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Factors Influencing the Implementation of Disease Prevention Programs for Children

Many disease prevention and health promotion programs are directed at the health of children and young people because they can prevent both immediate problems (mortality and morbidity) and long term problems. However, even where there is evidence to support such public health interventions, implementation in different settings and countries has met with varying degrees of effectiveness and sustainability. The issues addressed in this synthesis concern the main reasons for the success or failure of such programs in Europe.

The research evidence shows that the most effective programs for children and young people are carried out at the government level, supported by society in general, and promote national policies to decrease poverty and increase social equality. The second most effective interventions are coordinated government policies such as pricing, legislation and other policies. For example, the most effective interventions against tobacco use are increasing the price of tobacco, banning tobacco product advertising, banning smoking in public places and legislation prohibiting the sale of tobacco products to young people. There is also evidence that simultaneous, multi-dimensional inputs at national, local and individual level increase the effectiveness of general health promotion campaigns. The health promotion interventions that are least likely to work are ones that deal with single issues, are ‘negative in the message’, and delivered at only one level of society.

In examining effective public health interventions it is essential not to conceptualize children as “mini-adults,” but rather to see them as having specific health needs related to their age and stage of development. Nevertheless, a child is also a person, a citizen, and an individual in his or her own right with equal value to any other individual. This statement is clearly laid out in the United Nations Declaration and Convention on the Rights of the Child. Further, the burden of ill-health in children and young people has, in many ways, greater significance than the burden of ill health in adults as it can have a longer life-time effect and wider impact – on parents, families and society.

There is evidence that some disease prevention and health promotion interventions, when carefully planned, systematically implemented, well assessed and aimed at specific health problems, can make a difference. Some of these are outlined in the next section, along with interventions where the evidence is unclear. Such interventions may work in a controlled setting (for example, a vaccine trial), but the effectiveness of a program will depend on a sustainable strategy for long-term application in the local context. The following two items will be considered in this review to determine the factors that influence effective implementation of programs: interventions applicability in settings other than those of the original research and their sustainability over time.

Examples of public health interventions that show evidence of effectiveness

Preventing or decreasing social inequalities and poverty

The consequences of poverty and socio-economic inequity, including parenting difficulties, are still the major threats to child health, even in developed countries. Epidemiological and other evidence clearly indicates that the elimination of these factors will, in the long term, have the greatest effect on child, adolescent and adult health.

Immunization

Evidence indicates that immunization programs with high coverage offer one of the most cost effective health interventions, compared to other methods of preventing illness.

Folic acid supplementation during pregnancy

A meta-analysis undertaken by the Cochrane collaboration has shown that folic acid supplementation taken by women in the period around the time they conceive has a strong protective effect against foetal neural tube defects.

Promotion of breast feeding

A meta-analysis undertaken by the Cochrane collaboration indicates that extra support for mothers reduces cessation of breast feeding before the child being six months old. Extra health or medical professional support is beneficial for any breast feeding (mixed with bottle feeding) and non-health or medical professional support is effective in exclusive breast feeding. The benefits of professional support for breast feeding include a significant reduction in the risk of gastro-intestinal infections and atopic eczema. Research indicates that general support both from health and medical professionals and non-professionals enhances both the number of mothers breastfeeding and the length of time for which they do so.

Prevention of sudden infant death syndrome (SIDS)

Sudden death in the first year of life was moderately common (around 1 to 2 per 1000 live births) in Europe until a decade ago. Systematic epidemiological reviews found an association between babies sleeping face downwards and an increased risk of these sudden deaths, which led to the general recommendation that babies, during the first year of life, should be put down to sleep on their backs. Subsequently there has been a significant drop in sudden infant deaths.

Injury prevention

Examples of interventions that have been shown, by epidemiological studies, to be effective in reducing unintentional injury in children and young people include compulsory cycle helmet use, area wide traffic calming methods, child-safety restraints, child-resistant containers and window bars to prevent falls. Legislation generally has been found to be most effective means of implementing these, but environmental modification and education also play a part in preventing or reducing childhood injuries and their effect when combined is encouraging.

Cessation of cigarette smoking

A synthesis of the Health Evidence Network on interventions for tobacco control has shown that one of the most effective public health interventions to encourage cessation of smoking in adults and adolescents is increasing the price of cigarettes. Smoking restrictions, cigarette advertising bans and more accessible nicotine replacement therapy are also recommended. There is little evidence that school-based programs for the prevention of smoking uptake by young people are effective, but there is some limited support for the effectiveness of community interventions in helping prevent the uptake of smoking in young people.

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Factors That Influence the Success and Failure of Public Health Programs

To be most successful, public health interventions need to address all the direct and indirect influences on children’s’ and young people’s health and take action on many fronts including public policy, local communities and families, and children themselves.

