The Editor's Letter
In early 2010, I approached Longwoods Publishing with a bold idea: to develop a four-part Healthcare Quarterly series on child health in Canada. Anton Hart and Dianne Foster-Kent immediately embraced my plan. Since then, they and their hard-working team have provided immense support to collecting and publishing insightful, multidisciplinary studies that have expanded the boundaries of knowledge and practice relating to the health and well-being of children and youth in Canada.
The series launched in October 2010 with the publication of an issue devoted to the social determinants of health. That collection was followed in May 2011 by an issue exploring mental health and by a third, in October 2011, on health system performance. If you have not yet had an opportunity to peruse these issues, I encourage you to do so; they are all freely available online.
Investing in children's health
I am now pleased to bring you the fourth issue in the Child Health in Canada series. The essays gathered here take an in-depth look at various facets of investing in children's health. The fundamental tenet underpinning this issue is the belief that every child deserves to be healthy. Turning that conviction into reality takes, as our contributors show, major investments in time, money, policy-formation, monitoring, education and system change.
A recent report from the Canadian Coalition for the Rights of Children (CCRC) – chaired by Kathy Vandergrift, one of the authors included in this special issue – draws on evidence showing that "a positive return on investment in early childhood care and development" is paid not just at the individual but also the group level. The "benefits," the authors argue, "include increased capacity for success as adults, reduced healthcare and other social costs over a lifetime, and greater social cohesion through participation in community-based initiatives focused on the common goal of raising healthy children who are integrated into society" (2011: 55). Taking a similar position, earlier this year the Canadian Paediatric Society (CPS) noted that children and youth not only are "our most powerful assets," they also offer "the best possible return on public investment toward ensuring a strong economy and a healthy nation" (2012: 4).
Having spent most of my career in the child-health sector, I know that what these experts are saying is the truth. Time and again I have seen proof that securing a strong foundation for children and youth is essential for their health, well-being and prosperity as adults – a prosperity that encompasses the families and communities to which they will one day belong and the businesses and organizations they will build.
In August 2011, I had the good fortune to enjoy a lengthy conversation (published in this issue) with Alan E. Guttmacher, the director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda, Maryland. Drawing on decades of experience as a pediatrician and researcher, Guttmacher is crystal clear that investing in children's health is a moral duty. If we fulfill that duty by prioritizing children's health, he reasons, we will not only be better equipped to deal with kids' illnesses, but also to set young people on the road to lifelong wellness – physical, mental and social.
Some may say that my vision of planning and building such a foundation for children is unattainable: It's too expensive, it's too complicated, it's unrealistic. Well, I disagree. My first-hand experience of Canadians' generosity and determination to do what's best for children drowns out the skeptics and raises my spirits. And my confidence is well supported by the essays in this special issue of Healthcare Quarterly. These nine articles provide insightful examples that focus our attention on what's possible when we target our investments at giving children the optimum start in life.
The first of our contributions outlines implications for policy-making in Canada arising from the United Nations' 1990 Convention on the Rights of the Child. Kathy Vandergrift and Sue Bennett carefully outline the main findings and recommendations of the CCRC report I mentioned earlier. As that report shows, Canada falls short of other similar countries on critical measures such as infant mortality, child poverty and early childhood development and care. Taking a rights-based approach coordinated at both the provincial and federal levels would, the authors contend, strongly support policy-making attuned to children's health and development by, for example, erasing "the current fragmented approach to health services" and buttressing community investments geared to reducing disparities and advancing equity.
The focus on rights continues in our second article. Here, Lynell Anderson asserts that, when compared to similar wealthy nations, Canada suffers from a "family policy deficit" and a lack of access to quality child care services. Exacerbating these problems is the absence of "an agreed-upon set of measurable objectives" for assessing and monitoring family policy-related progress. Anderson concludes with a call to support the recently proposed New Deal for Families (of which she is a co-author), a three-pronged policy framework that emphasizes both child care and families' desires to spend more time together. While not inexpensive, the New Deal is certainly a public investment that merits broader consideration.
Our first two articles' broad-based analytic approach continues in Kerry McCuaig's call for an "integrated" model that brings together education, child care and family and intervention supports. Too often, as her opening narrative makes clear, supports are designed and delivered in fragments, thus leading to lack of participation and impact. McCuaig's quick rendition of Quebec's "natural experiment" in "enriching parental leave and expanding educational child care for preschoolers" is fascinating in its lessons for the rest of Canada. While she does not advocate one jurisdiction's approach as the final solution for all, McCuaig is persuasive in advocating for solutions that take "a life-cycle approach to human development."
Our next two essays address specific innovations that, if correctly planned, implemented and evaluated, stand to have a real impact on children's health. James Dunn begins by illuminating how children's built environments – locally, regionally and nationally – can be designed to promote healthy child development (i.e., emotional development and maturity, language development, cognitive development and communication skills and general knowledge). Dunn's article tacks back and forth from general principles to specific "attributes." With regard to the latter, one of the most compelling calls-to-action in his piece is that, to effect health promotion for children, we must "specify which factors at what levels matter to which aspects of healthy child development."
