By Paul Dworkin, MD

Authors of Can Measures Change the World? are challenging us to not measure more, but instead focus our collective efforts on finding measures that accurately represent systems (the whole). Little attention or energy is dedicated to researching how, and under what circumstances, measures actually “work” when applied to a comprehensive system. We must focus just as much effort on understanding how the existing measures we collect can be more effectively used to change complex social systems as to identify new measures. Measurement theory provides insight on measure’s capacity to change the world, but only through an accountability-orientated measurement framing. Nelson, Chandra and Miller argue that we must view and analyze existing data differently – focusing almost exclusively on “catalytic-measurement.” The points made in this article from the Stanford Social Innovation Review were made visible at a meeting recently attended, “Child Well-Being Measurement: Aligning Data to Strengthen Systems, Support Families, and Promote Equity.” On February 7, 2018, I was excited to attend a convening organized by the Robert Wood Johnson Foundation and the Doris Duke Charitable Foundation to identify strategies to build consensus about indicators and measures of child well-being. The eloquent title of the meeting reflected the daunting challenge of the task at hand- “Child Well-Being Measurement: Aligning Data to Strengthen Systems, Support Families, and Promote Equity.” The organizers focused the meeting on three key areas: indicators of child well-being to compare child populations at the national, state, and local levels; measures of child well-being to evaluate the effects of local policies and programs for children and families; and key domains of well-being of special significance in assessing equity and disparities. The format of the meeting was both productive and instructive, as all participants received, in advance, a series of papers on key topics and the agenda included paper discussants and respondents, with ample time allotted for audience questions and comments. Skilled moderators ensured timely adherence to the ambitious agenda.

The carefully selected speakers were uniformly informative, inspiring, and thought-provoking. Similarly, audience input was thoughtful, relevant, and clarifying. I am pleased to offer a brief synopsis of take-away messages that I believe should inform our thinking on capturing meaningful indicators and measures of child well-being. I apologize, in advance, for my inability to credit all key concepts to their sources, as well as any errors in attribution or interpretation.

During the welcome and introductions, meeting sponsors Martha Davis and Lola Adedokun wasted little time in “throwing down the gauntlet” on such issues as the imperative that data be meaningful to families, that indicators and measures focus on flourishing, data collection build on assets, and measures target that which is impactful for children, families, and communities. Meeting facilitator Rosemary Chalk was emboldened to suggest that perhaps we already have access to sufficient indicators and measures and that we should consider directing our best efforts to embracing helpful unifying frameworks and promoting such new constructs to achieve equity as children’s social capital. The truism, “what gets measured gets done,” and the unintended consequences of the observation that, “we measure what we treasure,” emphasized the importance of the group’s task at hand.

The opening session offered an overview of national, state, and local indicators of child well-being. Christina Bethell emphasized the importance of not viewing data in isolation, but rather within the context of a learning system model that engages common measures across all sectors and uses established measures to achieve consensus. Such an approach requires enhanced data literacy. Measures, to be effective and meaningful with respect to well-being, must capture experience, feelings, and emotions such as hope. While we are closer than we might surmise in securing powerful data on flourishing, we are currently squandering the opportunity to use data to engage diverse groups and inform our collective actions.

Respondents endorsed the key themes of Bethell’s commentary. Kristin Anderson Moore highlighted the efforts of federal agencies to build effective national data systems with a focus on the “whole child” and early childhood, while lamenting the lack of data at the community and tribal levels. She also emphasized the importance of distinguishing measures of child well-being from context, such as social determinants, as critical independent variables, as well as calling for an overarching conceptual model to inform communities at the local level. Other relevant concepts included the importance of identifying contextual measures that contribute to enhanced child well-being, the need for both child- and population-level data, and the need for measures of relationships as critically important inputs and determinants of child well-being.

Charlie Bruner passionately and personally spoke to the extraordinary importance of maintaining a focus on human characteristics and the parent-child relationship in our quest for data. Bruner’s sobering observation that, for the first time in our history as a nation, children face the prospect of poorer well-being than their parents, reinforced the need to acknowledge that, “context matters,” and that we must be vigilant in our considerations of the impact of such issues as race, poverty, and place. Similar to Bethell, Bruner noted that we have far more data than we are able to analyze, and that we certainly have sufficient data to inform action at the national, state, and community levels.

