22 June 2018

Pushing past the postcode predictor

Public Health

You want to keep children out of gaol in their adult years and in employment, realising their potential as partners, parents and contributors to a better Australia? Wondering where to invest? 

Look no further. The postcode in which a child grows up is an excellent risk- stratification tool. 

A young Australian’s chance in life is predicted, at the population level, by their postcode. This is inequitable.

It is another example of the social gradient of health; a gradient first described by the expatriate Australian Michael Marmot in his study of the health and wellbeing of British civil servants.

The data in the Australian Early Child Development Census (AEDC) shows, postcode by postcode, a social gradient in child outcomes at school entry, which predicts their life-long trajectory of health and wellbeing.

The AEDC is undertaken every three years and captures more than 98% of Aussie kids in their first year at school. The comprehensive enrolment of this population makes the AEDC a valuable dataset. It rivals the importance of the Australian Immunisation Register (AIR) as a tool for improving public health.

Minimising vaccine preventable disease is a triumph of Australian public health.1,2 It is a rare example of a social gradient being all but eliminated.

Ironically, the social gradient for immunisation has been reversed in some postcodes. In these postcodes it is the children of affluent, well-educated parents who miss out on immunisation.2

In short, inequity is not inevitable!

Eliminating the social gradient in vaccine-preventable disease was a complicated process. 

Contrast this with the task of reducing the social gradient embedded in the AEDC data. Here the challenge is neither simple nor complicated – it is complex.

Appreciating the domains of the AEDC helps explain the complexity.

 The domains of the AEDC are:

• Physical health and wellbeing

• Social competence

• Emotional maturity

• Language and cognitive skills

• Communication skills and general knowledge

These “domains have been shown to predict later health, wellbeing and academic success”.3

The mix of protective and risk factors at work during the first 2000 days of a child’s life determines their strength or vulnerability in the domains. 

Both the dose of each factor and the timing of its impact during development will influence outcomes. That’s obvious for rubella. Replace rubella with, say, paternal depression, domestic violence or intergenerational unemployment and the complexity intensifies.

Improving the social determinants of health for children aged zero to five years is a problem that is at once pressing and complex. 

Complex problems do not yield to pre-planned projects that set out the steps to be followed in a linear pursuit of solutions. Confronted by complexity the only option is to try something, see what happens (measure the impact) and learn the way forward by discarding what fails and adopting what works. This is central to the strategy known as “collective impact.”

There are clues available to guide early work. It is known for instance that: 

• Good parenting buffers the impact of poverty

• Traumatised parents themselves need safe, sustained nurturing relationships if they are to provide safe, sustained nurturing relationships for their children

• Quality early child education and care improves development, especially for disadvantaged children

• the Maternal Early Childhood Sustained (nurse) Home-visiting (MECSH) program effectively supports disadvantaged families to establish the foundations of a positive life trajectory for their children

Children need a transformation of the healthcare system to evolve in partnership with a transformation in the social-care system. 

There are signs of this revolution getting under way internationally and in Australia. Sessions were devoted to child health inequity at the recent RACP Congress. NSW Health has actively developed policy in this area and the recent federal budget announced new investment in the First Two Thousand Days. 

Thrive at Five in Doonside ([email protected]) is a partnership between The Western Sydney Local Health District and the Western Sydney Primary Care Network. It is place-based and utilises the strategy of collective impact to improve the social determinants of health for children aged between zero and five years in Doonside. 

Nearby, The Hive, philanthropically funded, utilises a similar strategy in Mt Druitt. The Sydney Local Health District has a signature initiative at work in this space, Healthy Homes and Neighbourhoods.

The proof of the pudding will be in the reduction of vulnerability across the domains of the AEDC in the postcodes targeted by these initiatives. Success will demonstrate that inequity in child health is not inevitable. 

Failure is not an option.

Dr Michael Fasher is Clinical Lead, [email protected] in Doonside, NSW, and a panel member in a session discussing child health inequity at RACP18

References: 

1. Thanks to Dr Sue Woolfenden, senior staff specialist in the Department of Community Child Health and the clinical lead in Integrated Care at Sydney Children’s Hospital Network

2. Thanks to Professor Sharon Goldfeld, paediatrician, public health physician, Co-Group Leader of Child Health Policy, Equity and Translation at the Murdoch in Melbourne

3. https://www.aedc.gov.au