1
Introduction

Children are vital to the nation’s present and its future. Parents, grandparents, aunts, and uncles are usually committed to providing every advantage possible to the children in their families, and to ensuring that they are healthy and have the opportunities that they need to fulfill their potential. Yet communities vary considerably in their commitment to the collective health of children and in the resources that they make available to meet children’s needs. This is reflected in the ways in which communities address their collective commitment to children, specifically to their health.

In recent years, there has been an increased focus on issues that affect children and on improving their health. Children have begun to be recognized not only for who they are today but for their future roles in creating families, powering the workforce, and making American democracy work. Mounting evidence that health during childhood sets the stage for adult health not only reinforces this perspective, but also creates an important ethical, social, and economic imperative to ensure that all children are as healthy as they can be. Healthy children are more likely to become healthy adults.

Within this context, it is reasonable to ask what it means for children to be healthy and whether the United States is adequately assessing and monitoring the health of its children. Do available surveillance and monitoring approaches provide the information necessary to ensure that common priorities and shared resources are aligned with children’s needs and deployed to optimize their health? Are there ways to improve methods to better guide policies and practices designed to make children healthier? This report addresses these questions.

Children are generally viewed as healthy when they are assessed by adult



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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health 1 Introduction Children are vital to the nation’s present and its future. Parents, grandparents, aunts, and uncles are usually committed to providing every advantage possible to the children in their families, and to ensuring that they are healthy and have the opportunities that they need to fulfill their potential. Yet communities vary considerably in their commitment to the collective health of children and in the resources that they make available to meet children’s needs. This is reflected in the ways in which communities address their collective commitment to children, specifically to their health. In recent years, there has been an increased focus on issues that affect children and on improving their health. Children have begun to be recognized not only for who they are today but for their future roles in creating families, powering the workforce, and making American democracy work. Mounting evidence that health during childhood sets the stage for adult health not only reinforces this perspective, but also creates an important ethical, social, and economic imperative to ensure that all children are as healthy as they can be. Healthy children are more likely to become healthy adults. Within this context, it is reasonable to ask what it means for children to be healthy and whether the United States is adequately assessing and monitoring the health of its children. Do available surveillance and monitoring approaches provide the information necessary to ensure that common priorities and shared resources are aligned with children’s needs and deployed to optimize their health? Are there ways to improve methods to better guide policies and practices designed to make children healthier? This report addresses these questions. Children are generally viewed as healthy when they are assessed by adult

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health standards, and there has been a great deal of progress in reducing childhood death and diseases. But the country should not be blinded by these facts—several indicators of children’s health point to the need for further improvement, children in the United States do not fare as well as their European counterparts on many aspects of health, and there are marked disparities in health among children in the United States. Recent improvements in children’s health need to be sustained and further efforts are needed to optimize it. To accomplish this, the nation must have an improved understanding of the factors that affect health and effective strategies for measuring and using information on children’s health. This chapter starts with what is known about the health of children. It then moves to a discussion of why measuring children’s health is important. The chapter concludes with an examination of why critical differences between children and adults establish the need for children’s health to be held to a standard different from that used for adults. CHILDREN AND THE STATE OF THEIR HEALTH Dramatic improvements have occurred over the past several decades in such areas as reducing infant mortality, reducing mortality and morbidity from many infectious diseases and accidental causes, increasing access to health care, and reducing environmental contaminants, such as lead (Centers for Disease Control and Prevention, 1999b, 2000a). There have been steady increases in the proportion of immunized children, and both acute mortality and long-term disabilities resulting from certain infectious diseases have been greatly reduced. Learning how environmental exposure to lead adversely affects children’s development contributed to great reductions in ambient lead and significantly reduced childhood blood lead levels (Lanphear, Dietrich, and Berger, 2003). Average concentrations of lead in the blood of children younger than 5 years dropped 78 percent between 1976–1980 and 1992–1994 (U.S. Environmental Protection Agency, 2000a). Fewer adolescents are having babies—in 1999, the teenage pregnancy rate reached the lowest recorded rate since 1976 (Child Trends, 2003). Daily cigarette use fell by over 50 percent (from 10 to 5 percent) among 8th grade students between 1996 and 2002, and by over two-fifths (from 18 to 10 percent) among 10th grade students (Child Trends, 2003). Yet despite these improvements, some national indicators raise questions about the health of the nation’s children and point to the need for continued progress. The children behind each of these statistics face serious barriers to healthy childhoods and healthy, productive adult lives. For example, 12–19 percent of children in the United States have chronic health conditions (Newacheck, Hung, and Wright, 2002; Stein and Silver, 2002), an estimated 15 percent of children and adolescents ages 6–19 years are overweight (National Center for Health Statistics, 2002b), and 1 in 10 children have significant mental health conditions that cause some form of impairment (Satcher, 2001). Despite the

