13. Children in Australian society

Although most children in Australia enjoy excellent health, a minority experience the ill health expected in far poorer nations. Clinicians treating children are well aware that each child’s social circumstances affect not only the extent to which the child’s illness could have been prevented, but also how the recovery is managed. Dealing with the background factors contributing to a child’s health, such as the carer’s understanding of the illness, or the availability of community services, is often far more challenging than treating the disease process itself.

Here, we explore some of the health indicators in children, their determinants and the possible mechanisms involved. We present the evidence for strategies to improve child health and the initiatives already in place, together with the possible roles practitioners can play. We have attempted to grapple with some of the difficult issues that fall between public health initiatives and the problems facing the child before you in your consultation room (see Case study). How can the practitioner engage with community-based initiatives to improve child health? We present a combination of literature review, opinion and evidence, and outline some of the challenges to be addressed if we are to make progress.

Based on the most stringent definition of poverty (the lowest decile of gross income), 80% of Australian children (< 15 years of age) did not experience poverty over the period 1995–1997; of the 20% who did, only 1% were in persistent poverty in this period.1

However, despite Australia’s material wealth and the generally high level of education, many indicators of health and wellbeing in children and adolescents are discouraging. The rates of developmental and behaviour disorders in children are high2,3 (15% of those aged 4–12 years have emotional or behavioural problems4); the rate of children in out-of-home care (currently 4.2 per 1000) has been rising consistently since national data collection began in 1996;5 and a third of deaths in children aged 1–4 years have preventable causes (transport fatalities, drowning and assault). In teenage girls pregnancy rates are high, and suicide rates in young Australian males have quadrupled over the past 30 years.2 Children seeking asylum in Australia face multiple challenges in accessing health care despite complex health needs, including experience of trauma and effects of prolonged detention.6

There is a growing body of literature both in Australia and internationally documenting the association between socioeconomic status and mortality, with disadvantaged groups experiencing higher death rates for most major causes of death at all ages,7,8 and mortality rates rising stepwise as children’s level of disadvantage worsens (Box 1).9 It has been calculated that each year in Australia 1500 deaths of children aged 0–14 years can be attributed to socioeconomic disadvantage.10,11 In Aboriginal and Torres Strait Islander children, average death rates remain 2.5 times those in non-Indigenous children.3 There is also evidence that mortality inequalities have widened over time in Australia.9,12

On the other hand, wealthier groups in Australia are more able to implement healthy lifestyle behaviours, use preventive health services and take advantage of social policies to improve their health.3 Paradoxically, patients of lower educational and occupational status are the lowest users of preventive care services, and general practitioners spend less time with them, reporting being overwhelmed by the seriousness and extent of their problems.13,14

The determinants of child health are complex and operate at many levels, including global forces, government policies, the health care system, psychosocial factors, individual health behaviours, and biological reactions. These factors also interact with each other to determine the pathway to health (or disease), particularly if they occur at developmentally crucial times. Current understanding suggests that adverse environments in early life, interacting with a child’s genetic and temperamental predisposition, result in biological changes (such as neuronal connections) that determine coping, resilience and health outcome in adult life.15 This creates some pressure on society to “get it right”, as children in adverse circumstances are being programmed in a way that sets patterns of health for later life. Simple solutions, such as targeting behaviour change or welfare programs, are less likely to be as effective as action at all levels, including societal and cultural change.16

Attempts to understand the complex relationship between health outcomes and their determinants have led to the concept of social capital. Defined as “the social cohesion of a community, and the sense of belonging” that individuals feel,17 social capital represents the degree to which people feel they can request assistance from their neighbours, allow their children to play outside in safety, and participate in community activities. Social capital results in independent improvements in health indicators: higher behavioural scores in children, reduced school dropout rates, less criminality, and lower smoking rates among women.18 Although the precise pathways are poorly understood, the evidence suggests that creating opportunities for community networking is empowering and plays a role in improving child health in poor communities. Social capital programs based in schools have improved mental health outcomes and reduced risk-taking behaviours.19 A systematic review of the qualitative evidence suggests that good family relationships, friendships and neighbourhood networks help to mitigate the impact of disadvantage on the wellbeing of children and young people.20

