Health Services and Social Services
Overview
Health and social services comprise a very broad and diverse set of influences
on healthy child development. Health services include those services and
supports provided by doctors, nurses, pharmacists, dentists and other
health-care professionals that focus upon both the physical and mental
health of children and, at times, their primary caregivers. Social services
consist of a wide variety of programs, services and supports that address
both the basic needs of children (including the need for protection) and
aspects of their social and psychological development (such as awareness,
judgment, feelings, behaviour and relationships).
These services are important for two reasons. Throughout childhood, there
are opportunities to provide the conditions and supports that keep children
on healthy developmental pathways. Health and social services are important
primarily in that they can contribute to promoting this positive development.
And second, if these opportunities are missed, or if children are disadvantaged
in some way, services can help reduce the risk of negative consequences,
and in many instances partially or wholly ameliorate those that do occur.
There is a significant difference, however, in the availability of health
services compared with social services. Health services are available
to all children, including those at risk and those with special needs.1 ( 1. Availability is not the same as accessibility. Services may be available
but not accessible if people ate not aware of them, cannot get to them,
or have beliefs, languages, or cultures that are not compatible with them)
That is, they are more or less universal, with elastic public funding
that largely reflects usage. For example, a family physician can order
tests or refer to specialists in an effort to diagnose a child's health
condition, and the costs of those services will be covered, for the most
part, by the health-care system.
Health Services and Social Services
Social services, on the other hand, are not universally available to
young people and their families. They tend to be targeted towards those
at risk and those with special needs and are restricted in availability
by fixed levels of funding. So if, in the above example, the family physician's
concern was about a child's mental rather than physical health, the physician
could refer to a children's mental health program for assessment, but
there is no assurance that the child will be seen. Assuming that the service
even existed, access would largely depend upon factors such as severity
of need and competing demands on the assessment service.
Despite these differences in funding and availability, both service sectors
share the experience of having undergone restructuring in most provinces
over the past 10 years, with a resulting reduction of public expenditures
for many programs — despite increases in the demand for some services.
Relationship to Healthy Child Development
Health and social services contribute to healthy child development in
a variety of ways. They provide services and supports at all stages of
childhood, from preconception through young adulthood. They also provide
services and supports in response to changing life circumstances and health
status, ranging from wellness through to illness or other negative health
conditions. And they provide services and supports at different points
of intervention, from promotion and prevention through treatment and rehabilitation.
Health and social services contribute to healthy child development
in different ways at various life stages.
Health services and social services play a particularly important role
in getting children off to a good start in life. Their contributions can
begin even prior to conception through a variety of services for non-pregnant
women. These include services that diagnose and treat general health problems
—organic medical problems, nutritional status, sexually transmitted
diseases, immune status, gynecological, anatomic and functional disorders,
occupational exposures, and genetic risk —that could adversely affect
future pregnancy, fetal development and maternal health.
They also include services that diagnose and treat mental health disorders
and problem behaviours such as smoking, alcohol and other substance abuse.
And finally, they include services that promote responsible and effective
parenting such as comprehensive family planning programs, which provide
education and counselling, physical exams and lab tests, and information
and instruction on family planning methods (Carnegie Corporation, 1994,
p. 80).
Health and social services also provide invaluable supports for women
once they become pregnant, and to a lesser degree, for prospective fathers.
Medical services provide early diagnosis of pregnancy. Counselling services
support the continuation of pregnancy through referrals to prenatal care,
childbirth preparation classes, and adoption services. Good prenatal care
ensures a whole host of benefits including requisition of appropriate
laboratory tests, diagnosis and treatment of general and/or mental health
problems, assessment of nutritional status, screening for infectious diseases,
and identification and management of high-risk pregnancies.
Prenatal counselling and anticipatory guidance services promote healthy
choices and behaviours during pregnancy, early detection of possible abnormalities,
preparation for labour, information on infant nutritional needs and feeding
practices (including breastfeeding), and awareness of the emotional and
social changes brought on by the birth of a child.
Once a child is born, health and social services can contribute to its
early development by providing evaluation and support immediately after
delivery, linkage to continuous and comprehensive pediatric care after
discharge, diagnosis and treatment of maternal health problems including
postpartum depression, nutritional assessment and supplementation, infant
stimulation programs, home-visiting programs that support effective parenting
and parent-child attachment, and quality child care.
