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Children’s Health

Abstract and Keywords

The history of social work is deeply rooted in helping vulnerable populations improve their well-being, and children have been at the forefront of these efforts since the inception of the profession. Health is long understood to be critical to children’s well-being. Social workers who are skilled in integrating different systems can play pivotal roles in engineering new and improving existing health-care infrastructures and can act as advocates for fusing health-service systems with other social infrastructures to optimize outcomes for children. This entry reviews trends in children’s health throughout the world, particularly in the United States. It describes the dramatic improvements in reducing infant mortality, child mortality and morbidity from many infectious diseases as well as accidental and environmental causes, and the unequal progress in realizing children’s health. The challenges that lie ahead that pose risks to children’s health are discussed, including the health inequities created among and within countries by social, economic, and political factors. An argument for a comprehensive, integrated, evidence-based, and cross-disciplinary approach to improve children’s future health is presented.

Keywords: children’s health, developing countries, health, industrialized countries, United States, trends

Traditionally, health is defined as the absence of illness or disease, but more recent approaches use positive indicators of well-being and go beyond biomedical factors by incorporating multidimensional, socioecological perspectives of health (World Health Organization (WHO), 2012). Health is no longer understood from a cause-and-effect disease perspective alone. Health is more commonly understood to be the result of complex interactions and influences from biological, social, behavioral, and physical environments. In this entry, we explore the definitions of children’s health and its implications; trends in children’s health in the United States, other industrialized countries, and around the world; and the risks to children’s health.

Like the health of the general population, children’s health is an indication of the well-being of a society comparatively, at a particular point in time and over time. Societies tend to value the health of children in the present as well as for children’s potential. Trends in children’s health create expectations for the future and suggest a society’s future capabilities. Evidence suggests that children who have healthy childhoods are likely to be healthy and productive as adults, and children whose health is compromised are likely to have diminished opportunities as adults (Currie, 2009; WHO & United Nations Children’s Fund (UNICEF), 2012). We know too that factors impeding or enhancing adult health may also affect children, but perhaps differently than adults. For example, unsafe drinking water and poor sanitation will affect both adults and children but are more likely to threaten the survival of children. Unclean water and sanitation are closely linked to respiratory and diarrheal diseases—the two major causes of death for children under age 5 in the global south (Levine et al., 2011).

There is also powerful evidence that childhood deprivation and prolonged stressful experiences can have lifelong effects on children’s physical, social, emotional, and neurological development (Meaney, 2001; Shonkoff and Phillips, 2000) as well as on physical and mental well-being later in life (McEwen, 2003). Stunting, for example, which affects 200 million children, is nearly irreversible after a child is 2 years old, and stunted children demonstrate reduced work capacity and higher susceptibility to disease in childhood and risk during childbirth (UNICEF, 2005). Likewise, children with iron and iodine deficiencies perform more poorly in school than children who do not have these deficiencies and are more likely to have less productive livelihoods as adults (Grantham-McGregor et al., 2007; Samson et al., 2008).

Defining Health

At its initiation, the WHO officially defined health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1948). This official WHO definition has not been amended since its introduction in 1948. Some have argued that this definition of health confuses health with happiness, with health being a human right and happiness being a state of mind (Saracci, 1997). Others have argued that we increasingly confuse health with the broader concept of well-being (Üstün & Jakob, 2005). In practice, however, public approaches to health increasingly consist of a multidimensional view of health and incorporate the underlying social, political, and economic determinants of health problems that have created health inequities among and within countries and regions (Rowson, Willot, et al., 2012).

Efforts to improve health most often include addressing unequal access to health services, immunizations, medication, safe drinking water, education, and information (which most often disproportionately affect low-income or socially excluded groups); improving sanitation facilities; reducing exposure to toxic environments and contaminants; and regulating food, alcohol, and tobacco intake. Our understanding of the factors contributing to and hindering health, as well as the ways in which we can prevent disease, has deepened and widened over time. Our highly mobile, interdependent, and interconnected world has also made clear the global nature of health. In the early twenty-first century myriad opportunities exist for the rapid spread of infectious diseases and radionuclear and toxic threats. Infectious diseases are not only spreading faster (the WHO identifies 1,100 epidemic events worldwide from 2005 to 2010), but also appear to be emerging more quickly than ever before. Each year since the 1970s, newly emerging diseases have been identified at the unprecedented rate of one or more per year (WHO, 2009).

