:11, CICH 71:11, CIAR 71:18, CPHA 72:4&9, CPS 72:15, NCPC 8:5, P123 9:27, GUHD 12:1, KF 12:20, VIF 12:30)
3. Children and Governments
All levels of government - municipal, provincial/territorial and federal - were attributed a significant role in furthering the health of children through work with families, with communities and with each other. Each level of government was seen to have a responsibility. For some, the municipal and provincial governments, along with the voluntary organisations, provided the services and the federal government funded and promoted the broad policy framework for the services. One witness envisioned a ship where the community-based agencies were the engine, the provincial governments the sailors, and the federal government pilot and navigator. (C2000 4:6, NCPC 8:3)Within various levels of government, witnesses stressed the need for collaborative, intersectoral action that would involve a close connection of health with broader social, justice, employment and economic policies. Departments were urged to co-ordinate their efforts to develop a comprehensive strategy for children and their families. Intersectoral analysis, planning and collaborative action were seen as essential to healthy public policy for children. (CICH 71:3, CIAR 71:20, CPHA 72:3)
Governments were urged to develop indicators, criteria and guidelines for advancing child health. They were also pressed to consider fiscal and other policies that embrace a holistic approach considerate of the long-term as well as short-term needs of children. They were to conduct an impact analysis on all proposed policies to ascertain their effect on the health and well-being of children, youth, and families. They were to aim for good family policy in their exercise of fiscal restraint, to consider carefully how the burden of that restraint was distributed. They were reminded that Canada has two deficits, one economic and the other social, and that, in trying to correct one by aggravating the other, both of them might end up in a worse state. (CPHA 72:3,SLA 9:4, PHT 11:10, VIF 12:31)
B. DETERMINANTS OF CHILD HEALTH
1. Social and economic environment
Most witnesses argued that families must be able to rely on communities and governments for assistance in meeting their children's developmental needs. This mutual support was seen to be increasingly important in a time of major socio-economic changes and evolving family structures. Many witnesses deplored the reductions in federal transfers to the provinces, the erosion of funding for services aimed at children and families, and the absence of national standards attached to the social side of the Canada Health and Social Transfer. One witness described three factors facing many families with children: "the fact that one has to work so much longer to stay above the poverty line if you're working for minimum wage and that in over 70% of families you need two incomes to stay above the poverty line; the increased divorce rate; and the decreased availability of the extended family." (SLA 9:2)The strong association between poverty and negative health outcomes was mentioned frequently. Witnesses agreed that poverty is more than a lack of money. One asserted that: "Poverty, unemployment, and economic insecurity threaten the social, emotional, and spiritual health of families and communities and deny equal life chances to children." (CPHA 72:2-3) Poverty was related to adverse health outcomes for children in three ways: for the children directly, for pregnant women, and for families with children.