Undermining the social capital of Australian society is the marginalisation of certain groups. In Australia, considerably less progress has been made than in other countries (such as New Zealand and Canada) in addressing health inequalities between Indigenous and non-Indigenous people. In addition, the sense of hope and of having a valued role in society, which are determinants of health, may be less in Australian Indigenous groups compared with Indigenous people elsewhere.21

It has been argued that “institutional racism” is inherent in our health services, and takes the form of inadequate funding (which is not commensurate with the extra health need), inequitable Medicare primary health care spending on Indigenous groups, lack of access to Medicare for some asylum seekers, and culturally insensitive health services.22

Children are a powerless group within society, and it is relatively easy to violate their rights. This is obvious in sexual exploitation or prolonged detention of children seeking asylum, but in more subtle forms is pervasive throughout society. An example includes the difficulty in achieving legislation banning physical punishment in the United Kingdom — society’s most vulnerable citizens thus have less protection from assault than adults.23

Even children from privileged backgrounds are largely excluded from decision making, and are generally regarded as incomplete and incapable adults. This is distinct from regarding children as people who function responsibly and appropriately, given their age, and who can provide valuable insights into their own needs, especially those who have experienced adverse events, illness or disability. UK research has highlighted the lack of prioritisation of children’s needs in the restructuring of health care trusts, and the scanty consultation and participation of chronically ill or disabled children in the development of health services.24,25 The NSW Commission for Children and Young People has demonstrated some early success in consulting with children on their submissions regarding public education and young driver safety,26 in line with mounting evidence that children can contribute effectively to health service development.27,28

• society and environment — supportive and inclusive environments, economic security, effective public health programs;

• family, school and neighbourhood — parental and family cohesion, family friendly workplaces, a close bond with at least one consistent caretaker in the early years, access to appropriate services; and

• the child — physical and mental health, resilience, good language and communication skills, effective problem solving skills, and positive cultural identity.29,30

Societal problems directly affect how children present in the consultation room. Australian researchers have drawn attention to the links between mental health and behavioural problems in children and adolescents, and socially disorganised communities.19 Lack of social capital is strongly associated with child abuse.31 Suicide in young males is closely linked to unemployment rates.32 Children living in jobless families are more likely to present with developmental and educational difficulties. Asthmatic children who live in families where there is tension and conflict are more frightened by their symptoms than other children with asthma.3

Box 2 provides some examples of health inequalities, together with related national strategies and roles for individual health professionals.

One of the challenges is that health care in Australia largely takes place in an individualistic renumeration system based on patients voluntarily seeking care. Many Divisions of General Practice and profession leaders are committed to extending the GP’s patient-centred clinical role to improving the health of practice populations. However, barriers include the absence of targeted government funding for disadvantaged groups, the Medical Benefit Schedule rewarding mainly episodic care rather than preventive care, and the lack of formal responsibility by practices for a specified practice population (as occurs in New Zealand and the UK).37 This creates little opportunity for improving the health of communities, and engaging with community development programs. While this may not be regarded by health care professionals as their area of expertise, without targeting pre-existing health determinants, such as unemployment or poverty, little can be done in the consulting room to address the battery of problems some patients have on presentation.

Professor Stanley, Chief Executive Officer of the Australian Research Alliance for Children and Youth, asserts that the response of governments to societal problems tends to target solutions too close to the outcomes (building prisons rather than intervening early to reduce crime). In addition, when the approach focuses on individual factors (personal health risk) rather than population factors (tobacco production, advertising and distribution, and social factors affecting consumption), the result is a general shift in problems from rich to poor people (tobacco smoking), thus widening discrepancies.43 Initiatives that have been successful in rapidly improving health status alter mean population exposure (such as fluoridation of water to improve dental health), although for many interventions disadvantaged groups also require specific targeting. The way forward may lie in engaging the most disadvantaged communities, building on communities’ own resources and skills in developing resilience, and developing ways of working collaboratively to address health and broader issues.

