Many young children attend some form of formal or informal childcare on a regular basis. The use of these facilities is increasing with changes in working patterns of parents, an increase in single-parent families and high mobility rates where families are separated from extended family support (Australian Institute of Health and Welfare 2007a). The most common reason cited for using childcare is work related for before/after school care, family daycare and long daycare (Australian Bureau of Statistics 2005). In Australia, in June 2005, 46% of children aged 0–12 years received some type of childcare (Australian Bureau of Statistics 2005).

Formal childcare includes preschool, outside hours school care, long daycare, family daycare, occasional and other formal care (Australian Institute of Health and Welfare 2007a). Formal care was utilised by 33% of children in 2005 (Australian Bureau of Statistics 2005). Data for New Zealand date back to a one-off survey in 1998 (Statistics New Zealand 1998), but show a similar rationale as Australia for early childhood education and childcare placement for preschool and school-age children. Three times as many preschool-age children are placed in formal settings than informal settings.

In formal childcare settings there is an emphasis on the child’s growth and development, and programs are developed to address their needs. Preschool services are classified as formal childcare. They offer educational and developmental programs to children prior to attending school and are an important aspect of early childhood development. Formal care provides professionally qualified staff and is based on preparing children for school (Australian Institute of Health and Welfare 2007a, Australian Bureau of Statistics 2005).

Informal care refers to non-regulated care that occurs in the child’s home or elsewhere. This care is provided by family members, particularly grandparents who provide care for 20% of children, friends, neighbours, and babysitters and nannies. Many parents use a combination of formal and informal childcare (Australian Bureau of Statistics 2005).

Hayden (2002b) suggests that much research and literature in the area of childcare is focused on illness in childcare, reducing the spread of disease, and the incidence of infections within this environment. In addition, many of the relevant policies and guidelines have an illness, rather than health promoting, focus. While staying healthy in childcare is important, and there are useful strategies to limit the spread of infection (National Health and Medical Research Council 2005), this emphasis seems to have overshadowed the opportunities for developing health promoting environments. For current recommendations on exclusion from school, see Box 8.2.

School plays a major part in a child’s life, and the school curriculum and school environment are important settings for health promotion. Health Promoting Schools is a worldwide movement developed by the World Health Organization (2007) to support and promote the health and wellbeing of children and young people in schools. While the Health Promoting Schools models began as early as 1950, it was in the 1990s that schools in Australia and New Zealand became involved in the project. The New Zealand Canterbury District Health Board site is recommended to readers (www.cph.co.nz/About-Us/Health-Promoting-Schools.asp). This provides a good introduction and shows the intersection of Maori health concepts with Health Promotion aims. (See Ch 3 for a description of Maori health.)

A Health Promoting School fosters health and learning and is one that constantly strengthens its capacity as a healthy setting for learning (World Health Organization 2007). The model encourages active partnerships between education and health, and collaborates with family and community at a local level. Thus, Health Promoting Schools are strong in localities where these partnerships are established and maintained. Gary, the community nurse in the scenario, recognises the value of developing education and health partnerships, and takes the opportunity to contribute to the project. Using a Health Promoting Schools framework, Gary speaks to the group about relevant health issues for inclusion in the Expo.

Wainwright et al. (2000) and Whitehead (2006) suggest that the role of nurses in schools has been poorly evaluated and has focused on screening, surveillance and health education. The authors suggest an increasing role for nurses in health promotion and argue the need for interventions to be critically evaluated. Whitehead (2006) suggests that nurses need to engage with the Health Promoting Schools movement to build capacity and further emphasise the health promoting role of nurses. It is a pathway to strengths-focused practice.

Good nutrition is an important component of healthy development, and depends on having access to healthy foods (Hayden 2002a). This begins in infancy with promotion of breastfeeding, introduction of appropriate foods after 6 months and, later, assisting children to make healthy food choices by having these available to them.

Baur (2004) discusses the role of school canteens in promoting healthy food choices, as well as the school curriculum for promoting healthy eating and activity. This role is becoming increasingly recognised with specific programs being developed to assist school canteens to provide such choices. For example, the New South Wales Healthy School Canteen Strategy highlights a change in nutrition guidelines for school canteens to a government-endorsed approach where the government provides incentives and funding to change to a healthy school canteen policy. They encourage links between school canteens and the community, and aim to model healthy eating to children and families (Bell & Swinburn 2005).

In New Zealand, the Fruit in Schools project aims to increase the consumption of fruit by children (Ministry of Health New Zealand n.d.). The project has two aims. The first is to encourage and support schools in taking a Health Promoting Schools, or whole school community, approach to health (and includes strategies for increasing physical activity, promoting healthy eating, smoke free and sun protection). The second aim is to provide children in high-need groups with a piece of fruit a day. Such an approach provides practical support for children and assists in establishing an interest in healthy eating within the school environment. Further, the program demonstrates the links between health promotion and illness prevention, as a central motivation of the program is cancer prevention.

Pagnini et al. (2006) discuss the importance of promoting healthy eating and increased activity in long daycare centres and preschools. They discuss the opportunity to do this through the provision of food and incorporating messages about healthy eating and physical play into the curriculum. The report viewed these as core missions and highlighted the need to work in close partnerships with parents. This included support, and changing cultural and environmental factors, that influence healthy eating and physical activity. It identified the need for more child-friendly games, activities and books, as well as songs, posters, training for staff and access to health professionals to speak with staff and parents on these issues.

