Early Childhood Development and Social Determinants of Health Inequities (2015) PDF

Health Promotion International, 2015, Vol. 30, No. S2 ii102–ii115 doi: 10.1093/heapro/dav031...

Early childhood development and the social determinants of health inequities Timothy G. Moore1,*, Myfanwy McDonald1, Leanne Carlon2, Kerryn O’Rourke2 1 Murdoch Childrens Research Institute, Royal Children’s 3052, Australia, and 2VicHealth, 15-31 Pelham Street, *Corresponding author. E-mail: [email protected] for health equity’ was developed by VicHealth under the leadership of It is a conceptual and planning framework adapted from work done by of Health (Solar and Irwin, 2010). Social determinants of health – socioeconomic, political and cultural context; daily living These determinants and their unequal distribution according to status between population groups that are avoidable and unfair. The points for action (VicHealth, 2013). Fair Foundations can be accessed a social gradient: the further up the socio- upon a review of multiple forms of evidence, investigates the causes of these socially produced during the early years and what works to reduce framework, we report upon child health inequity at and cultural level; daily living conditions; the individ- interventions may improve the absolute conditions of interventions that have been shown to effectively are rare. Numerous interventions have been family, physical and social environments for are difﬁcult to achieve. Inequitable access to ser- during the early years, because those families to access them. Reducing inequities during early child- that incorporates: approaches to governance and quality services and facilitate secure, stable, ﬂexible the characteristics of proportionate universalism, programs in inclusive environments; strong, sup- for parents so they feel supported and Press. All rights reserved. For Permissions, please email: [email protected] 2015, Vol. 30, No. S2 ii103 inequalities in health Downloaded from https://academic.oup.com/heapro/article-abstract/30/suppl_2/ii102/643035 by Dalhousie University user on 26 August 2019 Developing Child, 2007; Shonkoff et al., 2009; Currie and Rossin-Slater, 2014). There are three key ways in in socio- which the life-long effects of early experiences impact on develop- the later achievements, health and longevity of individuals: ‘Biological embedding’ is a developmental process whereby prenatal and early childhood experiences affect physiological and neurological development in ways that have long-term consequences (Gluckman et al., 2010; Hertzman and Boyce, 2010); ‘The cumulative effect of adverse experiences’ during childhood can lead to toxic stress that inﬂuences every aspect of health and well-being in childhood and beyond (Anda et al., 2009; Brown et al., 2009; Shonkoff et al., 2009; Shonkoff, 2012); and ‘Escalations in risk over time’ shape children’s develop- ment so that exposure to adverse experiences at one stage of the life course increases the probability of simi- lar exposures subsequently (Repetti et al., 2002; Hertzman and Boyce, 2010). This article focuses on the social determinants of health in- equities during these critical early childhood years. The questions we seek to answer are: spectrum 1. What are the causes of inequities in health and devel- opment during early childhood, and how do these in- equities impact upon health and development during this period? 2. What works to reduce inequities in health and devel- opment during the early years? In terms of reducing inequities, we focus upon policies and practices that work—or show promise—in the Australian context or in countries similar to Australia such as the UK, Ireland, the USA, Canada and New Zealand. The ‘layers of inﬂuence’ outlined in Fair Foundations: The VicHealth framework for health equity (VicHealth, 2013) are used to explore each question. According to the Fair Foundations framework, there are three layers of inﬂuence that lead to inequitable, socially produced, systematic differential health and well-being outcomes: 1. The socioeconomic, political and cultural context, en- compassing governance, policy, and dominant cul- tural and societal norms and values 2. Daily living conditions, which are the circumstances in which people are born, grow, live, work and age; and T. G. Moore et al., 2015, Vol. 30, No. S2 inﬂuences. What follows is a brief description of the ﬁnd- ings of our review, including some key illustrations of how inequities in health and development during early child- hood could be achieved. We conclude with a description Downloaded from https://academic.oup.com/heapro/article-abstract/30/suppl_2/ii102/643035 by Dalhousie University user on 26 August 2019 of the strategies that, based upon the evidence we re- viewed, appear to have the strongest potential to reduce in- equities during early childhood in the Australian context. people being un- Socioeconomic, political and cultural level Over the last 50 years, developed nations have experienced are rapid and dramatic social changes resulting in signiﬁcant population changes in the conditions under which families