What Works in Reducing Inequalities in Child Health?

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 For Rodney Barker
and our children and their children
 ontents

C
Figures and tables vi
Acknowledgements vii
Foreword by Professor Terence Stephenson ix
Preface xi

One Introduction 1
Two What kinds of studies help us understand what works? 19
Three What works in early life? Infancy and the pre-school period 43
Four What works in childhood and adolescence? 59
Five What works in keeping children safe? 77
Six What works for vulnerable groups? 93
Seven Tackling the causes of the causes 111

References 129
Appendix: Web and other resources 155
Index 163

v
What works in reducing inequalities in child health?

ables and figures

T
Figures
1.1 Age-specific mortality in England and Wales, 1960–2000 10
1.2 Targeted intervention 16
1.3 Shifting the mean 16
2.1 The review process: young people and physical activity 26
2.2 ‘Help I’m ill’ 38
2.3 Upstream/downstream: options for oral disease prevention 39
3.1 Infant, neonatal and post-neonatal mortality rates, England and 46
Wales 1980–2007
3.2 Infant mortality by ethnic group, England and Wales 2005–06 47
4.1 ‘Stop bullying now’ 63
4.2 ‘Don’t leave us out’ 65
4.3 Disabled car 66
5.1 Safety device for children crossing the road, Newtown Public 85
School, 5 August 1938
6.1 Prevalence of mental disorders among 11- to 15-year-olds: 97
looked-after and private household children
6.2 Examination results for looked-after children and the 99
general population
6.3 Changes in immunisation status of children looked after on 101
31 March in 1999 and 2000
7.1 Mean income inequality ratio and under-five mortality rate in 113
wealthier OECD countries
7.2 Child well-being is better in more equal rich countries 114
7.3 The income gap is too large/too small/about right 116

ables
T
2.1 Horses for courses: different kinds of research evidence for 22
different kinds of question
3.1 Infant death rates: definitions 45
7.1 Examples of nudging and regulating actions 118

vi
 cknowledgements

A
Time is a scarce commodity for those of us lucky enough to be in work.
Sharing that time is a gift. Colleagues who commented, provided data, or made
suggestions include Lisa Arai, Audrey Brown, Ian Basnett, Ian Butler, Kalipso
Chalkidou, David Collison, Katherine Curtis-Tyler, Luise Dawson,Anne Goymer,
Ron Gray, Judith Harwin, Jennifer Hollowell, Jenny Kurinczuk, Catherine Law,
Kristin Liabo, Patricia Lucas, Gerri McAndrew, Di McNeish, Karen Melton, Guy
Palmer, Heather Payne, Douglas Simkiss, Mike Stein, Madeleine Stevens, James
Thomas and Harriet Ward. I have learned a great deal from my colleagues at the
National Institute for Health and Clinical Excellence (NICE), from the Canadian
Institutes of Health Research-funded International Collaboration on Complex
Interventions led by Penny Hawe and from the Cochrane Public Health Group
led by Liz Waters. I owe them all a huge debt, particularly since I suspect I may
not always have done justice to their insights.
I am grateful for permission to reproduce tables and figures whose provenance
is acknowledged in the text.
Although the family is now rarely a location for the formal organisation of work,
I have benefited from both the intellectual and domestic support of my husband
Rodney Barker. Without Ben Barker’s advisory and culinary visits, there would
have been no book. He, Hannah, Polly and Tom Barker have, as ever, provided
a structure and narrative to family life, and their friends, partners and children a
constant source of amusement.
I was fortunate enough to spend the decade leading up to the turn of the century
leading R&D in the children’s charity Barnardo’s, asking (among other things)
what works for children? My work included a report which was the predecessor
to this book. Once it became out of date, Barnardo’s readily agreed to allow
me to draw on it for the current work. I am grateful to those acknowledged in
my original report who allowed me to draw on joint work and to my former
colleagues in Barnardo’s for their encouragement. I warmly acknowledge the part
they play not only as a provider of services but also in pressing to have outcomes
for children on the policy agenda, and as leaders of the pack in terms of the use
of research evidence in child social care.
I completed the final stages of this book while a Visiting Fellow at All Souls
College, Oxford. I am grateful to the Warden, Fellows, Manciple, Bursar, the
Fellows’ secretary Humaira Erfan-Ahmed and all the college staff to have had
the opportunity to work in such unaccustomed splendour.
My publishers have been a model of encouragement. I thank them, in particular
Karen Bowler, Sylvia Potter, my meticulous copy editor, and the anonymous
referees. Angela Martin’s cartoons, like the work of the poet Piet Hein, convey
the joy of the fullness of life. I also thank Terence Stephenson for his foreword,
and RussellViner for sharing his room in University College London, which may
be less splendid than All Souls, but which has a charm of its own.

