Chapter 5: The Chief Public Health Officer's Report on the State of Public Health in Canada, 2009 – Setting trajectories for a healthy life

Chapter 5 - Setting Trajectories for a Healthy Life

Examining health in the context of the lifecourse model, as explained in Chapter 2, presents a view of health that acknowledges the complex interrelationships among biological, behavioural, psychological and social factors that contribute to health outcomes over a lifetime.^{footnote 24} Along the pathway from infancy to childhood to adulthood, events and exposures occur that can influence health in directions of advantage or disadvantage.^{footnote 3} The strength of this approach is that it identifies critical life stages for promoting positive health outcomes and mitigating negative outcomes.^{footnote 23} Childhood includes several critical periods of opportunity, such as prenatal, preschool and school-age, for creating optimal conditions for health and development.

From this examination of children's health and well-being, six areas of concern emerge, including: socio-economic status and developmental opportunities; abuse and neglect; prenatal risks; mental health and disorders; obesity; and unintentional injuries. Attention to these areas is critical because they can have immediate and long-term negative impacts on the health of Canada's children, they are persistent or worsening (including growing gaps between and within populations), and there is evidence that they are, in part, preventable through individual and social action.

In this chapter, examples of best practices from interventions as well as longitudinal research demonstrate what can be accomplished in setting healthy lifecourse trajectories and helping children to return to a path of good health. While there are likely many examples of proven and promising actions, only some are profiled here. These examples highlight the progress that has been made, as well as how to move forward in making further progress in these areas.

Socio-economic status and developmental opportunities

The socio-economic environment sets the context for the determinants of health in which children are born, grow and develop. Those environments that provide opportunities for positive development increase the likelihood of a healthy lifecourse, just as the absence of these same opportunities can have negative consequences for short- and long-term health outcomes.^{footnote 22} The following discussion highlights three types of interventions that are making a difference in terms of addressing inequalities in children's SES and developmental opportunities:

• broad poverty strategies;
• broad family and children's strategies; and
• programs for families and children.

Each has either shown success and could be applied more broadly, or is an area of promise where more work and investigation is required.

Broad poverty strategies

Efforts to meet basic needs are vitally important to families, as some still do not have the income, housing and/or food security required to achieve the conditions necessary for healthy child development.^{footnote 345}

Existing investments have contributed to the prevention and reduction of poverty in Canada. National efforts such as the Goods and Services Tax Credit and Employment Insurance (which provide assistance to low-income Canadians and those facing periods of unemployment) play an important role in preventing child and family poverty.^{footnote 229} Investments have also been made to improve family housing access (e.g. the National Housing Act) and to meet minimum requirements for residential health and safety (e.g. the Residential Rehabilitation Assistance Program and the Emergency Repair Program). ^{footnote 241 footnote 346–348} Further, Canadian and provincial/territorial government investments have contributed to increasing the supply of affordable housing for Aboriginals off reserve through efforts such as the Affordable Housing Initiative.^{footnote 349} Other broad investments that help to reduce poverty include enhancements to financial supports for vulnerable families (e.g. the Canada Child Tax Benefit, National Child Benefit Supplement, Child Tax Credit and Working Income Tax Benefit).^{footnote 350 footnote 351}

While the reduction of poverty is almost universally acknowledged as an important social and economic policy, evidence suggests that more could be done to reduce poverty in Canada.^{footnote 30 footnote 352} For example, the Standing Senate Committee on Human Rights, the Senate Subcommittee on Poverty, Housing, and Homelessness, and the Standing Senate Committee on Agriculture and Forestry have strongly recommended the creation of a national strategy to combat poverty in addition to the development of preventive measures aimed specifically at high-risk families.^{footnote 353–355} The House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities is reporting on the federal contribution to reducing poverty in Canada.^{footnote 356} Other similarly affluent countries (e.g. Finland and the U.K.), as well as some Canadian provinces and organizations (e.g. Quebec, Newfoundland and Labrador, Ontario and the Assembly of First Nations) are exploring this approach to poverty reduction (see textbox Child Poverty in Finland and the U.K.).^{footnote 219 footnote 357–361} As with other Nordic countries, Finland's low rate of child poverty can be attributed in part to taxes and transfers as well as broad family policies that support dual-income families.^{footnote 362} Within Canada, Quebec's Family Policy (1997) is an example, given its part in helping the province to achieve a consistent decline in child poverty rates over the last 10 years (see textbox Broad Family/Children's Strategies).^{footnote 360 footnote 363}

Broad family and children's strategies

The WHO Commission for Social Determinants of Health has called on governments to put in place an integrated policy framework or strategy for early childhood development.^{footnote 345 footnote 367} This framework would require coordination and policy cohesion and would articulate the roles and responsibilities of all sectors.^{footnote 345} As such, early childhood development would be integrated into the agendas of all sectors so that childhood health and development concerns are addressed in all policy decisions. The framework would also require government engagement of civil society organizations, caregivers and communities, allowing for local-level initiatives that provide families with financial and other supports. It would also facilitate effective early years program delivery, safer residential environments and increased community capacity for enhancing the lives of children regardless of SES. Such a strategy would involve a birthto-school approach ensuring that critical development stages are considered in decision-making. Countries with broad family and children's strategies that include opportunities for families and early childhood education report higher school readiness scores and lower child poverty rates.^{footnote 268 footnote 368 footnote 369}

Quebec’s Family Policy

When the Quebec government introduced its new family policy in 1997, poverty reduction, equal opportunity, a social market economy, transition from welfare to the workforce and increased supports to working parents were among the targeted goals.^{footnote 374} The policy broadly promoted social investments in families to address income disparities and to support parents, child education and care issues. Through its family policy, the province of Quebec offers subsidized early childhood education and child care to parents of children less than five years of age. For low-income parents, these services are free.^{footnote 375} Special financial allowances are also provided for daycare services to help integrate children with disabilities.^{footnote 376} For those who pay a fee for educational daycare, the cost is minimal ($7 per day) and includes a daily maximum of 10 consecutive hours, with snacks, meals and learning materials provided.^{footnote 377} Advocates of Quebec's child-care reforms have underlined their significant impact on reducing the barriers to employment for mothers of children less than five years of age. The employment rate for this group is estimated to have grown from approximately 61% to 69% over the last few years – from below to above the Canadian average. It is estimated that single-year revenues generated from this additional employment cover about 40% of the cost of these programs and services, with the remainder covered by the province.^{footnote 378} Evaluations of the initiative suggest that although use is distributed across income levels, there is a disproportionate need among lower-income families that may not be met.^{footnote 374 footnote 378} As well, programs do not always meet the child care needs of some families (e.g. parents who work shift hours), and quality and accessibility may vary.^{footnote 379} Additional commentary also suggests program use is lower among children with disabilities and from ethnic families, and could be further expanded in Aboriginal communities.^{footnote 374}

Sure Start Local Programmes

In 1998, the Sure Start Programme was launched in England to provide programs and services to improve the health and well-being of all children (up to the age of five), particularly those children and their families residing in disadvantaged communities. The end goal is to promote the physical, intellectual and social development of these babies and young children, while supporting the additional needs of their families, so that they have a greater opportunity to do well at home, in school and later in life. Programs and services are offered through Sure Start Children's Centres, and are both universal and targeted in approach. Each Centre is different and operates based on the specific needs of the community it serves. Centre offerings can range from early education and child care to health services and family support through parenting skills classes and job search assistance. Every Centre is required to offer home visitation and outreach services to all new parents. There are currently over 2,900 Centres across the country with plans to have one in every community in England by 2010. Programs have also been started in Scotland, Ireland and Wales. Criticism of the program suggests that those most in need are still not benefiting from the initiative, with uptake greatest among those in higher-income households.^{footnote 371 footnote 380–382}

Canada has no such strategy and, as noted in Chapter 4, continues to score poorly on the UNICEF Report Card on child poverty, elements of child well-being and delivery of early childhood development programs when compared to other similarly developed nations.^{footnote 274 footnote 345 footnote 365} In many instances, frameworks are proposed that recognize the general importance of issues (such as addressing childhood poverty and early child development) but often these remain conceptual rather than action-oriented.^{footnote 274} It is important to note that in Canada, a framework or strategy following the WHO approach may be more difficult to achieve given the federal/provincial and territorial context in which it would be required to operate.