Most conceptualizations of health have been developed for adults and do not reflect the salient and consequential effects of health during childhood (National Research Council (NRC) & Institute of Medicine, 2004). Children’s health during childhood can have profound implications for their physical and mental-health trajectories throughout life. The health experiences at each stage in life affect health opportunities at sequential stages, and for children in the United States and in developed and developing countries, that has resulted in wide disparities over time within and among countries (Keating & Hertzman, 1999). The rapid development that occurs during childhood creates changing health needs at different stages of development (NRC & Institute of Medicine, 2004). The challenges in measuring the health of children are complicated by the interaction of development with the lag time between the time the intervention is introduced and when it is later measured.

The NRC offers this definition of children’s health, which is more future oriented and places greater emphasis on the role of the environment than the above WHO definition:

Children’s health should be defined as the extent to which an individual child or groups of children are able or enabled to: a) develop and realize their potential; b) satisfy their needs; and c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments. (NRC & Institute of Medicine, 2004)

It can be difficult to differentiate the factors influencing children’s health and the health of children; for example, nutrition, genetics, and toxins all affect and modify children’s health. The factors that impede, protect, and promote children’s health are discussed in a later section.

Trends in Children’s Health

Since 1990 worldwide there have been dramatic improvements in reducing infant mortality, reducing child mortality and morbidity from many infectious diseases and accidental causes, increasing access to health care, and reducing environmental contaminants. The improvement in children’s health status around the world since the 1990s is striking, but far too many children continue to suffer from preventable disease and illness. Nor are the gains we have made distributed equally globally, regionally, within countries, and even within households. Where a child is born significantly influences his or her chances for survival and health throughout life (WHO & UNICEF, 2012).

The improvements came about through a combination of vaccination programs, nutrition programs, and better water and sanitation that to a certain degree was motivated by the global commitment to the Millennium Development goals (MDG) to be achieved by 2015. Four of the eight MDGs directly relate to health and all four are key to improving children’s health in developing countries. The four health-related MDGs are as follows:

  1. 1. Eradicate extreme poverty and hunger:

    • Reduce by half the proportion of people who suffer from hunger.

  2. 2. Reduce child mortality:

    • Reduce by two thirds the mortality rate among children under 5.

  3. 3. Improve maternal health:

    • Reduce by three quarters the maternal mortality ratio.

  4. 4. Combat HIV/AIDS, malaria, and other diseases:

    • Halt and begin to reverse the spread of HIV/AIDS;

    • Halt and begin to reverse the incidence of malaria and other major diseases.

Many countries are expected to achieve the health-related MDGs by 2015, whereas in other countries the rate of progress has been limited because of conflict, poor governance, economic or humanitarian crises, and lack of resources, some of which can be attributed to the effects of the global food, energy, financial, and economic crises on health. The progress on each of the four health-related MDGs as it relates to children is summarized below.

Impeding the realization of the MDG goal to halve the proportion of people who suffer from hunger was the rise in food prices and fall in incomes since 2008, and this has disproportionately affected children (Christian, 2010). Children whose nutrition is severely impaired are likely to be underweight (that is, weigh below minus two standard deviations from the median weight for the age of the reference population) or stunted (that is, height below minus two standard deviations from the median height for the age of the reference population). The percentage of children under 5 years of age who are underweight declined globally from 25% in 1990 to 16% in 2010 (104 million children) and stunting in children under 5 years of age decreased from 40 to 27% over the same period. In Asia, the number of stunted children was nearly halved between 1990 (190 million) and 2010 (100 million); however, in sub-Saharan Africa the number of stunted children increased from 45 million in 1990 to 60 million in 2010.

Worldwide, children in the poorest fifth of all households are almost three times more likely to be underweight than children in the wealthiest 20% of the households, with the greatest disparity among children in south Asia. So although there is progress, it is uneven regionally, within countries, and among households according to income.

Considerable progress is evident toward achieving the MDG goal to reduce child mortality (under age 5) by two thirds, although it is unlikely to be fully realized by 2015. Progress is uneven across regions and within countries. Since 1990 the global under-5 mortality rate has dropped 41%—from 87 deaths per 1,000 live births in 1990 to 51 in 2011 (UNICEF, 2012). And although 6.9 million children died worldwide before the age of 5 in 2011, this number is down from nearly 12 million in 1990 (WHO & UNICEF, 2012). The leading causes of death among children under age 5 are pneumonia (18% of all under-5 deaths), diarrhea (15%), preterm birth complications (12%), complications during birth (9%), and malaria (7%). More than a third of under-5 deaths around the world are attributable to undernutrition.

Five of nine developing regions show reductions in under-5 mortality of more than 50% from 1990 through 2010. Northern Africa already achieved this MDG goal and eastern Asia is close, but progress is slower than needed to achieve the MDG goal in south Asia and sub-Saharan African, the two regions that account for 82% of young child deaths in the world (United Nations (UN), 2012).

