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Population health and wellbeing: Identifying priority areas for Victorian children

Population health and wellbeing: Identifying priority areas for Victorian children Background: Population health information, collected using soundly-designed methodologies, is essential to inform policy, research, and intervention programs. This study aimed to derive policy- oriented recommendations for the content of a health and wellbeing population survey of children 0–12 years living in Victoria, Australia. Results: Qualitative interviews were conducted with 54 academic and policy stakeholders, selected to encompass a wide breadth of expertise in areas of public health and inter-sectoral organisations relevant to child health outcomes, including universities, government and non- government agencies across Victoria. These stakeholders were asked to provide advice on strategic priorities for child health information (data) using a structured interview technique. Their comments were summarised and the major themes were extracted. The priority areas of health and wellbeing recommended for regular collection include obesity and its determinants, pregnancy and breastfeeding, oral health, injury, social and emotional health and wellbeing, family environment, community, health service utilisation, illness, and socioeconomic position. Population policy questions for each area were identified. Conclusion: In contrast to previous population survey programs nationally and internationally, this study sought to extract contemporary policy-oriented domains for inclusion in a strategic program of child health data collection, using a stakeholder consultation process to identify key domains and policy information needs. The outcomes are a rich and relevant set of recommendations which will now be taken forward into a regular statewide child health survey program. Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:16 http://www.anzhealthpolicy.com/content/2/1/16 structural, economic, political and cultural environment Background Epidemiological child health data are an essential driver [5,7]. The National Child Health Performance Frame- for policy, advocacy, service design, health promotion and work, developed by the National Health Performance prevention programs. Such data can make population Committee, contains a set of indicators to measure trends health strengths, deficits and inequalities explicit, provide in health status, determinants of heath and the use and evidence of the influence that the social and political con- delivery of service [8,9]. Although these models are texts have on health [1] and provide evidence for important in understanding the spectrum of child health, improvement or worsening in health parameters over it is clearly not possible, and may not even be necessary, time. Data from population surveys may influence both to include all of these indicators of child health in a pop- the direction and content of policies and programs for ulation survey. The next step in developing a population government and non-government organisations, in areas survey is to prioritise the areas of child health relevant to such as education, health, transport, justice and the envi- the funders and users of population data. ronment. In designing a population health survey for chil- dren, there is a potentially exhaustive list of areas of health It is possible to apply some criteria to reduce the potential that could be examined. It is important that a) the areas list of areas. Only one epidemiological study of children's that are included reflect the changing mortality and mor- health has developed and reported criteria to prioritise bidity patterns in children and the changing environ- areas of child health. The New South Wales Child Health ments to which children are exposed and b) the results Survey [11] selected their areas of child health using the have the potential to inform policy and programs and are following criteria: 1) it is a priority for child health as doc- user-friendly. This paper will demonstrate a process of umented in a state or national child health policy docu- selecting areas of child health that meet these criteria, ment; 2) it meets the information needs of the NSW using preliminary work towards the development of a Department of Health and Area Health Services in rela- new survey on Victorian children as an example. tion to child health; 3) the information is not readily available from other sources; 4) the estimated sample size A recent review of national and international epidemio- is large enough to provide data that can be used to gener- logical studies of children's health and wellbeing demon- alise responses to the NSW population of children; 5) the strated that these studies included several different areas areas are not highly sensitive to respondents and likely to of child health such as chronic diseases, physical activity, cause failure to complete the survey. oral health, development, services, and neighbourhood and family interactions [2]. In developing a new popula- The Strategic Plan Health Gain for Children and Youth in tion survey for children, it is possible to simply apply an Central Sydney prioritised issues for children and youth existing survey to a new population. However, given that by analysing information on prevalence, severity of a con- population surveys are resource-intensive and time con- dition, community concern for the issue and efficacy of suming for families, there is an ethical obligation and available interventions [12]. Other important criteria have financial benefit for survey developers to collect only been developed for use in adult population health sur- information relevant to the specific population and the veys. According to the NSW Strategy for Population rationale for that survey. Unfortunately, there does not Health Surveillance, each area of health is considered in appear to be any standard procedure for identifying the terms of its burden (ie. incidence, prevalence, mortality, relevant areas of health for a population. A recent review years of potential life lost, hospitalisation rate), preventa- of the major national and international population sur- bility, communicability, public interest, and legislative veys of child health and wellbeing has demonstrated that requirements [13]. researchers often fail to report how they identified the rel- evant areas of child health [2]. In this paper we argue that the criterion through which all others need to be filtered is that the data have the