Although Canada does not have a broad family/children's strategy in place, other countries and some provinces in Canada are exploring this approach (see textbox Broad Family/Children's Strategies). Healthy Child Manitoba and Quebec's family policy, for example, are intended to ensure the development of child-friendly policies and a levelling of opportunities for all children regardless of region or economic status.^{footnote 30 footnote 370 footnote 371} A program such as Healthy Child Manitoba is a long-term crossdepartmental prevention strategy for children and families that seeks to help children be physically and emotionally healthy, safe and secure, as well as successful at learning.^{footnote 30 footnote 372} It is based on evidence that strengthening families can strengthen communities, and has established community-relevant parent/child coalitions across the province, including in rural and northern regions.^{footnote 30 footnote 372} Ontario has recently announced its intention to implement optional full-day learning for four- and fiveyear-olds as part of a long-term initiative to integrate children (aged 0 to 12 years) into a consolidated network of family care and learning centres supporting children and families and partnering with local schools.^{footnote 373} Expected long-term benefits include improvements to children's literacy, numeracy and school completion, as well as the building of greater resiliency and better health outcomes. In collaboration with Ontario's Poverty Reduction Strategy, the first phase of the program will be implemented among lower-income neighbourhoods.^{footnote 373}

Programs for families and children

The Early Childhood Development Knowledge Network of the WHO Commission on the Social Determinants of Health refers to early childhood development (ECD) as a “powerful equalizer” because it lays the critical foundation necessary to flourish — regardless of SES — and because the greatest impact of ECD can be seen among the most disadvantaged.^{footnote 345 footnote 367} Investments in ECD can allow children to grow into healthy adults who contribute economically and socially to society.³⁴⁵ Actions to improve ECD can also have a profound impact on children's health based on its symbiotic relationship with low SES. While low SES can negatively impact ECD, efforts to positively influence ECD can help to mitigate the impacts of low SES and even work to improve it over time as the child becomes an adult.^{footnote 345 footnote 367}

The greatest returns on taxpayers’ investments are those targeted to children.^{footnote 29 footnote 383} Ensuring a healthy start reduces the long-term costs associated with health care, addictions, crime and unemployment in the future.^{footnote 29 footnote 383} In fact, it is estimated that $1 spent in the early years saves between $3 and $9 in future spending on health, social and justice services.^{footnote 384} Investments targeted to children allow them to become better educated and to be well-adjusted and more productive adults.^{footnote 383} One of the areas of greatest return is in early childhood education (ECE) and care. A U.S. longitudinal study, the High/Scope Perry Preschool Project, illustrates the importance of early investment by showing that children who participate in programs can have better socio-economic outcomes as adults (see textbox High/Scope Perry Preschool Program).^{footnote 385 footnote 386}

Canada has made broad investments that support families with children, such as the federal/provincial/territorial Early Childhood Development Agreement (2000) and the Multilateral Framework on Early Learning and Child Care (2003), which focus on initiatives targeted at children under six years of age and their families.^{footnote 93} More recently, the Universal Child Care Plan ($100 per month for each child under six years of age) was established to assist with child care. As well, Canada has invested in expanded parental leave.^{footnote 388} Broad investments to provide assistance to First Nations communities have also been made through the First Nations Child and Family Services Program, which provides culturally relevant prevention and protection services for children and families that are on par with services offered elsewhere in the province or territory of residence.^{footnote 389} Similarly, broad investments for recent immigrants through the Immigrant Settlement and Adaptation Program help families adapt to Canadian society. As part of this program, Canada invests and partners with provinces and territories, service delivery organizations and stakeholders to create support networks for health care, promotion and prevention. For example, investments through hospitals such as Toronto's Hospital for Sick Children offer improved access and culturally relevant services to new immigrants.^{footnote 390 footnote 391}

As a result of these investments — and many others made at the provincial/territorial and municipal levels (e.g. public education and offering of full-day kindergarten) — Canada is doing well overall in several areas of child health, development and well-being. As noted earlier, however, the country does not fare as well as others on some issues and existing efforts are not meeting the needs of all Canadians. For example, a 2006 Canadian study on early childhood education and care shows that despite the availability of extended parental leave many mothers do not take it.^{footnote 392} Some are not eligible (e.g. self-employed), some choose not to take leave, and others cannot afford to live on employment insurance benefits (55% of their salary) that are not supplemented by their employer.^{footnote 392}

International comparisons indicate that countries that have further expanded parental leave for parents with young children are experiencing better childhood outcomes. Sweden (which reports lower rates of child poverty and higher scores on indicators of early childhood education and care) has established parental leave with coverage and flexibility that extend well into childhood.^{footnote 161 footnote 231 footnote 571} It provides up to a year and a half of parental leave with 80% of salary covered by the state (to a monthly wage ceiling). An additional month for the other parent, as well as a further 90 days of leave for either parent is available as needed.^{footnote 161 footnote 571} Additional leave can also be taken any time for child illness, and parents can reduce work time by 25% until their youngest child reaches eight years of age.^{footnote 161}

In terms of meeting the needs of specific populations, children of recent immigrants, Aboriginal children, those living with disability and/or mental illness or in a household with a parent facing these challenges, and children in single-parent homes appear to be most at risk.^{footnote 30 footnote 267 footnote 393} Some initiatives that specifically target vulnerable populations, however, have shown that those at risk can be successfully reached.^{footnote 394}

The Community Action Program for Children is one such example. Building on the capacity of communities and on inter-sectoral partnerships to identify and respond to the needs of local children, it provides funding to community groups and coalitions to address the health and development of children living in conditions of risk (e.g. low income, single parents, newcomers to Canada).^{footnote 394–396} National and regional evaluations of the program have found benefits for families participating in these programs, including lower rates of maternal depression and sense of isolation, and less emotional and behavioural issues reported among children.^{footnote 397}

The Aboriginal Head Start On Reserve program, which has been credited with positively influencing the developmental path of many Aboriginal children (see “Giving Children a Head Start” in the textbox Aboriginal Children in Canada) is yet another example of the success of targeted initiatives. However, the program serves only 9,000 or 13% to 15% of First Nations children from birth to six years of age, demonstrating that the expansion of successful initiatives targeted at vulnerable populations and/or the creation of further targeted programs may be warranted.^{footnote 398}

While individuals and populations have unique experiences and a single population is not universally more vulnerable, there is clearly a need to reach more Canadians and targeted programs provide one such vehicle. The textbox, Aboriginal Children in Canada, highlights select Aboriginal programs as examples of how individuals and communities are addressing the unique needs of this population.

