ARCHIVED - Summative Evaluation of the Community Action Program for Children : 2004-2009

KEY FINDINGS

Key findings are presented in sections below for each of the three outcome areas of CAPC, as identified as RMAF components -- relevance, impact and cost-effectiveness. In each section, evaluation evidence is assessed against the indicators for the related RMAF questions and supported with additional research linkages.

3.0 RELEVANCE

This section addresses questions pertaining to the persistence of threats to children’s health in Canada and alignment with federal government objectives for children. Outlined below are the specific RMAF questions on relevance that will be assessed against the evaluation evidence using the applicable indicators.

3.1 Threats to Children’s Health in Canada – Trends

CAPC was created based on the acknowledgement that some children in Canada live in greater conditions of risk than others. In order to assess the relevance of CAPC, the analysis for this section included an examination of the various conditions of risks in Canada and how and why they remain a threat to children’s health. It should be noted that while these conditions are examined under separate headings, inherent linkages exist among them.

A major source of data within this section was the 2009 CAPC Relevance Literature Report that included a synthesis of a wide range of data from a variety of sources. These include:

• Statistics Canada health and labour data
• The Survey of Labour and Income Dynamics (SLID)
• The Canadian Institute for Health Information (CIHI).

a) Trends in Poverty and Unemployment

Statistics Canada’s low income rate measures the percentage of families below the low-income cut-off (LICO)^{Footnote 1}. The LICO calculated by Statistics Canada is based on after tax income. The 2006 Census data indicates that 11.4% of the total Canadian population, an estimated 3.5 million people, lived in low income in 2005. In 2006, an estimated 880,000 young people aged 17 years and under were living in low income families (Statistics Canada 2008a). The low income rate was the highest among children and young people. In 2005, 14.5% of all children aged five years and under were part of a low income family.

Child poverty is associated with poorer physical and mental health, higher risk behaviour and social exclusion (UNICEF, 2007). The longer the child lives in poverty, the more prevalent their difficulties are likely to be later (Bradshaw, 2001; McCain et al, 2007). Chronic poverty during childhood can undermine the best efforts of teachers and schools and is strongly correlated to low educational achievement (Zigler et al, 1996; Bennett, 2008).

As discussed in this report, certain groups are more likely to have lower income than others in Canada. These groups include lone-parents, teenage mothers, people with lower levels of education, recent immigrants, and Aboriginal peoples.

The national unemployment rate was 6.6% in 2006 (Statistics Canada, 2008g) and has declined since 2001. However, Canada’s labour market is regionally diverse and unemployment rates varied in different markets. Unemployment rates in the Atlantic Provinces (Newfoundland and Labrador 18.6%, Prince Edward Island 11.1%, New Brunswick 10.0%, and Nova Scotia 9.1%) and parts of the North (Nunavut 15.6%, Northwest Territories 10.4%, and Yukon 9.4%) were the highest in Canada in 2006 (Statistics Canada, 2008g).

The unemployment rate among core working-age Aboriginal people in 2006 was 13.2%, down from 17.4% in 2001. Despite the large decline, Aboriginal people remain more than twice as likely as non-Aboriginal people to be unemployed (Statistics Canada, 2008g).

Despite improved opportunities, recent immigrants continued to have higher unemployment rates than the Canadian born:

• Although the unemployment rate for immigrant men fell from 11.4% in 2001 to 9.3% in 2006, it was almost double the rate for Canadian born men (5.2%); and
• Similarly, the unemployment rate for immigrant women fell from 15.7% in 2001 to 14.3% in 2006 but was almost three times the rate for Canadian-born women (5.0%).

Unemployment is linked to health issues for both those who are unemployed and their family members (Health Canada, 2004), including increased levels of psychological distress leading to more frequent use of health care services.

b) Trends in Single Parenting

The 1,414,100 single parents in Canada in 2006 represented 15.9% of all Census familiesFootnote 9; this was higher, in number and proportion, than any other recorded figure in the last 75 years.

Overall, single-parent families grew by 7.8% between 2001 and 2006. More than 80% of the lone parent families in Canada are headed by women (Statistics Canada, 2007c).

Single parents, especially single mothers, are more likely to face financial difficulties than other family types. Despite the fact that the median income ($36,765) of lone-parent families headed by women has increased overtime, they still have the highest incidence of low income among all different family types (married, common-law, and lone-parent families headed by men). Female headed lone-parent families with children have the lowest income rates. This disparity is illustrated by the fact that for every $100 of income received by a Canadian couple in 2005, lone-parent families headed by women received only $44 of income (Statistics Canada, 2008a). Lower income is linked to lower socio-economic status and affects health especially for children as discussed in greater detail earlier in the sub-section on trends in poverty and unemployment.

c) Trends in Teenage Pregnancy Rates

The birth rate of teenage women has been declining in Canada. In 2006, the birth rate was 13.6 per 1,000 teenage women compared to 35.7 per 1000 two decades earlier (Luong, 2008). While Canada’s teenage birth rate is only half of that in United States and United Kingdom, it is seven times higher than that of Sweden (Luong, 2008; McKay, 2006).

The likelihood of women giving birth in their teens varies with background and geographic regions in Canada. Women of Aboriginal background were more likely to be teenage mothers (Luong, 2008) and immigrant women were less likely to be teenage mothers than Canadian born women not of visible minority (Luong 2008; McKay, 2006; Galarneau and Morissette, 2004, SLID).

Negative health outcomes associated with teenage parenthood, for both mother and child, include:

• “More likely to have lower birth weights, increased infant mortality, increased risk of hospital admission in early childhood, less supportive home environments, poorer cognitive development, and if female, a higher risk of becoming pregnant as teenagers” (Langille, 2007; Botting et al, 1998); and
• “More often teenage mothers are likely to be socially-isolated compared to other teenagers, have mental health problems and have fewer educational and employment opportunities” (Langille, 2007; Wellings et al 1999).

d) Trends in Grade 12 Graduation Rates

In 2006, of the 17.4 million Canadians between 24 and 64 years of age, 24% had a high school diploma, 61% had some form of post-secondary qualifications, and the rest (15%) had less than high school education (Statistics Canada, 2008f). The number of Canadians ages 25 to 64 having a university degree has increased by 24% between 2001 and 2006. There has also been a decline in high school drop-outs from about 17% in 1990-1991 to about 10% in 2004-2005 (Statistics Canada, 2008h). It was also found that young males (12%) are more likely to drop-out than young women (7%).

In general, an increase in education is linked to an increase in income (Statistics Canada, 2008a); however, this was not the case for recent immigrants, whose earnings were often lower than expected given their education levels.

Education is an indicator of socio-economic status, along with income and employment (Currie and Lin, 2007). There is a strong relationship between poor child health and low socio-economic status in the United States, Canada and the United Kingdom. A recent study in the United States found incremental improvement in child health as family income and parental education went up (Commission to Build a Better America, 2008). In another study in Canada, it was found that the majority of young lone mothers aged 25 to 34 with less than high school education experienced low income in 2000 (Galameau, 2005).

e) Trends in Immigration Rates

The 2006 Census enumerated 6,186,950 foreign born people in Canada, representing one in five (19.8%) of the total population. This is the highest proportion in 75 years and has tripled in numbers during this same period (Statistics Canada, 2007a).