poten- In this paper, we propose that the first step in identifying tial to inform policy and programs. It is essential that sur- the relevant areas of child health is to consider a compre- vey developers consider dissemination and uptake of hensive intersectoral approach to child health and wellbe- results, ensuring there is utility for researchers and policy- ing, and its determinants. Theoretical models of health makers alike. To address this criterion, it is recommended and development, such as the social health model [3,4], that survey developers consult with stakeholders and ecological model [5,6], Lynch's model [7], the National potential users of the data, and then apply the remaining Child Health Performance Framework [8,9] and the life- criteria. Stakeholders can provide insights on policy and course perspective [10] are useful to understand the scope program decision making, the use of data in that process of children's health. For example, the ecological model and recommendations for the best data. This paper aims proposes that children need to be considered within their to demonstrate a process by which survey developers can family, school, neighbourhood and the larger social, consult with stakeholders to determine the relevant areas Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:16 http://www.anzhealthpolicy.com/content/2/1/16 Table 1: Interview questions for stakeholders the target group and who could be invited to take part, and so on. 1) Which key areas of child health are you interested in? 2) Thinking about current policy and programs within the key area, Materials which specific aspects of children's health and wellbeing would you measure in a statewide survey? The stakeholders participated in one-on-one interviews. 3) Would your organisation use the results of a statewide survey of The interviews were semi-structured and the questions children's health than measured these aspects? If so, how? What were adapted from those included in a quasi-delphi study results are needed? for the Victorian Adolescent Health and Wellbeing Survey 4) In what format would you want to receive the results so that they were meaningful for you? [14,15]. The stakeholders provided advice on the area of child health that they have expertise in, what they thought were the most important areas of health and discussed how they would use the results (Refer to Table 1). of child health for a population survey of child health and Procedure wellbeing. The interviews with the stakeholders generally lasted between 15–45 minutes. Interviewers recorded the major Method points of the interview, and produced a summary of each Participants interview. The summaries were then sent to the interview- Fifty four key stakeholders participated in this study. The ees to correct information and/or add further informa- sample was selected to represent the areas of health and tion. Once corrected, the responses for each question were development in the National Child Health Performance entered into an Excel database and the data was coded by Framework [8,9]. The National Child Health Performance two researchers using open coding. This is the process of Framework consists of three broad groups of indicators identifying persistent words, phrases, themes or concepts health status, risk and protective factors, and services and within the data so that the underlying patterns can be interventions. Health status has four subgroups: health identified and analysed [16]. A coding framework was and wellbeing, growth and development, mortality, mor- developed and two researchers coded each of the summa- bidity and disability, and safety and security. The risk and ries using focused coding (EW, ED). Agreement on key protective factors group has three subgroups: social, cul- themes was achieved by discussion. tural and environmental factors; biological and behav- ioural factors and health knowledge. The services and Results interventions group includes health services, health pro- Fifty-four stakeholders participated in this study. Stake- grams, health promotion and intervention, intersectoral holders were asked which aspects of child health they services and community services. were interested in. As demonstrated in Table 2, their areas of interest could be mapped to the National Health Per- To identify the indicators of health status, we consulted formance Framework. The total number of areas exceeds with stakeholders with expertise in children's physical, 54, because several stakeholders indicated more than one social and emotional wellbeing, development, disability, area of interest/expertise. mental health problems, illness, oral health problems, nutrition related problems, child abuse and parental Stakeholders were also asked what aspects of child health health and wellbeing. To identify the risk and protective they would include in a population survey of Victorian factors, we consulted with stakeholders with an under- children's health and wellbeing. As several different areas standing of the impact of the physical, family, economic, of health were identified, their responses were grouped social and school environment. We also consulted with according to major themes. These include obesity and experts in the area of child diet, activity and overweight determinants, social and emotional health and wellbeing, and obesity. To identify services and interventions, we family environment, health service utilisation, illness, consulted with stakeholders with knowledge about health community, oral health, injury, pregnancy and service utilisation, maternal and child health programs, breastfeeding and socioeconomic position. Table 3 dem- community services and health promotion programs. onstrates the overarching themes, the areas that represent the themes, and the specific data that are required by the Stakeholders were selected to encompass a variety of stakeholders. organisations, including university and government departments within Victoria. The stakeholders were iden- After gaining insight into the potential for each area of tified by the authors and though literature reviews. A child health to aid policy and program decisions, the snowball technique was also used where initial respond- remaining criteria can now be applied. Based on the crite- ents were asked to suggest others whom they know are in Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:16 http://www.anzhealthpolicy.com/content/2/1/16 Table 2: Stakeholders expertise Indicators of NHPF Subgroups of NHPF Stakeholders Areas of Expertise (numbers of stakeholders) Health