Important opportunities to influence children's development include school environments, which can be critical in promoting lifelong healthy practices. For example, the Joint Consortium for School Health (2005) brings together key representatives from the federal, provincial and territorial governments responsible for health and education across Canada to build capacity to promote the health of children in the school setting.^{footnote 411 footnote 412} Recognizing health issues facing children today, the Consortium is a venue to share information, learn from other's experiences and identify best practices to improve aspects of health, such as physical activity, nutrition, mental health, sexual health and injury prevention.^{footnote 411} The Consortium also promotes comprehensive school health, a framework that encompasses the whole school environment with actions addressing the social and physical environment, teaching and learning, healthy school policy, and partnerships and services.^{footnote 411} Research has shown that comprehensive school health is an effective way to tap into the linkage between health and education outcomes and encourage healthy behaviours that can last a lifetime.^{footnote 357 footnote 388}

Positive childhood development and the promotion of healthy behaviours can also occur in the “after-school” timeslot between when a child finishes the school day and, typically, the time spent at home with family (a critical period for school-aged children with working parents). That's when — with little to no supervision — poor choices on the part of children and youth can lead to accidents and injury, consumption of unhealthy foods, and excessive/unmonitored television viewing and computer use. Peer influence is also a strong factor in determining the types of activities in which children take part at this time of day.^{footnote 413 footnote 414} For these reasons, the afterschool period has been identified as crucial to influencing the health trajectories of school-aged children.^{footnote 415}

Children, families and communities can take advantage of this time by using it as an opportunity. Quality after-school programs can allow parents to worry less by knowing where their children are and what they are doing, and children may experience increased opportunities to develop social, physical, leadership and creative skills. When communities take part, cities and local agencies can experience stronger partnerships.^{footnote 414} Furthermore, when physical activity and healthy eating are components of organized after-school activities, there are residual benefits (see textbox Australia Gets Active After School). Canada's 2009 Report Card on Physical Activity for Children and Youth recommends a number of ways in which the after-school hours can be harnessed by communities and community programming to tackle a portion of the physical activity targets for children and youth. In this way, these programs can share in the responsibility of attaining physical activity targets with schools and families.^{footnote 414}

Abuse and neglect

There are an estimated 22 reported cases of maltreatment per 1,000 children from birth to age 11 in Canada and that number is believed to be increasing.^{footnote 246} Evidence shows that maltreatment can negatively influence risk factors for health and well-being such as educational attainment, trust, aggression, social connectedness and sexual behaviours, and result in adverse health outcomes in childhood, later in life and across generations.^{footnote 30 footnote 246 footnote 250 footnote 259 footnote 261} Children can be affected by abuse at home, at school and among peers.^{footnote 246 footnote 262} Even before birth, there is a prenatal risk of abuse as 6% of women are estimated to experience abuse while pregnant and this trauma can negatively impact the fetus.^{footnote 251–254} The following discussion highlights three key areas that contribute to reducing abuse and neglect and mitigating its impact on the health and well-being of children:

• education and awareness;
• community and health care services; and
• protective care.

Each has either shown success and could be applied more broadly, or is an area of promise where more work and investigation is required.

Aboriginal* Children in Canada

– Declaration from the Many Hands, One Dream Summit,
Victoria, British Columbia, 2005.

 

As of 2006, there were approximately 1.17 million First Nations, Métis and Inuit people in Canada.130 Of those, 273,000 — or almost one-quarter (23%) — were children under the age of 12 and the majority (70%) lived off reserve.^{footnote 130} Compared to the Canadian population, the Aboriginal population is on average significantly younger and, with higher fertility rates among women, that trend will not change in the foreseeable future.^{footnote 45} Interventions in childhood health and well-being present a unique opportunity to make a significant impact on the health of Aboriginal peoples through investments made on behalf of their youngest members. Providing pregnant women and parents of infants and young children with the supports they need during pregnancy, birth and parenting is important to ensuring the best possible health and development of infants and young children. And in fact, if these supports are consistently put in place, as a country, Canada is likely to reduce the gap in health and developmental outcomes between different segments of Canadian society and between Canada and other countries.

It is an opportunity that is two-fold. On the one hand, it can be seen as a move to improve the health of Aboriginal peoples. On the other hand it is a chance to get back to the roots of Aboriginal health, wellness and healing that involve the child, the family, the community and the greater environment. Through centuries of colonization, some of these experiences and values have been lost along with other cultural and spiritual knowledge and practices.^{footnote 44} Colonization has led to dislocation from traditional lands, cultural suppression, political marginalization, forced assimilation and the inequalities in health experienced by some First Nations, Métis and Inuit.^{footnote 399} In particular, residential schools created a significant disruption to the passage of child-caring knowledge and parenting skills within First Nations and Inuit populations.^{footnote 400 footnote 401} As seen in Chapters 3 and 4, Aboriginal children fall behind on many measures of health status in comparison to their non-Aboriginal peers. What follows are examples that demonstrate how First Nations, Métis and Inuit communities are successfully creating the conditions for lifelong health and development.

Aboriginal Healthy Babies, Healthy Children Program

The Aboriginal Healthy Babies Healthy Children (AHBHC) Program is part of the Aboriginal Healing and Wellness Strategy (AHWS) — a partnership consisting of 14 independent First Nations, Aboriginal, political and territorial organizations and the Government of Ontario to promote health and healing among the province's Aboriginal population. The goal of the AHBHC program is to improve the long-term health prospects of Aboriginal children from birth to six years of age. It is delivered through home visiting, early identification, screening and service co-ordination/referrals. The focus of AHBHC programming is on preparation for parenting, and prenatal and postpartum care through the utilization of Aboriginal cultural knowledge and practices. As part of the AHWS, violence and abuse in the home and community are addressed through education and awareness and the promotion of violence-free lifestyles. Service co-ordination and referral to other AHWS programs and services provided by community wellness workers, shelters and family violence healing programs, healing lodges, and a clearinghouse for anti-violence information are also utilized. Native traditional teachings are a part of all services in order to ensure that the unique needs of Aboriginal children, families and communities are addressed. Among the early successes of the AHBHC program are an increase in breastfeeding rates, better dental health among infants and children, improved eating habits among expectant mothers and their families, and a decrease in smoking rates and exposure to second-hand smoke through education services for parents and families.^{footnote 402} An evaluation of the program found that participating children had higher scores in infant development measures that included self-help, gross motor skills, fine motor skills and language development. Parents also reported that they felt more confident about their parenting and that they made better use of community services.^{footnote 403}

Giving Children a Head Start

Created in 1965, Head Start is the longest-running national school readiness program in the U.S. and has demonstrated success in reaching low-income children and their families by providing comprehensive education, health, nutrition and parent involvement services. Support is provided to the entire Head Start community through a Head Start Association by advocating for policies that strengthen services to Head Start children and their families, providing extensive training and professional development to Head Start staff, and by developing and disseminating research, information and resources that enrich Head Start program delivery. To date, nearly 25 million preschool-aged children have benefited from Head Start.^{footnote 404} An evaluation of three-year-olds who had participated in the program showed that Head Start programs have a demonstrated positive impact on cognitive development, language development, socialemotional development and parenting impacts such as employment and father-child interaction.^{footnote 405}

Following the U.S. framework, Canada's Aboriginal Head Start in Urban and Northern Communities (1995) and Aboriginal Head Start On Reserve (1998) programs were established to address the unique challenges facing First Nations, Inuit and Métis children and their families. The programs are designed to prepare Aboriginal children (up to the age of six) for school by helping to meet their emotional, social, health, nutritional and psychological needs. They provide an opportunity for preschoolers to learn traditional languages, culture and values — along with school readiness skills — while acquiring healthy behaviours. Programs are locally controlled and designed, and are based on six components: education; nutrition; culture and language; social support; parental involvement; and health promotion. Opportunities for Aboriginal children to learn their indigenous language is an important way to support their cultural identity, knowledge and connectedness to their community. Cultural identity — a strong component of self-esteem — is a determinant of social competence linked to healthy development and school success.footnote 406 The 2002–03 process evaluation of the Aboriginal Head Start On Reserve program demonstrated that it is effective in producing positive changes in children's readiness to learn and in First Nations language development. Kindergarten teachers of Aboriginal Head Start graduates found that participant children had better self-esteem, basic skills, were stronger learners, and displayed more independence and confidence compared with those who did not have the opportunity to participate in the program.footnote 407

Eel Ground First Nation School

More than 800 Mi'kmaq people call the Eel Ground First Nation in northeastern New Brunswick home. Within their community is a school for their children (from kindergarten through Grade 8) that has garnered attention across Canada and abroad for its unique programs and opportunities that are allowing these children to thrive in today's fast-paced technological environment while maintaining tradition.408 Among the Eel Ground School resources are fully equipped computer laboratories and classrooms that invite hands-on use of hardware and software across the curriculum starting from the earliest grades. Relying on technology, the school supports project-based learning where students construct knowledge using a framework that follows through planning, process, evaluation and reflection.^{footnote 409} Videoconferencing also allows for interactive visits made in “real-time” by a variety of people, from Mi'kmaq Elders, to students in First Nations and Inuit communities across Canada, to world renowned children's authors, and expands information sharing between communities.^{footnote 408 footnote 410} All students learn about their Mi'kmaq culture and traditions, including the Mi'kmaq language, often with the guidance of software programs. Other activities include student-driven projects — many of which have dealt with social and health issues such as FASD, drug abuse and West Nile Virus, and won numerous awards. Additionally, students learn about other lifestyle and health issues that are important to their growth and development through initiatives such as the school's diabetes screening program.408 The unique focus of the school on traditions and culture, combined with the incorporation of new technologies, has contributed to an increase in enrolment which has tripled in the last 30 years.^{footnote 408}

*The term ‘Aboriginal’ is used to refer collectively to all three constitutionally recognized groups — Indian, Inuit and Métis. Although not constitutionally recognized, the newer term ‘First Nation’ is used to describe Status Indians recognized under the federal Indian Act. When data exists to support discussion about these distinct population groups, specific details are provided for clarity.