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health country’s great wealth, some children are not surviving past childhood. Even with recent improvements in child mortality, approximately 7 out of 1,000 children die before the age of 1 (Federal Interagency Forum on Child and Family Statistics, 2003), and 44 percent of deaths of children between the ages of 1 and 19 are caused by unintentional injuries (Anderson and Smith, 2003). Children, particularly poor and minority children, are not faring as well as the public might think. The current and future prospects of these children, and the prospects of the nation as a whole, are reduced as a result. The nation needs to consider the significance of statistics such as these and adopt prudent policies to improve children’s health if it is to successfully maximize the potential of all its children and ensure the future health of the nation. Even more distressing than the absolute numbers are the sustained and marked disparities between white children and racial and ethnic minority children, and between children in poorer families and wealthier families. For example, blacks have higher infant mortality (Centers for Disease Control and Prevention, 2002d) and adolescent mortality rates, with the death rate for adolescent males increasing from 1985 to 2000 (125 to 130), while the rate for white adolescents males decreased (105 to 86) (Federal Interagency Forum on Child and Family Statistics, 2003). Teenage pregnancy rates have fallen but blacks still have higher rates than other population groups (Ventura et al., 2003). Hispanic children are more likely than both black children and white children to lack health insurance (Institute of Medicine and National Research Council, 1998) and twice as likely to drop out of school (Martinez and Day, 1999). These and other substantial disadvantages for some groups of children during childhood have major effects both on child health and on adult health outcomes and subsequent health care costs and productivity. These discrepancies are particularly disturbing given projected population changes over the next several decades. While the proportion of children is projected to stay relatively constant (24 percent), the non-Hispanic white child population is projected to decrease from 64 to 55 percent by 2020, while the percentage of Hispanic children is projected to increase from 16 to 22 percent (U.S. Department of Health and Human Services, 2001b). The health of the U.S. population generally, and children’s health in particular, lags behind that of many Western industrialized countries (Shi and Starfield, 2000). For example, while the infant mortality rate has decreased by more than 50 percent in the past two decades, the United States still has an infant mortality rate that is higher than all but 5 other Organisation for Economic Co-operation and Development (OECD) nations (Hungary, Mexico, Poland, the Slavic Republic, and Turkey) (Organisation for Economic Co-operation and Development, 2002). While this might be partly attributable to the more inclusive definition of live birth used in the United States, data suggest that this is not the only factor. An indepth comparison involving 13 industrialized nations in the mid-1990s showed that the United States ranked worst (13th) in rates of low birthweight. Similar poor rankings for postneonatal mortality (11th) indicate that the poor infant

