Reducing Health Inequality: Early Childhood Interventions to Improve

School Readiness in Scotland Presenter: Dr Rosemary GeddesCareer Development Fellow, MRC Human Genetics Unit, Scottish Collaboration for Public Health Research and Policy

Contributors:

Professor John Frank

Director, Scottish Collaboration for Public Health Research and Policy

Professor and Chair, Public Health Research and Policy, University of Edinburgh

Sally HawSenior Scientific Adviser, Scottish Collaboration for Public Health Research and Policy

WHAT IS THE PROBLEM?

UNICEF Children Well-being across the OECD

Inequalities in Health Outcomes and Risk Factors in Pregnancy, at Birth and Up to 3mths

Risk Factors % Least Deprived

% Most Deprived

Relative Risk * Risk Difference

Unplanned pregnancy 8 39 4.8 31

Smoked in pregnancy 9 43 4.9 34

Planned to bottle feed 15 46 3.1 31

Never breast fed 21 60 2.8 38

Health Outcome

Low birth weight 5 8 1.6 3

* Prevalence in most deprived divided by prevalence in least deprived

Source: Bromley & Cunningham-Burley, 2010

Inequalities in Health up to 48 months

Risk Factors % Least Deprived

% Most Deprived

Relative Risk Risk Difference

Maternal smoking 8 41 5.1 33

Eating habits - - 1.5 – 2.9 10-26

Low physical activity 18 34 1.9 16

Health Outcomes

Fair/bad health 1+ since birth

11 24 2.2 13

Behaviour to other children 10 24 2.3 14

Language development 12 26 2.2 14

Total difficulties (SDQ) 7 20 2.7 13

Conduct 23 41 1.8 18

Hyperactivity 13 27 2.1 14

Source: Bromley & Cunningham-Burley, 2010

Source: Power C, Mathews S. Origins of health inequalities in a national population sample. Lancet 1997: 350:1584-89.

Absolute range: Healthy life expectancy, Males – Scotland 1999- 2006

(Data not available 2003/04)

Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities

(updated in September, 2009, but very few changes in long-term trends)

Absolute range: Healthy life expectancy, Females Scotland 1999-2006

(Data not available 2003/04)

Source: Scottish Government Health Analytical Services (2008) Long-term monitoring of health inequalities

Education, Employment, Wealth & Health

Source: Fairer Society, Healthy Lives. The Marmot Review.2010.

Scotland: Media reports December 2009

“Fifth of Scots have poor literacy”• The BBC: • http://news.bbc.co.uk/1/hi/scotland/8393805.stm

“Literacy report shows Russell there really is a crisis in education”

• The Scotsman:• http://news.scotsman.com/opinion/Literacy-report--shows-Russell.5883656.jp

“Zero-tolerance approach to poor literacy needed, experts say”

• The Herald:• http://www.heraldscotland.com/news/education/zero-tolerance-approach-to-poor-literacy-

needed-experts-say-1.989347

Determinants of School Outcomes in Scotland – Why Schools Are Not to Blame

• “While individuals may defy this trend, no school in a deprived area is able to record a similar level of success to that achieved by almost all schools in the most affluent areas.”¹

• “...but the gaps between them (schools) are far less important than differences between students. In Scotland, who you are is far more important than what school you attend.”²

1. Literacy Commission. A Vision for Scotland: The Report and Final Recommendations of the Literacy Commission. Scottish Labour, December 2009. http://www.scottishlabour.org.uk/literacy

2. OECD. Quality and Equity of Schooling in Scotland. Paris: OECD, 2007.

WHAT DETERMINES THESE OUTCOMES?

`Sensitive periods’ in early brain development

Vision

0 1 2 3 7654

High

Low

Years

Habitual ways of responding

Language

Emotional control

Conceptualization

Peer social skills`Numbers’

Hearing

Source: Graph developed by Council for Early Child Development (ref: Nash, 1997; Early Years Study, 1999; Shonkoff, 2000.)

“Pre-school” years

School years

Synaptic Density

Source: Founders’ Network, slide 03-012. Rethinking the Brain, Families and

Work Institute, Rima Shore, 1997.

At Birth 6 Years Old 14 Years Old

The gradient worsens

Source: Fairer Society, Healthy Lives. The Marmot Review.2010.

Life Course Problems Related to Early Life

2nd Decade

3rd/4th Decade

5th/6th

DecadeOld Age

• School Failure

• Teen Pregnancy

• Criminality

• Obesity

• Elevated Blood Pressure

• Depression

• Addictions

• Coronary Heart Disease

• Diabetes

•Premature Aging

• Memory Loss

Source: Clyde Hertzman, Early Child Development: A powerful equalizer.

How can this be influenced?

WHAT WORKS?

Main findings of a rapid literature review• Early childhood intervention programmes can help to reduce

disadvantage due to social and environmental factors • Improvements in all domains of child development, school

achievement, delinquency & crime prevention, & life success• Successful interventions utilize a mixed (centre & home-based),

two-generation (child & parents) approach• Greatest effects are seen in those at highest social risk • High quality preschool can help to reduce disadvantage & can

raise early language, pre-reading & maths skills with the most deprived children displaying the strongest gains

• Home learning environment of more importance for intellectual & social development than parental occupation, education or income

• Activities influence children’s cognitive development & can moderate, but not eradicate, effect of socio-demographic disadvantage

Source: Geddes et al. Interventions for promoting early child development for health: an environmental scan with special reference to Scotland. April 2010.

