Correspondence: Dr Susan Woolfenden, Department of Community Child Health, Sydney Children's Hospital, High St, Randwick, Sydney, NSW 2031, Australia. Fax: 02 9382 8188; email: Susan.Woolfenden@SESIAHS.health.nsw.gov.au
The development of society, rich or poor, can be judged by the quality of its population's health, [and] how fairly health is distributed across the social spectrum.
Child health inequalities were first described in the mid-19th century as differences in infant mortality rates across occupational and social classes. Despite an overall improvement in health and advances in health care in many high-income countries, inequalities in mortality and morbidity have persisted and widened.[2, 3] For most health conditions, there is a ‘social gradient’; the greater the social disadvantage, the higher the prevalence of disease.
There is an increasingly robust evidence base for population-based child health inequalities in Australia. Research from ‘Growing Up in Australia’, the Longitudinal Study of Australia's Children, has demonstrated that social disadvantage is associated with poorer outcomes across most measures of physical and developmental health and that these start early in childhood, do not attenuate at older ages and have a clear gradient, with worse outcomes associated with increasing disadvantage. Most health professionals working with children will encounter inequalities in their daily practice related to service access and clustering of risk and to poor health, well-being and development among vulnerable populations of children (Table 1).
Table 1. Examples of inequalities
Children with a language background other than English who are socially disadvantaged with a language delay may have speech therapy services in the public sector delayed by up to 1 year compared with their more advantaged peers who access private therapy.
Socially disadvantaged children and their families have decreased access to health and early intervention services compared with more advantaged peers – ‘the inverse care law’. Language- background-other-than-English families can also have greater difficulties with access due to language and cultural barriers.
A child in out-of-home care because of abuse and/or neglect is likely to have experienced in utero drug exposure, family violence and/or poor attachment. The resultant challenging behaviour in the foster placement leads to imminent risk of placement breakdown.
There are increased rates of developmental and behavioural problems in children in out-of- home care that places them at increased risk of further care disruption.
An Aboriginal child from a socially disadvantaged background is struggling to read at school and starting to disengage from the school system.
Aboriginal children are twice as likely to be identified as developmentally vulnerable in their first year of school compared with their non-Aboriginal peers. This developmental vulnerability compounded by other social adversities creates future disengagement that leads to educational disadvantage.
The terms inequality and inequity are often used interchangeably to describe these differences in health status; however, they have quite different meanings. Inequality is a descriptive term that refers to differences between groups, such as a higher rate of cerebral palsy in preterm versus term babies. Inequity has a moral and ethical component. It refers to inequalities that are unfair, unjust, systematic, avoidable and unnecessary, such as the higher rate of preterm birth in children from socially disadvantaged groups compared with their more socially advantaged peers.
There has been longstanding debate in the health inequity literature as to what would constitute an unfair and avoidable inequality, especially around the role of personal responsibility in health and our innate biological predisposition to conditions.[7, 8] The debate around personal responsibility for health choices is irrelevant for young children who are never responsible for their choices and in whom inequalities in their health and health-care access are intrinsically linked to the social determinants of health such as the safety and social capital of the community they live in, their family's socio-economic position and ethnicity and the impact these have on home environment and the choices their parents make. With regard to the debate over the role of biology versus environment in the origin of inequalities, for some children an inequality may not be preventable or remediable because of biological differences, such as a chromosomal abnormality, but for the majority, social disadvantage contributes to or worsens any biological predisposition. Even for conditions where there is clearly a biological cause, there are inequalities in health outcomes that are related to social disadvantage. For example, children with cystic fibrosis from low-income families in the USA and UK have been found to have a significantly increased risk of death compared with those from higher income families.[11, 12]
Why Should We Address Inequities in Child Health?