Between 2001 and 2006, Canada’s foreign-born population increased by 13.6%; this was four times higher than the Canadian-born population, which grew by 3.3% during the same period. The newcomer population, estimated at 1.1 million, were responsible for more than two-thirds (69.3%) of the population growth between 2001 and 2006.

Between 1980 and 2005, the income gap widened between recent immigrants and Canadian-born workers (Statistics Canada, 2008a). This occurred in spite of the fact that recent immigrants came to Canada with increased educational qualifications. In 1980, a recent immigrant man and woman would each have earned 85 cents for each dollar earned by their Canadian-born counterparts. By 2005 an immigrant man earned 63 cents and an immigrant woman earned 56 cents per dollar compared to their Canadian-born counterparts. Lower income leads to lower socio-economic status and the associated ill-effects and risks for the family and children.

f) Trends in Childhood Injury Rates

Childhood injuries are a devastating problem around the world. About 90% of children aged 14 years and under who died due to injuries did so as a result of unintentional causes (WHO, 2006). In Canada, unintentional injuries are the number one cause of death for children between the ages of 1 and 14 years (Safe Kids Canada, 2006).

In a 10-year review (1993-2003) completed by Safe Kids Canada, it was found that, on average, each year 390 Canadian children age 14 years and under died from unintentional injuries and 25,500 children age 14 years and under were hospitalized for serious injuries such as traumatic brain injuries, internal injuries and complex fractures (Safe Kids Canada, 2006). Unintentional injuries are the leading cause of death for Canadian children and youth between 1 to 19 years of age (PHAC, 2009).

Childhood injuries can have long-term effects on children and their families, including long-term disabilities and death. Such injuries also put a strain on the health care system and are estimated to cost about $4 billion per year (Safe Kids Canada, 2006).

Summary – Threats to Children’s Health Persist

The trends in issues affecting child health indicate that threats to children’s health persist in Canada. While a few have declined, many remain unchanged or are actually increasing for population groups facing conditions of risk. Research evidence documents the critical importance of these factors to children’s health and development throughout their lives (e.g. Blair et al., 2003; Irwin et al., 2007; WHO 2008). Investments in programming specifically declined to engage populations facing conditions of risk, like CAPC, remain a critical component of a comprehensive strategy to promote and alleviate disparities in healthy child development. An examination of CAPC’s reach to and impact on these at-risk populations is explored in Section 4.1.

3.2 Government Objectives and Priorities

The origins of CAPC have strong international roots -- CAPC was initiated in response to the 1990 commitment by Canada to the United Nations (UN) World Summit for Children. At the World Summit, the leaders of 71 countries made a commitment to invest in the well-being of vulnerable children. The Brighter Futures Initiative, Canada's Action Plan for Children, was established in response to the Summit and involves a series of steps towards achieving a better tomorrow for Canadian children and their families. In 1993, the Government of Canada launched CAPC, a component of the Brighter Futures Initiative. This section describes the relevance of CAPC in the current international, federal and PHAC context.

a) International Commitments and CAPC

One of the principal landmarks for international priorities for children’s well-being was in 1989, when the UN General Assembly adopted the Convention on the Rights of the Child, which states “children should be fully prepared to live an individual life in society, and brought up in the spirit of the ideals proclaimed in the Charter of the United Nations” (UNICEF, 2007b). The Government of Canada submits periodic reports as required by Article 44 of the Convention. These reports specifically mention CAPC as an innovative initiative of the Canadian government’s health and social investment to help Canadian children develop to their full potential (UN, 2001).

In 2000, the world’s leaders met and signed the Millennium Declaration “pledging to free fellow men, women and children from the abject and dehumanizing conditions of extreme poverty”. This was followed by a commitment to targets, known as the Millennium Development Goals (MDGs), all of which involve the rights of the world’s children.

The objectives of CAPC are appropriate and relevant to all of the Goals; however, they contribute specifically to the targets set out for goals three, four and five:

• Promote gender equality and empower women;
• Reduce child mortality; and
• Improve maternal health.

During the UN General Assembly in 2002, the 27th Special Session was exclusively devoted to children. The General Assembly adopted a declaration that committed to seizing “the historic opportunity to change the world for and with children” (UNICEF, 2007b). The resulting plan of action of this Session was A World Fit for Children with four priority areas: promoting healthy living; providing quality education; protecting against abuse, exploitation and violence; and combating HIV and AIDS“. A World Fit for Children represents a remarkable worldwide consensus about strategies and actions to improve the situation of all children everywhere (Government of Canada, 2004).

In response, Canada developed its national plan of action in 2004, A Canada Fit for Children, as an endorsement of its commitment to children. The plan highlights the Canadian Government’s agenda and investments planned for children. CAPC is specifically mentioned as part of the plan and the investment, highlighting the relevance of CAPC to Canada’s commitment to international priorities.

b) Federal Government Commitments and CAPC

The 2004 national plan of action, A Canada Fit for Children, calls for strategies that are child-centred, multi-sectoral, forward looking and collaborative (Government of Canada, 2004). The four central themes of the document are: supporting families and strengthening communities; promoting healthy lives; protecting from harm; and promoting education and learning. These not only mirror the international priorities but also are at the foundation of the CAPC strategies and objectives.

As discussed in various sections of this report, Canada has a long history of supporting innovative initiatives for early child development. As part of its commitment to children, the Federal Government also launched key early childhood development programs in Canada, in addition to CAPC. These include: Canada Prenatal Nutrition Program (CPNP); Aboriginal Head Start (AHS); and the National Child Benefit (NCB). CPNP and AHSUNC are both integral components of maternal and child health programming within PHAC and are closely linked with CAPC programs and activities.

In addition to the international priorities for children, which are endorsed by the Government of Canada, the 2007-2008 Federal Government Report on Plans and Priorities (RPP) outlined priorities related to child and family well-being. Of the thirteen outcome areas in the RPP, one outcome area is of particular relevance to CAPC:

• Healthy Canadians
• Improve health outcomes for Aboriginal people, including in relation to improvements in maternal health; and
• Prevent diseases and address other health challenges.

CAPC’s long-term outcome identified in its RMAF, i.e., to “contribute to the health and social development of CAPC children (0-6 years) and their families living in conditions of risk”, directly addresses this Federal Government outcome area (“Healthy Canadians”). It also responds to the recent Speech from the Throne (Government of Canada, 2007), which emphasized improving the lives of Canadians and looking to the future of Canadian children.