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health mortality ranking is not a result solely of the high percentage of low-birthweight infants. Postneonatal mortality is less sensitive to low birthweight and more sensitive to receipt of good basic (primary) care (Starfield, 2000b). In another international comparison, the United States ranked lowest among major industrialized nations on equity of child survival (to age 2) and had the highest probability of dying before age 5 (World Health Organization, 2000). The United States also ranks poorly (23rd) in child (ages 1–14) death rates from injuries among 26 OECD countries (1992–1995 data). Among a subset of 15 of these countries (including Mexico, a developing country by OECD standards), the United States ranks in the worst 5 on 3 of the 5 categories of injury deaths: 11th for motor vehicle injury deaths, 15th for deaths resulting from fire, and 14th for deaths due to homicide (United Nations Children’s Fund, 2001). WHY MEASURING AND USING CHILDREN’S HEALTH DATA ARE IMPORTANT Measurement and appropriate use of data on children’s health and influences on health can help ensure that federal, state, and local policies are based on good information and are designed to enhance the health of children. This will reap benefits for both today’s children and the adults they will become. The use of child health reporting systems can improve awareness among policy makers and other stakeholders about the complex needs of children and their families (Halfon, Newacheck, Hughes, and Brindis, 1998). Good measurement and reporting of data as well as judicious integration of data help to target public expenditures and interventions toward identified problem areas and identify areas for further research. Comprehensive tracking systems can help to identify changes in patterns in children’s health and to develop appropriate public health responses. For example, recognition of obesity and asthma as significant public health issues might have been facilitated by more comprehensive data collection and monitoring systems that identified changes and the likely correlates of these changes. At the state and local levels, combining data from multiple sources can increase planning efficiency and provide a more useful picture of children’s health. States and localities have used child health tracking systems to target public health insurance enrollment activities (Box 6-4 is one example), to increase immunization rates and receipt of other preventive health services, to identify areas with particularly high incidence of such diseases as cancer, to facilitate case management among the many medical and other service providers sometimes involved in children’s lives, and to improve communication across agencies and with legislators and other policy makers (Association of State and Territorial Health Officals, 2003). Measurement systems that consider the relationship of various factors in the family, community, and physical environments also serve as early warning systems about things like toxic neighborhoods, risky family situations, and poor school environments. Monitoring of such influences can help identify

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health the need for policy or other interventions early and, if implemented, avoid potential long-term negative consequences. Good measurement systems also allow comparison within and across jurisdictions. They facilitate identification of specific geographic areas where health problems are concentrated. The establishment of state and local data systems allows these areas to compare their progress with that of other comparable areas and to identify areas that need improvement. Finally, good data systems at the local, state, and national levels provide early evidence of failures and successes so that more rapid and more targeted modifications can be made in interventions and public policies. THE COMMITTEE’S STUDY In 2000, Congress responded to concerns raised about risks to children’s health by directing the U.S. Department of Health and Human Services1 to fund a study by the National Academies. Congress requested the National Academies to conduct “an evaluation on children’s health [that would] assess the adequacy of currently available methods for assessing risks to children, identify scientific uncertainties associated with these methods, and develop a prioritized research agenda to reduce such uncertainties and improve risk assessment for children’s health and safety.” The Board on Children, Youth, and Families of the National Research Council and Institute of Medicine in consultation with the Department of Health and Human Services and expert advisers developed a statement of task that expanded this basic charge. The Committee on Evaluation of Children’s Health: Measures of Risk, Protective, and Promotional Factors for Assessing Child Health in the Community was formed to examine key issues regarding the definition and measurement of children’s health, influences that affect children’s health, and the optimal use of data on children’s health. Specifically, the committee was charged with considering these questions: How is children’s health defined? Are these definitions appropriate? If not, what is an appropriate definition of children’s health? What data and methods are being used to assess and monitor children’s health at the federal, state, and local levels? Are these data and methods adequate and appropriate? If not, what types of data and methods are needed and what are the strategies for their development and application? How could new technologies be used to link individual, family, community, and clinical data to assess and monitor children’s health? What are the technical challenges and limitations for linking such data? 1   The Consolidated Appropriations Act 2001 (P.L. 106–554).