Education and awareness

Canada has taken steps to enhance awareness and knowledge of family violence, including more effective ways to address it. For example, Canada's Family Violence Initiative was established in 1988 as a cross-government effort that aims to: promote public awareness of the risk factors of family violence and the need for public involvement in responding to the problem; strengthen the ability of the criminal justice, health and housing systems to respond to the problem; and support data collection, research and evaluation efforts to identify effective interventions.footnote 417 In addition, Canada collects information regarding the incidence of child maltreatment (see textbox Keeping Track of Child Abuse and Neglect), to increase awareness about family violence, and to strengthen capacity for addressing child abuse and neglect.footnote 246

While measuring the problem contributes to awareness and understanding, educational interventions can provide children with knowledge about their rights, as well as the skills to identify, report and seek help in situations of abuse.^{footnote 255} They can also teach children about social/ emotional competence and empathy. Efforts in this regard have demonstrated success in reducing levels of aggression among participants (see textbox Roots of Empathy).^{footnote 419} Studies have shown that children who are aggressive are more likely to bully their peers and to be the perpetrators of family violence as adults.^{footnote 205 footnote 420 footnote 421} The WHO states that child maltreatment by parents and caregivers can be reduced by providing training programs on child development, non-violent discipline and problem-solving skills.^{footnote 422 footnote 423} Education programs aimed at enhancing the awareness and skills of practitioners who are in contact with children who have experienced abuse (judges, prosecutors, teachers, police, health and social workers, psychologists) have also been shown to enable effective intervention.^{footnote 255}

School-based programs, aimed at teaching children about abuse and how to protect themselves, are widely used by communities as part of broader abuse prevention strategies.^{footnote 425} Preventive education programs can help children understand concepts, promote disclosure, reduce self blame and help to disseminate information about abuse.^{footnote 426} A recent study found a lower incidence of reported childhood abuse among study participants who had experienced school-based programs compared to those who did not experience these programs.^{footnote 427} Although research shows that school-based programs have shown improvements in children's overall knowledge and reliance on protective behaviours, evidence also showed that this awareness can heighten perception of risk, increase fear of strangers, as well as increase aggressive behaviour towards peers and/or siblings.^{footnote 425} The overall effectiveness of school-based approaches for reducing prevalence and raising awareness requires further investigation, as results are varied due to study length, approach, and cultural and emotional factors.^{footnote 426 footnote 427}

Community and health care services

The WHO's Report on Preventing Child Maltreatment (2006) suggests that a whole-of-population approach that balances healthy public policy with preventative and curative interventions can make a difference in combating child maltreatment.^{footnote 250 footnote 422} It also states that, although the prevention of child abuse is almost universally acknowledged as an important social goal, not enough has been done to address and investigate the effectiveness of existing interventions.^{footnote 250}

Improving community capacity and local leadership contributes to the prevention of violence, which can be achieved through initiatives such as child and parent life-skills training, incentives for high-risk adolescents to complete school.^{footnote 428} Crime-prevention programs that target at risk individuals, such as those with aggressive and anti-social behaviours, and early use of drugs and alcohol, can also have positive long-term impacts.^{footnote 428} In the case of initiatives aimed at parents and caregivers, barriers (such as access to and timing of programs, expense and perception of program value) exist that may prevent them from acquiring the necessary skills, resources and supports to prevent abuse.^{footnote 255}

Recent research indicates successful results for early prevention programs focused on families at risk. An analysis of 40 U.S.-based prevention programs demonstrated positive effects when they are provided to families with children aged 0 to 3 years at risk of child physical abuse and neglect.^{footnote 429} This finding is further supported by the success of a U.S. nurse home visitation model (see textbox Bringing Prenatal Care to High-risk Mothers in the Prenatal risk section of this chapter).^{footnote 430} Results from this program demonstrate the importance of reaching low-income women during their first pregnancy to establish healthy behaviours before unhealthy behaviours can develop.^{footnote 430} It also highlights the value of helping these mothers manage the broader social and economic factors that are influencing their choices and behaviours (e.g. education, employment, extended family dysfunction).^{footnote 430}

Canada is also taking action to prevent violence among vulnerable communities. For example, Indian and Northern Affairs Canada (INAC), through its Family Violence Prevention Program, provides funding for shelter services and community-based prevention activities on reserve. INAC's Child and Family Services Program also assists First Nations in providing access to culturally sensitive programming in their communities, and ensures that such on-reserve services are comparable to those available to other provincial/territorial residents in similar circumstances.^{footnote 389 footnote 431}

Protective care

The home environment is a critical component of healthy child development. For most children, it is a place of caring, and trust; for others it is a place of trauma. While the best place for a child is usually with his or her family, certain situations may warrant protecting a child from threat and imminent danger (e.g. where the physical and/or mental well-being of a child is in jeopardy or when parents feel they are not in the best position to care for their child at a given time).footnote 255 In these situations children are placed into foster care until dysfunction or difficulties have been resolved in the family home. In situations where children are unable to return to their families, they remain in foster/state-based care or become eligible for adoption.

The act of being uprooted from community and culture, in addition to family, is disruptive. Departments and organizations responsible for children and families recognize that, where possible, foster care options that keep siblings together and in the same community are optimal.^{footnote 432 footnote 433} This is the premise behind kinship care, an option that works with extended families to minimize the disruption for children when they are being removed from the family home environment (see textbox Kinship care).^{footnote 432 footnote 433}

Prenatal risks

Canada has had success in reducing prenatal risks and promoting healthy prenatal behaviours; however, not all pregnant women are being reached. Certain prenatal risks can result in serious health problems for the fetus and/or the child once it is born, including lifelong health and development issues.footnote 323 footnote 435

The following discussion highlights three key areas of action that contribute to minimizing risk and promoting benefits during this critical period:

• education and awareness;
• prenatal care; and
• targeting high-risk behaviours.

Each has either shown success and could be applied more broadly, or is an area of promise where more work and investigation is required.

