Jessica Ball, MPH, PhD, University of Victoria
Kenneth A. Moselle, PhD, Vancouver Island Health Authority

A persistent challenge for families is the fragmented system of services they need in order to support children's wellness. Systems of services and supports tend to be divided according to jurisdiction, professional specialization, private/public, age and other criteria for receiving services, and myriad other dimensions that drive a wedge between services that might otherwise be seen as part of a whole.

An impetus for strategic, integrated and intersectoral programming is to extend the reach of services and supports to improve timely, affordable access to health promotion, chronic disease prevention, primary health care, and clinical ancillary services for children and families (e.g., prenatal care, mental health and addictions services).

Despite prevailing, seemingly irrational, fragmentation of services and support for wellness, there is widespread acceptance in the population and public health sectors in many countries around the world that health is more than the absence of disease, and that health outcomes are influenced by many factors or determinants. There is consensus in the literature that many of the health problems that are having an increasingly adverse impact on individuals, families, and communities represent the convergence of a broad array of proximal and distal factors, ranging from advertising and media campaigns by large multi-nation fast food vendors, down to the choices of individuals, and the impacts of those choices on the person, their offspring, their families and the community at large. There are reciprocally reinforcing linkages distributed throughout that layered array of determinants (e.g., the reverberating and cyclical connection between use of substances, teen pregnancy, limited school achievement, and poverty). In order to address prominent health concerns that are embedded within systems of cause-effect relationships that remain perniciously stable by virtue of those internal connections and feedback loops, interventions must be staged that are informed by a fairly penetrating, fine-grained understanding of the determining factors and their interactions.

Among critical determinants, healthy child development is widely recognized as one key determinant of future health. Many cultures, including Indigenous cultures, have long held an holistic concept of wellness that includes the spiritual, mental, physical and emotional wellness of all family members, and embed these within a broad ecological system. This view strongly supports a strategic focus on early childhood development programming that explicitly encompasses a child's family members and to address both the needs of young children and their primary caregivers in their home and community environments. Related to this perspective, one study by Moselle and Ball (noted below) for the Public Health Agency of Canada in 2013 synthesized research findings to show that knowing one's mother tongue and one's cultural traditions can be seen as contributors to child health outcomes.

Projects conducted by members of ECDIP have:

  • Underscored a view of health as multiply- and often over-determined by proximal and distal factors;
  • Illustrated how cluster analysis of research findings about the ecological embeddedness of focal health problems facing a particular population of children (e.g., Indigenous children) can help to identify a select number of determinants that must be targeted in order to promote health and prevent chronic disease;
  • Shown that the conditions or health antecedents can be placed meaningfully on health trajectories that trace back to the period of early childhood (including the post-natal period of development, e.g., baby bottle tooth decay). In other words, efforts to intervene before the problems have become entrenched or clinically irreversible would, of necessity, need to reach back into the period of early childhood development (including the prenatal period)
  • Identified key components of a 'complete' set of programs that would address the clusters of determinants that over-determine the emergence of a constellation of health issues in a particular population (e.g., Indigenous children);
  • Set out parameters for integrated and intersectoral strategies for health promotion and chronic disease prevention within First Nations and Inuit contexts
  • Discussed promising practices and models, highlighting key components for successful implementation.

Analysis of the objectives, essential components and service recipients of existing programs within a health care delivery system can assist program decision-makers in identifying areas of overlap in program targets and practitioners' roles and functions where integration might be achieved. Health care delivery systems need to ensure streamlined and timely access to a range of services that will respond to the complex array of issues that outreach workers are likely to encounter when they are functioning in an outreach capacity. For example, when a public health nurse conducts a well-baby visit and identifies serious health and lifestyle issues of other family members, the nurse's capacity to move a range of services into place needs to be assured through good inter-professional communication and program integration. In one project, conducted by Moselle and Ball in 2013 for the Healthy Child Development Program of Health Canada, it was found that many of the proximal factors affecting key health issues for Indigenous children could be addressed in existing programs, but these programs needs to integrated and/or coordinated.

Early childhood programs as 'hook and hub'

Research has clearly shown that early childhood development programming can promote healthy development in both children and families, and can counteract various stressors and deprivations that can erode opportunities for optimal health and development. Although integration and inter-sectoral coordination involving Indigenous early childhood development programs are not yet prevalent, some First Nations, Inuit and Metis communities in Canada have demonstrated how early childhood development programs, such as Aboriginal Head Start, can serve as focal points for coordinating the broader system of health and community programs in their communities (Ball, 2004; Ball, 2012). 'Inter-sectoral' and 'integrated' programming such as these can maximize health promoting impacts on Indigenous children and families. These approaches can also optimize requirements for cultural safety and have various capacity development and motivational impacts on communities (Ball, 2005).

Addressing structural determinants of wellness

While elements of a 'complete' program often already exist within the array of services already delivered by various health and social service systems, there is a pervasive gap in that these programs do not address distal determinants of focal health concerns. A 'complete' program would need to be informed by an understanding of the range of proximal and distal factors that are related to targeted health outcomes. Proximal determinants are more immediately tied to specific health concerns (e.g., diet and exercise are tied closely to obesity), and targeted interventions are comparatively straightforward to address these concerns at the level of the individual child or family members. Health care workers and community development workers touch these factors directly – at least the more proximal factors. However, more distal determinants of health concerns, most notably non-medical/social determinants, are not so closely tied to any particular health condition. Services that address those more distal risk factors need to be accessed through a range of more focal programs. In other words, because distal risk factors are harder to impact directly, indirect approaches are needed to reduce their risk potency or counter-act them by enhancing proximal and distal protective factors. Responsibility rests with organizations such as FNIHB and other partners in government to influence policy and funding to create the intersectoral partnerships necessary to impact on the more distal, though potent determinants.


ECDIP Publications, Presentations, and Reports

Moselle, K., & Ball, J. (2013). Healthy Aboriginal child development and health promotion/chronic disease prevention: Prospects for integration and intersectoral coordination. Research analysis and concept paper prepared for Health Canada, First Nations and Inuit Health Branch Health Promotion, Disease Prevention Interprofessional Advisory Program Support Directorate. (4.5 MB)

Ball, J., Moselle, K., & Moselle, S. (2013). Contributions of culture and language in Aboriginal Head Start in Urban and Northern Communities to children's health outcomes. Research analysis, literature review, and concept paper prepared for the Public Health Agency of Canada. (2.8 MB)

Ball, J. (2008). Promoting equity and dignity for Aboriginal children in Canada. IRPP Choices, 14(7). (380 KB)

Ball, J. (2005). Early childhood care and development programs as 'hook' and 'hub' for inter-sectoral service delivery in First Nations communities. Journal of Aboriginal Health, 2(1), 36-53. (Available at National Aboriginal Health Organization website.)

Ball, J. (2005). Hook and Hub: Coordinating programs to support Indigenous children's early learning and development. Paper presented at the World Indigenous Peoples Conference on Education, Hamilton, Aotearoa New Zealand, November 27-December 1. (383 KB)

Ball, J. (2004). Early childhood care and development programs as hook and hub: Promising practices in First Nations communities. University of Victoria. (6.5 MB)

Media Resources

Lifeline: Creating community service hubs for Aboriginal children and families.

DVD (352 MB)
Booklet (4.4 MB)
DVD (45 min) and Booklet (36 pp) produced in partnership between Early Childhood Developoment Intercultural Partnerships and Laichwiltach Family Life Society (Jessica Ball & Audrey Wilson).
Available upon request. Email

ECCD as 'Hook' and 'Hub' in Development of Community-Based Services