For children directly, the Canadian Institute for Child Health observed: "The effects of poverty on children are roughly to more than double all aspects of child ill health. . .The accidental death rate, low birth weight, infant mortality rate, school performance, and psychiatric disorders - all increase by at least two-fold, and many increase more than two-fold. Likewise, pregnancy, smoking, and the use of drugs are all more of a problem for children living in poverty." (CICH 71:6) Another witness reiterated: "We know that growing up in poverty - and it isn't just the economic deprivation, it's the psychosocial deprivations that are highly clustered in a poor population - doubles the rate of just about every poor outcome for children except conduct disorder, which is the forerunner of delinquency, and it more than triples the rate of that." (SLA 9:4)
Pregnant women are themselves seriously affected by inadequate income with adverse results for a developing foetus. A Montreal Diet Dispensary survey on rent levels determined that some families spend 46% of their total income on rent, thus leaving practically no money for food. It noted that: "Fifteen percent of our mothers don't have a single penny and have neither welfare nor unemployment insurance. They have nothing. So we have to find a way to feed them. We offer them a litre of milk and an egg supplement every day." (MDD 11:26)
In relation to families with children, it was noted that there has been "a generational redistribution of wealth away from families with young children," a fact that is "a concern if we have a longitudinal and human development perspective on health." (CIAR 71:18) Campaign 2000 argued for a life cycle approach to addressing the needs of children that includes all families through their entire life courses: "Economically, it focuses on families with modest and medium incomes, as well as on poor families. These families are most vulnerable to life cycle events that lead to poverty."(C2000 4:3) Several witnesses called for changes to the tax system that would increase resources available to families, including changes so that one-income families with children would receive more equitable treatment. (SLA 9:3, KF 12:20, VIF 12:31)
Unemployment as well as underemployment among parents were targeted as major contributors to negative outcomes for children. The Canadian Institute for Child Health noted that, of the 41% of parents below the age of 30 with children who are living in poverty: "Many of those are families who aren't, as we've heard, welfare bums. Thirty-five percent of those families have members of the family who have actually had either college or university education. So it's not totally a matter so much of education. For these families in this economic climate. . .obviously we have to improve their employment in order to be able to provide an economic background so they can bring their children up in reasonable circumstances." (CICH 71:10) Campaign 2000 noted the real consequences of extended unemployment for families: "Stress levels are high. You see families having to move because they are no longer able to meet the cost of their accommodation. The indignities they feel in going into food banks is something you see. We also see the impact in the classroom in growing inattentiveness, stress, days missed, etc. The effects are very clear. They're ripple effects, but they ripple beyond just the family into the community and society as a whole." (C2000 4:5)
2. Physical environment
Witnesses linked this area of health determinants to developmental issues for children. Access to adequate and inexpensive housing, food, transportation and recreation were among the highlighted areas. Local communities were seen as central, "working together to challenge issues of isolation, poverty and inequality." (CICH 71:3), as changing to ensure that "a child in his neighbourhood, in his playground, in his day care, in his school, is surrounded by adults who are caring and who are able to be there for the child, even at times when his parents aren't available." (SLA 9:3)Housing was seen as a critical variable for children's health. The Toronto Department of Public Health talked about the impact of a lack of affordable housing for low-income families with children: "According to information from the Metro Toronto hostel services, children are the fastest-growing group of new homeless. Mother-led families relying on shelters were up 53% in November 1995, compared to November 1994, while couples with children increased 27%. In January 1996, landlord eviction applications to the sheriff's office were recorded to be 25% higher than that of the previous year." (PHT 11:10) In addition, "the number of families with children who have been involved with Children's Aid and have had to share accommodation has doubled. This is a situation that raises concerns around housing adequacy and overcrowding for children. The Ontario child health study has found that the lack of space at home may be responsible for slowing down intellectual and physicalmotor development, and has been shown to be a factor in poor school attendance." (PHT 11:10)
In Vancouver's YWCA Crabtree Corner, an emergency licensed child care and family centre in a corner of a city parking lot in the downtown eastside, all of the children live in poverty and face the accompanying physical conditions: "The families live in hotel rooms, rooming houses or shared space with several families in one- or two-bedroom suites, all substandard housing. Often the houses do not have fridges, stoves, running water and heat. Cockroaches, mice and other pests are standard, as are needles and condoms in the halls. The rents are very high. High rent means less money for food. A lack of money, cooking and refrigeration means poor nutrition. During the third week of each welfare cheque month, Crabtree has a long waiting list as mothers try to get their children into the day care so the children will be fed." (YCC 10:20)