Education and awareness

Social marketing campaigns, in concert with other tactics, have been used to inform and influence behaviours of the population as they relate to pregnancies.^{footnote 323} For example, national campaigns against alcohol and tobacco use during pregnancy have achieved good message recall and increased awareness of these issues in the short term and over time and, having done so, are believed to have contributed to positive changes in behaviours.^{footnote 435} Provincial efforts, such as the Born Free campaign (Alberta, 2000) and the With Child — Without Alcohol campaign (Manitoba, 2001) have shown similar results in regard to awareness of the risks of alcohol consumption during pregnancy (particularly the risk of FASD).^{footnote 435} Widespread messaging through the use of warning labels (e.g. health warnings on product packages), has shown modest benefits through increased knowledge and behaviour change, however, these benefits are predominantly reported among those at lowest risk of unhealthy behaviour.^{footnote 323} This is in keeping with the research findings on the effectiveness of other population-based prevention programs undertaken in Canada (although many remain unevaluated), which show that message uptake is greatest in lower-risk populations. So, while these efforts are important for reaching the general public, they are often less effective in getting through to higher-risk populations — especially when delivered in isolation.^{footnote 323}

Research has also shown that partners can have a strong influence in creating either detrimental or supportive environments for pregnant women.^{footnote 323} Negative influences may include substance use/abuse and physical and/or mental abuse (e.g. alcohol consumption by partners is associated with alcohol use by pregnant women). Positive influences can involve practicing healthy behaviours and participating in prenatal care activities.^{footnote 323 footnote 436} Peers, other family members and the broader community can also influence environments for these women. Education and awareness initiatives targeted at these groups can play an important role in creating healthy environments for pregnant women, making it easier to undertake healthy options.^{footnote 437–440}

Providing information to women on the benefits of adequate prenatal care is an important part of managing prenatal risk.^{footnote 323 footnote 441} However, research shows that educating women on this issue should begin as early as possible given that healthy choices and responsible sexual behaviours are partially determined by earlier events and exposures.^{footnote 323 footnote 441} Formalized programs, such as in-school initiatives for children and youth, can raise awareness on a variety of topics including drugs and health, sexual development, personal development and life management (e.g. including healthy relations built around rights, respect and responsibility). This can translate into healthier choices being made earlier in life with positive impacts in many areas before, during and after pregnancy.^{footnote 323}

Prenatal care

Ongoing prenatal care is important to achieving a healthy pregnancy and birth, and positively influencing the health of the child in the early years.^{footnote 335} It provides a pregnant woman with the opportunity to access health information and identify risks and underlying factors that can influence her health and the health of her fetus/ child.^{footnote 335} Prenatal care can also include activities targeted at partners and can provide a means of identifying issues related to living in poverty or with mental health challenges followed by the provision of counselling, skills training, parenting programs, breastfeeding support and child care.

Approximately 95% of pregnant women report receiving prenatal care during the first trimester of their pregnancy.^{footnote 311} Over time, Canada has been successful in increasing prenatal care and improving maternal and infant health. However, maintaining this level of success requires that delivery of these practices be continued and built upon where possible. Of those women who report having inadequate prenatal care, reasons cited include having no fixed address, poor access to health care, lack of transportation, child care issues, fear of repercussions for substance use and fear of disease screening.^{footnote 440} It is among this group that risky prenatal behaviours and circumstances may go unrecognized and unaddressed. Barriers to care can also be compounded in distressed communities where broad social problems do not offer ideal environments for supporting and managing healthy pregnancies.

Programs that work to break down barriers to prenatal care through community outreach have shown some success by targeting distressed communities and individuals. For example, the Canada Prenatal Nutrition Programs currently provides funding and support for at-risk pregnant women and their children in over 2,000 communities in Canada.^{footnote 442 footnote 443} The advantage of CPNP is that it allows for community-level decision-making to ensure the needs specific to each jurisdiction can be targeted. Evaluations after 10 years indicate that this approach has resulted in better health behaviours and outcomes for participants and their children.^{footnote 442} The Canada Prenatal Nutrition Program-First Nations and Inuit Component (CPNP-FNIC) primarily targets pregnant women and women with infants up to 12 months of age in First Nations and Inuit communities. The flexible framework of CPNP-FNIC allows community workers to tailor their program activities to the priorities and cultures of their communities.^{footnote 444}

Low-income and/or homeless women are more likely to positively respond to a health or social work practitioner who they trust. A British Columbia study found that pregnant women more accurately report their substance use in a setting they consider to be safe and non-judgmental that offers help to them and their children.^{footnote 445 footnote 446} On the other hand, interventions they believe can create problems for them (e.g. arrest or loss of custody) are avoided.^{footnote 446 footnote 447} Therapeutic, nonpunitive interventions are therefore considered to be most effective in terms of ensuring healthy outcomes for these women and their children. While outreach programs can have some impact on awareness and behaviours among high-risk populations, there is a need to address the broader social issues affecting these individuals and communities that is now being recognized and acted on by some programs (see textbox Bringing Prenatal Care to High-risk Mothers).

Understanding prenatal and maternal experiences is necessary to build and provide relevant services and optimize prenatal care. The Canadian Perinatal Surveillance System (CPSS) is an ongoing national health surveillance program aimed at improving the health of pregnant women, mothers and infants through systematically collecting and analyzing timely and relevant information about their health status and the factors that influence their health. As part of this commitment, the CPSS works with provincial/territorial partners and stakeholders to establish standardized indicators and variables to report, and is expanding surveillance into areas such as congenital anomalies and women's knowledge, perspectives, practices and experiences related to pregnancy, birth and parenthood. More work remains ahead, with the long-term goal of CPSS being to establish a comprehensive national data system that is also linked with vital, hospital and community statistics and services in order to greater understand needs, experiences and service uptake among pregnant women, mothers and their infants.^{footnote 449} Regardless of these efforts, information gaps remain. For example, little is known about pregnant women who are at greatest risk for unhealthy prenatal behaviours, do not seek some form of prenatal care or face barriers in accessing this care.

Targeting high-risk behaviours

As highlighted, preventive measures such as prenatal care and education and public awareness campaigns have improved maternal and infant health over time. However, some mothers and infants are still at risk based on current and previous experiences with STIs and substance use. Targeting high-risk behaviours involves reaching this unique sub-population.

Prenatal screening for some STIs is universally available in Canada and has resulted in successfully decreasing vertical transmission of infections such as HIV and syphilis.^{footnote 450–452} However, access and screening varies between provinces/territories, and no one method is used consistently. As well, the resources to identify, care for and treat pregnant women in high-risk situations are still insufficient.^{footnote 437 footnote 453}

Evidence indicates that interventions that have been successful in helping women to reduce or stop smoking during pregnancy include specific risk-prevention strategies such as support to minimize tobacco use, counselling, professional persistence (supporting smoking cessation tactics), addressing isolation/depression issues and creating safe opportunities for women to openly express themselves.^{footnote 315 footnote 437} Extending these interventions to include broader groups within communities, such as partners and other family members who may be smoking in the home, has also proven successful.^{footnote 315 footnote 454}

Physician-led alcohol interventions during pregnancy have had some success in reducing alcohol consumption among women from a range of socio-economic backgrounds and various risk profiles. Evidence suggests these programs could be beneficial when targeted at high-risk populations, especially if they are combined with home visitation over a significant period of time (two to five years following the pregnancy).^{footnote 455} Currently, 62% of health care providers report using a standardized tool to screen prenatal patients for alcohol use, however, only 40% of family physicians report discussing the risks of alcohol during pregnancy with women of childbearing age. Even fewer (17%) provide women with written information on prenatal alcohol exposure.^{footnote 456}

Similarly, mothers who receive substance abuse treatment during the early stages of pregnancy can reduce the impacts of drug use on the fetus.^{footnote 455} In some cases, it can result in the newborn's health being comparable to that of an infant not exposed to drug use.^{footnote 457} For example, programs that get heroin-addicted women to switch to methadone during pregnancy have resulted in newborns with higher birth weights than those whose mothers did not make the switch.^{footnote 457} In addition, some jurisdictions are creating innovative settings for supporting and treating both at-risk pregnant women and their newborns (see textbox The Fir Square Combined Maternity Care Unit).^{footnote 458}

Mental health and disorders

In Canada there are very limited data on the mental health of children. However, as noted in Chapter 3, it has been estimated that 15% of Canadian children and youth are affected by a mental disorder at any given time.^{footnote 201 footnote 459} Mental and emotional health problems experienced during childhood and youth may affect children now and into adulthood.^{footnote 27}

Canadians with mental health problems face a number of challenges that differ from those experienced with physical health problems. The Standing Senate Committee on Social Affairs, Science and Technology's final report, Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addictions Services in Canada, describes how these challenges can be exacerbated as individuals and families look for social, professional and public support that allows management, mitigation and interventions over the lifecourse. This can be particularly true for parents who are looking for help for their children.^{footnote 201} The Committee also highlighted the importance of upstream efforts to promote social and emotional well-being and, where possible, to prevent mental health disorders and illnesses early in life.^{footnote 460}

The following discussion highlights three key areas that contribute to the promotion of children's mental health and the prevention of mental illnesses and/or that support families coping with mental disorders or illnesses.

