The Social Determinants of Health:
Early Childhood Education and Care as a Determinant of Health

This summary is primarily based on papers and presentations by Martha Friendly, Coordinator and Director, Childcare Resource and Research Unit, Centre for Urban and Community Studies, University of Toronto, and Gina Browne, Professor, Nursing and Clinical Epidemiology and Biostatistics, and Director, System-Linked Research Unit, McMaster University. The presentations were prepared for The Social Determinants of Health Across the Life-Span Conference, held in Toronto in November 2002.

The opinions expressed in this publication are those of the authors and do not necessarily reflect the views of Health Canada.

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Current Situation

It is more than 30 years since the Royal Commission on the Status of Women recommended a national child care program. Since then, the labour force participation rate of mothers of preschool children has risen to almost 70%, and child development research has demonstrated that ECEC can provide developmental benefits for all children. Although the historic 2003 federal/provincial/territorial agreement on child care holds the promise of being a first step, Canada still does not have a national policy nor a pan-Canadian approach to ECEC.

The majority of young Canadian children whose mothers are in the labour force remain in private, unregulated arrangements of unknown quality (Friendly, Beach and Turiano, 2002). With the exception of Quebec, virtually all ECEC services for preschool children are targeted to at-risk or needy families, or are inaccessible for modest and middle-income families because user fees are too high. Other programs, like kindergarten, are not sensitive to the labour force needs of parents, or are of mediocre quality at best (Goelman et al., 2000).

Canada fares poorly on three commonly used indicators for ECEC.

1. Accessibility.
   Currently, there are regulated child care spaces for about 12% of Canadian children aged 0 to 12 (about 15% for children aged 0 to 6). This does not come close to meeting the needs of the 65 to 85% of mothers (depending on the age of their youngest child) who are in the paid labour force in every jurisdiction. At the same time, incoherent services that support an array of child care, kindergarten and early childhood development programs with overlapping objectives and populations means that public resources are being squandered, while not meeting families' needs (Friendly, 2002). Growth in child care has slowed dramatically over the last decade outside of Quebec, which has begun to establish a universal ECEC program for which all families pay $5 a day. Affordability is a problem for most families with modest and low-incomes. Between 1992 and 2001, eligibility levels for fee subsidies dropped in seven of nine jurisdictions in Canada.

2. Quality.
   On a scale commonly used to assess quality in child care centre research, scores range from 2 which is poor or inadequate, to 7 which is excellent. Using this scale in a study of six provinces and one territory, mean provincial/territorial scores ranged from 3.6 to 5.6. Research indicates that training in early childhood education and adequate wages are good predictors of program quality; however, most provinces and territories have low educational requirements for child care staff and providers, and low wages are the norm in most parts of Canada (Goelman, Doherty, Lero, LaGrange, and Tougas, 2000).

3. Financing.
   In 2001, provincial/territorial expenditures on regulated child care totaled $1.9 billion. Of this total, Quebec spent 58%. Total spending in the rest of Canada dropped about $70 million, in constant 2001 dollars (Friendly et al, 2002).

Factors that Affect the Issue

The quality of ECEC services is critical: poor quality services may even have a negative effect on child development. "High quality" ECEC services that support healthy child development employ qualified staff, have decent wages and working conditions, work with manageable numbers of children, provide creative and enjoyable activities for children, ensure a stable environment, respond to diverse populations, include children with disabilities and support parents in a variety of ways.

Effect of Early Childhood Education and Care on Health

Care and education outside the family is only one of a number of factors that have an impact on children during early life. Adequate income, good nutrition, a healthy environment, decent housing and early childhood services all affect the child, both directly and indirectly, through their effect on the family. But there is strong research support for the idea that ECEC can be a central factor in healthy child development (Shonkoff, 2000). There is good evidence that high quality ECEC programs:

• provide intellectual and social stimulation that promotes cognitive development and social competence, that can establish a basis for later success in elementary school.

• produce positive effects that persist into later life, especially, but not exclusively, for low-income children (Espinoza, 2002; Andersson, 1994; Osborn and Millbank, 1987). For example, a recent longitudinal study on outcomes for very low-income children in the U.S. found that - in addition to better school performance and lower juvenile crime rates - participants in the program since infancy had much higher earnings as adults - AND so did their mothers. The study participants were also much less likely to be smokers (Masse and Barnett, 2003).

ECEC policies and programs provide other important benefits to children, families and the community. ECEC permits parents to pursue an education, and to participate in training and employment. Without income from employment, most families lack the possibility of escaping poverty.

Two recent studies in Ontario provided comprehensive services (including quality child care and recreation, employment retraining and visits from a public health nurse) to lone -parent families on social assistance. Twenty-five percent of families offered the full range of services exited social assistance, compared to 10% of those without the services. Offering recreation services alone resulted in a 10% greater exit from social assistance, compared to parents of children who did not receive this service. It also resulted in improved health for both mothers and children. Recreation paid for itself through reduced use of health and social services (Browne et al, 1999; Browne et al, 2001).

