Growing up in Scotland: health inequalities in the early years

EXECUTIVE SUMMARY

This report uses data from the first four waves of the Growing Up in Scotland study ( GUS) to explore health inequalities in the early years. The measures explored include health outcomes and risk factors for poor health spanning the time from the early stages of pregnancy until just before the children's fourth birthday.

This report aims to answer the following questions:

• What is the extent and character of health inequalities in the early years?
• What factors, if any, correlate with the avoidance of negative early health outcomes, among families from disadvantaged backgrounds?

This report starts by introducing the measures of health and risk factors for poor health, that are the focus of the analysis. It also introduces the socio-demographic factors used to explore the extent of inequalities in these health measures. It then illustrates the extent to which poor health outcomes and exposure to risk factors for poor health are associated with socio-demographic factors at different stages in the early years. The final stage of the analysis attempts to answer the second of the above questions by identifying factors that appear to be associated with positive outcomes for children from disadvantaged backgrounds.

Health inequalities in the early years

This chapter mapped out the extent of health inequalities in the early years. The analysis spanned the period from around the time of the children's birth to just before their fourth birthdays. A wide range of measures were used to illustrate inequalities in outcomes such as the children's birth weight, their experience of long-term health problems, accidents, poor psychosocial health and wider developmental problems. It also looked at a range of risk factors for poor health which included maternal smoking, maternal health, children's physical activity levels and their diet (including breastfeeding). All these outcomes and risk factors were explored in relation to area deprivation, household income, and household socio-economic classification. It showed that:

• Exposure to the kinds of risks that can impact on health and development in the early years, and have been shown in the wider literature to have implications for later life, are not uniformly or randomly distributed across the population at this very early point in life. Significant inequalities exist with those in the most deprived areas, the lowest income households or routine and semi-routine households found to have worse health outcomes, and higher exposures to risks for poor outcomes, than their more advantaged counterparts.
• Although overall levels of outcomes such as long-term health conditions and poor general health are relatively low in the early years, and appear not to change much each year, this analysis shows that there is in fact quite a high degree of individual-level change in health outcomes in this period. However, this would not necessarily be evident in an analysis that compared a different group of children over time without being able to explore individual pathways in the way that GUS permits.
• While the persistence of poor outcomes was quite variable, exposure to risks such as smoking and poor maternal health were somewhat more stable. For example, of those children whose mothers smoked at some point in their early years, most were exposed to this on a prolonged rather than temporary basis.
• Across all the outcomes and risk factors explored, inequalities in exposure to risk factors were generally larger than those evident for outcomes. However, within the outcomes explored, behavioural, psychosocial and linguistic problems showed much starker inequalities than physical ones such as poor general health.
• The more disadvantaged households can be said to face a double burden in their experience of health inequalities as both the children and adults within them are at greater risk of negative outcomes.

Factors associated with avoiding negative outcomes among disadvantaged children

The analysis in this chapter explored the factors associated with avoiding negative outcomes among disadvantaged children with a particular focus on the concept of resilience. Resilience has been defined as "the process of withstanding the negative effects of risk exposure, demonstrating positive adjustment in the face of adversity or trauma, and beating the odds associated with risks" (Bartley, 2006). The kinds of factors that have been thought to help children at high risk of negative outcomes to avoid them are wide ranging. This chapter explored a range of possible factors including: maternal, family and household characteristics and behaviours; neighbourhood characteristics; and social support networks.

The extent to which these measures were associated with negative outcomes was explored for all children in the first instance.

The key findings were:

• The findings in relation to all children reinforce the evidence that there are strong associations between child outcomes and maternal health and behaviours such as smoking, long-term health problems or disability as well as confidence in parenting abilities. It should be recognised, though, that the experience of having a child with negative health outcomes may in itself influence these maternal measures.
• A number of factors within households also showed associations with the avoidance of negative outcomes, for example the consumption of fruit and vegetables and higher levels of physical activity. The findings also suggest possible associations with measures relating to tenure stability and major life events, parental feelings about household income and the home learning environment (the latter is likely to be related to the measures of cognitive and language development used in this stage of the analysis).
• It has also been suggested that neighbourhoods provide an important source of resilience for families. Based on two measures of satisfaction with local services and judgments of the child friendliness of local areas, positive assessments of these aspects were associated with fewer negative outcomes.
• The extent of social support appeared to be associated with avoiding negative outcomes. Regular attendance at parent and toddler groups throughout the child's life and the ability to draw on support at short notice were both more common among children with low negative outcomes.