They include:

• education and awareness;
• community support; and
• broad mental health strategies.

Each has either shown success and could be applied more broadly, or is an area of promise where further work and investigation is required.

Education and awareness

While there are no survey data on whether or how children experience stigma associated with mental illness, about 63% of Canadian youth with some form of a mental disorder reported that embarrassment, fear, peer pressure and stigma were barriers to seeking help.^{footnote 461} As well, 38% of Canadian adults reported that admitting their child had a mental illness (such as anxiety or depression) would cause embarrassment.^{footnote 461 footnote 462}

Increasing awareness and understanding of mental health, disorders and illnesses can positively influence the mental health of all Canadians, as misunderstanding and stigma can act as barriers to promoting mental health and seeking treatment for mental health illnesses and disorders.^{footnote 463} Although strategies to combat stigma have met with limited success, the following are believed to be helpful:

• increasing education and awareness to dispel commonly held myths about mental illness;
• challenging commonly held discriminatory attitudes; and
• providing a context for mental illness that makes it familiar.

Evidence shows that efforts to provide context have been the most effective for countering stigma and discrimination.^{footnote 463} In keeping with this finding, the Mental Health Commission of Canada has recently launched a national 10-year anti-stigma and discrimination reduction campaign.^{footnote 461 footnote 464} This campaign will be the largest effort ever made in Canada to reduce the stigma associated with mental illness. It will use social marketing techniques similar to those used for anti-smoking campaigns and efforts to reduce drinking and driving.^{footnote 464} The Commission will work with communities, stakeholders and specific at-risk groups.^{footnote 464} Other countries, such as Australia, New Zealand, the U.K. and the U.S. have developed anti-stigma initiatives that share the vision of shifting attitudes and behaviours about mental health disorders and illnesses with the goal of eliminating stigma.^{footnote 465}

Community support

Community-based prevention programs that work directly with families and children to develop protective factors and build resilience have had some notable success.^{footnote 466 footnote 467} For example, psychological depression prevention programs targeted at children and families at risk have shown some success in preventing and decreasing depressive illness in the short term.^{footnote 466} Other mental health promotion tactics (see textbox Better Beginnings, Better Futures) have been effective in reducing the prevalence of mental health problems by addressing risk factors such as dysfunctional family situations.^{footnote 467}

Research also shows that resilience develops and is enhanced by individual, family and community factors. All three areas have shown the potential to positively influence a child's level of resilience and related abilities to cope and adapt to stressful situations (see textbox Kauai Longitudinal Study):

• Individual factors — these unique aspects about “who we are” are comprised of both genetics and personality and can often drive behaviours that influence resiliencies through learning capacity, self-esteem, adaptive skills, social skills and overall physical health.^{footnote 471 footnote 472}
• Family factors — being part of a family, having a sense of belonging, attachment, good communications, strong family structure, positive parental and sibling relations, positive parenting styles, parental employment potential, good parental health and having strong external family support within communities (including assistance for mental health issues) can all influence resiliency.^{footnote 471 footnote 472}
• Community factors — it has been shown that having a sense of belonging and inclusion, cultural identity, community programs, access to services (e.g. health services, home visitations) and opportunities for community involvement promote better health over the long term.^{footnote 471 footnote 472}

Broad mental health strategies

In Canada, treatment for mental health disorders and illnesses is primarily a specialized health care service. In some communities, however, the need for care exceeds the services available.^{footnote 203} Although 92% of Canadian families with children report having access to a regular family physician, surveys available in Canada, the U.S. and the U.K. report that fewer than one in four children requiring specialized mental health services actually receive them.^{footnote 203 footnote 204 footnote 473} Investing in this area will significantly reduce the burden associated with children's mental health disorders and illnesses. However, a broader approach that acknowledges the role and breadth of specialized care, as well as mental health promotion, education and awareness, and support for families is necessary.^{footnote 203}

Although Canada is currently the only G-8 country without a mental health strategy, progress is being made on this front through the work of the Mental Health Commission of Canada — an arms-length national body supported by all levels of government.^{footnote 474 footnote 475} The Commission is embarking on major initiatives that include building a national strategy, mental health promotion, mental illness prevention and treatment, as well as launching antistigma campaigns, supporting homelessness research and creating a knowledge exchange hub.^{footnote 475} Such a strategy would specifically address children's mental health problems through promoting healthy development for all children, preventing disorders among children at risk, providing access to treatment for children with disorders and monitoring mental health outcomes (see textbox KidsMatter, Australia).^{footnote 476}

Obesity

In Canada and internationally, addressing the obesity epidemic is a major public health challenge.footnote 30 footnote 481 footnote 482 The rates of measured obesity among children have increased over time. Generally, those who have lower levels of daily physical activity and poor nutrition are most likely to have excess body weight and an increased risk of developing related disease and adverse health outcomes over the lifecourse.footnote 179 footnote 180 footnote 188 footnote 483–485 However, the issue is more complex than the balance of caloric intake/outtake; for example, genetic predispositions, as well as an individual's broader physical and social environments, can provide opportunities or present barriers to achieving a healthy weight.footnote 183 footnote 486–488 Over the past several decades, profound changes have occurred in the physical and social environments in which Canadians live, learn, work and play — from the "walkability’ of neighbourhoods and the marketing of foods to children, to the proximity and accessibility of grocery stores, and the increasingly sedentary nature of play.footnote 161 footnote 489 footnote 490

The following discussion highlights four key areas of action that could contributed to decreasing the number of overweight and obese children:

• education and awareness;
• advertising, taxes and subsidies;
• built environments; and
• home, school and community-based approaches.

Each has either shown success and could be applied more broadly, or is an area of promise where further work and investigation is required.

Education and awareness

Broad population-based initiatives have a role to play in supporting children and families in achieving healthy growth and weight. For example, Eating Well with Canada's Food Guide recommends how many servings children need from each of the four food groups every day in order to meet the basic requirements for vitamins, minerals and other nutrients, to reduce the risk of certain chronic vitality.^{footnote 491} As well, Canada's Physical Activity Guide to Healthy Active Living includes a version specifically tailored to families that provides advice on how to ensure children meet recommended daily physical activity requirements (see Appendix C).^{footnote 492}

While it is important to build awareness of recommended food and physical activity guidelines, the ultimate goal is for children's choices and behaviours to reflect that awareness. Tracking progress towards this goal requires measuring how many Canadian children are meeting minimum recommendations. A recent federal/provincial/territorial agreement established national goals to increase levels of physical activity.^{footnote 493} The Canadian Physical Activity Levels of Children and Youth Study (CANPLAY) set first-ever national physical activity targets for children and youth to be measured against the current baseline. The goals that are to be met by 2015 are:

• an increase in the proportion of children and youth who participate in 90 minutes of moderate-tovigorous physical activity above their daily living activities from 9% to 16%; and
• an increase in the average number of daily walked steps taken by children and youth from 11,500 steps to 14,500 steps, which is equivalent to an additional 30 minutes of physical activity per day.^{footnote 494}

Although it is too early to determine success, goals have been established and data measuring physical activity levels continue to be collected, indicating that progress is being made in terms of increased knowledge about children's weight and physical activities and their health. Similar efforts are required to monitor children's eating habits in Canada.