“Our Government is committed to strong leadership to realize that future -- a Canada that is safe for our families and healthy for our children”. (Government of Canada, 2007)

c) PHAC Commitments and CAPC

The vision PHAC outlined in the 2008-2009 Report on Plans and Priorities (RPP) was, “Healthy Canadians and communities in a healthier world”. The strategic outcome outlined was, “healthier Canadians, reduced health disparities, and a stronger public health capacity” (PHAC, 2009b). This is consistent with the Federal Government outcome “Healthy Canadians”. Various program activities planned by PHAC to achieve this outcome are: Health Promotion; Chronic Disease Prevention and Control; Infectious Disease Prevention Control; Strengthened Public Health Capacity; and Emergency Preparedness and Response. The PHAC activity, “Emergency Preparedness and Response” was also consistent with the Federal Government outcome area – “Safe and Secure Communities” (PHAC, 2009b).

Table 3 outlines the alignment between strategies used by CAPC and the PHAC activities.

Source: Compiled by HCA (2009) from Federal Government RPP (2007-08) and PHAC RPP (2008-09)

Summary -- CAPC and Government Objectives and Priorities

CAPC objectives are consistent with the commitments for improvements in maternal and child health at the international, national and Agency-levels. CAPC is a community-based initiative, and the design and delivery of activities and supports are driven by those community principles. The broad programmatic objectives resonate well beyond community needs and are consistent and reflective of worldwide initiatives focused on those children most at-risk.

CAPC is a significant means by which PHAC feeds into the Government of Canada’s strategic outcome and it is also a means by which Canada is delivering upon its international commitments to children. However, as noted in Section 2.3, the heterogeneous structure of CAPC makes it challenging to identify core objectives and services, and to measure CAPC outcomes nationally. This challenge is identified in the recommendations section as a key element for future considerations regarding program and evaluation design.

4.0 IMPACT

This section addresses questions pertaining to the impact of CAPC as outlined in the RMAF performance measurement and evaluation strategy. Following the principles and guidelines of meta-evaluation synthesis outlined in Section 2.0, national evaluation findings on impact (particularly for CAPC’s contribution to healthy child development) are further substantiated with regional evaluation findings for CAPC. The specific RMAF questions on CAPC impact and applicable indicators are:

4.1 Reach

a) Geographic Reach

A total of 3,177 communities across Canada were reached through CAPC projects (Table 4). Over half of the CAPC communities served were in Quebec and the Atlantic region. These community numbers should be interpreted with caution in Table 4 and 5 as the definition of a community could include multiple interpretations which may have led to instances of double-counting.

Source: NPP 2005-2006

Results from data collected though CAPC’s annual NPP illustrate that CAPC projects served a comprehensive mix of urban, rural and remote or isolated areas (Table 5). Some of the projects served both urban and rural areas. Overall, CAPC projects reached an average of 8.4 communities per project. Although only 20% of the Canadian population lives in rural and isolated areas, one-third (33.3%) of CAPC projects were specially focused on reaching communities in rural and or isolated areas, thereby increasing accessibility to health system supports and potentially reducing inequities in these communities.

Source: NPP 2005-2006

b) Reach to People Living in Conditions of Risk

CAPC was designed to support priority populations, especially children and families living in conditions of risk. This section looks at how CAPC has reached these populations. In total, more than 37,000 parents, caregivers and their families were reached through the November 2008 CAPC Snapshot.

The results, which have been compiled from the 2008 CAPC Snapshot and compared to 2006 Census data^{Footnote 11}, provide an indication of CAPC’s reach to various groups of people living in conditions of risk. The key findings are:

• Low-income Families: Overall, more than half (53.8%) of all CAPC parents and caregivers reported family incomes below the Low-Income Cut-Off (LICO) in their community. The highest proportion was found in Manitoba (77.3%), Saskatchewan (67.1%) and Ontario (65.2%). In comparison, only 19.3% of Canadian families fell below the LICO^{Footnote 12} based on the 2006 Census.

• Single Parents: One in four (24.2%) of the CAPC parents and caregivers who participated in the Snapshot survey were single parents. The highest proportions were found in Manitoba (56.0%), Saskatchewan (39.8%), and Alberta (32.9%). By comparison, 15.9% of the general Canadian population were single parents.

• Teenage Parents: About 5.3% of parents and caregivers participating in CAPC were 19 years of age and under. The highest proportions were reported in Alberta (16.4%) and Manitoba (10.0%). In comparison only about 1.1% of the Canadian population were teenage parents.

• Low Education: One in four (25.6%) CAPC parents and caregivers had not graduated from high school or equivalent. The highest proportions were found in Manitoba (51.9%) and Saskatchewan (40.6%). In comparison only 15.5% of the Canadian population had not obtained a high school diploma.

• Aboriginal Families: One in seven (13.4%) of the CAPC participants identified themselves as an Aboriginal person. The highest proportion was found in Nunavut (77.7%), Manitoba (68.9%), Saskatchewan (57.7%) and the Yukon (37.2%). In comparison only 4.0% of the Canadian population is Aboriginal.

• Born Outside Canada: One in five (21.2%) CAPC participants were born outside Canada. The highest proportion was noted in British Columbia (34.1%), Ontario (31.8%) and Alberta (27.3%). Overall, the proportion of foreign-born CAPC participants was similar to the general Canadian population (19.8%). More than four out of ten (43.2%) CAPC participants who were born outside Canada were recent immigrants^{Footnote 13}.

• Living in Rural/Isolated Communities: Approximately one-third (33.3%) of CAPC participants live in rural and/or isolated areas. In comparison only about 20% of the Canadian population live in rural and/or isolated areas.

• Children with Special Needs: Almost one in six (15.6%) CAPC children have special needs including, problems with hearing, seeing, speech, learning, moving, and/or behaviour. The highest proportions were found in the Yukon (39.2%) and Quebec (28.8%). Although comparative analysis is not feasible to the general population, it is interesting to note that in 2006 the Canadian Council on Social Development (CCSD) reported that about 4.5% of Canadian children aged 0 to 4 lived with disability.

It should be noted that these conditions of risk are not mutually exclusive. People living in conditions of risk are generally affected by multiple conditions of risk. In the 2008 CAPC Snapshot, an assessment of multiple risks indicated the following:

• Aboriginal Parents and Caregivers:
  • 80% of Aboriginal parents and caregivers had incomes below the LICO, 52% had not completed high school and 48% were single parents.
• Single Parents and Caregivers:
  • 87% of single parents had incomes below the LICO.
• Parents and Caregivers with Low Education:
  • Of the parents and caregivers who had not completed high school, 86% reported incomes below the LICO and 43% were single parents.

Overall, a high proportion of CAPC families live in conditions of risk, and the majority of parents and caregivers reached by CAPC are affected by multiple risks. Analysis from the 2008 Snapshot indicated that at least 76.4% of all respondents noted at least one risk factor. For every risk criteria examined, the proportion of families participating in CAPC is higher than the proportion in the general Canadian population as illustrated in Figure 2.

