Chapter 6: The Chief Public Health Officer's Report on the State of Public Health in Canada, 2009 – Conditions and priorities for a healthy future

Chapter 6 - Growing Up Well – Conditions and Priorities for a Healthy Future

Over time, our achievements in children's health have laid a strong foundation for the health of all Canadians.^{footnote 30 footnote 566} Significant gains have been made in reducing infant and childhood mortality, reducing and managing the prevalence of infectious diseases, and in understanding the factors that influence early childhood health and development. These successes have culminated in a population with one of the highest reported life expectancies in the world.^{footnote 566}

Still, there are some worrying issues that are emerging or persistent that can negatively influence the current and future health and well-being of Canada's children. The six areas of concern covered in this report show adverse impacts on the current and future health of Canadians, and in particular among certain sub-populations (such as children from low–income families and Aboriginal children). In addition, evidence shows that other countries or jurisdictions are doing better than Canada in terms of reducing or mitigating negative outcomes related to these issues.^{footnote 162 231 footnote 232 footnote 274}

Canada ranks the health and development of children among its highest priorities.^{footnote 93} We should consider whether the level of action being undertaken in this area is commensurate with that level of concern by asking ourselves whether doing well is doing enough.

If the answer is no, then Canada needs to determine how best to increase its efforts in an effective and meaningful way. The individual, family, community and societal initiatives highlighted in this report demonstrate that adverse outcomes related to the six areas of concern are not always inevitable or irreversible. In fact, they demonstrate effective efforts that can be replicated and expanded upon to improve children's health now and over the lifecourse.

This chapter outlines priority areas for action, along with the optimal conditions for health and development over the lifecourse. The evidence profiled in this report indicates that better data and information, improved and ongoing education and awareness, healthy and supportive environments, and co-ordinated, multi-pronged and sustained initiative and strategies are necessary for Canada to move forward in creating, improving and maintaining the conditions for growing up well.

Conditions for childhood health and development

An examination of children's health status, the factors influencing health and the evidence of successful interventions highlights the optimal conditions for childhood health and development. These include:

• strong, healthy and sustainable communities;
• access to high-quality early learning and education and primary health care;
• caring and safe environments;
• the ability to develop a sense of control, connectedness and responsibility; and
• opportunities to make healthy choices.

Having adequate income for basic needs is critical. A family's SES – particularly household income – should not be a barrier to optimal health and development conditions.^{footnote 161 220 footnote 567} Broad social investments (e.g. taxes/transfers, employment insurance) can help to reduce poverty and its effects on health.^{footnote 345} As well, accessible and available services and programs tailored to a population's needs can support healthy development generally, as well as mitigate the effects of low income by providing opportunities for things like safety promotion, leisure and recreation, school readiness, and skills training and development. Children can thrive when communities have adequate supports for families through available and accessible programs and services.^{footnote 367}

Among these resources, it is critical to include adequate health and developmental services such as primary health care, and early and late childhood programming.^{footnote 345 footnote 367} Canadian children have universal health care coverage – which has been critical to improving and maintaining children’s health over time – however, barriers to access remain. Similarly, although Canadian children have universal access to primary and secondary public education, opportunities for early childhood programming and care, and after-school activities needs to be available to children. Those who are unable to access these services for a variety of reasons are at a disadvantage – especially considering that the opportunities provided by these programs can often work to mitigate the negative effects and reinforce the positive effects of other determinants of health.

In addition to these programs and services, families and communities should provide a shared sense of security, respect and support that will create conditions from which further gains can be achieved. All children deserve to grow up in a nurturing environment where respect is shown for self and others, caring and loving are experienced, and is as safe as possible. The home, school and community are where children live, grow, learn and forge their connections to others. These connections can have a lasting impact on their lives and can influence future choices and relationships. Children also need to interact socially through play and other situations where they can learn about sharing, co-operation and empathy. If these skills are acquired in childhood, there is a better chance they will continue into adulthood.

Children need to participate positively in their home, school and community environments so that they can learn about choices, responsibilities and risks. Through relationships with caring and supportive parents, teachers and friends, children can develop a sense of self and others. When children have a feeling of belonging, when they are given choices and feel understood, they also experience a sense of control and the feeling that they matter.^{footnote 472} Within that connectedness, responsibilities are clearer and achievable, and risks can be judged more confidently. Risk taking is a part of healthy growth and development, and children must learn to distinguish and choose safer risks through weighing options, projecting outcomes and adopting good decision-making skills – all of which are possible within a supportive environment.^{footnote 545}

Support is also needed to make healthy choices. Choices are not always easy, and sometimes – especially for children – they are made within the context of decisions made by others (parents, caregivers, communities and governments) based on external factors such as cost and availability of programs and services, and exposure to marketing tactics. Understanding what constitutes a “healthy” versus a “less healthy” choice and creating the conditions needed at home, school and in the wider community is critical.

