Reducing Health Inequality: Early Childhood Interventions to Improve School Readiness in Scotland

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Reducing Health Inequality Early Childhood
Interventions to Improve School Readiness in
Scotland

• Presenter
• Dr Rosemary Geddes
• Career 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 Haw
• Senior Scientific Adviser, Scottish Collaboration
  for Public Health Research and Policy

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WHAT IS THE PROBLEM?
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UNICEF Children Well-being across the OECD
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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
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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
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Source Power C, Mathews S. Origins of health
inequalities in a national population sample.
Lancet 1997 3501584-89.
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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)
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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
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Education, Employment, Wealth Health
Source Fairer Society, Healthy Lives. The Marmot
Review.2010.
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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

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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.

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WHAT DETERMINES THESE OUTCOMES?
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Sensitive periods in early brain development
Pre-school years
School years
High
Numbers
Peer social skills
Conceptualization
Sensitivity
Language
Habitual ways of responding
Emotional control
Vision
Hearing
Low
1
2
3
7
6
5
4
0
Years
Source Graph developed by Council for Early
Child Development (ref Nash, 1997 Early Years
Study, 1999 Shonkoff, 2000.)
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Synaptic Density
At Birth
6 Years Old
14 Years Old
Source Founders Network, slide 03-012.
Rethinking the Brain, Families and Work
Institute, Rima Shore, 1997.
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The gradient worsens
Source Fairer Society, Healthy Lives. The Marmot
Review.2010.
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Life Course Problems Related to Early Life
2nd Decade
3rd/4th Decade
5th/6th Decade
Old 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.
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How can this be influenced?
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WHAT WORKS?
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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 childrens 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.
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Suggested mixed, two-generation approach to Universal Early Childhood Social-emotional Cognitive Development based on evidence of promising interventions Suggested mixed, two-generation approach to Universal Early Childhood Social-emotional Cognitive Development based on evidence of promising interventions Suggested mixed, two-generation approach to Universal Early Childhood Social-emotional Cognitive Development based on evidence of promising interventions Suggested mixed, two-generation approach to Universal Early Childhood Social-emotional Cognitive Development based on evidence of promising interventions Suggested mixed, two-generation approach to Universal Early Childhood Social-emotional Cognitive Development based on evidence of promising interventions Suggested mixed, two-generation approach to Universal Early Childhood Social-emotional Cognitive Development based on evidence of promising interventions Suggested mixed, two-generation approach to Universal Early Childhood Social-emotional Cognitive Development based on evidence of promising interventions
Delivery Population CONTINUUM OF CARE CONTINUUM OF CARE CONTINUUM OF CARE CONTINUUM OF CARE CONTINUUM OF CARE
Delivery Population Pregnancy Pregnancy 0-12 months 12-36 months 36-48 months
Highest risk of develop-mental and/or attachment disorder Medium risk Universal Children Enrichment of home environment e.g. Play_at_home Nurturing of holistic child development Childrens 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 Years Specialist input as required
Highest risk of develop-mental and/or attachment disorder Medium risk Universal Parent-Child Intensive midwifery support NFP 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 Teachers Specialist input as required
Highest risk of develop-mental and/or attachment disorder Medium risk Universal Parents Maternal education literacy Parenting preparation Support for addictions 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 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 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
Highest risk of develop-mental and/or attachment disorder Medium risk Universal Children Enrichment of home environment e.g. Play_at_home Nurturing of holistic child development Childrens centres Enrichment of home environment e.g. Play_at_home Nurturing of holistic child development Childrens centres Half-day preschool
Highest risk of develop-mental and/or attachment disorder Medium risk Universal Parent-Child Promotion of sensitive parenting with provision of support as needed Promotion of sensitive parenting with provision of support as needed Promotion of sensitive parenting with provision of support as needed Promotion of sensitive parenting with provision of support as needed Promotion of sensitive parenting with provision of support as needed
Highest risk of develop-mental and/or attachment disorder Medium risk Universal Parents Support for behaviour change Antenatal care according to medical risk 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 Support in accessing services Problem solving techniques Adult education for high school completion, job/employment support
Highest risk of develop-mental and/or attachment disorder Medium risk Universal Children Childrens centres e.g. drop-in centres, toy book libraries Resources e.g. Bookstart Enrichment of home environment Childrens centres e.g. drop-in centres, toy book libraries Resources e.g. Bookstart Enrichment of home environment Half-day preschool
Highest risk of develop-mental and/or attachment disorder Medium risk Universal Parent-Child Access to information on positive, sensitive parenting Access to information on positive, sensitive parenting Access to information on positive, sensitive parenting Access to information on positive, sensitive parenting Access to information on positive, sensitive parenting
Highest risk of develop-mental and/or attachment disorder Medium risk Universal Parents Standard antenatal care. Promotion of healthy diet, physical activity, breastfeeding smoking cessation. Ready Steady Baby Standard antenatal care. Promotion of healthy diet, physical activity, breastfeeding smoking cessation. Ready Steady Baby Information on healthy child development Information on available child, parent family services Core child health promotion programme with routine child development reviews Information on healthy child development Information on available child, parent family services Core child health promotion programme with routine child development reviews Information on healthy child development Information on available child, parent family services Core child health promotion programme with routine child development reviews
     
