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The Health Impact of Early Childhood Programs: Perspectives from the Brookline Early Education Project Melvin D. Levine and Judith S. Palfrey In the evaluation of early childhood programs the health status of the children enrolled is often a prominent issue. Planners and policy makers are likely to ask whether participation in such programs enhances children's health and, if so, whether the gains are substantial enough to justify the costs. In early childhood programs for which improved health is not a primary objective, program planners may want to know if the addition of a health-monitoring component would be cost-effective. As evaluators survey early childhood programs and their impact on health, they may consider the possibility of modifying the content of traditional preventive health care. They may examine the feasibility of collaborative service models that include the consoli- dation of early education and preventive pediatrics, so that communities can shape and upgrade simultaneously the health care and developmental monitoring of children. At first glance it might seem that the health of children is easily amenable to evaluation and measurement. Accurate numbers, however, are difficult to obtain and are often misleading. In this paper we outline some salient clinical and methodological issues that have become appar- ent to us in working at the Brookline Early Education Project analyzing the health impact of a comprehensive early childhood project. The first section of the paper delineates a number of critical issues facing evaluators. The second section discusses the scope of "health" by detailing the various background and process factors that need to be considered during evaluation. The third section outlines specific questions evaluators can ask as they measure the impact of health. Finally, drawing on our experiences with the Brookline Early Education Project, the last section 57
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58 reviews seven evaluation prototypes and discusses matching alternative evaluation strategies to specific questions. l RELEVANT ISSUES FACING EVALUATORS Defining Health and Its Borders Health is more than the absence of disease. It is the absence of handicap, social and emotional discord, and environmental stress as well as the presence of resil- iency, stamina, and homeostasis. There is growing aware- ness that traditional pediatric health cannot be viewed apart from psychosocial, behavioral, developmental, and educational status (Richmond, 1975; Rutter et al., 1970; Haggerty et al., 1975). Functional health and its promotion have increasingly become the purview of the pediatrician working in conjunction with professionals from other disciplines (Levine, Brooks, and Shonkoff, 1980). Health issues are likely to involve other areas. For example, it is essential for those managing children with musculoskeletal defects to address the functional (i.e., gross and fine motor and psychosocial) impacts of such handicaps. Professionals helping neurologically impaired children must involve themselves in the assessment of higher-order cognitive function, self-esteem, behavioral adjustment, and related family issues. Health maintenance must include anticipatory guidance and counseling, for patterns of behavior are as much within the domain of child health as are infectious diseases and specific organ disorders. Table 1 samples the broad spectrum of child health disorders. So many factors are involved that it is easier to describe what should be included under the rubric of "health" than to isolate issues irrelevant to health maintenance. Describing Health Status Characterizing the health status of groups of children is even more difficult than characterizing individual health. Since universally acceptable scoring and weighting systems do not exist, the health evaluation of a cohort enrolled in an early childhood project can be costly to obtain and difficult to interpret.
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59 TABLE 1 Some Negative Health Outcomes Whose Effects Early Education Projects Are Intended to Minimize 1. Poor growth and/or nutrition 2. Sensory deficits 3. Chronic illness and symptoms 4. Poor utilization of health services 5. Recurrent trauma 6. Neurological disorders 7. Neurodevelopmental dysfunctions 8. Psychosocial mobility 9. Mental retardation/multiple handicapping conditions lOe Life-threatening diseases A group's health status cannot be presented as a simple inventory of existing symptoms and conditions. Evaluators who wish to characterize the health status of a group of children need to take into account past medical events, family history, and current health. In addition, there must be estimates of vulnerability and resiliency, descriptions of health practices and knowledge (nutrition, exercise, and total environment), and accounts of medical service utilization. Describing Health Change After defining the limits of health as a subject matter and developing the descriptors to characterize group health status, evaluators must find measures of health change. This can be particularly challenging in the preschool child, as the morbidity itself evolves with age and many of the dysfunctions and disorders are self-limited or transient.