Status and Outcomes Life expectancy and wellbeing Child physical (4) Child social and emotional wellbeing (9) Mortality, morbidity and disability Child disability (3) Child mental health problems (5) Childhood injury (2) Child chronic illnesses (4) Risk and Protective factors Environmental factors Physical environment (2) Community environment (4) Exposure to tobacco smoke (4) Socioeconomic factors Economic environment (3) Child education (5) Parental employment (1) Community capacity Family environment (9) Social environment (7) Parental health (1) Health behaviours Health behaviours – All (2) Child physical activity (4) Child diet and nutrition (3) Child oral health behaviours (2) Sun protection (1) Vaccinations (1) Injury prevention (2) Person-related factors Birth defects (1) Health behaviours during pregnancy (ie smoking, alcohol, folate) (2) Services and Interventions Health service utilization (3) Maternal and Child Health Programs (1) Community services (1) Health promotion programs (1) Socio-demographic factors Socioeconomic position (2) Socioeconomic inequalities (2) Family structure (1) Population groups Socioeconomically disadvantaged groups (4) Rural and remote area residents (1) Overseas born (1) Indigenous Australians (1) NHPF – National Health Performance Framework ria developed for the NSW Child Health Survey and the Using these criteria, breastfeeding, development and criteria developed for the NSW Strategy for Population parenting style were excluded. Breastfeeding is already Health Surveillance, it is recommended that: being measured by maternal and child health centres and the Australian Bureau of Statistics. Although child devel- 1) The information is not being collected elsewhere (ie. opment is important, assessments of children's develop- databases, school records etc). mental status are extremely resource intensive and therefore unable to be employed in a population data 2) The question can be answered using a population collection. Parenting style was assessed by the authors to survey. be less useful for policy and program development. The remainder of the areas met the above criteria, and were 3) The domain impacts on children's mortality or therefore included. morbidity. The stakeholders indicated that the results from a child 4) The area of child health can be measured in a popula- population health survey could be used in the pursuit of tion survey (ie depending on data collection method and evidence-based policies, practice and programs, for service length). planning, for advocacy, to develop networks across com- munity, to support the generation of appropriate local 5) The data are user-friendly and the results have the responses, to develop interventions, to use in submissions potential to inform policy and programs for funding, and to use in publications. Some stakehold- Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:16 http://www.anzhealthpolicy.com/content/2/1/16 Table 3: Priority Areas of Child Health Identified by Stakeholders Themes Areas of Child Health Specific data required by stakeholders Obesity and determinants Physical activity 1) Need epidemiological data on childhood obesity, physical activity, Nutrition sedentary behaviours and nutritional intake in Victoria. Obesity 2) Need data on mediating and psychosocial variables. Social and emotional health and Social and emotional wellbeing 1) Need data on the prevalence and distribution of mental health wellbeing Behavioural problems problems. Mental health 2) Need data on the adequacy of mental health services and barriers to seeking help. Family Environment Family environment 1) Families have undergone substantial changes, and we need data on Parenting style how different family environments impact on children's health. Reading Exposure to smoking Health service utilisation Health service utilisation 1) We need data to ensure that our services are meeting the needs of the community, and ensure that people are satisfied with them. Childhood illness Chronic illness 1) Need data on the prevalence of chronic illness and disability. \par Disability Development Community Neighbourhood/Community 1) The community environment impacts on children's health; to get a complete picture of children's health, need to examine the community environment. Oral health Oral health 1) There are no population data on the oral health status of children, across this proposed age group. Injury Injury 1) Need data on the prevalence of injuries and how they are treated. 2) Need data on whether families are reducing the risk of injuries by protecting their home. Pregnancy and breastfeeding Breastfeeding 1) Need prevalence data on smoking, alcohol and folate intake during Smoking in pregnancy pregnancy. Socioeconomic position Health inequalities 1) A statewide survey of child health should include the child's socioeconomic position to examine distributional effects of health and program effectiveness. ers indicated the need to localise data and to make it more The main themes of child health tended to reflect the powerful in action terms; other stakeholders suggested changing patterns of morbidity, where there is increasing that rural/urban comparisons would be important. Stake- interest in the rising prevalence rates of obesity, mental holders suggested that the results should be available health problems, and oral health problems. The emphasis from both a representative sample and also from key on health service utilisation, disability and chronic illness minority groups such as Indigenous children. The results is reflective of the costs that such children impose on the should also contain some comparable measures to other health care system. The emphasis on family health, expo- work done elsewhere. sure to tobacco smoke, community and socioeconomic position is indicative of the more recent emphasis placed Discussion on the wider community environment and influences, This study demonstrated the process by which areas of and recognition that children's environments have child health can be identified and prioritised for a popu- changed profoundly. In terms of the specific data that the lation study of health and wellbeing. Conducting qualita- stakeholders recommended for each area of health, there tive interviews with stakeholders is a useful and efficient was a clear need for prevalence data and also for establish- method to identify current issues in a specific area, and to ing and modelling the determinants of child health. provide exposure to significant research papers and unpublished research. The areas of child health that were The areas of child health that emerged from the interviews identified in this study are not only useful in developing a are consistent with the stakeholders' areas of expertise. population survey of child health and wellbeing for Victo- Although it seems likely that the exact sample of stake- rian children, they are also useful for researchers and prac- holders will always influence the areas of child health that titioners in the field of child health, in terms of guiding are identified, the selection of these stakeholders was research, policy and program development. based on the National Child Health Performance Frame- work, an acceptable indicator framework. Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:16 http://www.anzhealthpolicy.com/content/2/1/16 In terms of the process by which researchers determine the the data for themes. All authors read and approved the priority areas of child health, we recommend that survey final manuscript. developers utilise a model of health and development, such as the National Child Health Performance Frame- Acknowledgements We would like to thank all of the stakeholders who participated in this work, to identify the possible areas of child health. To pri- study; and the specific funding provided by the Victorian Health Promotion oritise areas, it is recommended that survey developers Foundation for the study and the Public Health Research Fellowship consult with relevant stakeholders to ensure that the data awarded to EW. are user-friendly and the results have the potential to inform policy and programs. The selection of the stake- References holders' areas of expertise should be consistent with a 1. Doran T, Whitehead M: Do social policies and political context selected theory or framework of health. The areas of child matter for health in the United Kingdom? Int J Health Services 2003, 33:495-522. health identified by the stakeholders can be further 2. Maher E, Waters E, Wake M, Goldfeld S, Williams J, Oberklaid F: A prioritised using the proposed criteria, which are based on review of epidemiological studies on children's health and wellbeing. Australasian Epidemiologist 2003, 10:4-8. the NSW Strategy for Population Health Surveillance. 3. Learmonth G: The Health of Nations. , Open University Press: Milton Keynes; 1985. Limitations 4. Najman JM: A general model of the social origins of health and well-being. In The Social Origins of Health and Well-being Edited by: This study has limitations in its sampling methodology. Eckersley R, Dixon J and Douglas B. United Kingdom, Cambridge Uni- The stakeholders were identified by the authors and versity Press; 2001:73-83. through the use of snowballing. This methodology does 5. Bronfenbrenner U: The Ecology of Human Development: Experiments by Nature and Design. , Harvard University Press; have potential for selection bias and thus may limit gen- eralisability of results. Given that the stakeholders were 6. Turrell G, Oldenburg B, McGuffog I, Dent R: Socioeconomic sta- tus and heath: towards a national research program and a selected to ensure that there were representatives from all policy and intervention agenda. Queensland, Queensland Uni- areas of health, selective sampling was necessary. versity of Technology School of Public Health; 1999. 7. Lynch J: Social epidemiology: Some observations about the past, present and future. Australasian Epidemiologist 2000, 7:7-15. A further issue for discussion is the inclusion of children 8. Moon L, Rahman N, Bhatia K: Australia’s children: their health in such a study. Increasingly there is recognition that chil- and wellbeing 1998. AIHW Cat. No. PHE 7. Canberra, Austral- ian Institute of Health and Welfare; 1998. dren and parents need to be included in program plan- 9. Al-Yaman F, Bryant M, Sargeant H: Australia's children: Their ning and policy development. Given the format of the health and wellbeing 2002. Cat No PHE 36. Canberra, Austral- questions and the aim of this study, children's and par- ian Institute of Health and Welfare; 2002. 10. Ben-Shlomo Y, Kuh D: A life course approach to chronic dis- ent's perspectives were not obtained. It is recommended ease epidemiology: Conceptual models, empirical chal- that when the questionnaire is established and parents lenges and interdisciplinary perspectives. Int J Epidemiol 2002, and children can understand what is being measured, they 31:285-293. 11. Centre for Epidemiology and Research New South Wales Depart- should be consulted about the areas of health that are ment of Health: New South Wales Child Health Survey. NSW included in a population survey. This process is currently Public Health Bull 2002, 13:1-84. 12. Alperstein G, Thomson J, Crawford J: Strategic Plan: Health Gain being undertaken with a diverse group of parents and for Children and Youth of Central Sydney. Sydney, Health children. Services Planning Unit and Division of Population Health, Central Syd- ney Area Health Service; 1997. 13. New South Wales Health: Strategy for Population Health Sur- Conclusion veillance in New South Wales: Discussion Paper Publication Population child health data is important for informing No. (ESB) 970147. NSW, NSW Health; 1997. policies, programs and services in a range of sectors. How- 14. Centre for Adolescent Health: Investigating the feasibility of conducting a National Longitudinal Study of the Health and ever, the process by which researchers determine the pri- Wellbeing of Young Australians: Report for the workshop. ority areas of child health remains largely un-defined. The Melbourne, Centre for Adolescent Health; 2001. 15. Bond L, Thomas L, Toumbourou J, Patton G, Catalan R: Improving phases of this study included a rigorous research process, the lives of young Victorians in our community: A survey of including qualitative interviews with stakeholders in the risk and protective factors. Melbourne, Centre for Adolescent area of child health. Health; 2000. 16. Coffey A, Atkinson P: Making sense of qualitative data: Com- plementary Research Strategies. Thousand Okays, CA, Sage; Competing interests The author(s) declare that they have no competing interests. Authors' contributions All authors made substantial contribution to the concep- tion, design, analysis and interpretation of data. ED and JW conducted the data collection. ED and EW analysed Page 6 of 6 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Population health and wellbeing: Identifying priority areas for Victorian children

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Springer Journals