are raising young children (Giddens, 2002; Trask, 2010; Bauman, 2011). Although most children have beneﬁted from these changes, a minority have not and experience signiﬁcant that impact problems across all aspects of development, health and well-being (Stanley et al., 2005; Li et al., 2008). One outcome of these rapid social changes is that the nature of the problems facing society and governments have altered—they are now more likely to be ‘wicked’ pro- blems (Weber and Khademian, 2008; Moore and Fry, 2011). Wicked problems are complex and intractable and, as such, cannot be resolved using traditional govern- ance and leadership models, nor by service-driven ap- proaches (Grint, 2010; Moore and Fry, 2011). Some wicked problems (e.g. poverty, child abuse) are not new, but have become more of a concern because of an increas- ing awareness regarding the adverse consequences of these problems upon child development and the complex nature of their underlying causes. One ‘wicked’ problem that has wide-ranging and long-lasting consequences on young children is sustained poverty, which impacts on brain development and health during childhood, and psychological health and educa- tional outcomes in adulthood (Gibb et al., 2012; Blackburn et al., 2013; Duncan et al., 2013). Evidence suggests that policies targeting disadvantaged families— such as welfare-to-work initiatives—can have positive effects for both children and their families (Coley et al., 2007; Millar, 2010). However, the evidence indicates that factors such as mandatory employment requirements and irregular or insecure forms of employment can have a negative impact on children (Strazdins et al., 2010; Cooklin et al., 2011; Coley and Lombardi, 2012). Such social policies have differing impacts depending upon the context within which they are implemented; in the Australian context, the limited research available suggests that welfare-to-work initiatives have largely negative effects (Summerﬁeld et al., 2010; Grahame and Marston, 2011). International evidence indicates that policies targeting ﬁnancially disadvantaged families that involve the 2015, Vol. 30, No. S2 ii105 how a speciﬁc view of early childhood can impact upon public support for early childhood initiatives. In Australia, education and care during the early years has typically been viewed as a personal rather than a public Downloaded from https://academic.oup.com/heapro/article-abstract/30/suppl_2/ii102/643035 by Dalhousie University user on 26 August 2019 concern. As a result, there has been limited public support for universal high-quality early childhood education for all children in Australia (Fenech, 2013)]. Government invest- ment in initiatives that seek to improve the quality of learn- ing environments experienced by young children, for example, may be viewed as being of lesser importance than other education investments if young children lives are perceived to be as ‘uncluttered by inﬂuences.’ to the Daily living conditions Early child development Children’s development in both the short- and long term is shaped by the environments they experience in the pre- natal and post-natal periods. These environments are not always optimal: common environmental risk factors in pregnancy and early life include: stress, cigarette smoking, alcohol consumption, obesity, poor nutrition, poverty and exposure to environmental toxins (Martin and Dombrowski, 2008; Brown et al., 2011; Robinson, 2013; Platt, 2014; Taylor et al., 2014). There is now strong evidence that the biological and neurological development of an individual can be shaped by environmental conditions in the womb (Martin and Dombrowski, 2008; Robinson, 2013). One effect of sub- optimal prenatal conditions is premature birth, which is associated with greater risk of problems both in the short and in the longer term (Patton et al., 2004; Platt, 2014). One relatively common method for improving prenatal conditions is food subsidy and food voucher pro- grams that target pregnant women experiencing disadvan- tage. Although these programs may have some direct impact on pregnant women’s nutritional levels, there is limited evidence to support a sustainable impact on diet- ary behaviour (Black et al., 2012). Similarly, there is a lack of evidence to recommend one intervention over an- other in regards to the cessation of smoking during preg- nancy, although those that focus on parent attitudes and behaviours, as opposed to parent knowledge, appear to be more successful (Priest et al., 2008). Targeted motiv- ational smoking cessation interventions and holistic cessa- tion support have demonstrated some promising results among low-income pregnant women in the USA and the UK (Parker et al., 2007; Bryce et al., 2009). Postnatal environments are also vitally important for health and development, with early caregiving relation- ships being critical (National Scientiﬁc Council on the Developing Child, 2004; Siegel, 2012). Sensitive and T. G. Moore et al., 2015, Vol. 30, No. S2 disadvantaged groups access ECEC at a lower rate than other children, and the quality of ECEC in disadvantaged