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What does it take to create healthier environments for children? (First, get rid of the alligators…)

New digital media is bringing “unprecedented opportunities” for evidence-informed advocacy for healthier environments for children, according to Professor Helen Roberts from University College, London.

In a keynote address to the Australian Health Promotion Association conference in Sydney today, Professor Roberts outlined some challenges and opportunities for addressing inequalities in children’s environments.

She said the Internet was proving an “amazing tool” when used by “bright and principled young people to persuade us to persuade the decision makers to do the right thing”.

She gave as an example this Avaaz petition arising out of the recent clothing factory fire in Bangladesh.

Professor Roberts urged the health promotion sector to focus on addressing “the causes of the causes” of health problems. She said: “We need to put energy and creativity into changing the behaviour of those on the supply end of health insults to children.”

As previously mentioned at Croakey, Professor Roberts also delivered one of the all-time great public health images: “Trying to change children’s health behaviours without trying to change the food and transport environment is like trying to teach them to swim in a pool full of alligators.”

She also warned against the “powerful narrative” that “some mums, especially poor ones, are bad for your health”.

This notion persisted, she said, “despite overwhelming evidence that the vast majority of mothers protect and promote the health of their children”.

Professor Roberts stressed the importance of universal programs, saying that changing problems like obesity and violence at a population level meant shifting the mean – not just cuting off the tail of the distribution through targeted programs.

“Shifting the mean requires changing obesogenic environments, and tackling violence,” she said.

A lightly edited version of her talk follows below (and beneath that are some conference tweets).

****

Challenges and possibilities for improving children’s health

Helen Roberts writes:

I’m speaking today about inequalities in children’s settings, and challenges and possibilities – from the local to the global – at a time of austerity.

My impression is that we in the UK expend less energy and creativity than you guys in changing the behaviour at the supply end of health insults including the food, drug, alcohol and tobacco industries.

We Brits have a lot to learn about the ways in which you organise health promotion.

Your imagination, sleeves up ‘let’s get it done’ attitude and the fact that you have managed to resist the ‘doctors are in charge of everything’ model is a real lesson to us.  And we particularly admire the massive contribution made in Australia to the use of research-based advocacy.

The work of Simon Chapman among others has shown that there is a lot to be said for the careful accumulation of research evidence over time.

The steady drip drip drip of water on stone is likely to be more effective in changing the environment for the long term than a short term bright idea that someone thought up in the bath.

As Winston Churchill, the British war leader in the 2nd world war made clear, health is a pretty political subject. He said:

“The first lesson that you must learn is that, when I call for statistics about the rate of infant mortality, what I want is proof that fewer babies died when I was prime minister than when anyone else was prime minister. That is a political statistic.”

Health is political, and I’m aware from talking to colleagues from other parts of Australia of the challenges some of you face as a result of austerity measures.

Addressing “the causes of the causes”

The great advances in population health come from engineering, education, housing and transport interventions, and it is these, of course, that have the greatest potential for addressing the social determinants of health – the causes of the causes of health problems.

I am going to draw on a couple of recently completely studies in which I have been involved – but I want to talk about a range of geographical, social and emotional settings, starting with the local.

For many years, those of us who work on the importance for current and future health of early childhood interventions felt as if we were pushing a stone up a hill – but as my Canadian pal and colleague Clyde Herzman put it just before his death in London earlier this year ‘we are like rock stars now.’

Clyde was a modest man – but what I think he meant was you could sing the same song over and over again without anyone listening and then you suddenly realised that everyone was singing along.

The importance of early years support is not just recognised now, but acted upon worldwide (in some places more in terms of rhetoric than reality, but even that’s a start).

Reducing health inequities is, for the Commission on Social Determinants of Health, an ethical imperative. Social injustice is killing people on a grand scale.

My brilliant UCL colleague Michael Marmot had the bright idea as a young bloke to set up a long term cohort study following the lives of civil servants from the most junior to the most senior – the Whitehall studies.

He was able to show that small social class gradations were replicated in rates of illness and death. Many others have worked on the relationship between social class and health before and since – but this bike-cycling medical academic caught the imagination, and the WHO inequality reports have had a big impact in the UK and internationally.

Of course, it is hardly news to poor people that poverty is bad for your health – ‘ Well fancy that !’- but engendering the sense that there is an urgency to do something about it, and persuading politicians and policymakers that this is the case – and that inequality harms everyone not just the poor – is something else.

Many of you will know London, and perhaps one of the best illustrations of the relationship between settings and health is a visual representation of the underground, showing that the further east you travel, the worse your life and health chances (available here).

It’s not just that there are more poor people, but there are more outlets for unhealthy food, fewer parks, schools which struggle in the face of challenges.

But such is the power of the inequality tube map that our not especially left-leaning Prime Minister, David Cameron, has referred to it and the unfairness it illustrates.

Therein lies the impact of unconventional and powerful ways of presenting data.

Giving a message in a way that anyone can understand can be difficult for those of us who worry about detail but it is important for advocacy. Children born and brought up in East London are not going to have as many years of life as those born in West London.

Healthcare matters … (but)

And now for something I bet none of you will ever see again – a celebration of a country’s health system at an Olympic opening ceremony.

In London last year, the NHS in general and Great Ormond Street Hospital in particular played a starring role.

Even though the Olympic trip through the agrarian and industrial revolutions, the Beatles and the NHS showed an accurately bonkers picture of the British, it did depict the thing of which we Brits are most consistently most proud –  a national health service free at the point of use.

Of course, I don’t need to tell anyone in this room that acute hospital settings are pretty tangential to health though pretty important for ill health, so we have every reason to be grateful for them. Good access to an environment where medical attention is free and universal is absolutely essential to any of us promoting health.

But the role that the somewhat less glamorous drains and sewers, housing, education, transport and employment play are, of course, far more important in the production and re-production of good health.

The global context

Many health promoters act locally, regionally and nationally but health promotion takes place in a global context.

I was in Australia and New Zealand a decade ago at the start of the Iraq war.  Ten years on, and war is not only a matter between soldiers (devastating though that is). Non-combatant children are caught in the theatre of war.

Children in war zones, and mothers and children working in sweatshops to produce our cheap clothes, are just as much our responsibility as the child next door.  Of course, we may well feel that there is nothing we can do.  But maybe there is.

In terms of meeting challenges, one amazing tool is the use of the Internet by bright and principled young people to persuade us to persuade the decision makers to do the right thing.

This petition is gathering signatures world wide to encourage rich world clothes shops to adopt the kinds of building regulations we would expect in our own countries.

It strikes me that the new digital media – as well as sometimes providing opportunities to do the wrong thing also offer unprecedented opportunities for evidence informed advocacy.

Moving onto other settings including transport, housing, education and family, one of the problems for those of us interested in health promotion at a population level is that it is easier (though by no means a walk in the park) to obtain funding for evaluations of single issue behavioural interventions. In particular, some of the most robust research designs are more suited to these single issues.

While the majority of health promotion and public health interventions are very much more cost effective than clinical ones, very few are cost free.

There are fiscal, political, ethical and health economic questions about what to do, and when resources are scarce, what to do first.

As an author of the early years chapter of the 2010 Marmot report, I was thrilled of course, to see the early years given such emphasis in the final report and the publicity (even though I secretly worry that an emphasis on the early years is sometimes used to imply that your number is up by the time you start school).

Damaging narratives

It may never be too early, but it is definitely never too late to change a young person’s life.

I was a bit less thrilled by a sideswipe at not good enough mothers on the BBC website on the day the report was launched, suggesting that some poorer mothers don’t cuddle their babies enough.

There are competing narratives on what needs to be changed and a powerful one is that ‘some mums, especially poor ones, are bad for your health.’ This despite overwhelming evidence that the vast majority of mothers protect and promote the health of their children.

Hilary Graham’s work on women and smoking and ours on safety as a social value show mothers trading off one risk against another.

In our own study, a mother would sometimes trade off leaving children alone for a few minutes if she lived in a tenement four floors up and needed to hang the washing out. It was that or carry the wains under one arm, the washing under the other, down the stone stairs.

The solutions to these kinds of issues are not, of course, telling people what they already know – that smoking is bad for you or that you should never ever leave a young child alone.

What seems to work much better is trying to address the causes of the causes. Smoking levels have gone down – not, I suspect as a result of ‘educating’ mums, but as a result of sustained campaigns of the sort you have had here.

In discussing some of the environments and settings that affect a child’s health chances, and what needs to change, I’m going to draw on two recently completed studies, which evaluated interventions in different settings.

One is a policy intervention providing free bus transport for London children, and the other an evaluation of an intervention rolled out at scale and aimed at tackling overweight and obesity following an RCT which had showed a positive effect in the short term with obese children.

Our co-investigators on the quantitative side did find quite a bit to be positive about. But in talking to the people who commissioned the intervention, and those on the receiving end of this family based programme, there were negative as well as positive perceptions.

From the point of view of the commissioners, while they liked an intervention based on a trial, and one that provided what one called ‘a solution in a box,’ two key issues were the lack of long term follow-up data – a frequent problem in all kinds of interventions, and poor recruitment and drop out meaning that the cost per participant could be high.

From the point of view of parents and children, an unexpected cost was the emotional one – time foregone from other activities, time not spent in settings which participants considered more useful to their health or well-being, including the football stadium and the mosque, particularly if it was time with ‘their mates.

An intervention which showed an effect was competing with a highly obesogenic environment, and parents and children were aware of this.

Changing the food environment has been one proposal in a poor part of the UK to change the food environment – it will be interesting to see how it goes and I’d be interested to hear if you have had any similar kinds of scheme here.

Transport matters

Children’s needs are marginalised if urban roads exclude them from public space. Transport policies disproportionately impact on some children more than others.

There has been a massive increase in car travel by children and in fact most schools no longer have the extensive bike sheds I remember (and in many cases, the land on which they stood and the sports fields have been sold off.)

In one widely reported case, London parents were summoned to the headmaster for a possible child protection referral for allowing their children to cycle to school.

We were fortunate enough to have the chance to evaluate a natural experiment, the provision of free bus transport to all children and young people in London. This wasn’t designed as a health-promoting intervention as such but was brought about: “to help young people to continue studying, improve employment prospects and promote the use of public transport”.

We used mixed methods – quantitative, qualitative and economic data and our overall conclusions were positive – even positive in economic terms – about this provision – but – and this is a large but – in the context of a city where there is very good public transport, and where people across all social classes use it. It is more odd to use a private car in London than not to.

Our study found that young people didn’t exercise any less (though not any more either), they didn’t kick their grannies off the bus (though they did tend to colonise different parts of the bus), and they were able to feel part of the city and ‘hang out’ with their mates – except for one important group.

Young wheelchair users described problems with the ramps, problems with buses that were accessible but bus stops that weren’t and although being with your mates was no less important for wheelchair users, if your best pal was in also in a wheelchair, there probably wasn’t room for both of you. And either your able bodied friends had to join you downstairs with the grannies, or you were left with the grannies by yourself.

I want to end by saying something about the health promoting potential of universal services, such as the NHS and the free buses for kids, which might seem an odd thing to say at a time of cuts.

Targeted Vs Universal?

There are many arguments and counter arguments about universal and targeted services. So in societies where there are a lot of overweight kids, overweight starts to seem pretty normal. In societies where it is legal to hit small people (children) (but illegal to hit adults), we have problems.

By focussing only on the tail of the distribution, we might be able to do something, probably in the short term, for the most obese and overweight kids. By only censuring people who hurt their children badly, we imply that a smack is OK, even though if we were to smack another adult, we would be in trouble.

Targetting involves cutting off the tail, but the tail is part of the animal.

By shifting the mean, we make things better overall.  And although targeting services may seem a way to save money, targeting takes time, effort and is stigmatising. Efficient taxation should ensure that the costs of non-stigmatising services are re-couped.

Finally, as well as making sure that our children are in warm emotional settings and encouraged to feel positive about themselves and others, we should also try to do the same for ourselves.

There have been massive improvements in public health over the last century and there is scope for a lot more.

***

Some “take-homes” from the talk


Dr Lisa Gold from Deakin University also presented on the benefits of investing in healthy environments for children.


For those interested in finding out more about the Heckman equation see here…

And this is the short version:

Thanks to the #AHPA2013 Tweeters including:
@
bronmarie1 @Zockmelon @brydieclarke @Tessy_P
@gemmacrawford

***

For previous coverage of #AHPA2013:

What’s making the health promotion news on Twitter?

• Converging crises of environmental degradation and social injustice

 Indigenous tweeps out in force

• Conference preview by Suzanne Gleeson

In collaboration with conference organisers and tweeters, the Croakey Conference Reporting Service is providing an overview of key sessions and discussions.

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