Advertising, taxes and subsidies

Evidence shows that the commercial marketing of foods and beverages contributes to poor diets in children — specifically because this marketing is often for energy-dense, micronutrient-poor foods that are not considered necessary for a healthy diet.^{footnote 495} At the WHO Technical Meeting on Marketing of Food and Non-alcoholic Beverages to Children (2006), it was recommended that an international code be established to protect present and future generations from the damaging consequences of the consumption of unhealthy foods and to promote responsible food marketing to children.^{footnote 495}

In Canada, advertising on television directed toward children is regulated by the Broadcast Code for Advertising to Children in terms of the amount of time and nature of the presentation.^{footnote 496} Advertisements directed at children cannot present information that may cause them harm or exploit them as a result of their lack of experience.^{footnote 496 footnote 497} All advertising for foods and beverages in Canada follows the voluntary guidelines in the Code, except in Quebec where advertising to children is not permitted (see textbox Food Marketing to Children in Quebec). Additionally, advertisements that show food products during mealtimes must clearly show a product within the framework of a balanced diet.^{footnote 496} Public-based television networks, such as the Canadian Broadcasting Corporation (CBC), restrict advertising during children-specific programming and limit advertising during general/familytype programming.^{footnote 496} Provincial public broadcasting organizations also restrict advertising and on-air recognition during preschool children's programming.^{footnote 498} Regardless of these actions to limit advertising to children during certain times and programs, access to cable and satellite television, which offers unrestricted broadcasting, may undermine these efforts.

Economic incentive policies such as “fat taxes” and “thin subsidies” have been considered in some countries and jurisdictions in order to discourage the purchase of foods considered to have limited nutritional value, and encourage the purchase of more nutritious foods. In Canada, seven provinces exclude candy, chocolate bars and high-calorie beverages from tax exemptions, but it is not clear whether this results in a decrease in the consumption of these items.^{footnote 500} In the U.S., the State of California applied a general sales tax rate of 8.25% on selected snack foods in 1991.^{footnote 501 footnote 502} During the year the tax was in effect, snack sales reportedly dropped, but the food industry actively lobbied against the taxing of these food products and the tax was repealed.^{footnote 501 footnote 503 footnote 504} France experienced similar issues in its attempts to apply higher taxes to certain foods. Adopting these measures not only entails difficulties in deciding which foods to tax but also brings industry pressures and uncertainty as to how these taxes might affect food accessibility and affordability amongst those living in low-income conditions.^{footnote 505 footnote 506} Although taxes cannot tackle overweight and obesity issues in isolation, they can also be used to generate public funds which can be used to finance health promotion activities.^{footnote 501 footnote 505 footnote 507} In contrast, subsidies for foods of high nutritional value would provide the greatest benefit to low-income consumers by making nutritional foods relatively more affordable (e.g. provision of fresh foods to remote communities).^{footnote 505 footnote 506}

Built environments

The built environment also influences physical activity, nutrition and dietary habits. People who live in more mixed-use neighbourhoods (containing a balance of residential, commercial and community services) drive less, walk more, have greater access to healthy foods and report lower rates of obesity.^{footnote 508} Streetscape design to improve safety for pedestrians and cyclists, and neighbourhood design that promotes access to healthy foods, can positively impact health outcomes.^{footnote 509–511} Also, evidence shows significantly higher physical activity levels and lower obesity rates in more walkable environments.^{footnote 508 footnote 512–514}

As seen in Chapter 3, obese and overweight children are more prevalent in disadvantaged neighbourhoods where there is less access to healthy foods, limited access to recreational facilities and increased safety concerns.^{footnote 181 footnote 289 footnote 515–517} Specific considerations for future urban planning and/or community improvements include: increased mixed-land use, routing of traffic around residential areas, improved design of sidewalks and bicycle paths, and better lighting after dark. The design of new housing developments is also a critical component for influencing more positive behaviours and outcomes. A priority is to ensure safe and green play areas, as well as walking and sports areas.^{footnote 518}

Home, school and community-based approaches

The home environment is an important setting for physical activity behaviours. Parents can promote physical activity within the household, as well as ensure safe outdoor play areas (e.g. a fenced yard). Children who have limited opportunities for physical activity at home demonstrate low levels of overall activity, with more than 80% of time at home spent lying down, sitting or standing.^{footnote 519} The amount of time children spend outdoors is positively correlated with their physical activity levels.

Children's food choices and eating behaviours are also influenced by those closest to them: parents (32%), peers (31%), friends (6%) and family in general (7%).^{footnote 520} These relationships can create opportunities to steer children's dietary habits in a positive direction (which can lead to good health) or a negative direction (which can contribute to poor health). Conversely, children can also have an impact on family food choices given that they have been shown to influence up to 80% of their family's food budget.^{footnote 521} This places an even stronger emphasis on the importance of considering food marketing to children (see previous discussion in the Advertising, taxes and subsidies section).

Children from families that eat together regularly are less likely to be overweight or obese due to their consumption of a healthier diet, avoidance of eating while watching television, and better communication, family support and relationships.^{footnote 180} Also, people who eat meals outside the home tend to consume more calories than those who eat meals prepared at home. For example, evidence shows that children who buy lunch at school are more likely (47%) to be overweight than those who bring lunch from home.^{footnote 180 footnote 522–524}

Among children who are overweight or obese, treatment interventions that include both diet and exercise components appear to be more effective than dietary or physical activity modifications alone.^{footnote 525} In particular, family-based interventions targeting both parents and children have shown that parents’ weights are a strong predictor of children's weights and that treating childhood and parental obesity simultaneously yields positive results.^{footnote 526 footnote 527} A systematic review of controlled trials found that family-based lifestyle interventions that modify physical activity and nutrition, and that include behavioural therapy, helped obese children lose weight and maintain weight loss for at least six months.^{footnote 528}

Schools also provide opportunities for obesity prevention strategies for children (see textbox Annapolis Valley Health Promoting School Project). They can be a resource for education and information on healthy choices, as well as providing athletic facilities for physical activity.^{footnote 529–531} While school-based physical activity programs vary across provinces and territories, most have mandated physical education requirements for students from kindergarten to Grade 9. Some provinces require a minimum time commitment for physical activity.^{footnote 532–534} For example, Ontario has one of the higher minimum requirements of 165 minutes per week for children from kindergarten to Grade 10.^{footnote 532}

School-based approaches such as those outlined, have been shown to be effective at increasing daily physical activity (intra- and extra-curricular), helping students to meet basic daily physical activity goals, and establishing healthy behaviours now and over the lifecourse.^{footnote 519 footnote 525 footnote 535} However, further research and investigation is required to better understand and measure outcomes of increased involvement at the school level, as well as the applicability of specific programs to other populations and outside the school environment.^{footnote 530 footnote 536}

At-school interventions that improve dietary habits through behaviour-based approaches have had success, but circumstantial influences must be considered.^{footnote 525} For example, gender needs to be considered, given that girls and boys do not always respond the same way to a given intervention.^{footnote 530} Qualitative analysis of several interventions suggests that girls respond better to educational components based on social learning, while boys respond better to structural and environmental changes that facilitate increased physical activity and improved dietary intake.^{footnote 530 footnote 537}

Community-based initiatives can also make a difference to dietary behaviours and physical activity levels among children. Neighbourhoods with affordable recreational programs and access to safe play areas — including local community centres, schools, parks and playgrounds — encourage and allow children to explore healthy physical activities such as outdoor play and team sports. Recent research has found that community-based physical activity interventions are cost-effective and, compared with treatment strategies, offer good value for investment (see textbox Communities in Motion).^{footnote 541}

Unintentional injuries

Canada has had success in reducing unintentional injury among children over time, however, current death rates related to all injuries among children in Canada are higher than those of similarly affluent countries, and rates are also higher among certain sub-populations within Canada.^{footnote 79 footnote 163} Most childhood injuries are minor and result in a full recovery or good quality of life. But for some, the severity of the injury results in premature death, a severe impairment (where returning to good health may be difficult) or, in some cases, years of surgical, medical, psychological and rehabilitative interventions. As well, serious injury may be the catalyst for additional health issues that develop later in life.

Mechanisms exist in Canada and other jurisdictions that have had success in modifying risky behaviours and reducing rates of unintentional injury. These efforts can be categorized according to the following three key areas of action:

• education and awareness;
• legislation, products and standards; and
• inter-sectoral prevention strategies and initiatives.

Each area of action has either shown success and could be applied more broadly, or is an area of promise where further work and investigation is required.

Education and awareness

Learning about health and safety, and understanding action and associated responsibility, begins in the early years. Although all children deserve to be safe, predicting and managing risk is not always easy (see textbox The Nature of Risk).