Evidence that social capital, and thus child health, can be improved by early intervention and home visiting programs has driven the introduction in the past decade of government initiatives such as the Stronger Families and Communities Strategy: communities for children (a federally funded partnership with local community organisations [in 2000]),44 Families First (NSW [in 1998]),45,46 Best Start (Victoria), Pathways for Families (South Australia), Family CARE program (Queensland Health) and others in Australia and overseas. These programs generally aim to support parents of young children, encourage early childhood learning and development, and assist communities to become more child friendly through various interventions (including combinations of home visiting, improving access to health and early education services, fathering and culture-specific programs, and community capacity building initiatives).

Initially, home visitation programs in early childhood in the United States targeted child abuse, but unexpected positive effects were seen in maternal and child health. Box 3 presents some of the early findings in this area.

The local programs are generally multisectoral (including departments of education, community, health, disability and housing), an acknowledgement that social and environmental factors have more influence on child health outcomes than health interventions, drugs or other treatments. They also recognise that modifying early environments is a more powerful way of producing change than later interventions. The rationale is that the child’s social and emotional development is highly correlated with his or her sense of belonging and connectedness to family and school, and that educational development is affected by participation in quality early childhood development programs. This draws on the evidence that preschool experience reduces the gap in achievement between disadvantaged and advantaged children in the early years of school, and has long term academic benefits.49,52,53 Importantly, studies have demonstrated the greatest benefits in children from more deprived backgrounds (Box 3).47

Overseas studies have shown that the more effective home visiting programs employ nurses rather than paraprofessionals. The nurses begin visiting during pregnancy, and visit frequently and for long enough to establish a therapeutic alliance with the families. At least two and probably three components produce the greatest effects: an effective program model, the right visitor type, and a target population that is in need and sees the value of the service being offered.54

Harris suggests that practitioners should coordinate and organise preventive activities, possibly through practice nurses, and actively liaise with community and population health organisations to provide complementary interventions.14 Some practitioners may extend their role to advocating on behalf of groups of vulnerable children, making representations to the local council for safe playgrounds or roads crossings, encouraging the local schools to become asthma friendly, and ensuring the rights of children in care or in institutions are being respected (see Box 4).

Groups of professionals can be successful advocates and it is encouraging to note the policy statements of the Royal Australasian College of Physicians (RACP) about social justice issues, including “Children and the media”, and “Ethics of research in children”. In a recent “Inequity and health” policy statement, the RACP emphasises that the substantial and systematic health inequalities that exist in Australia reflect unjust differences in opportunity, access to services and material resources. They call on the government for a coordinated response to health inequities, and on health organisations to develop explicit plans for dealing with health inequities.

Few would refute that all children regardless of their ethnicity or background have a right to health and to realise their potential. If allocation of resources “to the maximum extent of their availability” is required in order to meet our obligations under the UN Convention on the Rights of the Child, are we doing enough to target children in need in Australia?

A study in the UK modelled the health effects if all children had health outcomes similar to those of the most privileged.55 The results showed a more than 50% reduction in hyperkinetic disorders and child abuse, and a 40% reduction in educational disability and mental disorders. Improving health outcomes is unlikely to be achieved by health interventions alone, but rather by collaborative economic and political approaches extending beyond the health sector.

We are faced with the challenge of improving child health through reducing inequity, building safe and resilient communities, addressing discrimination, and reducing marginalisation of certain population groups.

We are only beginning to understand the complex chain of influences that result in adverse outcomes, and we have yet to develop effective ways for health professionals to engage with community development programs. We are challenged to implement programs shown to be effective in clinical trials, and to monitor health and equity outcomes across discipline boundaries.

Some encouragement can be found in the mounting evidence that community programs make a difference to child health, the early government recognition of the importance of investing in young children, the acknowledgement that health interventions require the support of the social system, and the recent launch of an Australian national collaborative research network aiming to enhance child health and development.

1 Childhood mortality rates9

Age-standardised mortality rates for children aged 0–14 years, all causes and injury mortality, 1998–2000.

Quintile 1 = least disadvantaged; quintile 5 = most disadvantaged.