Sub-Saharan Africa continues to have the highest child mortality rates—children born in sub-Saharan Africa are 17 times more likely to die before their fifth birthday than children born in developed regions of the world and children born in south Asia are not far behind (WHO & UNICEF, 2012). Nearly half of all child mortalities occur in India (22%), Nigeria (11%), Republic of the Congo, Pakistan, and China and the majority of neonatal deaths (within the first month of life) occur in these countries (You, Jones & Wardlaw, 2012). All but 1% of neonatal deaths occur in developing countries (WHO & UNICEF, 2012).

As under-5 mortality rates fall, neonatal rates consume a larger share of child deaths, increasing from about 37% in 1990 to slightly above 40% in 2010, a trend that is expected to continue. Infant death rates are the highest in sub-Saharan Africa and in south Asia (UN, 2012).

Children in rural areas and children in the poorest households are most likely to die before the age of 5. Rural–urban disparities are the most pronounced in northern Africa and western Asia, eastern and southeastern Asia (excluding China), and Latin America and the Caribbean (where overall child mortality is quite low). Children from the poorest 20% of households also are nearly twice as likely to die before their fifth birthday as children in the richest fifth of households (UN, 2012). In all regions, children’s rates of survival are improved when mothers had at least a primary-school education (UN, 2012).

The health of infants and young children is closely associated with the health of pregnant women. Prenatal care for pregnant women that includes screening for conditions such as periodontal disease, obesity, and depression can lessen increased risk for preterm births, low birth weight, preeclampsia, miscarriage, and poor physical and socioemotional development of infants (Roberts, Bellinger, & McCormick, 2007; Sibai, Dekker, & Kupferminc, 2005). Women who do not receive pregnancy-related health services are more likely to suffer health problems and have a higher risk of dying as a result of pregnancy or childbirth. Worldwide, a woman dies from pregnancy- or childbirth-related complications every 2 minutes (a 50% decrease since the 1990s) and women in developing countries are 15 times more likely to die of birth- or pregnancy-related complications than women in developed countries (WHO & UNICEF, 2012). For every woman who dies as the result of a pregnancy or childbirth complication, approximately 20 others suffer injuries, infection, and disabilities (WHO & UNICEF, 2012).

Maternal mortality is defined as the death of a woman during pregnancy or childbirth or within 42 days of delivery (UN, 2012). Maternal mortality fell by 47% since 1990, but the rate of progress will not result in the attainment of the 2015 MDG target. Reducing maternal mortality is a critical issue for the poorest parts of the world, including sub-Saharan Africa, where 1 in 6 women dies as a result of pregnancy or childbirth compared with 1 in 30,000 in northern Europe (Ronsmans & Graham, 2006).

In 2010, of the estimated 287,000 maternal deaths worldwide, 56% took place in sub-Saharan Africa and another 29% were in southern Asia (UN, 2012). Maternal deaths are generally related to poor nutrition, early child bearing, and health care and are also attributed to disease, such as HIV. Sub-Saharan Africa has the largest proportion of maternal deaths attributed to HIV (91% of all AIDS-related maternal deaths worldwide) (WHO, 2012). Although the causes of maternal mortality are well known and preventable, a significant geographical disparity persists because of gaps in care in countries that have limited financial and human resources (Prata, Passano, Sreenivas, & Gerdts, 2010).

The number of HIV infections is declining but progress varies across the regions and there is concern about meeting this MDG goal. Sub-Saharan Africa is the region most affected by the AIDS epidemic, although in some 22 countries in the region recent rates of new infections fell. In 2010, 2.7 million people were newly infected, of whom 390,000 were children. Sub-Saharan Africa accounted for 70% of new HIV infections in 2010; however, the rate varies widely within the region and the epidemic continues to be most severe in southern Africa. The main route of transmission in sub-Saharan Africa continues to be heterosexual transmission, whereas drug-use injections are the main means of transmission in the Caucasus and Central Asia. Although HIV incidence and prevalence are substantially lower in Asia than in some other regions, Asia has the second largest number of people living with HIV (UN, 2012).

As of 2009, an estimated 17.1 million children around the world lost one or both parents to AIDS; 15 million of these children lived in sub-Saharan Africa (UN, 2012). Children orphaned as a result of AIDS are less likely to attend school and more likely to live in impoverished circumstances compared with their nonorphaned peers. The goal of universal access to treatment and services has yet to be reached, but important strides have recently been made in this area. At the end of 2010, 6.5 million people were receiving antiretroviral therapy for HIV or AIDS in developing countries and access rates have accelerated. Almost half of the recipients of antiretroviral therapy are HIV-positive pregnant women (WHO, 2012). Antiretroviral therapy helps prevent the transmission of HIV to the women’s children because without treatment, an estimated one third of children born to women living with HIV would become infected in the womb, at birth, or through breast-feeding (UN, 2012). In Africa, only 45% of HIV-positive pregnant women in low- and middle-income countries received treatment compared with Europe, where 94% of pregnant women in need in low- and middle-income countries had access to treatment (WHO, 2012). About 22% of children under age 15 living in developing regions received treatment for HIV (UN, 2012).