The problem of trying to feed children adequately was also related to physical barriers that limited access to inexpensive food. Parents in the Saint-Michel area of Montreal who were involved with the Project 1, 2, 3, GO! For a Good Start in Life listed adequate feeding of their children as a major priority. Because the neighbourhood had no supermarkets, parents were faced with buying more expensive food in convenience stores. In addition to an access problem, they faced a cost problem. The community solutions included the establishment of a restaurant providing inexpensive meals and a bringing together of the elderly and young mothers to share recipes and cooking experiences. (P123 9:27-28)
Access to safe and stimulating recreational environments in communities was promoted by several witnesses. The Canadian Institute for Child Health emphasised the need for communities to focus attention "on preventive approaches altering the environments in which children live and play." (CICH 71:4) This included a range of interventions from lowering speed limits to providing safe, quality care for pre- and school age children as well as the issue of adequate transportation for children and youth with disabilities. Data suggested that there was "inadequate transportation in 25% of instances of children with disability. That prevents them from participating in leisure activities, something the rest of children in society can do." (CICH 71:7) The Childcare Resource and Research Unit suggested that children's physical skills are enhanced in high-quality child care: "High-quality child care is that which goes beyond simply protecting the child's health and safety to also supporting and assisting the child's physical, emotional, social and cognitive development." (CRRU 10:10)
3. Personal health practices
Most of the discussions about personal health practices that affect child health were directed at women as the childbearers and childcarers. The emphasis was on supporting women - as teenagers, when pregnant and when caring for children - in making positive life choices about sexual and personal relationships, about prenatal nutrition, about breastfeeding and about child development. For some, it meant changes within the family, particularly getting more fathers involved. For others, it pointed to community involvement, particularly getting neighbourhoods more focused.Witnesses were cognisant of the influences on the lives of women that affect their ability to make good decisions for their children. For example, the overall poor health of families involved in the Crabtree program was related to the fact that they have "experienced multiple traumas, including multiple family deaths, systemic racism, sexism, classism, and physical, sexual and emotional abuse. (YCC 10:20) For the Toronto Coalition on Perinatal Nutrition, some risk factors that increase the chance of a woman delivering a low birthweight baby "may include poverty, poor nutrition before and during pregnancy, single parenting, teenage parenting, poor or no prenatal care, living with a violent partner, stress, smoking, drug and/or alcohol use and workplace stress." (TCPN 11:17-18)
Illiteracy was identified as one of the major factors limiting women in their personal health practices. One witness noted that many parents in a Moncton program operated below the grade 5 level. She questioned: "How many of you know people who follow someone on social assistance in a grocery store? Your constituents will ask you why you give them more money. They buy a pizza that's already made and they buy Campbell's soup. Well, yes, they can't read. What do you want them to buy, dog food. If we could teach them how to read, they would know what to buy when they go to a grocery store." (NCPC 8:14)
The ability to influence good health and to prevent poor developmental outcomes in children was attributed to careful health practices both before and after birth. The Toronto Coalition on Perinatal Nutrition pointed out that: "When a new mom is lacking self-esteem and confidence in herself, she may not be able to provide the nurturing relationship required by a child at this crucial point in its life." (TCPN 11:18) Both the Toronto Coalition and the Montreal Diet Dispensary concurred that preventing low birth weight through direct prenatal nutrition programs is very cost effective.(TCPN 11:19, MDD 11:25) After birth, according to the National Institute of Nutrition, "If a healthy lifestyle and healthy attitude toward food are established at a young age it can play a pivotal role in avoiding many of the food-related illnesses of later life. Eating disorders, chronic diseases such as heart disease and cancer, and obesity have strong links to nutrition." (NIN 11:1)
Working with young women was seen as vital. The Canadian Association of Family Resource Programs talked about "connecting with young people before they have children" through parenting workshops in high schools. (CAFRP 12:14) Toronto's Public Health Department talked about education on both sexuality and decision-making about relationships as preventive measures in relation to pregnancy among teenagers. It also emphasised working with young mothers to build up their self-esteem, to make them feel better about themselves in their roles as mothers and to help them stimulate their children. Program successes result in "getting mothers who, once they start feeling better about themselves, feel more a part of the community and that they can achieve something. Then their outlook will change, so perhaps we can get them back into the workforce and contributing." (PHT 11:12) Home visiting programs were strongly supported by several witnesses. (CICH 71:3, CPS 72:12)