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health What are the risk, protective, and promotional factors to children’s health, safety, and well-being? What data and methods are used to assess and monitor these factors? Are these data and methods adequate and appropriate? What new assessment tools or methods are needed and what are the strategies for their development and application? Ideally, how should data be used to inform both policy and practice to ensure children’s health, safety, and well-being? What are the ethical considerations in obtaining such data and in their application? The study committee included 13 members with expertise in key areas related to children’s health. The committee heard from a range of stakeholders active in various aspects of the field to benefit from a wider range of viewpoints and to obtain input on our charge. The committee’s first tasks were to (1) define what is meant by children; health, safety, and well-being; and risk, protective, and promotional factors and (2) determine how to approach the task of reviewing federal, state, or local data and methods. Children The committee adopted the term “children” to refer to groups of individuals from the time of birth to their 18th birthday. Surveys and other data sources employ differing age ranges, and the committee recognizes that, from a developmental perspective, there is no exact age at which childhood definitively ends. Numerous factors can affect the timing of one’s transition from adolescence to adulthood and, as a result, individuals transition from child to adult roles at different rates. For some, adult roles are assumed during adolescence, while for others this does not occur until the middle of the third decade of life. Nevertheless, many datasets and systems consider individuals before and after they reach legal majority, so the committee has chosen age 18 as a minimum age for ending childhood. However, while the committee asserts that data on children’s health should extend at least to that point, collection of data for those older than 18 should be an important data collection priority for the nation. The committee also recognizes that myriad factors affect the developing fetus prior to birth that impinge on and influence the health of children at birth. In this report these prenatal factors are considered and discussed as influences on children’s health. Although the terms “youth” or “adolescents” are often used to refer to older children and the terms “infants” and “toddlers” refer to very young children, for ease of reference, this report uses the term “children” to encompass all these groups. If a statement is intended to refer to a subset of the child population (e.g., infants, adolescents) the relevant descriptive term is used in the text.

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health Children’s Health, Safety, and Well-Being The committee was asked to assess definitions of health and questions related to children’s health, safety, and well-being. This section provides a brief overview of the committee’s approach to children’s health and outlines how safety and well-being were considered in the report. Chapter 2 discusses these issues in more detail. Health: Most available definitions or conceptualizations of health have been developed for adults. In the committee’s view, these approaches do not account for issues particularly salient for children and do not reasonably transfer to children’s health. Definitions of children’s health must account for their special characteristics, particularly rapid development during childhood. They also must consider multiple influences that interact over time in different ways as children develop and change. The committee proposes a new definition of children’s health that embraces health conditions, functioning, and health potential in a new conceptual model that considers multiple interrelated factors as influences. Safety: Safety generally refers to aspects of the environment that contribute to health, including the physical environment (e.g., absence of toxins or pollutants in ground water, use of car seats and bicycle helmets), social environment (e.g., low neighborhood crime rates, low rates of risky behaviors either by the children or adults), and psychological environment (e.g., the perception of not being in personal danger). Some environmental and behavioral influences might be conceptualized as contributing to less safe situations, while others might be viewed as health-promoting, safety-related, or protective. At any given moment in time, children are exposed to a range of risk and protective influences. To the extent that one or the other predominates (assuming this could be determined), it may be possible to characterize children’s social or biological environments as relatively safer, health-promoting, or risky. More often it is possible to characterize an environment as risky or safe with respect to a single influence or single set of variables. Such factors can be used to make statements about the likely current or future health of a given population and, in effect, are often used as “proxies” for the actual health of a given population. In this report, children’s safety is considered to be those influences that result in an environment that contributes positively to health and is discussed primarily in Chapter 3. Well-Being: Well-being is commonly considered to be the sense of self as appraised by the individual. Concepts such as quality of life, fulfillment, and ability to contribute constructively to society and one’s own family are important aspects of well-being. Well-being inherently involves comparisons with how one feels one should be, given one’s age, preexisting health status or the health status