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Copyright © 2005 by Davis et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Social Policy
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1743-8462
DOI
10.1186/1743-8462-2-16
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16029511
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Abstract

Background: Population health information, collected using soundly-designed methodologies, is essential to inform policy, research, and intervention programs. This study aimed to derive policy- oriented recommendations for the content of a health and wellbeing population survey of children 0–12 years living in Victoria, Australia. Results: Qualitative interviews were conducted with 54 academic and policy stakeholders, selected to encompass a wide breadth of expertise in areas of public health and inter-sectoral organisations relevant to child health outcomes, including universities, government and non- government agencies across Victoria. These stakeholders were asked to provide advice on strategic priorities for child health information (data) using a structured interview technique. Their comments were summarised and the major themes were extracted. The priority areas of health and wellbeing recommended for regular collection include obesity and its determinants, pregnancy and breastfeeding, oral health, injury, social and emotional health and wellbeing, family environment, community, health service utilisation, illness, and socioeconomic position. Population policy questions for each area were identified. Conclusion: In contrast to previous population survey programs nationally and internationally, this study sought to extract contemporary policy-oriented domains for inclusion in a strategic program of child health data collection, using a stakeholder consultation process to identify key domains and policy information needs. The outcomes are a rich and relevant set of recommendations which will now be taken forward into a regular statewide child health survey program. Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:16 http://www.anzhealthpolicy.com/content/2/1/16 structural, economic, political and cultural environment Background Epidemiological child health data are an essential driver [5,7]. The National Child Health Performance Frame- for policy, advocacy, service design, health promotion and work, developed by the National Health Performance prevention programs. Such data can make population Committee, contains a set of indicators to measure trends health strengths, deficits and inequalities explicit, provide in health status, determinants of heath and the use and evidence of the influence that the social and political con- delivery of service [8,9]. Although these models are texts have on health [1] and provide evidence for important in understanding the spectrum of child health, improvement or worsening in health parameters over it is clearly not possible, and may not even be necessary, time. Data from population surveys may influence both to include all of these indicators of child health in a pop- the direction and content of policies and programs for ulation survey. The next step in developing a population government and non-government organisations, in areas survey is to prioritise the areas of child health relevant to such as education, health, transport, justice and the envi- the funders and users of population data. ronment. In designing a population health survey for chil- dren, there is a potentially exhaustive list of areas of health It is possible to apply some criteria to reduce the potential that could be examined. It is important that a) the areas list of areas. Only one epidemiological study of children's that are included reflect the changing mortality and mor- health has developed and reported criteria to prioritise bidity patterns in children and the changing environ- areas of child health. The New South Wales Child Health ments to which children are exposed and b) the results Survey [11] selected their areas of child health using the have the potential to inform policy and programs and are following criteria: 1) it is a priority for child health as doc- user-friendly. This paper will demonstrate a process of umented in a state or national child health policy docu- selecting areas of child health that meet these criteria, ment; 2) it meets the information needs of the NSW using preliminary work towards the development of a Department of Health and Area Health Services in rela- new survey on Victorian children as an example. tion to child health; 3) the information is not readily available from other sources; 4) the estimated sample size A recent review of national and international epidemio- is large enough to provide data that can be used to gener- logical studies of children's health and wellbeing demon- alise responses to the NSW population of children; 5) the strated that these studies included several different areas areas are not highly sensitive to respondents and likely to of child health such as chronic diseases, physical activity, cause failure to complete the survey. oral health, development, services, and neighbourhood and family interactions [2]. In developing a new popula- The Strategic Plan Health Gain for Children and Youth in tion survey for children, it is possible to simply apply an Central Sydney prioritised issues for children and youth existing survey to a new population. However, given that by analysing information on prevalence, severity of a con- population surveys are resource-intensive and time con- dition, community concern for the issue and efficacy of suming for families, there is an ethical obligation and available interventions [12]. Other important criteria have financial benefit for survey developers to collect only been developed for use in adult population health sur- information relevant to the specific population and the veys. According to the NSW Strategy for Population rationale for that survey. Unfortunately, there does not Health Surveillance, each area of health is considered in appear to be any standard procedure for identifying the terms of its burden (ie. incidence, prevalence, mortality, relevant areas of health for a population. A recent review years of potential life lost, hospitalisation rate), preventa- of the major national and international population sur- bility, communicability, public interest, and legislative veys of child health and wellbeing has demonstrated that requirements [13]. researchers often fail to report how they identified the rel- evant areas of child health [2]. In this paper