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60 Sometimes changes in health are more apparent than real because different measures are used at different ages. Certain reflexes, for example, can be elicited in children who are three to six months old but not thereafter. Hearing and vision are easier to measure after three years of age than before. Some orthopedic difficulties may not be evident until a child attempts to walk. Children may have immunity to certain diseases at specific ages but not beyond. The descriptors of the health of children thus depend to some extent on which window one looks through at what time. Just as problematic for evaluators is the high prevalence of self-limited acute or subacute illnesses and the spontaneous health resiliency of young children (single, 1964; Miller et al., 1960). This makes it difficult to study both the occurrence of and recovery from acute disease. It may be particularly hard to attribute symptom abatement to treatment effects. Behavioral and developmental disorders of early child- hood reveal considerable instability over time as well. Although some researchers (Thomas and Chess, 1975; Taft, 1978) have suggested that behavioral characteristics may be maintained from infancy through childhood, others (Bell et al., 1971; Carey et al., 1977) have demonstrated that children who have "behavior problems" at age two or three may not be the same children who have difficulty in school. It may be impossible to identify precise endpoints of health change. For example, one may not be able to determine whether a child has had one prolonged episode of otitis media that never really healed or multiple ear infections (Giebink and Quie, 1978). This difficulty . . . - impedes any precise accounting of numbers of acute illness episodes during a given period. The measurement of health change is complicated for three reasons: (1) the actual content of health and morbidity evolves with age, (2) many conditions undergo spontaneous remission, and (3) some disorders are closely associated with others and are therefore indistinguishable from one another. Therefore, before looking at the impact of a program on health, evaluators should develop appro- priate methods of characterizing change: The health (of a group or individual) may vary depending on the period of time under scrutiny. The measures of health should therefore be dynamic, depending on the age and development of the children in a program. The measurement of health "progression" must somehow be differentiated from normal
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61 chronological change. To document enhancement, evaluators must show that a particular child or group of children at the end of two years improved in overall health character- istics. As difficult as this may be, such documentation stands as a critical requisite for the evaluation of health as a progressive phenomenon. Dealing With Low Prevalence Rates in Pediatric Morbidity Pediatric illness differs fundamentally from its adult counterpart. In the latter, a relatively small number of major illnesses (e.g., hypertension, obesity, coronary heart disease, cancer, and diabetes) are likely to be highly prevalent within a population. Evaluators of adult health programs may be able to measure the impact of a program on these distinct entities and thereby generalize about health status and program-induced change. In contrast, there is no single chronic organic condition of childhood common enough to scrutinize in such a fashion without a very large sample. Therefore, in studying chronic medical conditions in a service program for chil- dren, it is often necessary to employ aggregate ratings that "lump" children with such disparate conditions as congenital heart disease, juvenile rheumatoid arthritis, nephrotic syndrome, recurrent urinary tract infection, and asthma for purposes of analysis. The alternative is to use samples that are too large for most early childhood projects. Resiliency in childhood also differentiates child health from adult health. Most child health setbacks are likely to be acute and self-limited, leaving no scars or aftereffects. Cataloging of such events shows that in a single year most children have been "sick" as many as four or five times (single, 1966). For children such morbidity is par for the course, developmentally appro- priate, perhaps immunologically necessary, and ultimately inconsequential (Mortimer, 1968). Evaluators thus need to weight acute self-limited disease very differently in children. Absence of Data on Normalcy In assaying pediatric health status, we are hampered by a paucity of data on normalcy and normal variation.
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62 While information does exist regarding the prevalence of specific chronic diseases or congenital anomalies and the incidence of some acute illnesses, this information tends to reflect major social class differences (Morris, 1979), serious problems with reporting (Brewer and Kakalik, 1979; Bureau of Education for the Handicapped, 1979), and inadequacies in many of the measuring techniques (Balinsky and Berger, 1975). This distortion makes it especially difficult to determine if the health status of a partic- ular group of children is below or beyond what ordinarily might be expected. Normative data are even more deficient in assessing developmental status, behavior, family functioning, and health care utilization patterns. Much of traditional medical research has had the benefit of normative data. For example, it is possible to study the effects of a medication on a patient's glucose level, since norms for blood sugar are available. For many of the aggregate measures of community child health, however, no such norms exist (Starfield, 1974). What is "normal" or "to be expected" for a particular population must almost always be reestablished in undertaking evaluation research. In many instances this requires the use of comparison groups or control populations. Selecting Outcome Measures In documenting program effects on health, one critical issue is the precise outcomes to be measured at designated outcome points. One might be tempted to consider only the prevalence of morbidity as an outcome measure. This, of course, leaves out such issues as parental health knowledge, patterns of use, and children's health stamina. Furthermore, it is unlikely that the straightforward rendering of morbidity statistics constitutes an adequate reflection of project effectiveness. An early support project may be beneficial without diminishing the prevalence of a disorder. For example, one would not expect a program to lessen the occurrence of myopia, yet an effective effort might result in a reduction of previously undetected or untreated nearsightedness. In fact, an early childhood project may exert its greatest effects not on prevalence figures but on awareness, management, coping, and the prevention of complications. Another issue in selecting outcome measures is the need for a method of weighting. Health outcomes can be measured in terms of their severity, their impact (on
