Multisectoral initiatives and relationship-building to address early childhood health equity
This blog is the second of a two-part series looking at health inequities in early childhood.
In an earlier blog titled “The impact of inequities, poverty and racism on the health of children,” I discussed the complexity of health inequities in early childhood, how this alters the life course of children and adults, and the structural role that racism and poverty play in creating and exacerbating inequities. I pointed out that, because the roots of this topic are so complex, the solutions need to be complex as well. In this blog post, I look at what to consider for multisectoral and relational work to address early childhood health inequities in Canada.
Strategies to reduce early childhood inequities
Changes to the structural determinants that shape individual circumstances are required to address the widening equity gap. These changes move beyond strategies such as lifestyle, education and skill development that often mitigate immediate circumstances but do not address the root causes of inequities.
The DRIVERS for Health Equity study  frames policy improvement strategies for addressing early childhood health inequities. In addition to describing the negative effects of poverty on socioemotional and cognitive skills, communications and language development, DRIVERS also highlights the idea that improvements in working conditions and income protection for caregivers are also strategies for improving health outcomes for children.
In addition, it is just as important for practitioners to consider how services are provided as it is for them to consider what services are provided. Communities will engage with programs that they can relate to in a welcoming environment, that they have been part of creating and that address what is important to them. 
Working across sectors
Two documents from the Canadian Council on Social Determinants of Health (CCSDH) provide considerations for multisectoral initiatives to address healthy child development.
Implementing multi-sectoral healthy child development initiatives  provides an overview of 10 healthy child development projects, describing the sectors involved and outlining which social determinants are impacted, including education, social support networks, employment and working conditions, culture, and healthy child development. Lessons learned from the initiatives profiled include recommendations in three key areas:
- Engaging partners to co-develop mission, goals, research direction and intervention delivery, particularly to include non-traditional and Indigenous stakeholders in the process
- Building the team, which includes clear definition of each partner’s skills and capacity, relative roles and responsibilities, and deep engagement with members of the community to identify what parents and families really need
- Practical considerations such as flexibility, logistics and long-term planning
The second CCSDH resource, Improving healthy child development: Building capacity for action , builds on the previous document. Here, the authors highlight a number of potential areas for action for multisectoral partners to address early child health inequities, including:
- making multisectoral data accessible;
- creating a forum for dialogue and knowledge exchange;
- engaging communities and parents;
- translating evidence on children for policy-makers and the public; and
- standardizing the implementation of screening tools and assessments for children ages 0–3.
What does a multisectoral network look like?
One example of a multisectoral network for early child development (ECD) is the Calgary-based First 2000 Days Network, a collective that focuses as much on how services are being delivered as on what services are being offered and influencing social change through collective impact. The role of the network is to coach and support its member organizations on assessing current programs offered, identifying gaps and aligning efforts to improve the quality of programs and how well organizations actually work together.
The First 2000 Days case study titled Establishing the pre-conditions for systems-level change in early childhood development  notes that:
|Individual programs and services alone will never lead to better early development outcomes for children – the seemingly simple recognition that the plethora of ECD programs and services are actually a system dramatically shifts the possibilities for finding a pathway towards improved ECD outcomes.[5,p4]|
Partners in the ECD system
Who do the partners in this ECD system need to be? The Canadian Institute for Child Health has developed a series of modules to access data that describe the health of Canada’s children both broadly as well as specific to Indigenous children, in addition to an online partnership tool for service providers who work in the area of ECD.
This partnership tool helps practitioners identify key partners from other sectors to engage with by having users answer four questions based on their current work and role in early child health:
- What is your role or your organization's role related to young children and their families?
- What are the key issues you would like to address to help young children and their families in your community?
- What are the key challenges in addressing the issues you identified above?
- Which of the following stakeholders do you currently partner with?
Based on responses provided, the tool identifies partners not currently engaged with, plus resources to build and strengthen partnerships, so that the user can identify more quickly what sectors they could engage with to strengthen their ECD collaborative work.