As a child moves towards school age, the contributions of health and
social services often become more situation-specific. If a child is developing
normally, parents may only draw upon the occasional health service to
diagnose and treat the usual childhood maladies. As well, they may use
some of the more competency-based social services, such as family resource
centres or other parenting support programs.
However, for children who are living in circumstances that place them
at risk, or for those who have unique characteristics that translate into
special needs, a whole host of preventive and special services may come
into play. These include a variety of child and family services such as
mental health and child protection services, developmental and rehabilitative
services (e.g. physical therapy, language therapy), and school readiness
programs.
The same pattern holds true for school-aged children and adolescents.
Those who are developing normally tend to use health and social services
on an as-rieeded basis. Those who are at risk or have special needs draw
upon a variety of specialized services. Health and social services can
make a significant contribution to young people approaching adolescence
by providing both good information about personal health and programs
that promote positive life skills.
These can be provided in a variety of ways, including: programs that
build social support networks, especially those addressing factors that
predispose young people to engage in risky behaviour; adult mentoring
programs that foster a stable, supportive bond between a young person
and a caring adult; well-developed peer-mediated counselling and peer
tutoring programs; and life skills programs that stress interpersonal,
decision-making and coping skills (Carnegie Corporation, 1996, p. 19).
Services for Children with Special Needs
In 1991, 7.2% of
children and youth between 0 and 19 years of age living at home had
at least one disability (including physical, psychological and mental
disabilities). The rate was higher among boys (7.9%) than girls (6.3%).
Most (85%) children with disabilities had mild disabilities; 11% had
moderate disabilities; 4% had severe disabilities. The rates of moderate
and severe disabilities were higher among 15- to 19-year-olds (19%
and 5% respectively) (QCH, 1994, pp. 151-152). See Exhibit
9.1.
Almost 50% of all children and youth with disabilities had specialized
transportation services available in their communities; however, more
than 13,000 children and youth with disabilities had a need for transportation
services but did not have them in their communities, few (1.5%) children
with disabilities needed speciliazed accommodation features (e.g.
ramps, widened doors, automatic doors, elevators), but did not have
them (CKH, 1994, pp. 162-163). |
Health and social services contribute to healthy child development
in response to changing life circumstances and health status.
Most children get off to a good start in life, and then grow and develop
in a reasonably normal way. There are numerous health and social services
(described in the next section) that promote and support this well-being
and positive development.
But health status can change at any point in time, as can the conditions
or circumstances that contribute to it. For this reason, there are a number
of health and social services that respond to changing health status and
life circumstances. Most of these services are designed to lessen the
impact of what are hoped to be temporary setbacks in states and conditions
of well-being. They range from direct services to young people and their
caregivers, through to programs, services and other supports that are
intended to strengthen the conditions in which these young people and
caregivers find themselves.
For example, there are a variety of primary, secondary and tertiary health-care
services that diagnose and treat the full spectrum of childhood diseases
and other health conditions. Similarly, there are all kinds of social
services that attempt to offset difficult life circumstances (e.g. parental
illness or injury, unemployment, and changes in family structure). These
include respite services, food banks, mediation services, counselling
services, child welfare services, family in come security programs, employment
training programs, and subsidized housing.
For those with long-term or chronic health or developmental concerns,
such as disabling conditions, there are also a number of special health
and social services, ranging from rehabilitative services (e.g. physiotherapy
and speech and language therapy) to long-term services and supports (e.g.
attendant care).
| Exhibit 9.1: Distribution of children
aged 0 to 19 years with disabilities, by severity of disability, Canada,
1991 (%) |
| Mild |
85 |
| Moderate |
11 |
| Severe |
4 |
| Source: Canadian Institute of Child Health (1994). The
Health of Canada's Children: A CICH Profile, 2nd edition.
Ottawa: CICH, p. 152. |
Immunization is Key
Many childhood diseases are preventable.