we argue that the criterion through which all others need to be filtered is that the data have the poten- In this paper, we propose that the first step in identifying tial to inform policy and programs. It is essential that sur- the relevant areas of child health is to consider a compre- vey developers consider dissemination and uptake of hensive intersectoral approach to child health and wellbe- results, ensuring there is utility for researchers and policy- ing, and its determinants. Theoretical models of health makers alike. To address this criterion, it is recommended and development, such as the social health model [3,4], that survey developers consult with stakeholders and ecological model [5,6], Lynch's model [7], the National potential users of the data, and then apply the remaining Child Health Performance Framework [8,9] and the life- criteria. Stakeholders can provide insights on policy and course perspective [10] are useful to understand the scope program decision making, the use of data in that process of children's health. For example, the ecological model and recommendations for the best data. This paper aims proposes that children need to be considered within their to demonstrate a process by which survey developers can family, school, neighbourhood and the larger social, consult with stakeholders to determine the relevant areas Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:16 http://www.anzhealthpolicy.com/content/2/1/16 Table 1: Interview questions for stakeholders the target group and who could be invited to take part, and so on. 1) Which key areas of child health are you interested in? 2) Thinking about current policy and programs within the key area, Materials which specific aspects of children's health and wellbeing would you measure in a statewide survey? The stakeholders participated in one-on-one interviews. 3) Would your organisation use the results of a statewide survey of The interviews were semi-structured and the questions children's health than measured these aspects? If so, how? What were adapted from those included in a quasi-delphi study results are needed? for the Victorian Adolescent Health and Wellbeing Survey 4) In what format would you want to receive the results so that they were meaningful for you? [14,15]. The stakeholders provided advice on the area of child health that they have expertise in, what they thought were the most important areas of health and discussed how they would use the results (Refer to Table 1). of child health for a population survey of child health and Procedure wellbeing. The interviews with the stakeholders generally lasted between 15–45 minutes. Interviewers recorded the major Method points of the interview, and produced a summary of each Participants interview. The summaries were then sent to the interview- Fifty four key stakeholders participated in this study. The ees to correct information and/or add further informa- sample was selected to represent the areas of health and tion. Once corrected, the responses for each question were development in the National Child Health Performance entered into an Excel database and the data was coded by Framework [8,9]. The National Child Health Performance two researchers using open coding. This is the process of Framework consists of three broad groups of indicators identifying persistent words, phrases, themes or concepts health status, risk and protective factors, and services and within the data so that the underlying patterns can be interventions. Health status has four subgroups: health identified and analysed [16]. A coding framework was and wellbeing, growth and development, mortality, mor- developed and two researchers coded each of the summa- bidity and disability, and safety and security. The risk and ries using focused coding (EW, ED). Agreement on key protective factors group has three subgroups: social, cul- themes was achieved by discussion. tural and environmental factors; biological and behav- ioural factors and health knowledge. The services and Results interventions group includes health services, health pro- Fifty-four stakeholders participated in this study. Stake- grams, health promotion and intervention, intersectoral holders were asked which aspects of child health they services and community services. were interested in. As demonstrated in Table 2, their areas of interest could be mapped to the National Health Per- To identify the indicators of health status, we consulted formance Framework. The total number of areas exceeds with stakeholders with expertise in children's physical, 54, because several stakeholders indicated more than one social and emotional wellbeing, development, disability, area of interest/expertise. mental health problems, illness, oral health problems, nutrition related problems, child abuse and parental Stakeholders were also asked what aspects of child health health and wellbeing. To identify the risk and protective they would include in a population survey of Victorian factors, we consulted with stakeholders with an under- children's health and wellbeing. As several different areas standing of the impact of the physical, family, economic, of health were identified, their responses were grouped social and school environment. We also consulted with according to major themes. These include obesity and experts in the area of child diet, activity and overweight determinants, social and emotional health and wellbeing, and obesity. To identify services and interventions, we family environment, health service utilisation, illness, consulted with stakeholders with knowledge about health community, oral health, injury, pregnancy and service utilisation, maternal and child health programs, breastfeeding and socioeconomic position. Table 3 dem- community services and health promotion programs. onstrates the overarching themes, the areas that represent the themes, and the specific data that are required by the Stakeholders were selected to encompass a variety of stakeholders. organisations, including university and government departments within Victoria. The stakeholders were iden- After gaining insight into the potential for each area of tified by the authors and though literature reviews. A child health to aid policy and program decisions, the snowball technique was also used where initial respond- remaining criteria can now be applied. Based on the crite- ents were asked to suggest others whom they know are in Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:16 http://www.anzhealthpolicy.com/content/2/1/16 Table 2: Stakeholders expertise