Priority areas for action

This report highlights six health issues where new and continuous efforts are needed. An examination of what is and is not working across these issues highlights four priority areas for action where Canada can foster the optimal conditions for the best possible outcomes in children's health and development. These priority areas are:

• better data and information;
• improved and ongoing education and awareness;
• healthy and supportive environments; and
• co-ordinated, multi-pronged and sustained strategies.

Better data and information

In Canada, data on children's health and the effectiveness of related programs are lacking. Data are necessary in order to identify long-term trends and areas where success would dictate building and expanding upon existing programs. It can also highlight a lack of progress that may signify the need for the development and delivery of new programs, so that efforts are consistently meeting the needs of all children.

There are several areas where better data would be particularly helpful. Information regarding children's behaviours, such as dietary habits and levels of physical activity, as well as measures of how they feel about themselves at home, school and in the community are limited. Data on children's mental health are also greatly needed. Building awareness about mental disorders, and risk factors, reducing stigma and managing mental health and illness can only be achieved with appropriate data and research that identify the issues in these areas and successful efforts being made to address them.

Data on maternal, fetal and infant health, including relevant behaviours and health services, are being collected and analyzed through the Canadian Perinatal Surveillance System. This system uses existing national health administrative databases, such as vital statistics, and its own Maternity Experiences Survey, to report on perinatal health indicators for Canada. Areas for further work include strengthening congenital anomalies surveillance and improving understanding of First Nations, Inuit and Métis perinatal health.^{footnote 312 footnote 449}

Canada has made some progress in collecting data for abuse and neglect, and on injury surveillance. The Canadian Incidence Study of Reported Child Abuse and Neglect collects data on cases of abuse and neglect that are reported to and investigated by Canadian child welfare services.^{footnote 246} However, limited information exists on what is working or not working to address child abuse and neglect in Canada. The Canadian Hospitals Injury Reporting and Prevention Program is a unique database that collects “pre-event” data on emergency room visits in 15 hospitals across Canada such as what the person was doing and where they were when the injury occurred.^{footnote 568} While CHIRPP is a good starting point for tracking injuries in children and youth, reporting tends to be issue-specific and is not easily linked to detailed socio-economic information on children and youth. Both examples demonstrate that progress is being made and that, as information is collected, additional needs and requirements can emerge that aid in setting standards for collection over time.

Northern European countries have well-established health data and surveillance systems in place, and in particular, the Scandinavian countries have sophisticated data surveillance systems that track the health of the population from birth to death as primary care interactions occur.^{footnote 362} During childhood, available information includes: prenatal care, births, child health events, immunization, physician and dental contacts, and prescriptions. In Canada, provinces and territories have developed their own data collection processes, some with strong links to socio-economic information (e.g. Manitoba's Population Health Information System), however, these processes remain nationally uncoordinated and unlinked.^{footnote 569 footnote 570}

While data on the health status of the overall population could be improved, information on sub-populations as well as the effectiveness of targeted programs is even less available and co-ordinated. In addition, longitudinal data that follows children from childhood into adulthood are not available and will take a long-term commitment to data collection to initiate and maintain. Studies such as the High/Scope Perry Preschool Program show the benefit of investing in the collection of data on the same group of children from early childhood well into adulthood.^{footnote 386 footnote 387} With these types of nationally collected data and intervention evaluations, reporting on children's current and long-term health will become easier and more effective in terms of determining appropriate actions. A nationally co-ordinated surveillance, research and evaluation system is required.

Improved and ongoing education and awareness

Education and awareness play a role in establishing healthy behaviours, prevention practices, and managing disease and disability. To be effective, there is a need to educate early and often, with the optimal approach being a combination of both formal education and social marketing practices. Canada's efforts on tobacco cessation during pregnancy and the ‘Back to Sleep’ message illustrate this point.^{footnote 548} Evidence shows that, over time, risks have been reduced as a result of these campaigns.^{footnote 549}

Early education allows for the development of healthy practices through knowledge that is acquired before the need for information arises.footnote 323 For example, learning about mental health and resilience, or balancing nutrition and physical activity should start when children are young and just beginning to learn about choices and healthy practices.footnote 463 footnote 472 footnote 520 In the same vein, the ideal time to learn about healthy pregnancy and parenting is before pregnancy or, failing that, during the prenatal period.footnote 323 In addition, education and awareness activities are not one-time efforts; they need to be ongoing and sustained, allowing for the education of new generations and keeping others up to date on the latest information.