These include diptheria, tetanus, measles, rubella and congenital
rubella syndrome, mumps, pertussis, poliomyelitis and invasive infections
due to Haemophilus influenza.
fbr some diseases, the risk of long-term consequences is greater if
infection is in early childhood Major blood-borne pathogens such as
hepatitis B and hepatitis C cause long-term persistent infections
in children. The risk of chronic hepatitis B infection is 90% to 95%
if exposure occurs in infancy, but only 6% to 10% if acquired in adulthood
(Health Canada, 1998, p. 90). Hepatitis Cmay lead to chronic infections
in up to 70% to 80% of cases (WHO et al., 1999, p. 36). |
Health and social services contribute to healthy child development
at different points of intervention.
A true system of health services and social services is comprised of
a variety of services and supports that lie along a continuum of points
of intervention. This continuum ranges from promotion and prevention at
one end, to treatment and long-term care at the other. Having such a continuum
of services and supports enables health and social services to contribute
to healthy child development at all points of well-being.
For example, health and social services can promote good health and normal
development through services such as well-baby clinics and parent education
programs. They also can contribute to reducing risk and preventing illness
or other negative health conditions through immunization programs and
early identification programs that screen for developmental anomalies
or genetic disorders.
Where a concern is already evident, health and social services can intervene
early before the situation worsens,
through strategies such as home-visiting programs and child development
programs. In more serious situations, they can treat illness or other
negative health conditions through resources such as neonatal trauma units,
programs that treat postpartum depression, and primary care services for
childhood diseases.
And finally, for situations in which there is a long-term concern, health
and social services can contribute to healthy child development by providing
support (e.g. counselling and anticipatory guidance) to parents of children
with chronic illness or disabling conditions.
Child-care Subsidies
High-quality child care contributes
to greater social competency, higher levels of language development,
higher developmental levels of play, better ability to self-regulate
and fewer behaviour problems.
Wale all provinces have fee subsidies for low-income families, most
provinces limit their availability (OH) 1996, pp. 30-31). In fact,
in recent years, the number of child-care subsidies for low-income
parents along with operating or wage grants to child-care providers
were decreased in many provinces(GCS-r 1996, pp. 30-31). In 1993,
the income cut-off for child-care subsidies was less than $21,000
for a two-parent family with two children in seven provinces and one
territory (OSQ 1996, pp. 30-31). |
Conditions and Trends
In Canada, health and social services are by and large the responsibility
of provincial/ territorial and local governments. Given this decentralized
approach, there is considerable diversity across the country with regard
to legislation, funding, administration and availability of these services.
Along with this diversity, however, there appear to be a few common themes.
Fiscal restraint and systems change.
Perhaps the two most common themes across all jurisdictions are those
of fiscal restraint and systems change. With the persistent concerns about
deficits and debt, all levels of government have been seeking ways to
contain costs and restructure service systems to be more efficient and
effective. These two trends have had a significant impact on the funding,
organization and delivery of health and social services across all categories
of service: universal, targeted, and special services. And with the current
uncertainty about the state of the international economy, the concerns
— at least about cost —are not likely to go away.
In 1994, for the first time in 20 years, health expenditures showed a
decline, per person and as a percent of GDP (Health Canada, 1996, p. 26).
See Exhibit 9.2.
Health care spending on children accounts for less than 10% of all spending,
even though children under the age of 15 make up about 20% of the population
(CCSD, 1996, p. 30). Since 1980, the growth in per capita expenditure
on health has been about the same for all age groups. See Exhibit
9.3.
Increased emphasis on population health and early child development.
There has been a growing appreciation of the population health perspective,
particularly at the federal and provincial/ territorial levels of government.
Population health, with its emphasis on broad health determinants, has
become a very useful framework for understanding both the factors that
influence health and the opportunities for improving health status of
the population as a whole. One consequence of this improved understanding
of the factors that influence population health has been a renewed emphasis
on early child development.
There has always been a strong emphasis on getting children off to a
good start; but in the past, much of the rationale for this emphasis was
tied to preparing children for successful transition into the formal education
system. Now we understand that in addition to promoting school readiness,
investing in the early development of children holds other benefits as
well, particularly in terms of adult health status. As a result of this
growing awareness, governments at all levels have been either introducing
new programs to support early child development or, in some cases, shifting
the use of existing resources.