To identify resilience it is necessary to show what factors are associated with avoiding negative outcomes among children who are at an increased risk of them. It was clear from the analysis of health inequalities that for most of the negative outcomes of interest, children living in the most deprived areas, in the lowest income households and in semi-routine and routine households were most likely to experience them. Therefore the next stage of the analysis focused on children from disadvantaged backgrounds - those from any of the three socio-economic groups at most risk of negative outcomes. This approach disentangles the association between resilience and socio-economic background which might have explained the findings outlined above.

The analysis showed that:

• Only a few of the resilience measures were independently associated with avoiding negative outcomes. Therefore, factors such as area deprivation, income or socio-economic classification clearly have a major influence. In other words, this emphasizes the difficulty of countering very powerful economic and structural influences on early life.
• The significant resilience measures were quite different in nature to each other. For example, children were less likely to have negative outcomes if their mother had not experienced long-term health problems, or if they lived in a household with at least one adult in full-time work, or if they had a more enriching home learning environment. These different kinds of factors would have very wide ranging policy implications.
• Some of the significant associations that remain are surprising - for example, even within disadvantaged groups, older maternal age is a predictor of avoiding negative outcomes.
• It is clear that most of the resilience measures that are significantly associated with avoiding negative outcomes do not sit entirely within the health domain and that effective action to promote resilience and address child health inequalities requires action at many different levels and from a wide range of agencies and bodies.

Conclusions

• While the persistence of poor outcomes was quite variable, exposure to risks such as smoking and poor maternal health were somewhat more stable. This suggests that the consequences in later life associated with early exposure to such risks are likely to be evident for decades.
• The analysis of health inequalities, and the exploration of resilience, both highlighted the extent to which more disadvantaged households experience a double burden in their experience of health inequalities with children and adults within them being at greater risk of negative outcomes. The major focus on early years currently evident in Scottish Government policy making therefore needs to be alive to the fact that tackling health inequalities in children also requires action to address the health inequalities experienced by their parents and wider families.
• The findings from the exploratory analysis of resilience suggest that relatively few of the potential resilience measures explored were significant once socio-economic factors were taken into consideration, which indicates that boosting resilience cannot alone reduce children's risk of poor health outcomes.
• A major recent study of resilience and health (Mitchell et al., 2009) drew a number of conclusions but one has particular resonance in the context of this research - as poverty was such a strong predictor of poor outcomes (in their study the measure was mortality), resilience was likely to have only a very small contribution to the reduction of negative outcomes. However, this is not to detract from the finding that some factors (such as the home learning environment) were shown to be associated with the avoidance of negative outcomes which suggests that some levers to mitigate the impact of disadvantage might exist.
• Although a study such as GUS can demonstrate the sequence over time between possible explanatory factors and outcomes, it still cannot provide definitive conclusions about the direct relationship between them. There is always the possibly that some additional unmeasured factor, related to both the outcome and apparently explanatory factor, is what actually explains the association found. To truly establish cause and effect is very complex and usually requires experimental methods and the accumulation of evidence from numerous different sources. In the absence of experimental evidence, this kind of analysis therefore contributes to the wider accumulation evidence in favour of intervening in the early years. However, it should be noted that significant evidence about the effectiveness of interventions in the early years has already been accumulated (Hallam, 2008).
• The extent of the socio-economic inequalities identified in this piece of work, coupled with the suggestion that resilience to negative outcomes might come in the form of actions to address a wide and disparate range of factors makes it clear that that tackling health inequality requires input at many levels from a wide range of actors. This is not in the gift of the health service or other service providers alone.