child health inequities

SYMPOSIUM: SOCIAL PAEDIATRICS

Child health inequitiesNick Spencer

AbstractMany of the most common causes of mortality and morbidity in childhood

are socially patterned with risk increasing with increasing social disadvan-

tage. The social determinants that underlie this distribution of risk are

responsible globally for most childhood illness and death. In the UK,

social inequities, inequalities that are unjust and avoidable, account for

more than 30% of births before 32 weeks gestation, over 40% of activity

limiting longstanding illness and between 34 to 59% of different types of

mental health problems in childhood. These conditions constitute a large

part of paediatric practice.

Social inequities in child health arise as a result of the complex inter-

relationship of more distal social factors such as income and education

with more proximal factors such as health behaviours. The pathways by

which the social determinants exert their influence operate over time

and across generations. Socially related risk and protective factors cluster

in different social groups and accumulate over time.

Child health inequities are profoundly influenced by social and political

decisions which are beyond the control of individual paediatricians.

However, paediatricians can promote the health of disadvantaged chil-

dren and possible approaches are discussed including influencing local

and national government by advocacy.

Keywords advocacy; child health inequities; social determinants of

health

Introduction

Poverty and deprivation of basic necessities for a healthy life are

the most important determinants of child health globally. The

opening paragraph of the 2008 final report of the WHO

Commission on Social Determinants of Health powerfully

summarises the critical role of social determinants in population

health and in the health of children globally:

‘‘Social justice is a matter of life and death. It affects the way

people live, their consequent chance of illness, and their risk of

prematuredeath.Wewatch inwonderas life expectancyandgood

health continue to increase in parts of the world and in alarm as

they fail to improve in others. A girl born today can expect to live

for more than 80 years if she is born in some countries e but less

than 45 years if she is born in others. Within countries there are

dramatic differences in health that are closely linked with degrees

of social disadvantage. Differences of this magnitude, within and

between countries, simply should never happen.

These inequities in health, avoidable health inequalities, arise

because of the circumstances in which people grow, live, work,

Nick Spencer MPhil FRCPCH FRCPE DCH Emeritus Professor, School of Health

and Social Studies, University of Warwick, Coventry, CV4 7AL, UK.

PAEDIATRICS AND CHILD HEALTH 20:4 157

and age, and the systems put in place to deal with illness. The

conditions in which people live and die are, in turn, shaped by

political, social, and economic forces. ‘‘

In developing countries, over 1 billion children (more than

50% of children in developing countries) suffer severe depriva-

tion of one or more basic human need. The lives of these children

are blighted by these deprivations as the Commission on Social

Determinants of Health documents. Children in the UK are much

less likely to suffer such severe deprivation; however, despite

being one of the wealthiest countries in the world, the UK has

high levels of relative child poverty compared with other rich

nations and wide health inequities. This paper will summarise

the impact of inequities on children’s health in the UK and

consider the role of paediatricians in tackling these inequities.

Definition and relevance

Health inequities are inequalities that are unfair, unjust, avoidable

and unnecessary and that systematically burden populations

rendered vulnerable by underlying social structures, and political,

economic, and legal systems. As indicated above, inequities are

responsible for substantial mortality and morbidity among children

in both poor and rich nations. Table 1 shows the impact of social

inequity ona rangeof childhealth outcomesamongUKchildrenand

young people.The health outcomes shown in the table are relatively

common and represent a significant proportion of neonatal and

paediatric activity. The role played by social inequity in their aeti-

ology should be of concern to neonatologists and paediatricians.