System level emphasis on inter-sectoral action.
Given the variety of factors that influence health and well-being, and
the fact that some of the most powerful of these influences lie outside
the traditional health-care sector, the best way to improve population
health is through a multi-sectoral approach. For this reason, governments
at all levels have been searching for ways to connect the contributions
of various sectors including health, social services, education, finance,
justice, recreation, and housing.
These inter-sectoral efforts have both "horizontal" dimensions (in that
they connect different partners and sectors) and 'Vertical" dimensions
(in terms of layers of organizations and levels of government). Both of
these dimensions are important to varying degrees depending upon the type
of inter-sectoral action.
Many jurisdiction shave tried to strengthen the connections between sectors
within government through reorganization. The two most common approaches
have been to integrate responsibilities under one ministry or department,
and to create some form of inter-sectoral committee or structure. These
are examples of efforts to promote inter-sectoral action along a horizontal
dimension.
Reduced Spending and Care
In recent years, spending cuts on health care and overall reform
of the health care system have resulted in a shift away from traditional
services and settings. There are some indicators that continuity of
care has been affected by the shift away from hospital care without
alternative infra-stucture and supports being made available, fbr
example, non-voluntary short hospital stays have been associated with
infant re-admission, problems breastfeeding, parents' difficulty adjusting
and maternal dissatisfaction (Risk, 1996, p. 6). |
But there also are increasing efforts to stimulate inter-sectoral action
along the vertical dimension. Among other benefits, this should help alleviate
situations in which there have been disagreements over who should be providing
what, which resulted in children and families falling through the cracks
of an uncoordinated system.
The emphasis on inter-sectoral action has had very real implications
for the providers of health and social services, particularly in terms
of heightened expectations that they take an integrated and collaborative
approach to the planning and delivery of services.
Service level emphasis on holistic and customized packages
of support.
The other side of the "inter-sectoral action coin" is an increased emphasis
on comprehensive and customized packages of services at the consumer level.
For the same reasons that it is important to be able to draw upon the
contributions of different sectors at a systems level, it is also important
to be able to translate those inter-sectoral contributions into packages
of services and supports that respond to the unique circumstances and
needs of individuals and families.
As a result, funders and consumers are putting increased pressure on
service providers to find approaches that respond to the full range of
unique needs of those that require health and social services. In the
health sector, this has resulted in public health units joining other
sectors in community-based initiatives, with particular emphasis on providing
multi-faceted supports to those at risk. In social services, it has given
rise to more comprehensive and customized approaches to provision of services
and supports such as wrap-around services, family preservation programs,
and service brokerage.
Health and Social Services and Other Determinants
Income and Social Status
Income and social status are powerful influences on health and well-being
at all stages of life, but they are particularly influential on the life
chances of children. There are troubling correlations between low in come
status and the need for health services, particularly in relation to getting
children off to a good start. The same holds true for certain social services;
for example, child protection agencies report disproportionate numbers
of poor women and children among their caseloads.
The National Longitudinal Study of Children and Youth (NLSCY) found that
"single-mother family status and low in come significantly and independently
influenced child well-being" (Lipman, Offord and Dooley, 1996, p.89).
Education
Health and social services can provide a variety of supports that help
young people stay in school. For example, health services strive to maintain
health, but they also diagnose and treat illness or other health conditions,
which might interfere with school attendance. A vast array of social services
assess and treat emotional, behavioural or social concerns that could
interfere with school attendance and performance. Social services also
provide supports, such as child care, which allow young parents to continue
on with their education.
Health and social services also promote healthy early development, and
otherwise ensure that children are ready for school. Health services such
as primary care, immunization programs and in jury prevention programs
contribute to healthy early development, readiness to learn, and eventual
school attendance. Social services— particularly those that support
responsible and effective parenting, and early development —also
contribute to getting children off to a good start and to making a successful
transition into the formal education system.
Social Environment
Health and social services link to the immediate social environments
in a variety of ways. For example, some health services (such as home-visiting
programs and parenting programs) and many social services (including family
resource centres, mutual aid groups, parent and child drop-in programs,
child-care centres, and family preservation programs) include in their
design the strengthening of social networks to overcome the negative effects
on parents and families of social isolation.