Indicators of NHPF Subgroups of NHPF Stakeholders Areas of Expertise (numbers of stakeholders) Health Status and Outcomes Life expectancy and wellbeing Child physical (4) Child social and emotional wellbeing (9) Mortality, morbidity and disability Child disability (3) Child mental health problems (5) Childhood injury (2) Child chronic illnesses (4) Risk and Protective factors Environmental factors Physical environment (2) Community environment (4) Exposure to tobacco smoke (4) Socioeconomic factors Economic environment (3) Child education (5) Parental employment (1) Community capacity Family environment (9) Social environment (7) Parental health (1) Health behaviours Health behaviours – All (2) Child physical activity (4) Child diet and nutrition (3) Child oral health behaviours (2) Sun protection (1) Vaccinations (1) Injury prevention (2) Person-related factors Birth defects (1) Health behaviours during pregnancy (ie smoking, alcohol, folate) (2) Services and Interventions Health service utilization (3) Maternal and Child Health Programs (1) Community services (1) Health promotion programs (1) Socio-demographic factors Socioeconomic position (2) Socioeconomic inequalities (2) Family structure (1) Population groups Socioeconomically disadvantaged groups (4) Rural and remote area residents (1) Overseas born (1) Indigenous Australians (1) NHPF – National Health Performance Framework ria developed for the NSW Child Health Survey and the Using these criteria, breastfeeding, development and criteria developed for the NSW Strategy for Population parenting style were excluded. Breastfeeding is already Health Surveillance, it is recommended that: being measured by maternal and child health centres and the Australian Bureau of Statistics. Although child devel- 1) The information is not being collected elsewhere (ie. opment is important, assessments of children's develop- databases, school records etc). mental status are extremely resource intensive and therefore unable to be employed in a population data 2) The question can be answered using a population collection. Parenting style was assessed by the authors to survey. be less useful for policy and program development. The remainder of the areas met the above criteria, and were 3) The domain impacts on children's mortality or therefore included. morbidity. The stakeholders indicated that the results from a child 4) The area of child health can be measured in a popula- population health survey could be used in the pursuit of tion survey (ie depending on data collection method and evidence-based policies, practice and programs, for service length). planning, for advocacy, to develop networks across com- munity, to support the generation of appropriate local 5) The data are user-friendly and the results have the responses, to develop interventions, to use in submissions potential to inform policy and programs for funding, and to use in publications. Some stakehold- Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:16 http://www.anzhealthpolicy.com/content/2/1/16 Table 3: Priority Areas of Child Health Identified by Stakeholders Themes Areas of Child Health Specific data required by stakeholders Obesity and determinants Physical activity 1) Need epidemiological data on childhood obesity, physical activity, Nutrition sedentary behaviours and nutritional intake in Victoria. Obesity 2) Need data on mediating and psychosocial variables. Social and emotional health and Social and emotional wellbeing 1) Need data on the prevalence and distribution of mental health wellbeing Behavioural problems problems. Mental health 2) Need data on the adequacy of mental health services and barriers to seeking help. Family Environment Family environment 1) Families have undergone substantial changes, and we need data on Parenting style how different family environments impact on children's health. Reading Exposure to smoking Health service utilisation Health service utilisation 1) We need data to ensure that our services are meeting the needs of the community, and ensure that people are satisfied with them. Childhood illness Chronic illness 1) Need data on the prevalence of chronic illness and disability. \par Disability Development Community Neighbourhood/Community 1) The community environment impacts on children's health; to get a complete picture of children's health, need to examine the community environment. Oral health Oral health 1) There are no population data on the oral health status of children, across this proposed age group. Injury Injury 1) Need data on the prevalence of injuries and how they are treated. 2) Need data on whether families are reducing the risk of injuries by protecting their home. Pregnancy and breastfeeding Breastfeeding 1) Need prevalence data on smoking, alcohol and folate intake during Smoking in pregnancy pregnancy. Socioeconomic position Health inequalities 1) A statewide survey of child health should include the child's socioeconomic position to examine distributional effects of health and program effectiveness. ers indicated the need to localise data and to make it more The main themes of child health tended to reflect the powerful in action terms; other stakeholders suggested changing patterns of morbidity, where there is increasing that rural/urban comparisons would be important. Stake- interest in the rising prevalence rates of obesity, mental holders suggested that the results should be available health problems, and oral health problems. The emphasis from both a representative sample and also from key on health service utilisation, disability and chronic illness minority groups such as Indigenous children. The results is reflective of the costs that such children impose on the should also contain some comparable measures to other health care system. The emphasis on family health, expo- work done elsewhere. sure to tobacco smoke, community and socioeconomic position is indicative of the more recent emphasis placed Discussion on the wider community environment and influences, This study demonstrated the process by which areas of and recognition that children's environments have child health can be identified and prioritised for a popu- changed profoundly. In terms of the specific data that the lation study of health and wellbeing. Conducting qualita- stakeholders recommended for each area of health, there tive interviews with stakeholders is a useful and efficient was a clear need for prevalence data and also for establish- method to identify current issues in a specific area, and to ing and modelling the determinants of child health. provide exposure to significant research papers and unpublished research. The areas of child health that were The areas of child health that emerged from the interviews identified in this study are not only useful in developing a are consistent with the stakeholders' areas of expertise. population survey of child health and wellbeing for Victo- Although it seems likely that the exact sample of stake- rian children, they are also useful for researchers and prac- holders will always influence the areas of child health that titioners in the field of child health, in terms of guiding are identified, the selection of these stakeholders was research, policy and program development. based on the National Child Health Performance Frame- work, an acceptable indicator framework. Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:16 http://www.anzhealthpolicy.com/content/2/1/16 In terms of the process by which researchers determine the the data for themes. All authors read and approved the priority areas of child health, we recommend that survey final manuscript. developers utilise a model of health and development, such as the National Child Health Performance Frame- Acknowledgements We would like to thank all of the stakeholders who participated in this work, to identify the possible areas of child health. To pri- study; and the specific funding provided by the Victorian Health Promotion oritise areas, it is recommended that survey developers Foundation for the study and the Public Health Research Fellowship consult with relevant stakeholders to ensure that the data awarded to EW. are user-friendly and the results have the potential to inform policy and programs. The selection of the stake- References holders' areas of expertise should be consistent with a 1. Doran T, Whitehead M: Do social policies and political context selected theory or framework of health. The areas of child matter for health in the United Kingdom? Int J Health Services 2003, 33:495-522. health identified by the stakeholders can be further 2. Maher E, Waters E, Wake M, Goldfeld S, Williams J, Oberklaid F: A prioritised using the proposed criteria, which are based on review of epidemiological studies on children's health and wellbeing. Australasian Epidemiologist 2003, 10:4-8. the NSW Strategy for Population Health Surveillance. 3. Learmonth G: The Health of Nations. , Open University Press: Milton Keynes; 1985. Limitations 4. Najman JM: A general model of the social origins of health and well-being. In The Social Origins of Health and Well-being Edited by: This study has limitations in its sampling methodology. Eckersley R, Dixon J and Douglas B. United Kingdom, Cambridge Uni- The stakeholders were identified by the authors and versity Press; 2001:73-83. through the use of snowballing. This methodology does 5. Bronfenbrenner U: The Ecology of Human Development: Experiments by Nature and Design. , Harvard University Press; have potential for selection bias and thus may limit gen- eralisability of results. Given that the stakeholders were 6. Turrell G, Oldenburg B, McGuffog I, Dent R: Socioeconomic sta- tus and heath: towards a national research program and a selected to ensure that there were representatives from all policy and intervention agenda. Queensland, Queensland Uni- areas of health, selective sampling was necessary. versity of Technology School of Public Health; 1999. 7. Lynch J: Social epidemiology: Some observations about the past, present and future. Australasian Epidemiologist 2000, 7:7-15. A further issue for discussion is the inclusion of children 8. Moon L, Rahman N, Bhatia K: Australia’s children: their health in such a study. Increasingly there is recognition that chil- and wellbeing 1998. AIHW Cat. No. PHE 7. Canberra, Austral- ian Institute of Health and Welfare; 1998. dren and parents need to be included in program plan- 9. Al-Yaman F, Bryant M, Sargeant H: Australia's children: Their ning and policy development. Given the format of the health and wellbeing 2002. Cat No PHE 36. Canberra, Austral- questions and the aim of this study, children's and par- ian Institute of Health and Welfare; 2002. 10. Ben-Shlomo Y, Kuh D: A life course approach to chronic dis- ent's perspectives were not obtained. It is recommended ease epidemiology: Conceptual models, empirical chal- that when the questionnaire is established and parents lenges and interdisciplinary perspectives. Int J Epidemiol 2002, and children can understand what is being measured, they 31:285-293. 11. Centre for Epidemiology and Research New South Wales Depart- should be consulted about the areas of health that are ment of Health: New South Wales Child Health Survey. NSW included in a population survey. This process is currently Public Health Bull 2002, 13:1-84. 12. Alperstein G, Thomson J, Crawford J: Strategic Plan: Health Gain being undertaken with a diverse group of parents and for Children and Youth of Central Sydney. Sydney, Health children. Services Planning Unit and Division of Population Health, Central Syd- ney Area Health Service; 1997. 13. New South Wales Health: Strategy for Population Health Sur- Conclusion veillance in New South Wales: Discussion Paper Publication Population child health data is important for informing No. (ESB) 970147. NSW, NSW Health; 1997. policies, programs and services in a range of sectors. How- 14. Centre for Adolescent Health: Investigating the feasibility of conducting a National Longitudinal Study of the Health and ever, the process by which researchers determine the pri- Wellbeing of Young Australians: Report for the workshop. ority areas of child health remains largely un-defined. The Melbourne, Centre for Adolescent Health; 2001. 15. Bond L, Thomas L, Toumbourou J, Patton G, Catalan R: Improving phases of this study included a rigorous research process, the lives of young Victorians in our community: A survey of including qualitative interviews with stakeholders in the risk and protective factors. Melbourne, Centre for Adolescent area of child health. Health; 2000. 16. Coffey A, Atkinson P: Making sense of qualitative data: Com- plementary Research Strategies. Thousand Okays, CA, Sage; Competing interests The author(s) declare that they have no competing interests. Authors' contributions All authors made substantial contribution to the concep- tion, design, analysis and interpretation of data. ED and JW conducted the data collection. ED and EW analysed Page 6 of 6 (page number not for citation purposes)

Journal

Australia and New Zealand Health PolicySpringer Journals

Published: Jul 20, 2005

References