Reaching for the Top: A Report by the Advisor on Healthy Children & Youth

Appendices

I. Social Determinants of Child and Youth Health

A look through the lens of social determinants of health tells us a lot about our children and the many issues impacting and therefore affecting Canadian children and youth. The healthiest populations are those in societies - largely OECD countries - which are prosperous and have an equitable distribution of wealth.

There are varied categorizations of social determinants of health; within each determinant there is often much discussion - and disagreement - over how it should be measured. The World Health Organization looks at 12 social determinants of health. There are numerous other reports and studies that examine, in detail, other social determinants of health in Canada. While the mandate of this Report does not extend that far, it is important to reference the three social determinants that affect child and youth health that were raised repeatedly during the roundtables: poverty, housing and education.

Determinants of Health¹⁶⁸

Source: World Health Organization, undated.

i Poverty

Poverty is a key social determinant of health. A lengthy list of health-related issues among children correlate with poverty, including higher rates of unintentional injuries, mental health issues, poor eating habits, and less physical activity. Low-income Canadians are more likely to die earlier and to suffer more illnesses than Canadians with higher incomes, regardless of age, sex, race and place of residence.¹⁶⁹

Levels of child and youth poverty can be measured in a number of ways. The UNICEF Innocenti Research Centre Report Card comments that "Child poverty can be measured in an absolute sense - the lack of some fixed minimum package of goods and services. Or it can be measured in a relative sense - falling behind, by more than a certain degree, from the average standard of living of the society in which one lives."¹⁷⁰ While Statistics Canada is careful not to refer to the low income cut-offs (LICOs) as "the poverty line", the LICO is the most widely used measure to define child poverty rates. While Canada ranks a respectable 6^th out of 21 OECD nations in terms of child and youth material well-being as measured by UNICEF,¹⁷¹ one in six children and youth in Canada - approximately 1,071,000 - live in poverty, including 778,000 Canadian children living in low-income families.

And while poverty levels in some parts of Canada are improving, others are not.

One of the best ways for Canada to tackle poverty is to get more people participating in the economy - which begins with good health and education among our children and youth. Children and youth who have had a healthy start to life - through access to a variety of affordable, healthy foods, education programs and affordable, community-based physical education programs - are more likely to stay and be successful at school, and enter the job market and be successful in their chosen profession later in life. Positive parenting, high quality child care and nurturing neighbourhoods can also help mitigate effects of low socio-economic status.¹⁷²

ii. Housing

In 1986, the Ottawa Charter for Health Promotion recognized shelter as a basic prerequisite for health.¹⁷³ Research has demonstrated that living in substandard housing and poor neighbourhoods has both a direct and indirect impact on child and youth health. For example, children who experience overcrowded housing conditions have an increased likelihood of experiencing infectious disease.¹⁷⁴ Studies have shown the negative effect of inadequate heating and dampness on health, particularly for children and the elderly, who develop an increased incidence of infection in these circumstances.¹⁷⁵

A lack of adequate and affordable housing can aggravate other problems associated with low income. Individuals and families who are forced to spend a disproportionate amount of their income on rent often face food insecurity and thus malnutrition, and are unable to participate in healthy community activities such as active recreation and children's social programs. Families have to make difficult choices between money for transportation to work, clothing, school supplies and often food. This is exacerbated in remote locations (such as the north) where products - including food - tend to be more expensive.

One also needs to examine housing in the context of neighbourhood. If neighbourhoods have a higher tendency towards gang or other violence, parents are less likely to want their children to play outside, and children themselves are less likely to want to play outside. This results in less outdoor physical activity which leads to less healthy lifestyles and poorer health outcomes. Due to these phenomena, Canada's urban centres are at risk of a 'downward spiral'. Many North American sociologists have argued that once 40% of a neighbourhood's population falls below the poverty line, the entire neighbourhood becomes distressed - endangering the health of the entire community.¹⁷⁶

The issue of housing in Canada also has regional and social disparities. According to the 2007 Child Health Summit, "Living conditions for First Nations people rank 63^rd in the world - comparable with developing countries - and one of the root causes of poor health in these communities. Overcrowded housing, mould and unsafe drinking water help spread communicable diseases at a rate 10 to 12 times higher than the national average. Over 40% of homes are considered inadequate shelter."¹⁷⁷ If one accepts the premise that housing both directly and indirectly affects health outcomes, then we, as a society, need to find better ways of ensuring that the lack of suitable housing is not an impediment to success.

iii. Education

Every day over 1,000 children are born in Canada. They are lucky. There are few - if any - better places to be born and get a good education.

Education is closely tied to socioeconomic status, and effective education for children and lifelong learning for adults are key contributors to health and prosperity for individuals, and for the country. People with higher levels of education have better access to healthy physical environments and are better able to prepare their children for school. They also tend to smoke less, to be more physically active and to have access to healthier foods.

