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5 Measuring Influences on Children's Health
Pages 116-163

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From page 116...
... 5 Measuring influences on Children's Health A comprehensive system to monitor chi dren's hea th would contain an inclusive, continuing assessment and monitoring of the range of influences on children's hea th, inc uding children's biology and behavior, socia environments (family, community, culture, and discrimination) , physica envrronments, and services and policy contexts.
From page 117...
... , rather than using strategies that address single risk factors. For policy purposes, which children may be most at risk for later adverse outcomes, ted which may be most in need of specia assistance?
From page 118...
... MEASURING BIOLOGICAL INFLUENCES The range of biologica influences on children's hea th are assessed using "biomarkers," which are indicators signa ing events in biologica systems or samples (for review, see Nationa Research Council, 1989)
From page 119...
... Biologica factors that Influence hea th, such as genotypes for functions Iy important gegettc polymorphisms, variations in gene expression, and biochemica measures that reflect body stores or interna doses of environments exposures, are usefu biomarkers. Thus, the concept of biomarkers provides m orgartizahona framework for considering existing indicators and the potential influence of the biologica environment.
From page 120...
... A chi d's current hea th as reflected in his or her level of immunity or leve of cortisol production may a so serve as a va uable indicator of biologica susceptibility. Under certarn circumstances, age c m serve as a proxy for developments susceptibi ity, such as the age of risk for sudden infant death syndrome (infants)
From page 121...
... While patterns of changes in gene expression maybe a sensitive and specific biomarker of effect, no CUTTeltt pupal ation-based measurement activities of gene expression are current y taking place, except in drnica settings for research purposes. Challenges in Measuring Biological IIL'duences Severa methodologica issues are of concern in measurmg biologica influences.
From page 122...
... 122 CHIEDREN'S HEALTH, THE NAnONS WEAETH TABLE 5-1 Appropriate Biologica Samples in Wlticlt to Measure Biornarkers Indicating Feta Pediatric/Adult Exposure/Effect Sanrples Advantages Disadvantages Adult/Pediatric Urine Hair Blood Breath L rge sample size May indicate timing of exposure Battery of biomarkers may be wed Easy to obtain large quantities Szlivz Ezsy to obtain Transdermd Ezsy to obtain Nai s Placenta Urine Hair Breath Ezsy to obtain, may indicate timing of exposure Newbonna Cord blood L rge volume available, discarded sample, batte y of binnrarkers may be used Large sample size, discarded sample Umbilkd cord L rge sample size, discarded sample Amniotic fluid Large sample size, discarded sample Concentrates metabolites, discarded sample May indicate timing of exposure Easy to obtain Saliva Nzi s Transdermd Ezsy to obtain May indicate timing of exposure d Ezsy to obtain Meconit m Easy to obtain, may indicate timing of espy e, discarded s mple Requires cooperation, difficult in young children Requires cooperation, may not be desirable, requires special analytics techniqt es Invasive, Comfy, daffy r t to obtain in yot ng children, amot nt of blood baited in yot ng children Reqt ices specid eat ipment, technology is limited, requires cooperation Requires cooperation, sample sire baited Requires specid eat ipment, tee hnology is limited, rent irez cooperation Requires cooperation, may be diffct t in yot ng r Gild, sample size limited Narrow window of opportunity to collect, smgde time point for measurement Narrow window of opportunity to collect Narrow window of opportunity to collect Diffrct t to collect, nanow window of opportunity to collect Diffrct t to collect May not be available, may not be acceptable to parent Reqt ices specid eat ipment, tee hnology is limited Small sample Extremely dif irolt to obtzbn, invasive Requires sperizl equipment, tee hnology is limited None Obvicosly, biomarkers measured m newborn samples on y Dedicate feted exposure retrospectively
From page 123...
... Addressing Gaps in Measuring Biological Influences The importance of biomarkers has been insufliaently appreciated in assessing children's hea th and its ins fences. Biomarkers may be useful even beyond measuring the effect of chemica or environments agent exposure.
From page 124...
... MEASURING BEHAVIORAL INFLUENCES Given the centra role of chi dren's behavior on their hea th, whether by active parucipahon nn hea th promohon or disease intervention efforts or by behaviors that increase the rxk for poor hea th, a systemanc strategy for assessing and monitoring such hea th influences is critica. However, apa t from youth, parent, or teacher reports and limited use of urme or hair tests to detect the use of illicit drugs, there are no concrete or fu Iy objective tests for the presence of such behaviors.
From page 125...
... Data regarding child and youth risk behaviors are gathered routinely from a number of nationa surveys (see examples below) , some consisting of one-time investigator-initiated (even longitudina )
From page 126...
... Data regarding youth behavior and its implications for hea th are sometimes available from investigator-initiated surveys. For example, the Nationa Longitudina Survey of Adolescent Hea th (ADD-Hea th)
From page 127...