Epidemiology

The epidemiology of social inequities in child health can be repre-

sented in a number of different ways. For the purposes of this

review, I will focus on the Population Attributable Fraction (PAF) as

shown in Table 1 and the distribution of risk across social groups

that show a social gradient. As indicated above, the PAF shows the

proportion of the outcome occurring in a child population that is

attributable to social inequity. The choice of reference group

depends on the purpose for which the PAF is being used. For

example, the proportionof the outcome in the whole populationcan

be used as the reference. This yields a lower PAF than the approach

used in Table 1 in which the most advantaged groups are taken as

reference. Here, the most advantaged groups are used as reference

in order to fully represent the impact of social inequity on the

outcomes and to illustrate what could be achieved given optimal

social conditions. It is the same approach that was adopted by WHO

in the recent extensive study of infant growth in different countries

as part of the preparation of new WHO reference growth charts.

Only exclusively breast fed infants born in optimal social circum-

stances were entered into the study. The resulting charts, showing

that infants indifferent countriesof theworld grow in identical ways

given optimal circumstances, will be used as a gold standard or

reference against which infant growth can be measured.

The distribution of risk across social groups is useful in

demonstrating the presence of social gradients in child health

outcomes. Figure 1 shows the social gradient in very preterm

birth (22-32 weeks gestation) by a measure of area deprivation

derived using electoral ward-level Child Poverty Indices aggre-

gated into deciles for the Trent Region of England.

� 2009 Elsevier Ltd. All rights reserved.

Proportion of child health outcomes attributable to social inequity in the UK

Child health outcome Percentage reduction if all children had same

outcome as the most socially advantaged (%)

(Population Attributable Fractions)

Birth weight (based on data on 18,000 UK births from the Millenium Cohort Study e using

ONS Socio-economic classification as equity stratifier):

<2500gms 24

Very preterm birth (based on data from Trent region of England e using area deprivation

indices as equity stratifier) :

22e32weeks gestation 35

Neonatal morbidity (based on data from the Wirral in the North-west of England e using

area deprivation indices as equity stratifier) :

Respiratory distress 32

Infection 20

Hypoglycaemia 18

Disability/Limiting long-standing illness (based on data on >400,000 children and young

people aged 0-19 years from the 2001 UK

census e using ONS socio-economic classification as equity stratifier) :

41

Cerebral palsy (based on 150,000 births in the West Sussex region of England,

1983-2001e using area deprivation indices and social class as equity stratifiers) :

30

Psychological and behavioural problems (based on the UK survey of mental health among

5-15 year olds e using household income as equity stratifier) :

Emotional disorders 34

Conduct disorders 59

Hyperkinetic disorders 54

Ever had asthma diagnosed by a medical professional by age 3 years (based on the

Millenium Cohort Study using ONS socio-economic classification as equity stratifier) :

27

Table 1


Infants born in decile 10, the most deprived, are almost twice as

likely to be born at between 22 and 32 weeks gestation as infants

born in decile 1, the least deprived. However, an increased risk of

very preterm birth is not confined to those in the most deprived

10% of electoral wards in the Trent region; the risk tends to

increase as the level of deprivation increases. All the child health

outcomes shown in Table 1 demonstrate similar social gradients as

Unadjusted incidence/1,000 births

Least …

Decile 2

Decile 3

Decile 4

Decile 5

Decile 6

Decile 7

Decile 8

Decile 9

Decile 10

0 5 10 15 20

Figure 1 Unadjusted incidence of very preterm birth/1000 live births by

deprivation deciles in the UK Trent Region.


do many adult health outcomes. Social gradients give an insight

into the mechanisms by which social factors impact on health and

inequities develop and are perpetuated. The mechanisms and

pathways by which child health inequities are generated are more

fully discussed in the next section; suffice it to say here that social

gradients support the hypothesis that socially-related risk expo-

sures, acting cumulatively over time, result in increasing inci-

dence/prevalence of certain outcomes as living circumstances

become more disadvantaged.

It is important to note that not all adverse health outcomes

show a social gradient. For example, autism does not show a social

gradient indicating that the aetiological factors are not socially-

related. As can be seen from Table 1, different measures of social

circumstances (also known as equity stratifiers) can be used in

studying the epidemiology of social inequities in child health. The

equity stratifiers being used should be clearly specified as different

stratifiers may have different relationships with specific health

outcomes. Some epidemiologists recommend always trying to use

more than one equity stratifier in studying health outcomes.

