“Children are the world’s most valuable resource and its best hope for the future.”
—John F. Kennedy
Over the past decade, policymakers have increasingly recognized the importance of children’s issues. This heightened awareness has been due to new research findings on the relationships among factors such as early brain development, stressful environments, and poor outcomes in later life. Moreover, researchers and professionals who work with families with young children are noting the significance of conceptualizing child health policy broadly, so as to encompass the many aspects of social policy that affect children’s well-being. The purposes of this chapter are to identify major themes pertaining to social policies for children, explain how research has enhanced such policies, describe remaining gaps in children’s social policy and research, and explain how nurses can make meaningful contributions to advancing healthy social policies for children.
Many social policies affect children’s mental, physical, emotional, and spiritual health, especially children of racial minorities in low-income families who rely on public policies more than their more advantaged counterparts. Millions of children, disproportionately from ethnic or racial minorities, depend on welfare, foster care, and juvenile justice systems, which unfortunately too often fail to provide developmentally appropriate services and adequate oversight that children require to grow and thrive. Millions of middle- and upper-income families also rely on social policies to ensure children’s health. This is especially true during tough economic times when unemployment and other family social benefits become critical parts of the social policy fabric for families with young children.
Research Informing Social Policies for Children
Many research studies have contributed to policy outcomes. We focus on research pertaining to early brain development, social determinants of health, obesity, childhood indicators, framing of children’s policy issues, and the Nurse-Family Partnership program.
Research on Early Brain Development
Child advocates and researchers have connected child development and social policy for the past 40 years. New evidence about infant brain development in the 1990s further propelled children’s advocates and researchers to push for earlier intervention with young children and families. The groundbreaking report, From Neurons to Neighborhoods: The Science of Early Childhood Development (Shonkoff & Phillips, 2000), provided important findings about the effects of genetics, environment, and early stress on brain architecture. Policymakers and children’s advocates continue to use this report to inform children’s policies.
In the early 2000s, with new neuroimaging technology and research, scientists demonstrated the impact of neurophysiologic and neurodevelopmental stress, trauma, and neglect on children. Their findings pointed to the need for safe, predictable, and enriched environments for young children (Perry, 2002) and strengthened advocates’ arguments for better funding of early childhood education, prevention of child and abuse neglect (including home visitation programs), child protection and foster care, and mental health treatment. Advocacy groups such as Zero to Three (Gebhard, 2009) used the brain research to develop science-based policy agendas for improving children’s physical and social-emotional health, through physical health, family leave, child welfare, home visiting, and early care and education.
Research on Social Determinants of Health and Health Disparities
Research on the link between social determinants of health and health disparities has proliferated in recent years. One of the most widely cited policy reports on social determinants of health was issued by the World Health Organization (WHO) (2005). It included a definition of social determinants of health:
The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices… (WHO, 2005)
Several major national and international reports have reached similar conclusions about the relationship between social determinants of health and health outcomes. Specifically, the WHO final report (WHO, 2009), Healthy People 2020 (USDHHS, 2010), and a landmark Institute of Medicine study on health disparities (Smedley, Stith, & Nelson, 2003) all explain how social determinants often play a larger role in determining health outcomes than clinical interventions.
Regarding children, several major themes emerge from the plethora of recent reports in this area. Specifically, children of low socioeconomic and minority status experience significant shortfalls in their health compared to other children (Egerter et al., 2008). Disadvantaged and minority families have the highest rates of infant mortality. Similarly, compared to children in families with higher income, those in poor, near-poor, or middle income families were more likely to be in less than optimal health. Children from poor, racially segregated neighborhoods also have more challenges than other children in accessing services needed to maintain good health (Acevedo-Garcia, Osypuk, McArdle, & Williams, 2008).
Studies on social determinants of health and the factors that contribute to health disparities have enabled policymakers and professionals on the frontlines of care to recognize the importance of including issues such as poverty, housing, neighborhood safety, transportation, and environmental stress when developing strategies for improving child health outcomes. Such research has also highlighted the importance of integrating education and child development with child health care because of the intrinsic connection between educational attainment and health outcomes later in life. Research on social determinants of health and health disparities also points to the importance of social structures in determining many aspects of personal health and to the pervasiveness of racial discrimination across many sectors of society.
