UK children have “alarming gap” in health between rich and poor, report finds
BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j377 (Published 26 January 2017) Cite this as: BMJ 2017;356:j377All rapid responses
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The Royal College of Paediatrics and Child Health are correct to highlight inequalities in the health of children in the United Kingdom. Northern Ireland is currently consulting on measures to join the three other nations of the UK in legislating to protect children from second-hand smoke in vehicles [1]. It currently lags behind both England and Wales in reducing adult smoking prevalence and an estimated nineteen 11-15 year olds start smoking each day [2]. Analyses of survey data from both adults and children shows that such legislation will contribute to reducing health inequalities.
Analysis of The Health Survey for Northern Ireland 2013/14 [3] points to variation across socio-economic groups in children’s exposure to tobacco smoke in cars. Overall, 8.4% of adults with children in the home allow smoking in cars, 11.6% among those in manual socio-economic groups compared with 6.4% in non-manual socio-economic groups. After adjusting for survey weighting, age group and sex adults in manual socio-economic groups were almost twice as likely to allow smoking in cars (AOR 1.98, 95% Confidence Interval 1.23 to 3.17).
The Young Persons Behaviour and Attitudes Survey 2013 [4] reveals a similar pattern. Children aged 11-16 in Northern Ireland were asked “Do the adults smoke in your family car?” Levels of exposure were 34.9% overall, but 40.1% among those eligible for Free School Meals (FSM), and 33.3% among those not eligible. After accounting for age, sex and survey weighting children eligible for FSM are a third more likely to be exposed (Adjusted Odds Ratio 1.33, 95% Confidence Interval 1.02 to 1.75).
Applying the 34.9% exposure estimate to the 2013 population of 11-16 year olds in Northern Ireland [5] suggests that over 45,500 children are exposed to the high levels of smoke produced by smoking in cars [6]. This legislation will protect all of these children as well as having a positive impact on health inequalities in Northern Ireland.
References
1. Department of Health (2017): Regulations restricting smoking in private vehicles when children are present. Available at https://www.health-ni.gov.uk/consultations/regulations-restricting-smoki...
2. Hopkinson NS, Lester-George A, Ormiston-Smith N, et al. Child uptake of smoking by area across the UK. Thorax 2014; 69:873-875
3. Department of Health, Social Services and Public Safety (2015) Health Survey Northern Ireland 2013/14. Available at https://goo.gl/I2NlTu
4. Northern Ireland Statistics and Research Agency (2014): Young persons behaviour and attitudes survey 2013. Available at https://www.health-ni.gov.uk/publications/young-persons-behaviour-and-at...
5. Northern Ireland Statistics and Research Agency. Mid-year population estimates 2013, available from http://www.nisra.gov.uk/demography/default.asp144.htm
6. Sendzik T, Fong GT, Travers MJ, et al. An experimental investigation of tobacco smoke pollution in cars. Nicotine & Tobacco Research 2009; 11:627-634
Competing interests: No competing interests
We welcome the findings of the Royal College of Paediatrics and Child Health (RCPCH) report into the state of child health (1). It accurately describes the scale of the public health challenges, clearly recommends actions to improve child health, and portrays urgency for action.
The report highlights the stark inequalities in child health in the UK and its poor performance on a number of specific health indicators when compared with other Western European countries. It offers important policy recommendations and calls for action including implementation of strategic and coordinated cross-UK actions and the reduction of child poverty and inequality. Specific aspects of health in these recommendations include women’s health during and after pregnancy, tobacco control, obesity and mental health. We strongly endorse the report’s calls for ‘child health in all policies’ and for a reversal of public health cuts in England (reported as disproportionately affecting children’s services).
We are pleased that one of the under resourced public health areas – accident prevention, was acknowledged as a leading cause of death. Inequality in risk of injury is clear. For example, children living in the most disadvantaged areas of the country have a 50% higher risk of being burned, scalded or poisoned than those living in the most advantaged areas (2). However, it has to be noted that in the past much success has occurred in relation to accident prevention (3,4), and that much more could be done, both in homes and on the roads (5,6).
Young people’s views are drawn on throughout the report and mental health was highlighted as a major area of concern. Two sections in the report have a specific mental health focus and offer a good set of key actions. We would have liked to see some of these actions brought out more explicitly in the summary ‘report in a glance’ to ensure the importance of mental health is conveyed clearly to those who may not read the full report.
We agree that better data is needed for planning, evaluation and for promoting action. In addition we approve of some of the indicators that have been chosen. However, more of them need to be positive health indicators, particularly at a higher level than the individual (7,8). For example, the proportion of health promoting schools, and the proportion of health promoting hospitals. Indicators at this level will help to move the focus away from “victim blaming” and towards the unhealthy environments.
General practice could be one part of the solution to tackling health inequalities. Tools such as advocacy, preventative care and social prescribing could be used more. But, GPs and their teams would need additional support. Moreover workforce issues need to be addressed. It is now widely recognised that there are not enough GPs, particularly in areas of greatest public health need (9-11). Given the key roles of midwives and health visitors in pregnancy and early childhood we welcome the report’s statement that these services to all mothers should be preserved.
