Issues in measuring child health

Issues in measuring child health

Article: Write a review of the following article: McCormick MC. (2008). Issues in measuring child health. Ambulatory Pediatrics; 8 (2), 77-84. Assignment criteria: Your review MUST attend to the following: (i) Provide a brief summary of the article you have chosen to critique and how the article fits into the broader evidence base/literature on this topic (500 words) (ii) Write a critical review of your chosen article. This should include a critical appraisal of the perspective taken and arguments given to justify their approach. In your evaluation of the article you should refer to any strengths and limitations of the text (1200 words) (iii) Evaluate the implications of the article for policy makers and academic researchers (300 words)

Perspective
Issues in Measuring Child Health
Marie C. McCormick, MD, ScD
Assessing child health is critical to a variety of child health,
educational, and social programs, as well as to clinical research
and practice. However, despite the apparent wealth of measures
available in health, education, and legal and social welfare
systems, little agreement exists as to what are the most important
measures and for what domains of health. Development of improved
measures may capitalize on advances in conceptualization
of child health, including the dynamic nature of the interplay of
child health and development over time. The need for enhanced
measures can be illustrated by consideration of various aspects
of pediatric care: well-child care, acute illness care, and the management
of children with special health care needs. In particular,
the strong theoretical perspectives on aspects of development
such as cognition and behavioral development need to be
informed by the experience of various states of health and their
developmental implications. If generalist academicians are to
further their research and educational mission, they must engage,
and urgently, in the development and measurement of child
health.
KEY WORDS: child health status; health services research;
measurement
Ambulatory Pediatrics 2008;8:77–84
I
f an investigator or a clinician wishes to measure
general cognitive development in children, then
a few well-known instruments come readily to
mind—for example, the Bayley Scales of Infant Development1
for younger children and one of Wechsler instruments
for older children.2 If resources do not permit such
assessments, then a variety of questionnaires are available
that provide reasonable information.3,4 Likewise, for
behavior, the use of the appropriate Achenbach scale would
likely be recommended.5 However, no such ready responses
come to mind if the outcome is child health.
Being able to characterize and measure child health is
integral to a broad range of health and social activities
and programs. We use measures of child health to monitor
population trends in child well-being and to identify
changes that might signal the need for new interventions.
Clinically, measures of child health are important to characterize
the severity of a health problem and to monitor the
effect of treatment acutely and over time. If health is a goal
to be aspired to, then a clear definition of that goal would
seem to be imperative. Yet little consensus has emerged
as to what constitutes child health.
The lack of an integrated and useful definition of child
health in a developmental context has implications for
research in child health and for planning for interventions
to improve health. For translational research involving
specific conditions, moving beyond mortality averted and
symptoms alleviated requires a broad and structured
framework, or the work risks missing potentially signifi-
cant side effects. For those conducting research relevant
to educating practicing pediatricians, measures of child
health that reflect the activities of the majority of pediatricians
and their health promotion activities would be useful
in informing educational programs and developing quality
improvement strategies. In the program and policy arena,
there is a need to be able to summarize across pediatric
diagnoses at a more specific level for children with special
health care needs so that meaningful estimates can be made
of the need for pediatric subspeciality care, physicians, and
others, both for chronic and acute conditions. For example,
pediatric physical therapists are important for children with
cerebral palsy and injuries. In addition, there needs to be a
clear linkage between these more nuanced measures of
child health and the indicators routinely used, so that appropriate
monitoring and planning at the community level
can be achieved. Addressing the issues in the measurement
of child health would seem to be an important endeavor for
generalist academic investigators as they interface with clinical
medicine, population health, and the disciplines that
contribute theoretical and empiric literature to child health.
Although there appears to be a wealth of indicators of
child health, many, if not most, are not well suited to
many activities of general pediatricians. Newer conceptual
models may provide better guidance in developing better
measures for use, and potential applications of these models
to well-child care, acute illness care, and the management
of chronic illness in childhood can be illustrated. However,
there are significant challenges to the development of more
refined and meaningful measures of child health.
INDICATORS VERSUS MEASURES OF CHILD
HEALTH
Many of the routine statistics6–8 about child health tend to
be a mixture of diagnoses or specific conditions, contextual
characteristics (eg, proportion of children in poverty), risk
From the Department of Society, Human Development and Health,
Harvard School of Public Health, Boston, Mass.
Address correspondence to Marie C. McCormick, MD, ScD, Department
of Society, Human Development and Health, Harvard School of
Public Health, 677 Huntington Ave, Boston, Massachusetts 02115
(e-mail: mmccormi@hsph.harvard.edu).
Received for publication February 5, 2007; accepted November 21, 2007.
AMBULATORY PEDIATRICS Volume 8, Number 2
Copyright 2008 by Ambulatory Pediatric Association 77 March–April 2008
(teenage pregnancies) or protective factors (wearing seat