... a so contains rich data on some aspects of behavior in a large cohort over time. Challenges in Measuring Behavioral Influences There are many specia challenges in assessing children's behaviora, emotiona, and cognitive influences on hea th because information may be highly stigmatizing, raise fears that the chi d we I be "labeled," or may concern illega activity, such as crimina acts or subst race abuse.
From page 128...
... Addressing Gaps in Measuring Behavioral lu'duences Among the influences on chi dren's hea th, the sa ience of behavior to longterm hea th, especially regarding obesity, HIV/AIDS, sexually transmitted diseases, substance or a cohol use and addiction, motor vehicle accidents, teenage pregnancy, school dropout, and homicide and suicide, is generally accepted (Murray and Lopez, 1996)
From page 129...
... This reflects a more genera failure in behaviors hea th research. Another assessment gap is the fact that, among the few studies that attempt to address the problems noted above, few are nations IT representative (NHANES, NHIS, National Household Education Survey, and NHSDUH being notable exceptions)
From page 130...
... Addressing Gaps in Measunng Chemical Exposures The hea th effect of a physica agent to which chi dren are exposed may be unknown. A recent ana ysis by the EPA discovered that 43 percent of high production volume (HPV)
From page 131...
... Moreover, when data are avai able, they can sometimes be mapped only to re ative y large geographic units, such as metropolitan areas or counties. Data on smaller units, such as the census tract (geographic areas encompassing 4,000 to 6,000 individua s, with boundaries drawn to approximate neighborhood areas)
From page 132...
... , the safety of allowing their children to wa k to school (Dellmger and Staunton, 2002) , or other perceived features of the built environment In one investigation conducted as part of the A ameda County Study in Ca if ornia, participants were asked to rate the seriousness of six potentia neighborhood problems: crime, nighttime lighting, traffic, excessive noise, trash and litter, and access to public transportation (Ba four and Kaplan, 2002)
From page 133...
... 133 Addressing Gaps in Measuring the Built Environment Further research and systematic assessment are necessary to ascertain how the built environment affects sense of community or socia capita in ways that shape the development of younger chi dren. In addition, to improve measurement of the but t enviromment, standardized inst uments need to be developed, va idated, and implemented at geographic leve s usefu for loca planning.
From page 134...
... . The NSECH a so assesses fami y income, medica insurance coverage and adequacy, chi d care and child care affordability, and receipt of nutritiona benefits such as WIC and other low-income benefits.
From page 135...
... Data regarding limited aspects of parenting, nurturmg, day care/child care, and school readiness are collected periodically in other surveys. Challenges in Measunng Family Influences Decades of methodologies research have produced at least rough consensus on how to measure family environment components in surveys.
From page 136...
... Data collection efforts that aspire to understand family environments influences on chi dren's hea th shou d consider mcludmg measures of parenting and the home learnmg and physica environments but, here again, the measures used should match the conceptua orientation of linkages between family process and hea th outcomes. Addressing Gaps in MeasuringFamily Influences Clinica records pose a specia cha lenge in regard to the assessment of SES influences.
From page 137...
... A I m all, apart from privacy and confidentia ity issues surrounding the need to gather and store information about the exact addresses of mdividua s and families, the decennia censuses provide the geographic dimension of demographic and many economic risk factors. The Census Bureau is deve oping the American Community Survey (ACS)
From page 138...
... when studying the prevalence and effect of community violence m relation to children's hea th (Martinez and Richters, 1993; Smith and Martin, 1995)
From page 139...
... Ana ysts using these surveys base estimates of neighborhood effects on differences among relatively advantaged, most y white fami ies and children. If neighborhood conditions matter more for disadvantaged than advantaged children, then studies of neighborhood effects based on broad population samples may miss an important part of the story.
From page 140...
... Assessing the effect of violence on children is a so challenging. First, investigators must measure simultaneously multiple facets of community violence.
From page 141...
... At least one team of investigators has noted a strong positive re ation between exposure to community violence and the incidence of family violence ! OsofskY et a., 1993)
From page 142...
... For example, using the Hispanic Hea th and Nutrition Examination Survey, (conducted m 1982-1984) that oversampled Mexican Americans, Cubans, and Puerto Ricans, investigators have shown very different rates of asthma, lead levels, and hea th care utilization (Mendoza, Takata, and Martorell, 1994)
From page 143...
... Surveys such as the Current Popu ation Survey (CPS) have adopted the OMB st mdard related to racia and ethnic data and provide a time y and reliable method for capturing data on immigration.
From page 144...
... , a research agenda to develop va idated and standardized measures is warranted. Addressing Gaps in Measuring Cultural Influences In order to make data compatible for aggregation and ana ysis, collection of data on cu tura group membership shou d be systematized and standardized across a I levels of loca, regiona, and nationa data collection.
From page 145...
... MEASURING INFLUENCES ON CHILDREN'S HEALTH 145 used, questions related to languages spoken in the home shou d be incorporated in studies. Work toward standardizing the assessment of culture group membership should a so be done with the recognition that such membership a one does not capture cu tura processes.
From page 146...