Inequalities that are inequities in child health have a significant civic cost in that they reflect an ‘unjust society’. We know that children from disadvantaged environments, particularly those exposed to a range of early childhood adversities including poverty and abuse/neglect, are at increased risk for chronic health problems: developmental delay, mental health problems, school failure and increased adult mortality and morbidity,[11, 14-20] although there is an unclear and even conflicting relationship with children having a language background other than English.In addition, inequities have an economic cost. Estimates from the UK and USA indicate that if all children had the same level of health as their most advantaged peers (i.e. inequality based on inequity was eliminated) there would be a 30–70% reduction in the population-attributable proportion of chronic conditions such as cerebral palsy, intellectual disabilities, learning difficulties, mental health problems and injury, both accidental and non-accidental. This represents a significant saving in terms of health, education and welfare budgets and gains in productivity.[22, 23]
Inequity in Child Health Begins Early
One of the keys to future health, well-being and development is a solid foundation in early childhood development. Unfortunately, we have evidence that many children have a suboptimal start and thus are ‘developmentally vulnerable’. Developmental vulnerability means that they are significantly underperforming in one or more areas of child development (e.g. motor, language, self-help, socio-emotional, cognitive and behavioural). There is a growing global burden of developmental vulnerability, with 23% of children aged 2–9 years having or being at risk of disabilities.[24, 25] Data from the Australian Early Development Index 2009 census found that 20–25% of children starting their first year of school are ‘developmentally vulnerable’, with lower socio-economic status, (Fig. 1) as well as being Indigenous and living in remote areas, associated with its higher prevalence.
At the population level, most of the variance in developmental vulnerability between groups of children is associated with the environmental risk factors associated with socio-economic disadvantage (i.e. the social determinants of health), including poor parental mental health and education, lack of stimulating early childhood experiences, low family and neighbourhood income, and a lack of social capital. These risk factors interact with each individual child's innate biological sensitivity to adversity.[28-31] There is also emerging evidence of a transactional relationship between genes and the environment, where not only do genetic characteristics impact our response to the environment but environmental risk factors moderate gene expression. Cumulative exposure to ongoing risk factors without the buffering of protective factors, particularly during sensitive periods of neural development, can result in changes in neurobiology and neurochemistry that limit future developmental capability over the life course and particularly in the early years. (Fig. 2)
What Can We Do about Inequities in Early Childhood Development?
The good news is that public health investment that aims to diminish negative environmental factors associated with social disadvantage, when used wisely, can produce measurable improvements in health. Population-level early intervention programmes such as home visiting, high-quality early child care and other early childhood development programmes have clear high-level evidence of effectiveness in reducing developmental vulnerability, preventing developmental delay and improving school readiness.[16, 34, 35] In the long term, they have been shown to reduce high school drop-out rates and criminal behaviour, increase employment and delay child rearing.[16, 34, 35] Targeted early intervention for children at risk of developmental disability or those who have a diagnosed disorder also has increasing evidence of improved developmental outcomes.[35, 36]
What Is the Role of the Health-Care System?
Much of what determines health and well-being lies outside the health-care system. Equitable health care is therefore necessary but not sufficient as we tackle child health inequities. In Australia, we have demonstrated that it is possible to reduce some inequities in child health through health system initiatives such as a universal immunisation programme. To address inequity in early childhood development, we need well-organised, high-quality and accessible primary health-care services and services that promote early child development, detect problems early and facilitate access to enriching environments or specific effective interventions if required.[37, 38]
To detect problems early and facilitate appropriate pathways to support a child's development, it is accepted that one-off ‘developmental screening’ is not sufficient,[39, 40] and evidence in terms of its effectiveness in preventing or predicting later difficulties has been mixed. A National Health and Medical Research Council review in Australia and the American Academy of Paediatrics recommend instead the concept of ‘developmental surveillance’, characterised by (i) ongoing contact of families and children within a universal system; (ii) health professionals trained in child development and health promotion; and (iii) monitoring and responding to developmental concerns over time from infancy to the pre-school period. If concerns about early childhood development are identified, then access to suitable services to provide enriched and stimulating environments and further assessment, with standardised tools and assessment of possible causes, should be available along with timely and effective early intervention.[38, 41]
Universal Child Health Care in Australia
In Australia, the responsibility for ‘well-child care’, including undertaking developmental surveillance, falls under both federal and state jurisdiction. The Early Childhood Development Strategy launched by the Council of Australian Governments in 2009 has a focus on promotion of early childhood development, strengthened universal child health service delivery and improved support for vulnerable families. In addition, as part of the National Mental Health Reform, the ‘Health and Wellbeing Check for 3 year olds’ will be introduced, and we currently have the Medicare Healthy Kids Check. Most states have implemented strategies (or have strategies underway) to achieve universal developmental surveillance programmes through their maternal and child health programmes.