All sectors have a role to play in ensuring children, parents/caretakers and communities are informed about safety issues.^{footnote 163} There have been a number of educational initiatives that are effective at building safety awareness, including consumer product safety warnings/announcements, interactive safety programs (safety villages) and broad social marketing campaigns (see textbox Back to Sleep).^{footnote 163}

Education and awareness is the approach most often taken to reduce unintentional injuries (any other preventable negative outcome), however, on its own, it does not consistently lead to injury reduction and behaviour change; efforts that combine approaches seem to increase that probability (see the Inter-sectoral prevention strategies and initiatives section).footnote 550–553 For example, a systematic review of booster-seat use showed that interventions combining education with other incentives (such as free booster seats) had a beneficial effect on the acquisition and use of this safety equipment.footnote 551 footnote 552 Not-for-profit organizations, such as Safe Kids Canada, ThinkFirst and SMARTRISK, have also incorporated a range of additional activities (including mentorships and role playing) into their educational efforts targeted to children and youth.footnote 545 footnote 554 footnote 555

Legislation, products and standards

Through legislation and regulation, Canada has made progress in reducing injuries, particularly related to traffic and automobiles. Overall, traffic-related deaths and injuries have decreased over time, and part of this reduction can be credited to an increase in seatbelt use and car-seat use for children. Seatbelt use for most motorized vehicles is mandatory in all Canadian provinces and territories, as is car-seat use for infants and younger children. Based on evidence of increased child safety, legislation for mandatory booster-seat use for children too large for car seats, but too small for regular seatbelts, has also been passed in some provinces and territories.^{footnote 163 footnote 556}

Similarly, Canada is making progress in protecting children from head injuries and premature death while bicycling through mandatory helmet use. A cross-Canada study demonstrated that head injury rates among child and youth cyclists are about 25% lower in provinces and territories with helmet legislation, compared to provinces and territories without such legislation.^{footnote 79 footnote 557 footnote 558}

Consumer products, including household items, toys and playground equipment, can also be a source of injury for children. Product standards and regulations minimize the risk by adding safety measures, improving quality and controlling access — particularly in terms of age-appropriate products. National standards for playground equipment provide one example. Playground injuries are common in Canada and, although most are not serious, those due to falls from play equipment onto hard surfaces can include head trauma, spinal injuries and fractures.^{footnote 163 footnote 559}

National standards for playground equipment provide one example. Playground injuries are common in Canada and, although most are not serious, those due to falls from play equipment onto hard surfaces can include head trauma, spinal injuries and fractures.footnote 163 footnote 559 Nation-wide standards developed by the Canadian Standards Association (CSA) provide accepted measures for the assessment of playground equipment safety; however, compliance is voluntary. Some provinces/territories have enacted legislative requirements for all licensed child-care facilities (excluding residential child care) to be inspected for compliance with CSA standards, and to have a plan to minimize risk of injury.footnote 79 footnote 163 footnote 560 For schools, use of CSA-compliant equipment varies. Toronto's Hospital for Sick Children found that school playgrounds in Toronto that had been upgraded to the CSA standard experienced 49% fewer injuries compared to schools with playground equipment that had not yet been upgraded.footnote 79

Inter-sectoral prevention strategies and initiatives

While Canada has many injury prevention initiatives, a coordinated strategy does not exist. There are elements of a strategy in place — surveillance (through the Canadian Hospitals Injury Reporting and Prevention Program — CHIRPP), legislation and regulations — but there has been no co-ordination of these efforts to date. Many experts across the country are advocating for such a strategy and OECD countries with an injury prevention strategy in place have experienced progress in further reducing injury rates (see textbox Sweden's Success in Reducing Child Injury).^{footnote 561}

Experience from other countries, such as Sweden, outlines the benefits of a co-ordinated strategy to address an issue such as childhood injuries. Multi-sectoral efforts, strong leadership, ongoing surveillance, research and evaluation, as well as broad-based awareness and education, and public support have been shown to contribute to success.^{footnote 562}

Summary

The six areas of concern highlighted in this chapter (socio-economic status and developmental opportunities, abuse and neglect, prenatal risks, mental health and disorders, obesity, and unintentional injuries) are critical areas where Canada, as a society, can make a difference in the current and future health and development of children. However, in exploring each of these areas, fundamental issues have emerged illustrating that there is more to know and more to do.

Socio-economic and health inequalities highlight the interconnectedness between key factors that influence the health and development of children, such as meeting basic needs and having opportunities to develop, grow and participate at home, school and in society. There are vulnerable populations such as Canada's Aboriginal population who experience higher rates of adverse health outcomes and also report greater levels of child poverty, poorer living conditions and barriers to developmental opportunities. Canada's child poverty rates remain higher than other similarly affluent countries and early childhood development programs exist but are unco-ordinated and limited in availability and affordability. Building on all levels of Canada's social and child-oriented public policies is needed in order to break down the barriers associated with socio-economic and health inequalities.

In Canada, there are indications that childhood abuse and neglect may be on the rise. Prevention and mitigation of abuse/neglect are complex issues and require an understanding of a child's environment, SES, intergenerational factors and resiliency. It also requires better evaluation of the effectiveness of current preventive interventions and protective care options. Building on current surveillance efforts and continuing to do so over the long term will help to identify those in environments of greatest risk and in need of intervention.

Prenatal care and support continues to positively influence the health of pregnant women and infants in Canada by enabling healthy choices and encouraging risk avoidance during pregnancy. Much of this success can be attributed to prenatal care and screening, healthy pregnancy campaigns and other early education initiatives. However, the need for education and awareness programs is ongoing and the breadth of coverage and uptake of the messages needs to be expanded. Those who are most vulnerable to unhealthy behaviours remain difficult to reach. Targeted outreach programs that offer safe non-judgmental environments have had some success but are too few in number and in reach. Addressing the conditions and environments in which at-risk pregnant women live is critical. In addition, more data are needed to be able to understand and report on pregnant women's nutritional practices, use of care, and connections to family and community in order to better target programs to needs.

A significant barrier to promoting the mental health of children is the lack of knowledge in this area, beginning with the number of children affected by mental illnesses and disorders and extending to the best approaches for promoting mental health and preventing and managing mental illnesses and disorders. Reducing stigma, raising awareness, and increasing opportunities for prevention, treatment and support within communities and families is important. The latter can be best achieved by acquiring a better understanding of the effectiveness of current interventions. These efforts will require a co-ordinated and collaborative approach that may be facilitated through the creation of a national mental health strategy which is currently under development by Canada's Mental Health Commission.

Obesity is an area of concern for Canadian children and while the negative health impacts of living with obesity are well known, information about risk factors, including nutrition and physical activity practices of children and their families is limited, as are data related to the effectiveness of interventions. Comprehensive strategies should address the many individual and societal factors that lead to obesity. For example, home and community environments are critical to establishing lifelong healthy behaviours, as are infrastructure and strategies that support and promote safe play, access to affordable recreation, more nutritious foods and other supportive resources. Prevention and rehabilitation efforts undertaken in isolation are not as effective as collaborative, co-ordinated and multi-pronged approaches that involve all relevant sectors of society.

Injuries are one of the leading causes of death among children from birth to age 11 and most are preventable or can be reduced through understanding and mitigating risk. Educational programs have been instrumental in increasing parents’ and children's awareness and understanding of risk and ability to make safer choices. Legislation and regulation have also helped by making some products and services for families with children safer. However, as with many of the health risks explored in this report, these efforts are more effective when they are co-ordinated. Countries, such as Sweden, that have achieved greater reductions in childhood injuries have engaged in broad strategies or initiatives that offer leadership and that co-ordinate surveillance, regulation, education, prevention tactics, community support and infrastructure.

The successful interventions and initiatives profiled in this chapter are a beginning. They illustrate and confirm that all sectors of society can make a difference in identifying and implementing effective programs with measurable outcomes. These efforts provide a starting point from which to draw inspiration, think, plan and act. Chapter 6 highlights the way forward in terms of establishing the conditions for a healthy future.