... Discrimination is sometimes mentioned as possibly having a causative role in these disparities, but its contribution has rarelybeen studied direct y. There are many possible reasons for this, mcludmg a lack of understandmg of the mu tiple mechanisms by which discrimination may affect hea thi a lack of an a priori conceptua izing of discrimmation as a potentia influence separate from other socia stratification mechanisms, such as race, ethnicity, and socioeconomic status; and difficulty in operations Zing and measuring discrimination.
From page 147...
... Since the dimensions of discrimmation will be different for different minority groups, another cha lenge is to create instruments that tap into the unique aspects of discrimination in each group but can a so be used comparatively in studies of multiple groups. Perceived discrimination may be based on such factors as language or accent, skin color, food preferences, family or household structure, or customs.
From page 148...
... . Addressing Gaps in MeasunngDiscrimination D iscr im inat ion is a socia stratification mechanism that warr to Is further consideration as one of many mediators of hea th outcomes in mmority children, including the mu tiple leve s and mechanisms through which discrimmation may have either direct or mdirect effects on their hea th.
From page 149...
... Ultimately, large sca e nations su veys such as the Hea th Interview Survey, NHANES, and Nationa Longitudina Su vq of Youth should incorporate measures of racism and discrimination, whether Inmited to a single quest on or full instruments. One approach may be to create instruments that have a core set of generic items or subsca es that are appropriate to measure racia discrimmation among all minority groups, as well as additions items or questions sa ient to each particular ethnic minority group to ensure emic va idity.
From page 150...
... Existing surveys monitor the patterns of hea th service use and disease, but they lack the detail required to assess the appropriateness and effectiveness of the care provided. Nor do they provide a more nu raced assessment of hea th care access based on need.
From page 151...
... In addition, it is important to consider how hea th services de ivered by both the persona medica care system and population hea th services perform and affect hea th outcomes m children. Crossing the Quality Chasm outdmes severa domains to measure the qua ity of services provided.
From page 152...
... A though some effort has been directed at improving measurement of persona hea th care services, far less has focused on assessing the performance of the
From page 153...
... There are a so major gaps in understanding the de ivery of hea th services and the potentia effect of these services on specia populations. For example a though the number of chi dren in foster care has increased dramatically over the past two decades and the high preva ence of menta hea th conditions in this population is solid y documented, there has been little focus on the accessibi ity and appropriateness of hea th services provided to children in foster care.
From page 154...
... Moreover, there has been no effort to deve op ways of conceptua izing and assessing the adequacy of speciakty care services. Recent research is showing the variable nature of need for speciakty services, including the need for advice and guidance, confirmation of initia opinion, and need for definitive interventions that can be provided only at the specia ty level (Forrest, Glade, Baker, Bocian, Rang, and Starfie d, 1999; Forrest, Rebok, Riley, Starfield, Green, Robertson, and Tambor, 2001)
From page 155...
... POLICY There are re ative y few efforts to assess the effect of policy changes on hea th, particularly children's hea th. In rare cases (e.g., we fare reform, residentia mobility programs, hea th insurance)
From page 156...
... In genera, however, there is itUe activity in the United States to measure the effect of policies on children's hea th. The United Kingdom, Canada, and Austra ia have gone se era steps further by developing approaches that attempt to assess policy effects more systemancally and comprehensively.
From page 157...
... For en ample, state trends in hea th insurance coverage using the Census Bureau's CPS could be expanded to assess the effect of Medicaid or SCHIP policy changes on enrollment. Available nationa surveys such as the NHIS and the Medica Expenditure Pane Surveys cou d potentia Iy provide insight into effects on access and utilization.
From page 158...
... While Healthy People 2010 provides a possible framework for eva uating the effect of some influences on hea th, including policy changes, its structure does
From page 159...
... The effects of policy changes cannot be adequately assessed without tracking the way these changes and their consequences affect children's deve opmenta trajectories. A number of other countries are ahead of the United States in monitoring both hea th overall and children's hea th in particular.
From page 160...
... and ongoing data collection. In this case, sharp policy changes from one administration to the next or from one state to another aid eva uators, since they can then look for hea th care and hea th changes surrounding the policy changes.
From page 161...
... Understanding the factors that enhance collective efficacy wou d allow a community to develop policies mtended to improve it, thereby improving the hea thy deve opment of its children. Evidence about the importance of particular influences on hea th usua Iy comes from studies of the relative risk of particular mfluences on a specific hea th outcome.
From page 162...
... Existing ongoing data systems have severe limitations as a tool for assessing policy effects, inc uding their limited focus on particu ar diseases, the re ative lack of longitudina data, and the inability to link data across systems. Given the latitude afforded to states to implement policy, there is a so a need for better tracking of state-specific policy implementation from one year to the next Approaches being undertaken in Canada, Eng and, and Austra ia provide va uable models for the United States.
From page 163...
... MEASURING INFLUENCES ON CHILDREN'S HEALTH 163 family hea th care seeking and hea th care access. Simi arty, su vies focused on hea th outcomes have comparatively little Information on such influences as family and communities variables.


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