Despite these federal and state policy initiatives, there are significant challenges for universal and primary health-care services in Australia currently in meeting the needs of children, including insufficient awareness amongst some primary health professionals who have not had training in early childhood development about child development promotion, and the potential service gap for children living in socially disadvantaged circumstances. In Australia, up to 18% of children with significant developmental vulnerability are not identified before they start school, and there is emerging evidence that children from our more vulnerable populations are less likely to undergo ‘well-child’ checks. Unfortunately, our knowledge about the true impact of our health-care system on child health inequities in early childhood development, either positive or negative, is limited, with scant data available for any of the six areas highlighted in the National Health Performance Framework. We have limited understanding about whether high-quality and affordable primary health-care systems are available for children and delivered according to need and/or whether these systems actually facilitate access to appropriate services. Without these data, we are in a ‘silent zone of information’, as described by Lynch, which is the opposite of what we need to ‘close the ECD [early childhood development] gap’.
Society has a responsibility to protect children from adverse environments, as is clearly articulated in The Convention on the Rights of the Child, which recognises the vulnerability of children and makes their best interests paramount.[48, 49] We know that the availability of a universal system does not guarantee equity in health care and that improved health care systems, while necessary, are not sufficient without considering the broader social determinants of health. However, the systems we work in can aim to eliminate inequities in health care by ensuring that all children have access to high-quality primary health-care systems with sound developmental surveillance systems (horizontal equity) and that there is a greater allocation of resources to respond to the increased needs of those children living in disadvantaged circumstances (vertical equity). We need to continue to work towards health-care systems that aim to be free, but in the interim are at least affordable, easily accessible, implemented within an evidence-based framework and delivered along the principles of ‘proportionate universalism’. This is supported by the recommendation of the National Health and Hospitals Reform Commission to ensure that ‘children get access to the right mix of universal and targeted services, based on their age and their individual health and social needs’. Services need to engage with families from before birth right through schooling and cannot be limited to a single-funded visit. They need to ‘find’ those who may be ‘hidden’ from our current system, including asylum seekers, itinerant families, and children of parents with substance abuse or mental illness.
Paediatricians and other health professionals who work within service delivery systems for children must act as advocates and ensure that every encounter that a pre-schooler, toddler or infant has with our health and early childhood services is an opportunity for developmental surveillance. We should also encourage governments to use existing data to plan allocation of resources, community services, education and health in geographic locations where opportunities for prevention are greatest in a way that takes into account numbers of children as well as the prevalence of developmental vulnerability in a community. In order for systems to be effective, professionals working with children and families need to be trained on promotion of early childhood development and detection of developmental delays and deviations. This also needs to be matched with appropriate referral systems, pathways of care and service provision. Health professionals working with children should regularly evaluate their own services to highlight and work towards elimination of inequity in local service delivery.
Today, we are faced with the challenge of how best to respond to inequity in child health and, in particular, early childhood development through changing models of service delivery. This gives us the unique opportunity to consider how best to configure new services or improve upon existing services to ensure they are delivered equitably. We need a comprehensive high-quality primary health-care system that all children have access to and that has the flexibility to respond to differing levels of need in the population. A concerted effort is required involving workforce training, service redesign and ongoing monitoring and evaluation, involving not only health but welfare, education, employment, housing and other components of a civil society. Whether the investments in early childhood services for vulnerable children are done from a social justice perspective or as a wise economic investment, available scientific knowledge on early brain development provides supportive evidence on both grounds. Ensuring that all children have a good start in life from the antenatal period is the critical first step for improving the health and well-being of future generations.
Inequities are inequalities that are unfair, unjust, systematic, avoidable and unnecessary.
There are inequities in most measures of child health, including early childhood development, which are compounded as children age and have adverse long-term outcomes.
A comprehensive primary health-care system that embraces ‘proportionate universalism’ is an important component in addressing the adverse impact of the social determinants of health through promotion, early detection and intervention for developmentally vulnerable children.
Child health specialists need to develop specific skills to tackle child health inequity: these include advocacy, with training in equity focused health service delivery and health services research.