ECEC programs also benefit communities if they involve children from diverse populations, and help them learn tolerance and acceptance of difference. Community ECEC programs can also facilitate parents' participation, strengthening solidarity within a geographic community and across class, ethnic and racial boundaries.

For diverse groups in society, and particularly women and children with disabilities, access to ECEC services is particularly important for equity and social justice. Simply put, without full access to child care, equality for women and for children with disabilities cannot be a reality (Friendly, 2002).

Implications for Policy, Practice and Research

Canada has not even begun to develop a universal system of ECEC. This has negative implications in the short- and long-term for the children who miss early childhood education, the mothers who miss employment and training opportunities, and the communities that miss what could be a vital community institution in its own right (Friendly, 2002).

In contrast to Canada, over the 1990s, continental European nations put in place publicly-funded ECEC services for all children. Within Canada, Quebec has instituted a policy and begun to build a program that could be replicated in other provinces and territories. Thus, good models are readily available to show that child care and early childhood education can be organized to be seamless and universal.

Well-designed ECEC policies can contribute to accomplishing four goals:

1. enhancing children's well-being, healthy development and prospects for life -long learning

2. supporting parents in education, training and employment; and in their parenting role

3. fostering social solidarity and social cohesion

4. enhancing equity.

There is more than enough research showing the value of ECEC to the development of healthy children. In addition, a Canadian study shows that offering comprehensive services to single mothers and their children pays for itself within one year, due to reduced health and social service costs, and high levels of exits from social assistance.

The findings of this study refute the notions that cutting public health and recreation saves money, that employment retraining is all that is needed, that helping perpetuates dependence, and that single parents are unemployable. This work also suggests that policies and programs in the community will be more effective when they are intersectoral and comprehensive (e.g., involve health, social services and recreation services), and tailored to participants' needs. Comprehensive care was no more expensive than the use of other services and was associated with greater benefits (cost averted). It paid for itself immediately, helped to maintain the competence of children with a behaviour disorder, and resulted in at least a saving of $300,000 for every 100 mothers involved in the initiative. (Browne et al, 1999; Browne et al, 2001).

Browne's study and others suggest that public health can and should be a primary partner and supporter in the delivery of ECEC programs in the community, along with education, recreation and social services. In Aboriginal communities on reserve, Health Canada has an obligation to support ECEC through initiatives such as the successful "Head Start" program.

A sustainable funding program that supports a long-term agenda for ECEC research in the Canadian context is required. A plan for collecting reliable data on programs, parents, ECEC staff, wages, fees and other basic information is also needed.

Priorities for research include:

• examining the effects of differe nt policy and funding approaches on program quality, accessibility and viability

• replicating key U.S. child care development studies in the Canadian context

• examining processes associated with quality and longitudinal studies monitoring the effects of different qualities of child care on children over time

• researching the effects of different child care arrangements on women in employment and training programs

• studying the effects of different program models on children and families

• examining the effects of early childhood education programs on communities.

References

Andersson B.E. (1992). Effects of day care on cognitive and socioemotional competence of thirteen year-old Swedish school children. Child Development, 63, 20-36.

Browne G., Byrne C., Ro berts J., Gafni A., Jamieson E. (1998). When the Bough Breaks: Provider-Initiated Comprehensive Care is More Effective and Less Expensive for Sole-Support Parents on Social Assistance-Four Year Follow-Up. System-Linked Research Unit on Health and Social Service Utilization. McMaster University and Affiliated Health and Social Service Agencies, www.fhs.mcmaster.ca/slru/reports.htm.

Browne G. (2002). Presentation at The Social Determinants of Health Across the Life-Span Conference, Toronto, November 2002.

Espinoza L.M. (2002). High-Quality Preschool: Why We Need It and What It Looks Like. New Brunswick, N.J.: National Institute for Early Education Research, Rutgers University.

Friendly M. (2002). Paper presented at The Social Determinants of Health Across the Life-Span Conference, Toronto, November 2002.

Friendly M., Beach J. and Turiano M. (2002). Early Childhood Education and Care in Canada 2001. Toronto: Childcare Resource and Research Unit, University of Toronto.

Goelman H., Doherty G., Lero D., LaGrange A. and Tougas J. (2000). You Bet I Care! Caring and Learning Environments: Quality in Child Care Centres across Canada. Guelph, ON: Centre for Families, Work and Well-Being, University of Guelph.

Masse L.N. and Barnett S. (2002). Benefit Cost Analysis of the Abecedarian Early Childhood Intervention. New Brunswick, N.J.: National Institute for Early Education Research, Rutgers University.

Osborn A.F. and Milbank, J.E. (1987). The Effects of Early Education: A Report from the Child Health and Education Study. New York, New York: Clarendon Press.

Shonkoff J. and Phillips D. (2000). From Neurons to Neighbourhoods. The Science of Early Childhood Development. Washington, D.C.: National Academies Press.