Mechanisms and pathways

There is no direct causal relationship between social determi-

nants, such as area deprivation, maternal education and house-

hold income, and child health outcomes. They exert their effects

through mediating socially-related risk (and protective) expo-

sures such as health-related behaviours and environmental

conditions e what the WHO Commission on Social Determinants



of Health refers to as ‘causes of causes’ acting over the course of

individual lives. Risk exposures tend to cluster among those at

the lower end of the social spectrum and their impact can also

accumulate over time. Low cumulative household income from

birth to 10-11 years was associated with the highest risk of

activity limiting chronic illness in children participating in the US

National Longitudinal Survey of Youth-Children.

Socially patterned health outcomes are the biological expres-

sion of social determinants e in other words, the social trans-

lated into the biological. This process has been characterised as

social circumstances getting ‘‘under the skin’’, also known as

embodiment. In explaining social inequities in low birth weight,

Krieger and Davey Smith use the concept of embodiment as

follows:

‘‘Low birth weight as an embodied expression of social

inequality reflects socially patterned exposures (during and prior

to pregnancy) to such factors as maternal malnutrition, toxic

substances (e.g. lead), smoking, infections, domestic violence,

racial discrimination, economic adversity in neighbourhoods,

and inadequate medical and dental care.’’ [p. 95]

Social determinants can be considered as distal variables

exerting influence through more proximal risk factors. The

complexity of these relationships can best be understood as

pathways from distal through proximal variables to the outcome

of interest. Pathways enable biologically plausible temporal

relationships over the life course to be taken into account. For

children, the life course does not start at birth but fetal life and

intergenerational influences also need to be considered. Using

these concepts, the mechanisms by which social inequities and

social gradients are generated and maintained can be explored.

The prerequisites for constructing scientifically plausible,

comprehensive, explanatory pathways for social inequities in

child health are shown in Box 1.

As indicated in Table 1, there are considerable social ineq-

uities in low birth weight. The explanatory pathway for social

inequities in intrauterine growth retardation, shown in Figure 2,

incorporates the essential elements listed in Box 1.The equity

stratifiers are socio-economic status/poverty at mother’s birth

and at infant’s conception. The temporal relationships in the

pathway are plausible and the pathway incorporates a life course

Prerequisites for explanatory pathways for socialinequities in child health

C Equity stratifiers (distal variables) that have an empirically

proven relationship with proximal risk factors that are, in turn,

known to be associated with the outcome of interest

C Biologically plausible temporal relationships between variables

included in the pathway

C Incorporate a life course perspective including intergenera-

tional influences

C Incorporate scientifically plausible links between the social and

the biological

C Incorporate clustering and accumulation of socially related risk

and protective exposures

Box 1


perspective which is intergenerational. The links between the

social and the biological are shown in pathway from socio-

economic status at mother’s birth to her own birthweight to

pregnancy induced hypertension in the index pregnancy. Moth-

er’s birthweight is also linked to education as lower birthweight

is associated with reduced cognitive function and to childhood ill

health. The pathway allows for the clustering and accumulation

of socially related risk and protective exposures. Empirically

proven major pathways are indicated by bold arrows, minor

pathways by non-bold arrows and possible pathways by dotted

arrows.

Social inequities in child health can only be understood as

occurring as a result of complex relationships among socially

related risk and protective exposures acting over time and across

generations as the example of IUGR in Figure 2 illustrates.

Impact on adolescence and adulthood of social inequities in child

health

In addition to the direct impact on children of social inequities in

child health, the effects continue into adolescence and adult-

hood. The impact of low birthweight on health in adulthood is

now extensively documented. The latent effects of fetal

programming associated with IUGR increase the risk in later life

of coronary heart disease and other conditions such as non-

insulin dependent diabetes mellitus. Birthweight is also inversely

proportional to cognitive development. Raised blood pressure in

adolescence and in early adulthood has also been associated in

some studies with lower birthweight although other studies have

failed to confirm this relationship.