Multi-factorial interventions

There is evidence that multi-factorial interventions with coordinated inputs at national and local community levels are more effective than interventions at one level only, because they recognize the complex interactions of the individual, social, economic and environmental factors that influence people’s behaviors.

Availability of relevant and reliable data on the target population

Reliable, relevant data are needed to judge the success of any program. Data collection is the starting point to knowing whether, at population level, a health promotion intervention should be instituted and whether it is effective. Such data collection needs to be at the national and regional or local level to assess epidemiological prevalence, political willingness, health-system capacity and community preferences. The indicators to be used should be scientific, robust and comparable.

Socio-economic factors

As already stated, socio-economic factors are the major determinants of health in children, young people and adults. They have a profound effect on both mortality and morbidity ranging from birth defects through many childhood diseases, health-related behaviors and life expectancy. Socioeconomic conditions have to be taken into account when implementing any public health intervention because if the population is of high economic status then the prevalence of a given health problem may already be low and the intervention may not reach a significant level of benefit. If, however, the population is of low economic status the intervention may have a more significant effect.

There are many ways in which poverty affects health, including unemployment, debt, resources and fuel poverty, poor housing, environment, nutrition and education, and psychosocial effects such as social exclusion and feelings of powerlessness and deficits in social support and social capital, services access, availability and use. It appears that poverty can exert a negative influence on the development and intellectual aspects of children’s health independently of the educational levels of the parents. Research indicates a clear association between parental education – particularly maternal – and health outcomes in children in developed countries.

Education is not only associated with greater earning capacity, but also with enhances of self esteem and confidence. Although most developed countries tend to have high levels of literacy there are also marked variations in the availability of education across all social and gender groups. Poverty itself would seem to have a direct effect on child health through loss of self esteem and increased chances of mental illness. Other possible effects include iron-deficiency anaemia, suboptimal maternal nutrition influencing embryonic growth of the foetus.

Political factors

Governmental policies and programs (national and local) will have an effect on the levels of poverty and socio-economic inequality within the population. In the field of nutrition for instance, research shows that among low-income families affordability was the most important factor in food choice. Further, other research studies suggest that low income not only restricts the ability to buy foods rich in protective nutrients, but it also limits access to the shops where healthy foods may be purchased more cheaply. Political support in terms of resources and public support for specific public health interventions are both crucial to their success. The willingness of governments not only to enact legislation concerning public health matters (for example, safety belts use) but to ensure that such legislation is enforced is important (for example, if no resources are provided to enforce the law and monitor the wearing of safety belts then the intervention may not be effective). Furthermore, governments can have a profound effect on health interventions via pricing and taxation policies and these can be effective for reducing both alcohol and tobacco use and there is evidence that such measures may be more effective than educational policies

 National and health system factors

Within each country there is a need to consider how to adapt a public health intervention to local needs, for example, how far regional needs in child health should be taken into account at the national level, or how resources are redirected to prevention programs with a high political profile for example, AIDS prevention programs. Other national factors include the degree of development and organization of a country’s health system (national systems versus local private systems); its health system strengths, weaknesses, infrastructure, current coverage and utilization; health care seeking patterns influenced by socioeconomic and cultural factors; the various financing options, and human and financial resources; the human and other resources available; the acceptability and availability of non-governmental resources.

Mass media programs

There is some evidence for the effectiveness of mass media advertising programs. The education of the population, the duration over which the programs are delivered and their intensity all appear to be important factors, as well as the credibility of the source of the information.

School health education

Health education in schools has been used extensively in health promotion programs because of a perceived ease of access to large populations of young people. However, by itself, such promotions have been shown to have little effect on outcomes in many areas. For example, research indicates little evidence of effectiveness of such programs in reducing smoking uptake.

Therefore, in many European countries there has been a move away from dealing with single-issue interventions towards programs teaching young people social skills for handling pressure to smoke, drink, take illegal drugs, etc. At present, the evidence for the effectiveness of the programs is scarce, mostly because of lack of appropriate research.

 Conclusion

Poverty and socio-economic inequalities remain the greatest barriers to health in children, young people and adults. Many public health interventions are targeted at the health and development of children and young people because of the potential for quality life-years to be saved. The evidence about the effectiveness of such interventions is variable and needs to be critically examined as some may not be generalized or sustainable. Interventions carried out or supported by governments are more likely to be successful, as are multi-factorial interventions. When generalizing an intervention found to be effective under specific conditions, a number of target-population factors should be taken into account, including the socioeconomic and political circumstances, the degree of government support that can be expected, culture and religion, and type of health service delivery system.

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