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health of other persons in the social network, and physical status. For example, some children with attention deficit disorder and asthma that is controlled by medication, who are able to participate in a range of extracurricular activities and have many friends, may perceive themselves as healthy and fortunate, whereas others may not. Or children with no obvious physical illness but a subjective sense of poor well-being might be conceived to be in good physical health but potentially in compromised psychological health or in physical peril. Thus, one’s sense of well-being is an important component of overall health that has been shown to affect one’s overall functioning and prognosis, at least in adult health (Berkman and Syme, 1979). In the developmental literature, well-being is often considered to be a state broader than health that incorporates social, psychological, educational, behavioral, and economic dimensions. The term “health and well-being” is used to recognize that aspects of children’s life beyond traditional health considerations are important to both their current condition and to their future potential as adults, as well as to capture positive aspects of health. The committee contends that behavioral, psychological, and social well-being are core aspects of health and has incorporated these within the domain of health termed “health potential,” discussed in the next chapter. As used in this report, the term “health” therefore inherently embraces health-related aspects of well-being. Risk, Protective, and Promotional Factors (Influences on Children’s Health) A multitude of biological, behavioral, and environmental factors can either pose a risk to children’s health or act in a protective or health-promoting capacity. For example, children’s social environments can be characterized by a number of influences that can be viewed as safe, health-promoting, risky, or detrimental. Many factors (e.g., peers) can be either a risk to health or a protective factor, depending on the specific circumstances. Given this uncertainty, the committee adopted the term “influences on children’s health” to refer to risk, protective, and promotional factors. The distinction between health and influences on health is usually straightforward. In a few instances, however, the distinction is ambiguous. For example, risk behaviors are considered an influence in this report, although a strong case could be made that daily alcohol use by an adolescent indicates poor health in terms of functioning. Likewise, an individual’s genetic endowment is considered an influence because in most instances gene expression interacts with other factors before it causes disease or impairment in functioning. The committee recognizes that children’s health is the result of a dynamic set of factors. In a few cases, randomized, controlled trials or experimental studies (or both) have demonstrated a causal link between a particular influence and health. In other cases, while there is evidence to suggest a link between the influ-

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health ence and health, a direct causal link has not been established. In determining whether to include a given influence in this report, the committee included factors that meet at least two of these three criteria: (1) the existence of randomized control trials or experimental studies that demonstrate a causal link; (2) longitudinal prospective studies plus other nonexperimental or quasi-experimental evidence that supports a link; and (3) observational studies, plausible theory, or animal studies that support a link. Furthermore, inclusion required a substantial body of evidence with replicated studies and multiple, independent laboratories or researchers reaching the same conclusions. Typically, current research assesses the effect of a single or a small set of influences but does not allow an assessment of the relative importance of multiple influences in relation to one another. In the committee’s view, the relative lack of research on children’s health generally, and the interaction of various influences specifically, precludes a reliable ranking of influences. Instead, we have included all factors that meet a defined threshold of evidence and excluded those that, while plausible, do not yet have sufficient evidence to support their effect. The committee calls for research to allow refinement of the influences and their relative effect. Data and Methods Numerous federal, state, and local surveys and administrative data sources are used to inform policy and programmatic decisions. In specifying available data sources, the committee chose to focus on national data sources or state-level sources that are available in all or most states. Conducting a comprehensive review of the innumerable data sources that measure children’s health or a component of it in individual states or localities was not feasible. Instead, the committee highlights state or local examples to illustrate strategies proposed in the report. THE COMMITTEE’S PREMISES The committee approached its charge based on several underlying assumptions related to the importance of measuring and using data on children’s health: children are vital assets of society; critical differences between children and adults warrant special attention to children’s health; children’s health has effects that reach far into adulthood; the manifestations of health and definitions and causes of ill health vary for different communities and different cultures; and the tracking of data on children’s health and its influences is an essential part of efforts to improve children’s health and the health of the adults they will become.