Suggested mixed, two-generation approach to Universal Early Childhood Social-emotional & Cognitive Development based on evidence of promising interventionsDelivery Population CONTINUUM OF CARE

Pregnancy 0-12 months 12-36 months 36-48+ monthsHighest risk of develop-mental and/or attachment disorder

Medium risk

Universal

Children Enrichment of home environment e.g. Play@homeNurturing of holistic child developmentChildren’s centres with use of multi-agency integrated services

Full- or half-day child care at high quality child development centre (higher risk - higher number of hours up to a max. 30 hrs/wk) Enrichment of home environment

Full-day* high quality preschool Enrichment of home environment Child training e.g. Incredible YearsSpecialist input as required

Parent-Child Intensive midwifery support NFP

Attachment-based interventions to improve parent sensitivity§ Intensive midwifery & home visiting support NFP

Intensive home visiting support NFP

Positive Parenting e.g. Triple P, Parents As TeachersSpecialist input as required

Parents Maternal education & literacy Parenting preparation Support for addictions

Training to understand stages of child development & how to nurture Parenting/child management support e.g. Incredible Years More intensive support in accessing services, problem solving, adult education for high school completion, job/employment support, accessing benefits, addiction management etc

Children Enrichment of home environment e.g. Play@home Nurturing of holistic child developmentChildren’s centres

Half-day preschool

Parent-Child Promotion of sensitive parenting with provision of support as needed

Parents Support for behaviour change Antenatal care according to medical risk

Support for breastfeeding initiation & maintenance

Support in accessing services Problem solving techniques Adult education for high school completion, job/employment support

Children Children’s centres e.g. drop-in centres, toy & book librariesResources e.g. Bookstart#Enrichment of home environment

Half-day preschool

Parent-Child Access to information on positive, sensitive parenting

Parents Standard antenatal care. Promotion of healthy diet, physical activity, breastfeeding & smoking cessation.Ready Steady Baby#

Information on healthy child developmentInformation on available child, parent & family servicesCore child health promotion programme with routine child development reviews

Source: Scottish Collaboration for Public Health Research & Policy. 2010.

Source: Seven things legislators need to know about school readiness. US State Early Childhood Policy Technical Assistance Network. March 2003.

Monitoring

• Data to monitor children’s development and functioning in the Scottish population, and the effectiveness of related programmes, are lacking.

• More early-stage measures are needed as well as better late-stage measures, which would require data linkage.

• Data need to be collated and analysed centrally to reveal patterns of “unmet need” in child development by geographic, ethnic and socioeconomic position.

What is the EDI?

• The EDI is teacher-completed (20 minutes) checklist that assesses children’s school readiness when they enter school.

• It measures the outcomes of children’s pre-school (0-5 years) experiences as they influence their readiness to learn at school.

• As a result, the EDI is able to predict how children will do in primary school.

• The EDI is designed to be interpreted at the group level & does not provide diagnostic information on individual children.

What Does the EDI Measure?

1) Physical Health and Well-Being

Physical readiness for school day- e.g., arriving to school hungry

Physical independence- e.g., having well-coordinated movements

Gross and fine motor skills- e.g., being able to manipulate objects

turity

2) Social Competence

3) Emotional Maturity

Overall social competence- e.g., ability to get along with other childrenResponsibility and respect- e.g., accept responsibility for actionsApproaches to learning- e.g., working independentlyReadiness to explore new things- e.g., eager to explore new items

Pro-social and helping behaviour- e.g., helps other children in distressAnxious and fearful behaviour- e.g., appears unhappy or sadAggressive behaviour- e.g., gets into physical fightsHyperactivity and inattention- e.g., is restless

3) Emotional Maturity

4) Language & Cognitive DevelopmentBasic literacy- e.g., able to write own nameInterest in literacy/numeracy and memory- e.g., interested in games involving numbersAdvanced literacy- e.g., able to read sentencesBasic numeracy- e.g., able to count to 20

5) Communication Skills and General Knowledge

(No subdomains)- Ability to clearly communicate one’s own needs and understand others- Clear articulation- Active participation in story-telling (not necessarily with good grammar and syntax)- Interest in general knowledge about the world

Trajectories Established Early - Vulnerability on EDI and Grade 6 outcomes

0

10

20

30

40

50

60

70

Reading Writing Math

012 or more

Percentage of Grade 6 students not meeting provincial standards in relation to number of vulnerabilities in Kindergarten (EDI) Source: TDSB, 2007

N of domains with low scores:

International Early Development Instrument implementations

Translating School Readiness into Community Actions

• School readiness assessment provides communities with the opportunity to better understand how they can allocate resources & concentrate their efforts to work towards improving outcomes for children. The Early Years SOA is already set up for LAs to do this!

• EDI: brought stakeholders together; encouraged, established a forum for community mobilisation; developed & cemented inter-sectoral coalitions

• Numerous community initiatives resulted from the process – parenting programmes & resources; nutrition & dental interventions; literacy projects

Decrease in the % of vulnerable children as a result of improved ECD in Western Australia

Year 2003 2006

Floreat 47.22% 14.3%

Wembley 47.11% 11.8%

AEDI

Useful websites & references• Offord Centre for Child Studieshttp://www.offordcentre.com/index.html• Australian Early Development Index - click on AEDI http://www.rch.org.au/ccch/index.cfm?doc_id=10556• British Columbia ECD mapping portalhttp://www.ecdportal.help.ubc.ca/archive/faq.htm• Hertzman C, Williams R. Making early childhood count. CMAJ. 2009

Jan 6;180(1):68-71.• Lloyd JEV, Hertzman C. From Kindergarten readiness to fourth-grade

assessment: Longitudinal analysis with linked population data. Social Science & Medicine. 2009;68(1):111-23.

• Hertzman C. Tackling inequality: get them while they’re young. BMJ 2010; 340:346-8

• Marmot M. Fair Society, Healthy Lives. London: University College London; 2010.

Contact details: Rosemary.Geddes@hgu.mrc.ac.uk