Figure 2: Proportion of CAPC Families Facing Conditions of Risk vs. Canadian Families in the General Population

Source: Compiled by HCA (2009) from 2008 National Snapshot Survey and 2006 Census Data

Summary – Reach to People Living in Conditions of Risk

CAPC has reached a high proportion of Canadian families living in conditions of risk. In fact, CAPC families exhibit conditions of risk greater than the general population. This early intervention is important as research has shown that children growing up under conditions of risk often exhibit less than optimal development. These children have higher rates of poor health, developmental difficulties and social, cognitive and behavioural problems (Conger et Al, 2002; Mistry et al, 2004; National Research Council and Institute of Medicine, 2000).

4.2 Healthy Child Development

CAPC strives to contribute to the healthy development of children (0 to 6 years) living in conditions of risk. In order to assess this contribution, this section includes an analysis of findings from multiple lines of evaluation evidence and validates it through supporting evidence from the literature. The synthesis is presented under key CAPC RMAF outcome indicators:

• Enhanced capacity of children living in conditions of risk;
• Increased opportunity for knowledge and skills of parents and caregivers; and
• Increased and more effective initiatives to enhance community capacity.

These outcomes are supported by strong social, economic and educational arguments surrounding early childhood development programs (Sen, 1999; Urrutia, 1999; Vandell and Wolfe, 2000; Verry, 2000; Bennett, 2008). Research findings are outlined in the sections on each indicator of healthy child development to strengthen the value of the evaluation findings.

The assessment of participant and programmatic outcomes was a central component of the national qualitative analysis of CAPC. The qualitative analysis provides evidence on how projects contributed to improved health and social development of children, increased parental capacity and increased community capacity. The most common outcomes demonstrated in the qualitative data include:

• Parental personal improvements (50%);
• Improved healthy child development outcomes (48%); and
• Improved community capacity (42%).

Figure 3 illustrates these outcomes and additional reported outcomes.

Figure 3: Most Frequently Reported CAPC Outcomes (2003-2006)^{Footnote 14}

Source: Qualitative Analysis of the CAPC Story Data (2008)

A more detailed assessment of these outcome areas and a triangulation of these national qualitative findings with select regional evaluation results as secondary evidence are included in the following sections.

a) Improvements in the Health and Social Development of Children

Children need a wide range of stimuli – visual, verbal, social, emotional and physical – to promote normal progression into adulthood. Research on young children with high-risk backgrounds suggests that such positive stimuli are associated with fewer behavioural problems (Appleyard et al, 2007).

Almost half (48%) of all nationally reported outcomes in the qualitative analysis highlighted positive health and social development of children as a primary outcome. Using the research literature, health and social development outcomes were grouped under the following indicators^{Footnote 15}:

• Physical well-being / overall healthy development
• Social knowledge and competence
• Emotional development/maturity
• Language and cognitive development
• Special problems

A detailed summary of health and social development competencies and observed behaviour and skills of the CAPC children is presented in Annex-3.

Summary - Improvements in the Health and Social Development of Children

The meta-evaluation of the national qualitative analysis and comparable regional evaluations reveals that CAPC has positive effects on a variety of indicators for health and social development outcomes for children. The evidence indicates that CAPC projects have demonstrated a positive influence on motor skills, social knowledge and competence, language and cognitive development, as well as addressing special needs and problems and contributing to children’s overall school readiness.

Findings from the literature support these results. The evidence shows that early childhood development initiatives focusing on cognitive, language and social skills of children aged 0-6 years can contribute to their general development, school readiness, educational performance and employment prospects later in life. In addition, there are positive effects on self-esteem, motivation and social behaviour (Zigler et al, 1996; Bennett, 2008; Brooks-Gunn, 2003).

The literature also illustrates that motor development, especially gross motor skills, is the foundation for developing other skills including fine motor skills (Krapp and Wilson, 2005). Lower levels of motor development affect social development and competence, school readiness and communication of wants and desires (Favaro, Gray and Russell, 2003; Statistics Canada, 1996; Doherty, 1997). Earlier studies reveal that high quality early childhood interventions can have positive effects on children’s intellectual development, regardless of their family background (Lamb, 1998; Cleveland and Krashinsky, 1998). Other studies reveal that early childhood interventions lead to improvements in measures of intellectual ability (IQ), standardized academic achievement tests, and standardized tests of school readiness (Bennett, 2008; Barnett, 2006; Anderson et al, 2003; Carpenter, 2007). Longitudinal research has also found positive impacts on peer relationships and classroom skills (Doherty, 2007).

Strong positive effects have also been consistently found in terms of reduction in grade repetition and special education placement rates and increased high school graduation rates among disadvantaged children attending early childhood programs (Barnett, 2006; Anderson et al; 2003, Doherty, 1996). The literature also provides evidence that the positive outcomes from early childhood development initiatives lead to additional benefits at later stages in life (Campbell et al 2002).

b) Increased Parental Capacity

Parents who understand how children develop and who use effective parenting techniques raise healthier and happier children (Austin and Lenon, 2005). The RMAF outcome indicator related to parental capacity is parenting knowledge and skills.

Improved or increased parental capacity was the single most frequently reported outcome (50%) in the qualitative analysis. Parental capacity indicators identified in the research literature include self-improvement, knowledge development, and skill building.

• Parental Self-Improvement: The assessment for the parental self-improvement outcome indicator was based on domains^{Footnote 16} categorized in the research literature. The qualitative analysis and regional evaluations also presented findings corresponding to those domains, which are used here:
  
  • Life skills - The qualitative analysis found parental self-improvement through a set of improved life skills including time management, knowledge and confidence to take public transportation, appropriate decision making skills, and improved budgeting. The development of health-related life-skills included making healthier personal choices and improving personal health, overcoming addiction, and learning about food preparation (Meyer and Estable, 2008). These findings are substantiated by regional evaluations conducted in Manitoba and Atlantic that found that parents learned to stay organized, overcome personal and health challenges, and gained leadership and computer skills. Healthy living practices, cooking, and nutrition are other self-improvements reported by parents.
    
    "My participation in the program has made me a better mother because I got a channce to relax, socialize and learn new skills"
  • Emotional well-being - The qualitative analysis reported improvements in parents’ confidence and self-esteem, in addition to overall emotional well-being, reduced stress levels, and an increased sense of belonging often coupled with reduced isolation. Parents felt more accepted and valued for their contributions (Meyer and Estable, 2008). In Alberta, results from the impact evaluation showed that for the majority of participants, increased participation in CAPC was associated with statistically significant improvements in levels of family functioning. This effect was even stronger for families below the poverty line.
  • Social support networks - The qualitative analysis at the national level also indicated that reduced isolation, coupled with increased social skills and new friendships were key to building social support networks for CAPC participants. CAPC programs also increased cross-cultural interactions through sharing recipes and cooking food together (Meyer and Estable, 2008). A regional Manitoba evaluation indicated that parent CAPC participants appreciated being able to talk about parenting with other parents in similar situations and emphasized the importance of supporting and learning from each other. An impact evaluation of CAPC projects in Alberta demonstrated that CAPC participants have higher levels of social support than a NLSCY comparison group after accounting for conditions of risk. This difference is even stronger among those with the greatest number of risks.
    