Canada has also taken action by setting and promoting guidelines, recommendations and advisories on ideal nutritional behaviours, and physical activity levels. Injury prevention organizations such as Safe Kids Canada, ThinkFirst and SMARTRISK include a wide range of educational tactics (such as mentoring and role playing) to raise awareness and encourage risk management.^{footnote 79 footnote 545 footnote 554 footnote 555} Broad national strategies, such as Canada's Family Violence Initiative, also play a role in identifying issues, defining rights and removing barriers by raising awareness and understanding across sectors.^{footnote 417} Education and awareness will also be key to a Canadian mental health strategy because they are likely to help to break down barriers and stigmas associated with promoting mental health and addressing mental disorders.^{footnote 463 footnote 464}

While education and awareness activities are critical to Canada's success in improving children's health, evidence shows that knowledge dissemination is more effective as part of a larger strategy that involves surveillance, legislation/regulation, and community services and support. For example, Sweden's injury prevention strategy includes knowledge dissemination as part of its healthy public policy.^{footnote 561 footnote 562}

Healthy and supportive environments

Across all six health issues covered in this report, children's environments – from the prenatal environment to home, school and/or community – play a significant role in children's health and well-being. Children who are loved and cared for and feel safe and unthreatened can thrive. Parents and siblings are important role models as children watch, listen and learn from them and model their behaviours and attitudes.^{footnote 520} For example, evidence shows that children's food consumption and physical activity practices reflect those of their parents and other family members.

Communities and governments also play a role in establishing supportive and healthy environments. Communities can offer opportunities for recreation, physical activity, and safe and healthy transport through urban planning. Communities in motion, for example, represents a gathering of all community sectors to provide safe routes and games that encourage physical activity.^{footnote 542 footnote 544} Family friendly approaches in work environments encourage and support parents who strive to find a work-life balance (e.g. affordable daycare through Quebec's Family Policy, as well as parental leave in Sweden and in Canada).^{footnote 161 footnote 375 footnote 571} Legislation and guidelines provide information on exposures (e.g. advisories on minimizing methyl mercury in prenatal fish consumption), safety practices (e.g. vehicle restraints) and healthy behaviours (e.g. Canada's Food Guide).^{footnote 302 footnote 491 footnote 556}

Communities and government programs can also mitigate and contribute to reducing conditions of risk for children through supportive, healthy environments. Aboriginal Head Start, for example, has an all-family approach that reaches low-income Aboriginal families and provides children with opportunities to become school-ready, learn about traditions and culture, and adopt healthy practices.^{footnote 406 footnote 407} Other initiatives, such as Canadian Prenatal Nutrition Program, Community Action Program for Children, and Aboriginal Healthy Babies, Healthy Children, also target families in need by supporting parents, providing programs for children, and helping to create homes and communities where children have opportunities to grow up well.^{footnote 394–footnote 396 footnote 402 footnote 403 footnote 442}

When caring environments are jeopardized, opportunities need to be available to support parents in interacting positively with their children. The Olds Home Visitation Model shows that success can be achieved by targeting parents early and making a difference in the home environment of new parents and children.^{footnote 430} The Kauai Longitudinal Study demonstrates that when children are faced with adversity at home, some can overcome these experiences through an early bond with a caring adult and/or support from community members.^{footnote 472} Similarly, the Roots of Empathy initiative shows that teaching children about the impact of their actions on others can lessen aggressive behaviours, an outcome that may be carried into adulthood.^{footnote 424} And, while providing access to affordable, family friendly programming is a challenge, action to address this need is being initiated in jurisdictions with broad childhood strategies such as the U.K.'s Sure Start Programme.^{footnote 371 footnote 382 footnote 572}

Creating healthy and supportive environments is a huge undertaking that involves the cohesive efforts of many. Communities are at the forefront of these efforts as people living closest to the situation are often in the best position to develop solutions.^{footnote 573} The range of community-based programs presented in this report is evidence of this impact. There are many examples of specific individuals, schools and communities striving to create healthy and supportive environments and making a positive difference. In Canada, a lack of knowledge impacts such efforts. Better means of measuring activities, perceptions and supports in homes, schools and communities is required. Once we have a better sense of our strengths and weaknesses, we can move forward in our efforts to build and strengthen these childhood environments.

Co-ordinated, multi-pronged and sustained strategies

Although the work of individual programs across Canada is invaluable, evidence across the six areas of concern illustrates that there is value in co-ordinated, multipronged and sustained strategies that involve different sectors (e.g. health, education and the private sector) and that tackle issues on different fronts (e.g. community action, education campaigns and legislation). Such strategies have demonstrated success in reducing healththreatening behaviours and related health outcomes, especially when sustained over a significant period of time. Evidence suggests that they may be more effective at reaching a wider range of people (different tactics within the same strategy resonate with different groups of people), and may represent the difference between doing well and doing better than the rest. For example, Sweden's co-ordinated population-based injury prevention strategy relies on a healthy public policy approach and has resulted in Sweden's ranking as a leader in this area.^{footnote 561–563} This success is attributed to inter-sectoral collaboration that incorporates community leadership, a comprehensive surveillance system, multi-pronged education/awareness programs and co-ordinated legislation that makes safety a priority.

