In 1984, WHO expanded their definition of health as:
"the optimal state of health of individuals and groups…including the realization of the fullest potential of an individual physically, psychologically, socially, spiritually, and economically, and the fulfillment of one’s roles and expectations in the family, community, place of worship, and other settings” (Nutbeam & Kickbusch,, 1998).
To address and improve the health and wellbeing for children in Canada, we need to incorporate how an individual's health is impacted by their environment and community. Using a multilevel model can help guide and support our work to promote children's healthy growth and development. Expanding on the WHO definition, including the social determinants of health and using a population health approach to improve our health care system has many benefits. We need to continue to advocate for preventative care, early interventions, and equitable access to services.
To bring health and wellness together within our health care system, means to promote a healthy lifestyle that supports individuals to lead a full life with meaning and purpose. Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to their community (The Lancet, 2009).
A Multilevel Model to address Children's Health
It has been clear that health needs to encompass a multilevel model with a focus on the health of both the individual and the population. Let's use the socio-ecological model to focus on the importance of children's health.
Figure 1: The National Centre for Disease Control and Prevention (CDC, 2018)
This model (Figure 1) from CDC (2022) depicts how risk factors can influence each level and considers the interaction between the individual, relationship, community and society. Looking at this from a public health perspective, using an 'ecosocial framework' (Figure 2) supports the need to identify social, cultural and economic forces through population health strategies that addresses the interplay between the ecological and social determinants of health (CPHA, 2015).
Figure 2: CPHA: Global change and public health: Addressing the Ecological Determinants of Health (page 14)
The Ottawa Charter for Health Promotion (1986) states that the fundamental conditions and resources for health are peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity. These are foundational to address health disparities and improve overall health. As a public health professional, my practice is based on the Ontario Public Health Standards (OPHS).
Figure 3: Source: Ontario Public Health Standards (2021); page 6
Following these standards ensures the programs and services provided are evidence-based and informed for effective public health practice. Using the most up-to-date evidence available allows public health professionals to be responsive and address the needs and emerging issues of their community. This includes integrating population health assessments and focusing on health equity when delivering services.
As a nurse and health promotion specialist, my role is grounded in a population health approach. OPHS summarizes this well in Figure 3, portraying the population health approach and how it can be applied across the lifespan.
Individual & Relationships
Over the many years as a public health leader, supporting children and their families has been an integral factor to improve population health. Let's use the example of one of the most common chronic respiratory diseases in Canada - asthma. According to Asthma Canada (n.d.), asthma impacts over 850,000 children under the age of 14 and is the leading cause of school absences in Canada. Sick Kids (2021) also states that the annual economic burden of asthma across Canada is estimated at $52 million.
According to Health Quality Ontario (2020), Ontario has the highest age standardized prevalence at 12.08% in Canada. Statistics shared through Ontario Asthma Surveillance & Information System (OASIS) are as follows (Sick Kids, 2022):
Over 2 million Ontarians live are diagnosed with asthma
50,000 newly diagnosed in 2020
1 in 4 Ontario children are affected by asthma
There is a wide variety of risk factors that may increase chances for an individual to develop asthma or other chronic diseases. As a public health professional, we strive to prevent and lower the risk of chronic disease. I have facilitated discussions with individuals at different life stages such as preconception, prenatal, parenting and early child development. Topics included the importance of physical activity and healthy eating to help promote healthy weights, harm reduction related to smoking/alcohol/drugs, education on air quality/decreasing air pollutants, and mental health.
Children thrive when they have regular interactions with supportive adults such as their parents, extended family members, caregivers, educators. Education of their individual health concerns must include understanding of the child's environment including their relationships within these environments. Childhood experiences (both positive and negative), including physical, emotional and mental, have lifelong impacts and shape their development.
Community & Society
As we continue to move forward in considering strategies to promote child health, the social ecological model emphasizes the broader social factors that influence child/family resilience and their connections including family supports related to housing, jobs, transportation, neighborhood safety, social support, and access to resources (Bethell et al., 2019).
