Delivering improvements in population health of

children: The modern challenge

for Children’s Healthcare Services

Prof Victor NossarProgram Leader - Child and Youth Health NT Department of Health

Outline:

•Delivering healthcare to individual children & delivering improved outcomes for populations of children.

•How can we achieve significant improvements in outcomes for populations of children?

•What are the implications for Children’s Healthcare Services in Australia?

Children’s Healthcare Services have played an important role in Australia over many decades….

Children’s Healthcare Services have delivered:

• Modern paediatric care

• Neonatal Intensive Care

• Health & developmental screening & surveillance

• Immunisation

• Child safety & injury prevention

• Child development support

However, communities & Governments continue to demand improvements in :

• Child & infant mortality rates

• Rates of low birth weights

• Rates of overweight & obesity

• Breastfeeding rates

• Child injury rates

• Rates of substance misuse (licit or illicit)

• Rates of child maltreatment

& these have proved much harder to deliver!

Health promotion or health protection

Cure or management of health problems

We are told that there is a continuum:

& clinicians need to be able achieve both!

But the focus remains on providing care & support to address the health & developmental problems that children present with….

It is important to ask then

why, when prevention is valued and seen to be good clinical practice,

most effort and resources still are concentrated on responding to presenting problems and illnesses of children.

Why are there so few studies able to demonstrate improved population-level rates for children from interventions delivered through clinical responses?

Is there a distinction between healthcare for individual children & the health of populations of children?

Healthcare mainly focusses on the health or developmental needs of an individual child:

Even if the care is addressing the health or developmental needs of many individuals:

Or the care is addressing the health or developmental needs of very many individuals:

But

If that care is addressing health & developmental needs of a population:

The picture looks very different!

Programs that successfully improve health outcomes for populations are very different from those designed to address the health problems of individuals.

If you map the nature of the intervention (“prevention” or “cure”) against the level of the intervention (for an individual or for a population), the picture gets a little clearer.

Health Promotion/Health Protection(Proactive)

Response to health problem or issue(Reactive)

PopulationCare

IndividualCare

“Classical” Public Health

Clinical &

Curative Care

“Classical” Health Promotion

Population Health Outcomes

Individual Health Outcomes

Health Promotion/Health Protection

Response to health problem or issue

Population Care

Individual Care

Health Outcomes Achieved by Health Services

Ref: Nossar V. Integrated model of Children’s Health: Better Definition of Health Outcomes for Children and Training Requirements for Professionals. Association for Paediatric Education in Europe/European Society for Social Paediatrics. Bordeaux, France, 1998.

Caring for the needs of an individual child:

Population Health Outcomes

Individual Health Outcomes

Health Promotion/Health Protection

Response to health problem or issue

Population Care

Individual Care

Health Outcomes Achieved by Health Services

Individual Health Outcomes:

•Most often utilise strategies that respond to a problem, (even with “early intervention”.)

•Focus on the care of particular individuals and the responses addressing their problems and needs.

•Attention to the services being available, accessible, appropriate, and effective.

Caring for a population of children:

Population Health Outcomes

Individual Health Outcomes

Health Promotion/Health Protection

Response to health problem or issue

Population Care

Individual Care

Health Outcomes Achieved by Health Services

Population Health Outcomes Measures include:

• Infant or child mortality rates

• Rates of low birth weight

• Immunisation rates

• Breastfeeding rates

• Rates of substance abuse (licit or illicit)

• Injury rates

• Child abuse rates

Population Health Outcomes:

•Utilise more proactive strategies with a focus on whole populations.

•Based on systems approaches addressing key determinants of health in the population of interest.

•Focus on programs being available, appropriate, effective but also reaching high coverage.

Cutler DM, Meara E. Changes in the age distribution of mortality over the 20th century. NBER Working Paper 8556.

MA, USA, 2001.

1+1 A Healthy Start to Life Study has found very high rates of contact with clinical services for treatment of acute illnesses by Aboriginal children in their first year of life in the two large remote NT communities studied.

Ref: Bar-Zeev SJ, Kruske SG, Barclay LM, Bar-Zeev NH et al. Use of health services by remote dwelling Aboriginal infants in tropical northern Australia: a

retrospective cohort study. BMC Pediatrics 2012, 12:19 doi:10.1186/1471-2431-12-19.

