Improving Children's Health Through Integrated Public Health and Pediatrics

In December 2012, an article was published in the American Journal of Public Health (1) highlighting the importance of addressing environmental and social determinants of children's health. The article was designed to present the major health challenges of children in the United States along with solutions that can be undertaken by primary care physicians and pediatricians. One of the primary conclusions was that pediatricians can and should become involved in the larger area of public health so that they can help to address environmental and societal influences on children's well-being.

Early on, children's health was understood primarily as the absence of disease. In recent years, however, the definition has changed to refer to other social indicators. For instance, a 2004 Institute of Medicine report entitled Children's Health, the Nation's Wealth defined health more broadly, such as the extent to which children can reach their potential, satisfy their needs, and develop successful ways to interact with their biological, physical and social environments.(2) This definition takes much more into account than just the physical state of a child. Not surprisingly, organizations like the American Academy of Pediatrics and the Maternal and Child Health Bureau adopted this new definition and consider it as they decide where to award funding, where to focus research efforts, or how to present policy recommendations. Likewise, physicians themselves have begun to integrate the public health approach with more traditional clinical practices and applied these to helping children and their families.

Some of the challenges that are discussed in detail and which are highlighted as issues to resolve include: child poverty and its related effects on health; racial disparities in access to healthcare and health insurance; obesity; asthma; mental health issues; environmental toxins (such as lead exposure, poly-chlorinated biphenyls, mercury, mold, and fluorocarbons); and access to adequate preventative dental care.

Historically, pediatricians have been participants in the public health system. They are almost always considered trusted sources of information for new parents, who may come to them with questions and concerns about their children's health. Pediatricians are also frequently involved in programs that provide care to larger populations, such as daycare centers, schools, or in local communities.

The residency programs completed by aspiring pediatricians used to emphasize the biomedical problems of patients more so than any type of social or familial influence. Now, however, it is recognized that these social and environmental conditions should not be overlooked. For instance, illnesses such as asthma, obesity, oral health problems (dental decay), and mental health problems are much more complex both in their causes and their treatment than the average "biomedical problem" (such as an ear infection). The new training in residency programs emphasizes a "population approach" to these larger challenges. This training helps physicians consider factors like the child's family, the community in which he or she lives, the larger society, and the environment when attempting to address clinical problems.

One example of a program using this integrated approach is the Department of Pediatrics at the University of California, Los Angeles. Beginning in 2008, the department began a national effort to develop and implement a public health curriculum that could be included in pediatric residency programs. The project incorporated 12 public health competencies for medical education that were identified by the Association of American Medical Colleges, and input was obtained from more than 50 pediatric public health experts. This new curriculum was implemented in 6 residency programs, and the results were compared with 6 residency programs that did not have the special curriculum in place. The results of the comparison have not yet been released (the pilot was completed in June 2011), but will be of interest to many in the pediatrics and medical education communities. The hope is of course that an integrated approach to pediatrics training will improve patient outcomes and allow the US to tackle the looming challenges of obesity, asthma, etc.

In summary, the trends in children's health suggest that a broader understanding of what it means to be 'healthy' is an important step forward. By recognizing that there is more involved in chronic illness than just the disease itself, physicians can begin to integrate the vast amount of information from the public health sector into their clinical practice. A population-based approach to children's health, especially when incorporated into pediatric residency programs, can also contribute to better outcomes for all.

(1) Kuo A, Etzel R, Chilton L, Watson C, and Gorski, P. Primary Care Pediatrics and Public Health: Meeting the Needs of Today's Children. American Journal of Public Health 2012; 102 (12): 17-23

(2) National Research Council and Institute of Medicine. Children's Health, the Nation's Wealth: Assessing and Improving Child Health. Washington, DC: National Academies Press; 2004.

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