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63 function, on families, on society), and their relevance, so that composite morbidity may be subdivided into significance for treatment (prescriptive implications) and potential for impairment of future health or function (predictive weight). Even a low prevalence of disorders that are likely to thwart academic function or behavioral adjustment may be more important than a high occurrence of such disorders as flat feet. Evaluators might also want to select outcome measures that have significant implications for treatment. A project should be judged more harshly if it missed problems that were treatable than if it overlooked those for which no therapy was available. Outcome measures should not be too global, particularly with regard to developmental and behavioral assessments. A project that uses IQ as an outcome measure will not be pinpointing the prevalence of problems with attention, language, or other isolated information-processing deficits that can seriously impair function (Levine, Brooks, and Shonkoff, 1980). Similarly, the results of a developmental screening test by themselves are unlikely to be sufficient to describe a pro3ect's impact on children's development (Meter, 1973; Meissels, 1978). ~ more comprehensive picture would include parental reports of function, direct observations of behavior, or specific teacher accounts of skills, abilities, and interest. One challenge for those evaluating early childhood projects is the identification of measures that can be used to provide an in-depth assessment of function to determine whether the program has diminished or minimized the effects of so-called low-severity, high-prevalence dysfunctions of childhood, which include specific learning disabilities, primary attention deficits, and various forms of psychosocial maladaptation during the school years. In delineating outcome measures, evaluators should consider the objectives of the project under scrutiny. For instance, if health is a high priority of a given project and if assurance of primary care is an explicit goal, then it is appropriate to determine if the project has met that goal by assessing patterns of health care utilization of the enrolled children. This approach may be less relevant in projects that have had only an incidental commitment to health. Finally, within a given population uniformity of outcome measurement may be unrealistic and inappropriate, especially in programs emphasizing the individualization
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64 of services. To measure gains, evaluators may need to specify "target subgroups." For a subgroup with hearing deficits, incremental growth in vocabulary may be a better measure of program effectiveness than mean developmental scores at ace five. Evaluators can identify areas in which they would expect or hope to see progress for particular children. They might also weigh expectations For example, a project may not against accomplishments. be able to diminish the prevalence of problems with short-term memory in children, but it might be able to achieve a generalized improvement in the reading proficiency of children with short-term memory problems, a gain that would surpass what would be expected for nonparticipating children with this developmental dysfunction. Thus, although a project may not diminish the severity or prevalence of short-term memory problems, it may manage to have "better capers," more competent readers, and perhaps happier children within this target subgroup. In some cases a project may want to evaluate only specific target groups to demonstrate program effects. When an evaluation becomes this focused, however, either large numbers or elegant small sample designs are needed to demonstrate that intervention has been successful. Assessing the Cost-Effectiveness of a Health Program Evaluation A major challenge exists in the calculation of a cost-benefit ratio for health program evaluations. There is constant pressure to balance the expense and difficulty of acquiring a particular set of data against its ultimate value for children and its relevance to the objectives of a project. It may be simple to determine immunization rates for a particular population, but if the project is located in a town where most children are well immunize`] anyway, despite its economy this will not be a useful way of measuring program impact. On the other hand, if a service model is likely to improve a family's ability to cope with behavior problems, a series of expensive measures of behavior and parenting may be most relevant (Haggerty et al., 1975; Roghmann et al., 1973; Haggerty, 1965). There can be no one set of criteria for evaluating all projects. Those aspects of health chosen for evaluation will depend largely on the nature of the community, the objectives of the program, the
