Vibrant and Healthy Kids Aligning Science, Practice, and Policy to Advance Health Equity (2019) / Chapter Skim
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Summary
Pages 1-28
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Among the factors that may buffer negative outcomes in the early childhood period, supportive relationships between children and the adults in their lives are essential. Furthermore, reducing health disparities by addressing root causes, such as poverty and racism, is foundational to advance health equity.
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to promote better health outcomes, the committee recommends developing a comprehensive approach to school readiness that explicitly incorporates health outcomes, developing and strengthening curricula that focus on key competencies of educators, and improving the quality of ECE programs and expanding access to comprehensive high-quality and affordable ECE programs. The committee recommends leveraging the health care system to make care in the preconception through early childhood periods more continuous, equitable, integrative, and comprehensive by transforming services to apply a life course perspective and address the social, economic, cultural, and environmental determinants of health.
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, their odds for positive health diverge systematically over time, producing disparities in health outcomes across the life-span and across generations. These exposures accumulate over the life course to exert a cumulative effect on health that is probabilistic, not deterministic.
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The health of both men and women before they have children is important for not only pregnancy outcomes, but also the lifelong health of their children; thus, the committee included the preconception period as an important focus of the report. The committee also adopted the life course approach to its work because an individual's health status and outcomes reflect the accumulation of experiences over the life-span.
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It is important to note that risk and protective factors can be transferred intergenerationally, which makes parents and other family and community primary caregivers a central focus of interventions to improve child health. Within the context of the life course, the diagram's nested circles illustrate the complex sociocultural environment that shapes development at the individual level and the opportunities for interventions to improve individual health and developmental outcomes, as well as population health, well-being, and health equity.
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11. Health outcomes are the result of experiences across the life course.
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ROADMAP FOR APPLYING AND ADVANCING THE SCIENCE OF EARLY DEVELOPMENT With the goal of decreasing health inequities, the broad question this report addresses is, "For those children who are placed at risk for negative outcomes, what can be done -- guided by science-based evidence -- to expediently and effectively move each of them toward positive developmental health trajectories? " In this report, the committee provides 2 The process by which neurons within the brain change their gene expression, cellular architecture and connections with other neurons, and function in response to experiences and changes in the environment (i.e., change over time)
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• Support caregivers -- This includes both primary caregivers and caregivers in systems who frequently interact with children and their families. • Reform health care system services to promote healthy development -- Redesign the content of preconception, prenatal, postpartum, and pediatric care while ensuring ongoing access, quality, and coordination.
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Strong attachment presupposes effective parenting behaviors in everyday life, and "effective parenting" changes in complexity with development over time. There is an urgent need to develop preventive interventions well suited for fathers and other male caregivers; existing approaches that are developed for and tested with women cannot be assumed to generalize to other caregivers with equal effectiveness (e.g., in the successful recruitment, retention, and support of men and fathers who take care of young children)
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, programs need to include components that specifically address unique risk and protective processes within these subgroups of children. A growing body of evidence suggests that home visiting by a nurse, a social worker, or an early educator during pregnancy and as needed in the first years of a child's life improves a wide range of child and family outcomes, including promotion of maternal and child health, prevention of child abuse and neglect, positive parenting, child development, and school readiness.
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U.S. health care provides only limited attention to integration of health care for the whole family, health care across the life course, or integration of mental and behavioral health into clinical care.
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; therefore, the committee offers the following recommendations: Improving Access to Health Care Recommendation 5-1: The U.S. Department of Health and Human Services, state, tribal, and territorial Medicaid agencies, public and private payers, and state and federal policy makers should adopt policies and practices that ensure universal access to high-quality health care across the life course.
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Department of Health and Human Services, state, tribal, and territorial government Med icaid agencies, health systems leaders, and state and federal policy makers should adopt policies and practices that improve the organization and integration of care systems, including pro moting multidisciplinary team-based care models that focus on integrating preconception, prenatal, and postpartum care with a whole-family focus, development of new practice and payment models that incentivize health creation and improve service delivery, and structures that more tangibly connect health care delivery systems to other partners outside of the health care sector. Achieving this recommendation will require disseminating multidisciplinary team-based care models in community settings; developing integrated models for preconception, prenatal, postpartum, and pediatric care delivery modes; adopting and spreading integrated, whole-family and family-centered care models; developing and using new technologies that improve care and improve accessibility; aligning payment reform with health creation rather than service delivery; and developing systemic and cross-sector collaboration.