The proportion of children receiving immunizations continues to steadily increase and, as a result, both acute mortality and long-term disabilities resulting from certain infectious diseases have been greatly reduced. When the Expanded Programme on Immunization was launched in 1974, fewer than 5% of the world’s children were immunized during their first year of life against six killer diseases—polio, diphtheria, tuberculosis, pertussis (whooping cough), measles, and tetanus. In the early twenty-first century, nearly 85% of the world’s children under 1 year of age have received these life-saving vaccinations. New vaccines, such as those against pneumococcal disease, human papillomavirus, and rotavirus, have been introduced in recent years and the expansion of underutilized vaccines, such as the vaccines against yellow fever, hepatitis B, and Haemophilus influenzae type b, are being added to routine infant immunization schedules in an increasing number of countries, including low-income countries. More than 160 countries now include hepatitis B and Haemophilus influenzae type b into infant immunization schedules (United Nations Children’s Fund & World Health Organization (UNICEF & WHO), 2012).

Although the prevalence of diseases preventable by vaccination, such as pneumonia, diarrhea, meningitis, polio, and measles, dropped dramatically, these diseases continue to account for about a quarter of child deaths in low-income countries (Levine et al., 2011). In 2000, a total of 733,000 children died from measles; by 2010 this number had fallen to 114,000—nearly an 85% drop within a decade—and the prevalence of polio dropped even more precipitously, from more than 350,000 cases in 1988 to 1,410 confirmed polio cases in 2010. Polio has largely been eradicated in most countries, but international travel facilitates the continual spread of this infectious disease although only four countries remain endemic—Afghanistan, India, Nigeria, and Pakistan—down from more than 125 countries in 1988. At the end of 2011, 22.4 million children under 1 year of age worldwide went without all three recommended doses of the diphtheria/pertussis/tetanus vaccine; 20.1 million children in the same age group have not received a single dose of the measles vaccine (UNICEF & WHO, 2012).

Outside of the developing regions, benchmarks of children’s health are less focused on survival and reflect different standards of living. Unlike developing countries, all industrialized countries offer a range of interventions to pregnant mothers and to children after birth, regulate safe environments, and provide highly subsidized or free immunizations. Many countries include physical activity in the school curriculum.

Several studies have looked to measure and compare the status of children’s health across developed countries, specifically the 34 member countries of the Organisation of Economic Co-operation and Development (OECD) (Bradshaw, Hoelscher, & Richardson, 2007; OECD, 2009; UNICEF, 2007). The 2009 OECD study examined children’s health as one of six dimensions indicating child well-being. The health dimension measured health across the child’s life cycle: infant health is measured by mortality, low birth weight, and breast-feeding; two measures of immunization coverage (pertussis and measles vaccines by age 2); physical activity during mid- to late childhood; and mortality rates for children age 1 to 19 by all causes and by suicide. The statistics gathered from this OECD study are presented below.

Across almost all of the OECD countries, infant mortality is low or extremely low, with the lowest rates for 2005 in Japan (2.8 per 1,000 live births) and among the northern European countries (for example, Iceland is at 2.3 per 1,000 live births). The highest rates are in Mexico (18.8 per 1,000) and in Turkey (23.6 per 1,000). The United States and the Slovak Republic report substantially higher infant mortality rates than the average for OECD countries in 2005 (6.8 and 7.2 per 1,000, respectively).

The Nordic countries and South Korea perform best regarding low birth weights, ranging from 3.9 to 4.9% of live births, and Japan, the country with one of the lowest infant mortality rates, has among the highest low-birth-weight rates at 9.5%, joining Mexico (8.8%), Greece (8.8%), and Turkey (11.3%) as low performers on this indicator.

More than half of all OCED countries have breast-feeding initiation rates that exceed 90% and the rates in all OECD countries except Ireland exceed 63%. The top performers are Norway, Denmark, Iceland, and Sweden, whereas Belgium, France, Spain, and Ireland had the lowest breast-feeding initiation rates.

Immunization coverage among OECD countries is generally high and very high, from over 99% in Hungary, the Slovak Republic, and Sweden to 83% in Austria and 78% in Canada in 2005.

Physical activity among 11 to 15 year olds showed considerable variation across OECD countries. In almost half of all OECD countries, less than one fifth of the children aged 11 to 15 years participate in moderate exercise regularly. Children in France (13.5%) and Switzerland (13.8%) are the least likely to exercise, whereas children in the Slovak Republic (42.1%) are the most likely to exercise. Across all countries, girls were less likely to exercise than boys.