Using the asthma example above, assessing a child's support in their environment is key to the management of their chronic disease. Asthma education is essential to support individuals to control and manage their asthma through medications (such as inhalers) and minimizing their exposure to known triggers. Here is a great education video from Ophea Canada on how our school system can support Ryan's Law (an Ontario legislation enforced since 2015).
Looking from a socio-economic lens, Ontario implemented OHIP+ which provides more than 5,000 drug products (including inhalers for asthma, antidepressants and ADHD drugs) at no cost for individuals, ages 24 and under, who are not covered by a private plan.
In addition, the COVID-19 pandemic has impacted the mental health of many Canadian families, including children of all ages (Gadermann et. al, 2021). Considering social determinants of health, food insecurity and financial strain are determinants of mental health for individuals and families (Alegría et al., 2018) and highly important to intervene at the community and societal levels. According to a report by Statistics Canada (Polsky & Gilmour, 2020), one in five Canadian households experience challenges meeting their financial needs and food insecurity were linked to increased rates of mental health symptoms.
In a report published in 2022, Ontario is stated to have one of the highest rates of household food insecurity at 16.1%, which includes those reporting severe, moderate and marginal food insecurity (Tarasuk et. al, 2022). This report also highlights that the percentage of children under the age of 18, living with food insecurity in Ontario is 20.6% (Tarasuk et. al, 2022). Food insecurity and financial stressors is a complex issue that has many contributing determinants, as well as solutions.
Mental health, financial stress, and food insecurity have been long-standing public health issues. As a nurse working in public health, advocating for adequate income, affordable housing, and access to nutritious and culturally appropriate food has been a long-standing priority. If we broaden our scope to look at the root of many family challenges, we will see how adversity in childhood can also arise from past and ongoing forms of colonialism, racism, childhood poverty, a lack of stable housing, weak social supports and other individual and systemic barriers (Ellis & Dietz, 2017; McEwen & Gregerson, 2019).
Using the social ecological model provides the opportunity to identify and develop strategies addressing factors related to the individual (i.e. children), relationships (i.e family/caregivers), community (i.e. educators, access to services, supports available), and society (i.e. cultural norms, racism, systemic barriers). Here is a short video that provides a great example of Urie Bronfenbrenners ecological systems theory to support the importance of the SEM model to promote children's health.
Created by: Maggie Norris (September, 2017)
Taking this into account and reflecting on opportunities to modernize the Canadian Health Act, the shortage of family physicians, increased wait times at emergency departments (ED), and barriers for residents to access preventative, continuous and integrated care in our health system has been an issue for a long time. The pandemic has highlighted and magnified this at multiple levels. As a public health professional, providing care through a population health and equity lens is key (Dyck et al, 2018).
Discussions shared by a variety of health professional peers provided further insight on how the gaps in our health care system impacts our patients and communities. For example, dental colleagues have shared how basic universal oral care may help prevent many diseases from developing in the mouth. It was also shared that children miss three times more school days when they have poor oral health than their cohorts (Jackson et al., 2011). From a population health lens, this basic universal oral care can promote positive health and hygiene outcomes for the community as a whole.
Throughout the pandemic, access to medical care has varied and hesitancy to seek early intervention care has increased. Treatment and repeat visits to emergency departments has been a heavy burden for patients, community and our health system. I have been reflecting on the root of this and I keep coming back to equity and access. From an equity lens, we need to continue advocating and addressing social determinants of health, plus increasing access to health services.
In addition to our current universal health care funding, many people need to depend on subsidized income funding or private insurance to support their payments of their prescriptions and/or treatments. As a public health nurse, I have had clients who shared that they will often need to decide which medications they fill based on cost or decide to ration medications to make them last longer. One important option that our health system needs to leverage to help further address children's health is the positive impact Nurse Practitioners (NP) have for individuals, communities and the whole population. NPs can and do reduce wait times, save health care dollars and improve overall health outcomes (Bennet, 2018).
In conclusion, supporting and increasing focus on children's health, including their mental health and the need for increased access to services is key. Using a socio-ecological model supports this work especially when integrating a population and public health lens. This includes integrating population health assessments and focusing on health equity when delivering services.