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health Children Are Vital Assets of Society Children have intrinsic value in their own right. In the committee’s view, fully protecting the health and growth of children is one of society’s primary responsibilities. Optimal health and development are necessary preconditions to provide the opportunity for all children to reach their inherent potential. The reality that some children do not have the opportunity to grow up healthy and become productive members of their communities and the nation has enormous ramifications for all. Failure to optimize the health and development of children will result in future burdens of dependence that come from an unhealthy and unskilled workforce and dysfunctional families. Furthermore, growing scientific evidence demonstrates that disparities in health have their origins in early childhood and, if not addressed, are compounded over the life course (Ben-Shlomo and Kuh, 2002; Hardy, Kuh, Langenberg, and Wadsworth, 2003; Halfon and Hochstein, 2002; Institute of Medicine, 2001b). Therefore, the committee undertook its task with the conviction that it is important for the whole of society to be committed to ensuring that children are as healthy as possible and that all children are afforded an opportunity to optimize their individual health and development. In the committee’s view, maximizing children’s health will provide immediate benefits to them as well as determine their capacity to contribute to society and the common good over the long term. Critical Differences Between Children and Adults Many other reports have examined issues related to the health of Americans generally. Thus, a legitimate question is: Why should a report focus specifically on the health of children? The answer is that there are many differences between children and adults. Therefore, it is inappropriate to assume that what enhances or impedes adult health translates directly into children’s health. While many factors may be relevant to both child and adult health, a wide range of factors affect them differentially. Developmental Differences Children’s physiology and behavior differ in ways that require a different view of their health that is sensitive to rapid developmental change and unique developmental considerations. The particular patterns of gene expression, the relative sizes and growth of children’s organs, the injuries to which they are susceptible, and the manner in which they interact with their environments differ in many ways from adults. For example, the surface area of their skin and lungs is proportionately greater in comparison to their weight than at any other time of life. This makes children more vulnerable than adults to certain types of environmental exposures (National Research Council, 1993). Children’s behavior also differs in significant ways from that of adults. Children are by nature exploratory

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health and many of their exploratory behaviors, hand-to-mouth behaviors, crawling, climbing, testing the limits of their capacity, and experimentation involve activities that are not normative for adults. As a result, children have greater exposure to a number of hazards in their physical world. In addition, they lack the cognitive mastery and behavioral inhibitions that are normally associated with adults and consequently they may exhibit behaviors that place them at significant risk for negative long-term consequences. In addition, children grow more rapidly, most notably during the early years and again during adolescence, and change body and organ sizes and proportions at faster rates than at any other time of life. Furthermore, development occurs at different rates in individual children, and it is heavily influenced by a wide range of factors, from nutrition and nurturance to experiences and opportunities for learning (National Research Council and Institute of Medicine, 2000). The manner in which a child grows cognitively, emotionally, socially, and physically are key components of children’s health that are not routinely part of assessments of adult health. As a result, indicators of a healthy 6-week-old, 6-month-old, and 6-year-old will be different. Given these dynamic elements, in general, it is necessary to look at changes over time, rather than a point assessment to distinguish among different levels of health. Dependence Childhood is characterized by children’s dependency on their families and communities (Jameson and Wehr, 1994; Halfon, Inkelas, Wood, and Schuster, 1996). A newborn infant cannot survive without adult caregivers. Children are not free agents who can access services, determine diets, or change the environments in which they are raised. They lack voice and control of their own destiny. While autonomy increases with growth and development, during most of their childhood children are fundamentally dependent on the adults in their environment for the prevention of disease and the promotion and protection of their health and development. Different Manifestations of Poor Health The distribution of disease in childhood and the nature and types of health threats that affect children are different than in adults. Children have a lower prevalence than adults of chronic illnesses that require expensive, high-tech interventions and a higher prevalence of repeated acute illness. They also experience an array of congenital problems and inborn errors of metabolism that may not be seen in adults. What especially distinguishes the majority of children from adults is their greater resilience, less rapid biological deterioration, and continued ability to develop and grow in the face of negative health conditions. As a result, in many cases, interventions are more possible and more effective with children than with adults.

