Vibrant and Healthy Kids Aligning Science, Practice, and Policy to Advance Health Equity (2019) / Chapter Skim
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1 The Need to Intervene Early to Advance Health Equity for Children and Families
1 The Need to Intervene Early to Advance Health Equity for Children and Families
Pages 29-76
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From page 29... ...
. Despite increasing evidence about what contributes to poor health, these health inequities have persisted, and for some populations and outcomes, they are worsening.
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• hese health disparities are evident in the rates of infant and maternal mor T tality, low birth weight, and chronic childhood diseases (such as diabetes, asthma, obesity, depression, and anxiety)
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These disparities put children on a course for poor health outcomes later in life. For more information on maternal and child health disparities, see the section on Early Childhood and Maternal Health Disparities in the United States on page 41.
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From page 32... ...
report Communities in Action: Pathways to Health Equity reviewed the root causes of health disparities and concluded that health inequity arises from root causes that could be organized in two clusters: 1. Intrapersonal, interpersonal, institutional, and systemic mecha nisms (also referred to as "structural inequities")
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From page 33... ...
To achieve equitable health outcomes in the prenatal through early childhood periods and throughout the life course, all of these contexts need to be addressed. Health inequities are systemic challenges, and chronic childhood adversities have biological implications and affect childhood development, with lifelong impacts on health and well-being.
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From page 34... ...
Given these advances and the understanding of how science can be used to advance health equity during early development, the obert Wood R Johnson Foundation (RWJF) , as part of its Culture of Health Initiative, 1 The study of how genes are expressed due to changes in the environment and how these biological changes can be passed down from one generation to the next.
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2. Identify promising models and opportunities for translation of the science to ac tion and the intervention points during the prenatal and early childhood periods that will yield the greatest impact, with a focus on practice-based changes and the goal of facilitating broader systems change and alignment based on the science.
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An individual's health status and outcomes reflect the accumulation of experiences over the life course. Protective factors support positive, or flourishing, trajectories, while risk factors exacerbate the likelihood of poor trajectories (see Figure 1-1)
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. The outcomes that the committee seeks to improve across the life course fall into four categories, adapted from the 2016 National Academies report Parenting Matters: Supporting Parents of Children Ages 0–8: 1.
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Health disparities: Differences that exist among specific population groups in the United States in the attainment of full health potential that can be measured by differences in incidence, prevalence, mortality, burden of disease, and other adverse health conditions (NASEM, 2017)
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As noted in Communities in Action (NASEM, 2017) , advancing progress toward health equity (across the life course)
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. CURRENT STATE OF CHILDREN'S HEALTH Overall Well-Being of Children and Families in the United States This section begins with a broad overview of the current state of child health in the United States, followed by a summary of key health disparities in child and maternal health in the country.
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The most recent data available are presented. Chapter 3 provides a detailed overview of health disparities and critical influences or factors that can either promote or hinder healthy development, with a focus on factors that shape inequities at the child/family level and the community and population levels.
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From page 42... ...
. For infants of non-Hispanic black mothers, mortality was 15 percent higher in small and medium urban counties and 16 percent higher in rural counties (12.08)
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. Although all of these conditions have genetic components, they also often reflect the consequences of early childhood experiences and their influence through epigenetics and other physiological mechanisms.
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All states have developed some form of school readiness assessment, and most of them focus on children's social-emotional development, approaches to learning, and physical health and development, as well as cognitive abilities (Daily et al., 2010)
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Health Insurance Coverage From 2008 to 2016, the rate of uninsured children steadily decreased from 9.7 to 4.7 percent. However, the percentage of uninsured children increased to 5 percent in 2017 (Alker and Pham, 2018)
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The Census began collecting data for the health insurance series in 2008; therefore, there is no significance available for 2008. Data are sourced from Table HIC-5, Health Insurance Coverage Status and Type of Coverage by State -- Children Under 19: 2008 to 2017, Health Insurance Historical Tables, U.S.
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From page 47... ...
U.S. women in have the highest rate of maternal mortality because of complications from pregnancy or childbirth and among the highest rates of cesarean sections, and maternal mortality rates are rising for them while declining in other countries (see Figure 1-6)
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. People of color are much more likely to be affected by late initiation of prenatal care, which is most common in Pacific Islanders at 18.4 percent, with nonHispanic white women at 3.3 percent.
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Early Education and Care -- 2.1 10.8 15.5 14.9 Head Start (including Early Head Start) -- 2.1 6.2 9.0 8.9 Child Care and Development Fund -- -- 4.6 6.6 5.7 Other early education and care -- -- -- -- 0.3 6.
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Training -- 6.4 1.5 2.2 1.2 9. Refundable Portions of Tax Credits -- 3.1 34.5 81.8 74.0 Earned income tax credit -- 3.1 33.3 54.8 53.1 Child tax credit -- -- 1.1 25.4 19.4 Premium tax credit -- -- -- -- 0.6 Other refundable tax credits -- -- -- 1.6 0.8 10.