Research Related to Childhood Obesity
Minority children and poor children also suffer disproportionately from obesity, putting them at greatly increased lifetime risk of diabetes, and cardiovascular, respiratory, mental health, social and occupational problems. Although the rise in childhood obesity over the past several decades impacts the entire population, research has shown that Hispanic, non-Hispanic Black, and Native-American children and adolescents are disproportionately affected (Koplan, Liverman, & Kraak, 2005). Differential access to healthy foods in low-income communities is a major contributor to health disparities in diet-related chronic diseases and obesity (Story, Hamm, & Wallinga, 2009).
Using this research, advocates for children across various disciplines are developing strategies to focus on social and environmental determinants of obesity, rather than on individual behavior or predisposition (Robert Wood Johnson Foundation, 2010). A new focus has emerged on the “built environment,” which encompasses people’s living and working conditions and how they impact opportunities for physical activity and recreation, healthy food, and neighborhood safety. Increasingly, affected communities are involved in becoming places where safe physical activity and healthy eating are possible. For example, nursing students in New Mexico were involved in assessing the “walkability” of low-income neighborhoods, through a CDC Project Achieve (Action Communities for Health, Innovation and Environmental Change) project (CDC, 2010). In February, 2010, Michelle Obama announced the “Let’s Move” initiative, a collaboration between the White House and the federal Departments of Health and Human Services, Agriculture, and Education. “Let’s Move” aims to “to end the American plague of childhood obesity in a single generation” (White House, 2010).
Research on Childhood Indicators
The Annie E. Casey Foundation has long been a leader in providing data and analyzing how policies are meeting (or failing to meet) the needs of children and families. The annual release of the KIDS COUNT data book, which includes state data for 10 leading indicators, receives extensive media attention and is often a catalyst for policy development (Annie E. Casey Foundation, 2009a). Other foundations and organizations publish similar compilations of child and family indicators. These indicator data have played a vital role in defining the problems that social policies are then designed to ameliorate.
Research on “Framing the Problem”
Since the late 1990s, researchers and child advocates have become increasingly savvy about how to communicate research findings and thereby move public policy, primarily using frame theory. Frame theory suggests that people organize the world by using preexisting frames that guide their thoughts and feelings on an issue (FrameWorks Institute, 2001). Frames are strongly influenced by the media and can be very resistant to change. The FrameWorks Institute has been the leader in this area, conducting research to determine current frames around child and family issues and subsequently designing strategic communications to change these frames (i.e. “reframing”) to facilitate policy development. These efforts have advanced children’s policy, particularly in the area of child care, now reframed as “early care and education” (ECE).
Early framing research on child care (Nall Bales, 1998) found that the predominant frames were safety (i.e., importance of children being safe; dangers associated with bad child care) and work (i.e., child care as a service that allows mothers, especially those on welfare, to work). Neither of these frames focused on child development or child care as a setting to promote optimal development (Brauner, Gordic, & Zigler, 2004). Further, framing child care as a safety or work issue results in the public and policymakers seeing it as an individual, parental responsibility, rather than a public policy issue.
In an effort to advance child care on legislative and other public agendas, advocates hired consultants to help reframe the issue. The culmination of this work, which included extensive public opinion surveys, focus groups, and other research, was that advocates eventually reframed their issue as early childhood education (Gruendel & Aber, 2007). In particular, in line with the education frame, they began to focus on prekindergarten for 3- and 4-year-olds about to enter school. Partially as a result of these reframing efforts, the pre-k movement has taken off, with most states increasing funding for preschool, thereby increasing children’s access to these services (Clothier & Poppe, 2007).
One of the most effective frames for children’s policies is in terms of the economic benefits current investments in children will yield in the future. A RAND study (Karoly et al., 1998) provided the impetus for other analyses of how funding ECE programs would be cost-effective. These studies eventually led economists and researchers from the Minnesota Federal Reserve Bank to endorse such policies and form partnerships with early childhood programs (Early Childhood Research Collaborative, 2010).
Research on the Nurse-Family Partnership Program
One major success in linking research and policy that spans many of the issues discussed earlier in the chapter is the Nurse Family Partnership (NFP), internationally recognized as a highly effective home visiting intervention with young parents and their infants. The NFP was first developed and implemented in 1977 by David Olds, MD, a pediatrician and psychiatrist, and Harriet Kitzman, PhD, RN, FAAN, at the University of Rochester. The program partners low-income, first-time mothers with maternal and child health nurses during pregnancy and continuing until the child’s second birthday. Trusting relationships between the nurses and mothers have resulted in benefits to both mothers and children (Olds et al., 1997).
