Beyond the clinic: improving child health through evidence-based community development

Abstract

Background: Promoting child wellbeing necessarily goes beyond the clinic as risks to child health and development are embedded in the social and physical environmental conditions in which children live. Pediatricians play a vital role in promoting the health of children in the communities they serve and can maximize their impact by advocating for and supporting efficacious, evidence-based strategies in their communities.

Methods: To provide a succinct guide for community pediatric efforts to advance the wellbeing of all children and particularly disadvantaged children in a community, we conducted a theory-driven and structured narrative review to synthesize published systematic and meta-analytic reviews of policy-relevant, local-level strategies addressing potent and malleable influences on child health and development. An exhaustive list of policy-relevant, local-level strategies for improving child health was used to conduct a comprehensive search of recent (1990-2012), English language peer-reviewed published meta-analyses and systematic reviews in the 10 core databases of scientific literature. Our review of the literature encompassed six key conceptual domains of intervention foci, including distal influences of child health (i.e., income and resources, social cohesion, and physical environment) and proximal influences (i.e., family, school and peer). We examined intervention effects on four key domains of child health and development: cognitive development, social and emotional competence, psychological and behavioral wellbeing, and physical health.

Results: Published reviews were identified for 98 distinct policy-relevant community interventions, evaluated across 288 outcomes. We classified 46 strategies as meeting scientific criteria for efficacy by having consistent, positive outcomes from high-quality trials (e.g., tenant-based rental assistance, neighborhood watch programs, urban design and land use policies, access to quality childcare services, class size reductions, after-school programs that promote personal/social skills). Another 21 strategies were classified as having consistent evidence of positive outcomes from high-quality observational studies only, while 28 strategies had insufficient evidence available to assess their effectiveness based on published reviews. We did not limit the review to studies conducted in the United States, but the vast majority of them were U.S.-based, and the results therefore are most applicable to the U.S. context.

Conclusions: Based on our synthesis of published literature on community development strategies, we provide an illustration combining a comprehensive set of evidence-based strategies to promote child health and development across a wide-range of child health outcomes.

Figure 1

A framework for creating nurturing environments. Note. This figure is adapted with kind permission from Springer Science + Business Media: Clinical Child and Family Psychology Review, Creating Nurturing Environments: A Science-Based Framework for Promoting Child Health and Development Within High-Poverty Neighborhoods, 14(2), 2011, 114, Komro, K.A., Flay, B.R., Biglan, A. & PNRC, Figure 1.

Figure 2

Policy-relevant community strategies for improving child health and development. Note. ^aIntervention domains and outcome categories are defined by science-based framework for promoting child health and development within distressed neighborhoods (Figure 1). ^bStrategy meets criteria for efficacy based on a minimum of 2 high-quality trials (Level 1).

Figure 3

An illustration of combining efficacious community strategies to improve child health and development. Note. Superscript numbers link evidence-based strategies with corresponding studied outcomes. For example, quality preschool & early childhood education (superscript 17 under School Influences) has been shown to improve multiple primary outcomes in children (i.e., cognitive development, social/emotional competence, absence of psychological & behavioral problems) as well as affect distal and proximal outcomes (i.e., income & resources, school influences) that may positively impact child health and development.