Relationship-building to support health equity for Indigenous children
Health inequities among Indigenous children are inseparable from structural factors linked to colonialism, racism and unjust social structures. A recent article on relational approaches to health equity for Indigenous children  reinforces the importance of relational accountability between service providers and Indigenous families and giving privilege to the priorities set by Indigenous people for their own well-being rather than an agenda set by service providers. Learning from, not about families through caregiver experiences of their everyday lived realities is considered paramount, as well as recognizing how poverty impacts the entire family and community.
Relational accountability means recognizing that Indigenous knowledge and cultural practices are key determinants of health for caregivers and children. A powerful conclusion in this article offers learning to those of us who live and work on the colonial side of the system:
|The relational approaches described in this paper have relevancy beyond Indigenous contexts, to other [early childhood development] and maternal-infant programs involving families impacted by structural inequities … disrupting the pathways which link Indigenous children’s early experiences of social disadvantage with subsequent higher risks of health inequities. [6,p116-117]|
Central to a relational approach with Indigenous communities is taking direction from the leadership of Indigenous peoples to identify what is needed to strengthen early childhood experiences for Indigenous children.
As described by the National Collaborating Centre for Aboriginal Health, the Indigenous Early Learning and Child Care Framework “sets out a shared vision for providing high-quality, culturally-rooted, language-based, accessible, and affordable early learning and child care programs in Indigenous communities.”
The framework represents the collective concerns of Indigenous communities, while at the same time recognizing the distinct priorities of First Nations, Inuit and the Métis Nation for early learning and childcare for Indigenous children.
Disrupting the pathways related to early childhood health inequities means going beyond mitigating the impact of negative social and physical conditions; it means cutting them off at the root.
Photo credit : Daiga Ellaby
[1.] Goldblatt P, Siegrist J, Lundberg O, Marinetti C, Farrer L, Costongs C. Improving health equity through action across the life course: summary of evidence and recommendations from the DRIVERS project [Internet]. London (UK), Brussels (BE): UCL Institute of Health Equity, EuroHealth Net; 2015 [cited 2018 Dec 20]. 14 p. Available from: https://eurohealthnet.eu/sites/eurohealthnet.eu/files/publications/DRIVERS_Recommendations_rel2.pdf.
[2.] Moore T, McDonald M, McHugh-Dillon H. Evidence review: Early childhood development and the social determinants of health inequities [Internet]. Victoria (AU): Victorian Health Promotion Foundation; 2015 [cited 2018 Dec 20]. 133 p. Available from: https://www.rch.org.au/uploadedFiles/Main/Content/ccch/151014_Evidence-review-early-childhood-development-and-the-social-determinants-of-health-inequities_Sept2015.pdf.
[3.] Canadian Council on Social Determinants of Health. Implementing multi-sectoral healthy child development initiatives: lessons learned from community-based interventions [Internet]. Ottawa (ON): CCSDH; 2017 [cited 2018 Dec 20]. 24 p. Available from: http://ccsdh.ca/images/uploads/Implementing_Multi-Sectoral_HCD_Initiatives.pdf.
[4.] Canadian Council on Social Determinants of Health. Improving healthy child development: building capacity for action. Expert interview summary working paper [Internet]. Ottawa (ON): CCSDH; 2015 [cited 2018 Dec 20]. 24 p. Available from: http://ccsdh.ca/images/uploads/Improving_Healthy_Child_Development.pdf.
[5.] First 2000 Days Network. First 2000 days network case study: Establishing the pre-conditions for systems-level change in early childhood development. Calgary (A): First 2000 Days Network; [date unknown] [cited 2018 Dec 20]. 16 p. Available from: http://www.2000days.ca/first-2000-days-key-documents/.
[6.] Gerlach AJ, Browne AJ, Suto MJ. Relational approaches to fostering health equity for Indigenous children through early childhood intervention. Health Sociol Rev. 2018;27(1):104-119.
[7.] National Collaborating Centre for Aboriginal Health [Internet]. Prince George (BC): The NCCAH; c2019. The Indigenous early learning and child care framework; 2018 Nov [cited 2019 Mar 24];[about 4 screens]. Available from: https://www.nccah-ccnsa.ca/485/NCCAH_in_the_News.nccah?id=437.