Effective population-level approaches to improve Child Health outcomes

High variance apparently “ explained” by individual-level risk indicators ….does not mean that they are important determinants of the population level of any outcome.

(Rose G. Sick individuals and sick populations. Int J Epidemiol 1985; 14:32-8.)

Key question:

What are the significant population-level determinants of the health problem?

Upstream Factors

Global forces

Government

Culture

Determinantsof health(social, physicaleconomic environmental)

Health system

Psychosocial

Health behaviours

Culture

Physiological

Biological

HEALTH

Determinants of Health

Policies

Midstream Factors Downstream

Socioeconomic determinants of health. Turrell G et al. QU T. April 1999. Commonwealth Dept Health & Aged Care, Canberra

(Schwartz & Carpenter. Am J Public Health 1999; 89: 1175 - 80.)

Inappropriately focussing on individual level determinants of health while ignoring more important macro level determinants is tantamount to obtaining the right answer to the wrong question.

The heritability of body mass index (BMI) calculated from population studies is about 70%.

Ref: Stunkard AJ, Harris JR, Pedersen NL et al. The body mass index of twins who have been reared apart. N Eng J

Med 1990; 322: 1483-7.

Child neglect, on its own, explained 57 per cent of the variation in juvenile participation in crime.

Neglect was responsible for most of the variation in juvenile participation in crime, even accounting for poverty, single parent families and crowded dwellings.(Ref: Weatherburn D, Lind B. Social and economic stress, child neglect

and juvenile delinquency. NSW Bureau of Crime Statistics and Research. Sydney, 1997)

Ref: Population Health Approach - Public Health Agency of Canada (http://www.phac-aspc.gc.ca/ph-sp/approach-approche/index-eng.php

)

0123456789

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Disorder severity

x 1,000 population

Threshold scorefor the clinical range

“High risk” focussed strategy

While the level of risk of problem is high, the numbers affected are small.

0123456789

10

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Disorder severity

x 1,000 population

Threshold scorefor the clinical range

“Population health” focussed strategy

While the level of risk of problem is lower, the numbers affected are much bigger.

Population Health Outcomes:

•Utilise more proactive strategies with a focus on whole populations.

•Based on systems approaches addressing key determinants of health in the population of interest.

•Focus on programs being available, appropriate, effective but also reaching high coverage.

A key determinant of health outcomes: The impact of Disadvantage

Children living in social or economic adversity have much greater chance of significant health and developmental problems,

and these problems can extend into their adult lives.

Mortality Rates for Children 0-14 YearsBy quintile of SES disadvantage. Australia - 1985-87

0

2

4

6

8

10

12

14

1 2 3 4 5

SES quintile

Rat

e pe

r 10

00

BoysGirls

Affluent Poor

Source: C Mathers,1995

Socioeconomic gradients for behaviour problems in children 4 &

5 years of age

0

5

10

15

20

25

30

-2 -1 0 1 2

Socioeconomic status

% W

ith

beha

viou

r di

sord

ers

National longitudinal survey of children & youth – Canada 1994. Willms, 1999.

“the outcomes of biological risk conditions depended on the quality of the child-rearing environment and the emotional support provided by family members, friends, teachers, and adult mentors.”

Ref: Werner EE. Journeys from childhood to midlife: Risk, resilience, and recovery. Pediatrics

2004; 114; 492

Experiences of early childhood adversity get “under the skin”, affecting physiological and cellular pathways leading to disease susceptibility & becoming “biologically embedded” into the molecular genomic systems that determine vulnerability and resilience.

Ref: Boyce WT, Sokolowski MB, Robinson GE. Toward a new biology of social adversity. PNAS Early Edition:

www.pnas.org/cgi/doi/10.1073/pnas.1121264109

Attributable risk for children’s vulnerability to poor development associated with low family income is 10.8 percent

– if Canada could boost everyone’s income above that level, the prevalence of developmental vulnerability in children would only be reduced by about 10 percent.