    "I learned that I am not alone. Other moms have similar feelings, expressions, and strategies. I enjoyed the opportunity to connect with others."
  • Empowerment - The qualitative analysis at the national level indicated empowerment as an outcome of program participation. Assertiveness skills and the ability to speak up, ability to advocate for other parents and community, and the ability to teach another parent what to do, were some of the indicators of empowerment reported by CAPC participants (Meyer and Estable, 2008). The Manitoba regional evaluation indicated that most participants reported that they felt more self-confident to speak for themselves; this boosted their self-image.
  • Relationships - The national qualitative analysis revealed that participation in CAPC programs and its diverse activities helped improve personal and family relationships for parents (Meyer and Estable, 2008). As an example, it was found that most CAPC parents in Manitoba described that they felt more capable of supporting their children on a day-to-day basis and this contributed to improved family dynamics at home. In Alberta, results from the impact evaluation showed that, for the majority of participants, increased participation in CAPC was associated with statistically significant improvements in levels of family functioning. The effect was even stronger for families below the poverty line. This analysis included indicators related to family dynamics and relationships.
  • Education/Employment - The national qualitative analysis indicated that parent participants were able to upgrade their education, studies, and courses, and improve language skills and employment income (Meyer and Estable, 2008). Parents were also able to develop new skill sets as a result of volunteer involvement or participating in workshops. In the Alberta impact evaluation, results indicated a statistically significant reduction in the negative effect of low education for several outcome areas including social support, positive parenting and literacy activities of both parents and children, with increased frequency of participation in CAPC.
  • Knowledge and use of community resources - The national qualitative analysis revealed that parents feel a sense of empowerment when they have knowledge about community resources and are able to increasingly use them (Meyer and Estable, 2008). For example, the regional evaluation in Atlantic Canada indicated that 84% of the CAPC respondents are aware of community resources and 73% made use of them. In Ontario, regional evaluation findings indicated that more than 70% of the CAPC respondents experienced a positive change in their knowledge, confidence and ability to access community services (Harry Cummings and Associates, 2009). Results from the Alberta impact evaluation indicated that a greater level of participation in CAPC was related to more perceived sources of help; this was also associated with increased frequency of child participation in CAPC.
    "I have met alot of new friends through the drop-in and there is even access to a food bank located there every week for people that need the help if needed which has come in handy for me from time to time."
• Parenting Knowledge and Skills: Results of the national qualitative analysis included improvements in knowledge and skills related to healthy child development milestones; child behaviour; child nutrition; child rearing; child safety and injury prevention; and overall child health. The indicators below are in line with the indicators specified by the Early Childhood Learning Knowledge Centre (Meyer and Estable, 2008) for analysis of parenting knowledge and skills.
  • Stimulating and supporting children’s verbal and cognitive development - The national qualitative findings indicated that CAPC programs contributed to parents’ stimulation of children’s verbal and cognitive development. This includes parents changing the way they interact with their children, reading to children, playing games with children, and increases in parents’ vocabulary (Meyer and Estable, 2008). Other stimulating and supporting activities taken up by parents include singing with children and taking children to the library, activities that started after participation in CAPC. In British Columbia, regional evaluation data indicated that overall 82% of the parents reported at least two ways that their children gained language and cognitive development. In addition, the impact evaluation conducted in Alberta demonstrated that increased frequency of adult CAPC participation had a statistically significant positive effect on Parent-Child Literacy Activities for families above and below the poverty line. Results also indicate that CAPC parents with a moderate number of risks engage in more early literacy activities with their children than a NLSCY comparison group with the same risks. 
  • Increased coping abilities - The national qualitative analysis revealed that participation in CAPC programs has increased the coping abilities of parents.
    "This program has helped me be patient with my children and we get along much better."
  • Sense of competence as a parent - The national qualitative findings indicated improvements in parents’ self-awareness and self-esteem in parental roles after participation in CAPC (Meyer and Estable, 2008). In addition, the Ontario regional evaluation found an overall improvement in sense of parental competence, after participation in CAPC, which was statistically significant (Harry Cummings and Associates, 2009). Furthermore, results from an Alberta impact evaluation indicated that CAPC parents with the greatest number of risks had higher positive parenting scores than a NLSCY comparison group with the same risks.

Summary – Increased Parental Capacity

Increased parental capacity was examined from two perspectives: parental self-improvement and parenting knowledge and skills. This meta-evaluation indicates that CAPC has had a positive impact on both. Concerning parental self- improvement, national and regional evidence indicated that CAPC contributed to improvements in:

• Parental life-skills; emotional well-being; social support networks; empowerment; relationships; education/employment; and overall knowledge and use of community resources.

Research literature demonstrates links between parental self-improvement and long-term impacts for themselves and their children. Social support has been linked to health and avoidance of disease by multidisciplinary researchers since the 1970s (Cassel, 1974; Underwood, 2000). Evidence suggests that pregnant women with more social support are more likely to seek prenatal care (Schaffer and Lia-Hoagberg,1997), to deliver babies with normal birth-weights and Apgar scores (Killingsworth-Rini, et al 1999), to go to full term (Edwards et al., 1994), and to experience fewer complications with pregnancy, labour, delivery, and infant health (Norbeck and Tilden, 1983). Receiving social support during the early parenting period is also associated with a variety of positive outcomes, including higher rates of mothers completing their education (Roye and Balk, 1996). Social support is beneficial for infants, as indicated by better maternal-child interactions (Logsdon et al., 1994; Seguin, et al., 1999), higher rates of obtaining infant immunizations on time (Steven-Simon et al, 1996), fewer unintentional infant injuries (Harris and Kotch, 1994), and less child abuse (Bishop & Leadbeater, 1999).

This meta-evaluation also indicates that parents who received CAPC support were able to increase their parenting knowledge and skills. Knowledge areas include:

• Healthy child development milestones; child behaviour; child nutrition; child rearing; child safety and injury prevention; and overall child health.

Evidence from evaluations of early intervention programs similar to CAPC show that providing supports and interventions to parents of young children at-risk for later difficulties can improve parenting knowledge, skills, and behaviours and ultimately contribute positively to children’s developmental outcomes (Bradley, Burchinal, & Casey, 2001; Brooks-Gunn et al., 2000; Barnett & Hustedt, 2005). The literature consistently shows that children need responsive, consistent, stimulating and nurturing parenting to grow physically, cognitively, socially and emotionally (Hertzman, 2000; Thompson, 1998). Children who experience high quality care from their parents during the early years fare better than those with lower quality home environments (Hertzman, 2000; Mustard et al., 2000) There is also evidence that poor early parent-child relationships can lead to emotional and behavioural problems, low sociability, poor peer relations, drug use, delinquency and criminality in later life (Carlson and Sroufe, 1995; Warren et al, 1997; Garnier and Stein, 1998; Ogawa et al, 1997;). This provides overall validation that an increase in parenting knowledge and skills will contribute to positive long-term outcomes from CAPC.

c) Increased Community Capacity

Capacity building has emerged as a key strategy for enabling communities to address priority health issues across many PHAC funding programs including CAPC. PHAC’s Community Capacity Building (CCB) tool includes a set of assessment criteria for achieving community capacity. These criteria were used as the indicators below to synthesize and report the findings from multiple lines of CAPC evidence including the qualitative analysis and the annual NPP. Nearly half of all reported outcomes (42%) in the qualitative analysis identified improvements in community capacity.