vii
 Foreword

We know that social influences on health are far greater than medical ones. In
2007, a UNICEF report suggested that the well-being of children and young
people in the UK was worse than that in many other economically advanced
nations. However, most of the factors which the UNICEF report measured were
determined to a greater extent by social factors than by medical ones. One of
the most pernicious factors in society which seems to impair children’s health
and well-being is inequality.
Fortunately there remains a large section of society who believe in equality
of opportunity. Since young children particularly cannot create their own
opportunities, society and the state have to play a part in this as well as the family.
If anything, in the UK over the last decade, inequalities have got wider.We look
enviously at neighbouring countries in Europe and wonder why their societies
seem to function more coherently and why children and young people growing
up there score better on measures of well-being.
Helen Roberts has written a fine book which examines why inequalities arise
in developed societies and, more importantly, what can be done to try to reduce
these and improve the health and well-being of children and young people.This
debate is not so dramatic or emotive as those around open heart surgery, genetic
testing of the unborn or organ donation. However, the issues which Helen Roberts
raises affect far more children. I would commend this book to every reader who
would like to see a better society for our children in the future.

Professor Terence Stephenson

President, Royal College of Paediatrics and Child Health

ix
 Preface
Health is not bought
With a chemist’s pill
Nor saved by the surgeon’s knife.
Health is not only the absence of ills
But the fight for the fullness of life.

Piet Hein (1905-96)

Health matters to children, families and communities. It also matters to policy

makers and politicians. At the individual level, the plight of a sick child, at
the community level, the fate of a local hospital, and at a population level, the
availability or otherwise of a vaccine, attract ready media attention. Inequalities
on the other hand, tend to be less attractive as headline grabbers. As a colleague
put it: “Poverty is bad for your health. Well fancy that!” But the consequences
of neglecting inequalities in health are as dire as those of ignoring acute health
problems. Children born into poverty and disadvantage miss out on important
opportunities for health gain, and accumulate health risks as they grow into
adulthood.
With that in mind, the reader I have tried to imagine is the policy maker,
practitioner, or student who not only wants to know something about
inequalities in child health, but in a climate of budget austerity in many parts of
the wealthier world, wants to know what might be done to improve health and
reduce inequalities. The UK has an unrivalled reputation in terms of describing,
theorising and understanding inequalities in health. Theory is important if we
are to understand problems, but it is not enough.
While in the UK funding for public health research in the widest sense is
strengthening the evidence base, it is likely to take some time before there is the
same volume of evidence which has transformed clinical practice and survival
rates for children, with five-year survival for leukaemia tripling since the 1970s.
This shows that things do not have to be the way they are. There is no reason
why the worse-off children should not have the same life chances as the best-off.
Inequalities in health are damaging not only to the poorest children, but to us all.

Helen Roberts
London, 2012

xi
 O

ne
ntroduction

I
Investing in child public health is potentially the most important – and most effective –
commitment any society can make to its future.

Inequalities in child health remain a problem even in wealthy countries such as the UK. While
there has been progress in improving the health of the poorest, there is still some way to
go in narrowing health gaps and reducing the health gradient. A move to an austerity climate
worldwide risks not only impeding progress but undermining what has been gained.

The background of recent policy is best understood alongside an awareness of tensions

between different ways of approaching problems.There is dispute, for instance, about whether
universal or targeted services are the best way to address inequalities in health. Is it better
to concentrate resources on the poorest, or to provide better resources for all? As Graham
and Kelly (2004:10) put it ‘ “what works” to improve the life chances and health prospects of
poorer groups may not have the magnitude of effect necessary to bring them closer to the
population average – or to reduce wider social and health inequalities. Being clear about what
is being tackled should be integral to the development and delivery of policies to promote
equity in health.’ But there is no simple vaccine against poverty. Effective remedies involve
addressing tax and benefits, education, employment, housing, the environment, transport and
pollution. Health services are part of this picture, but by no means the major part.

At an individual and community level, social interventions are complex and like medical
interventions, capable of doing harm as well as good. They need to be subject to as much
evaluation as pharmaceuticals, if not more, before, during and after implementation.

nequalities and health

I
We live longer than we did 50 years ago, fewer babies die at or shortly after birth,
and there are fewer childhood deaths. But there remain unacceptable inequalities
in health between rich and poor. Attention to inequalities in health is by no
means new, but a resurgence in both science and policy offers new opportunities
to act on the basis of a growing body of evidence.
Recent policy interest in inequalities in health is illustrated by a range of reports
including, but not confined to, the Working Group on Inequalities in Health
(1980), also known as the ‘Black report’, the ‘Acheson report’ (Acheson, 1998),
the work of the Marmot Review (2010) and the Field (2010) and Allen (2011)
reports. Given the most recent focus, it can be difficult to recall that until relatively
recently, attention to inequalities in health was both marginal and marginalised.