SPECTRUM
OF RISK
Source Scottish Collaboration for Public Health
Research Policy. 2010.
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Source Seven things legislators need to know
about school readiness. US State Early Childhood
Policy Technical Assistance Network. March 2003.
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Monitoring

• Data to monitor childrens 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.

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What is the EDI?

• The EDI is teacher-completed (20 minutes)
  checklist that assesses childrens school
  readiness when they enter school.
• It measures the outcomes of childrens 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.

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What Does the EDI Measure?
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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
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turity
2) Social Competence
Overall social competence - e.g., ability to get
along with other children Responsibility and
respect - e.g., accept responsibility for
actions Approaches to learning - e.g., working
independently Readiness to explore new things -
e.g., eager to explore new items
3) Emotional Maturity
3) Emotional Maturity
Pro-social and helping behaviour - e.g., helps
other children in distress Anxious and fearful
behaviour - e.g., appears unhappy or
sad Aggressive behaviour - e.g., gets into
physical fights Hyperactivity and inattention -
e.g., is restless
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4) Language Cognitive Development

• Basic literacy
• - e.g., able to write own name
• Interest in literacy/numeracy and memory
• - e.g., interested in games involving numbers
• Advanced literacy
• - e.g., able to read sentences
• Basic numeracy
• - e.g., able to count to 20

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5) Communication Skills and General Knowledge
(No subdomains) - Ability to clearly communicate
ones 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
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Trajectories Established Early - Vulnerability
on EDI and Grade 6 outcomes
N of domains with low scores
Percentage of Grade 6 students not meeting
provincial standards in relation to number of
vulnerabilities in Kindergarten (EDI)
Source TDSB, 2007
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International Early Development Instrument
implementations
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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

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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
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Useful websites references

• Offord Centre for Child Studies
• http//www.offordcentre.com/index.html
• Australian Early Development Index - click on
  AEDI
• http//www.rch.org.au/ccch/index.cfm?doc_id10556
• British Columbia ECD mapping portal
• http//www.ecdportal.help.ubc.ca/archive/faq.htm
• Hertzman C, Williams R. Making early childhood
  count. CMAJ. 2009 Jan 6180(1)68-71.
• Lloyd JEV, Hertzman C. From Kindergarten
  readiness to fourth-grade assessment
  Longitudinal analysis with linked population
  data. Social Science Medicine.
  200968(1)111-23.
• Hertzman C. Tackling inequality get them while
  theyre young. BMJ 2010 340346-8
• Marmot M. Fair Society, Healthy Lives. London
  University College London 2010.
• Contact details Rosemary.Geddes_at_hgu.mrc.ac.uk