Other services —including community health programs, community
development programs and local economic development programs —attempt
to strengthen local social environments by working not just with individuals
and families, but with local groups and broader communities as well.
Natural and Built Environments
Health and social services link primarily with natural and built environments
through surveillance and regulatory functions, but also through awareness
and public education activities. For example, public health departments
play a leading role in the monitoring and enforcement of standards related
to the natural environment, such as air and water quality. They also play
a similar role with regard to public health standards for built environments
for children,
including parks, schools, housing units, child-care programs, and residential
care settings. Social services play a smaller role, but try to ensure
that local built environments are safe and welcoming to children and youth,
and are supportive of their developmental needs (e.g. youth programs at
malls and in high-density housing areas).
Personal Health Practices and Coping Skills
A variety of services are intended to promote healthy life choices and
improve coping skills in relation to child development. In the health
sector, services include: comprehensive family planning programs; health
education programs; programs that diagnose and treat health problems that
could affect pregnancy or birth; programs that diagnose and treat mental
health problems; and counselling and anticipatory guidance for parents
of children with a chronic illness or disabling condition.
In the social services sector, these include: family resource programs;
parent and child drop-in programs; individual, couple and family counselling
services; child and family mental health programs; child protection services;
respite programs; and community-based programs to prevent family violence.
Genetic and Biological Factors
Health and social services have a small but growing link to biology and
genetics as contributors to healthy child development. Most of the services
that have relevance for these two fields include a counselling component.
For example, prenatal health services provide genetic screening, diagnosis
and counselling, as well as diagnosis and treatment of gynecological anatomic
and functional disorders that could adversely affect pregnancy, fetal
development, or maternal health. Both health and social services also
counsel with regard to pregnancy continuation and positive health behaviours
related to pregnancy.
Culture
Some health and social services are intended to be bridging services
(i.e. they assist people from varying cultural backgrounds to become more
familiar and comfortable with mainstream health and social services).
In addition, health and social services are increasingly being designed
and delivered in a manner that is both sensitive and responsive to the
cultures of those they serve. In some instances, such as social services
within Aboriginal communities, the actual governance and delivery of services
is being turned over to the communities themselves.
Gender
Health and social services link to gender in a number of ways. Health
services link with the biological dimension of gender (e.g. reproductive
health), while social services may have more links with the social dimension
of gender —parental roles, societal attitudes, receptiveness to
services, and gender-related patterns of behaviour and service (e.g. sole-parent
led families, risk-taking behaviours).
References
Canadian Council on Social Development (1996). The Progress of Canada's
Children —1996. Ottawa: Canadian Council on Social Development.
Canadian Institute of Child Health (1994). The Health of Canada's
Children: A CICH Profile, 2nd edition. Ottawa: Canadian Institute
of Child Health.
Carnegie Corporation of New \brk (1994). Starting Points: Meeting
the Needs of Our Youngest Children. New\brk: Carnegie Corporation
of New\brk.
Carnegie Corporation of New\brk (1996). Great Transitions: Preparing
Adolescents for a New Century (Abridged Edition). New\brk: Carnegie
Corporation of New\brk.
Health Canada (1996). National Health Expenditures in Canada 1974-1994:
Summary Report. Catalogue No. H21-99/ 1992-2. Ottawa: Health Canada.
Health Canada (1998). Canadian Immunization Guide. Catalogue
No. H49-8/ 1998E. Ottawa: Canadian Medical Association.
Lipman, E.L., D.R. Offord and M.D. Dooley (1996). "What Do We Know about
Children from Single-mother Families? Questions and Answers from the National
Longitudinal Survey of Children and Youth." In Growing Up in Canada:
National Longitudinal Survey of Children and Youth. Catalogue No.
89-550-MPE, No. 1. Ottawa: Human Resources Development Canada and Statistics
Canada, pp. 83-91.
Rush, L (1996). 'Early Hospital Discharge of Mothers and Newborns." Child Action, Vol. 2(1). Ottawa: Canadian Institute of Child
Health.
WHO and Viral Hepatitis Prevention Board (1999). "Global surveillance
and control of hepatitis C." Journal of Viral Hepatitis, Vol.
6: 3547.
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