A presentation by Victor Nossar at The Journey, CHA COnference

1. Delivering improvements
in population health of
children:
The modern challenge
for Children’s
Healthcare Services
Prof Victor Nossar
Program Leader - Child and Youth
Health NT Department of Health

3. 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?

4. Children’s Healthcare Services have
played an important role in Australia over
many decades….

5. Children’s Healthcare Services
have delivered:
• Modern paediatric care
• Neonatal Intensive Care
• Health & developmental
screening & surveillance
• Immunisation
• Child safety & injury
prevention
• Child development support

6. However, communities &
Governments continue to demand
improvements 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 harder
to deliver!

7. We are told that there is a
continuum:
Health Cure or
promotion manageme
or health nt of health
protection problems
& clinicians need to be able achieve
both!

8. But the focus remains on providing care
& support to address the health &
developmental problems that children
present with….

9. It is important to ask then
why, when prevention is valued
and seen to be good clinical
practice,
most effort and resources still
are concentrated on responding
to presenting problems and
illnesses of children.

10. Why are there so few
studies able to demonstrate
improved population-level
rates for children from
interventions delivered
through clinical responses?

11. Is there a
distinction
between
healthcare
for
individual
children
& the health
of
populations
of children?

12. Healthcare
mainly
focusses on
the health or
developmental
needs of an
individual
child:

13. Even if the care is addressing the
health or developmental needs of
many individuals:

14. Or the care is addressing the health
or developmental needs of very many
individuals:

15. But
If that care is addressing health &
developmental needs of a population:

16. The picture looks very different!

17. Programs that
successfully improve
health outcomes for
populations are very
different from those
designed to address the
health problems of
individuals.

18. If you map the nature of
the intervention
(“prevention” or “cure”)
against the level of the
intervention (for an
individual or for a
population), the picture
gets a little clearer.

19. Health Promotion/Health Protection
(Proactive)
“Classical
” Health
Promotion
Population Individual
Care Care
“Classical Clinical
” Public &
Health Curative
Care
Response to health problem or issue
(Reactive)

20. 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
Ref: Nossar V. Integrated model of Children’s Health: Better Definition of Health Outcomes for
Children and Training Requirements for Professionals. Association for Paediatric Education in
Europe/European Society for Social Paediatrics. Bordeaux, France, 1998.

21. Caring for the needs of an individual
child:

22. 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

23. 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.

24. Caring for a population of children:

25. 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

26. 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

27. 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.

28. Cutler DM, Meara E. Changes in the age distribution of
mortality over the 20th century. NBER Working Paper 8556.
MA, USA, 2001.

29. 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: a
retrospective cohort study. BMC Pediatrics 2012, 12:19 doi:10.1186/1471-2431-
12-19.

30. Effective
population-
level
approaches
to improve
Child Health
outcomes

31. High variance apparently “
explained” by individual-level risk
indicators ….does not mean that
they are important determinants of
the population level of any outcome.
(Rose G. Sick individuals and sick populations. Int J
Epidemiol 1985; 14:32-8.)

32. Key question:
What are the significant
population-level
determinants of the
health problem?

33. Determinants of Health
Upstream Factors Midstream Factors Downstream
Government Health system Physiological
Policies
H
Determinants Psychosocial
E
Global of health
A
forces (social,
L
physical Health behaviours
economic T
environmental) H
Culture Culture Biological
Socioeconomic determinants of health. Turrell G et al. QU T. April 1999.
Commonwealth Dept Health & Aged Care, Canberra

34. Inappropriately focussing on
individual level determinants of
health while ignoring more
important macro level
determinants is tantamount to
obtaining the Carpenter. Am J Public Health 1999; 89: 1175 - 80.)
(Schwartz & right answer to the
wrong question.

36. The heritability of body
mass index (BMI)
calculated from
population studies is
about 70%.
Ref: Stunkard AJ, Harris JR, Pedersen NL et al. The body
mass index of twins who have been reared apart. N Eng J
Med 1990; 322: 1483-7.

37. 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 neglect
and juvenile delinquency. NSW Bureau of Crime Statistics and Research.
Sydney, 1997)

38. Ref: Population Health Approach - Public Health Agency of Canada
(http://www.phac-aspc.gc.ca/ph-sp/approach-approche/index-eng.php
)

39. “High risk” focussed strategy
x 1,000 population
10
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 severity
While the level of risk of problem is high, the numbers affected are small.

40. “Population health” focussed strategy
x 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 severity
While the level of risk of problem is lower, the numbers affected are
much bigger.

41. 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.

42. A key determinant of health
outcomes: The impact of
Disadvantage

43. Children living in social or
economic adversity have much
greater chance of significant
health and developmental
problems,
and these problems can extend
into their adult lives.

44. 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

45. Socioeconomic gradients for
behaviour problems in children 4 &
5 years of age
30
% With behaviour disorders
25
20
15
10
5
0
-2 -1 0 1 2
Socioeconomic status
National longitudinal survey of children & youth – Canada 1994.
Willms, 1999.

46. “the outcomes of biological
risk conditions depended on
the quality of the child-
rearing environment and the
emotional support provided
by family members, friends,
teachers, and adult mentors.”
Ref: Werner EE. Journeys from childhood to
midlife: Risk, resilience, and recovery.
Pediatrics 2004; 114; 492

47. Experiences of early childhood
adversity get “under the skin”,
affecting physiological and
cellular pathways leading to
disease susceptibility &
becoming “biologically
embedded” into the molecular
genomic systems that determine
vulnerability 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

48. Attributable risk for children’s
vulnerability to poor development
associated with low family income is
10.8 percent
– if Canada could boost everyone’s
income above that level, the
prevalence of developmental
vulnerability in children would only be
reduced by about 10 percent.
… even if all the principal risk factors
known to be associated with family
background could be eliminated,
childhood vulnerability would be
(Ref: Russell CC. Parenting in the20 percent. Priorities
reduced by less than beginning years:
for investment. Invest in Kids, Canada 2003, pp 27-31)

49. “What parents do is more
important than who they are.
Especially in a child’s
earliest years, the right kind
of parenting is a bigger
influence on their future
than wealth, class,
education or any other
common 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

50. Do we know
how to help
parents to
improve
children’s
development &
life outcomes?

51. • 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.

52. Key initiatives shown to improve child
outcomes
Population
Parenting
Programs
Immunisation
Smoking
Prevention/ Nurse Home School Connectedness
Cessation Visiting
Early Child
Mother Development
completin Programs
g 12 years
of Breastfeeding
Education
Community Development
Conception Birth 2 years 5 years 12 years 18
years
Advocacy - enhance social, political, economic and physical environment;
legislation (eg. seatbelts), structural changes (eg housing design)

53. “Achieving ‘real-world’ success with
prevention and early intervention
programs is difficult; therefore, close
attention must be paid to quality
control and adherence to original
program designs. Successful
prevention strategies require more effort
than 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)

54. Poverty and disadvantage diminish
the impact of many programs on
population – level outcomes, as the
people “at greatest need” are least
likely to access them.
To achieve improved population
– level outcomes effective
programs require high coverage.
Provision of a greater variety of
programs, each with variable
coverage, is unlikely to achieve the
same impact on population-level
health outcomes.

55. “The central problem for all developed
countries, … is that intervention happens
too late, when health, social and
behavioural problems have become
deeply entrenched in children’s and
young people’s lives.
Delayed intervention increases the cost
of providing a remedy for these
problems and reduces the likelihood of
actually 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

57. Ref: Early Learning & Development - The first five years determine a lifetime. Children
Now
http://dev.childrennow.org.s78640.gridserver.com/index.php/learn/early_learning_and_development/

58. The focus must be on
preventing the development
of these health, behavioural
& developmental problems
before they become
established, by supporting
best possible early
childhood development for
every child.

59. “Between 1998/99 and 2010/11 … £10.9
billion (including £7.2 billion for Sure
Start ) will have been invested in
programmes aimed in whole, or in part,
at improving the health of under-fives,
but this has not produced widespread
improvements in health outcomes.
Some health indicators have indeed
worsened – for example, obesity and
dental health – and the health
inequalities gap between rich and poor
has barelyHealth report, FebruaryGiving London, UK: www.audit-.
(Ref: Audit Commission. children a healthy start
changed.” 2010,
commission.gov.uk )

60. 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

61. The Early
Childhood
Series of
expert papers
can be
accessed at
http://www.det
.nt.gov.au/par
ents-
community/ear
ly-childhood-
services/ntecp
lan

62. 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.

63. 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?

64. The dilemma for those who
deliver Children’s
Healthcare Services is
whether we are in the
business of achieving better
overall health for children,
as well as providing the best
possible healthcare for
children.

65. THANKS &
QUESTION
S