belts), and characteristics of the health care system (insurance
coverage).9 They have often been selected for monitoring
child health in the community or at a population level and
may have little relevance to the health of an individual child.
More often than not, they are cross-sectional in nature,
reflecting the prevalence of these conditions or problems,
and they do not convey a life-course approach. In addition,
they often focus on the absence of health or negative states
and provide little sense of the combinations of and interrelationships
among the conditions or problems, even in individual
children. Although such indicators provide important
benchmarks for accountability for community health, they
are of limited use to pediatric researchers and educators.
Better approximations of the concept of health involve
self-ratings or proxy ratings of overall health. Generally,
these are questions that ask an individual to rate health
along a 4 to 5–point scale from poor to excellent. Although
such questions do correlate with other measures of current
and future health states, there is insufficient variance in the
response to make them useful, as only a tiny minority rates
their health at the lower end of the scale.10 Moreover, the
linkage between these types of questions and elements of
health care delivery is not always straightforward. Finally,
they provide little guidance to clinicians in measuring
changes in health, as they tend to be stable over time for
individuals and populations.
CONCEPTUAL MODELS OF HEALTH
One strategy to obtain a more useful operationalization
of child health would be to rely on existing conceptual
models of health and to identify measures that capture
the elements in these models. Currently, there are 3 major
conceptual models, each with attractive features for approaching
the measurement of child health.
World Health Organization Definition of Health
The oldest of these conceptual models is the definition
of health articulated by the World Health Organization
(WHO): ‘‘state of complete physical, mental and social
well-being not merely the absence of disease or infirmity.’’11
The advantages of this definition lie in its multidimensionality
and its focus on positive well-being in several dimensions
of health. Practically, this conceptualization of health has
been incorporated into a family of measures of health for
children, both general and disease specific.12 However, as
an adult-focused model, this definition appears relatively
static and fails to convey the dynamic nature of the interplay
of child health and development over time. Moreover, the
applicability of the dimensions of health to children is not
straightforward. For example, cognitive development might
have to be considered under mental health. Finally, because
it focuses on optimal health, it provides little guidance about
considerations of lesser states of health.
International Classification of Functioning, Disability,
and Health
The latter point is directly addressed by the more recent
addition to the WHO Family of International Classifications,
the International Classification of Functioning,
Disability, and Health.13 The underlying premise is that
health and disability are not separate entities but points
along a continuum of functioning that concludes with
death. Moreover, experiencing even temporary degrees of
disability is a near-universal experience, not the experience
of a few; thus, the experience of disability becomes a normative
one. The underlying thinking also emphasizes the
role of the environment in worsening or ameliorating the
functional impact of a given disability. The purpose for
the development of this conceptual framework is to provide
a common metric that can be used worldwide for assessments
at the individual, institutional, and social level.
Data-collection materials have been developed to assess
major domains of impairments of body functions and structures,
activity limitations and participation restriction, and
environmental factors. Although the items are scaled, no
overall scoring rules are provided. However, the intent is
to measure improvement in terms of functioning regardless
of actual diagnosis, including improvement in functioning
as a result of the elimination of environmental factors.
National Academy of Science Conceptualization
In addition to a focus on function, the dynamism of the
interplay of health and development over time has been
incorporated into a multidimensional conceptualization
by the Committee of Evaluation of Children’s Health of
the National Academies of Sciences and the Institute of
Medicine.14 This conceptualization begins with the following
definition:
Children’s health is the extent to which individual
children 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.14(p33)
The report goes on to identify 3 specific domains of
health. The first consists of health conditions, generally
in the form of diagnoses, injuries, and common symptoms,
acute or chronic, ‘‘that may be anatomical, physiological or
psychosocial.’’14(p35) Functioning, the second domain, is
considered to reflect ‘‘the direct and indirect effects of
one or more health conditions and their treatments.[on]
physical, psychosocial, cognitive and social functioning.’’14(p35)
The final domain is health potential, which
‘‘includes both health assets that provide the capacity to
respond to physical, psychological and social challenges
and risk states that increase vulnerability to other aspects
of poor health.’’14(p37) These domains are projected over
multiple time frames and transitions to emphasize the
potentially very long-term effects of child health on adult
health.
The first domain of this definition has clear parallels in
the International Classification of Functioning, Disability,
and Health (ICF),13 which postulates a progression from
anatomic derangement through to symptoms. Both emphasize
function as something separate but related. The
National Academy of Science (NAS)14 framework is
78 McCormick AMBULATORY PEDIATRICS
much more dynamic and adds the concept of ‘‘potential,’’
an important concept in assessing children because the
final ‘‘product’’ of health and development has yet to be
realized.

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