El bienestar infantil es un tema de interés para aquellos profesionales que creen que el propósito de las políticas públicas va más allá de procurar la riqueza material o de evitar males, como el analfabetismo o la enfermedad, entre los individuos en una sociedad. La importancia de definirlo y medirlo radica en la necesidad de identificar sus determinantes, e idear mecanismos para optimizarlo. Si bien es un tema complejo, incluso desde el punto de vista filosófico, en el mundo se han realizado esfuerzos valiosos por abordarlo desde un punto de vista científico y operativo. El Fondo de las Naciones Unidas para la Infancia es una de las instituciones líderes en la investigación sobre el bienestar en la población menor de edad, particularmente en los llamados "países ricos". En México se ha generado información sobre diversos aspectos del bienestar infantil, aunque existen dominios para los cuales todavía no se cuenta con información suficiente para permitir la comparación con otros países.
Child well-being is an interesting topic to all those professionals who believe that the purpose of public policies goes beyond the mere pursuit of the material wealth or the avoidance of harms such as illiteracy and disease among individuals in the society. It is important to define it and to measure it in order to identify its determinants and to plan mechanisms to optimize it. Although it is a complex issue, even from the philosophical point of view, there have been worldwide valuable efforts to approach it from a scientific and operational perspective. The United Nations Children´s Fund is one of the pioneer institutions in child wellbeing research, especially in the so called "rich countries". In Mexico, information has been generated regarding some issues concerning children well-being, however there are some dimensions for which there is not yet enough information to allow comparison with other countries.
"If youcan not measureit, youcan not improveit."
Lord Kelvin
Introduction
In the Preamble of the Constitution of the World Health Organization (WHO) signed on July 22, 1946 by the representatives of 61 states, health was defined as "... a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."1
But what does "well-being" mean? In recent years, and particularly in the "rich countries"—so classified by the United Nations—there has been interest in studying the extent and determinants of well-being in populations. However, there is no universally recognized definition of this term. Sometimes it is used indistinctly instead of other related terms such as "quality of life", "life satisfaction", "standard of living" or even "happiness."
Well-being can be understood as the possession of certain positive material conditions such as housing, education and health care, which has been called the "material well-being." However, it is intuitively clear that what we understand as "well-being" goes far beyond just having material wealth and absence of disease.
Well-being is also related to the perception of the individual over his own life. In this sense, there are two philosophical conceptions of "subjective well-being," the first being the hedonistic, which includes two aspects: cognitive and affective. Cognitive well-being refers to the level of the individual's satisfaction with his living conditions. Affective well-being, meanwhile, refers to the preeminence of positive affects such as joy and tranquility over negative affects such as sadness and anger.
The second approach of the subjective well-being has been called "eudaimonic well-being." Eudaimonia is a Greek word sometimes translated as "happiness" and other times as "human flourishing." For Aristotle, it meant the greatest of all possible goods and which is reached through the exercise of virtue (aretê). Eudaimonic well-being refers to the fulfillment of the "true potential of a person", i.e., to personal growth and to a sense of meaning and purpose in life.2
Interest in the subject of welfare transcends philosophical speculation. Absence of disease or of material wealth is not a sufficient outcome to measure the impact of public policy on the lives of people. However, is it possible to address the issue of well-being from a scientific approach? For a phenomenon to be the object of a scientific study, it must be measurable. Therefore, the question would be: is it possible to measure well-being?
Economists, psychologists, sociologists, physicians and policy makers have tried and searched to evaluate well-being in an holistic way, which is indicative of what is truly important for individuals.
Before measuring something, it is necessary to define it operatively. One way to define well-being is "a positive physical, social and mental state, not merely the absence of pain, discomfort or disability, which requires that basic needs are met, that individuals have a sense of purpose, and that they feel able to achieve personal goals and participate in society. It is enhanced by conditions that include strong interpersonal relationships, inclusive communities, good health, financial and personal security, rewarding employment, and a healthy and pleasing environment."3
There are many other definitions of well-being, but they generally agree that it is a multidimensional construct and attach importance to the inclusion of material prosperity or wealth, emotional well-being, physical well-being or health, social well-being, coping skills and productivity.4
Regarding the assessment of child well-being in particular, there are unique and particularly relevant aspects to consider such as family, school, recreation, growth, development, friends and classmates, along with the fact that they are more dependent persons and less able to change their context than adults.
A milestone in the promotion of child well-being is the Declaration of the Rights of the Child (1959) signed by all UN member countries (except the U.S. and Somalia) in 1989 and in which states commit to take actions to ensure a minimum level of well-being of minors.5 In addition, in 1976 the UN International Covenant on Economic, Social and Cultural Rights took place, and in 2000 the "General Comment 14" was issued, which ratifies and details the section in regard to "The right to the highest attainable standard of health."6,7
Measure of well-being
Life goals of individuals and societies go beyond the absence of disease or poverty. It is clear that people want to improve their conditions and not remain in a neutral state. If we refer to this "being better" as "well-being," we may say that actions are necessary to achieve this goal. The objectives for measuring well-being may be different and, according to these, the instrument to evaluate it should be designed. Its measurement has been used to compare populations, assess the impact of interventions, monitor changes over time, identify needs and problems in public policy, guide decision making, set goals, demonstrate accountability, evaluate programs, and carry out cost/utility analysis. Like any other measurement, the first step in how to measure well-being is defining the purpose of it.