Randomized, controlled trials in Elmira, New York (1977), Memphis, Tennessee (1988), and Denver, Colorado (1994) have demonstrated impressive and sustained results, with the strongest effects on improved prenatal health and later school readiness, decreases in childhood injuries and mother’s subsequent pregnancies, and increases in maternal intervals between births and employment rates. Researchers documented other positive outcomes in at least one of the clinical trials, including reductions in child arrests at age 15, child abuse and neglect, and language delays, and improvement in achievement test scores at grades 1 to 3 among the low-resource group (Eckenrode et al., 2010).
Evaluations of the NFP and other home visitation models convinced President Barak Obama in 2009 to initiate a multibillion dollar federal program to expand nurse home visitation. A home visitation provision was included in the Affordable Care Act (ACA), the federal health care reform legislation that was enacted in March 2010. The legislation will provide $1.5 billion over 5 years to states, tribes, and territories to develop and implement one or more evidence-based Maternal, Infant, and Early Childhood Visitation models. These are excellent opportunities for nurses to become involved in advocacy and consultation at state and community levels. As an example, because of her expertise as a nurse practitioner and children’s advocate, one of the chapter authors (Kahn) was recently appointed to the New Mexico home visiting task force.
Shortcomings in Linking Research and Social Policies for Children
Although research has contributed to policy and programs on behalf of children and their families, children’s outcomes remain unsatisfactory, in many areas, including those discussed in this chapter. For example, the reframing of child care as early education and the subsequent expansion of prekindergarten has not benefited infants and toddlers. Prekindergarten expansion has also not included advocacy on workplace issues, such as parental leave policies, which could provide additional relief from parenting stress. Although the infant mortality rate in the United States has dropped significantly since 1960 (from 26.0 to 6.9 per 1000 live births), progress on this indicator has slowed since 2000 and the U.S. lags behind other industrialized countries (Annie E. Casey Foundation, 2009b). Furthermore, discrepancies exist between what research indicates is needed for healthy development and what society delivers. For example, we are not able to ensure that most children receive the quality of child care that is commensurate with brain development research findings. Nor do we ensure that all children have adequate coverage and are able to access good quality physical and mental health care.
Further, overall financial investments in programs for children are still relatively low. In 2008, only 10% of the U.S. federal budget was spent on children, compared to 38% on older adults and disabled persons (Isaacs, Vericker, Macomber, & Kent, 2009). Moreover, the percentage of federal expenditures directed toward children has actually declined over time (from 20% in 1960 to 15% in 2008). During the first 2 years of the Obama presidency (2009-2010), laws were enacted that included substantial funding increases for the Child Care and Development Block Grant, Nurse-Family Partnerships, and the Child Health Insurance Program Reauthorization Act. This infusion of funding will be an important start to improving children’s health and developmental outcomes.
Who Speaks for Children?
Gaps in linking research and policy for children prompt questions about what advocacy for children’s policies is most effective. Certainly, data, framing, and political will are essential. Additionally, it is important to consider how to widen the advocacy community involved in children’s issues. The addition of well-known economists to ECE advocacy has been tremendously valuable in garnering political support for these issues. The work of Fight Crime, Invest in Kids, a national organization focused on linking the crime enforcement community with ECE, has also been important (Cohen, 2001). Nonetheless, advocacy remains difficult because the constituents themselves—children and parents—are not easily mobilized due to the realities of their daily lives. Children from families with low socioeconomic status and from racial and ethnic minority groups are particularly disadvantaged. But being raised in a middle- or upper-income family is no guarantee of attaining good health or educational outcomes.
Political realities also figure prominently here. Historically, children and families have not been high policy priorities. Moreover, with a tight economy and limited government resources, policymakers have limited capacities to assist families with children. Also, children’s advocates compete with those representing other groups, such as older adults.
National and state nursing organizations have much untapped potential in terms of educating the public and policymakers, testifying on behalf of children and joining other coalitions. In so doing, it is important for nurses to be mindful of research and policy linkages and to keep abreast with the types of resources provided in this chapter. Nurses can synthesize research and present their own findings so as to enhance the connections between research and policy. As discussed here, though, it is important to remember that data alone cannot change policies. In advancing children’s policies, other factors are valuable such as careful framing, working with professionals from other disciplines, keeping in mind the needs of the whole child, widening the policy community, and remaining hopeful that policy change can occur.
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