1
What works in reducing inequalities in child health?

It is a strength of this body of work, and the research on which it is based, that
even given changes in government, the days when inequalities in health were
branded ‘variations’ seem to be over.
There is now a very substantial body of work on theoretical, methodological
and policy issues in relation to inequalities in health. What this book focuses on
is an accessible overview for the non-cognoscenti, and examples of what works,
or appears to work, in practice. Outlined here is the extent to which we have
evidence that some interventions are more effective than others in improving
health and reducing health inequalities, and the extent to which this knowledge
is used, or discarded in favour of other imperatives. Having the evidence is only
part of the picture. Having the political will and the combination of knowledge
and skills to implement programmes or interventions which reduce inequalities
is key to creating fair shares in child health. While the book has a health title,
many things which have the potential to reduce health inequalities are not at
first sight health-related. Support to children and their families in the early years,
education and training, support for parents in and out of employment, housing
and a whole range of fiscal measures may lie outside the health system, but bring
well-documented health gains.
Evidence-informed practice is about ensuring that in so far as we are able given
our current state of knowledge, interventions in the lives of children do as much
good and as little harm as possible.The focus of this book is largely the UK, where
the devolved countries and differing regions may have differing levels of problems
in relation to alcohol, drugs and obesity, different levels of employment and
housing, and different levels of integration of health and social care. In the case of
the nations, there may be different policies on important issues, and different levels
of investment in relation to reducing inequality. In recent years, infant mortality has
fallen most in Wales and least in Northern Ireland, with McCormick and Harrop
(2010) suggesting that devolution provides a virtual ‘policy laboratory’ to better
understand policy and regional differences. Hirsch (2008) takes the comparative
element further, setting out proposals for reducing childhood poverty in the UK
to the level of the best in Europe. Notwithstanding this (largely) UK focus, much
of the material here is of relevance to other middle- and high-income countries.
Described in what follows are some of the inequalities in child health which
blight young lives, and examples of where there is good evidence that interventions
make a difference.The collection and analysis of evidence is better in some areas
than others, and we probably know a little more about the effectiveness of early
interventions, for instance, than about those in middle or later childhood. Some
kinds of intervention are more susceptible to robust evaluation than others, giving
us more confidence in adopting them (or stopping them if they are shown to cause
harm). Others may never have been evaluated at all, and it is important to bear in
mind that no evidence of effect is not the same thing as evidence of no effect.The
National Health Service (NHS) in the UK for instance, was not set up following
a series of pilots, randomised controlled trials (RCTs) and meta-analyses. As the

2
 Introduction

epidemiologist Jerry Morris put it: ‘The 1940s was the generation that said “Yes
we can.” You need a national health service? You go out and do it’ (Kuper, 2009).
The book covers health in its broadest sense – physical, mental and emotional
health and well-being. It also considers the determinants of health – the causes of
the causes of good or poor health.
Included are:

• Some of the methods which help us judge the effectiveness of an intervention.

How can we know what works when faced with a barrage of conflicting
studies? Should we give greater weight to some kinds of evidence than others?
Are there things we routinely do in childhood with the intention of doing
good which don’t in fact make any difference, or which even make matters
worse? What part can cost-effectiveness studies play?
• Interventions in pregnancy, early life and the pre-school period.This is an area
where a relatively large amount of scientific work has been done, and where
we have strong evidence of the effectiveness of some interventions.
• Interventions in childhood and adolescence.
• Interventions intended to keep children safe from accidental injury, a major
childhood killer.
• Interventions with groups we know to be particularly vulnerable, in particular,
children looked after by the state and disabled children.
• Interventions that tackle the causes of the causes.
• A resource list for those seeking research evidence and its links to policy, and/
or those who want to contribute to the evidence agenda themselves.

It will be clear that what is covered is by no means exhaustive. This is in part

because the evidence base of ‘what works’ remains patchy, and where the evidence
itself is most solid, often draws on research from countries whose systems and
child outcomes may be very different from ours (and by no means always better).
Despite wide-ranging trawls, it has not always been easy to find good examples
of current practice in the field based on robust research evidence.This may be in
part because, as well as a ‘push’ to use good evidence in the provision of services,
there can be a countervailing pressure, sometimes more attractive to creative
and imaginative practitioners, to be innovative. Indeed, funding will sometimes
depend on innovation, which can be a very strong disincentive to simply use the
best of what is already known. In these cases, just as the National Institute for
Health and Clinical Excellence (NICE) sometimes makes a recommendation of
‘only in research’ where a new technology looks promising but the evidence is
insufficiently strong, there may be a ‘middle way’ for those developing innovative
services for children to build on the best of existing evidence while working with
research partners to evaluate both process and outcomes for children.