• Participation – This indicator includes stakeholder involvement and representation, and the removal of barriers to accessibility. CAPC provides opportunities for participants to become engaged in the management and delivery of the project and programs. Almost 95% of the CAPC projects were found to have participant involvement (NPP, 2005-06). A more detailed analysis is presented in the Population Health Approach section later in this report. Findings discussed earlier in the Reach section reveal how CAPC has reduced barriers not only for communities located in rural or isolated areas, but also for children and families living in conditions of risk, especially Aboriginal people, newcomers, teenage parents and low-income parents. It is evident that CAPC values social inclusiveness and improves the accessibility of services, which in turn empower parents.
  
  "I got to sit on the Board as a parent member. I felt respected by the other Board members. This was a very positive experience for me... It helped me to develop confidence and was a fantastic esteem booster".
• Leadership – This includes involving and supporting community leaders, defining their roles and responsibilities, and developing accountability structures. Participants have demonstrated leadership by taking on a range of formal and informal roles in their CAPC projects including serving as board members, committee members, informal group leaders, and program spokespersons, among others. The most current national data from NPP indicates that 55% of all CAPC projects reported participant involvement directly in decision-making and 44% reported participant involvement on an advisory committee (NPP, 2005-06).
• Sense of Community – A sense of community and a sense of belonging are measured through a combination of CAPC outcome indicators discussed in this report. This includes ability to access community resources, social support systems, leadership roles, and increased inter-cultural interactions. One example of how CAPC fosters a sense of community is through the communal kitchens. In addition, the regional evaluation in Manitoba found that participants of CAPC projects based on Aboriginal traditions or Francophone culture appreciated that the projects recognized the importance of history, language, tradition, and cultural contexts in relation to health promotion.
• Collaboration and Partnerships – This indicator ranges from networking, to gaining support and taking action, to collaborating with various organizations across sectors. CAPC projects work with more than 6,600 partners across Canada (NPP 2005-06). Collaboration and partnerships are discussed in greater detail in the Population Health Approach section. Partnerships and collaboration enhance community capacity as they build community structures. This includes establishing links with pre-existing structures, forming new structures, and advocating suggestions to improve structures (Meyer and Estable, 2008).

The summary of outcome indicators for community capacity linked to the CAPC program is presented in Annex-4.

Summary – Increased Community Capacity

The evidence indicates that community capacity has been increased. Specific improvements include:

• CAPC projects are successfully implementing stakeholder involvement and representation, improving accessibility, building leadership and a sense of community, and collaborating and building partnerships with a range of organizations at multiple levels.

Child development theory and research shows that community capacity and community development are important to children’s developmental outcomes (Bronfenbrenner and Morris, 1998; National Research Council & Institute of Medicine, 2000). Healthy child development stems from healthy communities and healthy families. Neighbourhoods and communities affect children’s physical health and safety and play a key role in their access to social, educational and growth promoting opportunities (National Research Council & Institute of Medicine, 2000). Community danger and economic stress can compromise parent-child interactions and community cohesion (Sampson et al, 1997), both of which tend to be related to children’s health outcomes (Baumrind 1989; Thompson, 1998). Other organizations that are important to early childhood development, such as schools, parks, libraries, and child care centres, are embedded within community contexts and the quality of children’s developmental experiences within these organizations is linked to community resources and programming (National Research Council & Institute of Medicine, 2000).

4.3 Population Health Approach

CAPC’s work is rooted in participatory and population health approaches to health promotion and addresses a range of determinants of health. The CAPC approach is based on the premise that meaningful engagement of participants is mutually beneficial to the project and participants. Participant involvement can help projects ensure that they are meeting the needs of participants, and can create a supportive environment for health promotion and community capacity building. National performance measurement data (collected in the annual NPP) is assessed below across key indicators and principles of population health strategies. These include:

• Application of multiple objectives and strategies
• Partnerships and collaboration
• Participant involvement.

a) Multiple Objectives/Strategies

It was found that CAPC projects had multiple program objectives. Overall there were 19 objectives cited by the projects and they used various combinations of those objectives for the delivery of programs appropriate to the community. Most projects (89%) cited improved parenting skills and parent-child relationships as one of the main program objectives. Almost three-quarters of the projects had improved child development (75%) and decreased social isolation (74%) as the main objectives for the program (NPP 2005-06).

The program objectives were achieved through a variety of program delivery methods. Based on an analysis of data gathered from 394 CAPC projects (NPP 2005-2006), it was found that the most common delivery methods used by the projects were:

Child-focused activities including pre-school programs and play groups (reported by 72% of the projects);

• Parent support groups (68%);
• Parent/child groups (58%);
• Classes (54%);
• One-on-one support (42%);
• Home visits (39%); and
• Referrals / information (39%).

Other program delivery methods included: respite care; provision of resources; field trips and events; building partnerships; drop-in activities; promotional activities; meals and collective kitchens; committees and coalitions; outreach activities; transportation; professional training; and cultural ceremonies.

b) Partnerships and Collaboration

CAPC projects recognize the importance of building partnerships and collaborating across sectors to influence the broader determinants of health, integral to the population health approach. Almost all (97%) of the CAPC projects reported having partners. As noted earlier, there were more than 6,600 partners associated with CAPC projects, with an average of 17 partners per project. Approximately 46% of the projects had more than 10 partners and 51% of the projects had at least one partner but less than ten (NPP 2005-06).

CAPC projects worked with different types of partner organizations. Health organizations such as health departments, regional health authorities, community health centres, and hospitals were the most frequently reported type of partner (89% of the projects). The other most frequently reported partners were educational institutions; neighbourhood and community organizations; family resource, early childhood, and day care centres; and child protection and child and family services. Figure 4 shows the breakdown of types of CAPC partner organizations.

Figure 4: Type of CAPC Partners

Source: NPP 2005 – 2006

c) Participant Involvement

The analysis indicates that CAPC provided many opportunities for participants to become engaged in the management and delivery of the project and its programs. Almost all projects (95%) across Canada were found to have some degree of participant involvement. It was further determined that there were both informal (84% of projects) and formal (83% of projects) types of involvement. Based on current available data, it was determined that 55% of all CAPC projects had participants involved in decision making and 44% had participants involved in an advisory committee role (NPP 2005-06).

Volunteering was seen as an important form of participant involvement, with more than three-quarters (77%) of the projects reporting volunteers. In a typical month it was found that about 4,747 volunteers were involved for a total of 27,159 hours, which is almost 1.5 hours per volunteer each week. About half (49%) of all volunteers who donated time to CAPC projects were CAPC participants. About one quarter (24%) of the projects had participants working as employees as well. About 51% of past volunteers volunteered in the community. Several mothers volunteered to mentor teenage-parents. Research shows that these types of community-based models that engage both the public and participants can be very effective in delivering services to children and families (Hertzman, 2000; Jack, 2005; Mustard, et. al, 2000; Wandermann and Florin, 2003).