Next up is a stimulating article by an expert who we in the healthcare sector probably do not hear from enough: a strategic director at an advertising agency. In his contribution, Max Valiquette urges everyone involved in providing medical and other sorts of care to young people to get up to speed and use social media both to understand and to reach out to our "digital native" patients and clients. One of Valiquette's main points is that young people's digitally-driven "fundamental need to share is transforming everything, including healthcare." I assume many (perhaps most) Healthcare Quarterly readers are, like me, "digital tourists." I therefore recommend Valiquette's brief social-media lesson – in particular, his thoughts on privacy challenges – as a valuable introduction to this swiftly evolving domain.
To see it in print is deeply unsettling: the leading cause of death (30%) for children in Canada is unintentional injuries. Yet, as Pamela Fuselli and Amy Wanounou – of Safe Kids Canada – observe, there are "evidence-based, best practice strategies" that could prevent many of these sad events. The authors begin by setting out the "key elements" contained by successful interventions. Emphasizing the importance of reliable data to intervention-planning, Fuselli and Wanounou shed light on their propositions through the examples of playground design and cycling helmets. While the former largely entails "environmental modification" and design standards to achieve safety, the latter is principally a matter of legislation (coupled with, I would argue, enforcement).
During my interview with Alan Guttmacher, one of the main impediments to progress he raised was the tendency "to erect healthcare systems to deal with the problems of the past rather than the ones of the future." A good example of the consequences of this approach, he offered, is the "obesity epidemic," the magnitude of which has "overwhelmed" both healthcare systems and providers. Childhood obesity, and strategies to help prevent it, is the topic of the essay by Catherine Birken and her four co-authors (all are affiliated with SickKids and carrying out obesity-related research there). Every one of us knows that the problem is large and growing. Mining the evidence on obesity prevention, Birken et al. enjoin us to consider the determinants of obesity (e.g., nutrition, physical activity) and their contexts (e.g., family, culture) when planning and implementing ways to combat it. On the matter of how and when to tackle the problem, I am particularly struck by their observation that, while young children often access the primary healthcare system, "the opportunity for obesity prevention in this setting is unrealized." Further, the "multi-level" approach the authors advocate chimes well with the "integrated" model discussed by Kerry McCuaig in her article.
Erecting systems to deal with future (or even present) problems often requires major reconceptualization of shortcomings, desired outcomes and resource (time, money, people) allocations. As discussed by Charlotte Moore Hepburn and Marilyn Booth, Ontario's Provincial Council for Maternal and Child Health (PCMCH) appears to be just such a comprehensive, forward-looking intervention. Designed to improve the province's maternal-child health sector, the PCMCH unites the maternal–newborn and child–youth sectors in a "single entity" geared to priority setting, service planning, care delivery and quality improvement. Hepburn and Booth describe the evolution, composition and methodologies of this collaborative "life-course" approach, yet another example of the power of integration that has already brought about several improvements for new mothers and young people in Ontario and from which other jurisdictions can learn.
One year ago, the second instalment of Child Health in Canada focused entirely on mental health. Now, in the final essay in this issue, we return to that topic through the lens of investment. Gail MacKean and her five co-authors contribute a literature review of family-centred care (FCC) in the context of mental health services for children. Many of the challenges facing care providers and planners will be familiar, including, as we have heard several times in various contexts throughout this series, the transition to adulthood and the associated hand-off between child- and adult-oriented healthcare systems. One of the lessons in MacKean et al.'s article is the need to revisit and revise our models of care so that they embody FCC and make it a "best practice" and a "common standard of care" – not just in mental health, but in all facets of children's healthcare.
Towards the end of our interview, Alan Guttmacher mused that we need "to have multiple conversations in which we elevate children's lives." I trust that the essays presented in this issue of Child Health in Canada – and the entire series – will add to the richness and rigour of those elevating conversations as we all strive to ensure that young people in this country get the support and care they need to enjoy lives that are as healthy and meaningful as possible. For my part, it has been an honour and a pleasure to steward this series to fruition, and I look forward to continuing to learn from all of you how best to care for children today and in the future.
About the Author
– Mary Jo Haddad, RN, BScN, MHSc, LLD, CM President and Chief Executive Officer The Hospital for Sick Children, Toronto, Ontario
Canadian Coalition for the Rights of Children. 2011. Right in Principle, Right in Practice: Implementation of the Convention on the Rights of the Child in Canada. Ottawa: Author. Retrieved May 11, 2012. <http://rightsofchildren.ca/wp-content/uploads/CCRC-report-on-rights-of-children-in-Canada.pdf>.
Canadian Paediatric Society. 2012. Are We Doing Enough? A Status Report on Canadian Public Policy and Child and Youth Health. Ottawa: Author. Retrieved May 11, 2012. <http://www.cps.ca/english/advocacy/StatusReport2012.pdf>.
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