Very preterm infants born before 32 weeks gestation are

highly vulnerable in early infancy but also have increased

morbidity into later childhood and adolescence. Infants born

before 32 weeks in a Swedish study were four times as likely to

be receiving assistance for disability in their 20s as infants born

at normal gestational age. Even those infants born between 32

and 37 weeks had a significantly increased risk of disability.

Chronic illness in childhood, which is strongly socially

patterned, has been shown to be associated with an increased

risk of disability in adulthood in a Norwegian study. Mental

health problems in early childhood are associated with adoles-

cent and adult psychiatric problems particularly anxiety and

depression. Figure 3 shows continuity of influence from parental

social class at birth through behaviour problems at various ages

in childhood to depression at age 30 based on data from the 1970

British Cohort Study. The correlation coefficients between mental

health problems and social risk at each point in the life course are

shown.

What can paediatricians do about child health inequities

Child health inequities are profoundly influenced by social and

political decisions which are beyond the control of individual

paediatricians. Even relatively powerful medical organizations

such as the Royal Colleges and the BMA may have limited

influence on social and health policy which determines the

health of the population. The main determinants of striking

improvements in child and population health in developed

countries, and some less developed countries, this century are


Intergenerational/childhood factors (distal)

Pathways to IUGR in developed countries

Factors at conception

(intermediate)

Pregnancy factors

(proximal)

Low socio-economic

status/poor at

mother’s birth

PIH, pregnancy-induced hypertension; IUGR, intrauterine growth retardation

Mother’s birth

weight

Exposure to/

adoption of poor

health behaviours

Low weight

Short stature

Young age

Low SES/poor Poor nutrition

PIH

Abuse/stress

Smoking

IUGR

Heavy work

Low weight gain

Childhood

ill health

Sub-optimal

nutrition

Low education

Major pathway Minor pathway Possible pathway

CRITICAL PERIODS FOR INTERVENTION

Figure 2 Pathways to intrauterine growth retardation in developed countries.

Birth Age 5 Age 10 Age 16 Age 30

Schoon et al. 1003

Parental

social

class

Social risk

Behaviour

problems

.56 .53

.96

.89

.22

.30

.12

.47.97

Behaviour

problems

Behaviour

problems

Social risk Social risk

Depressed

mood

Social

status

Figure 3 Developmental econtextual model of psychosocial adjustment based on data from the 1970 British Cohort Study.


PAEDIATRICS AND CHILD HEALTH 20:4 160 � 2009 Elsevier Ltd. All rights reserved.


changes in living standards and nutrition rather than medical

intervention. However, paediatricians can promote the health of

disadvantaged children in a variety of ways including influencing

local and national government.

Although good empirical evidence exists for the social and

political policies which improve the health of poor children over

a period of time, there is a dearth of evidence supporting health

interventions designed to reduce the health effects of social

disadvantage. Available evidence is summarised in a review

prepared by the NHS Centre for Reviews and Dissemination but

many of the studies provide very weak evidence of effectiveness.

More recent work highlights ‘what works’ in reducing child

health inequalities. Many of the strategies suggested below

remain unevaluated. This is a limitation which needs to be

overcome by further research. However, it should not stand in

the way of paediatricians advocating for poor children and

employing the proposed strategies.

Strategies for reducing child health inequities can function at

a number of different complementary levels: national, local and

individual. Paediatricians might choose to focus at one or all of

these levels but will need to be fully informed of the magnitude

and extent of health inequities and committed to a non-victim

blaming approach which accepts other disciplines and parents as

equal partners. Political action and advocacy on behalf of poor

families and children by doctors is not new. There is a long and

honourable tradition of medical intervention on behalf of indi-

viduals and communities.