Children who have had the benefit of early childhood education programs experience benefits that persist later in life. These benefits include better school performance and lower juvenile crime rates. Providing quality, clinically-tested education is extremely important in a child's formative years. In particular, experiences from conception to age six have the most important influence of any time in the life cycle on the connecting and sculpting of the brain's neurons.¹⁷⁸ Positive stimulation early in life improves learning, behaviour and health into adulthood. The YMCA's 'Play to Learn' program is a wonderful example of a program that recognizes the importance of starting positive stimulation early.

Canada is fortunate to have internationally-recognized experts in Early Childhood Development (ECD) to inform the public policy discussion. In March 2007, the Council for Early Child Development released the much-anticipated follow-up report to The Early Years Study entitled, "Early Years 2: Putting Science into Action."¹⁷⁹

The Early Years Study had clearly demonstrated how children's experiences in the early years directly impact their neurobiological development and the formation of coritco-cortical connections; once these neural connections are formed, they are difficult to modify later in life making it challenging to alter a child's developmental trajectory. The Early Years 2 Study builds on its predecessor, with eight more years of neuroscientific research demonstrating the positive correlation between ECD and a child's neurological development. Both studies are clear: if we want Canadian children to be successful and competitive later in life, we must do everything we can to stimulate their early development.

Investing Early Pays Off Later

It has been repeatedly demonstrated that investments in early childhood education pay off in better life and health outcomes later in life. ECD research estimates that every $1 invested in early childhood development is worth $3 - $18 later in life.¹⁸⁰

The benefits of ECD have been clearly demonstrated in evidence-based research and include:

• Higher intelligence scores;
• Higher and timelier school enrolment;
• Less grade repetition and lower dropout rates;
• Higher school completion rates;
• Improved nutrition and health status;
• Improved social and emotional behaviour;
• Increased earning potential and economic self-sufficiency as an adult; and,
• Increased female labour force participation.¹⁸¹

The economic and societal benefits of ECD reflect both savings to social services, and increased economic productivity. Individuals who complete high school and then pursue further education have an opportunity to contribute more significantly to Canada's economy, and to advance the national interest. The correlations between improved nutrition and health status with decreased use of health care services and social services are well known.

Literacy

On the whole, young people today have higher levels of education than the previous generation. The International Adult Literacy Survey found nearly one-third of Canadian youth to have among the highest level of literacy skills among reporting countries.¹⁸² Canada has also seen significantly lower drop-out rates in schools than there were in the 1990s, suggesting that programs that have been put in place to improve literacy are working.¹⁸³

Focus of this Report: Health Itself

The social determinants of health are central to the challenges that Canadian children and youth face with respect to their health. As stated previously, it is within Canada's grasp to be the best place on earth for a child to grow up in, but we have work to do in order to achieve this goal. The three determinants outlined above, provide some of the challenges that children and youth face. These determinants serve as important reminders that child and youth health cannot be evaluated within the single silo of health, nor the silo of poverty. The multiple factors that impact a child's development and environment all must be taken into account when evaluating their health status.

II. Additional Health Indicators

Countless reports, expert panels and organizations have made recommendations regarding the health indicators that should be used to best measure and improve child and youth health outcomes. In their report, "Improving the Health of Young Canadians: Canadian Population Health Initiative," the Canadian Institute for Health Information (CIHI) measured five assets for children and youth: parent nurturing, parental monitoring, volunteering, peer connectedness (involvement in the community) and school engagement.¹⁸⁴ CIHI is also working with the Canadian Child and Youth Health Coalition (CCHYC) to lay the groundwork for the Coalition's Health Indicator program.¹⁸⁵ The objectives of this program are to identify existing indicators and develop new indicators that will be used to monitor and evaluate the health of, and the health services provided to, infants, children, youth, and their families. The CIHI Health Indicators Framework has been adopted as the basis for this project.

In addition, the CIHR's Institute of Human Development, Child and Youth Health has requested submissions for research in the field of child health indicators. This request follows a symposium by CAPHC [Canadian Association of Paediatric Health Centres] in 2006 focusing on this subject.

Other child and youth indicators for specific health outcomes have been recommended by organizations such as the Canadian Paediatric Society, Breakfast for Learning (nutrition)¹⁸⁶ and Active Healthy Kids Canada (physical activity).¹⁸⁷

Additional Health Indicators to Consider

There are a number of additional indicators that should be considered for measurement nationally and by each jurisdiction. These include:

• Perinatal mortality
• Blood lead levels in children and youth
• Prevalence of Type 1 and Type 2 diabetes
• Prevalence of Asthma
• Hospitalization due to Asthma or respiratory illness (under 5, 5 - 18 years)
• Rates of STI and HIV diagnosis (15 - 18 years)
• Suicide among children and youth
• Alcohol rates among youth
• Self-rated health
• Type of Smoking (e.g. occasional, daily)
• Smoking initiation
• Exposure to second hand smoke at home, in vehicles and in public places
• Frequency of drinking
• Leisure time physical activity
• Body Mass Index
• Immunization coverage
• Leukaemia (5-year survival)
• Child transportation safety
• Exposure to hazardous noise

It is only by specifically considering a broad range of measurable health indicators in the context of child and youth health, that we as a society will be able to appropriately compare child and youth health outcomes with similar jurisdictions and begin, as early in life as possible, to address the root causes of adverse health effects.