neighbourhoods is generally poorer than other neighbour- hoods (Baxter and Hand, 2013; CCCH, 2013). It is im- Downloaded from https://academic.oup.com/heapro/article-abstract/30/suppl_2/ii102/643035 by Dalhousie University user on 26 August 2019 portant to note that if an improvement in the quality of ECEC results in increased costs for families from disad- vantaged backgrounds, there is likely to be increased in- equity; children from higher socioeconomic backgrounds whose parents can afford ECEC will reap the beneﬁts and enter school with skills their disadvantaged counterparts will not have had as many chances to develop. , Family environments While families who are relatively well resourced have beneﬁtted from recent rapid social change, poorly re- sourced families can ﬁnd the heightened demands of con- temporary living and parenting overwhelming (Gallo and Matthews, 2003; Barnes et al., 2006a,b), with negative impacts on their children. Gaps in family functioning are cumulative: the more advantaged families are initially, the better they are able to capitalize and build on the enhanced opportunities available, so that the gap between them and those unable to do so progressively widens (Social Exclusion Task Force, 2007; Rigney, 2010). There also appears to be an increase in the numbers of families with multiple and complex needs (Cleaver et al., 2007; Bromﬁeld et al., 2010). Such families are often ex- periencing a range of external stressors (such as housing instability, poverty and social isolation) and parents with- in those families may also be grappling with their own ex- periences of trauma and victimization (Bromﬁeld et al., 2010). Poor quality or insecure housing, and especially home- lessness, negatively affects child health and well-being (Dockery et al., 2010; McCoy-Roth et al., 2012). In Australia, housing is especially relevant to the health in- equities experienced by ATSI children, particularly in re- mote communities where the type of infectious diseases that infants commonly present with are linked to poor housing conditions and overcrowding (Kearns et al., 2013; Jervis-Bardy et al., 2014). Interventions that focus primarily on housing infrastructure do not appear to solve housing inequities in these communities. Housing in- terventions that aim to improve the absolute position of children in remote ATSI communities require a multi-level, multi-faceted, ‘ecological’ approach (McDonald et al., 2008; Bailie et al., 2011, 2012). signiﬁ- Physical and social environments The nature and quality of the physical environment in which children grow up can have a signiﬁcant impact on their health and development (Evans, 2006; Sustainable 2015, Vol. 30, No. S2 ii107 Ou et al., 2011) and it is often those with the greatest need that are least able to access available services (Ghate and Hazel, 2002; Fram, 2003). The importance of providing accessible, comprehen- Downloaded from https://academic.oup.com/heapro/article-abstract/30/suppl_2/ii102/643035 by Dalhousie University user on 26 August 2019 sive universal services for reducing inequity during the early years is underlined by a recent study which demon- strates signiﬁcant differences in levels of vulnerability among Australian children by jurisdiction. Differences in the availability of universal health services could account for differences in jurisdictional levels of developmental in- equity; two of the three states with the most comprehen- sive universal service coverage during the early years also have the smallest levels of inequity in child develop- mental vulnerability (Brinkman et al., 2012). One approach to improving service access is intake promotion and support (e.g. contacting parents prior to appointment to discuss potential barriers to attendance). Pre-intake prompting and support for improving families’ registration with and use of services in UK have reported mixed ﬁndings (Yuan et al., 2007; Michelson and Day, 2014). The processes of service delivery (i.e. how services are delivered) appear to play a key role in vulnerable fam- ilies’ engagement with services (CCCH, 2006; Moore et al., 2012b). Another major problem with the current service system is that the planning and delivery of services continues to be heavily segmented, with government departments and their funding streams operating autonomously as ‘silos’, making it difﬁcult to conduct the joint planning needed to develop and implement a cohesive approach to support- ing families of young children, especially those with mul- tiple and complex needs (Moore, 2008). Place-based or ‘collective impact’ approaches to service delivery—involv- ing a comprehensive, collaborative multi-level effort to simultaneously address all the factors that affect child, family and community functioning in a deﬁned a socio- geographic area—would appear to address at least some of these problems; however, the evaluation of such ap- proaches is still in the early stages (Moore and Fry, 2011). Individual health-related behaviours and attitudes The health and well-being of children are strongly inﬂu- enced by the knowledge, attitudes