Witnesses suggested varied but comprehensive methods were needed to assist women in making positive choices for themselves and their children. Through the Toronto Coalition on Perinatal Nutrition and Support Programs, "women learn from each other, and, therefore, programs encourage role modelling, mutual aid and support. We also encourage peer leadership, particularly in areas such as breastfeeding and parent-child bonding." (CPNSP 11:19) For other women, electronic computer-based projects, including one operated out of Dalhousie University, providing reconditioned computers to teen moms in their own homes facilitated "connecting with each other on-line and with experts in terms of accessing support around raising their children." (GUHD 12:7)
Positive support for the women and other family members who provide daily care for children was strongly encouraged by witnesses. For Kids First, "education about the importance of attachment, parenting and nurturing on the development of trusting, affectionate, empathetic children is critical." (KF 12:20) The Canadian Institute for Child Health saw a need "to develop an integrated and comprehensive parent education program to meet the developmental needs of pre-school children." (CICH 71:5) According to the Canadian Public Health Association, the federal government could co-ordinate the provision of education and training on parenting skills, includingthe continuation of initiatives such as the Nobody's Perfect parenting program.(CPHA 72:3) The Vanier Institute of the Family recommended "marriage preparation programs, parenting classes, respite services, parents-without-partners groups or programs specifically designed for children whose parents are separating or divorcing." (VIF 12:30)
4. Individual capacity and coping skills
The issues of personal competence and sense of control as characteristics relevant to the health of a child were highlighted. Witnesses touched on a variety of social and physical variables that contribute to strong, resourceful children. It was noted that resiliency in children involves social competency, ability to problem-solve, autonomy, a good sense of self, a sense of purpose in a future, a caring and supportive environment, and high expectations. (CPHA 72:10)One witness referred to a possible physiological base for positive outcomes for children, pointing to research in neuroscience and brain development and research on the neuroimmune system and its responsiveness to early experiences. He suggested that "people familiar with this literature are using phrases like neurosculpting, where individuals' experiences create specific kinds of networks and pathways at the neural level that have tremendous impacts on health." (CIAR 71:17) Another issue, the development of gender identity, was also raised: "Developing gender identity is obviously very complex, beginning in fetal life. There is little argument, however, that gender identity determines to large extent the choices we make and the life paths we're choosing. Understanding the influences of gender is central to any analysis of the various determinants." He called for particular attention to the girl child and pointed specifically to data showing that mental health worsens amongst adolescent girls atage 11. (CICH 71:5)
For another witness, "the quality of caring that a child receives in his first three years of life is the most important single factor in that child's development, apart from genetics. We know now that there are certain windows of opportunity: a window for intellectual development, a window for emotional control, and a window for the potential for attachment. Attachment is the source of the capacity for trusting and forming satisfying ongoing relationships. It is the basis for all socialisation. It is the basis for having the capacity to be sensitive to the feelings of others, and it is the basis for willingness to change one's behaviour to please others. We know that those windows of opportunity close by the third year of life." (SLA 9:2) One witness reported on the findings of a meta-analysis that: "regular non-parental care, prior to the age of five, of more than 20 hours per week has an unmistakably negative effect in . . .social and emotional development, behavioural development of children, and bonding." (NFFRE 10:4)
But, as many witnesses emphasised, it is not just parents who make the difference; there are kids who succeed in spite of problems in their immediate family: "When we look at kids who beat the odds, one of the factors almost universally found in the research is that a buffering factor is provided either within the extended family or within the local community. The buffering factors we're talking about here are individual adults who are close enough to the child to provide supports for that individual, and to provide the kind of support that makes up for some of these issues that may be problematic early in life. (CIAR 71:18) At YWCA Crabtree Corner, success for the seriously disadvantaged children was linked to the bond that develops between the children and the child care staff: "The children then have somebody in their lives who they know thinks they're wonderful. I've heard in the literature that this is referred to as a cookie person, somebody on your block who says hello to the child or gives the child a cookie, or somebody like a day care worker who is special. That one person can build a lot of resiliency into a child's ability to cope." (YCC 10:25)