Working to ensure continuous care from prevention, early detection, treatment, rehab, and community support all need to occur across our health care system. Most importantly, support is needed for research and development, to review and evaluate the changes and effectiveness of our system and the effect on population health and programs/services.
Comment below and share your thoughts on we can further improve children's health using a multi-level model.
References
Alegría, M., NeMoyer, A., Falgas, I., Wang, Y., & Alvarez, K. (2018). Social Determinants of Mental Health: Where We Are and Where We Need to Go. Current Psychiatry Reports, 20(11), 95. https://doi.org/10.1007/s11920-018-0969-9
Asthma Canada. (n.d.). Asthma at School. Retrieved November 7, 2022, from https://asthma.ca/get-help/asthma-in-children/asthma-at-school/
Bennett, G. (2018). Fulfilling Nurse Practitioners' Untapped Potential in Canada: Results from the CFNU Pan-Canadian Nurse Practitioner Retention & Recruitment Study. Canadian Federation of Nurses Unions, 48.
Bethell, C., Jones, J., Gombojav, N., Linkenbach, J., & Sege, R. (2019). Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample: Associations Across Adverse Childhood Experiences Levels. JAMA Pediatrics, 173(11), e193007. https://doi.org/10.1001/jamapediatrics.2019.3007
Centre for Disease Control and Prevention. (January, 2022)The Social-Ecological Model: A Framework for Prevention |Violence Prevention|Injury Center|. https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html
Canadian Public Health Association (CPHA). (2015, May). Global change and public health: Addressing the Ecological Determinants of Health. Canadian Public Health Association: Discussion Document. Retrieved October 23, 2022, from https://www.cpha.ca/sites/default/files/assets/policy/edh-discussion_e.pdf
Dyck, L. A., Snelling, S., Morrison, V., Haworth-Brockman, M., & Atkinson, D. (2018). Equity reporting: A
framework for putting knowledge mobilization and health equity at the core of population health status reporting. Health Promotion and Chronic Disease Prevention in Canada, 38(3), 116–124. https://doi.org/10.24095/hpcdp.38.3.02
Ellis, W. R., & Dietz, W. H. (2017). A new framework for addressing adverse childhood and community experiences: The building community resilience model. Academic pediatrics, 17(7), S86-S93.
Gadermann, A. C., Thomson, K. C., Richardson, C. G., Gagné, M., McAuliffe, C., Hirani, S., &
Jenkins, E. (2021). Examining the impacts of the COVID-19 pandemic on family mental health in Canada: Findings from a national cross-sectional study. BMJ Open, 11(1), e042871. https://doi.org/10.1136/bmjopen-2020-042871
Health Quality Ontario. (2020). Asthma Care in the Community for People 16 Years of Age and Older. https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-asthma-in-children-and-adolescents-quality-standard-en.pdf
Jackson, S. L., Vann William, F., Kotch, J. B., Pahel, B. T., & Lee, J. Y. (2011). Impact of poor oral health on children’s school attendance and performance. American Journal of Public Health, 101(10), 1900 1906. https://doi.org/10.2105/AJPH.2010.200915
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McEwen, C. A., & Gregerson, S. F. (2019). A Critical Assessment of the Adverse Childhood Experiences Study at 20 Years. American Journal of Preventive Medicine, 56(6), 790–794. https://doi.org/10.1016/j.amepre.2018.10.016
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https://www.canada.ca/content/dam/phac-aspc/documents/services/health-promotion/population-health/ottawa-charter-health-promotion-international-conference-on-health-promotion/charter.pdf
Polsky, J.Y., Gilmour, H. (2020). Food insecurity and mental health during the COVID-19 pandemic. Government of Canada, Statistics Canada. https://www150.statcan.gc.ca/n1/pub/82-003-x/2020012/article/00001-eng.htm
SickKids. (2021).The Ontario Asthma Surveillance System (OASIS). https://lab.research.sickkids.ca/oasis/
Tarasuk, V., Li, T., Fafard, St-Germain AA. (2022) Household food insecurity in Canada, 2021. Toronto: Research to identify policy options to reduce food insecurity (PROOF). Retrieved from https://proof.utoronto.ca/
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