Summary – Population Health Approach

The population health approach is consistent with the global emphasis on increasing health equity by targeting the determinants of health (WHO, 2008). In their efforts to affect these determinants, CAPC projects offer a range of intervention strategies consistent with the principles of the population health approach. Specific findings have demonstrated that:

• CAPC designs and delivers programs to be responsive to the determinants of health.
• CAPC projects have multiple objectives and they are delivered using a multitude of strategies.
• CAPC projects demonstrate a high degree of partnership and collaboration with a wide variety of organizations. These partnerships are integral to the availability and quality of support provided to children and families living in conditions of risk.
• CAPC has a strong commitment to providing opportunities for participant involvement with a positive impact on participant self-development and service delivery to children and families.

5.0 Cost-Effectiveness

This section addresses the questions pertaining to cost-effectiveness as outlined in the performance measurement and evaluation strategy of the CAPC RMAF. Outlined below are the specific RMAF questions and the applicable indicators. The primary source of data in this section is the 2009 Assessment of the Economic Impact of the CAPC.

5.1 Program Operational Costs

a) Leveraging Additional Resources

CAPC projects leverage the resources they need to provide programming. In 2005-2006, they leveraged $48.6 million in resources. As such, CAPC program funding accounts for approximately half of the estimated value of the program (Table 6). Funding from CPNP and the Aboriginal Head Start in Urban and Northern Communities (AHSUNC) program account for 10.5% of the total value and other partners contribute another 22%. The value of in-kind goods and services and human resources account for 17% of the total funding.

Source: Assessment of the Economic Impact of the CAPC (2009)

In addition to goods and services, CAPC projects receive support in the form of in-kind human resource time paid for by other local organizations. In 2005-2006, 91% of projects received in-kind support in the form of human resources. The estimated total number of in-kind hours provided annually by partner organizations was 230,064 and the value of these resources is estimated at $4.7 million based on average salaries for various CPNP and CAPC positions. About 77% of CAPC projects have current and past program participant volunteers who contribute about 291,800 hours per year to the projects. Based on CAPC salaries for similar work, the value of the participant volunteer time is estimated at $2.7 million annually. For 77% of the CAPC projects, other community volunteers also provide support in terms of management and program delivery. These other volunteers contribute approximately 268,300 hours a year at an estimated value of $2.5 million.

As shown in Table 6, the core funding of $58.9 million for CAPC programs came from PHAC as CAPC, CPNP and AHSUNC funding. However, the successful implementation of CAPC is also attributable to diverse additional sources of funding, much of which is leveraged from outside the PHAC-CAPC investment. These funds are important in the calculation of the cost per CAPC participant.

b) Participant Costs

Although cost per participant is actually a cost-efficiency indicator, it is an important factor in assessing program cost-effectiveness. CAPC uses multiple approaches to program delivery and the density of the population varies widely across various communities. Even if a single approach were used, costs can vary across provinces/territories and communities and can show higher costs for sparsely populated areas due to lower enrolment and participation. In the case of CAPC, the national average participation was 174 participants per project, with Saskatchewan having the lowest regional average at 57 and British Columbia having the highest regional average at 493 (Table 7).

The cost per participant was calculated based on 67,884 participants^{Footnote 17}. The cost per participant was $1,187 based on PHAC and partner funding ($80.5 million) as input costs. Considering the fact that almost 20% of total program costs were offset by in-kind contributions from the community (Table 6), it can be said that the actual total cost per participant is $1,433.

Summary – Program Operational Costs

In an analysis of similar early childhood development programs completed by the World Bank, cost per participant varied from $25 to over $2500 (World Bank, 2008). Although affordability can be an important criterion in deciding which program approach to adopt, the cheapest program may not be the best in fostering healthy child development and the most expensive programs do not always produce the best quality services. In some cases, lower cost, less intensive services generate sufficiently positive impacts to warrant the investment. At the same time, it would appear that the greater the investment and the more comprehensive and long-term the programs, the greater the long-term returns (Harvard, 2007). The overall cost per participant for CAPC was $1,433 to achieve the various outcomes set out in the RMAF, falling within the mid-range of the World Bank’s assessment of the cost per participant for similar programs.

Overall, CAPC projects have successfully leveraged an amount equivalent to that of their CAPC funding. This means that overall, CAPC funding represents only 50% of the total investment, as demonstrated by the more than $48 million in additional resources leveraged by projects in a typical year (Table 6). The ability of CAPC to leverage additional resources and funding demonstrates the community support and ownership for CAPC programs, as well as the “buy-in” and mutual interest of the partners. This leveraging, combined with the cost per participant, data illustrates that CAPC is indeed operating in a cost efficient manner.

5.2 Cost Savings and Cost Avoidance

This section provides an overview of the economic impact of CAPC in terms of costs avoided and saved in terms of health, social and justice systems in Canada. This indicator measures cost-effectiveness directly. The section includes an examination of the revenues possibly gained due to participation in CAPC (a conservative yearly estimate of 31,000 children of 0-5 years) and what costs could have been saved for the Canadian society as a whole if the entire population of at-risk Canadian children 0-5 years (343,000) had participated in CAPC projects.

The assessment of the economic impact of the CAPC program was based on the minimum estimates of impacts on various outcomes as reported in the literature for similar early childhood intervention programs: grade retention; special education; high school drop-out; community sentencing; institutional sentencing; obesity rates; and maternal depression.

The potential economic impact of CAPC was derived from studies reported in the international literature on early childhood development initiatives and CAPC evaluation reports. These data were then used to construct a model for the selected outcomes and to emulate the relationship between program delivery and outcomes. Data from the Canadian Community Health Survey, National Longitudinal Survey of Children and Youth, Youth Court Survey, Youth Custody and Community Service Survey, Manitoba Centre for Health Policy and provincial government ministries were used to establish rates in the Canadian population among children with similar at-risk characteristics.

These minimum estimates, based on rate of occurrence as collated from the economic literature, represent the economic modelling of impacts identified in Table 8. The applicable comparator groups, timeframe, data parameters, statistical significance and sources for each outcome are identified in full (along with noted limitations) in the Assessment of the Economic Impact of CAPC (2009).

Source: Assessment of the Economic Impact of CAPC (2009)

The synthesis of findings from the economic impact assessment and supporting evidence from literature are presented in this section.

a) Grade Retention in Elementary School

The elementary school grade retention rate (formerly referred to as failure rate) among low-income children in Canada is 6% (Brownell, 2008) and the average cost per year of school is $9,704. Sensitivity analysis conducted in 2009 for the economic impact assessment of CAPC indicated that, if participation in CAPC were to be associated with a reduction in grade retention rate from 6.0% to 5.4%, then 186 grade repetitions would have been avoided and $1.58 million in costs to the education system would have been saved, as shown in Table 9 just preceding the Summary at the end of this section.