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Implementation of this recommendation will require • An update of clinical care guidelines and standards by the Women's Preventive Services Initiative, Bright Futures, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, American Academy of Family Physicians, and others actively developing clinical care guidelines and standards to include this new content of care; • Medical accreditation bodies, relevant programs, and agencies to develop performance monitoring and quality improvement based on this new content of care; • Clinical care educational authorities, such as the Accredita tion Council for Graduate Medical Education, to develop curricula, training, experiences, and competencies based on the updated guidelines; and • Public and private payers to cover services reflecting this new content of care. This work should take place in a larger framework of social and reproductive justice and include more diverse voices, especially from communities most affected by adverse birth and child health outcomes.
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, the committee concludes that providing resources to ensure families have access to sufficient and healthy foods can improve birth and child health outcomes. Because safety net programs such as WIC and SNAP have been shown to improve birth and child (and adult)
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Given the strong evidence that economic security matters, an important factor in reducing health disparities in early childhood is to ensure that families with young children have adequate resources. The committee concludes that public programs that provide resources to families in the form of cash, tax credits, or in-kind benefits improve childhood well-being and life course outcomes and that these effects are long lasting.
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In partner ship with researchers, policy makers should model variations in the level of benefits, length of leave, and funding mechanisms to determine alternatives that will have the largest impacts on improving child health outcomes and reducing health disparities. Recommendation 6-6: Federal, state, tribal, and territorial policy makers should address the critical gaps between family resources and family needs through a combination of benefits that have the best evidence of advancing health equity, such as increased Sup plemental Nutrition Assistance Program benefits, increased hous ing assistance, and a basic income allowance for young children.
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Poverty, substandard and/ or unstable housing, minority racial/ethnic status, and proximity to known sources of pollutants heighten children's risk of exposure and poor health and developmental outcomes. The committee identified three areas where current efforts could be improved to prevent and mitigate the impact of environmental toxicants in the prenatal through early childhood periods: Recommendation 6-7: The Administration for Children and Families, Maternal and Child Health Bureau, and federal and state regulators should strengthen environmental protection in early care and education settings through expanded workforce training, program monitoring, and regulations.
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Allocation of Adequate Resources to Support ECE Programs and Educators Intentional policies and allocation of adequate resources to support these programs and educators are needed for ECE programs to contribute significantly to a health promotion and equity strategy. Recommendation 7-1: The committee recommends that early care and education (ECE)
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an implementation study to examine the design and implementation of this comprehensive ECE approach that incorporates health stan dards and (b) an outcomes study that examines the impact on children's school readiness and achievement, and health outcomes, with particular attention to eliminating dispari ties and gaps prior to school entry.
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The strategic plan should be modeled after and build on the relevant performance standards of Early Head Start and Head Start, which emphasize mixed settings, the whole child, family and community engagement, transition between home and school, and continuous quality improvement. It should also strengthen those program components discussed in Chapter 7 that lead to stronger school readiness and health outcomes, including mitigation of the impact of adverse experiences and toxic stress for children, families, teachers, and staff.
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In brief (additional details available in Chapter 8) , the committee recommends: Policy makers and leaders in the health care, public health, social service, criminal justice, early care and education/ education, and other sectors should • Recommendation 8-1: Support and invest in cross-sector initiatives that align strategies and operate community pro grams and interventions that work across sectors to address the root causes of poor health outcomes.
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Crosscutting Research Needs A tremendous amount is known about what works to advance health equity in early development (and the lifelong benefits of doing so) , and efforts to translate this science into action and to scale up effective interventions needs to be accelerated.
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The research recommended below is important to continually improve efforts and increase impact but should not impede action. Here the committee provides guidance on charting the course for future research to better meet the health and social needs of the nation's children in the future and, specifically, to advance health equity.
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In particular, understanding how these interactions may vary across the life course in response to changing plasticity of biological systems, different stages of personal and cognitive development, 6 For reference, this is Recommendation 2-1 in this report.
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(See Box S-1 for a high-level overview of the report's findings and Table 9-1 for a summary of recommended actions in this report.) Furthermore, these actions need to take a life course, multigenerational approach to decrease health inequity, as children's well-being depends on the well-being of the primary caregivers and the quality of their relationship.
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During the prenatal and early life periods, critical biolog ical systems that will help shape health across the life course are developed and affected by the early environment. Intervening early, when the plasticity of these systems is at its greatest, is the best way to improve chances of developing in ways that optimize health outcomes.
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