5. Services for health
Witnesses told the Committee about the multiple programs and services needed to ensure healthy children. They saw governments and communities working together to ensure that informal and formal services were available to families with children. The services went beyond the traditional health sector and included those in educational, recreational and social areas. Most witnesses argued for diverse programs; some with universal application and others aimed at particular segments of the population.The arguments for universal applications across the population of all children, youth and families emphasised that: "Countries with comprehensive health care and social programs, especially universally applied ones that support families through maternity leave, child and family allowances, housing provisions, home visitation, and childcare services, have low infant mortality rates." (CICH 71:3) Targeted services addressing the needs of specific groups were viewed as expensive and stigmatising: "a strategy focusing exclusively on those people already in poverty not only doesn't work, because it doesn't even particularly reduce poverty, but it is also potentially a highly divisive strategy. It would pit modest-income families. . .against the people who are living in even more dire situations of deprivation. . .it is one of the dangers of moving toward proposals focusing ever more on targeting our resources to those, as we put it, most in need." (C2000 4:7)
Specific children-focused services included centre-based care, nursery schools, regulated family day care, head start programs, child development centres, and a continuation of the community action programs currently offered through the federal Child Development Initiative. Some witnesses pressed for a national policy, ensuring that "all regions of Canada offer a range of flexible child care services under provincial jurisdiction, planned at the local level and complemented by improved parental leave." These services "would not be intended for targeted groups - children with mothers in the paid labour force or children who are in poverty or children who are at risk - but would be a comprehensive system of services that would vary with the local community." (CRRU 10:11)
For some, there was need for more focus on all families through "communities from which families draw their strength by investing in family resource programs such as toy-lending libraries, public libraries, recreational facilities and programs and community development initiatives" with additional assistance to "vulnerable families or vulnerable family members through such measures as targeted income support programs, transportation or housing subsidies, clothing and food banks, headstart programs of poor children." (VIF 12:30) Other witnesses argued that the government should be targeting "the minority of parents experiencing difficulty. . .The government would be able to focus more directly on specific programs to offer direct assistance and to help people rather than try to set a safety net for all of the country. The net is too wide and many people are falling through." (NFFRE 10:8) Aboriginal children and immigrant children were identified as needing particular attention. (CPHA 72:4,CPS 72:11, YCC 10:21)
The primary emphasis was on the development of a responsive community support system. Through intersectoral collaboration, it was to provide "integrated or seamless services to children at the local level." (CIAR 71:20) Seen as essential "to promote healthy child development, enhance learning, and help families through difficult transitions," this community support system would include health education, nutrition programs; child care and family resource programs; family life education and youth support, education and training programs. (C2000 4:5) The Community Action Program for Children, one component of the federal government's Child Development Initiative, was praised for doing things differently and for empowering the community. (CPHA 72:4, YCC 10:21, CAFRP 12:8)
In addition to the range of services needed for children's health, witnesses outlined the multiple players involved in delivering services. On one level, there were the family-responsive participatory efforts: "Family resource programs do a great deal to promote mutual aid-type activities, either informally or more formally, such as community kitchens and baby-sitting co-operatives. Some programs are involved in activities that promote nutrition, including through food banks, teaching about nutrition and the community kitchens. Some of them access funding through the federal government for the prenatal nutrition programs." (CAFRP 12:9)
On another community-oriented plane, witnesses mentioned the volunteer and paid service workers: "We have volunteers who are specifically recruited to meet the language needs of our participants. All programs in the city are community collaboratives and are delivered by a multi-disciplinary team of staff, including nurses, dieticians, social workers, home visitors, early childhood educators and community workers. The result is a more holistic response to the complex multifaceted issues these high-risk pregnant women face." (TCPN 11:18)
2 References from Evidence: abbreviated organisational name followed by numbers of the meeting and page.