If this saving were extended to the entire at-risk Canadian population aged 0-5 years in 2006, then the potential savings would have been $17.54 million (Table 10). Evidence from the literature indicated that retention rates in elementary schools vary with children’s socio-economic status (Brownell et al, 2008; Guèvremont et al, 2007). In addition, early childhood development programs have been shown to reduce grade retention among at-risk, vulnerable children (Barnett and Masse, 2006, Anderson et al, 2003).

b) Special Education

Early childhood development programs have been shown to reduce the need for special education placement among at-risk children – those with developmental challenges, learning disabilities, behavioural problems, and literacy and language needs (Barnett and Masse, 2006; Anderson et al, 2003). Using 10% as the rate of remedial education among children in Canada (Alberta Learning, 2003) and an average annual cost of $2,588, the sensitivity analysis conducted in 2009 indicated that, if participation in CAPC were to be associated with a reduction in special education placements from 10% to 9.5%, then 155 special education placements could have been avoided, thus avoiding a cost of $378,166 to the education system in the first year of schooling (Table 9). If this saving were projected to the entire Canadian at-risk population aged 0 to 5 years in 2006, the potential savings would have been $4.19 million (Table 10).

The savings to the education system would be approximately $8.03 million if the 155 CAPC children in special education programs did not require the programs from Grade 1 to 8 and $33.55 million if projected to the at-risk Canadian population aged 0 to 6 years.

c) High School Completion

The high school drop-out rates in Canada are significantly higher among disadvantaged children (Brownell et al, 2007). Research has shown that early childhood interventions are associated with reduced high school drop-out rates among those at-risk (Currie, 2005; Barnett and Masse, 2006; Harvard, 2007; and Bennett, 2008). The average annual public cost of a high school drop-out is $7,291, based on estimated costs associated with lost revenue to the government (tax revenue of $226 and EI revenue of $68) and the costs of social welfare (social assistance of $4,230 and EI costs of $2,767). In addition it was found that an individual who dropped out of high school earns on average of $3,491 less in a year and about $104,222 less over one’s work life (20 to 54 years). The associated lifetime EI and tax revenue loss to the government is $2,063 and $6,882 respectively (Hankivsky, 2008).

The sensitivity analysis completed in 2009 to assess the economic impact of CAPC found that, based on the public cost of $7,291 per high school drop-out associated with revenue losses in annual tax and EI and the costs of social assistance, the potential public gain from CAPC children would have been $8.86 million per year. In addition, the individuals would have gained $4.24 million per year in total income (Table 9). If the entire Canadian at-risk population of children aged 0-5 years is considered, an estimated $145.27 million would have been saved or avoided as public and private costs (Table 10).

Considering that high school graduates earn $104,222 more than high school drop-outs, it was estimated that the public and private cost saved or avoided would have been $137 million for current CAPC participants and $1.52 billion for the entire population (Table 10). The Conference Board of Canada estimated the cost of drop-outs in the entire 1989 student cohort at $2.7 billion in private costs and $1.3 billion in public costs^{Footnote 18} (Lafleur, 1992).

d) Youth Crime

Youth crime rates are significantly higher among vulnerable youth than the national average (Turpel-Lafond, 2009) and early childhood programs have been found to play a role in reducing delinquency rates among disadvantaged youth (Barnett and Masse, 2006; Garces, Thomas and Currie, 2002).

The results of the sensitivity analysis conducted in 2009 indicated that, if participation in CAPC were to be associated with a reduction in the rate of community sentencing from 24.4% to 22.0% and in the rate of institutional sentencing from 11.5% to 10.4%, then 1,113 sentences would have been avoided and costs of $42.54 million ($8.21 million in community sentencing and $34.32 million in institutional sentencing) to the justice system would have been avoided (Table 9). If the entire Canadian at-risk population aged 0 to 5 years were to have participated in CAPC, the project cost saving/avoidance to justice system could potentially be $472 million (Table 10).

e) Childhood Obesity

Obesity rates among low-income children in Canada are significantly higher than the national average (Oliver and Hayes, 2008), and early, family-based interventions have the potential to have impact on the diet and physical activity of children at an early age and to reduce future obesity. Results from studies in Canada indicate that physician costs increase as one gets older and that the incremental lifetime physician and other healthcare costsFootnote 19 for an obese person increase by $5,537 to $8,489 (Janssen, Lam and Katzmarzyk, 2009; Birmingham, 1999). This trend also corresponds to findings in studies conducted in the US (Finkelstein et al, 2008).

The results of the sensitivity analysis conducted in 2009 indicated that, if participation in CAPC were to be associated with a reduction in post pre-school obesity rates from 12.4% to 11.7%, then 191 obesity cases and $1.63 million in direct health care costs would be avoided (Table 9). If the entire Canadian at-risk population aged 0 to 5 years were to have participated in CAPC, an estimated $18.04 million would potentially be saved (Table 10).

g) Maternal Depression

Early childhood development programs with family-focused interventions – including a focus on family relationships, parenting skills and parent mental health – are associated with prevention of parental depression, reduced depression symptoms, and in some cases, reduced need for formal treatment (Knitzer et al, 2008; Chazan-Cohen et al, 2007; US Department of Health and Human Services, 2006; Barlow and Cohen 2004). For the purpose of assessing the economic impact of CAPC, the number of mothers experiencing depression in 2006 (out of the 27,000 participating mothers) was calculated based on various rates of maternal depression in the Canadian and CAPC populations (Simpson and Charles, 2008; Dennis et al, 2009). The average annual healthcare cost of maternal depression that can be avoided due to the predicted impact of CAPC was estimated at $411 per mother (Roberts et al, 2001; Sword et al, 2001). A longitudinal study revealed that a program that targets pregnant teens and at-risk young mothers produced an estimated social return on investment in the range of $0.80 in the first year to $13.95 in the seventh year, per dollar spent (Louise Dean Centre, 2008).

The results of the sensitivity analysis indicate that if CAPC were to be associated with a reduction in maternal depression rates from 25.0% to 17.0%, then an estimated 2,028 cases of maternal depression would be avoided by participation in CAPC, thereby saving over $830,000 in healthcare costs annually (Table 9).

Source: Assessment of the Economic Impact of CAPC (2009)

Source: Assessment of the Economic Impact of CAPC (2009)

Summary – Cost Savings and Cost Avoidance

It was found that the cost-benefit ratiosFootnote 21 for various early childhood development projects analyzed in the study range from 0.5 to 16.1 (PHAC, 2009c). The rate of return to government for early childhood programs has been found to be between 2:1 and 7:1 (Bennett, 2008). Moreover, when the opportunities to develop certain abilities are missed early in life, later remediation is less effective or more costly (Cameron, 2004; Knudsen, 2004; Shonkoff, 2000).

The economic modelling that was completed demonstrated positive returns from many early childhood initiatives that target children and families at risk. From the discussions on costs, funding and potential cost-savings and cost-avoidance, it is reasonable to infer that the potential long-term benefits from CAPC to society through savings in health, social and justice systems is significant compared to the investment.