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Act (ACA) , which expanded health care access for children and families through a combination of Medicaid expansions, private insurance reforms, and premium tax credits (Kaiser Family Foundation, 2019)
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. CHANGES IN THE ECONOMIC, SOCIAL, AND CULTURAL ENVIRONMENT Income inequality has been growing -- the income gap between higherand lower-income individuals has increased substantially over the past 8 See https://www.acf.hhs.gov/occ/ccdf-reauthorization (accessed July 29, 2019)
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In terms of family structure, American families have changed, with a Pew Research Center (2015b) survey finding that there is no longer one dominant family type in the United States today (as compared to 1980, where 61 percent of children were living with married parents in their first marriage -- today, that number is 46 percent)
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Data are sourced from Pew Research Center's analysis of 1960 and 1980 decennial census and 2014 American Community Survey. SOURCE: Pew Research Center, 2015b.
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children lived in a household where more than one language is spoken (dual-language learners) , with Spanish being the most common other language for these children (Child Trends, 2016)
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Within the context of the life course, the diagram's nested circles illustrate the complex sociocultural environment that shapes development at the individual level and the opportunities for interventions to improve individual health and developmental outcomes and population health, well-being, and health equity. The context and conditions here continue
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The outer level, "socioeconomic and political drivers," is adapted from the WHO social determinants framework and represents the level at which structural inequities operate. These structural inequities are deeply embedded into policies, laws, governance, and culture; they organize the distribution of power and resources differentially across characteristics of identity (i.e., race, ethnicity, gender, class, sexual orientation, and others)
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. Systems have existing patterns and BOX 1-5 Example of Systems, Policy, and Programmatic Changes Conceptual Example: How do we build more integrated care that helps support people in both the clinical and social drivers of poor health outcomes?
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It is often driven by a recognition that the standard approaches are not achieving the system's goals for some people. Programs usually do not change the goals or rules or the system itself; rather, they generally offer a new way to achieve improved outcomes within the current system's structures (such as a support group for new mothers offered in a primary care setting)
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Search terms included the following cate gories: prenatal and early childhood, neurobiological, socio-behavioral, biology/biomarkers, health indicators/outcomes, structural inequities, social determinants of health, and model/ intervention.
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From page 61... ...
and strong evidence for one or more salient health outcomes that is being targeted and has a large population health impact, the intervention or policy could be deemed appropriate despite its limitations. This is true for several interventions and policies recommended in this report.
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. Therefore, the committee makes some recommendations for improving programs that are not optimally or extensively implemented but have the potential to be updated, scaled, or better used to promote related services that advance health equity.
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Promising Models In its Statement of Task, the committee was asked to identify promising examples of models that apply the science of early development to health equity. The committee adapted the selection criteria used in the Communities in Action: Pathways to Health Equity (NASEM, 2017)
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From page 64... ...
The committee used these promising models as examples throughout the report to highlight bright spots that have been able to use what is known from the science to advance health equity in the preconception through early childhood periods. Furthermore, "promising" does not imply that the model is new but rather that it is a program or intervention that met the committee's core criteria, and each promising model has a unique approach and is at a different phase of development: some have been around for more than 30 years and have changed based on evaluations or input from users, while others have emerged in the past few years.
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The fourth criterion is that the model is designed to have or has evidence of having an impact on a group or population that experiences health inequities. The fifth core criterion "states that the solution needs to be multisectoral, meaning that it engages one or more sectors" (ideally, at least one "nontraditional" sector, meaning other than public health or health care)
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5. The developing child plays an important role in interactions and development: Children are active participants in their own development, reflecting the intrinsic human drive to explore and master one's environment.
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7. Trajectories -- positive or negative -- are not immutable: The developing child remains vulnerable to risks and open to pro tective influences through adolescence and young adulthood, although early life represents the stage at which interventions are most effective in positively influencing a child's development.
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Disparities in the child's birth and early developmental outcomes are therefore the consequences of not only differential exposures during pregnancy and early childhood but of differential parental life course trajectories set forth by early programming mecha nisms and influenced by cumulative life adversity.
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From page 69... ...
These actions need to take a life course, multigenerational approach to make progress on health inequity, because the well-being of a child depends on the well-being of a parent/caregiver. Multipronged, cross-sector interventions, focused on prevention, early detection, and mitigation and working at the policy, system, and program levels, are needed to move toward health equity.
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2017. The impact of adverse childhood experiences on health service use across the life course using a retrospective cohort study.
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https://www.childtrends.org/indicators/ immigrant-children (accessed July 13, 2019)
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https://inequality.org/facts/ income-inequality (accessed July 16, 2019)
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https://www. kff.org/report-section/the-uninsured-and-the-aca-a-primer-key-facts-about-health insurance-and-the-uninsured-amidst-changes-to-the-affordable-care-act-how-have health-insurance-coverage-options-and-availability-changed (accessed July 16, 2019)
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https://www.pewsocialtrends. org/2015/12/17/1-the-american-family-today (accessed July 16, 2019)
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From page 75... ...
https://www2.census.gov/programs surveys/cps/techdocs/cpsmar18.pdf (accessed July 16, 2019)
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