Broad child- and family-oriented initiatives have shown some success in directly addressing the interconnectivity of income to other socio-economic factors within families. Finland and the U.K. have both experienced reduced childhood-related poverty with the application of broad family policies that provide taxes/transfers to families with children but also address issues such as parental support and child care.^{footnote 219 footnote 362 footnote 365} Similarly, Quebec's Family Policy works to equalize opportunity so that household income does not determine access to early education and care.^{footnote 375 footnote 377 footnote 378}

Work to develop successful strategies to address the six issues highlighted in this report is taking place in Canada, though it is still very much in its infancy. Moving forward will take strong federal/provincial/territorial collaboration and commitment. I strongly encourage these efforts and highlight the following areas of need and potential:

• As a leading cause of death for children, injury prevention is a high priority issue that would benefit from a broad prevention initiative.
• Co-ordinated approaches to poverty reduction and childhood development programming have seen some success in other jurisdictions and a more co-ordinated children's strategy may be effective in Canada.
• Canada's Mental Health Commission is working toward the development of a national strategy for mental health with the goal of improving conditions for those experiencing mental disorders and illnesses, creating multi-pronged awareness and anti-stigma programs as well as the development of knowledge hubs for information exchange.^{footnote 464 footnote 475}
• An emerging population health issue, such as childhood obesity, could benefit from a broad population approach to effectively tackle the multiple components of the issue for all Canadians.

Moving forward – Making a difference

Looking back over Canada's history of child-focused efforts, it is apparent that advances have been made in disease and injury prevention, health promotion and related social development. Canada is seeing the benefits today of its investments in a proactive approach to the health, safety and well-being of its children. As we celebrate the 20th anniversary of the United Nations Convention on the Rights of the Child, it is appropriate that we look toward the future and reaffirm our commitment to children having the right to the highest attainable standard of health.^{footnote 90 footnote 93}

There are still worrying trends and Canada is not doing as well as other countries in some areas, which underlines the need for additional efforts to ensure a better future for all its citizens. Some Canadian children experience conditions for optimal childhood health and development and, as a result, they are doing very well. The four priority areas for action detailed in this report, when met with success, will do much for improving these conditions for an even greater number of children.

Taking action requires time, effort and resources. These investments, if made today, will have a positive impact not only on the current health of our children but also their future health. We also know that resources targeted to supporting families with children – prenatally and in the early years of childhood – can have the greatest impact over the lifecourse and, as such, make good sense from both a financial and social perspective.

Moving forward, efforts must focus on addressing the persistent and emerging issues that are affecting the immediate and long-term health of Canada's children, and that show signs of being preventable. Increasing rates of obesity and sedentary lifestyles must be addressed. We should continue to monitor injuries and prenatal health to ensure risks are being minimized. The mental health of our children needs to be better understood, and situations of abuse and neglect must be prevented and avoided. In particular, our efforts must focus on addressing the health trajectories of Canada's vulnerable populations of children such as those living in low-income households, Aboriginal children and children with disabilities. Inequalities in SES and opportunities for development – with their long-term impact on health and intergenerational pervasiveness – are an ongoing concern.

Although current social supports for families and children have set the stage for healthy lives and continue to do so, the evidence presented in this report shows that there is a real need to supplement these efforts. Actions require a balance between targeted and universal programs and must be co-ordinated and multi-pronged to effectively address Canada's extensive geography, diversity and vulnerable populations. They must also be sustained over time to see the benefits of these early investments. This kind of balance ensures that, regardless of the conditions into which children are born, they have opportunities to follow a path towards a healthy life.

Better data and information through increased surveillance and evaluation can strengthen our capacity to measure children's health and evaluate actions intended to improve outcomes. We can also increase our ability to make a difference for those in greatest need. Canada does not have a strong record of measuring the effectiveness of initiatives. That means that as efforts wane, we remain unaware and unable to effect change until those beside us and behind us move ahead of us.

We need to build on initiatives to educate and raise awareness, so that they are not undertaken in isolation or limited to one-time efforts with short-term impacts. To sustain positive results, these efforts must reach populations at the earliest possible opportunity and be continuous in nature.

What works for individual children or communities may not be transferable to others. However, understanding the reasons for this, and identifying a framework for what does and does not work, is the challenge for moving beyond our current status in terms of children's health.

As a caring and compassionate society that considers the potential of each and every child to lead a healthy and productive life, we must acknowledge that doing well, when we can do better, is not enough.