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65 availability of evaluation funds, and current public policy questions. Identifying The Evaluation Consumer In designing an evaluation of health outcome, it is essential to understand the needs and priorities of those for whom the evaluation is intended. The content of an analysis depends largely on its intended audience. It can be argued, however, that all evaluations should be able to undergo some degree of rigorous scrutiny, even if intended primarily for nonacademics. Purely anecdotal reports and testimonials are inadequate measures of health care provision under any circumstances; highly esoteric statistical analyses, on the other hand, may have little impact on school committee decision making or on the deliberations of legislators. Often evaluations must apply several formats, each designed for a unique constitutuency. Timing and Staging A critical issue for evaluation is timing. The health effectiveness of a program can be documented while it is . . ~ one could consider assessment in progress. Alternatively, of its impact at the end of a project or at a short or long interval following termination. Decisions about timing must consider what is being measured and demon- strated. If a major goal is to minimize morbidity and suffering and to cushion the traumatic impact of daily events and environments, then it is crucial to offer evaluations while the project is in progress. If the goal is to look at the long-range effects of intervention or general service, postintervention analyses are needed. Findings inevitably reflect the timing of an evaluation, and the implications can be -treat, especially for issues of cost-effectiveness Because of the instability of health conditions in childhood and the high degree of resiliency, the timing of evaluations significantly influences the attribution of program effects, which can be misleading from a public policy viewpoint. For example, if children in a particular program have less difficulty adjusting to the first weeks of kindergarten than nonparticipants, evaluators may feel that they have documented a measurable effect. It may turn out, however,
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66 that the two groups are virtually indistinguishable if they are evaluated in mid-February of the kindergarten year. Allocators of resources would wonder if great expenditures to promote "educational readiness" were really worthwhile if their effects were demonstrable only during the earliest months of kindergarten and thereafter washed out. Traditional health issues follow a similar pattern. If a child's flat feet are detected in an early childhood project, but the child has no pain or functional limita- tion and it is documented that the finding would otherwise not have emerged until the first or second grade, what has been gained? In any event, by the time the child is eight or nine, the parents are likely to be aware of the condition. In that case, what is the value of early detection? Assuming that the condition is discovered early and the child given corrective shoes, does it really make a difference (Bleck, 1971; Cowell, 1977)? In some cases it may be better not to diagnose a problem that is going to resolve itself or that may not cause symptoms or require treatment for several years. It may be that years after a program ends there is little difference in the prevalence of previously undiagnosed findings. One might argue that ultimately the important problems will be detected. There is a danger that early detection may obligate programmers to unnecessary expenditures for interventions, especially for conditions that are likely to remit spontaneously. Once again, it is important to review the objectives of a project. The timing of an evaluation of program effects should relate to the objectives. In stating objectives there should be some consideration of the anticipated or desired duration of effects. Outcome measures can then be timed to assess these accordingly. Having delineated these issues for the evaluation of program effects on health, we now turn to a more detailed examination of the measurement of health status. The next section describes this as a necessary step in demon- strating the influence of a specific program on health. THE SCOPE OF CHILD HEALTH As early childhood programming expands, the literature from education (e.g., U.S. General Accounting Office, 1979; Lazar, 1977; Bronfenbrenner, 1975; White, 1975; Zigler and Valentine, 1979) and pediatrics (e.g.,
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67 Richmond, 1975; Thomas and Chess, 1975; Taft, 1978; Carey et al., 1977; Roghmann et al., 1973; Klaus and Kennell, 1976; Morris et al., 1976; Badger et al., 1976) makes it clear that the scope of child health that can be addressed is very wide. Clearly, evaluators should focus on those aspects of a health program that are most likely to reveal efficacy. In our work at the Brookline Early Education Project (Pierson, 1974) and the school clinics at Children's Hospital Medical Center in Boston (Levine, 1979), we have found it most helpful to define (1) the background health characteristics of the children, (2) the ongoing health and developmental processes at home and in the program, and (3) the outcomes that the program intends to achieve. Only with these areas clearly defined does it become possible to address specific questions regarding program impact. Background Variables From the intrauterine period onward, the experiences of children vary significantly. Some endure prenatal and postnatal trauma, some are born into impoverished and disorganized families, some inherit genetic disorders, and some fail to receive adequate nurturance. Others, because of their constitutional makeup, never adjust optimally to their milieu and continually hunger for greater satisfaction from it. Still others arrive with ease, cope readily, and manifest little or no disability in dealing with the external world. Programs dealing with young children generally take these variations into account for staffing and pro- grammatic reasons. To do so for outcome measurement is equally critical. Children who are more "at risk" will require greater levels of service; their outcomes may turn out to be excellent, but they differ from children not at risk. For instance, the most pertinent outcome measures for a middle-class deaf child might be ease with a hearing aid, skill in using a total communication system, and ability to attend a normal school for at least some of the day. On the other hand, outcome measures for a normally hearing child from a socio- economically depressed and disorganized home might be assurance of primary health care, money for food, and an adequate after-school, supervised program. Because the health needs of children are so varied, programmers, monitors, and policy makers should keep
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Representative terms from entire chapter: