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Victor Nossar - Challenge of the Future: Role of Child Health in Improving Population Health of Children
 

Victor Nossar - Challenge of the Future: Role of Child Health in Improving Population Health of Children

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A presentation by Victor Nossar at The Journey, CHA COnference

A presentation by Victor Nossar at The Journey, CHA COnference

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    Victor Nossar - Challenge of the Future: Role of Child Health in Improving Population Health of Children Victor Nossar - Challenge of the Future: Role of Child Health in Improving Population Health of Children Presentation Transcript

    • Delivering improvements in population health of children: The modern challenge for Children’s Healthcare ServicesProf Victor NossarProgram Leader - Child and YouthHealth NT Department of Health
    • Outline: • Delivering healthcare to individual children & delivering improved outcomes for populations of children. • How can we achieve significant improvements in outcomes for populations of children? • What are the implications for Children’s Healthcare Services in Australia?
    • Children’s Healthcare Services haveplayed an important role in Australia overmany decades….
    • Children’s Healthcare Serviceshave delivered: • Modern paediatric care • Neonatal Intensive Care • Health & developmental screening & surveillance • Immunisation • Child safety & injury prevention • Child development support
    • However, communities &Governments continue to demandimprovements in : • Child & infant mortality rates • Rates of low birth weights • Rates of overweight & obesity • Breastfeeding rates • Child injury rates • Rates of substance misuse (licit or illicit) • Rates of child maltreatment& these have proved much harderto deliver!
    • We are told that there is acontinuum:Health Cure orpromotion managemeor health nt of healthprotection problems& clinicians need to be able achieveboth!
    • But the focus remains on providing care& support to address the health &developmental problems that childrenpresent with….
    • It is important to ask thenwhy, when prevention is valuedand seen to be good clinicalpractice,most effort and resources stillare concentrated on respondingto presenting problems andillnesses of children.
    • Why are there so fewstudies able to demonstrateimproved population-levelrates for children frominterventions deliveredthrough clinical responses?
    • Is there adistinctionbetweenhealthcareforindividualchildren& the healthofpopulationsof children?
    • Healthcaremainlyfocusses onthe health ordevelopmentalneeds of anindividualchild:
    • Even if the care is addressing thehealth or developmental needs ofmany individuals:
    • Or the care is addressing the healthor developmental needs of very manyindividuals:
    • ButIf that care is addressing health &developmental needs of a population:
    • The picture looks very different!
    • Programs thatsuccessfully improvehealth outcomes forpopulations are verydifferent from thosedesigned to address thehealth problems ofindividuals.
    • If you map the nature ofthe intervention(“prevention” or “cure”)against the level of theintervention (for anindividual or for apopulation), the picturegets a little clearer.
    • Health Promotion/Health Protection (Proactive) “Classical ” Health PromotionPopulation IndividualCare Care “Classical Clinical ” Public & Health Curative Care Response to health problem or issue (Reactive)
    • Health Outcomes Achieved by Health Services Population Health Promotion/Health Protection Health Outcomes Population Individual Care Care Individual Health Outcomes Response to health problem or issueRef: Nossar V. Integrated model of Children’s Health: Better Definition of Health Outcomes forChildren and Training Requirements for Professionals. Association for Paediatric Education inEurope/European Society for Social Paediatrics. Bordeaux, France, 1998.
    • Caring for the needs of an individualchild:
    • Health Outcomes Achieved by Health Services Population Health Promotion/Health Protection Health Outcomes Population Individual Care Care Individual Health Outcomes Response to health problem or issue
    • Individual Health Outcomes: • Most often utilise strategies that respond to a problem, (even with “early intervention”.) • Focus on the care of particular individuals and the responses addressing their problems and needs. • Attention to the services being available, accessible, appropriate, and effective.
    • Caring for a population of children:
    • Health Outcomes Achieved by Health Services Population Health Promotion/Health Protection Health Outcomes Population Individual Care Care Individual Health Outcomes Response to health problem or issue
    • Population Health Outcomes Measures include: • Infant or child mortality rates • Rates of low birth weight • Immunisation rates • Breastfeeding rates • Rates of substance abuse (licit or illicit) • Injury rates • Child abuse rates
    • Population Health Outcomes: • Utilise more proactive strategies with a focus on whole populations. • Based on systems approaches addressing key determinants of health in the population of interest. • Focus on programs being available, appropriate, effective but also reaching high coverage.
    • Cutler DM, Meara E. Changes in the age distribution ofmortality over the 20th century. NBER Working Paper 8556. MA, USA, 2001.
    • 1+1 A Healthy Start to Life Study has found very high rates of contact with clinical services for treatment of acute illnesses by Aboriginal children in their first year of life in the two large remote NT communities studied. Ref: Bar-Zeev SJ, Kruske SG, Barclay LM, Bar-Zeev NH et al. Use of health services by remote dwelling Aboriginal infants in tropical northern Australia: aretrospective cohort study. BMC Pediatrics 2012, 12:19 doi:10.1186/1471-2431- 12-19.
    • Effectivepopulation-levelapproachesto improveChild Healthoutcomes
    • High variance apparently “explained” by individual-level riskindicators ….does not mean thatthey are important determinants ofthe population level of any outcome. (Rose G. Sick individuals and sick populations. Int J Epidemiol 1985; 14:32-8.)
    • Key question:What are the significantpopulation-leveldeterminants of thehealth problem?
    • Determinants of Health Upstream Factors Midstream Factors Downstream Government Health system Physiological Policies H Determinants Psychosocial EGlobal of health Aforces (social, L physical Health behaviours economic T environmental) HCulture Culture BiologicalSocioeconomic determinants of health. Turrell G et al. QU T. April 1999.Commonwealth Dept Health & Aged Care, Canberra
    • Inappropriately focussing onindividual level determinants ofhealth while ignoring moreimportant macro leveldeterminants is tantamount toobtaining the Carpenter. Am J Public Health 1999; 89: 1175 - 80.) (Schwartz & right answer to thewrong question.
    • The heritability of body mass index (BMI) calculated from population studies is about 70%.Ref: Stunkard AJ, Harris JR, Pedersen NL et al. The bodymass index of twins who have been reared apart. N Eng J Med 1990; 322: 1483-7.
    • Child neglect, on its own, explained 57 per cent of the variation in juvenile participation in crime. Neglect was responsible for most of the variation in juvenile participation in crime, even accounting for poverty, single parent families and crowded dwellings. (Ref: Weatherburn D, Lind B. Social and economic stress, child neglectand juvenile delinquency. NSW Bureau of Crime Statistics and Research. Sydney, 1997)
    • Ref: Population Health Approach - Public Health Agency of Canada(http://www.phac-aspc.gc.ca/ph-sp/approach-approche/index-eng.php )
    • “High risk” focussed strategyx 1,000 population10 9 8 Threshold score 7 for the clinical 6 range 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Disorder severityWhile the level of risk of problem is high, the numbers affected are small.
    • “Population health” focussed strategyx 1,000 population 10 9 8 Threshold 7 score 6 for the clinical 5 range 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Disorder severityWhile the level of risk of problem is lower, the numbers affected aremuch bigger.
    • Population Health Outcomes: • Utilise more proactive strategies with a focus on whole populations. • Based on systems approaches addressing key determinants of health in the population of interest. • Focus on programs being available, appropriate, effective but also reaching high coverage.
    • A key determinant of healthoutcomes: The impact ofDisadvantage
    • Children living in social oreconomic adversity have muchgreater chance of significanthealth and developmentalproblems,and these problems can extendinto their adult lives.
    • Mortality Rates for Children 0-14 Years By quintile of SES disadvantage. Australia - 1985-87 14 12 Rate per 1000 10 8 Boys 6 Girls 4 2 0 Affluent 1 2 3 4 5 Poo r SES quintile Source: C Mathers,1995
    • Socioeconomic gradients forbehaviour problems in children 4 & 5 years of age 30 % With behaviour disorders 25 20 15 10 5 0 -2 -1 0 1 2 Socioeconomic statusNational longitudinal survey of children & youth – Canada 1994. Willms, 1999.
    • “the outcomes of biologicalrisk conditions depended onthe quality of the child-rearing environment and theemotional support providedby family members, friends,teachers, and adult mentors.” Ref: Werner EE. Journeys from childhood to midlife: Risk, resilience, and recovery. Pediatrics 2004; 114; 492
    • Experiences of early childhoodadversity get “under the skin”,affecting physiological andcellular pathways leading todisease susceptibility &becoming “biologicallyembedded” into the moleculargenomic systems that determinevulnerability and resilience.Ref: Boyce WT, Sokolowski MB, Robinson GE. Toward a new biology of social adversity. PNAS Early Edition: www.pnas.org/cgi/doi/10.1073/pnas.1121264109