and behaviours of their parents, caregivers and family (Law et al., 2012; Peters et al., 2013). Parent knowledge regarding child de- velopment and nutrition are associated with improved child outcomes (Hess et al., 2004; Campbell et al., 2013). Vulnerable families may not have the same level of access to health information as other families or may not even know that particular health services exist (Carbone et al., 2004; Claas et al., 2011; Leurer, 2011). Migrants and families from non-English-speaking T. G. Moore et al., 2015, Vol. 30, No. S2 Socioeconomic, political and cultural context 1. Because traditional governance and leadership ap- proaches are not an appropriate or effective means for addressing the complex problems that lead Downloaded from https://academic.oup.com/heapro/article-abstract/30/suppl_2/ii102/643035 by Dalhousie University user on 26 August 2019 to inequity (Grint, 2010; Moore and Fry, 2011) decision-makers (e.g. government, non-government organizations) need to ask questions of and engage communities, service providers and institutions. 2. Because all children beneﬁt from high-quality ECEC, especially children experiencing disadvantage (Durlak, 2003; Sylva et al., 2003, 2012; Camilli et al., 2010), the quality agenda in early childhood educa- tion and care needs to be maintained. 3. Because families with young children experiencing disadvantage are less likely to utilize ECEC services (Baxter and Hand, 2013), we need to implement pol- icies that make it easy for families with young children experiencing disadvantage to access high-quality ECEC. 4. Because for young children, the key developmental environments are relational (National Scientiﬁc Council on the Developing Child, 2004; Siegel, 2012), we need to implement policies that enable greater workforce ﬂexibility for all parents and care- givers so they can spend more time with their children during the early years. 5. Because employment for parents at any cost could in- crease inequity (those in the most disadvantaged groups are likely to be employed in the most insecure and in- stable jobs, and insecure, unstable employment can have a negative impact upon children) (Strazdins et al., 2010; Cooklin et al., 2011; Coley and Lombardi, 2012), we need to implement policies that ensure secure and stable employment for primary caregivers. 6. Because public perceptions of early childhood can impact upon public support for strategies that aim to support young children’s learning and development (Fenech, 2013), and because a number of misconcep- tions about early childhood and ECEC exist among Australia’s general public [e.g. young children are ‘pas- sive absorbers of content’ and ECEC is a ‘child mind- ing service’ (Kendall-Taylor and Lindland, 2013)], we need to improve public understanding of the import- ance of the early years and the role of ECEC. Daily living conditions 7. Because most Australian families are doing well (and will continue to do well if any risks or problems are identiﬁed early) and because all families will struggle at some point (and some will struggle more than others) (Moore and McDonald, 2013), we need a 2015, Vol. 30, No. S2 ii109 to engage in decision-making and collaborative processes. 15. Because knowing what services exist, and what they provide, is a key facilitator of families’ engagement Downloaded from https://academic.oup.com/heapro/article-abstract/30/suppl_2/ii102/643035 by Dalhousie University user on 26 August 2019 with services (Parvin et al., 2004; Carolan and Cassar, 2007; Boerleider et al., 2013), families need information about services and child development in a range of different languages, tailored to differing circumstances and via a range of mediums. inequities Individual health-related context 16. Because parents need to be able to get support for themselves, their child and their family when it is needed, parents needs to know what services are available, what type of support is offered by those ser- vices and feel conﬁdent to approach those services (Carbone et al., 2004; Carolan and Cassar, 2007; Boerleider et al., 2013). For some families, the conﬁ- dence to approach services will rely upon the ‘ap- proachability’ of those services (see Strategy 12). 17. Because knowledge of child development helps parents understand their child and their child’s behaviour (see, for example, Campbell et al., 2013; Hess et al., 2004), parents need to know about child development, the fac- tors that promote positive health and development, and have the capacity to support their child’s development. 18. Because a parent’s attitudes about parenting mediate how they behave towards their children (Gutman and Feinstein, 2007; Kruske et al., 2012; Prady et al., 2014), parents need to feel conﬁdent and supported in their role as parents. Some parents will be conﬁdent in their parenting role, some will require reassurance and others may require more intensive support. of the ex- services CONCLUSIONS As Urie Bronfenbrenner claimed: ‘every child needs at least one person who is crazy about [them]’. 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