3
What works in reducing inequalities in child health?

What are the causes of the causes of ill health and

inequalities in health?

Germs and genetics are important factors, but so are social class, gender, ethnicity,
disability, sexuality and our geographical context. Housing, employment, transport,
education and the wider environment are also elements with a key influence on
health and inequalities in health.
A World Health Organization poster caption asks: ‘Why treat people without
changing what makes them sick?’,1 and defines the social determinants of health
as including the conditions in which people are born, grow, live, work and age,
as well as the health system. These circumstances are shaped by the distribution
of money, power and resources at global, national and local levels, which are
themselves influenced by policy choices. It is the social determinants of health
which are principally responsible for health inequalities – the unfair and avoidable
differences in health status seen within and between countries.

What do health inequalities mean for children?

In better-off countries, we almost never see children going without shoes and most
children in middle- or high-income countries do not go hungry. Few children
live on the streets. But inequalities in health are a problem not just for the worst
off, but for all of us. There are (at least) two ways of looking at inequalities in
health and what we might do about them. One is to concentrate on the gap
between the best off and the worst off. The other is to think about the slope
between those at the bottom of the pile and those at the top – ‘the gradient’ –
since differences will usually be seen all the way up. Perhaps one of the clearest
examples of this relates to a long-term study of British civil servants (Marmot et
al., 1991), which showed not only those in the lowest grade such as messengers
having much higher mortality than those at the top of the civil service, but also
that there were differences all the way up the finely graded civil service hierarchy.
Even those at the very pinnacle do not entirely benefit from their situation, given
that for many, whatever their political views, it is deeply disturbing to live in a
society where there is an unfair distribution of health and well-being.
Inequalities in health do not just relate to socioeconomic status, though since
this is where we tend to have the most consistent data, it is the dimension most
frequently referred to in this book. Other dimensions of inequality can relate to
whole countries. Figure 7.2. for example, shows differences in child well-being
in countries which are more and less equal. Ethnicity is a further dimension, and
Figure 3.2, for instance, shows inequalities in infant mortality by ethnic group.
Children looked after by the state and children brought up in private households
also have different life chances, resulting in inequalities in health and life more
broadly.

1
www.who.int/social_determinants/en/

4
 Introduction

In addressing inequalities in health, we can put efforts into improving the

health of the poorest, trying to close the gap between those at the top and those
at the bottom, or we can try to alter the slope or the gradient so that people all
the way up are doing better (although there will still be a gap between the best
and the worst off). Graham and Kelly (2004:10) suggest that each of these adds a
further layer to the policy challenge. As they point out, improving the health of
the poorest is a goal in line with policy trends, whereas narrowing the gap and
reducing the health gradient are more challenging.
Inequalities in health are closely tied to wealth (and poverty). Children born
into poverty are more likely than their better-off neighbours to:

• die in the first year of life

• be born small, be born early, or both
• be bottle fed
• die or be seriously injured in a childhood accident
• smoke and have a parent who smokes
• become overweight or obese
• have or father children before they are ready to
• parent alone
• die younger.

But these outcomes are not just true of the poorest children – mortality,
breastfeeding and accidental death in childhood and other health-related factors all
form a gradient from the poorest doing worst to the least poor tending to do best.
While these are clearly matters of concern, children and young people are not
simply ‘objects of concern’. They are active citizens with views and rights. Each
chapter makes reference to the views of children and young people, and draws
on studies where their voices are heard. As Mayall (1995) suggests, it is critical
to understand children’s own experiences in evaluating services. While abstract
issues such as inequalities in health are not, on the whole, ones which children
would themselves raise using those terms, they have an early understanding of
injustice, as anyone familiar with the phrase “That’s not fair!” will know. Even at
an early age, they can be aware of the links between health, wealth and well-being.
A study carried out by Newman (2000) asked a large sample of junior school
children, ‘if you had one wish come true, what would it be?’ Responses showed
both generosity and altruism:

‘If I had a wish I would wish that my house was not being repossessed.’
(Girl, 10)

‘I wish I would not suffer from asthma so my mother doesn’t have to

do so much dusting. I wish my dad could have more time off work.’
(Boy, 10)