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health Childhood Has a Long Reach What happens to children early in their lives can have profound implications for later health and well-being during adulthood (Wadsworth, 1999). A great deal of information is emerging on the high degree to which early events and conditions of childhood serve as precursors of adult disease. From Neurons to Neighborhoods, a recent report of the National Academies, states: “What happens during the first months and years of life matters a lot, not because this period of development provides an indelible blueprint for adult well-being, but because it sets either a sturdy or fragile stage for what follows” (National Research Council and Institute of Medicine, 2000, p. 5). Experiences early in life establish a physical, psychological, and social foundation on which future development and adult health are based. This can include prenatal and perinatal insults as well as exposures in childhood that lead to negative adult health outcomes. For example, early exposure to ultraviolet light has implications for the development of melanoma in adulthood. Habits and behaviors developed during childhood can also lead to health problems in adulthood. Diet and exercise habits acquired in early childhood have been shown to have cumulative effects that alter adult health outcomes in the absence of appropriately targeted interventions. Both positive and negative influences early in life not only have direct effects on health during childhood, but also act to influence future health at each stage of development. Both negative and positive factors and health disparities compound their effects over a lifetime. At each stage, previous health affects current and future health, and the cumulative effects of early differences in health may result in profound differences in later health (see Keating and Hertzman, 1999). Failure to influence children’s health in a positive way may result in later excessive morbidity. The later consequences may be even more difficult and expensive to change than might prevention efforts put forth earlier in life. The capacity of an adult to contribute as a productive member of society may also be dramatically affected by poor health experienced as a child. This also means that there is often a long lag time between the measurable effects of interventions in childhood and changes in health later in life. This in turn makes it much more difficult to assess whether health is improving in both the short and the long run. Community and Cultural Variation Although there are some absolute notions of health (e.g., absence of disease), the manifestations of health differ across social and cultural groups. This is reflected in the differing notions of health across human societies and within societies over time. Common and technical use of terms like “disease,” “illness,” and “impairment” is embedded in a cultural context, which will determine whether certain symptoms, signs, or disease manifestations are considered normal or worthy of distinction in either a positive or negative way. For example, notions of

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health normal body size differ substantially in different parts of the world and over generations. Aspects of health, social, and cultural norms influence concepts of health as well as understanding of the causes and consequence of the variety of its aspects. When these notions translate into individual and group behaviors and attitudes, they can have a major effect on health. Culture also provides a framework for the use of home remedies. For example, in some Hispanic and Asian communities, health is a balance between “hot” and “cold,” and an imbalance in favor of one can cause illness necessitating a remedy from the other to restore harmony (Risser and Mazur, 1995). Other cultural variations that can be misconstrued are the traditional practices of cupping and coining, which can be mistaken for child abuse (Hansen, 1998), and home remedies for such folk illnesses as caída de mollera (fallen fontanelle), mal ojo (evil eye), and empacho (intestinal blockage). In addition, social or cultural views on health, as well as the circumstances of a given community, may affect the priorities of that community in terms of what is considered important. It is therefore critical for specific societies and communities to define the measures they deem most salient to their local circumstances and for those working to improve health to take into account cultural differences and the priorities of that community. For example, a low-income community in which food is scarce and healthy children are defined by carrying extra weight may not consider obesity a priority health problem compared with reducing other more immediate threats to health, such as crime. Use of Data to Improve Children’s Health How can the nation assess whether movement toward the goal of optimizing children’s health society-wide is being achieved? Without the capacity to measure and monitor progress, there is no way to know whether changes in policy make a difference toward improving children’s health. Lack of valid and reliable information impedes comparisons across time or place or in response to interventions. Without data to measure and monitor children’s health, the effect of changes in the social, cultural, and physical environment will remain unknown. What is measured is often what gets attention. Conversely, aspects that are more difficult to assess are more likely be ignored. This report addresses the questions of whether what is measured is what ought to be measured; whether it is being measured in an appropriate manner; and whether information is being used in a way that will optimize children’s health. THE COMMITTEE’S VISION Although the committee views the findings in this report as relevant to multiple audiences, federal, state, and local decision makers are considered to be the primary audience. The committee proposes strategies to address gaps in knowl-