Child mortality rates vary by sex, country, and age across OECD countries. Girls have lower mortality rates than boys across all ages and are less likely to commit suicide than boys. Belgium has high child mortality rates across all ages, whereas its neighbor, Luxembourg, has among the lowest rates for all age groups. Risk-taking behaviors among teens (that is, smoking, drinking, and teen pregnancy) vary widely and increase with age. Teen birth rates are notably high in Mexico, the United States, and Turkey—three to four times the OECD average—whereas Japan, South Korea, Switzerland, and the Netherlands boast the lowest rates. Drinking and smoking vary moderately among OECD countries.

We now turn to indicators of children’s health in the United States. In the United States children’s health is often measured by indicators of infant and child mortality, low birth weight, breast-feeding initiation, teenage pregnancy, and the presence of chronic health conditions (including asthma, learning disabilities, behavioral problems, obesity, risk-taking behaviors, and mental health). In general, children in the United States are viewed as healthy and significant progress has been made with regard to childhood mortality and disease. Infant and child mortality has fallen, the spread of infectious disease among children has been curbed as immunization coverage has become nearly universal, accidental fatalities have decreased, fewer children are exposed to environmental toxins and, as a result, there are fewer long-term disabilities from infectious disease and environmental exposure (such as to lead), and cigarette smoking and teenage pregnancies have fallen. Further improvement is possible and needed. In general, children in the United States do not fare as well on health indicators compared with their counterparts in other industrialized countries, such as infant mortality rates, and there are marked disparities in health among U.S. children depending on the race or ethnicity of children and household income.

The statistics demonstrate substantial and sustained disparities between the health of poor children, Black or African American, Latino, and other ethnic minority children and White children, and children from wealthier households. For example, infant deaths have fallen since 1990 from 9.2% to 6.4% in 2009, with 26,531 infants dying before the age of 1 in 2009 (Guyer, Freedman, Strobino, & Sondik, 2000; U.S. Department of Health and Human Services, 2011. The leading causes of infant mortality continue to be congenial malformations and short gestation, low birth weight, and sudden infant death syndrome (National Center for Health Statistics, 2012a). The fall in infant mortality rates is not uniform across race and ethnicity. Infant mortality rates among non-Hispanic Black infants were 13.4 per 1,000 live births compared with 5.7 per 1,000 for non-Hispanic Whites and 5.5 per 1,000 for Latinas (National Center for Health Statistics, 2012a).

Two of the leading causes of infant deaths were pregnancy-related complications and unintentional injuries (U.S. Department of Health and Human Services, 2011). Prenatal care rose from nearly 76% of all women receiving care in 1990 to 82% by 2007 (U.S. Department of Health and Human Services, 2011). Rates vary considerably among women, with Mexican, Central American, and Hispanic and Latina women among the least likely to receive prenatal care in 2007 (70.7, 71.1, and 72.4%, respectively). In 2008, 71% of women began prenatal care during their first trimester, whereas 7% did not receive prenatal care until the third trimester or not at all (U.S. Department of Health and Human Services, 2011).

Low birth weight is a major cause of infant mortality and is linked to a child’s health. In 2009, 8.2% of infants were born weighing under 5 pounds, with the rate among non-Hispanic Black mothers (13.3%) being highest and showing little progress since 1990 (U.S. Department of Health and Human Services, 2011). Non-Hispanic Whites showed the lowest rates for low-birth-weight babies (7.2%), yet this rate has steadily increased from 5.7% since 1990 (U.S. Department of Health and Human Services, 2011).

Breast-feeding, known to contribute to the health and development of infants, has significantly increased since the 1980s, reaching 75.5% of all infants in 2007, and was highest among mothers age 30 and above, at 79.8%, and lowest among mothers aged 20 or younger, at 58.5% (U.S. Department of Health and Human Services, 2011). Mothers with a high-school diploma demonstrated the largest portion of the population increase in breast-feeding since the start of the twenty-first century (U.S. Department of Health and Human Services, 2011).

Preventive health services such as immunizations to prevent infectious diseases, screening, and early detection of disease such as cancer can increase longevity and improve the quality of life. Early childhood immunization has been shown to be a safe and cost-effective means of controlling disease within the population that has led to a 95% drop in vaccine-preventable diseases since the mid-twentieth century (National Center for Health Statistics, 2012a). Coverage is the average of the percentage of children ages 19 to 35 months who have received the following vaccines: diphtheria, tetanus, pertussis, poliovirus, measles, mumps, and rubella, and hepatitis B. Coverage reflects individuals receiving individual shots, not each individual receiving the full series of shots. In 2010, coverage rates were over 90% for children throughout the United States, with the rates varying by state and type of vaccine. Children from lower income households whose parents have less education are less likely to be immunized early in life and throughout their lives. The percentage of children who receive recommended vaccinations rises with maternal education and income, although these gaps have narrowed since the beginning of the twenty-first century (National Center for Health Statistics, 2012a).

Teenage birth rates have declined among most racial and ethnic groups since 1990 (National Center for Health Statistics, 2012b). Birthrates fell by 32% for teenagers under 18 years of age and by 13.6% for 18 to 19 year olds since 1990. The most dramatic fall in teenage birth rates has been among Black or African American teenagers under 18 years of age, although this group continues to have the highest teenage birth rates. Birth rates among Black or African American teenagers 15–17 years of age decreased from 10.1% in 1990 to 4.9% in 2010, from 6.6% to 4.7% for Hispanic teenagers, and from 3% to 1.7% for non-Hispanic White teenagers.

Nearly one in five children older than 5 years of age was obese in the United States in 2010 and rates are slightly higher among boys than among girls. Obesity is defined as a body mass index for age and sex at or above the 95th percentile on the growth charts of the Centers for Disease Control and Prevention. Excess body weight in children is associated with higher morbidity in childhood and adulthood. The prevalence of obesity for all ages increased in the 1990s and has remained high. Obesity among children 2–5 years of age rose from 7% in 1988 to 10% in 2000 and has since held steady; for 6 to 11 year olds obesity increased from 11% in 1988 to 15% in 2000 and has not increased significantly since then; and among adolescents 12–19 years of age, obesity rose from 11% in 1988 to 15% in 1999–2000 and has not increased significantly since then (National Center for Health Statistics, 2012a). Household income has generally been found to be inversely associated with obesity in childhood, but the association may vary by race. Obesity is inversely related to the educational level of the head of the household.

Chronic health conditions among children under 18 years of age include asthma, learning disabilities, attention deficit and attention deficit–hyperactivity disorder, speech problems, and oppositional defiant or conduct problems. Nearly 30% of non-Hispanic Black children were reported to have at least one or more chronic health condition in 2007 compared with 18.3% of Hispanic children and 22.5% of non-Hispanic White children (U.S. Department of Health and Human Services, 2011). Chronic health conditions were higher for children living in poverty (27% of poor children and 24.2% of near-poor children reporting at least one condition compared with 18.9% of children in households above 400% of the poverty level). Black or African American children have higher rates of asthma at 10.3%, compared with 6.5% of Hispanic children and 3.1% of non-Hispanic White children. The most common reason for hospitalizations for children under age 9 was respiratory-related illness (asthma and pneumonia) (U.S. Department of Health and Human Services, 2011).

Pediatric AIDS and HIV rates are low by global standards, affecting an estimated 166 children below 13 years of age. Non-Hispanic Black children account for more than three fourths of diagnosed cases (U.S. Department of Health and Human Services, 2011). Overall, the prevalence has decreased since 1992; this decrease is predominantly attributed to the increased use of antiretroviral therapies (U.S. Department of Health and Human Services, 2011).

Mental-health disorders are the most common reason for hospitalizations among children aged 10–14 and the second most common cause of hospitalization for teens between 15 and 19 and young adults between 20 and 21 years of age. Females were more likely than males to experience a major depressive episode (11.7% compared with 4.7%), and prevalence increases with age. A major depressive episode was also associated with higher rates of illicit drug use (35.7% compared with 17% without a major depressive episode) and 6.3% of high-school students reported at least one prior suicide attempt in the past year. Prior attempts were more likely to be reported by females (8.1%) than by males (4.6%). Non-Hispanic White and Asian students were the least likely to report a prior suicide attempt and non-Hispanic students of more than one race were most likely to report at least one prior suicide attempt within the past year (U.S. Department of Health and Human Services, 2011).

Risks to Children’s Health

In this section we explore some of the risk factors that obstruct healthy childhoods for all. A solid body of research has demonstrated that children’s health is determined by the interaction of environmental influences and complex processes including biology, genetics, culture, physical and emotional environment, behaviors, and stressors (NRC & Institute of Medicine, 2004). The same influences can have different effects depending on a child’s stage of development, predisposition, household income, and culture (NRC & Institute of Medicine, 2004). For example, research indicates that the physiological systems of children may be altered by the nutrition and health of the mother during pregnancy in ways that can predispose children’s vulnerability to hypertension, coronary heart disease, and diabetes (NRC & Institute of Medicine, 2004). Likewise, children’s exposure to chemical, biological, and physical influences in the environment affects anatomical, physiological, metabolic, functional, toxicokinetic, and toxicodynamic processes. Exposure can begin in utero through transplacental transfer of environmental agents from mother to fetus or in nursing infants via breast milk. The understanding that children may be at increased risk at different developmental stages, with respect to both biological susceptibility and exposure, has educated us about the importance of maternal health and the need for risk assessment approaches that incorporate environmental factors if we want to adequately protect children (WHO, 2006).