… even if all the principal risk factors known to be associated with family background could be eliminated, childhood vulnerability would be reduced by less than 20 percent.(Ref: Russell CC. Parenting in the beginning years: Priorities

for investment. Invest in Kids, Canada 2003, pp 27-31)

“What parents do is more important than who they are.

Especially in a child’s earliest years, the right kind of parenting is a bigger influence on their future than wealth, class, education or any other common social factor.”

Ref: Allen G. Early Intervention: The Next Steps. An Independent Report to Her Majesty’s Government. HM

Government, UK. Jan 2011. http://www.dwp.gov.uk/docs/early-intervention-next-

steps.pdf

Do we know how to help parents to improve children’s development & life outcomes?

•Good nutrition and nurturing support optimal brain & physical development, as well as later learning and behaviour.

•There are also initiatives that can measurably improve early child development.

Ref. McCain MN, Mustard JF. Reversing the real brain drain: Early Years Study- Final Report. Ontario Children’s Secretariat 1999. pp25-26

Key initiatives shown to improve child outcomes

Immunisation

Smoking Prevention/ Cessation

Nurse Home Visiting

School Connectedness

Breastfeeding

Early Child Development

ProgramsMother

completing 12 years

of Education

Advocacy - enhance social, political, economic and physical environment;

legislation (eg. seatbelts), structural changes (eg housing design)

Conception Birth 2 years 5 years 12 years 18 years

Community Development

Population Parenting Programs

“Achieving ‘real-world’ success with

prevention and early intervention

programs is difficult; therefore, close

attention must be paid to quality

control and adherence to original

program designs. Successful

prevention strategies require more effort

than just picking the right program.”

(Aos, S et al, Benefits and Costs of Prevention and Early Intervention Programs for Youth – Washington State,

www.wsipp.wa.gov/rptfiles/04-07-3901.pdf Sep 17, 2004)

Poverty and disadvantage diminish the impact of many programs on population – level outcomes, as the people “at greatest need” are least likely to access them.

To achieve improved population – level outcomes effective programs require high coverage.

Provision of a greater variety of programs, each with variable coverage, is unlikely to achieve the same impact on population-level health outcomes.

“The central problem for all developed countries, … is that intervention happens too late, when health, social and behavioural problems have become deeply entrenched in children’s and young people’s lives. Delayed intervention increases the cost of providing a remedy for these problems and reduces the likelihood of actually achieving one.”

Ref: Allen G. Early Intervention: The Next Steps. An Independent Report to Her Majesty’s Government. HM Government, UK. Jan 2011.

http://www.dwp.gov.uk/docs/early-intervention-next-steps.pdf

Ref: Early Learning & Development - The first five years determine a lifetime. Children Now

http://dev.childrennow.org.s78640.gridserver.com/index.php/learn/early_learning_and_development/

The focus must be on preventing the development of these health, behavioural & developmental problems before they become established, by supporting best possible early childhood development for every child.

“Between 1998/99 and 2010/11 … £10.9 billion (including £7.2 billion for Sure Start) will have been invested in programmes aimed in whole, or in part, at improving the health of under-fives,

but this has not produced widespread improvements in health outcomes.

Some health indicators have indeed worsened – for example, obesity and dental health – and the health inequalities gap between rich and poor has barely changed.”(Ref: Audit Commission. Giving children a healthy start.

Health report, February 2010, London, UK: www.audit-commission.gov.uk )

To deliver better outcomes:

• Understand importance of early child development.

• Develop a better mix between programs delivering improved population-level outcomes for children& young people, and programs delivering care for identified problems.

• Ensure that programs for children & young people are more evidence-based.

• Learn the lessons about wide-scale application of evidence-based programs.

The Early Childhood Series of expert paperscan be accessed at http://www.det.nt.gov.au/parents-community/early-childhood-services/ntecplan

Challenges:

• We cannot continue to rely on creating more services to pick up children & young people after problems become established.

• We need to understand much better (& then address) the real determinants of health & development outcomes for children.

We need to keep asking:

• Why effective interventions remain limited in application?

• Why does most of the effort and resources continue to be focused on treating problems after they have arisen?

The dilemma for those who deliver Children’s Healthcare Services is whether we are in the business of achieving better overall health for children,

as well as providing the best possible healthcare for children.

THANKS & QUESTIONS