Bailey (2006) suggests that physical education and sport in schools has a number of benefits, and can be understood in terms of child development in the domains of physical, social, affective, lifestyle and cognitive development. Additionally, there are opportunities for children to engage in physical activity in less formal ways. Beighle et al. (2006), for example, studied children’s physical activity during recess and found that children engaged in physical activity for the majority of the recess period, indicating opportunities to encourage activity within the school environment. However, gender differences in physical activity are evident, even in primary-school-aged children.

A Western Australian government survey of child and adolescent physical activity and nutrition in 2003 (Department of the Premier and Cabinet WA 2005) showed that primary school girls undertook significantly less physical activity than boys during break periods at school. Both primary-school-aged girls and boys undertook a range of physical activities during a week, both in and around home and at school. The materials provided by the Western Australian Premier’s Physical Activity Taskforce demonstrate the multilayered messaging associated with promoting healthy behaviours. Information is provided for teachers, parents, children and parent associations.

Bullying is a serious threat to healthy child development and it is purposeful in attempting to injure or inflict discomfort on another (Crothers & Levinson 2004). Often bullying is a means of establishing dominance or maintaining status (Smokowski & Kopasz 2005). It is common in schools and tends to occur repeatedly. It includes name calling, physical assault, threatening, stealing, vandalising, slandering, taunting and excluding (Smokowski & Kopasz 2005 p. 101). Bullying crosses technology boundaries, being communicated via messages on telephones, SMS text and emails, and in chat rooms (Rivers, in Smith 2004). Long-term effects can be devastating, as it creates humiliation and fear for the victim and has detrimental effects on self-image and self-perception.

In both New Zealand and Australia, schools are responsible for ensuring that policies exist and are enforced to minimise bullying, as they provide safe physical and emotional environments for children (Kazmierow 2004).

Health promoting strategies will focus on building skills and strengths in children, appropriate to their age. Holistic system-based approaches are promoted to create positive school environments. However, the motivations for bullying are numerous and can affect strategies that may be helpful. For example, in earlier childhood, behaviour that is labelled bullying is most likely physical. Greater social development usually sees this sort of assertion of self over others diminish, but emotional bullying may increase. Promoting good self-esteem and assertion in children may diminish emotional bullying (Rigby 2003).

While early childhood is a time of activity, learning and fun, children are often faced with difficult circumstances. Many face difficult relationships with family or friends. Bullying and child abuse have been identified as the major reason for younger children contacting help lines (Boystown 2005). If children are not in nurturing or supportive family environments, or if those environments are in crisis, young children rarely have intrinsic or external resources to cope effectively (Boystown 2005). Telephone counselling lines are a last resort for children. Nurses’ advocacy role and legal obligations are discussed in detail in Chapter 4.

Being a victim of, or witnessing, violence is a significant reason for children to seek help. Often they experience physical, emotional or sexual abuse. Research into domestic violence has identified preschoolers as blaming themselves for the violence, having sleep disturbances, anxiety and social isolation. Primary-school-aged children also experience difficulties with school, both attending and doing the work, problems concentrating, fighting with peers, rebelling against authority, aggression, depression, and girls particularly being withdrawn and anxious (Gevers 1999 p. 17).

Domestic violence is multidimensional and influenced not only by the violence, but also by separation from a parent, frequent moves, age, sex and the child’s personality. It puts these children at risk, in both the short and the long term (Gevers 1999 p. 17). Some children learn to use violence as a way of solving problems. All domestic violence is traumatic and has chronic long-term impacts on the child psychologically, whether as a victim or as a witness to it (Gevers 1999, National Association for Prevention of Child Abuse and Neglect n.d.). Violence is a complex issue, but an important one for health promotion action in schools and communities.

Talking about bodies, sexuality and self-protection is important in the early years. Box 8.3 describes a recently developed resource to assist parents and teachers.

The inquisitive, exploratory nature of young children means that injuries and accidents are common. Many are preventable; some are inevitable. The 0–14-year age group has been identified as the group most likely to sustain an injury, with 25% being reported in this group (Australian Bureau of Statistics 2006a). The most common were cuts at 28%, falls below one metre 55%, falls more than one metre 51%, attacks by other people 51%, and 37% from bites or stings. Of these injuries, 54% occurred during leisure time, sports activities comprised 15%, and 12% occurred while at school (Australian Bureau of Statistics 2006a). The risk of injuries at home is more common in younger children, and boys have been found to be at higher risk of injury than girls, and this proportion increases with age (Kendrick et al. 2007).

Unintentional poisoning, childhood falls, pedestrian injuries, burns and passenger injuries are all cited as common injuries in the New Zealand data (Safekids New Zealand n.d.). In a study of fractures in New Zealand elementary school settings, Rubie-Davies and Townsend (2007) found that across 76 schools (over 25,000 students) in a 1-year period, 118 students sustained a total of 131 fractures. Compared to international data, this rate is low, but, interestingly, fewer fractures were involved in playground equipment than expected. The researchers suggest that injury may be influenced more by the way students interact than the safety of equipment.

The Health Expo suggested in the scenario is a way to provide a school with the opportunity to share information and showcase strategies in a number of child health areas. Promoting healthy development in early childhood is a key to prevention and to promoting resilience, strength and wellbeing in young children. It is a means of building on the protective factors they have and protecting them from intrinsic and extrinsic risks and vulnerabilities (see Table 1.1 in Ch 1). However, these years are often marked by episodes of acute illness. The second part of the chapter discusses the contexts of care for childhood acute illness episodes.