Exposure to environmental hazards and pollutants is a major contributor to children’s deaths, particularly in developing countries (WHO, 2006). Children’s size, physiology, and behaviors intensify their vulnerability to environmental hazards more than for adults (Creel, 2002). Children under age 5 have a higher inhalation rate and a higher ratio of body surface area to body weight, and they eat more food per unit of body weight than adults, all of which may increase their exposure to pathogens and pollutants (WHO, 2006). Younger children who crawling and put objects in their mouths have a higher potential risk, and school-age children may be exposed to other harmful risks as they assume household responsibilities and engage in labor.

The health risks to children in developing countries are most likely to be indoor and outdoor pollutants, lack of adequate nutrition, contaminated drinking water, unsafe waste disposal sanitation systems and facilities, vector-borne diseases, and hazardous chemicals. Rapid globalization and industrialization coupled with unsustainable patterns of production and consumption have released large quantities of chemical substances into homes and the environment. About half of the world’s households use biomass fuels for heating and cooking; about 1 billion persons, mostly women and children, are regularly exposed to these types of indoor pollutants, which are estimated to be 100 times greater than WHO-determined acceptable levels (Creel, 2002). This type of indoor pollution (wood, animal dung, crop residue) is highly associated with child mortality caused by acute respiratory illness (Creel, 2002). Researchers have found links between acute respiratory illnesses and lung cancer, stillbirths, heart disease, and low birth weights. More than half of acute respiratory illnesses are associated with outdoor pollutants such as sulfur dioxide, ozone, nitrogen oxide, carbon monoxide, and volatile organic compounds, mainly from motor-vehicle exhaust, power plant emissions, open burning of solid waste, construction, and related activities (WHO, 2006). Increased use of pesticides, battery recycling, mercury levels in fish, and higher levels of nitrates, arsenic, and fluoride disproportionately affect children. Although children in both developed and developing countries are exposed to environmental contaminants, the exposure levels tend to be significantly higher among children in the least developed countries (WHO, 2006). Lead is another contaminant that affects children in developing and developed regions of the world. Lead can contaminate soil, air, drinking water, and food and is more dangerous for younger children because their digestive systems absorb lead at higher rates than that of adults. Lead exposure can decrease brain function, cause anemia and hearing and kidney damage, and impair fertility (Creel, 2002).

Vector-borne disease is strongly related to environmental factors such as irrigation, land clearing and deforestation, and climate changes. Vectors (for example, mosquitoes, fleas, lice, biting flies, and bugs) typically become infected by a disease agent while feeding on infected vertebrates (such as birds, rodents, other larger animals, or humans) and then pass the disease on to a susceptible person or other animal. Malaria is an example of a vector-borne disease affecting millions in developing regions, whereas Lyme disease is an example of a vector-borne disease prevalent in North America. Children whose systems are less developed are more susceptible to the ill effects of vector-borne diseases. Malaria is the most deadly vector-borne disease; it kills over 1.2 million people annually, mostly African children under the age of 5. Dengue fever, together with associated dengue hemorrhagic fever, is the world’s fastest growing vector-borne disease. It is only recently that we have begun to understand how climate and population changes can contribute to the prevalence of vector-borne disease and the importance of vigilance through integrated protective and preventive measures (such as mosquito nets, safe insecticides, and natural vector controls such as bacterial and fish larvicides) (WHO, 2012).

The risks to children from environmental contaminants linked to asthma, lead poisoning, vectors, and malnutrition are common to children in developed and developing regions of the world, but in industrialized countries there is greater emphasis on understanding genetic and biological predispositions for disease and illness and behavioral and environmental influences affecting health outcomes in children. Disruptions in genetic formation caused during or after conception may produce immediate or later-in-life disorders and others may be hereditary. Biological processes are based on gene structure and may be affected by interactions with physical and social environments (NRC, 2004). Although we study both the genetic and the environmental influences on health in the industrialized and developing world, we are more likely to see research focused on genetic contributions to children’s health in developed rather than developing countries. In part this is because there are many more environmental safeguards structured into environments affecting children in developed countries.

Children’s emotions, beliefs, and attitudes affect health primarily by how they modify children’s explicit and overt behaviors (for example, attitudes toward health, expectations, and risk-taking behaviors). Diet, exercise, smoking, drinking, wearing a seat belt when driving, and attitudes toward seeking health-care services will affect health during childhood and later as an adult. Environments that promote health, healthy behaviors, and healthy lifestyles are linked to better health outcomes (NRC, 2004). In addition, emotions, beliefs, and attitudes may also exert effects on children’s health by affecting how children react to illness and environmental stressors and influencing physiological behaviors (NRC, 2004).