Audience reactions reinforced the importance of explanatory models, the need to standardize measures and their definitions, and called for determining the predictive validity of indicators and measures and the importance of tracking children’s developmental trajectories across domains on a pathway to success. Communities, providers, and families require training on how to effectively use data to inform actions.

Session 2 focused on gaps in the field, including the building of integrated administrative data sets, responding to local practice needs, and creating measures that serve disadvantaged families. Renee Boynton-Jarrett posed the provocative question of whether we perpetuate inequities through our measures and metrics and shared her experience with the Child Opportunity Index, which is a tool used to inform interventions that address inequities across a neighborhood or region. John Fantuzzo reinforced earlier speakers’ contentions that we are, “…sitting on tons of really good information about children’s development.” He advocated for a child well-being indicator system that is locally designed and used and produces actionable intelligence. He also noted that such a system must be sustainable and provide a return on the public’s investment. He reiterated the need for data literacy and capacity among all users, including providers and families. Respondent Patricia Bowie called out the critical importance of family and neighborhood context and the imperative of “…putting learning close to where it matters most.” She effectively advocated in support of an emphasis on flourishing and thriving, as opposed to vulnerability and mitigating risk, and endorsed our predicament of having access to much data but limited applications. Her cogent and compelling analysis of data use as reflecting excessive accountability and compliance with too little learning and reflection demands a rethinking of our priorities. She advanced the appealing concept of local learning platforms to inform local actions.  General discussion highlighted some gaps in the field, such as the need for greater understanding of how to use indicators (as opposed to the need for more indicators), the need for meaningful measures in the birth to 3 space to capture the goal of “flourishing by 3,” and the need for measures that capture the critical importance of early childhood relationships, as exemplified by David Willis’ reference to “relational health.”

Speakers and audience, alike, maintained their focus and enthusiasm during the 3rd and final session which addressed innovative approaches to examining child well-being, including longitudinal research studies and minority perspectives. Discussant Krista Perreira emphasized the importance of both quantitative and qualitative measures and the opportunity to embed the latter within longitudinal cohorts. Perreira poignantly referenced the devastation of Hurricane Maria on Puerto Rico to call out the need to also consider environmental context for family and child well-being. Sara McLanahan shared her impactful research on the importance of measures of family structure, instability, and complexity. As a developmental-behavioral pediatrician, I was particularly struck by the assertion that children have their own agency in building social capital and, “…take matters in to their own hands.” McLanahan also distinguished between bonding and bridging social capital, as well as the extent to which the chronic stress of family instability undermines social capital. The final respondent, ethnographer Linda Burton, spoke of society’s reproduction of inequity and the diminished social capital among minority populations that perpetuate inequities and the importance of such protective factors as security, intellectual curiosity, verbosity, and self-awareness of feelings that can mitigate the adverse outcomes of children with “anemic” social capital. She emphasized the power of advocacy that combines stories and data.

Claire Gibbons and Lola Adedokun shared the unenviable task of offering final observations on the day’s convening. They shared a series of critical concepts that should inform next steps in achieving consensus on indicators and measures of well-being:

  • Health is not equivalent to well-being and is insufficient to ensure that individuals flourish and thrive
  • Despite the abundance of data, indicators and measures for young children remain a challenge
  • Data must be meaningful and inform action at the local level
  • Providers, families, and advocates must have ready access to meaningful and impactful data
  • Such critical inputs and determinants of well-being as relationships, mindfulness, hope, and love are challenging to discuss and uncomfortable for public health specialists
  • To hope to achieve equity we must acknowledge the pernicious impact of historic and institutional racism and not use poverty as a euphemism
  • We must question whether the need to adapt to adverse circumstances is a fair and equitable expectation for underserved populations

Of course, a six-hour meeting is inadequate to even begin to identify the specific strategies to helpfully align data to promote children’s well-being. This convening is, however, an auspicious start. We look forward to contributing to the work that follows.

Paul H. Dworkin, MD is the executive vice president for community child health at Connecticut Children’s, the director of Connecticut Children’s Office for Community Child Health and the founding director of the Help Me Grow National Center. Dr. Dworkin is also a professor of pediatrics at the UConn School of Medicine.