National and local strategies

In the UK, there is a particularly pressing need for paediatricians

to take political action on behalf of poor children and their

families. Paediatricians need to confront the political nature of

the solutions. The present UK government, in contrast to their

immediate predecessor, recognises the role of poverty and social

disadvantage in the determination of health outcomes; however,

professional groups, including paediatricians, will need to

participate actively in the political process to ensure that

appropriate child and family orientated policies are enacted. An

example is the change in UK government policy on child care

which has been strongly influenced by the findings of systematic

reviews undertaken by paediatricians (amongst others) demon-

strating that good child care enhances child development and

educational attainment.

Healthy Alliances are encouraged by the government. In alli-

ance with national campaigning groups such as the End Child

Poverty Coalition (ECPC), paediatricians. individually and

through the College, can bring research data to public attention

and contribute to the development of alternative strategies for

health gain. The author has co-authored a briefing paper on

poverty and child health for the End Child Poverty Coalition and

the College President, along with other College members, had

a letter published in the Observer newspaper in support of the

ECPC’s campaign to persuade the government to keep its

promise on eliminating child poverty by 2020.

Some countries have appointed Children’s Commissioners

whose task it is to represent the interests of children and

monitor progress of the UN Convention on the Rights of the

Child in their country. BACCH and the RCPCH supported the

establishment of Children’s Commissioner posts in England,


Wales, Scotland and Northern Ireland. Professor Al Aynsley-

Green is the Commissioner for England and he has led an

advocacy campaign on the social factors that influence child-

ren’s health and well-being.

If paediatricians are to promote the health of children, they

have to become more than just providers of treatment and care

during illness but advocates for children in order to protect them

from forces beyond the control of the individual child and family

which may damage their health and threaten their wellbeing.

Advocacy for children is often limited to representing the child

against its parents in child protection cases. However, advocacy

can be a much broader concept. This broader concept of advo-

cacy can be illustrated using a specific example with an impor-

tant relationship to health inequities: the prevention of childhood

accidents.

The example of childhood accidents

Childhood accidents are now the commonest cause of child death

beyond the age of 1 year. Road traffic accidents (RTAs) become

an increasingly dominant cause of death as children get older.

Both RTAs and fatal accidents in the home show a strong social

class gradient. Decontextualised health promotion strategies

have concentrated on education of mothers. Evidence shows that

health education alone is ineffective in reducing accidents.

Strategies which modify the child’s environment are needed in

order to effectively prevent accidents. Incidence of RTAs is

increased by proximity to busy roads and strategies which

separate residential areas and busy roads have proved effective.

In the home. reliance on mobile gas and oil heaters, as well as

structural problems and overcrowding, are associated with fatal

accidents.

An initiative to prevent childhood accidents in Newcastle

utilizes some of the approaches to advocacy shown below in

practice points. Of particular interest is the use made of a survey

by local parents which demonstrated a lack of safe crossing

points on the children’s’ route to school. These data were used

by a multidisciplinary group to lobby for environmental change.

Individual level strategies

Many health workers work mainly with individual children and

families either in clinics or surgeries or in the family home. Even

at this level, strategies for reducing inequities can be employed.

Poor families often experience poor services as a result of the

operation of the ‘inverse care law’. The powerlessness associated

with poverty and deprivation tends to lead to an unequal power

relationship between client and health worker and class, cultural

and language barriers can further impede communication. As

a consequence, access to good child health care may be relatively

difficult for poor families whose children are more likely to need

specialist as well as non-specialist child health services.

Strategies at this level for reducing inequalities involve

ensuring access of poor families to high quality child health

services. The basic principles are summarized below in practice

points.