In the United States and other industrialized countries, the issues of access to clean drinking water and sanitation have largely been resolved (despite outbreaks of salmonella, hepatitis, and other contaminants), in contrast to the roughly 780 million people around the world who, according to the WHO and UNICEF, lack access to clean drinking water and the estimated 2.5 billion people (roughly 40% of the world’s population) who are without access to safe sanitation facilities. Environmental factors that pose risks to children in the United States are ozone, respirable particulate matter, lead, sulfur dioxide, carbon monoxide, and nitrogen oxides among outdoor pollutants (all of these are regulated by the Clean Air Act); indoor pollutants include combustion products, by-products of smoking, formaldehyde, benzene and trichloroethylene, and molds (NRC, 2004). The outdoor pollutants affect the development of the lungs and the nonregulated indoor pollutants are associated with respiratory ailments such as asthma, allergies, respiratory irritations, and central nervous system effects.

Injuries are the leading cause of death in the United States for children and account for more deaths than suicides, homicides, cancers, and other diseases. The majority of deaths are caused by automobile accidents, followed by use of playground equipment (NRC, 2004).

Poverty and healthy childhoods tend to be inversely correlated. In a review of the literature on children’s health and socioeconomic status in the United States, Canada, and Britain, Currie (2009) found that differences in the health of children of high and low socioeconomic status are apparent at birth. Poor children are more likely to have low birth weight than children from higher income families, and health gaps between rich and poor children continue throughout early childhood and beyond. Poor children were more likely to suffer from chronic conditions than rich children and, by their teenage years, poor children were twice as likely to be limited by chronic illness compared with nonpoor children. Chronic poverty was also found to have more significant effects on health than transitory poverty, especially with regard to children’s mental health and aggressive behaviors (Currie, 2009). Researchers have also found that children who have histories of abuse are more likely to report health problems, and children who have been abused or neglected are more likely to suffer from infectious disease, pain, hypertension, diabetes, asthma, and poorer general health (Widom, Czaja, Bentley, & Johnson, 2012).

Health inequities exist across the globe—in every country, every region, and sometimes within households. The inequitable distribution of power, income, services, and goods globally, nationally, and within households results in visible disparities and disparate life trajectories for children. A girl born in the early twenty-first century can expect to live for more than 80 years if she is born in an industrialized country, but less than 45 years if she is born in one of the least developed countries. These dramatic inequities in health within and between countries are largely avoidable and are shaped by the political, social, and economic policies between and within countries that affect which children shall thrive and which will suffer. Since the 1990s, power, economic, health, and social differences have widened in many regions and within countries, creating a greater risk for children living in poorer and poorly governed countries. Globalization has made clear the convergence of social, health, and economic issues within and across borders, and although many health risks are localized in poor communities and countries, the ease of which the risk of disease and ill health can spread is very real.

Future Directions

Going forward, we must keep in mind the good practices that have yielded dramatic improvements to children’s health in both the developing and the developed world, particularly since 1990, but we also must challenge ourselves to do better. Our expanded understanding of health and the determinants that impede or promote health leave us in a position to do more than react to disease or illness; rather, we can expand efforts to promote and prevent disease, injury, and illness. We know too that inequitable distributions of opportunities, services, and power affect health trajectories, so the impact on health should be a part of larger social and economic policy discussions, and health policies must account for the larger social and political environments. Action on the range of determinants of health must involve the whole of government, civil society and local communities, business, global actors, and agencies. Policies and programs should embrace all of the key sectors of society and not just the health sector.

Social workers who are skilled in integrating and moving across different systems can play pivotal roles in engineering the new infrastructure of health systems, whether they practice domestically or globally, and can act as advocates for the fusion of social, economic, health-care, and political systems to the benefit of children. These efforts at integrated systems must begin early because, as research has demonstrated, both positive and negative influences early in life affect children’s health at current and later stages of development and adulthood. Earlier interventions tend to be less intrusive and less costly than later efforts.

Efforts should be built on evidence of effective interventions and documented need, thus building policies on reliable, valid, comprehensive sources of data of children’s health. Comprehensive tracking systems are needed to help identify changing patterns in children’s health and to develop appropriate public-health responses; such systems should include measurement of the environmental factors affecting children’s health. Monitoring of such influences can help identify the need for interventions early and potentially avert long-term negative consequences.

International and domestic funding is needed at levels high enough to meet the challenges ahead and, with such funding in place, we must use it to create cross-disciplinary, evidence-based, and integrated systems across countries to ensure healthy futures for children.


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