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health edge about children’s health and influences on it, tools available to measure both, and ways to use data about children’s health and influences on children’s health to inform policy decisions. The committee’s recommendations aim to focus on action and results, address future health measurement needs, and improve understanding of children’s health and influences on children’s health through specific research priorities. To make the report as practical as possible and facilitate its use, the committee focuses on feasible next steps such as integrating existing datasets, and outlines strategies by which children’s health might be improved. The definition of children’s health and the conceptual framework presented in this report have important policy implications for the ultimate health of the nation, as well as the health of the nation’s economy, its workforce, and its viability as a future leader among nations. Given the rapid strides in the development of new technologies, such as electronic information systems and the Human Genome Project, the committee has addressed future information needs both in terms of specific types of indicators as well as the types of systems and infrastructures necessary to make better data available at national, state, and local levels. Where indicators, measurement tools, and measurement systems are not available, the committee has identified research to address gaps in knowledge. Research to examine the interaction of multiple influences and improve understanding of the dynamic nature of children’s health is also identified. STRUCTURE OF THE REPORT This report has seven chapters. The next chapter focuses on our definition and conceptualization of children’s health. It outlines a definition of children’s health that reflects the committee’s view that children’s health is a developmental, multifaceted state that is socially and culturally defined and specifies its components. The chapter presents the conceptual framework adopted by the committee for thinking about both the internal and external influences that affect children’s health. Chapter 3 reviews the scientific evidence pertaining to the ways in which various influences have been shown to affect children’s health. It outlines influences specific to children including their biology (their genetic make-up and internal biological environment), and the behaviors they exhibit as they interact with their surroundings. The chapter also outlines influences external to the child, including the family, community, culture, and physical environments as well as policy environments and services systems. Chapter 4 outlines the available tools and data for measuring children’s health and the adequacy of these methods, including specifying gaps based on the committee’s definition of health. Chapter 5 provides a similar review of tools, data,

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Children’s Health, The Nation’s Wealth: Assessing and Improving Child Health and gaps for measuring the influences discussed in Chapter 3. Chapters 4 and 5 focus primarily on available national data. Chapter 6 discusses data systems, outlines the value of data integration, and presents strategies to begin to develop improved data systems, including discussion of the ethical, technical, and political challenges inherent in these strategies. This chapter introduces the potential value to state and local policymakers of improved use of available state-level data. Chapter 7 presents the committee’s conclusions and recommendations. This chapter focuses on what can be done at the federal, state, and local levels to improve children’s health by advancing efforts to measure and use information on children’s health and its influences. This final chapter also outlines the committee’s recommendations aimed at improving knowledge of how various factors interact to affect health and their relative importance. Finally, several appendixes follow the body of the report. Appendix A provides short descriptions of existing core datasets for measuring children’s health and compares them based on periodicity, age, and geographic level surveyed. Appendix B examines the extent to which current major surveys capture data on children’s health and its influences and provides a comparison across surveys in both narrative and tabular form. Appendix C presents information on national-level syntheses that use secondary data to track multiple indicators over time and examples of the indicators they track. The glossary in Appendix D defines frequently used terms, Appendix E identifies acronyms referred to in the text, and Appendix F provides biographical sketches of the committee members and staff responsible for the report.