The RCPCH report quite rightly stresses the importance of comprehensive personal, social and health education (PSHE) in schools which can lead to improved health outcomes and social mobility. Unfortunately, there are also workforce issues in this sector. Schools in disadvantaged areas are struggling to recruit. In addition, they are more likely to have unqualified, inexperienced, inappropriately trained and high turnover teaching staff (12). This may explain the substantial attainment gap between rich and poor pupils as quality of teaching is a critical determinant of pupil attainment (12).
Making PSHE statutory for all schools would be a very good initial step forward in trying to improve child health and reduce inequalities. In the report children themselves expressed the need for PSHE and offered their suggestions for practice. However, if teachers are to be effective at encouraging good health – they will need training and support.
We continue to recommend increased investment in public health within local authorities in order to allow Directors of Public Health to take effective action on health inequalities (13-15). Well-resourced and multidisciplinary teams would be able to lead, support, train and drive forward improvements in child health.
It should also be noted that other local authority sectors have the potential to impact on child poverty and health inequalities through, for example, support for children’s centres, play provision, and actions to reduce obesogenic environments. The ongoing cuts in overall funds to local authorities are, therefore, a major concern.
We firmly believe that early intervention, prevention and health promotion can reduce and resolve issues before they become entrenched and more difficult to treat later in life. As the report recognises there is already an existing evidence base on interventions to guide practice and barriers to implementation need to be overcome. Radical action is now needed to urgently address the “alarming gap” in health between rich and poor children (16).
References
1) Royal College of Paediatrics and Child Health. State of child health. 2017. http://www.rcpch.ac.uk/state-of-child-health
2) Orton E, Kendrick D, West J, Tata LJ. Independent Risk Factors for Injury in Pre-School Children: Three Population-Based Nested Case-Control Studies Using Routine Primary Care Data. PLoS ONE 2012 7(4): e35193. doi:10.1371/journal.pone.0035193
3) Hemenway D. While We Were Sleeping. Success Stories in Injury and Violence, Berkeley: University of California Press, 2009.
4) Watson M C and Errington G. Preventing unintentional injuries in children: successful approaches. Paediatrics and Child Health.2016; 26(5), 194-199
5) Public Health England. Reducing unintentional injuries in and around the home among children under 5 years. London: Public Health England, 2014.
6) Public Health England. Reducing unintentional injuries on the roads among children and young people under 25 years. London: Public Health England, 2014.
7) Catford JC. Positive health indicators – towards a new information base for health promotion. Community Medicine. 1983; 5: 125-132.
8) Watson MC and Watson EC. Premature deaths across England. Time to focus on positive health indicators to reduce health inequalities BMJ 2013;347:f4210.
9) Goddard M, Gravelle H, Hole A, Marini G. Where did all the GPs go? Increasing supply and geographical equity in England and Scotland. Journal of Health Services Research & Policy. 2010; 15(1): 28–35.
10) Limb M. Increase GP trainees by 450 a year to avoid crisis, says taskforce. BMJ 2014;349:g4799.
11) Baker M, Ware J, Morgan K. Time to put patients first by investing in general practice. Br J Gen Pract 2014;64:268–9.
12) Social Market Foundation. Social inequalities in access to teachers. Social Market Foundation Commission on Inequality in Education: Briefing 2. 2016. London: SMF.
13) Watson M C and Lloyd J. Promoting the health of the population BMJ 2014;349:g6195.
14) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761.
15) Watson M and Tilford S. Directors of public health are pivotal in tackling health inequalities BMJ 2016;354:i5013.
16) Mayor S. UK children have “alarming gap” in health between rich and poor, report finds. BMJ 2017;356:j377
Competing interests: No competing interests
Re: UK children have “alarming gap” in health between rich and poor, report finds
Dear Dr Godlee,
The recent report by the Royal College of Paediatrics and Child Health highlights the stark gap in health between rich and poor children in the UK. (1) They note that improvements made in recent years have slowed. The data on infant mortality (IMR) released by the ONS this week suggests that these improvements are reversing.(2)
In 2015 infant mortality increased for the first time in a decade. (2) But what is more concerning is that the rate has been increasing for the poorest children since 2010, whilst continuing to decline for more advantaged groups, widening inequalities (see Figure 1). Infant mortality is a sensitive indicator of the prevailing socioeconomic conditions affecting children. In recent years child poverty has risen and services that support children have been cut. (3) It should be of great concern to health professionals and policy makers that these changes may now be leading to increased infant mortality amongst the most disadvantaged families.
Figure 1. Infant mortality rate (95% confidence interval) by socio-economic classification 2008-2015. https://www.dropbox.com/s/xr90k3u4dm1j67h/IMR_plot29apr.pdf?dl=0
Figure footnote: Source: ONS. For the purposes of the analysis we have grouped IMR for joint registrations by NS-SEC groups into professional (1, 1.1, 1.2, 2), intermediate (3,4) and manual groups (5 and below). In 2011, NS-SEC was rebased on the new Standard Occupational Classification (SOC2010). (2)
References
1. Major S. UK children have ‘alarming gap’ in health between rich and poor, report finds. The BMJ [Internet]. BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j377 (Published 26 January 2017)
2. ONS. Childhood mortality in England and Wales: 2015. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... (accessed 1 May 2017)
3. Taylor-Robinson D, Whitehead M, Barr B. Great leap backwards. BMJ. 2014 Dec 2;349:g7350.
Competing interests: No competing interests