    • Attributable risk for children’svulnerability to poor developmentassociated with low family income is10.8 percent– if Canada could boost everyone’sincome above that level, theprevalence of developmentalvulnerability in children would only bereduced by about 10 percent.… even if all the principal risk factorsknown to be associated with familybackground could be eliminated,childhood vulnerability would be(Ref: Russell CC. Parenting in the20 percent. Prioritiesreduced by less than beginning years: for investment. Invest in Kids, Canada 2003, pp 27-31)
    • “What parents do is moreimportant than who they are.Especially in a child’searliest years, the right kindof parenting is a biggerinfluence on their futurethan wealth, class,education or any othercommon social factor.” Steps . An Ref: Allen G. Early Intervention: The Next Independent Report to Her Majesty’s Government. HM Government, UK. Jan 2011. http://www.dwp.gov.uk/docs/early-intervention-next- steps.pdf
    • Do we knowhow to helpparents toimprovechildren’sdevelopment &life outcomes?
    • • Good nutrition and nurturing support optimal brain & physical development, as well as later learning and behaviour.• There are also initiatives that can measurably improve early child Ref. McCain MN, Mustard JF. Reversing the real brain drain: Early Years Study- Final Report. Ontario Children’s Secretariat 1999. pp25-26 development.
    • Key initiatives shown to improve child outcomes Population Parenting Programs Immunisation SmokingPrevention/ Nurse Home School Connectedness Cessation Visiting Early Child Mother Developmentcompletin Programsg 12 years of BreastfeedingEducation Community DevelopmentConception Birth 2 years 5 years 12 years 18yearsAdvocacy - enhance social, political, economic and physical environment; legislation (eg. seatbelts), structural changes (eg housing design)
    • “Achieving ‘real-world’ success withprevention and early interventionprograms is difficult; therefore, closeattention must be paid to qualitycontrol and adherence to originalprogram designs. Successfulprevention strategies require more effortthan just picking the right program.” (Aos, S et al, Benefits and Costs of Prevention and Early Intervention Programs for Youth – Washington State, www.wsipp.wa.gov/rptfiles/04-07-3901.pdf Sep 17, 2004)
    • Poverty and disadvantage diminishthe impact of many programs onpopulation – level outcomes, as thepeople “at greatest need” are leastlikely to access them.To achieve improved population– level outcomes effectiveprograms require high coverage.Provision of a greater variety ofprograms, each with variablecoverage, is unlikely to achieve thesame impact on population-levelhealth outcomes.
    • “The central problem for all developedcountries, … is that intervention happenstoo late, when health, social andbehavioural problems have becomedeeply entrenched in children’s andyoung people’s lives.Delayed intervention increases the costof providing a remedy for theseproblems and reduces the likelihood ofactually achieving one.” Ref: Allen G. Early Intervention: The Next Steps. An Independent Report to Her Majesty’s Government. HM Government, UK. Jan 2011. http://www.dwp.gov.uk/docs/early-intervention-next-steps.pdf
    • Ref: Early Learning & Development - The first five years determine a lifetime. Children Nowhttp://dev.childrennow.org.s78640.gridserver.com/index.php/learn/early_learning_and_development/
    • The focus must be onpreventing the developmentof these health, behavioural& developmental problemsbefore they becomeestablished, by supportingbest possible earlychildhood development forevery child.
    • “Between 1998/99 and 2010/11 … £10.9billion (including £7.2 billion for SureStart ) will have been invested inprogrammes aimed in whole, or in part,at improving the health of under-fives,but this has not produced widespreadimprovements in health outcomes.Some health indicators have indeedworsened – for example, obesity anddental health – and the healthinequalities gap between rich and poorhas barelyHealth report, FebruaryGiving London, UK: www.audit-. (Ref: Audit Commission. children a healthy start changed.” 2010, commission.gov.uk )
    • To deliver better outcomes: • Understand importance of early child development. • Develop a better mix between programs delivering improved population-level outcomes for children& young people, and programs delivering care for identified problems. • Ensure that programs for children & young people are more evidence- based. • Learn the lessons about wide-scale
    • The EarlyChildhoodSeries ofexpert paperscan beaccessed athttp://www.det.nt.gov.au/parents-community/early-childhood-services/ntecplan
    • Challenges: • We cannot continue to rely on creating more services to pick up children & young people after problems become established. • We need to understand much better (& then address) the real determinants of health & development outcomes for children.
    • We need to keep asking: • Why effective interventions remain limited in application? • Why does most of the effort and resources continue to be focused on treating problems after they have arisen?
    • The dilemma for those whodeliver Children’sHealthcare Services iswhether we are in thebusiness of achieving betteroverall health for children,as well as providing the bestpossible healthcare forchildren.
    • THANKS &QUESTIONS