Well-being is measured using indicators. There are two main groups of indicators: objective and subjective. The first are derived from verifiable facts. For the second, the individual is asked to make his own personal assessment of a particular aspect of his life. It is increasingly recognized that what individuals, including children, think and feel about their life is important and can be reported in a valid manner.
Regarding the measurement of child well-being, traditional measures have been objective and about negative data, e.g., infant mortality, low birth weight and malnutrition. For subjective measures, evaluations have been made by questioning parents or teachers focusing on the family and the future of the child. The trend is to carry out more subjective measures in younger children, question the child directly and focus on positive data and on the present.
A large number of domains have been proposed to measure the construct of child well-being. How many and which domains are chosen to build the instrument depend on the purpose and on the population to which the instrument will be applied. Some useful strategies for selecting domains are performing a literature review and the creation of focal groups, both with experts and with subjects of the study population.
Once the domains to be assessed are selected, the indicators are constructed. An ideal indicator should be appropriate for age and culture, should measure positive, not just negative outcomes, adequately describe the dispersion of the measurements and reflect changes in time and after the interventions. The indicator shall have the same meaning throughout the years, should be cost-efficient, reflect the goals of society and be applied with methodological accuracy, particularly in the sample selection. It has to be understandable by a variety of audiences, to relate to priority and relevant issues, and possible to be tracked over time because good data are continuously generated. Finally, a small number of indicators should be used in order for ease of application.
How is child well-being measured worldwide?
The United Nations International Children's Emergency Fund (UNICEF) has developed indicators to measure well-being in "rich countries." It has reported objective well-being using diverse indicators constructed from official databases. It has also reported subjective well-being in collaboration with the study group Health Behaviour in School-aged Children (HBSC).8 HBSC protocol surveys are conducted in schools through self-administered questionnaires in classroom to 11-, 13- and 15-year-old children.
Survey questions cover a range of health indicators and health-related behaviors as well as life circumstances of adolescents. Questions include demographic aspects and family issues, socioeconomic status, parents, school environment, health and behavior.9,10 Since the time of the 2009/2010 survey from the HBSC study, UNICEF produced a report on "Social determinants of health and well-being among young people"11 consisting of diverse indicators related to child well-being among the participating countries.
The Organization for Economic Cooperation and Development (OECD) generated its own indicators.12 The OECD recognizes the importance of the measurement of subjective well-being and has even developed guidelines for its study. In the report "Comparative child well-being across the OECD," the well-being of 30 member countries was evaluated. Mexico ranked in 26th place in the domain of housing and environment, 28th place in the domain of health care and security, 29th place in education and material welfare and 30th place in risk behaviors. Well-being in the school environment could not be assessed because no data were available for evaluation of this domain. In this report no indicators of subjective well-being were included because the aim was to provide guidance on issues that may be subject to change through public policy.
England, Ireland, Spain, U.S. and Chile are among the countries that have been identified to develop models for evaluating child well-being in populations with high methodological standards.13-18 It is very important to note first that each country should create its own indicators so that useful information can be available for guiding public policy and second, that the countries have databases with sufficient disaggregated information in order to enable the calculation of indicators for comparison purposes among countries.
In Mexico, there have been significant efforts to evaluate diverse aspects of child well-being. These include the National Health and Nutrition Survey whose latest version was published in 2012 by the Instituto Nacional de Salud Pública.19 It also includes the National Addiction Survey, the National Survey of Child Abuse and the National Survey on Adolescent Psychiatric Epidemiology developed by the Instituto Nacional de Psiquiatría,20,21 and the National Household Income and Expenditure Survey prepared by the Instituto Nacional de Estadística y Geografía.22 In addition to these institutes, Mexico has agencies devoted to evaluate aspects of educational welfare (Instituto Nacional de Evaluación para la Educación) and social welfare (Consejo Nacional de Evaluación de la Política de Desarrollo Social), which periodically report their indicators.
In 2001, the "Forum on well-being indicators in early childhood in Mexico" was held with the participation of UNICEF, UNESCO and other institutions related to the care of children in Mexico such as the Secretaría de Educación Pública, Secretaría de Salud, Desarrollo Integral de la Familia and the Universidad Nacional Autónoma de México, among others, with support from the Inter-American Development Bank and other sponsors. Instruments were developed and field tests were performed. The information was reported in 2006.23-25
Although the subject of well-being is an issue that concerns us all as individuals and to health professionals and social scientists as professionals, it is a difficult issue to address from an operational point of view, starting with its definition and continuing with its measurement.
Not all agree that well-being is synonymous with health because it would mean matching a single aspect of well-being—health—to the entire concept. However, health is not an easy concept to define and is a fundamental base to achieve this "human flourishing" to which the concept of eudaimonia refers. The theme of well-being or "happiness" is not an abstract philosophical issue, but an issue deeply tied to the human condition and to everyday decision making by any one of us.
The purpose of this paper is not only to keep in mind this obvious idea but to show that it is an issue that, although complex, may be approached from a multidisciplinary scientific perspective in order to understand the determinants of well-being in society and to devise mechanisms to increase it.
Conflicts of interest
The authors have no conflicts of interest to declare.
Received 16 December 2013;
accepted 18 December 2013
E-mail:fernandabmhim@gmail.com