Conclusion

Inequities in child health have a profound impact on the health of

UK children accounting for a high proportion of many common


Practice points:

Childhood accidents

C In the area of childhood accidents, advocacy must address the

social context in which accidents occur. Advocacy might

concentrate on the following issues:

C the evidence linking accidents to poor social conditions

C the evidence linking residence in poor areas and proximity to

heavy traffic

C the evidence demonstrating the relative effectiveness of

environmental change over education strategies

C the evidence linking home accidents to overcrowding,

poor housing conditions and inappropriate forms of

heating

C lobbying national and local government to modify children’s

environments using traffic calming strategies and more long-

term strategies which reduce reliance on the private car

C forming healthy alliances with local and nationally and

professional groups to influence transport and housing policy

locally and nationally

C promote community participation and community diagnosis

locally which can identify from the perspective of

community residents the main sources of danger to their

children.

Individual-level strategies:C accessible, flexible and relevant services ‘free at the time of

use’

C locally provided services of high quality minimizing the

financial burden imposed by the need to travel to specialist

services

C paediatricians who respect parental skills and treat parents as

genuine partners in the care of their children

C paediatricians who recognize the special problems of caring

for children in poverty and modify their case management and

treatment regimes accordingly

C paediatricians who carry out non-discriminatory practice

respecting cultural differences and recognising the ‘double

jeopardy’ faced by ethnic minority families.


adverse child health outcomes. Social determinants exert their

influence through complex pathways and are mediated by health

behaviours and environmental factors. Child health inequities

require action at the national political level but paediatricians can

contribute to reducing inequities through individual action and

through the College. A

FURTHER READING

Chen E, Martin AD, Mathews KA. Trajectories of Socioeconomic Status Across

Children’s Lifetime Predict Health. Pediatrics 2007; 120: e297e303.

End Child Poverty Coalition. Unhealthy lives. Available at: www.

endchildpoverty.org.uk http://www.endchildpoverty.org.uk/files/

Intergenerational_Links_between_child_Poverty_and_poor_health.

pdf. briefing paper Hirsch D, Spencer N.

Krieger N, Davey Smith G. Bodies Count, and Body Counts: Social epi-

demiology and embodying inequality. Epidemiol Rev 2004; 26: 92e103.

Manning D, Brewster B, Bundred P. Social deprivation and admission for

neonatal care. Arch. Dis. Child. Fetal Neonatal Ed 2005; 90: 337e8.

Meltzer H, Gatward R, Goodman R, Ford T. The mental health of children

and adolescents in Great Britain. London: The Stationery Office, 2000.

NHS Centre for Reviews and Dissemination. Review of the Research on the

Effectiveness of Health Service Interventions to reduce variations in

health. CRD Report 3, CRD. University of York, 1995.

Schoon I, Sacker A, Bartley M. Socio-economic adversity and psychosocial

adjustment: a developmental-contextual perspective. Soc Sci Med

2003 Sep; 57(6): 1001e15.

Smith LK, Draper ES, Manktelow BN, Dorling JS, Field DJ. Socioeconomic

inequalities in very preterm birth rates. Arch. Dis. Child. Fetal Neonatal

Ed 2007; 92: 11e4.

SpencerN.Poverty andchild health. 2nded.Abingdon:RadcliffePress, 2000.

Spencer N. Weighing the evidence: how birthweight is determined.

Abingdon: Radcliffe Press, 2003.

Sundrum R, Wallace A, Logan S, Spencer NJ. Cerebral palsy and socio-

economic status: a retrospective cohort study. Archives of Disease in

Childhood 2005; 90: 15e9.

What works for children. Available at: www.whatworksforchildren.org.uk/.

WHO Commission on Social Determinants of Health. Closing the gap in

a generation: health equity through action on social determinants of

health. Final report. Geneva: World Health Organisation, 2008.

PAEDIATRICS AND CHILD HEALTH 20:4 162 � 2009 Elsevier Ltd. All rights reserved.

http://www.endchildpoverty.org.uk

http://www.endchildpoverty.org.uk

http://www.endchildpoverty.org.uk/files/Intergenerational_Links_between_child_Poverty_and_po5or_health.pdf



http://www.whatworksforchildren.org.uk/

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